PFD report

Alice LITMAN · Prevention of Future Deaths report

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Issued 5 Dec 2023•West Sussex, Brighton and Hove

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
5

Raised in this report

Recipients
4

Named on the report

Responses found
4

Of 4 recipients

Stated actions
33

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 raised5

  1. Lack of provision of mental health care for people waiting for gender-affirming treatment
    Part of recurring concern: Inadequate interim care for patients awaiting gender-identity treatment
  2. Delays in access to gender-affirming healthcare
    Part of recurring concern: Unreliable access to gender-affirming healthcare
  3. Lack of clarity for Primary Care clinicians supporting young transgender individuals
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.17

  1. Action

    Author a specific transgender policy document.

    Stated by Royal College of General PractitionersStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
  2. Action

    Participate in the current review led by a former Royal College of Paediatrics and Child Health president.

    Stated by Royal College of General PractitionersStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
  3. Action

    Publish specific transgender-care e-learning packages on the RCGP website.

    Stated by Royal College of General PractitionersStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Decisions on specific therapy, including medication, are specialist responsibilities outside general practitioners’ scope of practice.

    Stated by Royal College of General PractitionersOutside remitThe respondent said that this matter was outside its role or authority.

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 provision of mental health care for people waiting for gender-affirming treatment

Wider context from the report

“c) The lack of provision of mental health care for those waiting for gender affirming treatment. ”

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

Delays in access to gender-affirming healthcare

Wider context from the report

“b) The delays in access to gender affirming healthcare. ”

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

Lack of clarity for Primary Care clinicians supporting young transgender individuals

Wider context from the report

“d) The lack of clarity for clinicians who are in place to support young transgender individuals in Primary Care ”

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

Lack of clarity for mental health clinicians supporting young transgender individuals

Wider context from the report

“e) The lack of clarity for clinicians who are in place to support young transgender individuals in the Mental Health Setting. ”

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

Lack of knowledge and training for managing and offering mental health care to transgender people

Wider context from the report

“a) The knowledge and training for those in the mental health setting for managing and offering care to those in the transgender community. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Author a specific transgender policy document.

Verbatim wording from the response

“RCGP has been concerned regarding the support and services for transgender individuals for many years. In this regard we have worked with NHS England and equivalent organisations in Devolved Nations, with the General Medical Council and others over this time to improve the knowledge and understanding of the needs of these patients. This has included specific e learning packages which are available on our website as well as authoring a specific transgender policy document. Specifically, our recommendations are (see - https://www.rcgp.org.uk/representing-you/policy-areas/transgender-care)”

Source location

Response from Royal College of Genereal Practitioners
Page 1 · response
Published 11 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

Participate in the current review led by a former Royal College of Paediatrics and Child Health president.

Verbatim wording from the response

“It is worth noting that RCGP has been represented at the current review being undertaken by Professor ████████, Former President of the Royal College of Paediatrics and Child Health and our understanding is that we do not expect any change in the view that such individuals need timely access to specialist care and that general practitioners would not be expected to make decisions on treatment. With regard to adult patients, RCGP is supportive of potential plans by NHS England to have a system of regional hubs whereby guidance and support can be sought and especially in wider aspects of care such as sexual health, mental health support and safeguarding as well as prescribing.”

Source location

Response from Royal College of Genereal Practitioners
Page 3 · response
Published 11 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 specific transgender-care e-learning packages on the RCGP website.

Verbatim wording from the response

“RCGP has been concerned regarding the support and services for transgender individuals for many years. In this regard we have worked with NHS England and equivalent organisations in Devolved Nations, with the General Medical Council and others over this time to improve the knowledge and understanding of the needs of these patients. This has included specific e learning packages which are available on our website as well as authoring a specific transgender policy document. Specifically, our recommendations are (see - https://www.rcgp.org.uk/representing-you/policy-areas/transgender-care)”

Source location

Response from Royal College of Genereal Practitioners
Page 1 · response
Published 11 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 innovative waiting-list reduction and patient-support measures, including nurse-led triage and peer-support worker roles.

