Zoe Zaremba inquest: 25-year-old autistic woman died by suicide after losing trust in her NHS mental health team

Zoe Zaremba died in June 2020. The Bedale woman went missing on the night of June 13, and her body was found a week later in overgrowth near the North Yorkshire town.

She was diagnosed with autism as a teenager, an inquest into her death heard, and she stopped trusting her medical team after a series of errors which saw her treated for a serious personality disorder that she did not have.

Ms Zaremba was also not given a person-centred care plan which took into account the risk factors between autism and suicide.

The inquest heard that Ms Zaremba was detained under the Mental Health Act 17 times from 2016 to 2020, and presented herself to A&E departments 37 times with evident self-harm and attempts to end her life.

Her therapy, which was not provided by her NHS team, was also hindered by the pandemic.

Assistant Coroner Jonathan Broadbridge has now written to mental health minister Gillian Keegan, the NHS, and the CEOs of North Yorkshire Clinical Commissioning Group and Tees Esk and Wear Valleys NHS Foundation Trust to ask how they will work to prevent future deaths.

In the letter he wrote: “Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking.

“She felt she was not being listened to by community mental health services.

“Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.”