Concerns raised 5 Failure to procure interpreting services through agencies specialising in British Sign Language View source Lack of availability of British Sign Language qualifications and training View source Failure to recruit and retain sufficient BSL-proficient clinicians View source Lack of statutory regulation for British Sign Language interpreters View source Lack of British Sign Language interpreters available to support deaf mental health patients View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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. The report was sent to Cabinet Office; that does not assign responsibility.
PFD Monitor interpretation Failure to procure interpreting services through agencies specialising in British Sign Language
Wider context from the report “1. Matter for the Cabinet Office (Equalities. The Disability Unit/BSL Advisory Board. Sponsoring the Procurement Act 2023.
AND the Minister of State (Minister for Social Security and Disability)
The Chief Executive of the NRCPD provided evidence that the Procurement Act offers NHS bodies and Integrated Care Boards (ICBs) the opportunity to collaborate with organisations like NRCPD to develop contracts that improve the delivery of BSL interpreting services. At present, contracts for interpreting services are often awarded to larger agencies, where BSL interpreting forms only a small part of broader contracts primarily focused on spoken languages, rather than being handled by agencies specialising in BSL. Evidence also highlighted the absence of statutory regulation for BSL interpreters. The NRCPD Chief Executive emphasised that establishing a statutory regulator would help professionalise and elevate the status of BSL interpreters, which in turn would promote the role and increase the number of specialists available to support deaf mental health patients. Since the Cabinet Office holds responsibility for disabilities, I raise these concerns regarding the national shortage of BSL interpreters and the lack of regulation in this area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cabinet Office; that does not assign responsibility.
PFD Monitor interpretation Lack of availability of British Sign Language qualifications and training
Wider context from the report “3. Matter for the Department of Education.
Evidence was heard that the lack of BSL interpreters was in part due to the lack of availability of BSL qualifications and training .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cabinet Office; that does not assign responsibility.
PFD Monitor interpretation Failure to recruit and retain sufficient BSL-proficient clinicians
Wider context from the report “2. Department of Health and Social Care
Evidence indicates that clinicians who are fluent in British Sign Language (BSL) provide a significantly better experience for deaf patients compared to non-BSL - speaking clinicians relying solely on interpreters.
The NHS England response to the earlier Prevention of Future Deaths (PFD) report outlined the role of Integrated Care Boards (ICBs) in commissioning interpreting services for NHS Trusts. However, there is a clear shortage of BSL-proficient clinicians , and insufficient efforts are being made to recruit and retain these professionals . This gap is failing to meet the needs of deaf individuals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cabinet Office; that does not assign responsibility.
PFD Monitor interpretation Lack of statutory regulation for British Sign Language interpreters
Wider context from the report “1. Matter for the Cabinet Office (Equalities. The Disability Unit/BSL Advisory Board. Sponsoring the Procurement Act 2023.
AND the Minister of State (Minister for Social Security and Disability)
The Chief Executive of the NRCPD provided evidence that the Procurement Act offers NHS bodies and Integrated Care Boards (ICBs) the opportunity to collaborate with organisations like NRCPD to develop contracts that improve the delivery of BSL interpreting services. At present, contracts for interpreting services are often awarded to larger agencies, where BSL interpreting forms only a small part of broader contracts primarily focused on spoken languages, rather than being handled by agencies specialising in BSL. Evidence also highlighted the absence of statutory regulation for BSL interpreters. The NRCPD Chief Executive emphasised that establishing a statutory regulator would help professionalise and elevate the status of BSL interpreters, which in turn would promote the role and increase the number of specialists available to support deaf mental health patients. Since the Cabinet Office holds responsibility for disabilities, I raise these concerns regarding the national shortage of BSL interpreters and the lack of regulation in this area .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cabinet Office; that does not assign responsibility.
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.
