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Gender Svcs Suicides & Unexplained Deaths & Appleby Review Data

Reference: 25-26305

Date response sent: 10/10/2025

Details of enquiry

My new FOI request relates to the audit referred to in this document: ‘Review of suicides and gender dysphoria at the Tavistock and Portman NHS Foundation Trust’ which was published on 19 July 2024 and can be found here:

https://www.gov.uk/government/publications/review-of-suicides-and-gender-dysphoria-at-the-tavistock-and-portman-nhs-foundation-trust/review-of-suicides-and-gender-dysphoria-at-the-tavistock-and-portman-nhs-foundation-trust-independent-report

  1. Was this a formal internal audit and how was it commissioned?
  2. Which department did the audit?
  3. How was the audit presented and in what file format?
  4. Can you supply me with any text that the auditors produced as part of the audit or alongside it (redacted as appropriate)?
  5. Is there any other relevant data included in the audit which doesn’t risk identifying individuals?

Response sent

  1. Was this a formal internal audit and how was it commissioned?

The mortality audit was agreed at local level, no formal meetings were required to ratify this decision, as it forms part of normal clinical practice.

The Trust routinely conducts a mortality review for every death of a patient.

A senior clinician expressed a wish to review a case series of deaths within GIDS and undertook a mortality audit, which forms the basis of Dr Louis Appleby’s report.

The Trust follows clinical guidance and reports published over several previous years, in relation to learning from deaths , eg National Quality Board 2017, CQC Review- Learning Candour and Accountability 2016, NHS Patient Safety Strategy 2019.

  1. Which department did the audit?

The mortality audit was undertaken by a Senior Clinician at the Trust.

We have withheld their name as our Trust’s policy is not to release into the public , the names of staff who are below Director level. This is explained in more detail in the attached annex to our FOI Procure. (Att 1 25-26305 FOIA Procedure Annex to Appendix 6)

This data is also exempt under Section 40(2) of the FOIA, Personal information about third parties, where complying with the request would contravene the UK General Protection Regulation or the Data Protection Act 2018. This is an absolute exemption that does not require the authority to carry out the public interest test.

  1. How was the audit presented and in what file format?

The audit was presented as a senior clinician’s case notes review of the electronic patient records of deceased individuals.

It was presented around 2021 and covered deaths from 2018 to 2021.

The output was presented in November 2021.

This was a case series, ie a review of deaths, occurring within a given period, 2018-2021, and completion of the case series review was November 2021

  1. Can you supply me with any text that the auditors produced as part of the audit or alongside it (redacted as appropriate)?

Yes, a presentation of the clinical audit findings, and this is attached (att 2 25-26305 Investign into Deaths_R)

  1. Is there any other relevant data included in the audit which doesn’t risk identifying individuals?

Having undertaken several file searches, and to the best of our knowledge there is no other relevant data included in the audit.

 

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