PFD report

Leia Dorothy Pandora Sampson-Grimbly · Prevention of Future Deaths report

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Issued 25 Jul 2024•North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
12

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Excessively long waiting lists for first appointments at Gender Dysphoria clinics
    Part of recurring concern: Unreliable access to gender-affirming healthcare
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Work with NHS England and other providers to develop ways to reduce GIC waiting lists and support patients while waiting.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 July 2025.
  2. Action

    Publish the adult Gender Dysphoria Clinic review report and its findings and recommendations.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 29 July 2025.
  3. Action

    Conduct a review of adult Gender Dysphoria Clinic operations, service models, quality concerns and improvement actions.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 29 July 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    NHS England, as commissioner of specialised gender dysphoria services, is responsible for commissioning sufficient service capacity.

    Stated by North London NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Excessively long waiting lists for first appointments at Gender Dysphoria clinics

Wider context from the report

“Waiting lists are far too long for first appointment at a Gender Dysphoria clinic. ”

Is this part of a recurring concern?

Yes — Unreliable access to gender-affirming healthcare.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Work with NHS England and other providers to develop ways to reduce GIC waiting lists and support patients while waiting.

Verbatim wording from the response

“England and other providers to develop innovative ways of reducing the waiting list and providing support to patients while on the waiting list.”

Source location

Response from Tavistock and Portman NHS Foundation Trust
Page 2 · response
Published 29 July 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Publish the adult Gender Dysphoria Clinic review report and its findings and recommendations.

Verbatim wording from the response

“The review is led by ████████, Medical Director of Lancashire and South Cumbria Integrated Care Board, and previously NHS England’s North West Regional Medical Director. Following on-site visits to every GDC in England, the report detailing the review’s findings and recommendations will be published in the autumn of 2025. The report will inform NHS England’s work to build a new service specification for the GDCs over 2025/26, which will involve a process of public consultation. In the context of reducing waiting times and waiting lists, NHS England will particularly want to learn the review’s findings and recommendations around productivity and efficiency within each of the GDCs.”

Source location

Response from Department for Health and Social Care
Page 5 · response
Published 29 July 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct a review of adult Gender Dysphoria Clinic operations, service models, quality concerns and improvement actions.

Verbatim wording from the response

“This response has focused on waiting times to Children and Young People’s Gender Services and NHS England’s efforts to increase clinical capacity in this field. However, it may assist HM Coroner to learn that in April 2024 NHS England took the decision to conduct a review of the operation and delivery of adult Gender Dysphoria Clinics (GDC), in line with the recommendations of the Cass Review and in recognition that waiting times for adult gender services are also unacceptably high.”

Source location

Response from Department for Health and Social Care
Page 5 · response
Published 29 July 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a new service specification for adult Gender Dysphoria Clinics through public consultation.

Verbatim wording from the response

“The review’s terms of reference and key lines of enquiry have been published, and they describe that the review will examine the operating procedures in each service; the appropriateness of the service model for the presenting population; areas of concern, and any action being taken to improve quality. It will identify areas for improvement in relation to service quality, good practice that could be shared with other clinics, and any support that should be made available to services to assist improvement.”

Source location

Response from Department for Health and Social Care
Page 5 · response
Published 29 July 2025

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

NHS England, as commissioner of specialised gender dysphoria services, is responsible for commissioning sufficient service capacity.

Verbatim wording from the response

“The waiting times for such GIC assessments is currently around 2.5 years, which is broadly in keeping with the national picture, though there is some variation in waiting times. NHS England (NHSE) is the direct commissioner of specialised services for individuals with a diagnosis of gender dysphoria. Prior to 2019/20, seven specialist centres were commissioned in England, based in or near Newcastle, Leeds, Sheffield, Northampton, Nottingham, London and Exeter.”

Source location

Response from Tavistock and Portman NHS Foundation Trust
Page 2 · response
Published 29 July 2025

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Insufficient specialist clinical staff and increasing demand have prevented NHS England from commissioning enough capacity to meet waiting-time expectations.

