Dear Coroner,

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

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 commissioned in England, based in or near Newcastle, Leeds, Sheffield, 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. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

2nd February 2024

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 health”:

hub/trans-healthcare
• 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- practice/courses/gender-identity-healthcare-credentials-gihIn September 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.

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 consultation with those with lived experience and their families, have kindly agreed to 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 26 January 2024

Private and Confidential

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.

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 ­

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.

It is worth noting that RCGP has been represented at the current review being undertaken by Professor , Former President of the Royal College of Paediatrics and Child Health and 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.

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

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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 reassuring you, and 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, and we continue to actively engage with colleagues within NHS England to look at solutions to this issue.