PFD report

Amarnih Lewis-Daniel · Prevention of Future Deaths report

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Issued 11 Dec 2023•East 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
6

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
13

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 raised6

  1. Lack of knowledge of guidance for safe prescribing of bridging hormones
    Part of recurring concern: Inadequate interim care for patients awaiting gender-identity treatment
  2. Lack of local support for patients awaiting Gender Identity Clinic assessment and treatment
    Part of recurring concern: Inadequate interim care for patients awaiting gender-identity treatment
  3. Lack of clarity about responsibility for patient wellbeing during the waiting period
    Part of recurring concern: Inadequate interim care for patients awaiting gender-identity treatment
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.7

  1. Action

    Refresh adult gender dysphoria service specifications, including consideration of service inefficiencies and further clinical-capacity expansion.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 18 December 2023.
  2. Action

    Commission waiting-list support resources, including referral screening, outreach and peer workers, advice lines, and pre-assessment workshops.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 December 2023.
  3. Action

    Establish and fund the UK’s first accredited gender identity healthcare training programme.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 December 2023.

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

  1. Position

    Sufficient gender dysphoria clinic capacity cannot be commissioned because specialist clinical staff are unavailable amid increasing demand.

    Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant 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

Lack of knowledge of guidance for safe prescribing of bridging hormones

Wider context from the report

“5. Those in attendance at the inquest were unclear about guidance available to GPs and other healthcare professionals to support them with the safe prescribing of bridging hormones, during the lengthy waiting period. The BMA’s guidance on the role of GPs in managing patients with gender incongruence (2022) and the Royal College of Psychiatrist’s advice relating to bridging prescriptions was not known by the healthcare professionals in attendance at the inquest hearing. There is a concern that primary and secondary/tertiary services are not working optimally, to support those during the lengthy waiting periods. ”

Is this part of a recurring concern?

Yes — Inadequate interim care for patients awaiting gender-identity 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of local support for patients awaiting Gender Identity Clinic assessment and treatment

Wider context from the report

“2. The inquest also heard that there is little local support available to patients who are waiting for assessment and treatment by Gender Identity Clinics. ”

Is this part of a recurring concern?

Yes — Inadequate interim care for patients awaiting gender-identity 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of clarity about responsibility for patient wellbeing during the waiting period

Wider context from the report

“3. There was a lack of clarity as to who is responsible for the wellbeing of the patient during the wait for period, for any distress caused by the gender dysphoria. There was a lack of consensus as to whether it would be the referrer or the GID clinic itself. ”

Is this part of a recurring concern?

Yes — Inadequate interim care for patients awaiting gender-identity 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of specialist knowledge in local mental health services about supporting people with GID

Wider context from the report

“4. Local mental health services have very little specialist knowledge as to how best to support a person suffering from GID. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Very long waiting lists for Gender Identity Clinics

Wider context from the report

“1. The inquest heard that there are very long waiting lists for GID clinics. In September 2023, the average waiting time was in the region of 7 years. The expert instructed at the inquest identified that long waiting lists could intensify distress arising from gender dysphoria. ”

Is this part of a recurring concern?

Yes — Unreliable access to gender-affirming healthcare.

Open source report

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

Failure of primary and secondary/tertiary services to work optimally together to support patients during lengthy waiting periods

Wider context from the report

“5. Those in attendance at the inquest were unclear about guidance available to GPs and other healthcare professionals to support them with the safe prescribing of bridging hormones, during the lengthy waiting period. The BMA’s guidance on the role of GPs in managing patients with gender incongruence (2022) and the Royal College of Psychiatrist’s advice relating to bridging prescriptions was not known by the healthcare professionals in attendance at the inquest hearing. There is a concern that primary and secondary/tertiary services are not working optimally, to support those during the lengthy waiting periods. ”

Is this part of a recurring concern?

Yes — Inadequate interim care for patients awaiting gender-identity treatment.

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

Refresh adult gender dysphoria service specifications, including consideration of service inefficiencies and further clinical-capacity expansion.

Verbatim wording from the response

“NHS England’s overall planned spend on all gender dysphoria services (adults and children) in 2023/24 is £78.17m – up from £33.4m in 2018/19, representing an overall increase in funding of 134% in five years. In 2024/25 NHS England will refresh the service specifications for adult gender dysphoria services, which will include consideration of how to identify and address inefficiencies that may reside in the way in which GDCs manage and deliver their services and which may contribute to long waiting times – and how to expand clinical capacity further taking the learning from the pilot services. It is too early in the current year to provide precise figures for the planned budget for gender dysphoria services in 2024/25 but the figure given represents recurrent funding commitments and so should be regarded as the opening baseline figure for planning assumptions.”

Source location

Response from NHS England
Page 4 · response
Published 18 December 2023

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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 waiting-list support resources, including referral screening, outreach and peer workers, advice lines, and pre-assessment workshops.

