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Feminism: Sex and gender discussions

GIDS rated ‘inadequate’ by CQC

194 replies

TheFleegleHasLanded · 20/01/2021 00:28

www.theguardian.com/society/2021/jan/20/gender-identity-development-service-for-children-rated-inadequate

OP posts:
ChattyLion · 20/01/2021 09:16

I’ll answer my own question: from Newsnight’s Hannah Barnes

mobile.twitter.com/hannahsbee/status/1351793414812086274

CQC say inspection prompted by concerns reported by healthcare professionals & Children’s Commissioner, who’d been given evidence by me& @deb_cohen for
@BBCNewsnight

Why did this take more than ten years since Sue and Marcus Evans first raised concerns (for eg- others may have done so at that time too), and all the many many whistleblowers who’ve resigned and gone public since?
What do the years passing say for the internal governance and the external quality inspection system?
.

WinterIsGone · 20/01/2021 09:19

Here's the link to the cqc
www.cqc.org.uk/provider/RNK/inspection-summary#genderis

And the actual report the page links to
api.cqc.org.uk/public/v1/reports/7ecf93b7-2b14-45ea-a317-53b6f4804c24?20210120085141

gardenbird48 · 20/01/2021 09:34

Apparently Ben Hunte was on r4 this morning emphasising the waiting times - that sounds like it is the least of their problems given that so many children will desist of their own accord.

I wonder how many children on the waiting list could actually be helped by other mh services but because the magic word was mentioned they get funnelled straight off to sit on the GIDS waiting list presumably with no further help. This could be a particular problem for the children that have underlying causes for their dysphoria.

If the children with obvious issues that could be treated by counselling or psychotherapy were taken out and the autistic children were seen by an autism specialist (which I believe GIDS doesn’t have??) - I wonder how many would be left....

Hannahs twitter thread gives some shocking detail about poor record keeping, poor reference to care standards policies and as mentioned above a totally unforgivable lack of recording important aspects of the patients such as whether they are autistic in a way that can be used for monitoring and research.

It is quite shocking that in an area that a) so little is known about and b) the currently offered ‘treatment’ can have such an impact on children’s long term health that organisations such as GIDS and Mermaids that are perfectly positioned to gather teams of good quality data are not even trying!!

ItsAllGoingToBeFine · 20/01/2021 09:37

Have the standards at GIDs really gone down so dramatically since the last inspection, or are they arse covering?

gardenbird48 · 20/01/2021 09:41

@ItsAllGoingToBeFine

Have the standards at GIDs really gone down so dramatically since the last inspection, or are they arse covering?
Could we dare hope that some sense is reawakening in the captured CQC? Maybe someone in Government has had a stern word about their objectivity?
AnnaMagnani · 20/01/2021 09:44

It v much hasn't got inadequate due to long waiting times - the report, and the v helpful twitter thread show basic failures in safeguarding, documentation, care, consent, clinical assessment and leadership.

And if waiting times are that long, business cases should be being made to expand the service, manage the waiting list, work differently etc etc. It's basic NHS management and just wasn't being done.

However the Guardian and Ben Hunte seem to have preferred to report the issue is just long waiting lists, as that is their preferred narrative.

ArabellaScott · 20/01/2021 09:49

What an absolutely heartbreaking and damning report. Thanks for the thread by Hannah Barnes. Informative.

It's just unacceptable that children are being treated in such a shoddy, slapdash and unsafe way.

I note that the service is 'good' at being kind, and to hell with everything else - evidence, safety and accuracy apparently all disregarded so long as the service is 'kind'.

That's not 'kind', fwiw. Good care isn't always about giving patients what they say they want. Good care is diligent, scrupulous, compassionate, yes, but also rigorous and reflective.

I hope something is done very soon to fix this mess, we've failed far too many children here. I say 'we' as this problem is endemic throughout society at the moment, from Stonewall infiltrating classrooms to the police hanging out with puppy fetishists. It has to stop, now.

