Thread by @DadTrans

Since 2017, during a moral panic, too many UK Trans youth have died waiting for Gender Services or CAMHS. For many, state failures were a factor in their deaths. It is vital we learn from, & discuss their deaths responsibly. This thread is my attempt to do so CW: Death Suicide 1/

Before discussing individual cases it is important to know that there is rarely one cause for suicide. All deaths by suicide are avoidable & there is always help available if you need it.
Samaritans - 116 123
Papyrus - 0800 068 41 41 (Text 07786 209697) Childline - 0800 1111 2/

In writing this thread I have referred to Samaritans media guidelines on reporting suicide & for reporting Inquests, & to Papyrus guidelines for journalists. I encourage anyone discussing suicide to familiarise themselves with these valuable guides 3/papyrus-uk.org/guidelines-for…

Every death is too many. This is a far too long list. You may know of some of these deaths, others will be new to you. Please respect the privacy of grieving families & friends who may have known these youth by different names. 4/

These deaths are complex & multi factoral without a single reason. Not all of these deaths are by suicide. All are reported to have involved an element of self harm. Where lack of Trans health or mental health access was reported during inquest or investigation this is stated. 5/

Many of the Trans youth who have died had adverse childhood experiences or conditions which impacted their well-being. I have noted this where known & noted as relevant in their death. Where possibled data in this thread is published & referenced with few exceptions noted. 6/

The data is derived from a combination of Local Child Safeguarding Practice Reviews, Significant Case Reviews, NHS Trust Board minutes, Coroner published Prevention of Future Deaths Reports, Newspaper Reports & INQUEST case studies. 7/

In some instances, additional information has been provided by friends or families of those who have died. I have taken reasonable steps to verify information provided in this way. I have reproduced published photographs & have permission for those which were not previously so 8/

It should be noted that Prevention of Future Death reports are copied to the Secretary of State for Health & Social Care, & when relevant other bodies including Department for education. In some cases I have referred to formal responses from those departments 9/

In investigating these deaths I learned too many Trans youth have been fatally abandoned by services who should have been there to support them. They deserved so much better. I've also learned that Trans youth want to live, with the right suppport, Trans youth will thrive 10/

There is substantial evidence that access to Trans inclusive mental healthcare & Transgender healthcare including GnRH analogues is a protective factor. In my view it is relevant that not one of the youth who has died since 2017, had accessed Trans healthcare via the NHS. 11/

I agree with the National Suicide Advisor that suggesting 'puberty blockers' are a single factor in any suicide is simplistic, & unsupported by data. However I am aware of no Trans youth who accessed timely gender affirming care, including puberty blockers who died by suicide 12/

What follows is a description of deaths of youth up to & including the age of 18 who have died with a public record they were Trans or were reported as having 'gender identity issues'. It is important to understand that this is not a list of all Trans youth who have died 13/

As will become clear when reading this thread, sometimes families had no knowledge a young person was Trans until after they died. Where a Trans young person is unsupported at home, their identity post death may also have been suppressed, by families, police or coroners. 14/

The National Confidential Inquiry into Suicide found that LGBT+ patient deaths are "likely to be underestimated". I believe that Trans young people who were not 'patients' & had no clinician contact were even less likely to have their identity recorded 15/ documents.manchester.ac.uk/display.aspx?D…

Following guidelines referenced above no detail on method of death is given. I have given issues identified with access to mental or Trans health or other services. Following a summary of facts, I've tried to give a sense of who they were, using words of friends & family 16/

For each young person I've given name, age, date of death & a single photograph.
CW suicide. What follows is a description of deaths
All deaths by suicide are avoidable.
Help is available: Samaritans -116 123 Papyrus -0800 0684141 (Text 07786 209697) Childline -0800 111
17/

Sam Marx. Age 17. Died 20 Feb 2017. Suicide.
Sam had been referred to CAMHS & specialist health services & "diagnosed with gender dysphoria". A Significant Case Review was carried out 3 years after Sam's death which identified multiple failings 18/

Failings included need for greater awareness & training for professionals working with Trans children & young people & "the voice of the child must be heard & reinvigorated & children & young people need to be given the opportunity to be involved in decisions impacting them" 19/

Sam had multiple adverse childhood experiences. He was autistic & ADHD. Seeking Trans healthcare "Sam was frustrated at lack of progress..no treatment had commenced & this added to his anxiety". Sam had missed appointments & appointments had been cancelled. 20/

