Transgender child, found dead in park aged 15, was let down by systemic failures from all the organisations involved

The five-day inquest into the death of Jason Pulman, 15, who was a Bexhill College student, has concluded. He was found dead in Hampden Park, Eastbourne, on April 19, 2022. The inquest concluded he had taken his own life, the Inquest Charitable Trust (ICT), representing Jason’s family, said.

His family had reported him missing earlier on the day he was later found dead. The trust said the jury found that ‘systemic communication and administrative failures by all of the organisations involved in his care, with the exception of his school, possibly contributed to his death’.

The jury also concluded that Sussex Police ‘responded inadequately to the family’s missing person report and that a referral to British Transport Police might have prevented his death’, the ICT added. Sussex Police and Sussex Partnership NHS Foundation Trust have apologised following the coroner’s findings.

The teenager was referred to the Gender Identity Development Service (GIDS) in London in February 2020 by his GP. The Inquest Charitable Trust said 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. The trust added that the inquest heard Jason was known to social services and had a complex history of trauma and mental ill health. During the start of the pandemic, Jason’s mental health further deteriorated.

The inquest heard that Jason received ‘on and off support’ from CAMHS and social services, the trust said. He was discharged from CAMHS in October 2021. A spokesperson for the Inquest Charitable Trust said: “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. 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 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 7.30pm.”

The ICT said the inquest heard Jason was stopped by a Southeastern Railway Revenue Protection Officer and handed a penalty fare at 5.37pm. The inquest heard evidence from that officer that he would have stopped Jason had he been aware he was a missing child. In a statement, 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.”

A vigil was held in Hastings following Jason’s death. He would spend a lot of time in Hastings with his friends. A spokesperson for Sussex Partnership NHS Foundation Trust said: "We offer our sincere condolences to Jason's family and friends. We fully accept the findings of the jury and apologise that more support was not offered to Jason. 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.”

A Sussex Police spokesperson 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. In addition, we have introduced contingency measures to ensure reports are graded and resourced appropriately.”