Recurring concern

Unreliable interpreter provision for healthcare communication

First to latest report 6 Mar 2014 — 10 Dec 2025

Reports that mention this concern: 5
Times this concern has been raised: 6
Stated actions linked to this concern: 10

What this concern includes

Includes failures in the healthcare interpreter-support process, including recognising the need for an interpreter, deciding when one is required, establishing relevant protocols or roles, arranging interpreter access and using an interpreter during care.

What is not included

Excludes communication, handover or information-sharing failures that are not materially tied to the need for interpreter support.
Excludes interpreter issues outside healthcare provision.
Excludes general shortages or weaknesses in healthcare services that do not specifically affect interpreter provision.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2

Cambridgeshire and Peterborough NHS Foundation Trust1

Care Quality Commission1

Clarendon Nursing Home1

Cornwall Council1

Cornwall Partnership NHS Foundation Trust1

London Borough of Croydon1

NHS Cornwall and the Isles of Scilly Integrated Care Board1

NHS England1

Royal Cornwall Hospital1

Thornton Heath Medical Practice1

Reports and published responses 5 reports

See individual reports that have raised this concern, and the actions taken in response

10 Dec2025
Cornwall and Isles of Scilly
Concerns raised1
1. Failure to provide an interpreter during ante- and post-natal visits for a woman who did not speak English
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Cornwall Council
Royal Cornwall Hospitals NHS Trust
Stated actions 8
1. Cornwall Council
  Secure funding to update infant-feeding guidance and strengthen interpreter and translation solutions.
2. Cornwall Council
  Deliver mandatory infant-feeding training covering cultural practices, professional curiosity, interpreters and safe formula guidance, including recorded catch-up.
3. Cornwall Council
  Confirm interpreter pathways and procurement or enablement options using the draft interpretation procedure.
1. Cornwall Council
  Finalise and publish the organisation-wide Interpretation and Translation SOP and provide service-wide staff training.
2. Cornwall Council
  Horizon-scan national interpreter-service practice and share relevant examples for incorporation into the updated SOP.
3. Cornwall Council
  Add targeted quality-assurance checks on bottle-content recording and interpreter use.
4. Royal Cornwall Hospitals NHS Trust
  Strengthen interpreter and language support in maternal care.
5. Royal Cornwall Hospitals NHS Trust
  Report interpreter and language-support audits through AMaT and Perinatal Safety Trust Board reports every three months.
AI-generated summary

Izzah Fatima Ali · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Izzah Fatima Ali, a nine-month-old infant, died after developing profound iron-deficiency anaemia associated with consumption of cow’s milk. The report identified concerns about healthcare professionals failing to establish what was in her bottles, insufficient consideration of cultural practices, and the repeated absence of an interpreter during ante- and post-natal visits.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide an interpreter during ante- and post-natal visits for a woman who did not speak English
Wider context from the report
“1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry. In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle. It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact. That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle. It also reflects a lack of appreciation around different cultural practices: while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries, for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity. - A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved, contrary to guidance. ”
Source location
Izzah Fatima Ali · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Secure funding to update infant-feeding guidance and strengthen interpreter and translation solutions.

Verbatim wording from the response
“Funding secured for rapid mitigations”

Source location
Response from Cornwall Council
Page 1 · response
Published 18 December 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver mandatory infant-feeding training covering cultural practices, professional curiosity, interpreters and safe formula guidance, including recorded catch-up.

Verbatim wording from the response
“Staff training and mandatory webinar”

Source location
Response from Cornwall Council
Page 2 · response
Published 18 December 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Confirm interpreter pathways and procurement or enablement options using the draft interpretation procedure.

Verbatim wording from the response
“• A meeting has taken place with the resettlement team within Cornwall Council on January 23, 2026. Within this meeting we discussed how we can make any improvements and work closely together to ensure we are meeting the needs of families where English is not their first language. Draft Standard Operating Procedure (SOP) on Interpretation and Translation has been updated to reinforce professional use of interpreters and safeguard practice which also includes the importance of documenting need in record.”

Source location
Response from Cornwall Council
Page 2 · response
Published 18 December 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Finalise and publish the organisation-wide Interpretation and Translation SOP and provide service-wide staff training.

Verbatim wording from the response
“Policy/Standard Operating Procedure alignment on interpreter/translator services across the organisation”

Source location
Response from Cornwall Council
Page 2 · response
Published 18 December 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Horizon-scan national interpreter-service practice and share relevant examples for incorporation into the updated SOP.

Verbatim wording from the response
“External best practice initiated”

Source location
Response from Cornwall Council
Page 2 · response
Published 18 December 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Add targeted quality-assurance checks on bottle-content recording and interpreter use.

Verbatim wording from the response
“1-3 months (embed)”

Source location
Response from Cornwall Council
Page 3 · response
Published 18 December 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Strengthen interpreter and language support in maternal care.

Verbatim wording from the response
“c. Strengthened interpreter and language support in maternal care”

Source location
Response from Royal Cornwall Hospital NHS Trust
Page 2 · response
Published 18 December 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Report interpreter and language-support audits through AMaT and Perinatal Safety Trust Board reports every three months.

Verbatim wording from the response
“d. Audits of interpreter and language support will be reported to the Clinical Audit Assurance software (AMaT) and through Perinatal Safety Trust Board report. This commenced in January 2025 and will continue to be audited every 3 months.”

