Care failings may have contributed to transgender boy’s death, inquest concludes

Systemic failures by services supporting a transgender teenager who took his own life could have contributed to his death, a jury inquest has concluded.

After a five-day-inquest, jurors said that Jason Pulman, 15, who was found dead in Hampden Park in Eastbourne on April 19, 2022, died by suicide potentially because of his mental health and gender identity issues.

The jury at Hastings Coroner’s Court said there were failings by all services involved in Jason’s care and that the police inadequately responded to his disappearance.

The jury said: “Jason’s emotional and mental health needs were inadequately assessed and provided for.

“Systemic communication and administrative failures by all of the organisations involved in his care, with the exception of Bexhill College, may possibly have been contributing factors.

“We refer in particular, to the fact that the police responded inadequately to the missing person report and failed to keep the family informed, bearing in mind Jason was a child with a history of complex needs.”

During the inquest, jurors heard how Mark and Emily Pulman last saw Jason on April 18 at 7.30pm, and when going to wake him up in the morning found his door tied shut and his bedroom window open.

Once they reported it to the police, Jason’s disappearance from home as classed as ‘medium risk’ as they believed there was “nothing to suggest immediate risk of suicide”.

The coroner’s court heard how Jason struggled with his mental health in adolescence and began self harming aged 13 and had later tried to kill himself.

Of the police response, Mrs Pulman told the PA news agency: “I felt their response was inadequate. We didn’t hear anything from them.

“I would repeatedly call them and we just got told someone will be with you when they’re available and then we didn’t hear anything until 7.30pm which was an hour before Jason took his life so it was completely inadequate.

“I strongly believe that if he was listened to he would have been found.”

The teenager, who was born a girl, came out as transgender aged 14 and was referred to the Gender Identity Development Service (Gids) in London in February 2020 by his GP.

After following up on its progress in October that year, he was told there was a 26-month wait for his first appointment.

Jurors heard how Jason became increasingly frustrated at the wait and his stepfather Mr Pulman noted in the months before his death he appeared to have “given up” in his behaviour to his family and himself.

Asked by the coroner what his main struggles were in 2022 before he died, his mother Mrs Pulman said his gender dysphoria, relationships and friends, the coroner said.

It was reported Mrs Pulman said: “He was just waiting for it all to make sense, he had so much confusion going on in his head.”

While Mr Pulman told PA news agency that Jason was self-medicating on drugs and alcohol which could impact his mindset, he said of his Gids referral: “In his world, that was the answer, in his world we don’t know whether that was the whole answer, but to him that appointment was everything.”

Mrs Pulman added: “He was driving himself crazy waiting for that appointment because when was it coming? When was he going to get help?

“My son died a lost boy because he was so confused by the end that he didn’t know what he was or what he was doing.”

Jason’s inquest comes as the Cass Review into children’s gender care was published earlier this week and recognised shortfalls in the workforce and that it was “very distressing” that some people are “sitting on a waiting list, not knowing what’s going to happen to them, not knowing where to get information, and feeling really isolated”.

In a statement following the inquest, Mrs Pulman said she hoped lessons would be learned from Jason’s death.

She said: “We hope CAMHS will be properly resourced. We hope the police will learn how to risk assess, and not set the bar too high.

“This week, above all, we hope the government will stop toxifying this whole issue, and just look at the children.”

Paying tribute to Jason, the 38-year-old added: “He was a kid that wanted to change the world, that wanted to fight for causes he believed in and he did do.

“He was just so genuine and just wanted everyone to be happy and feel comfortable, which is what he wanted as well.”

A Sussex Police spokesman said: “Our sincere condolences remain with Jason’s family following their tragic loss.

“Our service fell below the standards expected and we accept the coroner’s findings.

“Following a full internal review into the circumstances leading to Jason’s death, a senior officer met with Jason’s family in person to formally apologise.

“A multi-agency working group was launched to share learning and put measures in place to ensure vulnerable children with complex mental health needs receive the best possible service.”

The force also said it introduced contingency measures for checking reports are resourced and graded appropriately.

A Sussex Partnership NHS Foundation Trust spokesperson also said they fully accepted the findings and apologised that more support was not offered to Jason.

They added: “We are committed to supporting children and young people who are experiencing mental ill health related to their gender identity, and delivering care in a holistic way, in line with national guidelines.”

An East Sussex County Council spokesperson also said: “We continue to work with partners to identify any lessons we could learn to improve the way we support young people with complex needs.”