Verbatim wording from the response

“and surgical treatments.” We are working with NHS England and other providers to develop innovative ways of reducing the waiting list and providing support to patients while on the waiting list; this includes the development of new roles including nurse led triage and peer support workers. While, sadly, this extra workstream will not have had an impact on this case, we believe it will have a significant impact on those waiting for care within the clinic in the future.”

Source location

Response from Travistock and Portman NHS Foundation Trust
Page 2 · response
Published 11 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

Share the strengthened transgender-support policy through the staff Communications e-bulletin.

Verbatim wording from the response

“We recognise the need to work effectively with community and third sector organisations to enable appropriate and effective signposting. One way in which we do this is through our involvement with the Adult Mental Health Alliance, bringing together experts from across the sector and presenting an opportunity to share ideas around improving care pathways for young transgender individuals. The Trust has a Supporting People who are Trans Policy which contains an extensive list of third sector organisations. Following the meeting with Alice’s parents, the Trust is reviewing, and adding to, this list of organisations. The strengthened policy will be shared in the Communications e-bulletin sent to all staff and incorporated into the mandatory training offer.”

Source location

Response from Surrey and Borders Partnership NHS Foundation Trust
Page 2 · response
Published 11 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

Incorporate the strengthened transgender-support policy into the mandatory training offer.

Verbatim wording from the response

“We recognise the need to work effectively with community and third sector organisations to enable appropriate and effective signposting. One way in which we do this is through our involvement with the Adult Mental Health Alliance, bringing together experts from across the sector and presenting an opportunity to share ideas around improving care pathways for young transgender individuals. The Trust has a Supporting People who are Trans Policy which contains an extensive list of third sector organisations. Following the meeting with Alice’s parents, the Trust is reviewing, and adding to, this list of organisations. The strengthened policy will be shared in the Communications e-bulletin sent to all staff and incorporated into the mandatory training offer.”

Source location

Response from Surrey and Borders Partnership NHS Foundation Trust
Page 2 · response
Published 11 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

Review and expand the third-sector organisation list in the Supporting People who are Trans Policy.

Verbatim wording from the response

“We recognise the need to work effectively with community and third sector organisations to enable appropriate and effective signposting. One way in which we do this is through our involvement with the Adult Mental Health Alliance, bringing together experts from across the sector and presenting an opportunity to share ideas around improving care pathways for young transgender individuals. The Trust has a Supporting People who are Trans Policy which contains an extensive list of third sector organisations. Following the meeting with Alice’s parents, the Trust is reviewing, and adding to, this list of organisations. The strengthened policy will be shared in the Communications e-bulletin sent to all staff and incorporated into the mandatory training offer.”

Source location

Response from Surrey and Borders Partnership NHS Foundation Trust
Page 2 · response
Published 11 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 co-produced mandatory, age-specific training for staff supporting transgender people, including clinicians working with under-18s and young adults.

Verbatim wording from the response

“Together with the Chief Nursing Officer, I met with Alice’s parents in December 2023 to discuss the steps that the Trust can take to implement learning from Alice’s death and the subsequent inquest. This included discussion about a mandatory training package for all staff which will help them in their approach with people from the transgender community. Recognising the importance of consultation with those with lived experience and their families, ████████ have kindly agreed to co-produce this with the Trust and other relevant external agencies. We would like to thank them for the information they have already sent us around organisations we may wish to work with. We also acknowledge that, for the training to remain impactful, it will require regular review and update.”

Source location

Response from Surrey and Borders Partnership NHS Foundation Trust
Page 1 · response
Published 11 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

Distribute guidance to primary-care professionals on CYP gender services, relevant learning modules, and waiting-list support resources.

