A “bold and brave” young trans woman died after experiencing a “push back” from the system, an inquest has heard.

Alice Litman had been waiting to receive gender-affirming healthcare for almost three years when she died on May 26, 2022, in Brighton.

The conclusion of the inquest into her death took place at Woodvale Coroner's Court, Brighton, today. It heard how Alice, of Albion Hill, was found on Undercliff Walk by a cyclist on his way to work after she had fallen from the cliff.

The 20-year-old’s mental health first began to deteriorate back in 2019 when she made her first attempt to take her own life.

Alice had been receiving support from Child and Adolescent Mental Health Services (Camhs) in Surrey, but the support was “sporadic” and “not always welcomed by Alice”, assistant coroner for West Sussex, Brighton and Hove Sarah Clarke said.

She was discharged from Camhs when she was 18, to be transferred to adult mental health service, but at the time she was not considered to meet the different threshold for adults.

“Alice’s experience in being discharged from Camhs no doubt added fuel to her belief that professionals were not supportive of her transition. She was young and had already experienced what she perceived as a ‘push back’ from the system,” the coroner said.

The most commonly asked question throughout the inquest was “If not your service, then where should Alice have gone?”, the coroner said.

Concluding the inquest today, after it was adjourned in September, the coroner summed up the evidence that had been given previously by the Tavistock Gender Identity Clinic (GIC), Surrey and Borders Partnership NHS Foundation Trust (Camhs), WellBN Alice’s GP and online transgender clinic GenderGP which had prescribed Alice cross-sex hormones.

She said: “Alice took the brave and bold decision to begin her transition in August 2019.

“I do not consider that Alice was ‘unable’ to access hormone treatment on the NHS, but I do accept that by the time of her death she had not been able to.”

She recorded a narrative conclusion, saying that the 20-year-old died as a result of descent from height.

From Alice’s early teens, it had been apparent that she had struggled with her mental health.

At the time of her death, she had been on the waiting list for gender identity services for 1,203 days, which, the coroner concluded, contributed to a decline in her mental health.

The coroner has ordered a prevention of future death report to raise her concerns about the factors that led to Alice’s death.

Factors raised include the delays in access to gender-affirming healthcare, the lack of provision of mental health care for those awaiting said treatment and the lack of clarity for clinicians who are in place to support young transgender individuals in primary care, such as GP services.

The report will be sent to GIC, NHS England and Surrey and Borders NHS Partnership Trust.

Samaritans can be called on 116 123, or emailed at jo@samaritans.org