Sophie Williams

Barnet Enfield and Haringey Mental Health NHS Trust 
Trust Headquarters 
St Ann’s Hospital 
St Ann’s Road 
London N15 3TH 

PRIVATE AND CONFIDENTIAL 
For the attention of: 
His Majesty’s Assistant Coroner  
North London Coroner’s Court 
29 Wood Street, 
Barnet 
EN5 4BE 

Date: 20 April 2023 

Dear Sir, 

This letter forms the Barnet Enfield and Haringey Mental Health NHS Trust’s (“the Trust”) response 
to the applicable sections of the Prevention of Future Deaths Report following the hearing touching 
the death of Sophie Gwen Williams, held on 17th -19th January 2023 before Assistant Coroner Taylor 
at North London Coroner’s Court. 

"Matters of concern, for trans persons on a Personality Disorder Pathway, arise out of a provision 
of the following: 

A. by local NHS Trusts.

1. The assignment over a single, named point of contact, available (aside from holiday

and sickness absence) when needed by the patient

2.

the training of staff assigned to provide care and treatment to such persons, both at
the time of their appointment, and annually thereafter, with a focus on:

a. The needs of the trans persons
b. gender affirming care
c. dissociation and psychosis

3. Scrutiny of the delivery and implementation of such training, by way of Quality

Assurance

1 

 4.  The absence from the assessment protocol of a provision to ensure that a full 

account is taken of: 

a.  any previous diagnosis and treatment 
b.  all other information (including information from those who have previously 

c. 

provided care and treatment to the patient)available to the member of the 
team 
the risks to (and effects on) patients with (or likely to develop) conditions of 
dissociation and/or psychosis including, in particular, the risks of self-harm 
and loss of life 

d.  the views of those who are close to the patient, including the patient’s carers, 
family, and advocates (both formal and informal), who should be contacted, 
for that purpose.” 

The above matters were considered, and the steps taken by the Trust are outlined below. 

1.  The assignment of a single, named point of contact, available (aside from holiday and 

sickness absence) when needed by the patient. 

Service Users on the Personality Disorder pathway are notified of a named contact person within the 
team at the point of initial assessment. From 20th March 2023, all service users will be given a named 
point of contact from the point of referral. This name will be provided to all service users in the referral 
acknowledgement letter sent prior to any first assessment 

2.  the training of staff assigned to provide care and treatment to such persons, both at 

the time of their appointment, and annually thereafter, with a focus on: 

a.  The needs of the trans persons 
b.  gender affirming care 
c.  dissociation and psychosis  

The Personality Disorder Service received training in ‘Working with trans people and gender affirming 
care’ on 7th December 2022 which 95% of the Personality Disorder Team attended; this was delivered 
in a workshop format by the Personality Disorder Pathway Lead who is a senior social worker and 
the Mentalisation-Based Therapist (MBT).  

Further training has been scheduled for the team on 3rd of May 2023 on ‘diversity Identity training’, 
covering:  awareness  of diverse  identity; micro  affirmation;  how  to  case note transgender,  intersex 
and gender dysphoria, inequalities that transgender people experience across a range of domains.  
Attendance at the training sessions will be expected of all team members. Those not attending will 
be logged and followed up accordingly.  

2 

 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 3.  Scrutiny of the delivery and implementation of such training, by way of Quality 

Assurance  

Training is monitored at monthly meetings with line management staff and training sessions held on 
the first Wednesday of each month. Clinical supervision is provided to all staff on a monthly basis 
where  learning  from  training  will  be  discussed.  Staff  within  the  team  are  able  to  access  case 
discussions  and  outcomes  entered  onto  the  electronic  clinical  records  system  (Rio)  with  training 
compliance monitored at annual staff appraisals. 

4.  The absence from the assessment protocol of a provision to ensure that a full 

account is taken of: 

a.  any previous diagnosis and treatment 

The personality disorder initial assessment protocol and guide includes the explicit expectation, that 
when assessing conditions, staff also examine previous treatments and diagnosis referred to in their 
records, and done so in consultation with the service user. 

b.  all other information (including information from those who have previously 
provided care and treatment to the patient) available to the member of the 
team 

Records of previous engagements and treatments will be sought from within the Trust and also from  
external clinical records to inform and develop the assessment and treatment plan for each service 
user. Information provided by the service user and from those individuals providing support (where 
appropriate and with the permission of the service user) will inform the process of treatment .  

c.  the risks to (and effects on) patients with (or likely to develop) conditions of 

dissociation  

Within  the  assessment  protocol  and  the  guide,  there  are  specific  parameters  referring  to  the 
assessment  of  dissociation  and  psychosis .In  particular, the  need  for those  assessing to  consider  
any possible risk from self-harm and/or suicidality .  

d.  the views of those who are close to the patient, including the patient’s carers, 
family, and advocates (both formal and informal), who should be contacted, 
for that purpose. 