Verbatim wording from the response

“Additionally, with the support of NHS England’s Medical Director for Primary care, a set of guidance will be distributed for general practitioners and other primary care professionals providing information on the CYP Gender Services, access to learning through the MindEd modules (see above) and signposting other resources while patients remain on the waiting list.”

Source location

Response from NHS England
Page 7 · response
Published 11 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

Implement an enhanced risk-assessment approach with local CYP mental health services for children and young people on the national waiting list.

Verbatim wording from the response

“In order to strengthen further the approach to risk mitigation on the waiting list, NHS England is now in the process of implementing an enhanced risk assessment approach with local mental health services through an initiative that is being managed jointly by the NHS National Director for Mental Health and the NHS National Medical Director for Specialised Services. It is planned that from April 2024 all local mental health services for children and young people across England will have arrangements in place to offer appointments to children and young people on the national waiting list for CYP Gender Services, and their families.”

Source location

Response from NHS England
Page 7 · response
Published 11 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 NHS England contracts.

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 4 · response
Published 11 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

Provide additional funding to local mental health teams to deploy resources for timely waiting-list risk-assessment access.

Verbatim wording from the response

“Additional funding will be made available to local mental health teams by NHS England so that each mental health service can identify and deploy additional resource, thereby ensuring that local mental health service provision is not denuded and in order to secure timely access to the service.”

Source location

Response from NHS England
Page 7 · response
Published 11 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

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

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 5 · response
Published 11 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

Reconfigure children’s and young people’s specialised gender services, including closing the Tavistock service and establishing around seven regional services.

Verbatim wording from the response

“NHS England is currently leading a significant programme of work to reconfigure the provision of specialised services for children and young people with gender incongruence, in line with the interim recommendations of the independent Cass Review. This involves the managed closure of the current CYP children’s gender service at the Tavistock and Portman NHS Foundation Trust on 28 March 2024, and the establishment of around seven new regional services by 2026, the first of which are planned to become operational in April 2024 through collaboratives hosted by Great Ormond Street Hospital for Children NHS Foundation Trust and Alder Hey Children’s NHS Foundation Trust.”

Source location

Response from NHS England
Page 6 · response
Published 11 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

Commission and deliver an accredited postgraduate training programme in gender identity healthcare.

Verbatim wording from the response

“first accredited post-graduate training course in gender identity healthcare; the course began in 2020. Although aimed primarily at health professionals who wish to specialise in gender identity healthcare, individual modules are also suitable for other healthcare professionals who work in local settings and who wish to improve the experience of individuals with gender dysphoria in using generalist services intended for the whole population including mental health services or primary care services: https://www.rcplondon.ac.uk/education-practice/courses/gender-identity-healthcare-credentials-gihn 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 3 · response
Published 11 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 and fund five pilot services to expand gender dysphoria clinical capacity and reduce established-clinic waiting lists.

Verbatim wording from the response

“NHS England has sought to address the serious imbalance between the demand for gender dysphoria services and the shortage in trained clinicians who are available to train and work in this field, which has led to long waiting times. In 2019/20, NHS England re-procured the provision of gender dysphoria services for adults. The expectation was that the re-procurement would bring forward new entrants and enable NHS England to increase the number of GDCs, and funding was identified by NHS England for that purpose. That expectation was not met. In fact, no new providers came forward from either the NHS or independent sector. All of the seven existing GDCs submitted bids and award of renewal of contract was confirmed for all of them. In the circumstances, NHS England sought to grow capacity in an alternative way. Five pilot services were developed.”

Source location

Response from NHS England
Page 3 · response
Published 11 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

Run the tender for a substantive Cheshire and Merseyside gender 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 4 · response
Published 11 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

Decisions on specific therapy, including medication, are specialist responsibilities outside general practitioners’ scope of practice.

Verbatim wording from the response

“A particular focus from members has been the continuing very long waiting lists for access to specialist advice and care. This has been especially a concern regarding children and young people where the waiting lists are frequently over 2 years in duration but also for adult patients, where access can be very difficult. The RCGP’s view is that for Children and Young people, GPs can provide holistic general care and support to the individual and their family, however decisions on whether or when to provide specific therapy such as medication is a specialist area of responsibility and outwith the scope of practice of general practitioners.”

