Failures ‘by all services’ involved in trans teen’s care likely contributed to his death, inquest finds

A jury inquest has concluded that systemic failures by services supporting Jason Pulman, a trans teenager who took his own life, could have contributed to his death.

Warning: The following article contains discussions about mental health, self-harm and suicidal ideation.

15-year-old Jason Pulman was found dead in Hampden Park, Eastbourne on 19 April 2022, the Independent reports. During a five-day-inquest at Hastings Coroner’s Court, jurors that Jason had struggled with his mental health, began self harming aged 13 and had later made a suicide attempt.

Jurors also heard how Jason’s parents – Emily and Mark – last saw their son on April 18 at 7.30pm; the following morning they found his door tied shut and his bedroom window open.

They reported Jason’s disappearance to police, but it was classed as ‘medium risk’ as officers believed there was “nothing to suggest immediate risk of suicide”.

Speaking to PA about the police response, Emily Pulman said: “I would repeatedly call them and we just got told someone will be with you when they’re available and then we didn’t hear anything until 7.30pm which was an hour before Jason took his life so it was completely inadequate.

“I strongly believe that if he was listened to he would have been found.”

The jury concluded that there were failings by all services involved in Jason Pulman’s care, including the police, who were found to have inadequately responded to his disappearance.

The jury said: “Jason’s emotional and mental health needs were inadequately assessed and provided for. Systemic communication and administrative failures by all of the organisations involved in his care, with the exception of Bexhill College, may possibly have been contributing factors.

“We refer in particular, to the fact that the police responded inadequately to the missing person report and failed to keep the family informed, bearing in mind Jason was a child with a history of complex needs.”

Broadcaster India Willoughby, who is transgender, praised ITV News for covering the story, and highlighted the long waits that transgender people currently face for care in the United Kingdom.

Well done @ITVNews . The story of Jason – a trans teenager who killed himself after waiting two years for treatment. Ddn’t even get an appointment. More cases like this are INEVITABLE due to Cass. ⁦@wesstreeting⁩ ⁦@YvetteCooperMP⁩ ⁦@NHSEngland⁩ #CassKillsKids pic.twitter.com/pI7dsKtQ33

— India Willoughby (@IndiaWilloughby) April 12, 2024

The release of the findings of Jason Pulman’s inquest closely follows a 9 April inquest into the death of 17-year-old trans boy Charlie Millers, 17, who died at Prestwich Hospital, in Manchester, on 2 December 2020. 

26-month wait for his first appointment

Jason came out as transgender aged 14 and was referred to the Gender Identity Development Service (GIDS) in London, a service provided by the Tavistock Clinic, in February 2020 by his GP. After following up on its progress in October that year, he was reportedly told there was a 26-month wait for his first appointment.

The Gender Identity Development Service at the Tavistock was a groundbreaking institution when it was established as NHS England’s sole provider of care for trans and gender-questioning young people in 1989.

But as the years wore on, waiting lists spiralled, with young people forced to wait years for a specialist.

Approximately 210 trans youth were referred to Tavistock’s GIDS in the 2011-12 financial year. Just 10 years later, that number had risen to 3,500 people, in 2021-2022. 

The court heard that Jason became increasingly frustrated at the wait and Mr Pulman said that the teen had appeared to have “given up” in his behaviour to his family and himself in the months leading up to his death.

Mr Pulman spoke to PA news agency about the teen’s Gids referral saying: “In his world, that was the answer, in his world we don’t know whether that was the whole answer, but to him that appointment was everything.

“He was driving himself crazy waiting for that appointment because when was it coming? When was he going to get help?”

Cass Review

The inquest’s findings come just days after the Cass Review into children’s gender care was published.

NHS England commissioned the independent review, headed by Dr Hilary Cass in 2020, to address the rise in referrals at the Tavistock Clinic.

The review recognised shortfalls in the workforce, saying that it was distressing that people are “sitting on a waiting list, not knowing what’s going to happen to them, not knowing where to get information, and feeling really isolated”.

Cass also noted that a “considerable amount of research” had been published around clinical decision-making for youth gender services but that evidence suggest that the work is of “poor quality” and unreliable.

The final report expands the recommendations made in an interim report released in March 2022, which called for a decentralised approach to care provision in England in the form of regional hubs.

Police response

A Sussex Police spokesman told The Independent: “Our sincere condolences remain with Jason’s family following their tragic loss.

“Our service fell below the standards expected and we accept the coroner’s findings. Following a full internal review into the circumstances leading to Jason’s death, a senior officer met with Jason’s family in person to formally apologise.

“A multi-agency working group was launched to share learning and put measures in place to ensure vulnerable children with complex mental health needs receive the best possible service.”

Readers affected by the issues raised in this story are encouraged to contact Samaritans free on 116 123 (www.samaritans.org) or Mind on 0300 123 3393 (www.mind.org.uk). Readers in the US are encouraged to contact the National Suicide Prevention Line on 1-800-273-8255.