Source location
Response from Royal Cornwall Hospital NHS Trust
Page 2 · response
Published 18 December 2025
Open published response
28 Apr2022
Manchester South
Concerns raised1
1. Lack of clear national protocols to prevent language barriers to accessing care
Linked response

NHS England
Stated actions 1
1. NHS England
  Encourage Trusts to review interpreter systems and processes to prevent similar access failures.
Respondent positions 1
1. NHS England
  National NHS translation and interpretation framework arrangements provide Trusts with access to services addressing language barriers in care.
  Existing arrangements considered sufficient
AI-generated summary

Vilem Bock · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Vilem Bock was admitted to Tameside General Hospital with sepsis and suspected pulmonary embolism, but his CTPA was delayed because arrangements for an interpreter were not made. He developed a large retroperitoneal haematoma while receiving anticoagulation, subsequently developed sepsis, and died after further deterioration. The report raised concern about the lack of clear national protocols to prevent language barriers from obstructing access to care.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clear national protocols to prevent language barriers to accessing care
Wider context from the report
“1. The Trust in question has taken steps since the death of Mr Bock to improve the identification of the need for an interpreter to prevent language being a barrier to access to treatment. However, it was unclear from the evidence given that from a national perspective there were protocols in place to ensure that other Trusts would avoid a similar situation arising where language was a barrier to accessing care ”
Source location
Vilem Bock · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Encourage Trusts to review interpreter systems and processes to prevent similar access failures.

Verbatim wording from the response
“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. Trusts have been encouraged to review their systems and processes for interpreters to avoid a similar situation arising. This ensures that key learnings and insights around events, such as the sad death of Mr Bock, are shared across the NHS at both a national and regional level, and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location
Response from NHS England
Page 2 · response
Published 29 April 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
National NHS translation and interpretation framework arrangements provide Trusts with access to services addressing language barriers in care.

Verbatim wording from the response
“Following the inquest, you raised concerns in your Report regarding whether, from a national perspective, there were protocols in place to ensure that other Trusts would avoid a similar situation arising where language was a barrier to accessing care.”

Source location
Response from NHS England
Page 1 · response
Published 29 April 2022
Open published response
28 Feb2019
South London
Concerns raised1
1. Failure to obtain interpreter support for assessment of needs
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Yong Keng Hong · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Yong Keng Hong, an asylum seeker with very little English, was transferred from hospital to a care home after displaying self-harm and suicidal behaviour. Despite advice for constant observations and an immediate mental health referral, the observation regime was not implemented, no interpreter or risk assessment was arranged, and his call bell was returned; he used it to hang himself from a curtain rail on 12 July. Concerns included failures in observation, communication, risk assessment, clinical follow-up and staff training.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to obtain interpreter support for assessment of needs
Wider context from the report
“(1) His GP made an immediate referral to mental health services and advised constant observations, however: (a) the observation regime advised by the GP was not implemented (b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding (c) no risk assessment was carried out prior to making the decision to return his call bell. (2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement (3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments ”
Source location
Yong Keng Hong · Prevention of Future Deaths report
Page 1 · concerns
Open source report
8 Oct2014
North London
Concerns raised2
1. Lack of a framework for primary care staff to decide when an interpreter is required
2. Unavailability of interpreters to primary care staff when needed
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Chloe Siokos · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Chloe Siokos was found dead at her home on 22 January 2013 after her husband set a fire in the house and then hanged himself; the inquest concluded unlawful killing. The report identifies concerns about the absence of a framework for deciding when primary care interpreters are required, limited interpreter availability, and the lack of a system flagging when one patient's circumstances may affect care provided to another patient.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a framework for primary care staff to decide when an interpreter is required
Wider context from the report
“That there was no framework for primary care staff to make a decision when an interpreter is required. ”
Source location
Chloe Siokos · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of interpreters to primary care staff when needed
Wider context from the report
“That interpreters should be available to primary care staff more readily ”
Source location
Chloe Siokos · Prevention of Future Deaths report
Page 2 · concerns
Open source report
6 Mar2014
North London
Concerns raised1
1. Lack of national guidance on the role of interpreters during labour, particularly in theatre
Linked response

Department of Health and Social Care
Stated actions 1
1. Department of Health and Social Care
  Bring concerns about interpreter roles during labour and in theatre to NICE for future consideration.
AI-generated summary

Andrei Ciprian Matei · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Andrei Ciprian Matei was born following an emergency caesarean section and died aged 65 minutes after suffering progressive intrapartum hypoxia. The report identified concerns about the timing and method of delivery, failure to respond to abnormal fetal monitoring and obtain a further fetal blood sample, and the lack of national guidance on interpreters during labour and in theatre.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of national guidance on the role of interpreters during labour, particularly in theatre
Wider context from the report
“(1) There was no national guidance on the role of interpreters during labour in particular when the interpreter is required in theatre. ”
Source location
Andrei Ciprian Matei · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Bring concerns about interpreter roles during labour and in theatre to NICE for future consideration.

Verbatim wording from the response
“Although the guidance I have detailed does not, and in my view could not reasonably specify the exact roles of interpreters during labour or in theatre, NICE may wish to consider a review of their current guidelines in this respect. I will ensure that the matters you raise are brought to their attention for future consideration.”

Source location
2014-0089-Response
Page 3 · response
Published 25 February 2014
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Failure to provide an interpreter during ante- and post-natal visits for a woman who did not speak English

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8

Concerns raised1

Lack of clear national protocols to prevent language barriers to accessing care

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to obtain interpreter support for assessment of needs

Concerns raised2

Lack of a framework for primary care staff to decide when an interpreter is required

Unavailability of interpreters to primary care staff when needed

Concerns raised1

Lack of national guidance on the role of interpreters during labour, particularly in theatre

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Stated actions 8

Stated actions 1

Respondent positions 1

Stated actions 1