Evidence
Date of report: 30/04/2024
Ref: 2024-0229
Deceased name: Jason Pulman
Coroner name: Michael Spencer
Coroner Area: East Sussex
Category: Suicide (from 2015) | Child Death (from 2015)
This report is being sent to: NHS England | National Referral Support Service
REGULATION 28 REPORT TO PREVENT DEATHS | |
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THIS REPORT IS BEING SENT TO: NHS England National Referral Support Service, NHS Arden and Greater East Midlands Commissioning Support Unit (Arden & GEM). |
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1 | CORONER I am Michael Spencer, Assistant Coroner for the coroner area of East Sussex. |
2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
3 | INVESTIGATION and INQUEST On 27 April 2022 I commenced an investigation into the death of Jason PULMAN aged 15. The investigation concluded at the end of the inquest on 12 April 2024. The conclusion of the inquest was that: Narrative: Jason Pulman died as a result of suicide. Jason died by hanging, potentially through his mental health and gender identity issues. Within this context, it is possible his relationship with his boyfriend exacerbated his low mood. It is also possible Jason may have been prevented from committing suicide if British Transport Police had been notified that Jason was a missing person who was possibly on a train. |
4 | CIRCUMSTANCES OF THE DEATH Jason Pulman was found on 19 April 2022, by a member of the public, [REDACTED]. He was pronounced dead on the scene. |
5 | CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) On 10 April 2024, i.e. during the course of the inquest, [REDACTED] published her report on the independent review of gender identity services for children and young people (the Cass review). Her recommendations included that: “a smaller number of secondary services within CAMHS and paediatrics should be identified initially to act as Designated Local Specialist Services (DLSS) within each area. This would increase the available workforce through a flexible, multi-site staff group working between the DLSS and the regional centre, with the opportunity to provide targeted training and upskilling.” |
6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. |
7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by June 28, 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to: I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. |
9 | Dated: 30/04/2024 Michael SPENCER Assistant Coroner for East Sussex |
The post Jason Pulman: Prevention of future deaths report appeared first on Courts and Tribunals Judiciary.
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