From 20th March 2023, the assessment protocol requires all clinicians to ask the service user to invite 
family members, carers, and those from whom they receive support from, to attend the assessment; 
this  ensures that  the  process  of  delivering  treatment  proceeds  in  the  most  appropriate  way  .  The 
contact details of carers, supporters, family and advocates, including the nature of their involvement, 
will be uploaded onto the Rio as part of this process. 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The  Trust  is  grateful  for  the  opportunity  to  demonstrate  the  enhanced  procedures  its  developed 
following  Sophie’s  passing.  Further  learning  and  training  is  being  provided  to  staff  with  regular 
reviews; covering the needs of trans people, the provision of gender affirming care and patients with 
dissociation and/or psychosis.  

Finally, the Trust offers its sincere condolences to the partner, friends and family of Sophie. In doing 
so, the Trust remains committed to the delivery of patient-centric and holistic care to its service users. 

We hope the above has addressed the matters raised in the Prevention of Future Deaths report. 

Yours Sincerely  

Director of Nursing – Quality Governance  
Barnet, Enfield and Haringey NHS Trust  

4

Mr J Taylor 
HM Assistant Coroner 
North London 
St Pancras Coroner's Court, 
Camley Street, 
London 
N1C 4PP 

Dear Coroner, 

National Medical Director 
NHS England 
Wellington House 
133-155 Waterloo Road
London 
SE1 8UG 

24 May 2023 

Re: Regulation 28 Report to Prevent Future Deaths – Ms Sophie Gwen Williams 
who died on 20 May 2021 

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  27 
February  2023  concerning  the  death  of  Ms  Sophie  Williams  on  20  May  2021.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Sophie’s family and loved ones. NHS England are 
keen  to assure  the  family  and  the  coroner  that  the  concerns  raised  about Sophie’s 
care have been listened to and reflected upon. 

I am grateful for the further time granted to respond to your Report, and I apologise for 
any  anguish  this  delay  may  have  caused  Sophie’s  family  or  friends.   I  realise  that 
responses to Coroner Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones and appreciate 
this will have been an incredibly difficult time for them. 

The Trusts directly involved in Sophie’s care are better placed to answer many of the 
concerns raised in your Report, and NHS England have been sighted on the response 
from  The  Tavistock  and  Portman  NHS  Foundation  Trust.  NHS  England  are  the 
commissioner  for  specialised  gender  dysphoria  services,  and  we  have  therefore 
focused  on  the  Matters  of  Concern  relating  to  clinics  providing  gender  identity 
treatment, where we are in a position to address the concerns raised. 

Provision  of  support  for  patients  from  clinics  providing  gender-identity 
treatment  

NHS England has directly supported NHS Gender Dysphoria Clinics in developing and 
establishing  forms  of support  for  patients  while  they  remain  on  the  waiting  list. In a 
recent  discretionary  investment  exercise,  NHS  England  sought  proposals  from 
Gender Dysphoria Clinics that would either increase the number of clinical staff in their 
service  or,  in  recognition  of  the  workforce  constraints,  would  improve  the  patient 
experience in other ways, such as support while on the waiting list. While not certain 
it would have changed the outcome in this case, 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:  

•  Screening  at  referral  so  that  dedicated  Named  Professionals  can  work  with 
patients  and  GPs  to  address  complex  needs,  and  for  signposting  to  local 
services and local support groups in less complex cases. 

•  Gender Outreach Workers and Peer Support Workers who meet with patients 

in local community settings.  

•  Advice  and  support  lines  delivered  by  third-sector  support  organisations with 

NHS funding. 

•  Pre-Assessment workshops with people on a waiting list, providing them with 
information  on  assessment,  intervention  pathways  and  community-based 
support.  

