Coroner asks ambulance service to carry antidote

Fern Foster
Fern Foster was described by her family as articulate, bright, kind and caring [Foster Family]

A coroner has said ambulance services must carry an antidote to a poisonous substance after a 22-year-old mother took her own life.

Fern Foster, from High Wycombe, Buckinghamshire, had autism and died in July 2020 on the day she was informed that her child might be placed for adoption by social services.

Crispin Butler, the senior coroner for Buckinghamshire, has written to NHS England and the National Ambulance Service Medical Directors, and said that "action should be taken to prevent future deaths".

At her inquest in April, Mr Butler recorded Ms Foster's cause of death as suicide and said she died as a result of taking poison.

The inquest heard how Ms Foster's child had gone into foster care about a month after she was born in January 2020.

When she learned of the "significant adverse news" about her child she did not have "physical professional support", the coroner said.

No-one was present to assist her with processing the information, to safeguard her mental wellbeing or address her "likely increased risk of suicide", he added.

Ms Foster, who had aspirations to become an English teacher, had previously indicated her intention to end her life if her child was adopted and had taken two overdoses, Mr Butler said.

The report was also sent to the National Ambulance Resilience Unit, Association of Ambulance Chief Executives, National Coding Group and the Emergency Call Prioritisation Advisory Group.


Ms Foster then purchased a "substance", the name of which was redacted in the report, which she took on 8 July 2020.

Mr Butler said there needs to be a "triaging and prioritising ambulance attendance" to an incident where the substance has been taken.

He asked the ambulance service to carry an antidote to the substance, which has been trialled elsewhere but was "not part of regional or national protocol".

"In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action," he said.

An NHS England spokesperson said: “NHS England extends its deepest sympathies to the family and friends of Fern Foster. We are carefully considering the prevention of future deaths report sent to us by HM Coroner and will respond in due course.”

A copy of the report was also sent to Ms Foster's family, South Central Ambulance Service, Thames Valley Air Ambulance, Buckinghamshire Council Adult Services, Buckinghamshire Council Children’s Services, Oxford Health NHS Foundation Trust, Thames Valley Police and Buckinghamshire Safeguarding Adults Board.

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