Source location

Response from Royal College of Genereal Practitioners
Page 2 · response
Published 11 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

Mental health care for GIC patients is the responsibility of GPs or secondary mental health services, with the GIC sharing information as required.

Verbatim wording from the response

“It is important to note that the condition the GIC is commissioned to treat is Gender Incongruence, coded HA60 in the International Classification of Diseases version 11; this is ‘a condition related to sexual health’ and not a mental health diagnosis. Accordingly, the provision of mental health care for those both on the waiting list, and those who are actively being treated by the GIC, continues to be dealt with either through their GP or secondary mental health services, as was the case for Ms. Litman. The GIC works closely with colleagues from primary care or secondary mental health services, including sharing information to facilitate patient care as required.”

Source location

Response from Travistock and Portman NHS Foundation Trust
Page 2 · response
Published 11 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 service capacity could not be commissioned because specialist clinical staff were unavailable amid substantially increasing demand.

Verbatim wording from the response

“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. 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 11 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

Local mental health service commissioning, including training and education, rests with Integrated Care Boards rather than NHS England.

Verbatim wording from the response

“Commissioning responsibility for local mental health services rests with Integrated Care Boards (ICB) 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. We anticipate the other recipients of your Report will address these concerns in more detail.”

Source location

Response from NHS England
Page 2 · response
Published 11 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.16

  1. 1

    Collaborate with NHS organisations, the General Medical Council and others to improve understanding of transgender patients’ needs.

    Stated by Royal College of General PractitionersStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
  2. 2

    Continue engaging NHS England commissioners to develop provisions proposed in the Report.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023.
  3. 3

    Work with third-sector partners to increase awareness of heightened risks for transgender people awaiting gender-affirming treatment.

    Stated by Surrey and Borders Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 December 2023.
  4. 4

    Build wider connections with seldom-heard communities, including transgender people, to inform future Trust developments.

    Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023.
  5. 5

    Implement a standardised framework for involving and co-producing services with people using services, families and carers.

    Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
  6. 6

    Raise awareness within Trust services of heightened risks for people awaiting gender-affirming treatment and improve responsiveness to their needs.

    Stated by Surrey and Borders Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 December 2023.
  7. 7

    Implement the Gender Experience Summary process for all CYP gender-service waiting-list patients.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
  8. 8

    Consult publicly on the proposed CYP gender-service referral pathway and make a final decision.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023.
  9. 9

    Agree a process for Child Death Overview Panels to alert NHS England about deaths of children and young people with gender distress.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
  10. 10

    Draft a service specification to restrict CYP gender-service referrals to tertiary pathways through general paediatric and CYP mental health services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
  11. 11

    Change NCMD reporting and supplementary suicide forms to better identify gender distress and specialist-service waiting or treatment status.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
  12. 12

    Review waiting-list referrer forms for clinical risk and provide risk-mitigation advice to patients’ GPs.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
  13. 13

    Improve the NCMD alert system to notify NHS England when a child or young person with gender distress dies by probable suicide.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023.
  14. 14

    Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share 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 11 December 2023.
  15. 15

    Evaluate the Gender Outreach Worker role and share its 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 11 December 2023.
  16. 16

    Commission waiting-list support resources including named professionals, outreach and peer workers, support lines, and pre-assessment workshops.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.

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

  1. 1

    Some concerns about Alice’s care are better addressed by the Tavistock clinic and clinicians directly involved at Surrey and Borders NHS Trust.

    Stated by NHS EnglandRedirects 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

Collaborate with NHS organisations, the General Medical Council and others to improve understanding of transgender patients’ needs.