” Open source report
Concerns raised 5 Lack of assigned government responsibility for beach safety policy and legislation View source Unavailability of seasonal lifeguards during periods of required beach safety coverage View source Difficulty sourcing PPE for beach safety operations View source Lack of clear legal duties for beach safety and lifeguard provision View source Failure to provide advance notice of changes requiring beach safety mobilisation View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Michael Pender and 2 others · 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
Michael Pender, Jan Klempar and Paul Mullen drowned at beaches in Cornwall during summer 2020 after entering difficulty in the sea; the beaches would ordinarily have had lifeguards, but none were present at the relevant times following the easing of COVID-19 lockdown restrictions. The principal concerns were difficulties in recruiting and preparing seasonal lifeguards, lack of advance notice to the RNLI about the relaxation of lockdown, difficulties sourcing PPE, and wider uncertainty about responsibility for beach-safety policy and the provision of lifeguards.
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. The report was sent to Cabinet Office; that does not assign responsibility.
PFD Monitor interpretation Lack of assigned government responsibility for beach safety policy and legislation
Wider context from the report “In 2016, seven men drowned at Camber Sands in East Sussex. My colleague, HM Senior Coroner Mr Craze, wrote a series of PFDs. This led to the publication by the MCA of previously lacking guidance for landowners and local authorities on how to manage beach safety and is to be welcomed.
The MCA also commissioned from DWF a report reviewing legal responsibilities for beach safety that was available in January 2019 but not published until November 2020. It identified a confused and conflicting legal landscape where there was no clear legal duty to provide lifeguards and most owners/occupiers were acting out of social conscience than for any other reason. All stakeholders wanted greater clarity to be introduced. That has not happened and there has been no formal government response to the review. Indeed, it appears as though there is no government department that has responsibility for the area. In a letter from the Secretary of State for Transport, Mr Harper, to me I was informed:
Neither the MCA, nor the Department for Transport (DfT), has any wider responsibilities for beach safety policy or legislation.
This may provide an explanation for why this concern has remained for so long. As long ago as 2006, a local MP observed that it was a ‘ridiculous anomaly’ that there was more regulation for swimming in a public pool than there was for swimming in the more dangerous environment of the sea, or that there were stricter standards for working on a vessel at sea than there were for members of the public going to the coast.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cabinet Office; that does not assign responsibility.
PFD Monitor interpretation Unavailability of seasonal lifeguards during periods of required beach safety coverage
Wider context from the report “i) The government took the decision to offer furlough to those in receipt of PAYE as at the end of February 2020. Most of the c1600 lifeguards who work on the 250 beaches where the RNLI are present are seasonal employees. They did not qualify for furlough. At that point in time, the RNLI was in the process or recruiting and training the seasonal lifeguards it required. When furlough was not offered, a number had to seek alternative means of income. As lockdown was eased and lifeguards were required, the RNLI did not have immediately available to it the seasonal employees it required to provide beach safety around the coast.
I found this contributed to the problems that ensued in a partial sense. I do not suggest that had the seasonal lifeguards been furloughed all of the difficulties could have been avoided. The evidence revealed some lifeguards may not have wanted to take up their position in light of COVID and there were additional complications like how new lifeguards became formally qualified when providers were not available as well as how the RNLI could have provided COVID secure places of work in the time available;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cabinet Office; that does not assign responsibility.
PFD Monitor interpretation Difficulty sourcing PPE for beach safety operations
Wider context from the report “iii) The RNLI had considerable difficulties sourcing PPE on the open market. Thought may wish to be given to whether it should have priority access to government stock in the event of a future pandemic.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cabinet Office; that does not assign responsibility.
PFD Monitor interpretation Lack of clear legal duties for beach safety and lifeguard provision
Wider context from the report “In 2016, seven men drowned at Camber Sands in East Sussex. My colleague, HM Senior Coroner Mr Craze, wrote a series of PFDs. This led to the publication by the MCA of previously lacking guidance for landowners and local authorities on how to manage beach safety and is to be welcomed.
The MCA also commissioned from DWF a report reviewing legal responsibilities for beach safety that was available in January 2019 but not published until November 2020. It identified a confused and conflicting legal landscape where there was no clear legal duty to provide lifeguards and most owners/occupiers were acting out of social conscience than for any other reason. All stakeholders wanted greater clarity to be introduced. That has not happened and there has been no formal government response to the review. Indeed, it appears as though there is no government department that has responsibility for the area. In a letter from the Secretary of State for Transport, Mr Harper, to me I was informed:
Neither the MCA, nor the Department for Transport (DfT), has any wider responsibilities for beach safety policy or legislation.
This may provide an explanation for why this concern has remained for so long. As long ago as 2006, a local MP observed that it was a ‘ridiculous anomaly’ that there was more regulation for swimming in a public pool than there was for swimming in the more dangerous environment of the sea, or that there were stricter standards for working on a vessel at sea than there were for members of the public going to the coast.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cabinet Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide advance notice of changes requiring beach safety mobilisation
Wider context from the report “ii) The lack of advance notice given to the RNLI of government’s intention to relax lockdown and allow people to travel to the beach again. The RNLI anticipated the difficulties developing. It wrote to the Department of Transport and the Prime Minister to make sure the relevant people were aware of the problems. By letter of 24 April 2020, Kelly Tolhurst MP, Minister for Aviation, Maritime & Security informed the RNLI Chief Executive that: ‘Officials will ensure RNLI is notified as far in advance as possible to enable you to mobilise your assets as appropriate.’ That did not happen. The RNLI learned of the decision to relax lockdown at the same time as the general public and was put in an impossible situation of needing to provide lifeguards on beaches the next day. Mr Pender drowned before there were any lifeguards on any beaches.
” Open source report
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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 Pass concerns about RNLI access to adequate PPE to the Department of Health and Social Care.
Verbatim wording from the response “○ On the concerns around the RNLI not having access to an adequate supply of PPE, we have passed your concerns onto DHSC, which they have acknowledged receipt of. The procurement and distribution of healthcare related supplies including PPE is being examined in Module 5 of the Inquiry, and we await the Inquiry’s recommendations on this issue.” Source location Response from Cabinet Office
Open published response
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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 Consider beach safety policy, including clarity about landowners’ and occupiers’ duties and departmental responsibility.
Verbatim wording from the response “I note your concerns in relation to beach safety policy more generally, including the calls for greater clarity for landowners and occupiers on their duties, and the lack of clear departmental responsibility within government. Government is currently considering these issues and we would be happy to provide your office with an update as this progresses.” Source location Response from Cabinet Office
Open published response
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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 Share concerns about RNLI lifeguard furlough eligibility with HM Treasury and HM Revenue and Customs.
Verbatim wording from the response “○ On the issue of the RNLI lifeguards not being eligible for furlough, we have shared your concerns with HMT and HMRC given their oversight of the policy, which they have acknowledged receipt of. Covid economic support schemes, including the Coronavirus Job Retention Scheme, are being examined in Module 9 of the Inquiry, and we await the Inquiry’s recommendations on this issue;” Source location Response from Cabinet Office
Open published response
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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 Existing regular communication between DfT, MCA and RNLI addresses advance notice for lifeguard recruitment and training.
Verbatim wording from the response “○ On the RNLI receiving advance notice to allow them to recruit and train lifeguards, the Department for Transport and the Maritime and Coastguard Agency have advised they maintain a strong working relationship with the RNLI with regular communication with the organisation. Government communication is also a subject that was covered in Module 2 of the UK Covid-19 Inquiry so we await their recommendations in relation to this;” Source location Response from Cabinet Office
Open published response
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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 HMT and HMRC oversee the policy concerning RNLI lifeguard eligibility for furlough.
Verbatim wording from the response “○ On the issue of the RNLI lifeguards not being eligible for furlough, we have shared your concerns with HMT and HMRC given their oversight of the policy, which they have acknowledged receipt of. Covid economic support schemes, including the Coronavirus Job Retention Scheme, are being examined in Module 9 of the Inquiry, and we await the Inquiry’s recommendations on this issue;” Source location Response from Cabinet Office
Open published response
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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 DHSC is responsible for procurement and distribution of healthcare-related supplies, including PPE.
Verbatim wording from the response “○ On the concerns around the RNLI not having access to an adequate supply of PPE, we have passed your concerns onto DHSC, which they have acknowledged receipt of. The procurement and distribution of healthcare related supplies including PPE is being examined in Module 5 of the Inquiry, and we await the Inquiry’s recommendations on this issue.” Source location Response from Cabinet Office
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations