Sophie Williams
27 Feb 2023 · Coroner John Taylor · North London
The coroner's concerns
1. lack of single named point of contact for trans persons on personality disorder pathway
“lack of provision of the following: (A) by local NHS Trusts: (1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient (2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on: (a) the needs of trans persons (b) gender-affirming care (c) dissociation and psychosis (3) Scrutiny of the delivery and implementation of”
2. assessment omits comprehensive risk evaluation for dissociation psychosis patients
“absence from the assessment protocol of a provision to ensure that full account is taken of: (a) any previous diagnosis and treatment (b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team (c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life (d) the views of those who are”
3. lack of help-line and specialist referral pathways for gender identity patients
“clinics providing gender-identity treatment (and in relation to both current and prospective patients): (1) a help-line, available when needed by patients (2) the direction of patients to specialist carers (3) provision of mental health care for those patients on waiting-lists (4) liaison (at both local and national levels) among all clinicians concerned (or expected”