Thread by @Shame_On_TEWV

CW: Suicide

Zoe's inquest. Day Two.

#JusticeForZoe

Dr Kuster (Zoe's inpatient psychiatrist) returns to give evidence. First questioned by Jean's solicitor. She asks Dr Kuster about a phone call which had come to her attention, the call was not documented in Zoe's notes. 1/

On May 5th 2020 an MDT took place regarding Zoe's care, and this was attended by Dr Kuster. The meeting included discussion of an advanced directive. The solicitor informs Dr Kuster that Zoe had an appointment with her GP on the 4th but had not ever mentioned an advanced 2/

directive (the advanced directive didn't arrive with the GP until May 12th). She did however tell the GP she would be having a call with Dr Kuster the next day, following the meeting. The solicitor suggests that before the professionals meeting (of which Zoe was not in 3/

attendance), there appears to be no record of Zoe discussing an advanced directive. The solicitor asks Dr Kuster, "Did you prompt Zoe to have an advanced directive?" He responds, "Absolutely not".

She concludes her questions.

4/

Dr Oswald from the Tuke Centre in York joins the court via video link.

The questions for Dr Kuster are now handed over the representative for TEWV. She asks Dr Kuster to recall the conversation yesterday about Zoe's static risk factors. She asks if static risk factors are 5/

factors not subject to change - permanent factors. Dr Kuster replies that yes for the most part static risk factors do not change, but some do change, just very slowly over time. In this way they are different to dynamic risk factors which would change faster. The TEWV rep 6/

asks whether these static risk factors were present in 2018. Dr Kuster replies that he believes so. She asks about Zoe's dynamic risk factors. Dr Kuster suggests that every time there was an issue with Zoe's notes, or an attempt to rectify notes, Zoe's risk would increase. 7/

The TEWV rep asks Dr Kuster whether there were dynamic risk factors following Zoe's discharge from hospital in May. He says yes, the ongoing interaction with the information governance department about her notes, and the reduced input from the Tuke Centre in York due to COVID 8/

restrictions on face to face appointments - Zoe's appointments were reduced to email contact. Regarding the appointments ending with the Tuke Centre, Dr Kuster stated that TEWV staff "were not as aware as we could have been". The TEWV rep brings Dr Kuster's attention to the 9/

addendum placed in Zoe's notes after her discharge, which told staff to no longer use the EUPD diagnosis. She asks Dr Kuster, would this have reduced Zoe's dynamic risk factors? Dr Kuster replies yes. She then asks about the discharge plan, which included 72 hour follow up 10/

from the ward staff and phone calls from Dr Kuster. She asks if this type of follow up was normal? Dr Kuster explains that for most people, follow up is done by community/crisis services. However, in some cases, where people may struggle to engage, ward staff will conduct 11/

the 72 hour follow up. He stated that Zoe didn't want to work with community services, and also didn't like speaking to people she didn't know. As she knew the ward staff, this was an adjustment they were happy to make for her. The TEWV rep asks, so this was a reasonable 12/

adjustment for Zoe? "Yes, we tried to avoid a person Zoe didn't know calling her". The TEWV rep moves on to mental capacity in regards to Zoe refusing care and her advanced directive. She asks Dr Kuster if anything can be done to compel capacitous patients to engage in the 13/

community. He replies, "very little". He explains that community treatment orders exist, but they are usually around people receiving depot medication. They discuss Zoe's admission under section 2 & whether she could have been placed on a section 3. Dr Kuster explained 14/

that they felt this would have been detrimental to Zoe. The TEWV rep asks Dr Kuster if Zoe's discharge risk assessment had recorded an accurate level of risk, been "more robust", would it have changed her community care or discharge decision. Dr Kuster replies no to both.

15/

Questions end.

The coroner thanks Dr Kuster for his evidence and says "the answers you've given have been extremely helpful and frank".

16/

The next person called to give evidence was Dr Dyas, Zoe's GP.

Zoe was registered with the practice since birth, and first saw Dr Dyas in 2014. Dr Dyas explained that when they met, Zoe was already diagnosed as autistic and had already been referred to CAMHS.