The  Gender  Outreach  Worker  role  (referred  to  above)  is  directly  commissioned  by 
NHS England and is being formally evaluated by a host Gender Dysphoria Clinic so 
that  learning  can  be  shared  across  other  NHS  Gender  Dysphoria  Clinics  (the 
evaluation  will  be  delivered  to  NHS  England  in  September  2023).  The  role  has  a 
number of potential positive benefits: 

•  Patients  are  signposted  to  local  services  for  support  in  housing  and 
employment, as well as mental and physical health needs – helping to ensure 
that such needs do not go un-met. 

•  Providing support at an earlier stage may mean reduced need for primary and 
secondary  care  services  further  along  the  pathway  including  A&E  and  crisis 
services. 

•  Patients are better informed and prepared for the process of assessment and 

diagnosis once they are seen by the Gender Dysphoria Clinic 

•  Demands upon administrative and clinical staff are reduced, including the need 

to manage distress, which frees up time for patients in the service. 

•  More tailored support can be offered to patients while on a waiting list, such as 
those who are particularly vulnerable or who may have particular needs (age; 
disability; ethnicity; health needs). 

Additionally,  NHS  England  has  funded  and  established  four  new  adult  Gender 
Dysphoria Services in novel settings (primary care and sexual health clinics) as part 
of piloting activity since 2020, with the ambition of increasing clinical capacity through 
a  newly  trained  clinical  workforce  (more  detail  is  provided  below).  One  of  the  pilot 
services (in Greater Manchester) is evaluating the role of Care Navigator, which is a 
non-clinical role that provides direct peer-support to patients from the point of referral 
including  support  in  accessing  local  health  services.  Most  of  the  pilot  services  are 
testing  new  delivery  models  that  serve  a  defined  local  geography  and  population 
(Greater Manchester; East England; Cheshire and Merseyside) and this local model 
is proving to be helpful in establishing a community presence for these services, which 
facilitates the provision of integrated community support to patients on the local waiting 
list. The final evaluation of the Greater Manchester pilot, including the Care Navigator 
role, is expected in imminently. 

  
 
 
 By    November  2023,  NHS  England  will  have  disseminated  amongst  all  NHS 
commissioned Gender Dysphoria Clinics a description of existing helplines used by 
Gender  Dysphoria  Services  –  and  a  description  of  other  forms  of  support 
commissioned  by  NHS  England  -  so  that  an  assessment  of  ‘best  practice’  may  be 
made by Gender Dysphoria Clinics in forming their response to HM Coroner’s finding 
of concern about the lack of this support for the benefit of patients on their waiting lists.   

Provision of mental health care for those patients on waiting lists 

Commissioning  responsibility  for  local  mental  health  services  rests  with  Integrated 
Care  Boards  (ICB),  rather  than  NHS  England.  The  make-up  of  local  services  will 
therefore differ according to each ICB’s commissioning strategy. Also, an individual’s 
GP plays an important role in supporting patients who have physical and mental health 
support needs, including referral to local NHS services (being mindful that evidence 
shows  that  transgender  and  non-binary  people  are  more  likely  to  experience  poor 
mental  health  than  the  general  population).  The  NHS  Long  Term  Plan  for  Mental 
Health describes an expansion of local mental health care so that more people can 
access treatment by increasing funding at a faster rate than the overall NHS budget – 
and by at least £2.3bn a year by 2023/24. Since 2019/20 every local health system 
has received funding to deliver multi-agency suicide prevention services, and mental 
health crisis teams have been strengthened. 

Descriptions  of  support  and  helplines  being  disseminated  to  NHS  commissioned 
Gender Dysphoria Clinics will include mental health support. This will  
include  direct  wellbeing  support  from  peer-support  workers  and  Gender  Outreach 
Workers.  

The  setting  and  implementation  (where  practicable)  of  criteria  for  deciding 
whether (and, if so, which) patients (other than those terminally ill) should be 
given priority for receiving gender-identity treatment. 

Currently,  based  on  expert  clinical  opinion,  patients  are  seen  based  on  the  referral 
date to a Gender Dysphoria Clinic.  This is considered an appropriate process in that 
if patients are triaged based on risk, this could negatively impact patients who do not 
exhibit  significant  risk  and  who  have  been  waiting  longest.  In  the  absence  of  firm 
evidence, the solution is likely to be improving access to more timely healthcare for 
individuals with gender dysphoria.  

