University Hospitals Birmingham NHS Foundation Trust

6. Mrs R complains about the care her father, Mr R, received from the Trust between 13 June and 18 August, and 12 and 27 September 2021. She says:

• the Trust did not listen to her, or her father, when they told staff Mr R felt unwell on 26 September 2021 • the Trust did not arrange regular BSL interpreters during Mr R’s admissions and the care the Trust provided to Mr R did not meet his needs because of this.

7. Mrs R says the lack of accessible care and poor communication led to Mr R suffering while he was in hospital. She believes the stress of this contributed to his death, which added to her distress at an already difficult time. Mrs R believes if staff had listened to her concerns on 26 September and provided treatment earlier, her father may have survived.

8. Mrs R also complains on behalf of herself, and her children, that:

• the Trust inappropriately used her children to interpret during Mr R’s admission • the Trust did not provide a sufficiently competent BSL interpreter for the complaint meeting • the Trust’s complaint response was unclear.

9. Mrs R says the poor communication and using her children as interpreters caused her and her children additional stress and distress which had an impact on their grief. Mrs R said the Trust not providing a competent interpreter meant information was not correctly translated which affected the responses she received. Mrs R said she felt the Trust was fobbing her off and dismissing her by not providing a clear complaint response.

10. By bringing this complaint to us Mrs R is seeking an apology, service improvements, and a financial remedy.

11. Mr R was admitted to the Trust on 13 June 2021 following a fall where he suffered a head injury and was vomiting. The Trust performed an ECG which showed Mr R had atrial fibrillation. Atrial fibrillation is a heart condition that causes an irregular and fast heart rate.

12. On 14 June the Trust commenced antibiotics as Mr R had elevated inflammatory markers, which indicated an infection. The Trust also started Mr R on furosemide due to oedema in his legs. Oedema is swelling caused by a fluid retention and furosemide is medication that treats heart failure and fluid retention.

13. On 16 June the Trust performed an abdominal ultrasound which showed an infection in Mr R’s gallbladder. The Trust commenced Mr R on a more intensive course of IV antibiotics which was completed on 25 June.

14. On 29 June Mr R complained he was having chest pains and tightness when breathing. The Trust performed an ECG and a chest X-ray.

15. On 30 June the Trust noted Mr R’s inflammatory markers had slightly risen from his course of antibiotics. The Trust repeated Mr R’s blood tests and planned to monitor him.

16. On 9 July Mr R complained of chest pains and shortness of breath. On 14 July the heart failure team reviewed Mr R and advised that he had right side heart failure. This is when the right ventricle is too weak to pump blood to the heart.

17. The heart failure team advised the heart failure had caused the oedema Mr R was experiencing. Heart failure can cause fluid retention as the heart is unable to effectively pump blood around the body. This can cause reduced function of the liver and kidneys, and the body starts to retain water. The Trust restricted Mr R’s fluid intake to 1.5 litres to help reduce the oedema alongside the furosemide.

18. On 24 July the Trust documented Mr R had lost 13kg of fluid retention and Mr R reported his breathing had gotten better. The Trust commenced discharge planning on 5 August.

19. The Trust discharged Mr R on 18 August.

20. On 12 September Mr R was re-admitted to hospital with chest pain, oedema in his legs and stomach, shortness of breath on exertion and he was occasionally coughing up mucus. The Trust documented Mr R was in heart failure.

21. On 26 September 2021 Mr R began to deteriorate, and the Trust commenced antibiotics and requested investigations.

22. Mr R sadly died on 27 September.

26 September 2021

27. Mrs R said on 26 September whilst she was visiting her father, he expressed that he was not feeling well. Mrs R said she informed two nurses her father was unwell. She said the first nurse informed her they were too busy with other patients and the second nurse said her father was just hungry.

28. Mrs R said her father deteriorated very quickly and three hours later at approximately 8.15pm she was informed he may not survive the night. Mr R sadly died the next day. Mrs R believes if Mr R was provided treatment earlier, he may have survived.

29. The Trust said the nurses had highlighted Mrs R’s concerns to the medical team and it apologised that the nurse did not act on the concerns she raised straight away. The Trust said it has provided feedback to the team to ensure that they always act on the concerns of a patient’s relative in a prompt fashion.

30. NICE guidance on recognising deterioration says staff should be competent in the monitoring, measurement, interpretation and prompt response of the acutely ill patient appropriate to the level of care they are providing.

31. From the records we can see Mr R was reviewed by a junior doctor at 1.34pm on 26 September due to his decompensated heart failure. Decompensated heart failure is when a person is experiencing symptoms of heart failure which requires prompt medical attention. The junior doctor noted Mr R’s observations were stable and there were no new concerns raised.

32. The junior doctor documented they listened to Mr R’s chest and a crackling sound could be heard and that he remained in a state of fluid overload. They said they would continue to treat this with furosemide which is medication to treat water retention.

33. At 5.47pm we can see the Trust performed Mr R’s observations and he had a NEWS2 score of two. NEWS2 is a tool used to detect clinical deterioration. A NEWS2 score of two requires the registered nurse in charge to be informed, and the registered nurse in charge will decide whether the frequency of observations should be increased.

34. Mr R scored two due to his temperature rising to 38.4°C and a raised heart rate at 98 beats per minute. NEWS2 details a normal temperature to be between 36.1°C and 38°C and a normal heart rate to be between 51 and 90 beats per minute.

35. At 5.53pm we can see the Trust noted Mr R did not look well and a doctor had been asked to review him.

36. We can see a doctor reviewed Mr R at 6.17pm. They noted they had been asked to see Mr R due to his agitation, high temperature and fast heart rate. They noted Mr R looked unwell (he was pale and clammy) and he was agitated and unsettled. The doctor documented Mr R was visibly rigoring. This is when the body has episodes of shivering and feeling cold or very hot with a fluctuating temperature.

37. On examination the doctor documented Mr R’s chest was crackly and his abdomen was distended due to the oedema (fluid swelling). The doctor queried whether Mr R had sepsis. The doctor started Mr R on IV antibiotics, and they requested a chest X-ray to find the source of infection.

38. At 7.14pm we can see the Trust reviewed Mr R’s chest X-ray and noted there was no evidence of lung consolidation (collection of fluids such as pus, water, blood). The Trust performed another examination and noted there was no evidence of skin infection, and it planned to continue to treat Mr R with antibiotics. The Trust performed a further review at 8.13pm and noted Mr R was very unwell and it informed Mrs R that he may not survive the night.

39. We understand Mrs R told us she approached two nurses requesting a review due to her father being unwell. Whilst we have not seen any evidence of this noted within the records, we do not doubt Mrs R’s version of events.

40. The Trust has also acknowledged Mrs R raised her concerns to its staff and it apologised that the nurses did not act on the concerns straight away. Mrs R has told us she raised her concerns to the nurses between 5pm and 5.15pm.

41. From the evidence we have seen, we have found the Trust has acted in line with NICE guidance on recognising deterioration. We can see the Trust performed observations at 5.47pm and a following a NEWS2 score of two, a nurse reviewed Mr R at 5.53pm.

42. We can see the nurse documented Mr R did not look well, had a raised temperature and requested a doctor to review him. We can see this medical review took place at 6.17pm. We have found this is in line with NICE guidance on recognising deterioration which says staff should monitor and interpret a patient’s measurements and provide a prompt response.

43. Our nursing adviser confirmed the Trust acted in a timely manner in its assessment and escalation of Mr R, even if this was not an immediate review. We recognise 45 minutes would have been a long time for Mrs R whilst she was worried about her father’s wellbeing. We can see the Trust acted within about 45 minutes of Mrs R raising her concerns. We can see the Trust was reviewing Mr R regularly, approximately every hour, from 6.17pm. We have found this is in line with NICE guidance on recognising deterioration.

44. We understand Mrs R will be disappointed by our decision, particularly as she feels her father may have survived with an earlier intervention. We can see Mr R was very poorly with fluid retention caused by heart failure and we have seen nothing to suggest his death could have been avoided. We hope our decision provides reassurance that the Trust acted promptly in its assessment and treatment of Mr R on 26 September.

BSL interpreters and Mr R’s care

45. Mrs R said during Mr R’s admissions at the Trust, the Trust did not arrange regular interpreters. The Trust said it had offered interpreters to Mr R and he had refused and was keen to use a white board and pen. The Trust also said it checked Mr R was able to understand what was being said to him.

46. Mrs R said that Mr R’s first language was BSL, and his written English and reading was not very good. Mrs R said her father also had poor eyesight which made it even harder for him to read and write. Mrs R said due to the lack of interpreters Mr R was not able to express how he was, if he was in pain or if there was anything he needed.

47. We note the SignHealth report says that for many Deaf people, English is a second language they have never heard. Because of this, written communication is not always appropriate. NICE guidance on patient experience says if you have difficulties in speaking or understanding English, an interpreter should be provided to help you.

48. From the records we can see the Trust documented Mr R was deaf on his admission to the Trust on 13 June. On 15 June the Trust documented Mr R’s ability to read and write the English language was limited and he was provided flashcards.

49. We can see the Trust arranged interpreters on three occasions during Mr R’s admission before he was discharged on 18 August. We can see the Trust arranged interpreters on 15 July, 21 July and 9 August.

50. We can see Mr R was re-admitted to the Trust on 12 September and interpreters were arranged on two occasions after this. We have not seen any evidence the Trust provided interpreters during this admittance.

51. From the evidence we have seen, we have found the Trust has not acted in line with NICE guidance on patient experience. Mr R was admitted to the Trust for nearly two months prior to his discharge on 9 August and he was only provided an interpreter on three occasions.

52. We can see on 29 June the Trust noted it was having difficulty sourcing a BSL interpreter and it was unable to book an interpreter until 15 July. On 15 July the Trust informed Mr R it would be able to book an interpreter as needed.

53. We can see the Trust was regularly using family members to interpret rather than arranging for an interpreter to be present. We can also see the Trust was using written communication to provide Mr R with information about his care and treatment despite it being recorded on 15 June that his written English was limited.

54. Our nursing adviser described the Trust’s use of interpreters as inconsistent, and it regularly relied on family members to interpret. We do not think this is in line NICE guidance on patient experience which says an interpreter should be provided if a patient has difficulties in speaking or understanding English.

55. We have found the Trust has failed to act in line with the NICE guidance on patient experience, as it did not provide regular interpreters for Mr R. We will next look at whether the Trust not providing regular interpreters impacted the care Mr R received.

56. Mrs R says the lack of accessible care and poor communication led to Mr R suffering whilst he was in hospital. Mrs R said this impacted the care and treatment the Trust provided. She has explained her father’s care by doctors was treated as secondary to those with hearing abilities.

57. GMC good medical practice says doctors should promptly provide or arrange suitable advice, investigation or treatment where necessary.

58. We have reviewed the medical records from Mr R’s admission to the Trust from June to August. We can see Mr R was frequently reviewed by doctors and was referred to specialists such as cardiology and microbiology where appropriate. We can see the Trust was regularly performing investigations such as X-Rays, ECG, CT scans, ultrasounds and blood tests. The Trust also referred Mr R to the diabetic team and dietitian for advice regarding his diabetes and hypoglycaeI (low blood sugar).

59. We can see the Trust was treating Mr R with IV antibiotics for a gallbladder infection. We can also see the Trust was also providing furosemide which was treatment for heart failure related oedema (medication to reduce fluid overload caused by heart failure).

60. We can see Mr R was re-admitted to the Trust on 12 September. Mr R presented with chest pain, oedema in his legs, shortness of breath on exertion and occasionally coughing up mucus. The Trust documented Mr R was in cardiac failure and it commenced furosemide to treat this and the fluid retention. The Trust also referred Mr R to the heart failure team and placed Mr R on oxygen.

