Big shake-up at the Tavistock after Care Quality Commission inspection rates the GIDS ‘inadequate’

Care Quality Commission report

The current GIDS Executive leadership team has been disbanded following the Keira Bell judgement and the Care Quality Commission’s inspection rating of ‘inadequate’ –  the lowest a healthcare provider can receive from the Care Quality Commission. It means that a service is “performing badly.”

The most significant change announced is the recruitment of a range of clinical and operational experts from outside the service to deliver psychological treatment and therapy “for issues relating to a range of mental health conditions.” This is the service that should have been in place from the start and it is exactly what we have been campaigning for over the past five years. Finally children and young people will be receiving the mental health support they really need, which is good news, but it leaves us with a question.

How and why, over the last decade, have so many children been denied this treatment and instead had their bodies medically altered, leaving them with medically damaged bodies for life?

In this post we will try to answer this question.

The Care Quality Commission Inspection Report 2021

The CQC inspection report is truly shocking.

You can read the full report here. We have documented the key points in a pdf you can download here.

The inspection report exposes a shocking level of clinical negligence in the care of children and young people at the Tavistock that would be unacceptable for any service. But in the case of the GIDS, the reckless approach is particularly inexcusable given that, before the Keira Bell judgment, it preceded entering children into the medical experiment of puberty blockers and cross-sex hormones; life-changing medical intervention on healthy bodies, with life-long effects. No degree of carelessness is excusable under these circumstances.

The Care Quality Commission Inspection report reveals the extent to which children have been failed by a service based on ideology rather than evidence-based clinical good practice. When a service is belief-driven, normal rules of governance and clinical practice cease to apply.

CEO Paul Jenkins talks of being caught in a ‘political battleground’ in the video here. The truth is the GIDS caved to activist pressure in place of evidence-based clinical good practice long ago. Long waiting times cannot be used as an excuse for negligence.

The Inspection report is damning. Inspectors found:

  • Staff did not always manage risk well. Many of the young people waiting for or receiving a service were vulnerable and at risk of self-harm. The size of the waiting list meant that staff were unable to proactively manage the risks to patients waiting for a first appointment.
  • For those young people receiving a service, individual assessments were not always in place with plans for how to manage risks.
  • Staff had not consistently recorded the competency, capacity and consent of patients referred for medical treatment before January 2020.
  • Staff did not develop all-inclusive care plans for young people. Records of clinical sessions did not include any structured plans for care or further action.
  • Staff did not fully 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 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.
  • records showed that the service may not have fully investigated or considered the needs of patients with autistic spectrum disorders.

The Care Quality Commission Inspection Report 2016

The current report begs the question: how was it possible that the Care Quality Commission Inspection report in 2016 awarded the GIDS a rating of ‘good’? All the failings documented in the current report must have been apparent in 2016. David Bell’s disturbing internal report was issued in 2018.

In fact we have evidence of the way the service approached its young referrals in 2016, through a Channel 4 documentary, Kids on the Edge: The Gender Clinic. In our report at the time we saw evidence of the ‘conversations’ referenced by the CQC report and we flagged concerns that children were being treated as adults fully capable of making informed decisions. In our recent re-visit to The Gender Clinic, in light of the Keira Bell judgment, Susan Matthews noted that well-known research-based evidence (in this case that the most likely outcome for a little boy exhibiting this kind of behaviour is homosexuality as an adult and that transsexual would be the least likely outcome) was not shared with the parents.

Could it be that the same ideology operating within the GIDS clouded the reality for the CQC too? The Care Quality Commission is a member of the Stonewall Diversity Champions Scheme, as is the Tavistock & Portman NHS Foundation Trust. The Care Quality Commission gained entry into Stonewall’s Workplace Equality Index in 2015, placing at 94, up from 111 the previous year, but had been working with Stonewall since 2012. In 2014 The Care Quality Commission ran an in-house LGBT Role Models course with the help of Stonewall.

For evidence of the Stonewall ideological mind set within the CQC we don’t have to look very far.

