PFD report

Imogen Alice NUNN · Prevention of Future Deaths report

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Issued 24 Mar 2025•West Sussex, Brighton and Hove

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
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
19

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 available British Sign Language interpreters for Deaf patients with mental health difficulties
    Part of recurring concern: Failure to provide reliable community mental health assessmentsPart of recurring concern: Unreliable and delayed access to interpreters for safety-critical 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.7

  1. Action

    Hold a stakeholder meeting to brief stakeholders on the plan to publish a refreshed Accessible Information Standard.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
  2. Action

    Work with the BSL Advisory Board to inform statutory guidance with professional standards and contract-level requirements for interpreter provision.

    Stated by National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPDStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
  3. Action

    Contribute to statutory guidance under the BSL Act by promoting high-quality, regulated interpreting requirements in service specifications and contracts.

    Stated by National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPDStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    Individual NHS Trusts and employers determine staffing levels and workforce composition, including appropriate weekend cover.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 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. ”

Is this part of a recurring concern?

Yes — Failure to provide reliable community mental health assessments; Unreliable and delayed access to interpreters for safety-critical 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

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

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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

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

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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

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

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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

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

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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

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

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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

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

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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

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

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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

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

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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

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

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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

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

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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

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

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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

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

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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

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

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.12

  1. 1

    Publish a new 10 Year Workforce Plan to support appropriate NHS workforce numbers and distribution.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
  2. 2

    Discuss all Regulation 28 reports through the national working group and share key learning across NHS national and regional services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 27 March 2025.
  3. 3

    Improve public-facing information explaining Deaf people’s rights and how to verify professional registration.

    Stated by National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPDStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
  4. 4

    Provide guidance on quality assurance and ethical conditions for British Sign Language interpreter provision.

    Stated by National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPDStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
  5. 5

    Collaborate with NHS England, Integrated Care Boards, and training providers to co-develop endorsed specialist training and continuing professional development opportunities.

    Stated by National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPDStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
  6. 6

    Engage in policy discussions supporting specialist pathways and recognition for interpreters working in high-risk domains.

    Stated by National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPDStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
  7. 7

    Continue upholding and enforcing registration standards covering safeguarding awareness, professional ethics, and mandatory continuing professional development.

    Stated by National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPDStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2025.
  8. 8

    Collaborate with Deaf communities on training, policies, and guidance so lived experience informs the approach.

    Stated by National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPDStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
  9. 9

    Explore the feasibility of structured mental health specialisation pathways involving supervised practice, mentorship, and formal assessment.

    Stated by National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPDStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
  10. 10

    Work with health and social care providers to promote use of NRCPD-registered communication professionals.

    Stated by National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPDStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
  11. 11

    Champion Deaf-led principles across national policy, commissioning, and professional standards through the regulatory role.

    Stated by National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPDStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
  12. 12

    Commission expert-led work to define readiness, competencies, experience requirements, and safe practice guidance for mental health interpreting.

    Stated by National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPDStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    ICBs, rather than NHS England nationally, commission BSL training according to local needs, budgets and planning frameworks.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Publish a new 10 Year Workforce Plan to support appropriate NHS workforce numbers and distribution.

Verbatim wording from the response

“In our 10 Year Health Plan we committed to publishing a new 10 Year Workforce Plan. Our workforce plan will ensure the NHS has the right people in the right places to deliver the best care for patients.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 27 March 2025

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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

Discuss all Regulation 28 reports through the national working group and share key learning across NHS national and regional services.

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. This ensures that key learnings and insights around events, such as the sad death of Immy, 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 27 March 2025

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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

Improve public-facing information explaining Deaf people’s rights and how to verify professional registration.

Verbatim wording from the response

“• Improve public-facing information and engagement, so Deaf people and their families can understand their rights and how to check whether a professional is registered.”

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

Provide guidance on quality assurance and ethical conditions for British Sign Language interpreter provision.

Verbatim wording from the response

“We commit to:”

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

Collaborate with NHS England, Integrated Care Boards, and training providers to co-develop endorsed specialist training and continuing professional development opportunities.

Verbatim wording from the response

“• Working collaboratively with NHS England, Integrated Care Boards, and training providers to co-develop endorsed training and CPD opportunities aligned with regulatory standards and workforce needs.”

Source location

Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
Page 12 · 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

Engage in policy discussions supporting specialist pathways and recognition for interpreters working in high-risk domains.

Verbatim wording from the response

“• Engage in policy-level discussions to support the development of specialist pathways and recognition for interpreters working in high-risk domains such as mental health, domestic violence, and end-of-life care.”

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

Continue upholding and enforcing registration standards covering safeguarding awareness, professional ethics, and mandatory continuing professional development.

Verbatim wording from the response

“NRCPD asserts that the use of qualified, registered communication professionals is not optional but is essential to safe, equitable, and dignified care.”

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

Collaborate with Deaf communities on training, policies, and guidance so lived experience informs the approach.

Verbatim wording from the response

“• Work in collaboration with Deaf communities in the development of training, policies, and guidance, ensuring their insight and experience meaningfully inform our approach.”

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

Explore the feasibility of structured mental health specialisation pathways involving supervised practice, mentorship, and formal assessment.

Verbatim wording from the response

“• Exploring the feasibility of structured pathways to specialisation in mental health, similar to RID's Alternative Pathway Programme for healthcare interpreting, which includes supervised practice, mentorship, and formal assessment.”

Source location

Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
Page 12 · 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 health and social care providers to promote use of NRCPD-registered communication professionals.

Verbatim wording from the response

“• Work collaboratively with health and social care providers to promote understanding of the importance of using NRCPD-registered professionals.”

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

Champion Deaf-led principles across national policy, commissioning, and professional standards through the regulatory role.

Verbatim wording from the response

“NRCPD is committed to using its platform and regulatory responsibilities to elevate these principles, and to advocate for them within national policy, commissioning frameworks, and professional standards.”

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

Commission expert-led work to define readiness, competencies, experience requirements, and safe practice guidance for mental health interpreting.

Verbatim wording from the response

“NRCPD acknowledges its responsibility to define these core competencies and to provide Registrants with clear guidance on how they can be acquired, establishing a transparent and supportive pathway from qualification to safe, ethical practice in complex settings.”

Source location

Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
Page 11 · 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

ICBs, rather than NHS England nationally, commission BSL training according to local needs, budgets and planning frameworks.

Verbatim wording from the response

“NHS England does not currently commission British Sign Language (BSL) training at a national level. However, we recognise the fundamental importance of ensuring clinicians and NHS staff have the skills to communicate effectively with all patients. To support this, NHS England provides planning guidance and works closely with Integrated Care Boards (ICBs) to help them plan and deliver training that reflects local needs. ICBs commission”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 27 March 2025

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