At time of death Sam was thriving at school. He had hoped to stay there but was refused. He was let down by multiple failings in the agencies meant to support him. He Died Waiting For Care #DWFC. Link to Significant Case Review (SCR) into Sam's death: 21/pkc.gov.uk/media/49838/CP…

Leo Etherington 15. May 2017. Suicide.
Reporting on the Inquest states "Leo struggled with gender identity issues since the age of eight and felt he “should have been born a boy”". Leo was supported by his family who used his name 22/

Leo was "told by the family GP that he would not be eligible for gender reassignment surgery on the NHS". Following Leo's death there were multiple media stories quoted Leo's father that Leo was "angry at his school" for not supporting a name change until he was age 16. 23/

Leo's father & the school wrote a joint submission to the IPSO stating “The circumstances surrounding Leo’s death are extremely complex and I do not believe that the school could have been more supportive of him or of our family. DM & Telegraph retractions printed retractions 24/

Tyla Cook. 16. 15 November 2017. Died of Natural causes contributed to by overdose.
Tyla had a complex mental health history & was under the care of a health trust. The coroner criticised the NHS & CAMHS for multiple failings in a Prevention of Future Deaths Report (Reg 28) 25/

Tyla had waited too long for a referral to Eating Disorder services, He lacked a documented care & crisis plan. Tyla was autistic & this combined with NHS communication failings impacted the circumstances around his death. 26/

The agencies involved in his death had failed to meet to discuss learning 2 years after. Tyla was known to GIDS & had first started assessment in May 2017, restarted in October. Tyler Died Waiting For Care of both CAMHS & GIDS. Reg 28 Report: #DWFC 27/judiciary.uk/wp-content/upl…

Jayden Lowe. 18. Died Sep 22nd 2018. Suicide.
Jayden was referred to GIDS by GP. He waited 11 months without being seen & resorted to seeking private care. Prior to death he had heard he would never access children's service & was referred to adult services with 2 year wait 28/

The coroner found delays in Jayden’s treatment were a “significant factor”. Jayden's family said private health started very recently before death was "too little, too late". Jayden had "good grades" & "wanted to study art history at Cambridge". Died Waiting for Care #DWFC 29/

Cameron Haswell. 18. 11th August 2019. Suicide. Cameron;s family did not know Cameron was "struggling with gender identity". Cameron's family said others shouldn't feel shame about their gender identity or need to keep it a secret. 30/

"If Cameron had told us we would have had their back…we would never have made Cameron feel anything other than supported and loved". Cameron's loved to hang out with friends at the local skate park. Their favourite song was 'Sunflower' by Post Malone. 31/

Daniel (Danny) France. 17. 3 April 2020. Suicide.
Danny had been referred to GIDS & CAMHS. There were "considerable delay in obtaining appointments for the Gender Identity Clinic, & about the shortage of availability for psychological therapies such as CBT". 32/

According to the Prevention of Future Deaths Report "Danny was repeatedly assessed as not meeting the criteria for urgent intervention & yet the waiting list for psychological therapy was likely to be over a year" He fell into a "gap between urgent & non-urgent services" 33/

Commenting on coroner's statement of delays for gender healthcare, Danny's father said delays were happening to Trans youth "while they're going through massive changes in their own bodies & they're in bodies they hate which is phenomenally difficult for their mental health". 34/

Danny's death was avoidable. He Died Waiting For CAMHS and for Trans HealthCare #DWFC. Link to Report To Prevent Future Deaths (Reg 28) Report: … 35/judiciary.uk/wp-content/upl…

Ellis Murphy-Richards. 15. September 30th 2020. Suicide.
Ellis had a history of self-harm & suicidal ideation. The coroner found services failed to assess risk, failed to share information, deviated from agreed safety plan & failed to conduct a mental health assessment. 36/

Ellis "lit up a room" he loved music, singing, playing violin, guitar. He was "passionate about LGBTQ+ rights equality & diversity". His Grandmother said "he was a ‘wonderful child...kind, caring, he loved his family, loved his friends…‘He was delightful and I miss him' 37/

Given absence of record, it can be inferred Ellis was not referred to GIDS & never received Trans healthcare. Note Reg 28 report is in another name but uses he/him. No reference to gender identity. Link to Prevention of Future Deaths Report (Reg 28):
38/judiciary.uk/wp-content/upl…

"Sam", 15. 20th October 2020. Suicide. No image. Sam is an alias used in a Child Safeguarding Practice Review. Sam was referred to GIDs in June 2017 but had to wait 22 months for the first appointment. During wait period Sam had multiple hospital visits for self harm 39/