Verbatim wording from the response

“NHS England also continues to support the expansion of services in the established GDCs where this is possible. In 2021/22 NHS England invited all seven GDCs to put forward a business case for funding for the expansion of clinical capacity or direct patient support as part of a discretionary investment process. An additional investment of £2.2m was set aside for this purpose. Although all this funding was deployed into the GDCs by NHS England, some of the funding was directed by the providers to non-clinical forms of support for patients on the waiting list due to the difficulties in attracting clinical staff to work in the service itself. There is clinical opinion that telephone and online support are a useful service for patients on the waiting list. We have also commissioned support resources at Gender Dysphoria Clinics, to include:”

Source location

Response from NHS England
Page 3 · response
Published 18 December 2023

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 and fund the UK’s first accredited gender identity healthcare training programme.

Verbatim wording from the response

“As mentioned above, to support the growth of clinical capacity NHS England also established and funded the UK’s first accredited training programme in gender identity healthcare which was launched in 2020 and delivered through the Royal College of Physicians. The purpose of this investment is to encourage growth in the specialist clinical workforce available to contribute to the assessment and care of those presenting with gender incongruence and to treatment following a diagnosis of gender dysphoria.”

Source location

Response from NHS England
Page 3 · response
Published 18 December 2023

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 the procurement process for a substantive Cheshire and Merseyside gender dysphoria service contract.

Verbatim wording from the response

“In 2023 the pilot services at Chelsea and Westminster Hospital NHS Foundation Trust (London) and GTD Healthcare (Greater Manchester) were moved to substantive seven-year contracts with NHS England following positive evaluations. The GTD service is now open to new referrals of patients who are registered with a GP in Greater Manchester, and the London service is now taking increased numbers of patients from the waiting list of its nearest GDC – the Tavistock and Portman NHS Foundation Trust. NHS England is currently out to tender to award a substantive contract for the service in Cheshire and Merseyside following positive evaluation of this service, and there is an expectation that a similar process will be followed for the other two pilots when their evaluations are complete in 2024 (East England) and 2026 (Sussex).”

Source location

Response from NHS England
Page 3 · response
Published 18 December 2023

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

Deploy £2.2 million of additional investment to established clinics for clinical-capacity expansion or direct patient support.

Verbatim wording from the response

“NHS England also continues to support the expansion of services in the established GDCs where this is possible. In 2021/22 NHS England invited all seven GDCs to put forward a business case for funding for the expansion of clinical capacity or direct patient support as part of a discretionary investment process. An additional investment of £2.2m was set aside for this purpose. Although all this funding was deployed into the GDCs by NHS England, some of the funding was directed by the providers to non-clinical forms of support for patients on the waiting list due to the difficulties in attracting clinical staff to work in the service itself. There is clinical opinion that telephone and online support are a useful service for patients on the waiting list. We have also commissioned support resources at Gender Dysphoria Clinics, to include:”

Source location

Response from NHS England
Page 3 · response
Published 18 December 2023

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

Move the London and Greater Manchester pilot services to substantive seven-year contracts following positive evaluations.

Verbatim wording from the response

“In 2023 the pilot services at Chelsea and Westminster Hospital NHS Foundation Trust (London) and GTD Healthcare (Greater Manchester) were moved to substantive seven-year contracts with NHS England following positive evaluations. The GTD service is now open to new referrals of patients who are registered with a GP in Greater Manchester, and the London service is now taking increased numbers of patients from the waiting list of its nearest GDC – the Tavistock and Portman NHS Foundation Trust. NHS England is currently out to tender to award a substantive contract for the service in Cheshire and Merseyside following positive evaluation of this service, and there is an expectation that a similar process will be followed for the other two pilots when their evaluations are complete in 2024 (East England) and 2026 (Sussex).”

Source location

Response from NHS England
Page 3 · response
Published 18 December 2023

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 five pilot gender dysphoria services to expand clinical capacity and reduce established-clinic waiting lists.

Verbatim wording from the response

“In the circumstances, NHS England sought to grow capacity in an alternative way. Five pilot services were developed. The proposal was to build a new clinical workforce using professionals who had tended not to specialise in gender identity healthcare previously, based in primary care and local sexual health services, which presented the opportunity to develop and expand clinical capacity to an extent not possible under the historical delivery model. There were various eligibility criteria for accessing the different pilot services (for example, being registered with a GP in the relevant geographical catchment area) but all the pilot services only took patients from the waiting lists of the established GDCs, in chronological order of waiting. Between April 2020 and August 2023 around 2,500 individuals were removed from a GDC waiting list to be seen by one of the pilot services.”

Source location

Response from NHS England
Page 2 · response
Published 18 December 2023

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

Sufficient gender dysphoria clinic capacity cannot be commissioned because specialist clinical staff are unavailable amid increasing demand.

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. NHS England 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. Unfortunately, waiting times for a first appointment at a GDC remain very high. Of patients who received their first appointment in November 2023 they had on average been referred 382 weeks previously.”

Source location

Response from NHS England
Page 2 · response
Published 18 December 2023

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

Clinical responsibility during a GDC waiting period rests with the patient’s GP or involved local healthcare professional, not an unseen clinician.

Verbatim wording from the response

“It is clear that no individual healthcare professional can be deemed to hold clinical responsibility for a patient that they have never seen for the purpose of a clinical consultation. Consequently, the individual healthcare professional that holds clinical responsibility for a patient while they remain on the waiting list for a GDC will be the patient’s GP, if the patient presents to the GP, or the local healthcare professional who is involved in the provision of care to the individual. Our response above has described some of the various training and support materials that are available to the relevant health professionals.”

