THE lack of understanding and support for autism by a North East NHS trust lead to the death of a woman who was “driven to her death” by a wrong diagnosis, a coroner has concluded.

Zoe Zaremba, 25, died in June 2020 and her body was found in undergrowth around a mile from her home in Aiskew Bedale following a six day search by police.

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The inquest had already heard that Zoe faced “a lack of understanding” of her autism and did not receive a care plan for her needs following an independent review.

North Yorkshire coroner John Broadbridge ruled that the lack of understanding and lack of support did contribute towards her death.

Mr Broadbridge said a misdiagnosis of EUPD made by the Tees, Esk and Wear Valley NHS Trust had a “detrimental” impact on Zoe.

The inquest heard how this had caused Zoe a lot of trauma and that Zoe had a “vivid film-reel like record of the events” that she would regularly return to.

Mr Broadbridge said: “The trust as aware of how deeply difficult she found this diagnosis and Zoe’s sense of injustice and distress I found to be profound."

He said that there was nothing done to change the diagnosis for Zoe for 18 to 19 months, during that time Mr Broadbridge said Zoe was “lurching from crisis to crisis.”

The combination of this lack of understanding and support and the breakdown of trust meant that Zoe did not want to engage with mental health services and became quite reserved as a result.

He concluded: “Zoe’s death was contributed to, by the actions and inactions of the mental health clinics entrusted to keep her safe, within a care system that was under developed to manage an autistic individual with complex needs.”

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Yesterday the inquest heard that Tees, Esk and Wear Valleys NHS Trust accepted all the findings and recommendations within the independent review, and that training was under way in the trust to address the issues.

However, Mr Broadbridge made an argument that Zoe’s case should be heard by a much wider audience and said he would be writing a letter to Gillian Keegan, the Minister of State for Care and Mental Health in the hope to make changes in the care of people with autism.

He said: “I feel that it is important that North Yorkshire Clinical Care Comissioning Group, should be informed and consider whether to take action as to how to address the issues that have emerged.

“I also feel it is important that I recognise others take action and will also address it also to NHS England, and make sure that there is a comprehensive recipient and reply.

“I think Zoe’s case needs to be added to those voices trying to make change."

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Mrs Jean, mother to Zoe Zaremba, said she was “very pleased” with the outcome of the inquest.

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