Verbatim wording from the response

“RCGP has been concerned regarding the support and services for transgender individuals for many years. In this regard we have worked with NHS England and equivalent organisations in Devolved Nations, with the General Medical Council and others over this time to improve the knowledge and understanding of the needs of these patients. This has included specific e learning packages which are available on our website as well as authoring a specific transgender policy document. Specifically, our recommendations are (see - https://www.rcgp.org.uk/representing-you/policy-areas/transgender-care)”

Source location

Response from Royal College of Genereal Practitioners
Page 1 · response
Published 11 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

Continue engaging NHS England commissioners to develop provisions proposed in the Report.

Verbatim wording from the response

“The Trust will continue to engage with its commissioners, NHS England, to develop provisions proposed in your Report.”

Source location

Response from Travistock and Portman NHS Foundation Trust
Page 2 · response
Published 11 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

Work with third-sector partners to increase awareness of heightened risks for transgender people awaiting gender-affirming treatment.

Verbatim wording from the response

“The Trust is also part of the Surrey Suicide Prevention Strategy [Appendix GW1], which is a multi-agency collaboration between health, local government, people with lived experience and the voluntary/community sector. Within the priorities for 2023-2026 is the improvement of emotional wellbeing in particular groups, including the LGBTQI+ community. Our Chief Nursing Officer co-chairs the Surrey Suicide Prevention Strategy Group with our Public Health colleagues. In addition, we are a member of the Surrey Adult Mental Health Alliance alongside several third sector community organisations providing emotional and wellbeing support. In learning from the inquest touching upon Alice’s death, we will work with our third sector partners to increase their awareness of the heightened risk to those in the transgender community awaiting gender affirming treatment.”

Source location

Response from Surrey and Borders Partnership NHS Foundation Trust
Page 2 · response
Published 11 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

Build wider connections with seldom-heard communities, including transgender people, to inform future Trust developments.

Verbatim wording from the response

“A key aspect of the Trust’s five-year strategy, announced in July 2023, is to strengthen involvement with people who use services, their families, and carers. It is our aim that co-production is part of everyday practice at every level across the Trust. In March 2023, the Experience and Participation Team established a working group with people who use our services, their families and carers to develop a co-production framework. This framework will enable the Trust to have a standardised approach to involving and co-producing services across the Trust. As part of this, the Trust is working to build wider connections with our seldom heard communities, including those who are transgender to ensure any new developments across the Trust meet the needs of the people who use our services.”

Source location

Response from Surrey and Borders Partnership NHS Foundation Trust
Page 2 · response
Published 11 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

Implement a standardised framework for involving and co-producing services with people using services, families and carers.

Verbatim wording from the response

“A key aspect of the Trust’s five-year strategy, announced in July 2023, is to strengthen involvement with people who use services, their families, and carers. It is our aim that co-production is part of everyday practice at every level across the Trust. In March 2023, the Experience and Participation Team established a working group with people who use our services, their families and carers to develop a co-production framework. This framework will enable the Trust to have a standardised approach to involving and co-producing services across the Trust. As part of this, the Trust is working to build wider connections with our seldom heard communities, including those who are transgender to ensure any new developments across the Trust meet the needs of the people who use our services.”

Source location

Response from Surrey and Borders Partnership NHS Foundation Trust
Page 2 · response
Published 11 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

Raise awareness within Trust services of heightened risks for people awaiting gender-affirming treatment and improve responsiveness to their needs.

Verbatim wording from the response

“We recognise concerns around the lack of mental health provision for those awaiting gender affirming treatment and note that you have written to NHS England in this regard. In relation to our own services, we are committed to raising awareness of the heightened risk associated with those waiting for gender affirming treatment and ensuring that our services are more responsive to the needs of the people they support.”

Source location

Response from Surrey and Borders Partnership NHS Foundation Trust
Page 2 · response
Published 11 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

Implement the Gender Experience Summary process for all CYP gender-service waiting-list patients.

