Alice Litman

Sarah Clarke 
West Sussex, Brighton and Hove  
Coroner’s Office  
Woodvale 
Lewes Road 
Brighton 
BN2 3QB 

Dear Coroner, 

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

2nd February 2024  

Re: Regulation 28 Report to Prevent Future Deaths – Alice Litman who died on 
26 May 2022.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  5 
December 2023 concerning the death of Alice Litman on 26 May 2022. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Alice’s family and loved ones. NHS England are keen to assure 
the  family  and  the  coroner  that  the  concerns  raised  about  Alice’s  care  have  been 
listened to and reflected upon.  

Before addressing the concerns raised in your Report, may I respectfully remind HM 
Coroner that NHS England did not have a role in relation to Alice’s inquest. However, 
NHS England wishes to assure Alice’s family and HM Coroner that the concerns raised 
about Alice’s care have been listened to and reflected upon.  

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.   

Background to NHS England’s role as Commissioner 

in  England,  based 

NHS England is the direct commissioner of specialised services for individuals with a 
diagnosis  of  gender  dysphoria.  Prior  to  2019/20,  seven  specialist  centres  were 
in  or  near  Newcastle,  Leeds,  Sheffield, 
commissioned 
Northampton, Nottingham, London and Exeter. Each of the Gender Dysphoria Clinics 
(GDCs) is operated by a Mental Health NHS Trust and is staffed by a multidisciplinary 
team  to  include  the  wide  range  of  clinical  professionals  needed  to  deliver  highly 
individualised care and meet the presenting needs of the whole person (typically and 
variously:  clinical  psychologists;  specialist  physicians;  consultant  psychiatrists; 
consultant  endocrinologists;  clinical  nurse  specialists;  voice  and  communication 
therapists; counselling therapists).  

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. 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 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.  

You have raised the following Matters of Concern: 

1. The  knowledge  and  training  for  those  in  the  mental  health  setting  for 

managing and offering care to those in the transgender community  

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. 

Generally, NHS England expects local mental health services to have the necessary 
skills, experience and competence to meet the needs of individuals who are on the 
waiting  list  for  gender  dysphoria  services  and  who  have  co-existing  mental  health 
issues and / or personal, family or social complexities in their lives. Local services do 
not need to be expert in the diagnosis of, and response to, gender dysphoria to meet 
these needs, though the need to improve knowledge of the issues facing patients with 
gender  dysphoria  amongst  healthcare  professionals  in  all  healthcare  settings  is 
recognised,  and  to  that  end  there  are  various  training  and  educational  resources 
available to local services and health professionals including: 

•  Training  materials  and  courses  delivered  by  NHS  organisations;  see  for 
example the courses available from the Nottingham Centre for Transgender 
Health  (Nottinghamshire  Healthcare  NHS  Foundation  Trust)  which  include 
courses  on  “understanding  trans  youth”  and  “working  with  trans people  at  a 
time of crisis”: https://ncth.nhs.uk/training 

•  General  Medical  Council  advice  for  medical  professionals  on  “Trans 
Healthcare”  including  “the  importance  of  providing  good  general  medical 
services to transgender and gender diverse people including supporting their 
mental 
https://www.gmc-uk.org/professional-standards/ethical-
hub/trans-healthcare 

health”: 

•  Professional guidelines such as the British Psychological Society’s guidelines 
for applied psychologists working with gender diverse individuals with mental 
distress,  but  which  may  also  be  applied  by  health  professionals  working  in 
other  disciplines  including  counselling,  nursing,  psychotherapy  and  social 
work: https://explore.bps.org.uk/content/report-guideline/bpsrep.2019.rep129 
•  Various  online  courses  for  GPs  through  the  Royal  College  of  General 
Practitioners  including  “Gender  Variance”  and  “Mental  Health  and  Suicide 
Prevention”. 

•  More  specific  to  pathways  of  care  for  gender  dysphoria,  NHS  England 
commissioned the Royal College of Physicians to design and deliver the UK’s 

 
 
 
 
 
 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-
September 
practice/courses/gender-identity-healthcare-credentials-gihIn 
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 

2. The delays in access to gender affirming healthcare 

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  2019/2020,  NHS 
England  re-procured  the  provision  of  gender  dysphoria  services  for  adults.  The 
expectation was that that 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. 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 of 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. They were located as follows:  

a.  The Trans Plus service, delivered in a sexual health setting at Chelsea and 
Westminster Hospital NHS Foundation Trust in London (from April 2020) 
b.  The  Indigo  Service  in  Greater  Manchester,  based  in  primary  care  and 

delivered by GTD Healthcare (from December 2020) 

c.  CMAGIC,  a  primary  care  service  in  Cheshire  and  Merseyside  hosted  by 

Mersey Care NHS Foundation Trust (from March 2021) 

d.  The  East  of  England  Gender  Service,  managed  by  the  Nottinghamshire 
Healthcare  NHS  Foundation  Trust  in  partnership  with  Cambridgeshire  and 
Peterborough NHS Foundation Trust (from June 2021) 

e.  A  primary  care  service  in  Sussex  hosted  by  Sussex  Partnership  NHS 

Foundation Trust (from October 2023) 

NHSE  directly  funded  the  pilot  services  on  top  of  the  funding  provided  to  the  seven 
established GDCs.  

 
 
 
 
 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).  
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. 

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:  

•  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 
•  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 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:  

•  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). 

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. 

3.  The  lack  of  provision  of  mental  health  care  for  those  waiting  for  gender 

affirming treatment 

Commissioning responsibility for local mental health services rests with 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. We anticipate the other recipients of your Report will address these concerns 
in more detail as they relate to the care provided to Alice. 

From a policy perspective, the NHS England Long Term Plan contains a number of 
commitments  to  expand  access  to  community  mental  health  support  for  those  who 
require  it.  This  includes  commitments  for  345,000  more  children  and  young  people 
aged  0-25  to  access  to  NHS  funded  support  each  year  by  2023/24.  This  includes 
through brand new Mental Health Support Teams in schools and colleges. We have 
seen  significant  increases  in  the  number  of  young  people  being  supported.  Over 
732,000 CYP aged 0-18 accessed NHS support in the 12 months to October 2023. 
This is an increase of 218,000 from the start of the LTP. However, the prevalence of 
mental health need has also increased in recent years, with 20.3% of 8 to 16-year-
olds  having  a  probable  mental  disorder  in  2023,  compared  to  12.5%  in  2017. 
Increasing access remains a challenge despite the increases in young people being 
supported. 

The NHS England Long Term Plan also committed to delivering a comprehensive offer 
for  0-  to  25-year-olds  that  reaches  across  mental  health  services  for  children  and 
young  people  as  well  as  adult  services.   Integral  to  this  is  improving  the  care  and 
support  given  to  young  adults  aged  18-25,  ending  the  use  of  rigid  age-based 
thresholds which see young people automatically discharged from children and young 
people’s  mental  health  services  when  they  reach  18  years  of  age.   Equally  as 

 
 
 
 
  
 important  is  improving  the  support  given  to  young  adults  within  adult  mental  health 
services and NHS England is investing an additional £1bn per year in transforming 
community  mental  health  services  so  that  more  people  with  severe  mental  health 
problems – including young adults – can access support within their communities.  The 
NHS has committed to ensuring that by the end of 2023/24 370,000 people (including 
young adults) will have access support through these new models of care. 

4.  The  lack  of  clarity  for  clinicians  who  are  in  place  to  support  young 
transgender individuals in Primary Care; and the lack of clarity for clinicians 
who  are  in  place  to  support  young  transgender  individuals  in  the  Mental 
Health Setting 

We are responding to these two questions with a single response, and by reference 
to “young transgender individuals” we are focusing on individuals below the age of the 
18th birthday, as the issues that relate to adults who are 18+ years have been covered 
in our response to the previous questions (above). 

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.  

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

Risk Mitigation 

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 

 
 
 
 
 
 
 cases reviewed, in response to which risk mitigation advice has been provided to the 
individual’s GP.  

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. 

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. 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.  

As an outcome of this initiative, the individual’s local mental health team will initially 
screen for urgency based on the information from the GES, and a process of clinical 
triage will determine priority order, before providing an initial assessment of needs and 
risks including mental health needs and safeguarding. The outcome of the assessment 
might be for onward care within CYP mental health services or to remain under the 
care  of  their  general  practitioner  for  local  support.  All  individuals  will  remain  on  the 
national  waiting  list  for  CYP  Gender  Service  unless  they  ask  to  be  removed. 
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.  

Other  relevant  matters  that  may  assist  HM  Coroner:  National  Child  Mortality 
Database 

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):  

•  A  process  has  been  agreed  for  Child  Death  Overview  Panels  (CDOPs)  to 
alert NHS England following the death of every child or young person identified 
with gender distress. 
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). 

• 

 
 
 
 
 
 
 •  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. 

•  Agreement  that  in  early  2024  NCMD  will  undertake  an  initial  analysis  of 
completed  reporting  forms  for  children  and  young  people  who  have  died 
between April 2019 to March 2023 with gender distress. This will help identify 
other  factors  and  possible  themes  for  learning  that  can  be  shared  with  local 
CYP mental health teams in advance of April 2024 as part of the mobilisation 
of the risk assessment service so that they are aware of increased risk and can 
consider enhanced suicide prevention strategies. 

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.  

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

Honorary Secretary of Council 

Sarah Clarke 
Assistant Coroner for the Brighton and Hove and West Sussex 

16.01.2024 

Dear Ms Clarke 

Regulation 28 Report to Prevent Future Deaths - touching on the death of Alice Litman 

Thank you for your Regulation 28 letter regarding the passing of Alice Litman dated 6 December 
2023. On behalf of the Royal College of GPs (RCGP), I would like to offer my condolences to the 
friends and family of Alice Litman. I am responding as the Honorary Secretary of RCGP. 

The Royal College of General Practitioners (RCGP) is the largest membership organisation in the 
United Kingdom solely for GPs. It aims to encourage and maintain the highest standards of 
general medical practice and to act as the ‘voice’ of GPs on issues concerned with education; 
training; research; and clinical standards. Founded in 1952, the RCGP has just over 54,000 
members who are committed to improving patient care, developing their own skills and 
promoting general practice as a discipline. 

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) 

Based on the above principles, and with consideration of current guidance from various 
organisations, we believe the overall role of the GP in providing care to patients with gender 
dysphoria is to: 

Royal College of General Practitioners 
30 Euston Square, London, NW1 2FB 
Tel: 020 3188 7400  |  info@rcgp.org.uk  |  rcgp.org.uk 
Patron: HRH The Duke of Edinburgh (1972  2021)  |  Registered Charity Number 223106 
-

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
     
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1.  Holistically assess the patient’s health needs, collaborating with other healthcare 

professionals and services as relevant. 

GPs should be mindful that patients often find it very difficult to confide in their feelings of 
gender incongruence and that approaching a healthcare professional to discuss their gender 
identity needs can be considerably distressing for them. GPs and their practice teams should 
approach these patients openly, respectfully, and sensitively, with an awareness and 
understanding that a person’s outward appearance may not necessarily correspond to their 
gender identity, particularly at early stages of the person’s journey to exploring their gender 
identity. 

2.  Promptly refer patients to a Gender Identity Clinic (GIC) or equivalent if they exhibit 
signs of gender dysphoria and request treatment or wish to consult with a gender 
identity specialist for further advice. Liaise and work with GICs and gender specialists in 
the same way as any other specialist, to jointly provide effective and timely treatment for 
patients. This includes considering taking on the ongoing prescribing of medication for 
patients and the monitoring of any side effects, with the appropriate funding, after a 
patient has been discharged from a GIC. 

It is common for GPs to work under Shared Care Agreements (SCAs) set up between GICs and 
practices to provide joint care for patients. It is important that SCAs are agreed upon by all 
parties involved, ensuring the appropriate levels of resource, competence and expertise are 
established, as informed by the patient’s level of medical risk. NHS bodies need to ensure that 
local shared care arrangements are adequately funded to support the ongoing care and 
treatment of patients. 

When responsibility for ongoing medical monitoring and prescribing is assumed by a GP, the 
limitations of this need to be recognised and mitigated. This is especially important for children 
and young people, where there is concern regarding the outcomes of some interventions. The 
GIC involved in the SCA should have access to the patient’s GP records and be accessible to 
provide specialist consultation to GPs to ensure the patient is being monitored correctly and the 
appropriate dosages of medication are being prescribed based on the progress of the patient. 

3.  Recognise that the family members of a patient experiencing gender dysphoria also face 
significant challenges and refer these family members to further support services where 
appropriate. 