17/

Dr Dyas described Zoe as "very intelligent, very witty, she had a real dry wit... I found her to be open and honest". The coroner asked, did Zoe trust you? She replied, I believe so. The coroner asked whether it was clear Zoe had difficulties related to autism. Dr Dyas said 18/

yes, and explained that Zoe was a very helpful patient, who frequently provided a lot of information which was of use to her. The coroner asked if the surgery adapted to Zoe's needs. Dr Dyas explained that Zoe was good at sharing her needs, for example, asking for the lights 19/

to be turned off. The practice usually attempted to give her double or extended appointments as Zoe often needed more time to be able to process things and describe her experiences. She also preferred to use the self check in option, rather than speaking to the receptionist. 20/

When there were problems with it, or it was out of order, Zoe struggled. The coroner asked if Zoe had clear insight into her difficulties? Dr Dyas responded that she did, and that she was well educated about autism and happy to share that information.

21/

The coroner asked if Zoe ever attributed blame to anyone for her autism, or resented who she was. Dr Dyas struggled to understand this question, replying, "I don't think Zoe saw autism as a bad thing". She said she couldn't recall Zoe ever thinking it was negative.

22/

The coroner then said that eventually there became a resentment against other people and the actions they took. Dr Dyas said she didn't understand the question, and stated that Zoe sometimes found other people's behaviour difficult.

The coroner moved on to talk about Zoe's 23/

mental health surrounding the employment tribunal in 2016. He said that at this point Zoe was seeking talking therapy but declining antidepressants. He asked about her declining antidepressants, had she taken them before? Dr Dyas was unsure and got out her laptop to look up 24/

some notes. She explained that Zoe was prescribed sertraline by a colleague in February 2016, but she didn't want to take them. In March 2016 she describes how Zoe still didn't want the sertraline and was using St. John's Wort. The coroner talks about Zoe being slow to take 25/

up the offer of antidepressants and asks, did she have an aversion? Dr Dyas stated that Zoe would have wanted to understand and research them first. The coroner asks, would you have been able to talk her round? Dr Dyas replies that Zoe would research and make up her own mind 26/

after careful consideration. It was part of her process. The coroner then states that in December 2016 Zoe took an overdose & was admitted to hospital. He says "we have a young lady who is cautious about meds but behaves whereby she takes an excess of [specific medication]." 27/

He asked Dr Dyas where Zoe had got this medication from, and Dr Dyas explains that it was prescribed to Zoe in December 2016.

The coroner moves on to talk about Zoe's admission in December 2016. He says that Dr Kuster saw Zoe then and called the Northallerton mental health 28/

team to recommend Zoe be assigned a care coordinator.

Zoe had described to her GP that the community team were unwilling to provide talking therapies adapted to autism. She was keen to pursue therapy but the CMHT wouldn't provide it. She also described how difficult the 29/

admission had been and how unpleasant the crisis team had been. She had submitted a complaint to the Trust about failures in her care.

It was suggested by TEWV that Zoe refused to see the community team, and as such her CMHT referral was closed in Jan 2017.

30/

Zoe commented to her GP that she was not able to live in an unfair world and would take her own life at some point.

The coroner asks Dr Dyas, do you get the sense that Zoe was worsening? Were you able to engage her? Dr Dyas replied, yes, to some degree. She described Zoe's 31/

distress surrounding the tribunal & how she was struggling to deal with the uncertainty of it. Dr Dyas describes that "the hearing was the pinnacle of repeated triggers", & if it had had a better outcome, things would have improved. She commented, Zoe just wanted an apology.
32/

The coroner spoke about the employment tribunal and said that the adjustments Zoe had asked for at work were reasonable but she wasn't able to get a satisfying outcome to the tribunal. In April 2017, struggling with the tribunal, exacerbated by autism, there was evidence of 33/

an "increased obsession or fixation" on getting the court case out of the way.