The Care Quality Commission – Evidence of Ideological Capture

In the CQC guidance Relationships and sexuality in adult social care services Guidance for CQC inspection staff and registered adult social care providers there is a section called  What is sexuality? This is their answer:

“Sexuality encompasses a person’s gender identity, body image and sexual desires and experiences.”

This section also includes a definition of ‘gender identity’:

“gender identity – the sense that we are male or female or not aligned with either gender.”

In a report on sexuality there is no mention of sex.

Even more revealing is the CQC publication Sexual Safety on Mental Health Wards (2018).  In the Introduction there is this curious little sentence:

“We have done our best to be respectful and use appropriate language. The terminology in this area is constantly developing and evolving – as you read on, please bear in mind that it is not intended to cause upset or disrespect.”

Does this mean the language of sexual abuse or something else? The report contains a glossary of words you would expect to see in a publication of this nature but also includes, in top position, a definition incongruent in a report such as this:

“LGBT+: encompasses people who identify as lesbian, gay, bisexual, transsexual and all spectrums of sexuality and gender (including intersex and non-binary).”

The replacement of ‘sex’ with ‘gender’ is apparent in the language of the report, as in this section:

“Staff must behave in ways that ensure that patients feel supported and able to speak freely. This means that staff who know the patient must find the time to engage patients in regular one-to-one conversations. This should be carried out by a staff member of the same gender as the patient when requested or indicated.”

These are some of the findings of the report:

“Where we could determine the sex of the person who carried out the sexual incident, they were male in 495 reports and female in 153 reports.

In 328 of the reports, the sex of the person affected was not recorded. In the reports where sex was reported, females were more likely to be the person affected: 267 reports versus 229 reports where a male was the person affected.

For the females who were affected, 66% of the people who carried out sexual incidents were male, 16% female and in 18% the sex was not known. For the males who were affected, 61% of people who carried out sexual incidents were male, 17% female and in 21% the sex was unknown.

Most of the alleged incidents took place in communal areas (416 incidents).

For the great majority of the reports we could not determine with any certainty whether the ward admitted both men and women (mixed-sex) or was single-sex.”

To sum up the key findings: women are most at risk of sexual assault in mental health wards, the perpetrators are majority male in assaults on both sexes, and there are significant data gaps in the recording of sex, including whether the wards are mixed or single sex. Did the CQC address these serious failings in data collection and make recommendations for the protection of female patients, the most at-risk group?


In their recommendations it is acknowledged that:

“we do know that in two-thirds of cases where the report indicated that a female was the person affected, a man was alleged to be the person who carried out the incident.”  

And yet “Healthcare professionals and representatives of arms-length bodies that we consulted with agreed that CQC should not simply recommend that all mental health wards become single-sex.”

More important to the CQC is ‘diversity’:

“The diversity on a mental health ward reflects the diversity of the country. It is important that the ward environment meets the needs of everyone – and does not make predetermined gender-based assumptions.”

The report found that women are the highest risk group for sexual assault and the perpetrators are overwhelmingly male. There was no evidence that LGBT people are a high-risk group. Yet there is no reference to the need to respond to women’s legitimate fears, only to the needs of the ‘LGBT’ community:

“Respond to the needs of people who identify as lesbian, gay, bisexual, or non-binary or who are transgender.”

Belief-based care

Facts and evidence are irrelevant to people operating from a belief system. Beliefs can be irrational and illogical, it doesn’t matter to the true believer. Facts and evidence will simply not be seen, or will be denied in order to protect the belief. The Care Quality Commission report on Sexual Safety on Mental Health Wards provides a classic example of how this works: all the significant facts and evidence staring the CQC in the face were missed. The belief in gender ideology overrode the evidence in plain sight.

This is why we do not base clinical and medical care on beliefs. We base clinical and medical care on research, facts and evidence.

Going back to 2016, what plain facts and evidence did the CQC miss in their inspection report on the GIDS? This was a time before newspaper reports, Newsnight broadcasts and the Keira Bell judgment forced the evidence into the public realm. By 2021 the CQC could no longer ignore it.

