PFD report

Vilem Bock · Prevention of Future Deaths report

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Issued 28 Apr 2022•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of clear national protocols to prevent language barriers to accessing care
    Part of recurring concern: Unreliable interpreter provision for healthcare communication
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

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

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 29 April 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

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

    Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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 ”

Is this part of a recurring concern?

Yes — Unreliable interpreter provision for healthcare communication.

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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

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

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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

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

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Discuss all received Prevention of Future Deaths reports through the Regulation 28 Working Group.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2022.

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

Discuss all received Prevention of Future Deaths reports through the Regulation 28 Working Group.

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
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026