Hove GP put kids at harm by prescribing hormones without proper assessment or monitoring, damning report finds

A Hove GP practice prescribed cross-gender hormones to scores of children after “wholly inadequate” assessments, and without properly explaining the risks or making sure they understood them, an NHS investigation has found.

One of the GPs who worked at WellBN has been suspended as a result of the investigation, which was published this afternoon.

It found children being treated by WellBN and their families – some as young as 11 – were not properly informed of the impact the drugs have on fertility.

Most of the children treated by the practice, which has a branch in Western Road, also had possible neurodevelopmental issues, but there was no evidence this was taken into account when prescribing the drugs.

None of them had a clear diagnosis of gender incongruence of gender dysphoria from a specialist.

In 20 of the 78 cases looked at, the drugs were prescribed without a face to face appointment.

The practice said these were all cases where the children were already being prescribed the hormones, often by private providers. In one case, a family was told to get a private prescription so Well BN could use that to justify its own prescribing.

Serious safeguarding failings were also identified, with some patients even advised to avoid contact with social care in case questions were asked about gender medication.

The probe into the supply of medication for gender dysphoria was launched a year ago by NHS Sussex.

It followed the launch of a High Court challenge against the practice lodged by the father of a transgender teenager who had been prescribed cross-sex hormones without parental consent.

The father, known only as ATN, wanted the practice to stop prescribing gender affirming hormones to under-18s.

In April last year, the practice said it would no longer prescribe hormones to new under-18 patients and this week, it wrote to families of existing patients to say it would be withdrawing prescriptions from them too.

More than a third of the patients whose care was investigated lived outside Sussex, with the furthest living 480 miles away.

The report criticises the actions of two GPs, which it refers to as Dr A and Dr C. In June last year, one of the partners, Dr Sam Hall, quit the practice.

Dr Christopher Tibbs, regional medical director for NHS England in the South East said: “The welfare and safety of these children, young people and their families is our primary concern.

“It is clear from the independent report published today that children and young people were put at risk of harm because of the actions of some practitioners at the WellBN practice who provided specialist diagnosis, care and treatment that they were neither qualified, nor commissioned to deliver by the NHS – under no circumstances should this have happened.

“We understand that this will be a difficult time for many of the young people who have been treated at the WellBN practice.

“These children, young people and their families have been offered a referral to a specialist NHS gender service should they wish to, and we have made arrangements for additional support as they come to understand the consequences of the failings identified.

“The report has been shared with the clinical regulatory bodies who will determine what further action may be taken with those involved.

“In the meantime, NHS England has suspended one of the GPs identified in the report, from working in general practice in the NHS in England while further investigations into their professional practice failures are completed.”

Dr Charlotte Canniff, joint chief medical officer for NHS Surrey and Sussex Integrated Care Board said: “Our priority has always been to ensure that children and young people are receiving safe, evidence-led care within commissioned NHS services.

“The findings from this investigation show that the care provided by WellBN was outside national NHS guidance and specialist oversight.

“We will work with NHS England to support the actions going forward and fully deliver the recommendations to the ICB within the report.

“We remain committed to supporting all of the families in scope of this investigation and more widely to receive appropriate care – the majority of those within the investigation have now been referred to a gender specialist NHS service and we will work to support all remaining children and young people to see these specialists quickly and agree their onward care.”

The result of the investigation has been welcomed by campaign group PHSE Brighton, which supports parents with concerns about the safeguarding of gender distressed children.

Co-founder Adrian Hart said: “One child being harmed is too many. Since we were founded in 2023, we have met families, doctors, social workers, and teachers, all of whom have raised concerns about the failure to adequately safeguard gender distressed children and provide them holistic care.

“Harm has been happening in plain sight; the wilful ignorance of public sector bodies needs to end. It’s imperative there is a proper investigation into how this has been allowed to happen.”

In a statement on its website, WellBN said: “Following a recent investigation by NHS Sussex into the care of our TNBI young people, we would like to reassure all patients that WellBN continues to provide safe, high-quality care and support to our community.

“We understand that some patients may have questions or concerns. We want to make it clear that our services remain fully operational, and there is no change to the care, treatment, or support our patients receive.

“Our priority remains providing compassionate, safe, and effective care for all patients. At the same time, we recognise the seriousness and sensitivity of the matters raised within the investigation.

