30 Apr 2024 Jason PULMAN · Prevention of Future Deaths report East Sussex
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Concerns raised 8 Lack of clarity about national gender-service referral mechanisms and available resources View source Insufficient CAMHS resources causing long waits for treatment View source Insufficient specialist workforce capacity within CAMHS and paediatrics for gender identity services View source Failure of CAMHS teams to be aware of enhanced support offered to gender-service patients View source Unavailability of assured mental wellbeing support for young people waiting for gender services View source Long waits for access to gender services View source Failure to refer young people awaiting gender services for specialist psychiatric support from CAMHS View source Delays in access to specialist gender dysphoria treatment while on the GIDS waiting list View source See 5 more concerns
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Jason PULMAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jason Pulman, aged 15, was found dead on 19 April 2022 and the inquest concluded that he died by suicide, by hanging. Evidence indicated that he had not received specialist gender dysphoria treatment while waiting for GIDS and was awaiting further CAMHS assessment. The principal concern was that unclear referral mechanisms and inadequate resources for mental health support during waits for gender services could lead to similar circumstances recurring.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Referral Support Service; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about national gender-service referral mechanisms and available resources
Wider context from the report “5. I am concerned that if urgent clarity is not provided to CAMHS teams, patients and parents on the appropriate national referral mechanisms for gender services, and the resources available for those services , there is a risk that the circumstances arising prior to Jason’s death could be repeated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Referral Support Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient CAMHS resources causing long waits for treatment
Wider context from the report “4. During the inquest, I heard evidence from senior management at the CAMHS run by Sussex Partnership Foundation Trust to the effect that (i) they were unaware that enhanced support was being offered via CAMHS and (ii) due to existing pressures on resources the enhanced support would likely have an impact on the already very long wait times for CAMHS treatment , which in turn would give rise to a risk of patients taking their own lives while waiting for treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Referral Support Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient specialist workforce capacity within CAMHS and paediatrics for gender identity services
Wider context from the report “2. On 10 April 2024, i.e. during the course of the inquest, ████████ published her report on the independent review of gender identity services for children and young people (the Cass review). Her recommendations included that: “a smaller number of secondary services within CAMHS and paediatrics should be identified initially to act as Designated Local Specialist Services (DLSS) within each area. This would increase the available workforce through a flexible, multi-site staff group working between the DLSS and the regional centre, with the opportunity to provide targeted training and upskilling.”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Referral Support Service; that does not assign responsibility.
PFD Monitor interpretation Failure of CAMHS teams to be aware of enhanced support offered to gender-service patients
Wider context from the report “4. During the inquest, I heard evidence from senior management at the CAMHS run by Sussex Partnership Foundation Trust to the effect that (i) they were unaware that enhanced support was being offered via CAMHS and (ii) due to existing pressures on resources the enhanced support would likely have an impact on the already very long wait times for CAMHS treatment, which in turn would give rise to a risk of patients taking their own lives while waiting for treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Referral Support Service; that does not assign responsibility.
PFD Monitor interpretation Unavailability of assured mental wellbeing support for young people waiting for gender services
Wider context from the report “3. The Arden and GEM has provided an update on its website entitled the “National Referral support Service for the NHS Gender Incongruence Service for Children and Young People”. This states: “The NHS understands it isn’t easy having to wait a long time to be seen by gender services, and young people may need some extra support with their mental wellbeing while they wait . The NHS is offering this support, if needed, through local Children and Young People Mental Health services (CYPMH), also known as Children and Adolescent Mental Health Services (CAMHS). People will be contacted to ask if they are happy for their details to be shared with their local CYPMH / CAMH service so they can speak to a professional about how they are feeling. This support offer is voluntary and the people’s place on the Children and Young People’s Gender Services waiting list will not change. This service will be contacting parents, children and young people on the waiting list by email or post to ask if they wish to access this support between April and May 2024.”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Referral Support Service; that does not assign responsibility.
PFD Monitor interpretation Long waits for access to gender services
Wider context from the report “3. The Arden and GEM has provided an update on its website entitled the “National Referral support Service for the NHS Gender Incongruence Service for Children and Young People”. This states: “The NHS understands it isn’t easy having to wait a long time to be seen by gender services , and young people may need some extra support with their mental wellbeing while they wait. The NHS is offering this support, if needed, through local Children and Young People Mental Health services (CYPMH), also known as Children and Adolescent Mental Health Services (CAMHS). People will be contacted to ask if they are happy for their details to be shared with their local CYPMH / CAMH service so they can speak to a professional about how they are feeling. This support offer is voluntary and the people’s place on the Children and Young People’s Gender Services waiting list will not change. This service will be contacting parents, children and young people on the waiting list by email or post to ask if they wish to access this support between April and May 2024.”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Referral Support Service; that does not assign responsibility.
PFD Monitor interpretation Failure to refer young people awaiting gender services for specialist psychiatric support from CAMHS
Wider context from the report “1. I heard evidence at the inquest that Jason did not receive specialist gender dysphoria treatment because he was on the waiting list for the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Trust. There was also evidence that clinicians did not refer Jason for specialist psychiatric support from Child and Adolescent Mental Health Services (CAMHS) in part because the guidance at the time suggested any specialist gender dysphoria treatment should be provided by GIDS . Jason was awaiting a further assessment from CAMHS at the time of his death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Referral Support Service; that does not assign responsibility.
PFD Monitor interpretation Delays in access to specialist gender dysphoria treatment while on the GIDS waiting list
Wider context from the report “1. I heard evidence at the inquest that Jason did not receive specialist gender dysphoria treatment because he was on the waiting list for the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Trust . There was also evidence that clinicians did not refer Jason for specialist psychiatric support from Child and Adolescent Mental Health Services (CAMHS) in part because the guidance at the time suggested any specialist gender dysphoria treatment should be provided by GIDS. Jason was awaiting a further assessment from CAMHS at the time of his death.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations