Jason Pulman

Dear Sir 

Inquest touching on the death of Jason Pulman 

On behalf of NHS Arden & Greater East Midlands Commissioning Support Unit (AGEM CSU), I am 
responding to your Report to Prevent Future Deaths (hereafter “your Report”) dated 30 April 2024 
concerning the death of Jason Pulman, reported on 19 April 2022. I would like to express my deep 
condolences to Jason’s family and AGEM CSU would like to assure Jason’s family and HM Coroner 
that the concerns raised have been carefully considered and reflected upon. 

AGEM CSU have had the opportunity to respond after viewing NHS England’s response and as 
they have noted, NHS England commissions AGEM CSU to manage the administration of the 
national waiting list for Children and Young People’s Gender Services on behalf of NHS England. 

AGEM CSU can confirm that we hold no clinical records relating to Jason as the historical waiting 
list did not transfer to AGEM CSU until May 2023. The presumption is therefore that his clinical 
records would have been held by the Tavistock and Portman NHS Foundation Trust. 

Background to AGEM CSU’s role as a Referral Management Service. 

In June 2021, NHSE commissioned AGEM CSU to provide an interim referral holding service for 
NHS Tavistock and Portman Gender Identity Development Service (GIDS). This service was to 
accept and hold referrals from non-NHS Trust referral routes i.e., GPs Schools, Local Authorities 
(LA) with the aim of relieving the pressure on GIDS. In October 2022, this was expanded to include 
all referrals into the service and GIDS no longer received any new referrals. 

The physical waiting list transfer, of patients that are not under treatment by GIDS, to the CSU was 
finalised in May 2023. A patient’s place on the waiting list is based on chronological order to 
produce a single national waiting list of Children and Young People waiting to be seen by gender 
services. 

The Children and Young Person’s Gender National Referral Support Service (CYP-GNRSS) 
provides an administrative referral management and does not see patients. Patients and referrers 
are advised that should a patient require clinical support, this should be provided via their GP or 
other local clinician. The AGEM CSU website does contain information related to where help can be 
sought. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 You have raised the following Matters of Concern that relate to AGEM CSU: 

The  Arden and GEM has provided an update on its  website entitled the “National  Referral  Support 
Service for the NHS Gender Incongruence Service for Children and Young People”.  This states “The 
NHS understands it isn’t easy having to wait a long time to be seen by gender services, and young 
people may need some extra support with their mental wellbeing while they wait.  The NHS is offering 
this support, if needed, through local Children and Young People Mental Health Services (CAMHS). 
People  will  be  contacted  to  ask  if  they  are  happy  for  their  details  to  be  shared  with  their  local 
CYPMH/CAMS service so they can speak to a professional about how they are feeling.  This support 
offer is voluntary and the peoples place on the Children’s and Young People Gender Service will not 
change.  This service will be contacting parents, children and young people on the waiting list by email 
or post to ask if they wish to access this support between April and May 2024.” 

From April 2024 NHSE have established a process whereby all children and young people who are 
on the waiting list for CYP gender services are contacted by the CSU on behalf of NHSE and 
offered an assessment by their local NHS Mental Health Services; NHS England has put additional 
funding into local mental health systems for this purpose. All children and young people who are 
identified with mental health needs will receive ongoing support from their local services while they 
remain on the waiting list for CYP gender services. More than a third of patients on the waiting list 
have consented to be seen by their local mental health service. For consented patients, the CSU 
will be sending referral information to each CYP MH provider starting towards the end of June 2024. 
The website was updated in April 2024 to reflect this new supportive offer.  As Jason passed away 
before this supportive measure was put in place, he unfortunately could not access this support.

Michael Spencer 
East Sussex Coroner’s Office 
Unit 56 Innovation Centre 
Highfield Drive 
St Leonards on Sea 
East Sussex  
TN38 9UH 

Dear Coroner, 

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

28 June 2024 

Re: Regulation 28 Report to Prevent Future Deaths – Jason Pulman who died 
on 19 April 2022.   

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 30 April 
2024  concerning  the  death  of  Jason  Pulman  on  19  April  2022.  In  advance  of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Jason’s family and loved ones. NHS England are keen to assure 
the  family  and  the  coroner  that  the  concerns  raised  about  Jason’s  care  have  been 
listened to and reflected upon.   