We have had a decade where reality has left the room. Gender ideology has told us that male people are women, female people are men and children are mini adults. A medical and psychological experiment has been conducted on the children of this generation because adults in positions of responsibility over children’s welfare and safeguarding have submitted to a belief system imposed by a bullying, silencing and aggressive trans activist movement. Never before has a civil rights movement targeted children as this one has.

As evidence of a medical scandal continues to emerge, the Cass Inquiry is underway and we will have to await the findings. But what comes next must be a full Public Inquiry into how this medical experiment on children was ever allowed to begin.

Urgent questions need to be asked:

How this generation of children has been led to believe they can become the other sex by medical means.

How an NHS service has entered children into a medical experiment they know cannot achieve this aim.

How the NHS has been allowed to medically damage the healthy bodies of children and young people, leaving them medical patients for life.

How this has been allowed to happen in the absence of any evidence base.

How activists with no clinical or medical professional qualifications have been allowed to provide training and consultancy within the NHS.

How a bullying culture has been enabled and allowed to flourish within the medical profession so that professionals are afraid to speak out.

Lessons must be learned. Children have been damaged in service of an ideology. This must never be allowed to happen to our children again.

This Post Has 12 Comments

  1. jane hutton

    but CEO Paul Jenkins is still there?


    Woke ideology and identity politics has infiltrated our institutions at almost all levels. Trans ideology is a classic example of this. It is becoming increasingly likely that you will not be able to get a job or have career advancement unless you can state that a man can become a woman, and vice versa. With regard to the earlier CQC inspection of the Tavistock I would have little doubt that the inspection team had all received “equality and diversity” training, and would not have been appointed unless they were fully on board.

    Then the Cass Inquiry was announced in September 2020 (presumably someone in NHS England “woke” up to the fact that perhaps there was a problem). . This would have concentrated the minds of the CQC that perhaps they needed to get their act together, especially in light of the Keira Bell verdict.

    The Tavistock and probably NHS England are going to get the pants sued off them.

  3. Laila Khan

    CQC need to respond to the questions asked here as a matter of urgency. If you look at the NHS 2019 Review of Single Sex Policy across the Health care estate. It defines what is meant by ‘ Single Sex’ would have thought that needed no further clarification of a policy that has taken 2 decades to implement that also became part of the NHS National Constitution, the right to single sex accommodation . MH wards remained stubbornly mixed-sex, despite a vast body of research that stated the outrageous amount of sexual violence endured by women from men on the wards. Men also subjected to such abuse again the predominant perpetrators were again identified as men. Diversity being used as a trope to overlook women/girls rights to safety and security is reprehensible and is a thread that runs through MH services since the so called ‘enlightened’ 1960 when
    mixing the sexes in MH wards became ‘all the rage’. A fashion General hospitals were soon to blithely follow…and years of wasted energy decades ensued in re-versing this travesty.
    That CQC failed to act to not only defend NHS SSA policy but include reference to the Equality Act 2010 that recognises sex as one of the 9 protected characteristics , ensuring safeguards for women and girls and their right to single sex public services.
    In the 2019 NHS review of SSA we are drawn to Annex B that describes how NHS services must provide the correct service to trans patients. We are told throughout that gender is a given, and they use the Equality 2010 act to support this ideology. Something that they do not invoke in the main body of the 2019 review . Women are not mentioned as a protected category in fact it seems to have been wilfully ignored, where sex not gender is used throughout.
    The 2019 SSA NHS review appears to woefully not see the contradictions /conflict it is promoting on one hand women/girls/men/boys have a commitment from the NHS to access SSA. However this commitment is also applies to people who self identify as the opposite sex/gender.
    This confusion also appears to have transferred itself to the EU Strategy on Gender Equality. In which the opening salvo states that Sex, Race , Disability have now been defined collectively as an ‘identity’ . The fact that all 3 of these characteristics are immutable. Sex, Race, Disability are fixed and one cannot ideologically gender oneself out of all 3.
    This just demonstrates how such gender beliefs are creating havoc with everyone’s lives and that such beliefs should not influence public policy .