Source location

Response from NHS England
Page 6 · response
Published 18 December 2023

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

Commissioning responsibility for local support services rests with Integrated Care Boards, not NHS England.

Verbatim wording from the response

“Commissioning responsibility for local services rests with Integrated Care Boards (ICBs) rather than NHS England. The make-up of local services, and their approach to service delivery, training and education, can differ according to each ICB’s commissioning strategy.”

Source location

Response from NHS England
Page 4 · response
Published 18 December 2023

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.6

  1. 1

    Evaluate the Gender Outreach Worker role to inform learning across NHS gender dysphoria clinics.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 18 December 2023.
  2. 2

    Publish online training materials for health and education professionals supporting young people with gender distress.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 December 2023.
  3. 3

    Discuss received Regulation 28 reports through the national working group and share key learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 December 2023.
  4. 4

    Directly fund the five pilot gender dysphoria services alongside funding for established clinics.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 December 2023.
  5. 5

    Maintain the Liaison and Diversion standard operating procedure for all providers.

    Stated by TogetherStated completedThe respondent said that this action was complete when they made their response on 18 December 2023.
  6. 6

    Maintain information-sharing agreements with NELFT and ELFT.

    Stated by TogetherStated completedThe respondent said that this action was complete when they made their response on 18 December 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3

  1. 1

    Some concerns are better addressed by the relevant Gender Dysphoria Clinic, involved healthcare professionals, or the Care Quality Commission.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    Requesting the court to use Paragraph 5 falls outside the Liaison and Diversion practitioner's remit.

    Stated by TogetherOutside remitThe respondent said that this matter was outside its role or authority.
  3. 3

    The judiciary, rather than the Liaison and Diversion practitioner, decided whether to use Paragraph 5.

    Stated by TogetherRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Evaluate the Gender Outreach Worker role to inform learning across NHS gender dysphoria clinics.

Verbatim wording from the response

“The Gender Outreach Worker role (referred to above) is being formally evaluated by a host Gender Dysphoria Clinic (Leeds and York Partnership NHS Foundation Trust) so that learning can be shared across other NHS Gender Dysphoria Clinics in 2024/25. The role has a number of potential positive benefits:”

Source location

Response from NHS England
Page 3 · response
Published 18 December 2023

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 online training materials for health and education professionals supporting young people with gender distress.

Verbatim wording from the response

“• In September 2023 NHS England published online training materials for health and education professionals in how to support young people up to 18 years with gender distress: https://www.minded.org.uk/catalogue/TileView”

Source location

Response from NHS England
Page 5 · response
Published 18 December 2023

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

Discuss received Regulation 28 reports through the national working group and share key learning across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 7 · response
Published 18 December 2023

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

Directly fund the five pilot gender dysphoria services alongside funding for established clinics.

Verbatim wording from the response

“NHS England directly funded the pilot services on top of the funding provided to the seven established GDCs.”

Source location

Response from NHS England
Page 3 · response
Published 18 December 2023

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

Maintain the Liaison and Diversion standard operating procedure for all providers.

Verbatim wording from the response

“Together have separate ISAs in place with NELFT and also ELFT - attached. In addition, we have the Standard Operating Procedure for Liaison and Diversion (all providers) – attached.”

Source location

Response from Together UK
Page 1 · response
Published 18 December 2023

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

Maintain information-sharing agreements with NELFT and ELFT.

Verbatim wording from the response

“Together have separate ISAs in place with NELFT and also ELFT - attached. In addition, we have the Standard Operating Procedure for Liaison and Diversion (all providers) – attached.”

Source location

Response from Together UK
Page 1 · response
Published 18 December 2023

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

Some concerns are better addressed by the relevant Gender Dysphoria Clinic, involved healthcare professionals, or the Care Quality Commission.

Verbatim wording from the response

“In your Report you raised five matters of concern. Some of these matters of concern are better addressed by the Gender Dysphoria Clinic at the Tavistock and Portman NHS Foundation Trust, the healthcare professionals directly involved in Amarnih’s care at North East London NHS Foundation Trust and the Care Quality Commission (CQC). We note that you have also addressed your Report to these organisations.”

Source location

Response from NHS England
Page 1 · response
Published 18 December 2023

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

Requesting the court to use Paragraph 5 falls outside the Liaison and Diversion practitioner's remit.

Verbatim wording from the response

“• ████████ did not request for the court to use Paragraph 5. It is not within the remit for an L&D Practitioner to do so, The case note indicated that the judiciary made this decision.”

Source location

Response from Together UK
Page 2 · response
Published 18 December 2023

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 judiciary, rather than the Liaison and Diversion practitioner, decided whether to use Paragraph 5.

Verbatim wording from the response

“• ████████ did not request for the court to use Paragraph 5. It is not within the remit for an L&D Practitioner to do so, The case note indicated that the judiciary made this decision.”

Source location

Response from Together UK
Page 2 · response
Published 18 December 2023

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