Verbatim wording from the response

“However, in many cases the information on file was too limited to achieve an effective desk-top review, with many elements of the referrer form not completed by the referrer. As a result, a new approach has been implemented by NHS England – a process where the child and parents complete a ‘Gender Experience Summary’ (GES) which aims to provide more meaningful detail of the circumstances of the individual. All waiting list patients are now being asked to complete the GES form.”

Source location

Response from NHS England
Page 7 · response
Published 11 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

Consult publicly on the proposed CYP gender-service referral pathway and make a final decision.

Verbatim wording from the response

“NHS England is currently out to public consultation on the proposal and will make a final decision by the spring of 2024.”

Source location

Response from NHS England
Page 6 · response
Published 11 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

Agree a process for Child Death Overview Panels to alert NHS England about deaths of children and young people with gender distress.

Verbatim wording from the response

“It may assist the Coroner to know that as an outcome of recent discussions led by NHS England’s National Clinical Director for Children and Young People’s Mental Health and senior representatives of the National Child Mortality Database (NCMD):”

Source location

Response from NHS England
Page 7 · response
Published 11 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

Draft a service specification to restrict CYP gender-service referrals to tertiary pathways through general paediatric and CYP mental health services.

Verbatim wording from the response

“As part of the transition to the new provider model the national waiting list for children and young people who are waiting for access to a specialist service is now held by NHS Arden & GEM Commissioning Support Unit on behalf of NHS England. As at November 2023 there were 5,662 patients on this waiting list. Following discussion with the new service providers and presidents of relevant Royal Colleges NHS England has drafted a service specification to change the referral pathway to move the CYP Gender service into tertiary access only with only two referral pathways via NHS general paediatric services and CYP mental health services. This will ensure that primary care and secondary care clinicians take a holistic view of each child or young person, to identify mental health needs including risk assessment for self-harm and suicide.”

Source location

Response from NHS England
Page 6 · response
Published 11 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

Change NCMD reporting and supplementary suicide forms to better identify gender distress and specialist-service waiting or treatment status.

Verbatim wording from the response

“• Changes have been made to the NCMD reporting form and supplementary suicide form to better identify children and young people with gender distress and those waiting/open to NHS/private provider for treatment.”

Source location

Response from NHS England
Page 8 · response
Published 11 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

Review waiting-list referrer forms for clinical risk and provide risk-mitigation advice to patients’ GPs.

Verbatim wording from the response

“In order to address the concern of unmitigated clinical risk of individuals on the waiting list NHS England has been supported by clinicians with expertise in younger people with gender incongruence at Nottinghamshire Healthcare NHS Foundation Trust working in collaboration with that provider’s CYP mental health clinicians. An MDT convened for this purpose has conducted a desk-top review of individual referrer forms held through the waiting list (which had been transferred from Tavistock and Portman NHS Foundation Trust), and this has identified risk of self-harm in around 40% of”

Source location

Response from NHS England
Page 6 · response
Published 11 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

Improve the NCMD alert system to notify NHS England when a child or young person with gender distress dies by probable suicide.

Verbatim wording from the response

“• Improvements are being made to the NCMD alert system to NHS England when a child or young person with gender distress dies by probable suicide (whether or not they on the waiting list for CYP Gender Services).”

Source location

Response from NHS England
Page 7 · response
Published 11 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 all Prevention of Future Deaths reports through the Regulation 28 Working Group and share 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 8 · response
Published 11 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

Evaluate the Gender Outreach Worker role and share its 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 4 · response
Published 11 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

Commission waiting-list support resources including named professionals, outreach and peer workers, support 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 of 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 4 · response
Published 11 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 about Alice’s care are better addressed by the Tavistock clinic and clinicians directly involved at Surrey and Borders NHS Trust.

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, and the healthcare professionals directly involved in Alice’s care at Surrey and Borders NHS Partnership NHS Trust. We note that you have also addressed this Report to these NHS providers who no doubt will respond directly.”

Source location

Response from NHS England
Page 1 · response
Published 11 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