4.  Provide appropriate treatment or signposting to patients presenting with gender 

dysphoria alongside other social or medical issues. This may include referring the patient 
to mental health services or engaging with social care, safeguarding or sexual health 
colleagues. 

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. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 , Former President of the Royal College of Paediatrics and Child Health and 

It is worth noting that RCGP has been represented at the current review being undertaken by 
Professor 
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. 

I hope that these comments are helpful. RCGP is committed to improving the care and support 
for transgender patients. Our sincere condolences are with Alice’s family. 

Yours sincerely 

RCGP Honorary Secretary

26 January 2024 

Private and Confidential 

Ms Sarah Clarke 
Assistant Coroner for Brighton, Hove and 
West Sussex 
Sent by email: 

 Chief Executive 

Chief Executive’s Office 
Surrey and Borders Partnership NHS Foundation 
Trust 
18 Mole Business Park 
Randall’s Road 
Leatherhead 
KT22 7AD 

Dear Ms Clarke 

Alice Litman (deceased) 
Regulation 28 Report to Prevent Future Deaths 
Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”) 

Thank  you for the  Regulation 28  Report to  Prevent  Future Deaths (PFD  report)  dated  5 December 
2023,  in  relation  to  the  inquest  touching  the  death  of  Alice  Litman.  I  have  considered  the  report 
carefully,  together  with  the  Trust’s  Chief  Medical  Officer,  the  Chief  Nursing  Officer,  the  Director  of 
Education and other senior colleagues from the relevant divisions.  

In the PFD report, you highlighted a number of concerns relevant to a variety of organisations involved 
in Alice’s care and treatment.   

We have reflected on those concerns which are relevant to the Trust and have outlined below the steps 
that have been taken and are being taken to address these.  

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

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 working with people from the transgender community. Recognising the importance of 
 have kindly agreed to 
consultation with those with lived experience and their families, 
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.  

Our Director of Education is working with the Equality, Diversity and Inclusion Business Partner in order 
to identify and approach relevant external organisations to assist us in our development of the training 

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 offer. It is also intended that people with lived experience will be involved in co-producing this training 
with a view to supporting both those who use our services and their carers. The importance of delivering 
age  specific  training  is  acknowledged  and,  as  such,  we  will  be  developing  co-produced  training 
specifically for clinicians working with under 18s and young adults.  

The lack of provision of mental health care for those waiting for gender affirming treatment. 

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.  

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. 

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

A  further  priority  of  the Surrey Suicide  Prevention  Strategy  is  to reduce  attempted  suicide  amongst 
children and young people. It is intended that the bespoke mandatory training offer for those working 
with under 18’s and young adults will assist clinicians to better support young transgender people in 
the mental health setting.  

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.  

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.  

On behalf of the Trust, I would like to offer our sincere condolences to Alice’s family for their loss and 
to thank them wholeheartedly for sharing their experience and views with us. This has greatly assisted 
us  in  reflecting  upon  our  approach  to  supporting  the  transgender  community  and  we  hope  that  our 
actions outlined above assures you and Alice’s family and friends that we have learnt, and continue to 
learn, from her death.  

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 Yours sincerely, 

Chief Executive 

Page 3 of 3

29th January 2024 

on behalf of the Senior Coroner for West Sussex Brighton & Hove 

Dear Madam,  

Inquest into the death of Alice Litman 
Regulation 28 Response  

I am writing on behalf of The Tavistock and Portman NHS Foundation Trust (Gender Identity Clinic) 
in  response  to  your  Report  to  Prevent  Future  Deaths  made  on  5th  December  2023,  following  the 
conclusion of the inquest touching on the death of Ms Alice Litman.  

At the outset, I would like to reiterate how sorry the Trust was to learn of Ms. Litman’s 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 
relating 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, with a specific focus on the care available to 
them in other clinical settings.  

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 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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. 

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

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. 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  Trust  is  grateful  for  your  careful  consideration  of  this  matter,  and  hope  this  letter  assists  in 
  family  and  friends,  that  the  Trust  and  the  GIC  are  continually 
reassuring  you,  and 
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,  and  we  continue  to  actively  engage  with 
colleagues within NHS England to look at solutions to this issue.  

Yours sincerely 

Chief Medical Officer 

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