“Our thoughts remain with the families involved, and we are committed to supporting them appropriately throughout this process.

“We are committed to working closely with NHS partners and regulators to address any recommendations identified within the report and to continue strengthening the services we provide.

“Our dedicated teams continue to work every day to ensure patients can access the care they need, when they need it. Patient safety, wellbeing, and continuity of care remain our highest priorities.

“Patients should continue to attend appointments, contact us in the usual way, and access services as normal.”

In the 2024 Cass Review, Baroness Hilary Cass recommended “extreme caution” in providing hormone treatment to children and said there must be a “clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18”.

In March 2025, the NHS paused gender-affirming hormone treatment for 16 and 17-year-olds after a separate review found evidence did not support its continued use.

It had already stopped the use of puberty blockers, with a temporary ban in March 2024 being made indefinite in December of the same year.

The NHS Sussex investigation looked at the care of 78 children and young people who received a prescription for gender care from 2023 to 2025.

In only six cases was the practice able to provide proof the child was capable of consenting. Of the rest, 50 children were under the age of 16.

The report says the practice was not commissioned by the NHS to provide this specialist care.

It said it was clear staff genuinely wanted to help distressed children who had experienced delays in being referred to specialist services.

But it added: “The practice has stated that in a number of cases the parents described access to its service as ‘’life saving’ as their children were presenting with suicidality and dysphoria which represented a risk to their life as well as their social and psychological development’.

“However, that does not change the fact that prescribing without assurance of holistic specialist assessment and diagnosis, without referral to endocrinologists and without the associated tests and monitoring (i.e. outside the requirements of the service specification for the commissioned specialist services) increased the risk of moderate to severe physical and psychological harm in the longer term.”

When collating the evidence for the investigation, NHS Sussex found appointment record-keeping was “extremely poor”.

Information often discussed in texts and emails outside clinical appointments but not included in patient notes – and GP entries on the notes themselves were often extremely brief.

The report said it was important to note that during the time the prescriptions were made, it was extremely difficult for children with gender dysphoria to get an appointment at a specialist service, with fewer than 15 of the 61 referred being seen and only four receiving ongoing care.

It said many of the children had come to WellBN after being prescribed hormones by private providers.

In many of these cases, it accepted the assessment of the children made by the private providers – even though it knew some of these services had only ever assessed the children via online appointments.

It said: “There was evidence that a parent of a child under 16years of age was advised by the care coordinator to get prescriptions of gender affirming hormones (GAH) from private prescribers even if never dispensed or given, so that a decision to assume prescribing of GAH could be later justified by WellBN ‘using the concept of harm reduction’.”

It said while six month reviews were planned, there was no evidence these took place regularly, “mainly occurring at a time of crisis”.

There was only evidence of four of the patients being seen by NHS paediatric endocrinologists. Most had either no or incomplete auxology assessments to monitor how they were growing.

Where the auxology tests flagged abnormalities such as high or low BMI, this rarely led to an appropriate response or increased monitoring.

Blood tests were often either incomplete, carried out at inappropriate times or too irregularly to allow effective monitoring.

No bone X rays were available.

The investigation also found some patients were prescribed up to a year’s supply of medication in August 2025, which the report says may have been due to concern the practice would be told to stop prescribing.

The report says while the practice was proactive in helping patients get ASD or ADHD assessments, there was no acknowledgemnt neurodiversity could have an impact on gender related distress – and no adaptations made to help these children understand the condition and their treatment.

There was also no evidence the practice made referrals where there were safeguarding concerns including domestic abuse, transphobic abuse, mental health concerns, the use of banned medications and social service or police involvement.

Nor was there evidence of any attempt to establish safeguarding history when a patient had changed their name and NHS number.

The report said: . It is noted with concern that in the Practice response it was stated that some patients had ‘refused’ safeguarding referrals ‘due to suspicion that the safeguarding process had previously been ‘weaponised’ against them’.

“Refusal appeared to be accepted as it was stated by the Practice that ‘in these instances, the clinicians were happy there was no cause for concern’.

“The MRT is concerned with the suggestion that safeguarding referrals could be ‘refused’ by a patient or their family.

“It was also of significant concern to the MRT that the emails from a practice care coordinator to families included examples of advising avoiding contact with social care in case questions were asked about gender medication.”

The full report can be read here.