Your Report raises five matters of concern. Some of these are better addressed by 
Sussex  Partnership  NHS  Foundation  Trust  who  we  note  that  you  have  sent  your 
Report  to  as  an  interested  party.  We  are  also  in  the  process  of  seeking  further 
information from the Trust. You have also sent your report to NHS Arden and Greater 
East Midlands Commissioning Support Unit (the CSU) who will respond separately to 
you, but there is a common position described in the responses made by NHS England 
and the CSU given that the CSU is commissioned to manage the national waiting list 
for Children and Young People’s Gender Services on behalf of NHS England.   

Background to NHS England’s role as Commissioner  

NHS England is the direct commissioner of specialised services for individuals with a 
diagnosis  of  gender  incongruence  /  gender  dysphoria.  NHS  England  commissions 
these services through separate service specifications that reflect the age differences: 
(a) providers of Children and Young People’s Gender Incongruence Services, up to 
the age of the 18th birthday and (b) Gender Dysphoria Clinics for Adults (Adult GDCs), 
to which referrals may be made from 17 years and above.    

Children and Young People’s Gender Incongruence Services  

As of 1 April 2024, there are two designated providers of Children and Young People’s 
Gender Incongruence Services in the NHS – these are delivered by a partnership of 
NHS Trusts led by Alder Hey Children’s NHS Foundation Trust in the North West of 
England,  and  Great  Ormond  Street  Hospital  for  Children  NHS  Foundation  Trust  in 
London. These services became operational on 1 April 2024 following the managed 
closure  of  the  Gender  Identity  Development  Service  for  Children  and  Adolescents 
(GIDS) at the Tavistock and Portman NHS Foundation Trust on 31 March 2024.  

                                                                                                                       
 
 
 
 
 
  
 
  
  
  
  
   
 
 
   
  The closure of the GIDS by NHS England and the establishment of new services are 
consistent with the recommendations of the independent Cass Review, the final report 
of which dated 10 April 2024 you have referred in your Report. I will not set out in full 
  advised  NHS  England  to 
the  recommendations  of  the  Cass  Review,  but 
establish  a  number  of  new  regional  services  that  work  to  a  fundamentally  different 
clinical model and that are hosted by designated children’s hospitals that have good 
links  with  children  and  young  people’s  mental  health  services,  and  that  can  offer  a 
broad and holistic approach to an individual’s care needs. NHS England’s planning 
assumption is that up to six additional new services will be established in children’s 
hospitals  by  2026,  with  the  next  new  provider  becoming  operational  in  November 
2024.  The  two  new  services  that  are  operational  work  to  an  interim  service 
specification  pending  the  outcome  of  work  to  build  a  new  substantive  service 
specification in 2024/25, for adoption in April 2025, through a process of stakeholder 
engagement and public consultation, to reflect the final recommendations of the Cass 
Report.  

The  consultant-led  services  provided  by  the  new  providers  of  Children  and  Young 
People’s Gender Incongruence Services are amongst those intended by the national 
Referral to Treatment standards to commence assessment within 18 weeks of referral. 
Unfortunately,  waiting  times  into  the  Tavistock  GIDS  were  historically  very  long 
because  of  recruitment  and  retention  challenges  against  a  backdrop  of  significant 
increased  demand  into  the  service,  and  it  will  take  some  time  for  waiting  times  to 
reduce  as  the  new  providers  increase  clinical  capacity  through  the  recruitment  and 
training of specialist clinical staff. The waiting list for the Children and Young People’s 
Gender Service was 5,676 individuals at 30 April 2024, of whom 69.4% have been on 
the waiting list for longer than 52 weeks.   

The main constraint in building a new clinical workforce is not funding, it is the shortage 
of workforce potential for both children’s and adult gender services. NHS England’s 
overall  planned  spend  on  all  gender  dysphoria  services  (adults  and  children)  in 
2023/24 was £78.17m – up from £33.4m in 2018/19, representing an overall increase 
in funding of 134% in five years. NHS England’s planning assumption is that the new 
providers of CYP gender services will begin to draw patients from the waiting list from 
November  2024,  with  the  priority  focus  between  April  and  October  2024  being  the 
ongoing care of patients transferred from the Tavistock GIDS.  

In order to facilitate the managed closure of the Tavistock GIDS and the transfer of 
children and young people to the new services, the CSU is commissioned to hold and 
manage the national waiting list on behalf of NHS England. The CSU assumed this 
role on a phased basis: (a) the CSU began processing and holding new referrals made 
to  the  GIDS  by  primary  care  clinicians  from  August  2021;  (b)  in  addition,  the  CSU 
began  processing  and  holding  new  referrals  made  to  the  GIDS  by  secondary  care 
clinicians from October 2022; (c) the historical waiting list was transferred to the CSU 
by Tavistock GIDS in May 2023. We plan for the CSU to maintain this role until 2026, 
by which time all new CYP gender services will be established and be operational, 
with each holding its own waiting list in the usual way.   