The  number  of  referrals  into  NHS  gender  dysphoria  services  has  increased 
significantly,  and  it  has  not  been  possible  to  grow  the  specialist  workforce  at  the 
required  rate  to  keep  pace  with  demand.  In  2019,  NHS  England  ran  a  national 
procurement exercise for both surgical and non-surgical services, in an effort to attract 
additional providers to start offering gender dysphoria services. Unfortunately, no new 
providers came forward, which reflects the difficulty in attracting, training, and retaining 
clinicians to work in this area of healthcare. For that reason, NHS England worked with 

 
 
 
 the  Royal  College  of  Physicians  to  design  and  fund  the  UK’s  first  Gender  Identity 
Healthcare Credential, which since 2020 has provided a route for clinicians to train in 
the  specialty  of  gender  dysphoria  healthcare.  In  addition,  NHS  England  has 
significantly increased financial investment in the Gender Dysphoria Clinics in recent 
years, to recruit additional clinicians where possible.  

Additionally,  the  four  new  pilot  services,  referenced  above,  are  testing  how  gender 
dysphoria  healthcare  delivered  by  Gender  Dysphoria  Clinics  could  be  delivered  in 
more local settings, and building a new clinical workforce rooted in primary care and 
sexual health clinics through appropriate professional training. These pilots work to a 
national  service  specification  and  are  being  independently  evaluated.  Positive 
evaluations of the pilots would present an opportunity to roll out the successful models 
of care more widely, thereby increasing assisting with reducing waiting times.  The four 
pilots  currently  in  operation  are  Trans  Plus  in  London  (Chelsea  and  Westminster 
Hospital NHS Foundation Trust), which opened in June 2020, Indigo Gender Service 
in Greater Manchester from December 2020 (managed by GTD Healthcare), CMAGIC 
in Cheshire and Merseyside from February 2021 (Mersey Care NHS Foundation Trust) 
and the East of England Gender Service from June 2021 (Nottinghamshire Healthcare 
NHS  Foundation  Trust,  in  partnership  with  Cambridgeshire  and  Peterborough  NHS 
Foundation Trust). The fifth new service will become operational in 2023 at Sussex 
Partnership NHS Foundation Trust. All of the new services are prioritising patients who 
are on the waiting list of an NHS Gender Dysphoria Clinic. Most of the referrals into 
Trans  Plus  and  the  East  of  England  service  are  taken  from  the  waiting  list  of  the 
Tavistock and Portman NHS Foundation Trust.  

By December 2023, NHS England plans to have commissioned on a substantive basis 
the second new adult Gender Dysphoria Service in Greater Manchester, subject to a 
positive pilot evaluation and tender process.  

Additional matters that may be helpful to HM Coroner 

We note the following that is set out in the incident report prepared by the Tavistock 
and Portman NHS Foundation Trust, regarding Sophie’s case: 

“The patient had then contacted us with the hope that our GIC (Gender Identity Clinic) 
could  honour  the  referral  date  of  the  Belfast  clinic,  thus  not  wait  long  for  their  first 
appointment at our clinic. They were informed that this wouldn’t be possible, and that 
funding needed to be raised in order to be seen at our clinic”.  

From  the  information  available,  it  is  unclear  to  NHS  England  as  to  why  the  Trust 
informed Sophie that funding would need to be identified in order to be seen at the 
Trust’s Gender Dysphoria Clinic. The same incident report prepared by the Trust infers 
that by that time, Sophie had registered with a GP in London. If that is the case, then 
the Trust should have been aware that NHS England had become the 'Responsible 
Commissioner’ for Sophie’s referral to the Trust and that the referral was funded via 
the established contract in place between NHS England and the Trust (source: NHS 
guidance  on  establishing  the  responsible  commissioner;  paras  19.5  and  19.6  that 
describe arrangements for patients who move across UK borders ). While not certain 

 
 
 it  would  have  changed  the  outcome  in  this  case,  NHS  England  will  investigate  the 
circumstances of this matter and ensure that the Trust is aware of, and is following, 
relevant guidance in this regard. 

I would also like to provide further assurances on national NHSE 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. 