Sam was seen by GIDS in July 2019, & they were due to "complete a report towards the end of 2020, before which Sam unfortunately died". "it was a cause of distress to Sam where agencies failed to correctly identify & refer to his gender identity" 40/

"A notable exception" was a CAMHS support worker who "was always correct and sensitive in their interactions with Sam". The safeguarding report identified "no clear & coherent multi-agency risk assessment undertaken which was understood by all the agencies involved." 41/

Sam’s dad felt "each agency blamed the other but did not offer any solutions or real support". In particularly GIDS was not involved to crucial meetings which meant "They were unaware of the level of self-harm Sam was undertaking until October 2020" 42/

GIDS were finally invited to an AMBIT meeting in October 2020 at time of Sam’s last admission to hospital. "Sam was due to hear shortly before his death that GIDS considered that he was not eligible for consideration of any physical interventions." (Referral to Endocrinology) 43/

During the 22 month wait, GIDS provided no support to Sam. "it was left for CAMHS to manage Sam’s gender identity...Once the service started to work with Sam CAMHS made a number of requests to GIDS for care & risk management plans but these were never received". 44/

"Sam avoided contact with his GP as on their records Sam was referred to as his natal gender and was referred to as his female name". When he did eventually vist the GP due to serious need "The GP was unable to prescribe medication as Sam was under the care of CAMHS" 45/

Because Sam was unable to maintain school attendance, was using drugs & was perceived to lack parental support [for blockers] "Sam was due to hear shortly before his death that GIDS considered that he was not eligible for consideration of any physical interventions". 46/

"This news would have been likely to have impacted significantly on Sam & increased his instability. There's no indication that Sam was aware of this decision prior to his death". Sam Died Waiting For Care #DWFC
Local Child Safeguarding Practice Review 47/walsallsp.co.uk/children/wp-co…

Rowan Thompson. 18. 3 October 2020. Cardiac Arrythmia contributed to by Neglect.
Rowan was an inpatient at the Gardener Unit, a medium secure adolescent mental health unit in Prestwich Hospital. December 2022 Inquest found that their death was contributed to by neglect 48/

There were multiple failures identified by the coroner including failure to communicate findings of blood tests. The inquest jury found "gross failure to provide medical care". Rowan had serious physical and mental ill health. "Rowan was a "brilliant and unique individual" 49/

Charlie Millers. 17. 7 December, 2020. Narrative verdict recorded. Not suicide.
The Reg 28 Report found multi-agency failings leading up to his death. The CPS reportedly unsuccessfully attempted to pursue a case of manslaughter by gross negligence against Prestwich hospital 50/

Charlie was ADHD with multiple child adverse experiences including "loss & bullying throughout his school years". Charlie's "ongoing gender dysphoria was a cause of significant distress". Charlie had been out as Trans since age of 9 & being seen by GIDS since 2016 51/

Charlie wasn't receiving Trans health. The head of GIDS stated: "he would not have progressed onto a treatment plan unless his mental health & self-harming had stabilised...This would not have been communicated to Charlie". Died Waiting for Care #DWFC 52/judiciary.uk/prevention-of-…

Axel Matters. 18. April 2021. Narrative verdict.
Axel was vulnerable, with a history of substance use. Inquest found health & social services neglect contributed to Axel's death. He was discharged by police into unsafe temporary accommodation, without due risk assessment. 53/

The coroner called out a "lack of national guidance & support in relation to the multi-agency approach that is needed to support those young people transitioning to adult health and social care services. Unless this is addressed nationally, sadly other deaths will occur" 54/

The inquest states Axel "identified as male from a young age". He had left home & changed his name by deed-poll. There is no reference to access to Trans health services. Axel loved playing boardgames & animals especially cats. Reg 28 Report (4/2024):
53/judiciary.uk/prevention-of-…

Ash Bannister. 16. 7 August 2021. Suicide.
Ash had a complex childhood in foster care, & long history of CAMHs involvement. They died after being moved from Croydon to a residential home in Leicester, & failings in their care by staff running the home 54/

The Reg 28 report found the home where Ash lived deviated from the Care Plan. At time of Inquest they had still failed to carry out an investigation, & children in their care "remain at risk" until "appropriate & effective action is taken & changes are implemented & embedded" 55/

Coroner had "grave concerns" United Children's Services were "running homes in knowledge that they have an inadequate investigation process in place for over two years."
Ash was "clever and amazing..they just needed the right support to get through." 56/judiciary.uk/prevention-of-…