The CSU has confirmed with NHS England that it holds no record relating to Jason. 
The presumption is therefore that his records were held by the Tavistock and Portman 

  
  
  
  
  
 NHS Foundation Trust, and that Jason’s details were never held by the CSU given 
that the historical waiting list did not transfer to the CSU until May 2023.  

I respond to your specific concerns below.  

1. That Jason did not receive specialist gender dysphoria treatment because he 
was  on  the  GIDS  waiting  list  and  was  also  not  referred  to  specialist 
psychiatric support.  

At  the  time  of  Jason’s  death  in  2022,  waiting  times  into  the  Tavistock  GIDS  were 
unfortunately long (and they remain long) largely because of the imbalance between 
the  increasing  demand  and  clinical  capacity.  The  Coroner  may  be  aware  that  in 
January  2021  the  Care  Quality  Commission  (CQC)  published  its  report  following  a 
focused  inspection  of  the  GIDS,  that  rated  the  GIDS  as  ‘inadequate’  and  that 
highlighted  in  particular  the  regulator’s  concerns  about  the  absence  of  a  structured 
approach  for  identifying  and  addressing  clinical  risk  relating  to  individuals  on  the 
waiting  list.  The  CQC’s  findings,  coupled  with  the  recommendations  of  the  Cass 
Review, were factors in NHS England’s decision in  July 2022 to announce that the 
GIDS would be brought to a managed close.  

NHS England has already taken a number of measures to address the concerns that 
you have raised:  

•  Too  often  in  the  past  a  child  or  young  person  was  referred  to  the  GIDS  by 
primary care clinicians without an assessment of their mental health needs or 
other needs such as neurodiversity or physical health needs (70% of referrals 
into CYP gender services are currently made by primary care) – and this has 
resulted in significant health needs being unmet while the child or young person 
has remained on the waiting list for a prolonged period.  

•  From April 2024 we have established a process whereby all children and young 
people who are on the waiting list for CYP gender services are contacted by 
the NHS and offered an assessment by local NHS mental health services; NHS 
England  has  put  additional  funding  into  local  mental  health  systems  for  this 
purpose. All children and young people who are identified with mental health 
needs will receive ongoing support by local services while they remain on the 
waiting list for CYP gender services.   

•  Additionally, in order to ensure that a child / young person’s mental and physical 
health needs are addressed at the point of referral to the CYP gender service 
NHS England has proposed that in the future all referrals to the Children and 
Young People’s Gender Service must be made through NHS secondary care 
services  –  mental  health  services  or  general  paediatric  services.  This  new 
arrangement  will  ensure  that  concomitant  health  needs  are  addressed  by 
secondary  care  clinicians  while  the  child  or  young  person  is  waiting  to  be 
assessed by the specialist CYP gender service. NHS England will make a final 
decision on this proposal in June 2024 following a public consultation on the 
proposal.  

•  During  the  same  public  consultation,  we  proposed  an  enhanced  relationship 
between the Children and Young People’s Gender Service and local secondary 
care services at the pre-referral stage, so that there is a coordinated approach 
across the health system in the care of vulnerable children and young people, 

  
 
 
  
  
 • 

particularly in regard to mental health needs; we will make a final decision on 
the proposal in June 2024.  
In 2023 NHS England published an online education and training resource for 
local health professionals and parents in supporting children and young people 
with  gender  distress.  NHS  England  will  work  with  key  stakeholders  such  as 
royal colleges of medicine and professional bodies to consider education and 
training  to  primary  and  secondary  care  services  in  supporting  children  and 
young people on this pathway, with the ambition of this training being in place 
in 2024.  

•  More broadly, from a policy perspective, the NHS 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 young 
people  up  to  25  years  to  access  to  NHS  funded  support  each  year.  This 
includes through new Mental Health Support Teams in schools and colleges. 
We  have  seen  significant  increases  in  the  number  of  young  people  being 
supported.  Over  781,000  children  and  young  people  aged  up  to  18  years 
accessed  NHS  support  in  the  year  to  February  2024.  This  is  an  increase  of 
267,000 from the start of the NHS Long Term Plan. 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 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  –  are  able  to  access  support  within  their  communities.   The  NHS  has 
committed to ensuring that by 2023/24 370,000 people will have access support 
through these new models of care.  

