Recurring concern

Unreliable and delayed access to interpreters for safety-critical communication

First to latest report 20 Dec 2019 — 7 Oct 2025

Reports that mention this concern: 3
Times this concern has been raised: 3
Stated actions linked to this concern: 9

What this concern includes

Includes failures of dedicated interpreter or interpretation-support arrangements where unavailable, delayed or inaccessible language or sign-language interpretation impairs urgent assessment, care, safeguarding, custody support or other safety-critical communication, including prison interpretation services and British Sign Language provision for mental-health patients.

What is not included

Excludes ordinary communication deficiencies where no interpreter or interpretation-support requirement is identified.
Excludes language-access problems limited to general information or routine administration where no safety-critical communication consequence is asserted.
Excludes generic staffing, training, funding or inter-agency coordination deficiencies unless they directly make a required interpreter unavailable or delayed.
Excludes failures concerning the content or quality of communication after an appropriate interpreter was available.
Do not duplicate the existing healthcare-specific interpreter-provision parent where the assertion is confined to that narrower healthcare boundary; this proposal covers the supported cross-setting interpreter-access condition.

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

Cabinet Office1

Department for Education1

Department for Work and Pensions1

Greater Manchester Mental Health NHS Foundation Trust1

HM Prison and Probation Service1

HM Prison Service1

National Registers of Communication Professionals working with Deaf and Deafblind People1

NHS England1

Reports and published responses 3 reports

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

7 Oct2025
West Sussex, Brighton and Hove
Concerns raised1
1. Lack of British Sign Language interpreters available to support deaf mental health patients
This report raised 4 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

Imogen Alice NUNN · 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

Imogen Alice Nunn died at home on 1 January 2023 after consuming a substance she had obtained approximately six weeks earlier, during a period of deteriorating mental health. The report raises concerns about failures in mental-health risk management and the shortage of British Sign Language interpreters and BSL-proficient clinicians supporting deaf patients.

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 British Sign Language interpreters available to support deaf mental health patients
Wider context from the report
“It was issued before the Inquest had concluded as it had already become apparent that there was a real lack of British Sign Language Interpreters (BSLs) able to help support Deaf patients in the community who were being treated with mental health difficulties. This was putting this cohort of individuals at risk. The overall lack of British Sign Language Interpreters was also evidenced directly by the Court in that this Inquest has had to be delayed/adjourned for two months due to there being no available Interpreters to interpreter for two deaf/mute witnesses over the two week period of the Inquest. ”
Source location
Imogen Alice NUNN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
24 Mar2025
West Sussex, Brighton and Hove
Concerns raised1
1. Lack of available British Sign Language interpreters for Deaf patients with mental health difficulties
Linked responses

Department of Health and Social Care
National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPD
NHS England
Stated actions 7
1. NHS England
  Hold a stakeholder meeting to brief stakeholders on the plan to publish a refreshed Accessible Information Standard.
2. National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPD
  Work with the BSL Advisory Board to inform statutory guidance with professional standards and contract-level requirements for interpreter provision.
3. National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPD
  Support NHS England and Integrated Care Boards in designing procurement frameworks aligned with the Procurement Act 2023.
1. National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPD
  Support Deaf organisations and sector partners in advocating for system-wide changes enabling practical real-time language provision.
2. National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPD
  Contribute to statutory guidance under the BSL Act by promoting high-quality, regulated interpreting requirements in service specifications and contracts.
3. National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPD
  Promote person-centred procurement models embedding interpreting provision from the outset of care planning.
4. National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPD
  Promote interpreter provision as a core communication function within care and safeguarding models.
Respondent positions 6
1. Department of Health and Social Care
  Individual NHS Trusts and employers determine staffing levels and workforce composition, including appropriate weekend cover.
  Redirects responsibility
1. NHS England
  Integrated Care Boards are responsible for commissioning community mental health services and ensuring adequate BSL interpreter provision.
  Redirects responsibility
2. National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPD
  NHS commissioners and procurement leads must require interpreting agencies to adopt continuity-based frameworks and confirm interpreter availability during care planning.
  Redirects responsibility
3. National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPD
  Systemic improvement in interpreter access cannot be achieved by NRCPD alone, requiring coordinated action by multiple organisations and sectors.
  Unable to act
4. Department of Health and Social Care
  Commissioning community mental health services, including adequate BSL interpreter provision, is the responsibility of integrated care boards.
  Redirects responsibility
5. Department of Health and Social Care
  NHS trusts and integrated care boards are responsible for making Equality Act reasonable adjustments to ensure accessible services.
  Redirects responsibility
AI-generated summary

Imogen Alice NUNN · 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

Imogen Alice NUNN was found deceased at her home on 1 January 2023 after leaving a party and being reported as a high-risk missing person; the circumstances text states that she had consumed a substance bought online. The principal concern was the lack of available British Sign Language interpreters for Deaf patients receiving mental health support, particularly for urgent assessments when patients were in crisis.

