Jason PULMAN · Prevention of Future Deaths report

On 27 April 2022 I commenced an investigation into the death of Jason PULMAN aged 15. The investigation concluded at the end of the inquest on 12 April 2024. The conclusion of the inquest was that:

Narrative: Jason Pulman died as a result of suicide. Jason died by hanging, potentially through his mental health and gender identity issues. Within this context, it is possible his relationship with his boyfriend exacerbated his low mood. It is also possible Jason may have been prevented from committing suicide if British Transport Police had been notified that Jason was a missing person who was possibly on a train.

Jason Pulman was found on 19 April 2022, by a member of the public, ████████. He was pronounced dead on the scene.

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.

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.”

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.”

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.

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.