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Service designApr 28, 2023

NHS England given deadline to respond to report on communication flaws after child dies

NHS healthcare providers should supply written appointment information in languages other than English once NHS England has created a ‘standard’ for tackling the issue.

That is the key recommendation contained in a Healthcare Safety Investigation Branch (HSIB) report that was released yesterday (27 April). The HSIB, which acted after an incident was reported to the Strategic Executive Information System – a national database for reporting serious safety incidents in health care – has given NHS England 90 days to respond.

Starting in July last year, an HSIB team investigated the systems used to book appointments for patients needing clinical investigations, such as diagnostic tests and scans. Concerns centred on a real patient safety incident – in which a child of Romanian ethnicity was referred for an MRI scan, requiring a general anaesthetic. The scan was booked, and a letter was sent to the child’s parents that included the appointment details and pre-appointment instructions.

However, the trust’s booking system could only produce appointment letters in English and had no processes or policies that would mean written appointment information was routinely translated.

Photo Credit: Shutterstock
HSIB calls for a standard to be issued covering written communications in other languages


Family couldn't understand instructions

While members of the child’s family recognised key details in the written information – such as time, date and location – they couldn’t understand instructions that said the child should not eat or drink in the run-up to the scan.

Once it emerged that the child had eaten, the MRI was cancelled but the radiology booking team was not asked to re-book and 11 weeks passed before it emerged that the scan had happened. When the scan was rebooked, a letter – again written in English – was sent to the family containing details about the fasting requirement.

As a result, the child again arrived at the scheduled scan appointment having recently eaten. After the MRI was finally carried out the following day, cancer was diagnosed. The child received treatment but was later placed on a palliative care pathway and died.

Some trusts are implementing changes to their written communications ... however, the NHS does have a duty to ensure that services reflect and are tailored to the needs of all their patients, their families, and carers [Matt Mansbridge, HSIB]

The HSIB’s investigation discovered that

  • written communications to patients about radiology appointments are routinely sent in English only
  • healthcare staff expect that written appointment information will be translated by a patient’s friend or family member
  • NHS England standards do not require written appointment information to begiven in any non-English language, other than for people with a disability
  • the confusion over the requirements for appointments can result in delayed care and additional costs if appointments need to be rebooked

The HSIB report states that the language needs of patients are not always clearly understood, pointing out there is conflicting national guidance on whether written communication needs should be recorded. While the national NHS system that holds patient information and populates it into many trust systems – the Personal Demographics Service – can store information on a patient's preferred written communication methods, this information is often not recorded.

Administrative staff are not routinely involved in assessing and testing electronic booking systems before they are implemented, the report adds.

Services must be tailored to the patient and families 

Matt Mansbridge, an HSIB national investigator, said: 'Some trusts are implementing changes to their written communications, and we have acknowledged that there is immense pressure and backlogs within radiology departments. However, the NHS does have a duty to ensure that services reflect and are tailored to the needs of all their patients, their families, and carers.'

He added: 'Having a consistent translation service that covers all communication supports the patient experience, could reduce the number of missed appointments, and saves cost and resource. This is why we made a recommendation specifically on creating a standard that covers written communications in other languages – it is a step forward in ensuring that every patient has the access they need to tests, treatment and follow-up care.'

Safety actions

HSIB says it may be beneficial

  • if the ‘preferred written communication method’ field of the Personal Demographics Service system is completed for patients who require written communications in a language other than English.
  • if NHS trusts identify mechanisms to appreciate the language needs of their patient demographic and adjust the written communications accordingly
  • to clarify the roles and functions of national organisations in supporting the 'health inequalities landscape'
  • for NHS healthcare providers to incorporate the NHS Service Standard into agreements with third-party developers of electronic clinical investigation booking systems

What are ‘clinical investigation booking systems?

These are used throughout the NHS to support the delivery of patient care. Healthcare services use paper-based or fully electronic systems, or a combination of the two (hybrid systems), to communicate to patients the time, date and location of their appointment.

These systems also produce information for patients about actions they need to take to prepare for their appointment. Written patient communication is a key output of clinical investigation booking systems.

To download a copy of the HSIB report, click 

Author: Ian A McMillan
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