Locket Ure-Williams. 15. 28 September 2021. Suicide. The Coroner found "failings by Surrey & Borders Partnership NHS Trust & CAMHS contributed to the death of a vulnerable teenager". Locket needed help from CAMHS. They Died Waiting for Care. #DWFC … 57/ inquest.org.uk/locket-ure-wil…

Emma Boland 15. January 17th 2022. Suicide.
Emma died unexpectedly after circulation of social media posts & subsequent school investigation which caused "great upset". Emma only started transitioning a short while before her death. She was loved & supported by her family. 58/

Unknown. 12. 6th February 2022. Coroner verdict to be determined.
Very little information is in public domain about this Yr 8 Trans boy. Only an article in a local newspaper removed following an IPSO complaint by the child's parents & school, & the upheld complaint itself. 59/

The child attended Radcliffe school in Milton Keynes, a letter was sent by other pupils at the school to the local newspaper which said he "was in year 8, was trans and using he/him pronouns" & he was "relentlessly bullied by his peers" 60/

Whilst the local newspaper article was retracted a statement of apology remains. I link below to the IPSO ruling. I think this case is indicative of the ways in which deaths & memories of Trans children even in a world of 24/7 social media, are hidden. 61/ipso.co.uk/rulings/01972-…

Virgil Rhone. 15. March 3, 2022. Narrative verdict. "Intent was uncertain"
Virgil was "relentlessly bullied" at school & had dropped out of education to be homeschooled. They had recently started college where they had 'found their tribe'. Virgil's death was unexpected 62/

Coroner criticised CAMHS failings: lack of information sharing between services & lack of continuity of care. CAMHS counselling "ended after six sessions". Virgil should have seen a clinical psychologist a "year earlier". At death they were on a waiting list for more support 63/

"Virgil was such a supportive person & helped people feel really comfortable with who they were..I think often the people who need help do it for other people". Virgil Died Waiting For Care #DWFC. Link to BBC News article about Virgil's death CW: Death 64/bbc.co.uk/news/uk-englan…

Jason Pulman. 15. 19th April, 2022. Suicide.
In Feb 2020, Jason’s GP had referred him to GIDS. This did not get through to them, unclear why not. CAMHS re-referred Jason to GIDS in March 2021 "Jason was told he would have to wait 26 months for 1st appointment". 65/

Jason's dad said he had “given up” on his family & on himself & began substance abuse. His mum said "He was driving himself crazy waiting for that appointment because when was it coming? When was he going to get help?" 66/

The Coroner identified "Systemic communication & administrative failures by all of the organizations involved in his care… may possibly have been contributing factors”. Including failures in CAMHS & the Police. 67/

Jason's parents called for better resourcing of CAMHS, better police risk assessments & above all “we hope the government will stop toxifying this whole issue, and just look at the children.” Both the police & NHS issued apologies to the family. 68/

Jason “was a kid that wanted to change the world, that wanted to fight for causes he believed in… He was just so genuine and just wanted everyone to be happy and feel comfortable, which is what he wanted as well.” Jason Died Waiting for Care #DWFC 69/

Max Sumner. 17. 13 May 2022. Suicide.
The coroner reportedly recorded 13 failings by CAMHS in Max's care. These included Lack of data sharing & multi agency working, lack of risk assessments, failure to involve Max's family, & failure to make referrals to other services 70/

When he was 16, Max told his dad he wanted to be known as Max & for people to use male pronouns when referring to him. Max was exceptionally proud of his trans identity & used every opportunity to champion LGBTQ+ rights 71/

Max had a love for drama & performance and was a talented artist. The Coroner’s decision to record Max’s sex differently on his death certificate from birth certificate is "ground-breaking" & a small comfort to Max's family in tragic circumstances.
72/inquest.org.uk/max-sumner-inq…

Alex Dews. 13. 14 July 2022. Narrative verdict.
"Alex was loved & well supported by his family". His school changed his name & "placed him on the vulnerable register". Alex needed mental health support, & was placed on a waiting list for school counselling in Nov 2021. 73/

Voicing suicidality, Alex's referral was escalated, & he was finally seen at end of March. "In May 2022 Alex had received his full sessions of counselling & was discharged" with "no time frame" for future services. 74/

Alex's mental health deteriorated & only then in June 2022 was he referred to CAMHS. The school defended their actions. They had discounted CAMHS as "the waiting list was so long & that if Alex was in receipt of iSpace support he would not be eligible for CAMHS services" 75/

In the Reg 28 Report. The coroner highlighted an impossible "decision whether to obtain quick support for Alex through counselling provision or whether to place Alex on a long waiting list for CAMHS..they were not able to offer both as he would be removed from NHS services" 76/

