23 October 2020

Before HM Senior Coroner Dr P. Harrowing
Avon Coroner’s Court
12-16 October 2020

The family of Alexandra Greenway, a 23 year old transgender woman from Bristol, have today spoken out about their frustration at the uncritical inquest into her self-inflicted death. They are concerned an opportunity to prevent future deaths has been missed.

The inquest concluded on 16 October 2020, finding that on the balance of probabilities Alexandra Greenway took her own life. In a short form conclusion, HM Senior Coroner Dr Peter Harrowing said her death on 11 May 2019 was a suicide.

The coroner did not draw conclusions on the quality of care Alexandra received from her GP or mental health professionals at Avon and Wiltshire Mental Health Partnership NHS Trust. The coroner previously rejected the family’s request for a wide ranging inquest (under Article 2 of the Human Rights Act) which could have considered the broader circumstances. This also meant the family were unable to access legal aid for the inquest, despite the NHS being represented at public expense.

Alexandra’s family had hoped the inquest would examine the broader circumstances, including Alexandra’s access to treatment for gender dysphoria, and the regard given to her higher risk of suicide and specific mental health needs as a transgender person. Evidence to the inquest confirmed that Avon and Wiltshire Mental Health Partnership NHS Trust had no specific policies or training relating to the treatment of transgender people in their services.

This is a national issue. The Royal College of General Practitioners report that Gender dysphoria and gender identity issues are not part of GP training. GPs face difficulties in accessing gender identity specialists in a timely way, which often has severe implications for the mental and physical health of their patients. The Royal College last year called for these gaps to be “urgently addressed”. Healthwatch UK report this is an issue across NHS services. 

Alexandra loved literature and enjoyed playing the guitar. She had an inquisitive mind and was regarded as gifted at school. She was interested in politics and human rights and studied clinical psychology at university. Alexandra’s experiences with gender dysphoria were formally recognised in 2013 when she was at university.

Whilst waiting to access treatment, Alexandra’s family report she felt forced to self-medicate with costly hormones purchased online. Due to the long waiting lists, Alexandra was first seen by gender specialists in 2016. She was able to access some medical treatment for her gender dysphoria, including a surgery in 2017. However, she had very difficult experiences with this including poor treatment by NHS staff. Alexandra wanted further medical interventions, including laser hair removal, but during a mental health assessment she described accessing treatment for gender dysphoria as being like a lottery.

In the months before her death Alexandra had reported increasing distress stemming from her desire for and struggle to access laser hair removal, as well as stress and dissatisfaction in her job. It is believed she was also in a polyamorous relationship and one of her partnerships or close friendships had recently ended, which she did not discuss with medical professionals or her family.

Alexandra had long term issues with mental ill health, including depression and previous suicide attempts dating back to her teens. Alexandra told her GP and other mental health professionals who assessed her that she wanted to access talking therapy. Her family report that she wanted to speak to someone who was aware of LGBT culture and experiences.

Just over a month before her death, on 10 April 2019 Alexandra was detained by police (under Section 136) after attempting to jump from a bridge. She was taken to the Bluebell Unit at Green Lane Hospital, who assessed that there was no imminent risk to her safety. Alexandra was discharged to the care of her GP and she was provided the number of a crisis line in case things got worse.

Her parents were not informed about this incident until after her death. No care plan was recorded by any of the services Alexandra was in touch with over this period. No discharge letter was ever sent to her GP. Two psychiatrists had recommended Cognitive Behavioural Therapy (CBT) for Alexandra, but the initial assessment call from Bristol Well-Being Therapies did not come until 40 days after her death. Had the call come, evidence to the inquest suggested that Alexandra was likely to be assessed as unsuitable for this service and referred elsewhere.

At the time of her death Alexandra was not receiving mental health treatment, with the exception of anti-depressants which she did not feel were helping. In the days leading up to her death, Alexandra’s boyfriend, who she lived with, reported that she appeared increasingly unhappy and distressed. He woke to Alexandra vomiting, having ingested toxic substances, and called an ambulance, but she could not be saved.

Jacqueline Greenway, Alexandra’s mother, said: “As a family we were devastated by the results of this inquest. The coroner had refused to establish an inquest which would look at the broader circumstances of Alexandra’s death. At the inquest we were not given the opportunity to read our statements to the court, say what she was like as a person, or even show a picture of our daughter. We are deeply disappointed that the coroner only delivered a short form conclusion, and did not agree with our submissions that concerns about systemic failures should be raised to prevent future deaths.

From the evidence we have, we think professionals assessing Alex’s suicide risk prior to her death failed to consider all the relevant factors, including her needs as a transgender woman. They did not take account of her long-standing dissatisfaction and distrust of medical professionals, developed through her negative experiences of GPs, the gender identity clinic, and mental health services, generally. She felt constantly marginalised and fobbed off.

We believe that there were systemic failings in Alexandra’s medical care. All services appeared to be under too much pressure. Communications were confused, and there was lack of immediate local services. People were not available to place phone calls, and Alex seemingly never saw the same person twice. The assessment of Alexandra’s suicide risk was not cognisant of her true personal circumstances, because little effort was made to uncover them. Possibly, Alex simply got tired of waiting in a vacuum.”

Selen Cavcav, Senior Caseworker at INQUEST said: “This inquest has looked at the final weeks of Alexandra’s life. She was a young woman trying to access suitable therapy and support passed from pillar to post. With oversubscribed, disconnected and under supported mental health services, she simply did not get help the help she needed. Now more than ever, access to gender informed specialist mental healthcare must be a priority in Bristol and nationally.

The inquest did not consider the broader systemic issues which clearly contributed to Alexandra’s experiences. Urgent national action is required to ensure the needs of transgender people are met at every level of our NHS, from GPs to A&Es to specialist mental health services.”


For further information, interview requests and to note your interest, please contact INQUEST Communications Team: 020 7263 1111 or [email protected]; [email protected]

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and Trans Media Watch guidelines for reporting on transgender people.

Alexandra’s family are represented by INQUEST Lawyers Group members Beth Grossman from Doughty Street Chambers on a pro bono basis. The family are supported by INQUEST caseworker Selen Cavcav.

Other interested parties represented at the inquest are Avon and Wiltshire Mental Health Partnership NHS Trust, and a GP involved in her care.  

The inquest into the death of student Natasha Abrahart in 2018 previously found failures in the actions of Avon and Wiltshire Mental Health Partnership NHS Trust. See media release, May 2019.


Further information: