It’s concerning if the reporting about the coroner’s conclusions and recommendations are accurate. It would suggest that he wasn’t presenting with accurate evidence.
The most obvious error would be if his recommendation included advice about managing waiting lists/ times at a non existent clinic.
This quote is ambiguous, ‘Having to battle with changes to her body without receiving the necessary preventative treatment, together with the many hurdles and setbacks, gradually eroded her belief that she would succeed and everything would be alright,” It could be interpreted as having not accessed treatment to stop ‘her’ body changing in puberty ‘she’ lost hope that her body could every be the way that ‘she’ wanted it to be.
Whilst a nod is given to ‘many hurdles and setbacks’, this reporting fall short of Louis Applby’s guidance on reporting suicide.
It is probable that the distress that underpinned the gender dysphoria was multifaceted and multiple factors led to gender dysphoria and that these same factor led to the overwhelm to which suicide was deemed to be the only source of relief.
It is sad, and unacceptable that this child did not get mental health support. Cass highlighted the need for GPs and CAMHS to take an active role in treating the distress experienced and not to operate from the position that only a highly specialist team can help.