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 available British Sign Language interpreters for Deaf patients with mental health difficulties
Wider context from the report
“During the course of the Inquest (which has yet to be concluded) I heard evidence that there was a lack of availability of British Sign Language Interpreters able to help support Deaf patients in the community who were being treated with mental health difficulties. This was particularly apparent when mental health staff were seeking an interpreter at short notice for a patient who was in crisis. The lack of interpreters available has meant that urgent assessments are being carried out with no interpreters present. The overall lack of British Sign Language Interpreters has also meant that this Inquest has itself had to be delayed/adjourned for two months due to there being no available Interpreters to interpreter for two deaf witnesses over the two week period of the Inquest. ”
Source location
Imogen Alice NUNN · 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
Hold a stakeholder meeting to brief stakeholders on the plan to publish a refreshed Accessible Information Standard.

Verbatim wording from the response
“loss. The AIS was co-designed with stakeholders such as Sign Health and the British Deaf Association. A meeting will be held by NHS England later in May 2025 to brief stakeholders on the plan to publish a refreshed version of the AIS. The revised AIS is expected to ensure that BSL interpreters are suitably qualified, and that their provision is a requirement for families and carers, as well as patients.”

Source location
Response from NHS England
Page 2 · response
Published 27 March 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
Work with the BSL Advisory Board to inform statutory guidance with professional standards and contract-level requirements for interpreter provision.

Verbatim wording from the response
“In accordance with the British Sign Language (BSL) Act 2022, the Department for Culture, Media and Sport has established the BSL Advisory Board, which is now tasked with developing statutory guidance. As the UK’s largest voluntary register of communication professionals working with Deaf and Deafblind people, NRCPD considers it incumbent upon us to contribute actively to this work.”

Source location
Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
Page 4 · response
Published 27 March 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
Support NHS England and Integrated Care Boards in designing procurement frameworks aligned with the Procurement Act 2023.

Verbatim wording from the response
“NRCPD’s Role in Supporting Procurement Reform”

Source location
Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
Page 9 · response
Published 27 March 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
Support Deaf organisations and sector partners in advocating for system-wide changes enabling practical real-time language provision.

Verbatim wording from the response
“• Support national Deaf organisations and sector partners in advocating for system-wide changes, including service models that make real-time language service provision a practical reality.”

Source location
Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
Page 10 · response
Published 27 March 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
Contribute to statutory guidance under the BSL Act by promoting high-quality, regulated interpreting requirements in service specifications and contracts.

Verbatim wording from the response
“• Contributing to the development of statutory guidance under the BSL Act”

Source location
Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
Page 9 · response
Published 27 March 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
Promote person-centred procurement models embedding interpreting provision from the outset of care planning.

Verbatim wording from the response
“We will commit to:”

Source location
Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
Page 14 · response
Published 27 March 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
Promote interpreter provision as a core communication function within care and safeguarding models.

Verbatim wording from the response
“• Promote models in which interpreter provision is recognised as a core communication function and not a peripheral support service, particularly where language access is essential to care and safeguarding.”

Source location
Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
Page 14 · response
Published 27 March 2025
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
Individual NHS Trusts and employers determine staffing levels and workforce composition, including appropriate weekend cover.

Verbatim wording from the response
“Individual NHS Trusts and other employers are responsible for determining staffing levels and workforce composition. They are best placed to understand their services and the needs of their patients in order to deliver safe and effective care. I would expect South West London & St George’s Mental Health Trust, and all other NHS Trusts to ensure that their staffing arrangements, including weekend cover, are appropriate, following the tragic death of Ms Nunn.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 27 March 2025
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
Integrated Care Boards are responsible for commissioning community mental health services and ensuring adequate BSL interpreter provision.

Verbatim wording from the response
“NHS England recognises that the provision of interpreters within community mental health services is important, both to support patients and to ensure that comprehensive mental health assessments take place in a timely manner. Commissioning of community mental health services is the responsibility of Integrated Care Boards (ICBs), and this includes responsibility for ensuring there is adequate provision of BSL interpreters to support deaf patients in the community. Should a Trust or local provider experience challenges in booking interpreters, they would be expected to identify this as a risk and work with their commissioner (ICB) to resolve the issue.”

Source location
Response from NHS England
Page 1 · response
Published 27 March 2025
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
NHS commissioners and procurement leads must require interpreting agencies to adopt continuity-based frameworks and confirm interpreter availability during care planning.

Verbatim wording from the response
“To embed this model into practice, NHS commissioners and procurement leads must require interpreting agencies to adopt a continuity-based framework. This includes demonstrating systems for assigning dedicated interpreter teams to long-term care cases, contributing to meeting scheduling logistics (without clinical involvement), and confirming interpreter availability at the planning stage.”

Source location
Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
Page 7 · response
Published 27 March 2025
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
Systemic improvement in interpreter access cannot be achieved by NRCPD alone, requiring coordinated action by multiple organisations and sectors.

Verbatim wording from the response
“This is not a challenge NRCPD can meet alone. But we are committed to playing our part, informed by evidence, guided by our registrants, and accountable to the Deaf and Deafblind communities we exist to protect.”

Source location
Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
Page 10 · response
Published 27 March 2025
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
Commissioning community mental health services, including adequate BSL interpreter provision, is the responsibility of integrated care boards.

Verbatim wording from the response
“You raised in your report concerns about the availability of British Sign Language (BSL) interpreters available in the local community. We fully recognise the importance of the provision of interpreters within community mental health services, both to support patients and to ensure that comprehensive mental health assessments take place in a timely manner. Commissioning of community mental health services is the responsibility of integrated care boards, and this includes responsibility for ensuring that there is adequate provision of British Sign Language interpreters to support deaf patients in the community.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 27 March 2025
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
NHS trusts and integrated care boards are responsible for making Equality Act reasonable adjustments to ensure accessible services.

Verbatim wording from the response
“It is for individual NHS organisations including NHS trusts and integrated care boards to comply with the Equality Act 2010. Under the Equality Act 2010, organisations have a legal duty to make changes in their approach or provision to ensure that services are as accessible to people with disabilities as they are for everybody else. These changes are called reasonable adjustments. The Reasonable Adjustment Flag was developed in the NHS Spine”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 27 March 2025
Open published response
20 Dec2019
Manchester City
Concerns raised1
1. Inconsistent use of interpretation services during healthcare interviews and ACCT reviews
This report raised 20 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

HM Prison and Probation Service
Stated actions 2
1. HM Prison and Probation Service
  Complete changes to the redesigned ACCT form and guidance and roll them out across the prison estate.
2. HM Prison and Probation Service
  Improve interpretation-service use at HMP Manchester by providing conference-style telephones for case reviews.
AI-generated summary

Tomasz Nowosad · 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

Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by neglect.

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
Inconsistent use of interpretation services during healthcare interviews and ACCT reviews
Wider context from the report
“5 4 It appears that there was no consistent use of the language line interpretation service by HMPS or GMMH staff, and it is suggested that wherever an identified need for the use of this service is recognised it should be used on all healthcare interviews as well as at ACCT reviews While some prisoners may speak some, little or virtually no English, it is essential that every effort is made to ensure that they can understand, so far as it possible, the issues being raised and discussed with them. ”
Source location
Tomasz Nowosad · Prevention of Future Deaths report
Page 7 · 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
Complete changes to the redesigned ACCT form and guidance and roll them out across the prison estate.

Verbatim wording from the response
“A number of your concerns relate to the Assessment, Care in Custody and Teamwork (ACCT) case management process for those identified as being at risk of self-harm or suicide. We have been working hard to improve the way that this system operates. Following a comprehensive review, we have devised a new version of the form and associated guidance, and I am pleased to note that much of what you have suggested has been adopted as part of that. We believe the new version will make the system easier to operate and thereby improve the quality of care offered to prisoners. It was piloted in ten establishments in 2019 and the feedback has been positive. We are currently making some further changes before rolling it out across the prison estate later in 2020.”

Source location
2019-0445-Response-from-HMPPS
Page 1 · response
Published 8 January 2020
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
Improve interpretation-service use at HMP Manchester by providing conference-style telephones for case reviews.

Verbatim wording from the response
“Second, interpretation services (5.4). You express concern about inconsistent use of such services by staff. A national contract with The Big Word ensures the availability of interpretation services across the prison estate. The new ACCT guidance will emphasise the importance of their use throughout the process, and the new ACCT form will include prompts to consider the use of the service at every significant point, including assessments and case reviews. In advance of the roll out of the new version of ACCT, the Governor of HMP Manchester has taken action to improve the use of the service at the prison, for example by making conference style telephones available for use at case reviews.”

Source location
2019-0445-Response-from-HMPPS
Page 2 · response
Published 8 January 2020
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

Lack of British Sign Language interpreters available to support deaf mental health patients

Concerns raised1

Lack of available British Sign Language interpreters for Deaf patients with mental health difficulties

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.7

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6

Concerns raised1

Inconsistent use of interpretation services during healthcare interviews and ACCT reviews

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.2

Stated actions 7

Respondent positions 6

Stated actions 2