PlantMam · 20/01/2021 09:52

This is the online article that accompanied the Newsnight broadcast, dated June 2020:

www.bbc.co.uk/news/health-51806962

The news reports of Marcus Evans quitting as governor are end of Feb/early March 2019:
www.dailymail.co.uk/news/article-6762379/Former-governor-says-fears-hurrying-children-transgender-path.html

From the CQC report:

‘Staff used a recognised risk assessment tool. The service had introduced a standard risk assessment form in April 2020. This form had been completed on most of the records we reviewed. However, on some records, staff only completed very brief details. The risks were not always assessed by staff in relation to the impact of the risk and the likelihood of risk incidents occurring. On some risk assessment forms, staff had not recorded all the risks discussed in the notes of meetings. This meant that someone unfamiliar with the patient may find it difficult to identify the risks quickly.’

From the timeline it looks like both the formal consent procedure (Jan 2020) and the standardised risk assessment (April 2020) were a reaction to KB’s judicial review.

Newsnight must’ve been collecting their evidence for a while (possibly ever since Marcus Evans went public - so over a year) and it was NN who then triggered the CQC inspection.

Hilary Cass was announced as leading the NHS England independent review in September 2020. My Google-fu is failing on the timeline for that - initially something was promised by someone in (Theresa May’s?) government? Then nothing said for ages, then announced as a ‘review’ but with no one yet engaged to lead it?

And yes, the Evans’ concerns were first recorded in 2005 Shock

Need to look up the dates for Michael Biggs’ stuff about the puberty blockers review and the David Bell stuff and make a complete timeline...

PlantMam · 20/01/2021 10:04

From the CQC report

‘The trust had produced a standard operating procedure specifically for the Gender Identity and Development Service. Staff were required to report any safeguarding concerns to a supervisor, regional lead or senior clinician. The matter would then be reviewed by the trust’s safeguarding team or the GIDS safeguarding lead and referred to the relevant multi-agency safeguarding hub if necessary. The GIDS safeguarding lead said that this procedure would be reviewed in November 2020. Most staff we spoke with gave examples of safeguarding concerns they had raised. For example, a clinician referred a patient to the multi-agency safeguarding hub following concerns about parental neglect and sexual abuse. Another clinician made a referral about a 17-year-old young person who was living independently in inappropriate housing, experiencing poor physical health and was not receiving any support.’

Yet in Sonia Appleby’s (the actual safeguarding lead) statement for her CJ fundraiser she says this:

‘In my claim, I allege that because I made "protected disclosures" to my line manager regarding concerns raised by GIDS staff ( that the health or safety of patients was being, had been or was likely to be endangered), I was subjected to detriments.

I allege these detriments are:

i) the Tavistock misused it's own procedures to besmirch me and therefore jeopardize the role of safeguarding within the Trust;

ii) there was an unwritten but mandated directive from the Tavistock management that safeguarding concerns should not be brought to my attention despite being the Trust Safeguarding Children Lead;

iii) and, clinicians were discouraged from reporting safeguarding concerns to me.’

Her whistleblowing claim was lodged in November 2019.

(9 days left to help her dig, btw)

AnnaMagnani · 20/01/2021 10:07

It's not unusual for a service to get Good for Caring and be shite at everything else - it's essentially the easiest one to get as staff will always do their best.

For a service to be graded Inadequate over all is rare and really speaks to structural problems - I once worked briefly at an Inadequate service, it was horrendous and I was glad to leave.

As the CQC Inspector told me, the problem for these services is always Well Led. It won't be the waiting lists or anything else they try to blame it on, it's always a failure of structure and leadership and you can see that in the report. The whole place looks haphazard.

Defaultname · 20/01/2021 10:22

@PlantMam

From Hannah Barnes’ twitter thread:

CQC notes there is still wide variation in practice with assessments ranging from “two or three sessions to over 25 sessions, with some young people receiving more than 50 sessions.” The CQC confirm staff reports seen by NN that some assessments consisted of two sessions

I’ve read countless social media comments from
people accusing Keira Bell about lying re: how few appointments she had before being prescribed blockers. It’s now there for everyone to see, some patients are referred to endocrinology after just 2 GIDS appointments.

The CQC report also confirms the rumours we’ve heard about how the assessment process at GIDS varies enormously dependent on which clinicians you are assigned.