We fast forward to May 2018 where Zoe was struggling with the community team. Her out of area referral to Harrogate had been rejected, and she wished to move from CMHT West to CMHT East. The 34/

coroner commented that "there were signs that she was already railing against being treated by one set of clinicians, but no exception was made for her?" Dr Dyas explained that Zoe wanted to move to the east sector CMHT and this was discussed as a way forward. Zoe had made 35/

several formal requests for this, but the manager of the team demanded Zoe request again, in writing. Zoe submitted this request, but it was refused. "Zoe was already upset by what she perceived as lies and inaccuracies in her records" commented the coroner. He asked if she 36/

had hope for a future or optimistic thoughts, Dr Dyas replies, yes. "If she was knocked back, that would trigger an adverse reaction? .. Did she remain gloomy and pessimistic?" asked the coroner. Dr Dyas stated that when Zoe came in for appointments she was usually struggling 37/

but that was the reason for the appointments. She said that outside of these times, she didn't know Zoe or what her mood/outlook was like generally, so she couldn't comment.

38/

We move to EUPD appearing on Zoe's notes. In Oct 2018 Zoe was assessed by Dr Wilson, a personality disorder specialist at the Trust. Dr Wilson found that Zoe did not have EUPD and supported the plan to do an individual funding request (IFR) for Zoe to receive CBT adapted to 39/

autism. Dr Wilson wrote to Zoe's GP and requested the EUPD diagnosis be removed and the practice submit the IFR. Initially it was rejected, as it was incorrectly submitted. Upon resubmission, the IFR was approved in December 2018. In January 2019 Zoe was assessed by the Tuke 40/

Centre in York and given a fixed number of sessions.

We jump ahead now to September 2019 where Dr Kuster once again discounts the EUPD diagnosis. The coroner describes ongoing triggers surrounding the diagnosis which became a cycle of admissions. He begins reading a 41/

list of Zoe's admissions & suicide attempts, including 37 A&E attendances. He reflects on them, stating that individually they are just single incidents, but when they are listed, they become more & more pronounced. He states, when you see them together, it becomes compelling.42/

This was said with emotion, which felt somewhat validating.

At this point he asks Dr Dyas to list Zoe's medication history, which included sertraline, diazepam, fluoxetine, and temazepam. They discuss Zoe's difficulty with fluoxetine which made her insomnia worse. As Zoe 43/

already struggled with sleep, this was detrimental to her health, so she stopped it after a few months.

The coroner states, "given her distress, there's not an awful lot of medication being given to her". Dr Dyas responded that medication was not the answer to Zoe's 44/

struggles and that it did not provide the help Zoe needed. Zoe also often found it unhelpful.

We move to the advanced directive which arrived at the GP practice on May 12th 2020. The coroner asked if Zoe had discussed it with Dr Dyas before then. She said she did not think 45/

so and had not recorded it anywhere, which she normally would do, to ensure Zoe's notes were complete and accurate.

Dr Dyas contacted the Medical Defence Union (MDU) to seek advice regarding legality, validity, and ethics. She was advised that she should speak to a 46/

psychiatrist, and that Zoe should have a formal capacity assessment. Dr Dyas contacted Dr Kuster, and they eventually managed to speak on June 4th. The coroner asked if anything had ever given the GP cause to doubt Zoe's capacity. She replied, no.

End of questions.

47/

Jean's solicitor begins her questions to Dr Dyas. She states that in 2018 in the lead up to seeing Dr Wilson, two key things were going on for Zoe:

1. To resolve the position with the CMHT

2. The problem of the EUPD diagnosis

She says in June 2018, Mark Spencer, the local 48/

manager, asked Zoe to make another request to change teams. Zoe spoke to Dr Dyas about this, saying she had already done this. In September 2018, they refused the request and said she had to stay with them.

Jean's solicitor said that before the EUPD label, there were already 49/

issues with Zoe's care. Problems surrounding a traumatic admission, unpleasant crisis team staff, the refusal to provide therapy adapted to autism, and lies and misrepresentation of Zoe in her notes. She struggled to work with the west CMHT due to this, then discovered the 50/

EUPD diagnosis on an A&E discharge letter, and then had her request to move teams refused, after they made her formally request it again.

