GP surgery made ‘catastrophic errors’ sending trans teenager to Tavistock clinic, inquest hears
A doctor’s surgery made “catastrophic errors” when it referred a transgender teenager with mental health problems to the controversial Tavistock clinic, an inquest heard.
Jason Pulman’s history of self-harm was not spotted by the Harbour Medical Practice in Eastbourne when it referred the teenager to the Gender Identity Development Service (Gids) run by the Tavistock and Portman NHS Foundation Trust in north London.
It meant Jason, who had a history of depression, self-harm and suicidal ideation, was placed on a 26-month waiting list at Gids, a controversial service which, before it closed last year, referred children for puberty blockers.
Before the treatment by Gids could begin, the 15-year-old was found dead in a park in East Sussex on April 19 2022.
An inquest into Jason’s death this week has raised questions about how a teenager with severe mental health problems, including multiple suicide attempts, was referred for gender-affirming treatment.
It comes as a landmark report by Dr Hillary Cass, a paediatrician, is set to advise that children should not be rushed on to a path to change gender, and that those who believe they are transgender may actually have mental health issues.
Referral was ‘really awful’
In the inquest at Hastings Coroner’s Court on Tuesday, Nick Armstrong KC, representing the Pulman family, said Harbour Medical Practice’s referral to Gids was “really awful”.
He said: “What Emily Pulman [Jason’s mother] says is Jason’s cutting started in 2019 and may not have been visible in 2020 but that’s something that would have needed to be explored carefully.
“It looks like it [the self-harm] is emerging at this point.”
He also said the surgery made “catastrophic errors” in its referral of the 15-year-old to the Tavistock Clinic.
Mr Armstrong said the referral form, which was completed by Karen Yates, an advanced nurse practitioner, was “brief and riddled with spelling errors” and had been mistakenly written on an adult’s form instead of a child’s form.
It also emerged at the inquest that Dr Idango Adoki, a GP at the practice, had not read or been informed about the report before it was sent to the Tavistock centre, despite his name appearing on the form.
Dr Adagi told the inquest: “I’m not at all happy with this and we have changed how we operate since then.”
Jason frustrated by waiting list
Jason, who was born as a girl but came out as transgender aged 14, was put on the waiting list for a gender dysphoria assessment, which decides whether someone has a sense of unease at their assigned gender.
The assessment could have been a potential gateway to puberty blockers, which were banned by the NHS last month.
But Jason grew frustrated at the length of the waiting list at the Tavistock centre, the inquest heard, and the teenager’s mental health deteriorated during the start of the Covid pandemic.
Jason was found dead by a member of the public in Hampden Park, Eastbourne, with a note that read “I’m sorry, mum”.
The inquest will decide if it was Jason’s intention to die. A jury of 11 will also consider whether the police response to the missing person report was adequate.