    1. Jo

      Totally agree. What did the CQC team ignore or cover up in 2016.? From good to inadequate in four years and decades of abuse of children ignored. Prosecutions should follow.

  4. Ian Court

    Massive thanks to Stephanie for bringing this shocking state of affairs to light and forcing the authorities to act. This is a medical and societal scandal of huge proportions.

  5. Kitty

    I listened to some of the Tavistock and Portman Hospital Trust AGM yesterday, on zoom, open to the public as it ever was in pre-zoom days, where member after member expressed the sympathy they had for the trust’s “hardworking” and “caring” staff, whose pride and careers had been damaged by their ideological not evidence based clinical practice.

    I heard no sympathy being expressed for the young, vulnerable individuals and their families deeply, horrifically affected for life by the board’s willingness to cock a deaf’un towards the many voices of protest to its practice over a period of years.

    The board’s conduct as a whole at its AGM yesterday was that of self-satisfied, narcissistic, career driven individuals concerned more about their reputations and their pensions than the thousands of lives they have screwed up with their promotion or acquiescence of quack ideas and snake oil.

    Their decision to turn off zoom comments from the public, which were only seen by members of the board, and not actually seen by the public, was another illustration that members of the board were, more than anything, simply and purely, professionally and personally affronted by the Keira Bell case; the CQC report; the Hillary Cass investigation and enquiry result.

    That I spend my days and nights trying not to think about how these individuals have played such a big part in this frankly barbaric cultural movement which has deeply affected my own family and those of many I knew before and have come to know.

    I look forward to the truth and reconciliation process where these people are held to account, if they don’t some of them end up in the prison estate of their choice.

  6. Katie

    You have done an amazing job and along with the brave Keira Bell have saved probably hundreds of children from undergoing unnecessary medication & surgery. Congratulations, well done and thank you. You are fantastic people.

  7. C. Hahn

    I so hope they do get the pants sued off them!

  8. Dick Heasman

    I wouldn’t hold out too much hope for the Cass Inquiry. From her comments on the Inquiry web page she doesn’t seem to have an open mind on whether children can have a gender identity, let alone whether Gender Identity is actually a thing.
    I hope I am wrong, she does seem to have acted courageously as a whistle-blower in the past.

  9. Lee McKenna

    Thanks from Australia. Your resources help me articulate what I need to say in a non-sensational way when I email politicians to warn them.

    The cynical me, says these changes by Tavistock are a PR attempt to ready themselves from future court cases. I fear the conveyor belt to the surgeon and hormones continues. Until gender ideology is debunked and removed from all medical services, clinics, and the overseeing medical bodies, I will continue to campaign.

    However, I understand what a HUGE win this is for us, as the Gender Reassignment Industry and the organizations that prop it up are having to adjust to public concerns. Every little adjustment they make, weakens their hold. We all need to keep going! Thank you Transgender Trends for all your TIRELESS work. When do any of you find time for sleep? Take care of yourselves. Love from Australia.

  10. charles lewis

    Dr. Michael Brady, the National Adviser for LGBT Health said: “Every child matters and children and young people who are exploring their gender or experiencing gender dysphoria, including those who are trans or non-binary, deserve the very best from the NHS.’
    Can someone tell this ass that no-one is non-binary. The human race is male and female — no more than that. Everything else is narcissistic posturing.

  11. Karen Richardson

    Obviously, male or female are we. Gender is a concept that is now confusing as it has lost its original meaning in the language used by groups such as Tavistock. Insanity. The only reasonable explanation is that “sex change” has been promoted as a method of sterilisation of vulnerable young people. The horror of this is truly shocking for a parent such as myself. It is a plain lie to tell children they can change sex. The word “gender” has been used where the word “sex” should have been used. The reality now is that our confused children with mental health problems have been made sterile for population control/ eugenics reasons. They were trapped by a lie.

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