They highlighted the lack of consistency of mental health provision & a "lack of clarity" of what school role is for counselling Trans youth or if this is "solely the remit of CAMHS". The school lacked clear referral documentation, & lacked guidance on how to support Alex 77/

Responses to the Reg 28 report from SH & DFE refers to "forthcoming guidance for Trans pupils". The school response is desperate @bphillipsonMP
DFE knew Trans youth were being failed in schools & instead of helping, published a charter of cruelty. … 78/ judiciary.uk/prevention-of-…

@bphillipsonMP Finn Hall. 16. 18 Nov 2022. Inquest to be held 30th July 2024.
Finn was a "fun, clever, special" person who would do "anything to help anybody". He had struggled with mental health from age of 11. He had asked for help & was known to CAMHS. 79/

@bphillipsonMP The family tried to get help prior to death but were referred to A&E. When Finn came out to his family, saying he had known for a long time, they supported him without qualification. "He's been known as Finn ever since - it was accepted by everybody in the family". 80/

@bphillipsonMP "He seemed a lot happier as Finn. He'd spoken to doctors about it and was getting referred to a transgender clinic". Finn Died Waiting for Care CAMHS & (reportedly) GIDS #DWFC 81/

@bphillipsonMP Lucy Clelland. 16. 21 April, 2023.
Lucy was known by a different name to her family but Lucy was how she was known online and to all of her friends. She was "desperate to medically transition" & was on the waiting list for the Sandyford the Scottish youth gender clinic 82/

@bphillipsonMP "Lucy loved so many things, & so deeply. She was in the process of being diagnosed with autism when she loved something it was all she could talk about". She loved listening to music for hours. "She loved computing, & would've gone to university for cyber security". 83/

@bphillipsonMP She was a "straight A" student in maths, & she loved maps & geography, & "would make her own make pretend continents and flags for fun". She loved "woolly jumpers & pretty skirts". Lucy was not supported in her gender identity at home. There is no public record of Lucy's name 84/

@bphillipsonMP I would like to write more about Lucy but to do so risks contravening guidelines on reporting deaths. I hope in the future I am able to do so, & am thankful to Lucy's friends who shared their memories of her. Lucy Died Waiting For Care #DWFC 85/

@bphillipsonMP Alex Bendall. 18. 23 April 2023. Inquest date to be set. Death not treated as suspicious. Alex was known by another name by his family. Before going missing he was about to start a new job caring for people with dementia. 86/

@bphillipsonMP Their disappearance was described as "completely out of character". Alex was "sensitive & very empathetic and loved to cook". He loved "playing the ukelele" and was "passionate about animal rights". 87/

@bphillipsonMP Corei Hall. 14. 12th October 2023.
Following Corei's death reportedly The Care Quality Commission investigated & shut down the mental health unit where Corei was staying. His mum said "Corei was a typical teenager who loved giraffes, Doctor Who & the colour yellow". 88/

@bphillipsonMP Corie was "passionate about everything", animals, bugs, sewing..his mates" "He had a wicked sense of humour & was full of sass, & he was also stubborn & a pain in the arse!". He was autistic & struggled with his mental health. "He was also subjected to transphobic abuse". 89/

Emma Alraabeah. 18. 26 Jun 2024.
Emma was an asylum seeker & refugee from Saudi Arabia, residing in the UK. According to those who knew her. She had fled Saudi Arabia due to "trauma & psychological abuse" from her religious family due to her gender identity 90/

After arriving in the UK c.2022, Emma experienced economic pressures but continued to be involved in "political & human rights activism" & "opposition to the Saudi regime". Emma cared deeply about human rights & was happiest taking part in protests outside the Saudi embassy. 90/

@threadreaderapp unroll

24 deaths of Trans youth age 18 & under.

- Feb 2017 to November 2020 there were 9 deaths.

Crucially on 1st December 2020 following Bell v Tavi, the NHS Service Specification for Gender changed overnight.

- December 2020 to June 2024 there were 15 deaths 91/

The 1st December edict by NHS meant puberty blockers couldn't be accessed outside of exceptional board approval. Whilst Bell was overturned on appeal in Sep 2021 Trans healthcare never returned. Cass re-inforced the status quo, removing any hope of accessing timely NHS care. 92/

I don't know how this tallies with the Gov Report on Deaths of Trans youth which referenced (still unpublished) 'GIDS audit" data. The numbers don't add up. Multiple coroners found GIDS failed to provide timely care for Trans youth. I for one do not trust their data is accurate.