The solicitor asks Dr Dyas, Zoe very much wanted community therapy adapted to autism? She replied, yes. EUPD on her records was a 51/

considerable source of distress and ongoing trigger for Zoe? She replied, yes.

They discuss the appointment Zoe had with Dr Dyas on May 4th 2020. In it they discussed: the addendum to Zoe's notes; her distress about surviving her recent suicide attempt and her time in the 52/

ITU; and her plans to take Dr Kuster's call the next day. Dr Dyas describes that Zoe would most certainly have kept that appointment with Dr Kuster, as she would have considered it rude to miss it. She describes Zoe always keeping appointments and always wanting them to be 53/

properly documented. She said there was no mention of the advanced directive, and that it would be very unlikely she forgot to document it, because she made an extra effort to keep Zoe's records accurate and full.

End of Questions.

Questions are now posed to Dr Dyas from 54/

the TEWV representative. The rep asks if the IFR was normal practice. Dr Dyas said she hadn't made that kind of request before, which is why it was initially incorrectly submitted at first. The TEWV rep asks about the timeline and indicates that it went through very fast and 55/

Zoe was seen quickly, stating that within 2/3 months of the diagnosis being refocused, the specialist support was in place. The GP replied that the assessment was quick, but that didn't constitute therapeutic work. She said she didn't know if they had started at that point. 56/

The TEWV rep snapped back - "They had started" and sat down, ending questions immediately. (This was later found to be untrue)

The coroner commented that he didn't understand what had just occured between the TEWV rep and Dr Dyas, but moved on.

57/

He thanked Dr Dyas for her evidence, saying "I'm grateful to you for your evidence, as someone who Zoe had long, consistent contact with in your practice. Very grateful, thank you."

58/

Dr Oswald from the Tuke Centre in York joined the court by video link and was questioned by the coroner. He asked her qualifications, and she explained she was a consultant clinical psychologist. They begin to talk about the point of contact for Tuke staff. Dr Oswald 59/

explained that initially they were in touch with Dr Wilson, and then the main point of contact was the GP. The coroner asks how contact with mental health services was maintained. Dr Oswald explains that initially there was no contact. In September 2019, Elm Ward staff 60/

invited Dr Fardo (Zoe's therapist at the Tuke Centre) to a formulation meeting. She was unable to make it, but requested the minutes. They were never received. Later in 2019 the Tuke Centre contacted the CMHT about Zoe's increased risk of suicide and discovered that they were 61/

not working with Zoe. The coroner asked how much was shared between themselves and mental health services, "I'm worried you rely on the patient to do that". Dr Oswald replies, to some extent, that is what happened. Information came through Zoe. "We relied on the information 62/

as given by Zoe". The coroner asked if communication would have been beneficial. Dr Oswald states that generally, joined up care and communication is ideal. This was complicated in Zoe's case due to her different levels of relationships. The coroner asks, did Zoe refuse to 63/

allow communication, is that documented anywhere? Dr Oswald says not that she is aware of. The formulation meeting would have taken one of Zoe's alloted sessions and she didn't want to lose that, given how important it was to her.

The coroner asks about Zoe's diagnosis of 64/

Asperger's and how that differs to autism. Dr Oswald provides a brief history of the diagnosis. She then describes Zoe specifically and says she had high cognitive abilities and this masked her significant social, sensory, and communication difficulties. She struggled to 65/

identify and describe her feelings, needed extra time to process, and preferred specific closed questions to open questions. If she was confronted with this communication style she would shut down and struggle to talk.

The coroner asks, for people unfamiliar with Zoe, would 66/

it be difficult for them to understand how she was presenting? Isn't it normal for mental health professionals to attempt to explore emotions in a mental state exam, he asked.
Dr Oswald replies, yes some understanding of ASD will be needed. She said on first impression, Zoe 67/

might not have appeared autistic, "leaving the door open for misinterpretation of her behaviour". The coroner asked about her body language. She explained that non verbal communication may not be well integrated in autistic people, and Zoe's body language did not make it 68/

obvious to neurotypical people how she was feeling.

Dr Oswald explains that Zoe was over and under responsive to situations. She sometimes became overwhelmed by overstimulation & other times needed more stimulation. For Zoe, movement was deeply important, "it was crucial to 69/

her well being". Due to a sports injury she wasn't able to engage in sports, and this was detrimental to her mental health.

The coroner deeply questions Dr Oswald about autism. He states that he is trying to relate to Zoe's case and autism, so he doesn't fall back on 70/

preconceptions about autism when he makes his findings of fact. This was an important moment in the court.

There was much discussion of autism. The coroner asks, was Zoe typical of a person with autism? Dr Oswald replies, yes, Zoe had a very typical female presentation of 71/

autism. The coroner asks about the term "female presentation", asking, "is there something I need to learn about that?" Dr Oswald provides an explanation of male/female presentation of autism. She says from her clinical experience a common conflicting diagnosis is BPD Vs ASD, 72/

and that this was more common for females. The coroner asks, so it's important to recognise the differences between male/female ASD presentation? Dr Oswald replies, yes.

The court breaks for lunch and upon return, Dr Oswald takes the court through Zoe's case and assessments 73/

with the Tuke Centre. She received her first assessment in January 2019, then another in February. She was granted 5 sessions with an OT for sensory assessment, and 30 psychological therapy sessions. Her first therapeutic appointment was in June 2019. Despite being keen on 74/

therapy, Zoe had a number of hospital admissions between Feb-June which made it difficult to begin. Staff were comfortable in June that Zoe was supported by mental health services, & felt safe to proceed. In total she had 12 sessions. Usually the appointments were fortnightly 75/

but were punctuated by hospitalisations and suicide attempts. The Tuke Centre is an outpatient therapeutic service, it does not provide crisis care, out of hours support, outreach, or wrap around care. They only start work with clients who are able to keep themselves safe, 76/

although in some cases, they will make an exception if the person has the support they need from other services. Dr Oswald explains the latter was "the situation we thought we were in".

The coroner goes back to discussing how joined up care, with better communication and 77/

access to notes from other services would have been preferable. Dr Oswald agrees.

They then discuss Zoe's understanding of therapy and how she struggled to identify therapy goals - although she was engaged and working collaboratively with Dr Fardo.

The coroner says, Zoe 78/

thought herself to be suffering from PTSD, did you make a diagnosis? Dr Oswald explains that their service is not focused on diagnosis, however, in hindsight, Zoe's presentation and her distress was in keeping with a post traumatic stress presentation. The therapy also 79/

focused on managing emotions and used DBT skills to cope with and communicate emotions. They were developing an autism passport to aid communication of needs to other professionals.

80/

The coroner began talking about the EUPD diagnosis and said "I said obsessed yesterday, perhaps I should say preoccupied to such an extent that it was filling her mind. It's hard to say without speaking to her.. why". Was this ASD related?

Dr Oswald explained that it 81/

could be related to ASD to some extent, but also represents how deeply Zoe felt. Autistic people are often misunderstood for a lifetime. The injustice of being misunderstood is difficult. Autistic people can become highly focused but it would be wrong to think this was why 82/

she had become so preoccupied.

The coroner asks if suicide risk is higher in autistic people. Dr Oswald says it is, and although it's not fully understood why, it could be because the stressors which generally underpin suicide are higher in autistic people.

83/

The coroner asks if the preoccupation with a sense of injustice from a lifetime of being misunderstood could cause a lack of engagement with clinicians? Dr Oswald says not necessarily. Zoe was engaged with Dr Fardo, and well educated around autism.

84/

The coroner asked if Zoe's non engagement contributed to her death. Dr Oswald says she doesn't know, and that Zoe had difficulties building a relationship but actively sought care and wanted to learn to understand herself.