Verbatim wording from the response

“The consultant-led services provided by the GDCs when adult patients are referred to them are amongst those intended to commence within 18 weeks of referral. Unfortunately, NHSE has been unable to commission sufficient capacity to meet that expectation because of the lack of specialist clinical staff (recruitment and retention) – against a backdrop of significant increasing demand, reflecting an international trend. Unfortunately, waiting times for a first appointment at a GDC remain very high. The Trust will continue to engage with its commissioners, NHS England, to develop provisions to reduce waiting times where possible.”

Source location

Response from Tavistock and Portman NHS Foundation Trust
Page 3 · response
Published 29 July 2025

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

New clinical capacity cannot be built quickly because specialist staff require training and experience.

Verbatim wording from the response

“It may assist HM Coroner to know that new clinical capacity cannot be built quickly given the specialist skills that are needed to staff the multi-disciplinary team comprised variously of psychologists, psychiatrists, psychotherapists, paediatricians, social workers, nurses and endocrinologists (not exhaustive). Clinicians require training and experience to build their expertise and competencies. That is why, to support a rapid build of a new clinical workforce, NHS England has commissioned the Academy of Medical Royal Colleges and University College London to design and deliver a professional competency framework and training curriculum by 2026.”

Source location

Response from Department for Health and Social Care
Page 3 · response
Published 29 July 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.8

  1. 1

    Operate three new regional NHS gender services for children and young people.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 29 July 2025.
  2. 2

    Establish additional regional children’s gender services in North East and Yorkshire and the Midlands.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 29 July 2025.
  3. 3

    Provide funded mental-health assessments and referrals for eligible children and young people on the gender-services waiting list.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 29 July 2025.
  4. 4

    Provide psychological and psychosocial support through a separate service for young people receiving endocrine intervention under former shared-care arrangements.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 29 July 2025.
  5. 5

    Open the fourth regional children’s gender service in Cambridge and begin accepting waiting-list referrals.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 29 July 2025.
  6. 6

    Commission a professional competency framework and training curriculum to accelerate development of the specialist clinical workforce.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 29 July 2025.
  7. 7

    Support new providers to establish and lead regional integrated networks coordinating children’s care, wellbeing support and professional assistance.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 29 July 2025.
  8. 8

    Require local NHS mental-health or paediatrics assessment before adding children and young people to the national gender-services waiting list.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 29 July 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The identified gap in care was not considered to have affected the predictability or preventability of the death.

    Stated by North London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Operate three new regional NHS gender services for children and young people.

Verbatim wording from the response

“Since April 2024 NHS England has established three new NHS centres for children with gender incongruence in the North-West (managed by Alder Hey Children’s Foundation NHS Trust); South-West (managed by University Hospitals Bristol and Weston NHS Foundation Trust); and London (managed by Great Ormond Street Hospital for Children NHS Foundation Trust). A fourth new service will be operational by January 2026 (Cambridge University Hospitals NHS Foundation Trust). By 2026 it is planned that additional centres will be operational in North East and Yorkshire, and the Midlands.”

Source location

Response from Department for Health and Social Care
Page 3 · response
Published 29 July 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish additional regional children’s gender services in North East and Yorkshire and the Midlands.

Verbatim wording from the response

“Since April 2024 NHS England has established three new NHS centres for children with gender incongruence in the North-West (managed by Alder Hey Children’s Foundation NHS Trust); South-West (managed by University Hospitals Bristol and Weston NHS Foundation Trust); and London (managed by Great Ormond Street Hospital for Children NHS Foundation Trust). A fourth new service will be operational by January 2026 (Cambridge University Hospitals NHS Foundation Trust). By 2026 it is planned that additional centres will be operational in North East and Yorkshire, and the Midlands.”

Source location

Response from Department for Health and Social Care
Page 3 · response
Published 29 July 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide funded mental-health assessments and referrals for eligible children and young people on the gender-services waiting list.

Verbatim wording from the response

“NHS England established a funded mental health support offer for children and young people who were on the waiting list between April and August 2024 (and who were not already under the care of NHS mental health services). The process for obtaining consent to the referral to mental health services, and the transfer of patient records to the correct local mental health team, was overseen by the National Referral Support Service. The support offer involved a face-to-face assessment by the patient’s local NHS Children and Young People’s Mental Health Team to assess mental health needs and risks; review neurodevelopmental needs, if present; review safeguarding needs; and to allocate or refer to the appropriate service and pathway for further assessment or support.”

Source location

Response from Department for Health and Social Care
Page 4 · response
Published 29 July 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide psychological and psychosocial support through a separate service for young people receiving endocrine intervention under former shared-care arrangements.

Verbatim wording from the response

“To support the new providers in focusing their available clinical capacity on new patients from the waiting list, NHS England has also commissioned a separate service at Nottinghamshire Healthcare NHS Foundation Trust from April 2024 to provide psychological and psychosocial support to young people who were receiving endocrine intervention through a shared care arrangement between the former GIDS and one of two commissioned endocrine providers (Leeds Teaching Hospitals NHS Trust and University College London Hospitals NHS Foundation Trust) at the point of closure of GIDS.”

Source location

Response from Department for Health and Social Care
Page 3 · response
Published 29 July 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Open the fourth regional children’s gender service in Cambridge and begin accepting waiting-list referrals.

Verbatim wording from the response

“Since April 2024 NHS England has established three new NHS centres for children with gender incongruence in the North-West (managed by Alder Hey Children’s Foundation NHS Trust); South-West (managed by University Hospitals Bristol and Weston NHS Foundation Trust); and London (managed by Great Ormond Street Hospital for Children NHS Foundation Trust). A fourth new service will be operational by January 2026 (Cambridge University Hospitals NHS Foundation Trust). By 2026 it is planned that additional centres will be operational in North East and Yorkshire, and the Midlands.”

Source location

Response from Department for Health and Social Care
Page 3 · response
Published 29 July 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Commission a professional competency framework and training curriculum to accelerate development of the specialist clinical workforce.

Verbatim wording from the response

“It may assist HM Coroner to know that new clinical capacity cannot be built quickly given the specialist skills that are needed to staff the multi-disciplinary team comprised variously of psychologists, psychiatrists, psychotherapists, paediatricians, social workers, nurses and endocrinologists (not exhaustive). Clinicians require training and experience to build their expertise and competencies. That is why, to support a rapid build of a new clinical workforce, NHS England has commissioned the Academy of Medical Royal Colleges and University College London to design and deliver a professional competency framework and training curriculum by 2026.”

Source location

Response from Department for Health and Social Care
Page 3 · response
Published 29 July 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Support new providers to establish and lead regional integrated networks coordinating children’s care, wellbeing support and professional assistance.

Verbatim wording from the response

“NHS England is supporting the new providers to establish and lead regional integrated networks that comprise the various statutory services that are likely to be involved in the care and support of children who present with gender incongruence, so that there is a more coordinated and joint approach to the care for these children and young people, and their families, including wellbeing support while on the waiting list. This model will also enable and facilitate support to the various health and other statutory professionals across the network who may have infrequent experience of children and young people with gender incongruence.”

Source location

Response from Department for Health and Social Care
Page 3 · response
Published 29 July 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Require local NHS mental-health or paediatrics assessment before adding children and young people to the national gender-services waiting list.

Verbatim wording from the response

“Additionally, from September 2024, NHS England ended the ability of GPs to directly refer to children’s gender services. All children and young people who are considered for referral to the national waiting list for children’s gender services must now first be assessed by a local NHS mental health team or NHS paediatrics team. This arrangement ensures that an individual care plan is in place for the child or young person, as clinically indicated, before they are added to the waiting list. Clinical oversight remains with the local NHS team while the child or young person waits to be seen by the gender service. These arrangements are formalised in an ancillary service specification that is published.”

Source location

Response from Department for Health and Social Care
Page 4 · response
Published 29 July 2025

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The identified gap in care was not considered to have affected the predictability or preventability of the death.

Verbatim wording from the response

“The Trust has identified there was a gap in care in that the young person was taken off the Arden & GEM child waiting list in February when they were 17 and 1 month. They were then referred to the adult gender clinic when they were 17 years and 2 months, however the referral was not received by this Trust as it had not been correctly sent by the GP surgery. The gap in care had not been identified at the time of death and therefore as such it does not seem that it would have had an impact on the predictability and preventability of death.”

Source location

Response from Tavistock and Portman NHS Foundation Trust
Page 2 · response
Published 29 July 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026