Wonder how come the wait time vary so much? Do they triage the waiting list?

I wonder what percentage of assesors are 'trans', and how this might influence any decision regarding fast-tracking to puberty-stoppers? The 'trans' % at the BBC is high, I know, and I suspect it will be at GIDS, too. Yeah, emphasising the delays is like saying that the portions of school dinners are too small, when they've been identified as being strychnine-rich.
ArabellaScott · 20/01/2021 10:24

the Evans’ concerns were first recorded in 2005

Only 15 years to address this, then. Appalling.

Manderleyagain · 20/01/2021 10:27

@ItsAllGoingToBeFine

That is an atrocious report and absolutely not just about waiting times. I found it interesting that the dispassionate outsiders (CQC) found the service to be generally terrible but those in the bubble (children/parents) thought it was amazing.

Kind of echoes the whole give me what I want and everyone who highlights concerns is a hateful transphobe.

This stood out for me too. Lay people think they are getting a good service - the people are kind & they feel looked after. Maybe they feel their child's life improved because of the service? The inspector looks at the actual processes and sees things which are potentially dangerous and completely unacceptable. I think service users feel loyalty to places too sometimes.

The other thing that stood out (though there was lots in the thread) was it was rated good in 2016. Many of the clinicians will be the same people working in the way they do. I don't believe that basic things like assessment criteria being used and referred to in notes will have changed. There might have been smaller case loads and shorter waiting list, but would other things have changed in that time? How was it good in 2016? Is it that the cqc decided to do a v thorough job this time because they knew people were watching?

I would like to see a comparison of the 2 reports by someone who is used to reading that type of thing.

PlantMam · 20/01/2021 10:28

The whole section about record keeping has me boggle eyed.
Extract:

• Staff’s assessments of patients were unstructured, inconsistent and poorly recorded. Staff did not sufficiently record their reasoning in reaching clinical decisions. There were significant variations in the clinical approach of professionals in the team and it was not possible to clearly understand from the records why these decisions had been made.
• Staff did not develop care plans for young people. Many records provided insufficient evidence of staff considering the specific needs of young people, such as autistic spectrum disorders.
• Staff had only recently begun to record consent and capacity or competence clearly for young people who might have impaired mental capacity or competence. The records of young people who began medical treatment before January 2020 did not include a record of their capacity, competency and consent. When staff identified records without a written capacity assessment, they did not seek to address this or record it as an incident

Surely if you discovered that patient with impaired mental capacity hadn’t been properly assessed re: consent you have a duty of care to report potential negligence?

The CQC report also raises the excellent question as to why GIDS multi disciplinary clinical team doesn’t include any specialists re: autism/adhd

‘The staff team included clinical psychologists, psychotherapists, family therapists, specialist social workers and a counselling psychologist and assistant psychologists. The service also employed two psychiatrists, two specialist nurses and a large team of administrators.
Staff were experienced and qualified and had the right skills and knowledge to meet the primary needs of the patient group. However, staff did not necessarily have the skills or experience to meet the needs of young people with complex needs. For example, whilst some staff had previous experience of working with patients with autistic spectrum disorders, the service did not employ a specialist to focus on this area of clinical practice. This meant the service may not be sufficiently able to assess the needs of young people with complex needs.’

I am also concerned that this:

‘ Although staff did not provide interventions for physical ill health, we did not see consistent evidence that staff routinely asked young people about their physical health, in order to refer them to external services if needed. We reviewed physical health monitoring on 24 records. On 18 records (75%) there was no mention of physical health. Four records (16%) included a discussion of physical health at the initial meeting. This meant that staff were not consistently screening for physical health problems, unless these were included in the referral from the young person’s GP or local CAMHS.’

This is not my professional area at all, but considering how eating disorders seem to be prevalent amongst FtMtF detransitioners and that some of the GIDS patient base are on drugs that affect growth, is it unreasonable that I would expect height and weight to be recorded (and plotted on growth charts for screening purposes) at every appointment?

How can the bit about safeguarding be relatively positive, according to the CQC, when the rest of the report flags up so many missed opportunities, especially around potential comorbidities?

SunsetBeetch · 20/01/2021 10:38

I'm shocked but not shocked iyswim

stargirl1701 · 20/01/2021 10:40

Thread unroll here:

https://threadreaderapp.com/thread/1351793414812086274.html

persistentwoman · 20/01/2021 10:41

What shocking extracts. Yet, as everyone has been saying, this is precisely what women have been stating. I wonder how much their practice has been influenced by the toxic Memorandum of Understanding of Conversion Therapy being so eagerly and inappropriately applied to children?

As ever, digging into this whole mess sheds sunlight on appalling standards for the most vulnerable.

Scout2016 · 20/01/2021 10:46

If the appeal in Kiera's case was granted on the grounds that the court may not have applied Gillick Competence correctly, could this report be used as evidence that GIDS weren't assessing competence properly themselves? They could argue that they did, they just didn't record it, but I doubt that would wash. Can this report, and the last one, be used given they are new evidence?

OvaHere · 20/01/2021 10:46

I wonder how much their practice has been influenced by the toxic Memorandum of Understanding of Conversion Therapy being so eagerly and inappropriately applied to children?

Link for anyone who wants to read about this

www.transgendertrend.com/product/captured-the-full-story-behind-the-memorandum-of-understanding-on-conversion-therapy/

Cabinfever10 · 20/01/2021 10:54

I wonder what would happen if someone was to contact all current and former patients of gids going back say 10-15 years to follow up and ask all the questions that should of been asked and recorded, but weren't and what they think about the service now. You know actually gather some information about the long term outcomes

yourhairiswinterfire · 20/01/2021 11:01

No wonder they didn't produce any decent evidence in court! They're an absolute embarrassment-is anyone going to pay for this? Heads need to roll, there are no excuses for running such a circus when you're dealing with vulnerable children. I'm furious that these clowns were allowed to advertise and glamourise all of this on CBBC with the 'puberty blockers are a pause button' spiel.

And they have the absolute nerve to throw heaps of money at appealing a safeguarding judgement Angry

I feel awful imagining the true amount of children that have been so badly let down by everyone around them :(

Whatwouldscullydo · 20/01/2021 11:03

How does this affect the appeal anyway ?

I mean you can't argue a decision be overturned and kids sent back to be "treated" by a service deemed inadequate surely?

ArabellaScott · 20/01/2021 11:09

@yourhairiswinterfire

No wonder they didn't produce any decent evidence in court! They're an absolute embarrassment-is anyone going to pay for this? Heads need to roll, there are no excuses for running such a circus when you're dealing with vulnerable children. I'm furious that these clowns were allowed to advertise and glamourise all of this on CBBC with the 'puberty blockers are a pause button' spiel.

And they have the absolute nerve to throw heaps of money at appealing a safeguarding judgement Angry

I feel awful imagining the true amount of children that have been so badly let down by everyone around them :(

Yep.
PurpleWh1teGreen · 20/01/2021 11:10

Thanks to Winter for the link - I was struggling to get it to load.

It sounds like they have picked up the safeguarding failures and the failure to use the multi-dis team to consider alternative approaches.

-The service was difficult to access.

• Staff did not always assess and manage risk well.......individual risk
assessments were not always in place

• Staff did not develop holistic care plans for young people............. Staff did not sufficiently record the reasons for their clinical decisions in case notes.

There were significant variations in the clinical approach of professionals in the team and it was not possible to
clearly understand from the records why these decisions had been made.

• Staff had not consistently recorded the competency, capacity and consent of patients referred for medical treatment
before January 2020. However, since this date these decisions had been recorded.

• The teams did not always include the full range of specialists required to meet the individual needs of the patients.

Staff did not always work well together as a multidisciplinary team

• Staff did not always feel respected, supported and valued. Some said they felt unable to raise concerns without fear
of retribution.

• The service was not consistently well-led. Whilst areas for improvement had been identified and some areas
improved, the improvements had not been implemented fully and consistently where needed.

GIDS rated ‘inadequate’ by CQC
GIDS rated ‘inadequate’ by CQC