Questions end

85/

Questions now come from Ms Stone, Jean's solicitor. She asks Dr Oswald to expand on emotional regulation in ASD. Dr Oswald explains that it is a process in all people when we feel emotions. Sometimes autistic people can struggle to recognise and name their emotions; they can 86/

struggle with externalising emotions and co-regulating with others; and the environment can be over stimulating which can challenge emotional regulation strategies.

The solicitor asks, is this an area where there is a potential for an autistic person to be misconstrued? 87/

Dr Oswald replies, this can be a possibility. The solicitor says, when you're looking at someone experiencing "emotional dysregulation" it's important to look at autism as a potential cause? Dr Oswald replies, absolutely, yes. The solicitor states, you mentioned EUPD and a 88/

conflict of diagnosis between this and autism. Dr Oswald replies, yes, we see a significant number of females who get diagnosed at our centre with ASD with a past history of an EUPD label. However, they aren't exclusive, and you can have both. The solicitor asks, but you 89/

should always consider the ASD? Dr Oswald says yes, the impact of environment, sensory input, uncertainty, etc. can cause emotional difficulties. Each autistic person will be different to another and to non autistic people.

The solicitor brings up Zoe's distress around the 90/

EUPD label and asks if this type of upset is common in autistic people. Dr Oswald says yes, autistic people often express discomfort around mislabeling of autism as personality disorder. The solicitor asks, does that relate to sense of self and being recognised as an 91/

autistic person? Dr Oswald replies, yes, people who have really informed themselves and read diagnostic criteria and then face an environment which doesn't recognise autistic neurology, instead staff potentially see the behaviour as manipulative.

The solicitor asks, 92/

there's a perception that EUPD can negatively impact treatment of autistic people by clinicians? Dr Oswald replies, I think if the person has a sense that they are not fully understood this can have a negative effect. I don't think it's inherent to the EUPD diagnosis but the 93/

perception of being misunderstood can be detrimental.

(At this point I practically burst from my seat to shout about how incredibly wrong she was, but I restrained myself, and quietly anger snorted behind my mask instead.)

She continues, "to me, Zoe was one client where 94/

I've learned it was a very distressing situation". I have also had other clients who couldn't get rid of the BPD label.

The discussion now moves to autism and trauma.

95/

Dr Oswald explains that PTSD in autistic people needs careful consideration. She discusses how we decide what is and isn't traumatic, but that this is different for autistic people compared to neurotypical people. She explains that social trauma, what people might consider 96/

minor teasing in school or "harmless" incidents, can be very traumatic for autistic people. She explains that sensory trauma exists, that environments like school can be so overwhelming it's traumatic. She also explains that autistic people often have excellent memory recall 97/

and can have highly vivid memories of trauma, which is distressing. She explained that Zoe had extremely detailed memories of the employment tribunal and this was deeply traumatic for her.

The solicitor asks, so ASD PTSD treatment needs to be tailored? Dr Oswald says yes, 98/

and explains "you can't uncouple autism from any other mental health issues the person might experience"

She goes on to explain that suicide risk assessments also need to be tailored to autistic people. She says risk assessment tools and questions are focused on neurotypical 99/

people. Open questions can be difficult. The solicitor asks if an inability to access appropriate treatment could elevate suicide risk. Dr Oswald says, clinically, that makes sense, yes.
The solicitor asks Dr Oswald about a letter to Zoe's GP. She says, you said Zoe had ways 100/

of expressing herself which could have been misinterpreted as confrontational? Dr Oswald explains, I didn't perceive her as this but she may sometimes give short factual answers which could be perceived as abrupt or short by people who maybe spent little time with her or 101/

didn't have ASD experience. Zoe had experiences of her communication being misinterpreted by professionals.

The solicitor asks, she didn't always non verbally communicate her feelings, is this typical? Dr Oswald replies, absolutely, she could describe extremely distressing 102/

things which were deeply upsetting to her with no outward signs of distress.

Zoe said she wanted suicidal feelings to go away and wanted therapy, but previous experience of counseling was unhelpful, because they had no understanding of autism.

103/

The solicitor reads from Zoe's formulation from the Tuke Centre. (Paraphrased) 'Autistic woman. Emotional difficulties related to trauma. Difficult relationship and experiences with mental health services. However, ready and willing to engage therapeutically as long as she 104/

has support alongside Tuke Centre from other services. Recommend social care assessment.

The solicitor asks about the normal level of communication they would expect from mental health services to their service. Dr Oswald didn't have specifics but said services should keep 105/

them informed of certain things like hospitalisation, crisis etc. She says "the joined working between ourselves and other mental health services was not ideal". She agrees that a requirement for a single point of contact would be helpful.

106/

They move on to talk about adapted therapy for autism and how it's not just the sensory environment but also content and delivery. Dr Oswald explained that clinicians need to conduct themselves differently when working with autistic people. 107/

"Compassion and curiosity go a long way" but it's particularly important to validate and not "other" autistic people. Clinicians need a good understanding of ASD, this is key to building a good relationship.

The solicitor stated that after Zoe's death, the Trust developed 108/

an action plan to implement the changes recommended by the serious incident review (SIR). This included liaising with the Tuke Centre. The solicitor asks, have you been contacted by TEWV about this? Dr Oswald says no. The solicitor then goes on to state that the SIR found 109/

that Zoe's autism was one of the root causes of her death. She asks would you agree that Zoe *was* her autism & her autism *was* Zoe? She suggests there is a certain circularity to the concept that autism contributed to her death. Some autistic people live well and cope well.110/

There is no intrinsic reason why ASD would lead Zoe to take her life? Dr Oswald replies, yes that's right.
The solicitor says, trauma can be a contributory factor to suicide? Dr Oswald replies, yes, elevated risk can be seen in many marginalised groups, such as the LGBTQ 111/

community.

The solicitor asks about the preoccupation with injustice and whether this would contribute to disengagement. The solicitor says, you've described a desire to engage, so does this mean it wasn't that Zoe didn't want to engage, just that the relationship breakdown 112/

impeded this? Dr Oswald replies, yes. She perceived she wasn't understood as autistic. Coming to the Tuke Centre provided that validation

End of questions.

113/

The final questions are from TEWVs representative. She asks a number of questions about the Tuke Centre's contractual obligations when the client is funded by the CCG, and who would be the normal person to communicate to. They establish it would be the GP. She then asks Dr 114/

Oswald about her expertise and repeats that she is particularly experienced, much more so than ordinary mental health professionals. She asks Dr Oswald if she has more skills as a specialist in autism, and what kind of understanding other clinicians should have of ASD. Dr 115/

Oswald says she cannot answer this, but she does have more skills as a specialist. The TEWV rep states it is an important distinction to make, between Dr Oswald and a general member of a community mental health team. The TEWV rep then goes on to say that Zoe was given 116/

30 sessions of psychological therapy, but only completed 12. She said there were two reasons: 1. Zoe's hospital admissions interrupted sessions, and 2. Zoe died before finishing. She then says, there was also a third reason - the COVID-19 situation. Dr Oswald agrees that the 117/

pandemic meant they shifted to online appointments and many of their autistic clients (Zoe included) had paused their therapy until face to face appointments were back. The TEWV rep asks why the Tuke Centre didn't make a reasonable adjustment for Zoe & see her face to face. 118/

Dr Oswald explains that after the first lockdown they were able to move appointments to outdoor face to face. She also said they believed Zoe was receiving care from mental health services. The TEWV rep asked what care they thought she had, and Dr Oswald replied, a risk 119/

management plan with the crisis team.

End of questions.

The coroner thanked Dr Oswald and said he was "very very grateful" for her evidence.

120/

The coroner read brief statements admitted under Rule 23. He read the witness statements of the member of public & the police who found Zoe's body and the search undertaken.
I will not be including detail of these statements, or the specific location where Zoe was found. 121/

End of day two.

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Tomorrow may be the last day, depending on time. Either way, I will continue to update you.

Once again, be gentle and kind to yourselves reading this. Please mute the account if you need to.

Love and strength ❤️🖤❤️🖤

#JusticeForZoe