2. 

  recommendation  that:  “a  smaller  number  of  secondary  services 
within  CAMHS  and  paediatrics  should  be  identified  initially  to  act  as 
Designated Local Specialist Services (DLSS) within each area.” 

On 10 April NHS England published its initial response to the Cass Report, in which 
we  committed  to  publishing  a  detailed  implementation  plan  in  due  course.  In  the 
meantime, we have made the following commitment regarding the recommendation 
for the development of local services:   

“The clinical approach set out in our published interim service specification remains 
consistent with the findings and recommendations of your review and we will continue 
to apply this as we look to bring on board additional regional centres. As we look to 
develop a final version of this service specification, we will particularly strengthen the 
description  of  the  infrastructure  that  will  be needed  for  the  new  services to  operate 
within regional networks to ensure the specialist regional centres are connected with 

  
 
  
 a  matrix  of  local  secondary  care  paediatric  services,  children  and  young  people’s 
mental health services, primary care, and school nursing. We would expect to launch 
a public consultation on any revisions to the service specification during the course of 
24/25 and to provide Integrated Care Boards with the guidance and support they will 
need to build the local services”.  

3. Arden  and  GEM’  “National  Referral  support  Service  for  the  NHS  Gender 

Incongruence Service for Children and Young People” website update.  

As noted above in response to (1),  from April 2024 we have established a process 
whereby all children and young people who are currently on the waiting list for CYP 
gender services are contacted by the NHS and offered an assessment by local NHS 
mental health services; all children and young people who are identified with mental 
health needs will receive ongoing support by local services while they remain on the 
waiting list for CYP gender services.   

4. That  Sussex  Partnership  Foundation  Trust  were  (i)  unaware  that  enhanced 
support was being offered via CAMHS and (ii) due to existing pressures on 
resources the enhanced support would likely have an impact on the already 
very long wait times for CAMHS treatment, which in turn would give rise to a 
risk of patients taking their own lives while waiting for treatment.   

As stated above, the process whereby all children and young people who are on the 
waiting  list  for  CYP  gender  services  are  contacted  by  the  NHS  and  offered  an 
assessment  by  local NHS  mental  health  services  has  been  newly  established  from 
April  2024.  NHS  England  is  not  able  to  comment  on  what  senior  management  at 
Sussex Partnership NHS Foundation Trust knew at the time they gave evidence to the 
inquest.  

We confirm that formal notification of the initiative has been provided to all NHS mental 
health  providers  in  England  and  a  number  of  webinars  were  held  between  senior 
clinicians at NHS England and executive and operational leads of the various mental 
health providers in March 2024. Colleagues in the NHS England South East Regional 
Team  have  confirmed  subsequent  communications  have  been  shared  with  all 
Integrated Care Boards and relevant providers and will continue to be shared for the 
purpose  of  supporting  mental  health  providers  in  their  readiness  to  receive  these 
patients. A series of regional meetings have also been convened to further cascade 
this information and support implementation.  

NHS England will be contacting senior Trust representatives directly to understand the 
concerns further, including the suggestion that this initiative will pose a risk to other 
patients, which we strongly refute. NHS England has put additional funding into local 
mental health systems for the purpose of seeing children and young people on the 
waiting list for CYP gender services, and this initiative was established and overseen 
under the leadership of two senior clinicians: the NHS National Mental Health Director 
(Claire Murdoch), and the NHS Medical Director for Specialised Services (Professor 
James Palmer). The initiative was welcomed by the CEOs of the NHS mental health 
trusts when the proposal was put to them by the NHS National Mental Health Director 
in January 2024.  

 
 
 
 5. That if urgent clarity is not provided to CAMHS teams, patients, and parents 
on the appropriate national referral mechanisms for gender services, and the 
resources available for those services, there is a risk that the circumstances 
arising prior to Jason’s death could be repeated.   

I trust that the proposed actions that we have described above do, collectively, provide 
assurance that NHS England is taking a number of immediate measures to respond 
to  the  concerns  set  out  by  the  Coroner  in  your  Report,  with  a  focus  on  avoiding  a 
recurrence of the circumstances around Jason’s death.  

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

It  may  assist  HM  Coroner  to  know  that  as  an  outcome  of  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) in 2023:  

• 

• 

• 

• 

A new process has been adopted for Child Death Overview Panels (CDOPs) to 
alert NHS England following the death of every child or young person identified 
with gender distress.  
Improvements  have  been  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 Children and Young People’s 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.  
In March 2024 the NCMD completed 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 has helped to identify other factors and 
themes for learning that will be shared with local CYP mental health teams 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