Before HM Assistant Coroner Michael Spencer
Hastings Coroner’s Court,
Muriel Matters House, Breeds Place, Hastings, TN34 3UY
8 – 12 April 2024

Jason Pulman, a 15-year-old transgender teenager died a self-inflicted death on 19 April 2022 in East Sussex. His family had reported him missing earlier that day. Now an inquest has found that Jason died by suicide. The jury found that gender dysphoria was a contributing cause to his death.

The jury found that systemic communication and administrative failures by all of the organisations involved in his care, with the exception of his college, possibly contributed to his death. They also concluded Sussex Police responded inadequately to the family’s missing person report and that a referral to British Transport Police might have prevented his death.

Jason was the eldest of five siblings. A talented artist, Jason fought for every cause he believed in. His family said he “loved all the silliness in the world and using it to make all those around him smile.”

Jason was known to social services his entire life. He had a complex history of trauma and mental ill health, including serious self-harm, an overdose and substance misuse.

In February 2020, Jason’s GP had referred Jason into the Gender Identity Development Service (GIDS). Child and Adult Mental Health Services (CAMHS) subsequently re-referred Jason into GIDS in March 2021. At the time of his death, Jason remained on the waiting list for gender affirming healthcare.

During the start of the Coronavirus pandemic, Jason’s mental health further deteriorated and his self-harm intensified.

Jason received on and off support from CAMHS and social services. Jason took an overdose in late September 2021.  However, the following month CAMHS discharged Jason for the final time.

The inquest heard evidence that the multidisciplinary team meeting which considered providing Jason with CAMHS care for the last time was not adequately documented prior to him being discharged. The person who conducted the final assessment also said that “the learning” she took away, was Jason should have received therapy.

The jury heard that Jason’s mental health continued to deteriorate throughout 2022.

In March 2022, Jason’s college made a safeguarding referral to social services due to concerns shared between Jason’s family and the college. Jason was subsequently due to meet with a social worker in late April 2022. The inquest heard evidence that this referral should have been picked up by CAMHS as well as social services and the reason why this did not happen is not known.

On the morning of 19 April, Jason’s family found his room empty. The family called Sussex Police for the first time at 09:30 and gave information including the following:

• Jason was a child of 15;
• He had a history of trauma, self-harm and one known recent suicide attempt;
• He had problems with his mental health, and was on the GIDS waiting list;
• This was out of character behaviour and he had never gone missing before;
• He was known to misuse drugs and alcohol;
• There was a court order preventing contact with his biological father, who was known to the police;
• He was frail, small and vulnerable.

The jury heard evidence that the information given in the initial 999 call by Jason’s mother was not properly transcribed by the initial call handler, only stating that Jason had no suicidal intent, and was graded medium risk. This was relied on by officers later dealing with the case, who never checked whether this summary was accurate.

Jason’s case was eventually looked at by the duty sergeant at 13:21, who maintained the medium risk rating. No further work or reassessment was done on the case until the late shift.

Jason’s family called the police a total of five times on the day, providing updates they had received from the public and reiterating their concern that Jason was going to take his own life. Despite this, an officer only attended the home address at 19:30.

The jury heard evidence that the duty sergeant on the late shift would have sent out an alert to British Transport Police if he had looked at what Jason’s mother was saying. This was only done at 18:20, when Jason had been missing for approximately 20 hours. No officers contacted the family at all until the attendance at 19:30.

Tragically, Jason was stopped by a Southeastern Railway Revenue Protection Officer and handed a penalty fare at 17:37. The inquest heard evidence from that officer that he would have stopped Jason had he been aware he was a missing child. There was a further opportunity missed when Jason waited at Ashford International station, before boarding a train for the last time.

At around 20:35, Jason was found by a member of the public, having ligatured in a park.

The jury concluded that Jason died through suicide, with gender dysphoria as a contributing medical cause. They found that:

• 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.
• In particular, the police responded inadequately to the missing person’s report and failed to keep the family informed, bearing in mind Jason was a child with a history of complex needs.
• A referral to British Transport Police might have prevented Jason’s death.

Emily and Mark Pulman, Jason’s mother and stepfather said:

No parent should ever lose a child, and to lose Jason in the way we did, we will leave others to imagine. The jury has found that it might have been prevented, and we will just have to find a way of living with that.

We just hope the lessons will be learned. We hope CAMHS will be properly resourced. We hope the police will learn how to risk assess, and not set the bar too high. And this week, above all, we hope the government will stop toxifying this whole issue, and just look at the children.

Jodie Anderson, senior caseworker at INQUEST, said:

Jason’s inquest comes at a crucial time when the rights of young transgender people are being rolled back. A lack of access to gender affirming healthcare was a source of distress for Jason, as it will be for thousands of others who are now left stranded.

Meanwhile referrals to CAMHS have increased exponentially over the last decade and a chronic under resourcing leaves children like Jason without any quality therapeutic care for their mental health needs.

We are at crisis point. How many more families will be left devastated, dealing with the loss of a child in such traumatic circumstances?

The family are represented by INQUEST Lawyers Group members Rachel Harger and Emilia Pearson of Bindmans LLP, and Nick Armstrong KC of Matrix Chambers. They are supported by INQUEST senior caseworker, Jodie Anderson.