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director

Tavistock Centre 

120 Belsize Lane 

London NW3 5BA 

Tel: +44 (0) 207 435 7111 

Website:www.tavistockandportman.nhs.uk 

Mr J. Taylor 
HM Assistant Coroner 
North London Coroner’s Court 

24 April 2023 

Dear Sir 

Inquest touching the death of Sophie Williams
Regulation 28 Response 

I am writing on behalf of The Tavistock and Portman NHS Foundation Trust (‘the Trust’) in 
response to your Report to Prevent Future Deaths made on 27 February 2023, following the 
conclusion of the inquest touching the death of Ms. Sophie Williams. 

At the outset, I would like to reiterate how sorry the Trust was to learn of Ms. Williams’ death. 
It was clear at the inquest how much her family, friends and community felt her loss, and I 
extend my sincere condolences to them. 

The Trust is grateful to you for raising the matters of concern in your Report which you have 
outlined  relate  to  the  services  available  to  patients  who  are  being  treated  by  or  are  on  the 
waiting list to be treated by the Gender Identity Clinic (‘GIC’) at the Trust. 

As set out in the evidence presented by the Trust during the inquest, the role of the GIC is 
detailed in the service specifications published by NHS England for Gender Identity Services 
for  Adults  (Non-Surgical  Interventions).  The  treatment  pathway  commissioned  under  the 
service specification is as follows: 

1.  Referral  to  a  specialist  Gender  Dysphoria  Clinic  (self-referral;  or  by  primary, 

secondary or tertiary care). 

2.  Assessment for gender dysphoria, and diagnosis. 
3.  Individuals who meet the criteria for diagnosis of gender dysphoria related to gender 
incongruence  are  accepted  on  to  the  NHS  care  pathway  and  an  individualised 
treatment plan is agreed. 

4.  Therapeutic  interventions  delivered  by  the  specialist  Gender  Identity  Clinic;  and/or 

referral for interventions with other providers. 

5.  Ongoing review and monitoring during and after interventions. 
6.  Conclusion of contact: discharge to primary care. 

The  service  specification  states  that  “Gender  Dysphoria  Clinics  assess  and  diagnose 
individuals;  directly  provide  some  interventions  and  arrange  for  referrals  to  other  services, 
including for medical and surgical treatments.” The Trust is inevitably restricted to providing 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 those  services  which  it  is  commissioned  to  provide,  which  currently  does  not  include  any 
services for those on the list waiting to be seen at the GIC. 

The Trust however is keen to engage in a dialogue with its commissioners, NHS England, to 
discuss  the  provisions  proposed  in  your  Report  and  whether  these  services  should  be 
commissioned and funded in the future, and thus able to be provided by the Trust or other 
providers. 

to 

treat 

is  Gender 

Incongruence,  coded  HA60 

Addressing  the  specific  concerns  at  5B  of  your  Report,  the  condition  the  GIC  is 
commissioned 
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. 
Williams.  The  GIC  works  closely  with  colleagues  from  primary  care  or  secondary  mental 
health services, including sharing information to facilitate patient care as required. As part of 
that information sharing process, the GIC would raise any concerns it had about a patient’s 
mental  health  with  their  GP  directly,  for  example,  if  it  was  felt  they  might  benefit  from  a 
referral to secondary mental health services. 

the 

in 

Regarding the setting and implementation of criteria for prioritising patients for treatment, it is 
deeply regrettable that Ms. Williams could not maintain her existing place on the waiting list 
following a previous referral to a different GIC (as she had not yet been reviewed at the first 
clinic  to  which  she  was  referred).  Any  change  in  this  approach  would  have  to  be  agreed 
nationally,  not  unilaterally  by  the  GIC,  to  ensure  equity  and  consistency  for  service  users. 
The Trust will also discuss this arrangement with its commissioners in order to see if it there 
is  any  scope  for  a  different,  national  protocol  for  those  patients  moving  between  clinics 
before they have had their first appointment. 

The Trust is grateful for your careful consideration of this matter, and hope this letter assists 
in  reassuring  you,  and  Ms.  Williams’  family  and  friends,  that  the  Trust  and  the  GIC  are 
continually  exploring  avenues  to  provide  the  best  possible  service  to  their  patients.  This 
includes  measures  to  reduce  the  length  of  the  waiting  list  for  the  GIC,  as  the  priority  has 
always been, and remains, to ensure that patients have prompt access to the service. 

Yours sincerely 

Interim Chief Medical Officer