Services involved in the care of a transgender woman who took her own life are all  “underfunded and insufficiently resourced", a coroner said.

Alice Litman had been waiting to receive gender affirming healthcare for almost three years when she died on May 26, 2022 in Brighton.

The three-day inquest at Sussex County Cricket Ground in Hove heard how Alice, of Albion Hill, Brighton, was found on Undercliff Walk by a cyclist on his way to work after she had falled from the cliff.

Despite the best efforts of members of the public and paramedics who performed CPR there was nothing that could be done for the 20-year-old.

On the final day of the inquest, coroner Sarah Clarke said she would will consider a prevention of future deaths report and adjourned the inquest to give a narrative conclusion in two weeks’ time.

Ms Clarke said this report would not include Alice’s GP practice at the time of her death, WellBN.

Addressing the inquest, Ms Clarke said: “It is a very important inquest.

“I felt I got to know Alice very well.

“I have learned a lot also from this inquest and some of the issues raised.

“It’s extremely important we recognise how important these issues are not just here in Brighton and Hove but everywhere.”

The Argus: Alice Litman had waited 1,023 days to be seen at the Tavistock clinic at the time of her deathAlice Litman had waited 1,023 days to be seen at the Tavistock clinic at the time of her death (Image: The Litman family)

During the inquest, evidence was heard from the Tavistock Gender Identity Clinic (GIC), Surrey and Borders Partnership NHS Foundation Trust (Child and Adolescent Mental Health Services), WellBN, and online transgender clinic, GenderGP which had prescribed Alice cross-sex hormones.

“It seems to me all the services are underfunded and insufficiently resourced for the level of need the society we live in now presents,” Ms Clarke said.

Ms Clarke said she will consider several aspects in the next two weeks including the transition from child to adult mental health services, the training and knowledge offered to those caring for transgender patients and the lack of provision and long waiting lists in transgender care.

The court heard previously how trans people were being “let down” by “extraordinarily” long NHS waiting lists.

Alice’s mother Dr Caroline Litman, who worked as an NHS psychiatrist for 12 years, said she believed Alice “could have lived a happy healthy life had she not been failed by the healthcare system that should have supported her" and her daughter’s death was “preventable with access to the right support”.

The court heard Alice, originally from Surrey, first told her sister Kate she felt she was a woman in September 2018.

Alice started her journey to transition in August 2019, which gave her a “marked boost”.

But the long waits for puberty blockers and hormone treatment caused Alice’s mood to dip again and Dr Litman said the experience with CAMHS was “distressing”.

The Argus: Alice with her mum CarolineAlice with her mum Caroline (Image: The Litman family)

She said Alice was “cast out of care” when she turned 18 because she did not meet the threshold for adult intervention – despite having attempted to end her life on two occasions.

Sophie Walker, who represented Alice’s family at the inquest, said it was significant Alice was not on testosterone blockers and she became increasingly distressed by that.

Today at the inquest, Ms Walker said: “In effect the system in place to provide healthcare for trans youth does not exist.

“It is not able to be accessed at the time when they need it, or when they need it the most.”

She said for young trans people to get timely care they would need to be referred to clinics “in utero” and that people were waiting decades for care.

Healthcare providers The Tavistock and Portman NHS Foundation Trust, which ran the gender identity clinic, and her GP WellBN, told the inquest there was no denial of lifesaving emergency treatment but accepted there was a delay.

Following the adjournment, Alice’s father Peter Litman said the family was “disappointed” that the inquest had not been concluded but that they felt they had “finally been listened to”.

“We’re glad it’s being taken seriously,” he said.

A spokesman from WellBN said after the inquest: “We would like to pass our heartfelt condolences to Alice’s family at this very sad and difficult time as they have to relive the tragic circumstances of Alice’s death.
“We remain committed to providing the best possible care for our trans and non-binary patients and invite them to contact us directly if they wish to do so.”

A spokesman from the Tavistock and Portman NHS Foundation Trust said: “We were deeply saddened to learn of the death of a patient who was waiting to be seen at our Gender Identity Clinic, and offer our condolences to her loved ones. It would not be appropriate to comment while the inquest is ongoing.”


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