61. Our adviser said Mr R was medically stable and was receiving appropriate care. We can see when Mr R began to deteriorate on 26 September, the Trust promptly requested a chest X-ray, blood and urine microbiology, and commenced antibiotic treatment. Microbiology is the study of microorganisms such as bacteria, virus and fungus. Our adviser said this assessment and management was timely and appropriate.

62. We have found the Trust acted in line with GMC good medical practice in the care it provided to Mr R. We have seen the Trust was regularly performing investigations, and based on the results was commencing treatment. We have found this is in line with GMC good medical practice which says doctors should promptly provide suitable investigations and treatment.

63. We understand why Mrs R would be concerned the Trust was not meeting Mr R’s care needs as it had not provided regular interpreters. We hope our decision provides reassurance to Mrs R that Mr R’s care was not impacted due to this and there was no clinical impact to the Trust not providing interpreters.

64. We do however recognise how this would have been concerning and worrying for both Mr R and Mrs R. We have considered the impact of this in the impact section below.

Mrs R’s children used to interpret

65. Mrs R said the Trust regularly used her children (O and I) as interpreters and this was completely inappropriate. Mrs R said her children did not have the skill level to be able to translate medical terms and jargon, and they were also emotional and having to translate upsetting news. Mrs R said when her children had to translate, this meant the information being translated was not always correct as the children did not have the skill level to translate what they were being told into BSL.

66. The Trust apologised that Mrs R’s children were used as interpreters and said it would feed this back to the ward staff.

67. NHS guidance on interpreters says patients should always be offered a registered interpreter. It says reliance on family, friends or unqualified interpreters is strongly discouraged and would not be considered good practice.

68. At the time of the events complained about O was 16 and I was 12. We have included some instances below where the Trust used Mrs R’s children as interpreters. This is by no means an exhaustive list and it is to highlight the nature of the conversations the children were translating.

69. We can see on 19 August the Trust performed an assessment of Mr R and O, aged 16, acted as an interpreter for his grandfather.

70. We can see on 12 and 13 September the Trust used I, aged 12, to act as an interpreter on Mr R’s admittance to the Trust. We can see the Trust was taking Mr R’s history and performed an examination. The Trust also used I as an interpreter to discuss the plan of care for Mr R.

71. On 26 September we can see the Trust discussed Mr R’s prognosis with O who acted as an interpreter for Mrs R. We can see the Trust communicated through O that Mr R was very unwell and that he may not survive the night. The Trust also told Mrs R, via O, that it did not think Mr R should be provided CPR, his care escalated, if the need arose, due to his frailty and co-morbidities.

72. From the evidence we have seen, we have found the Trust has not acted in line with NHS guidance on interpreters. We can see the Trust was using Mrs R’s children, I and O, who were 12 and 16, to translate sensitive medical information regarding his condition, management plan and prognosis.

73. We have found this is not in line NHS guidance on interpreters which says patients should be offered an interpreter. The guidance also says reliance on family members is strongly discouraged. We will next look at the impact this had.

Impact

74. In summary, we have found the Trust failed to arrange regular interpreters during Mr R’s admissions. We have also found the Trust used Mrs R’s children to translate information relating to Mr R’s care and treatment. These actions are not in line with relevant guidance, and we consider them to be failings.

75. We have considered the impact of these failings below.

76. Mrs R said the poor communication and lack of interpreters led to Mr R suffering while he was in hospital. Mrs R believes the stress of this contributed to his death, which added to her distress at an already difficult time. Mrs R said this has worsened her depression and anxiety and caused unnecessary stress.

77. We note the SignHealth report found Deaf people have poorer access to health services, poor communication in consultations, and poorer access to health information.

78. As detailed in paragraph 62, we are not able to link a clinical impact to the Trust not providing regular interpreters. We have not seen any evidence to suggest Mr R’s access to services was impacted by the Trust failing to arrange interpreters. We understand Mrs R will be upset by our decision and it is not our intention to cause her any further distress.

79. Our nursing adviser said the Trust not providing interpreters would likely have impacted Mr R’s patient experience due to his ability to communicate freely being restricted. The SignHealth report found an interpreter not being provided during lengthy hospital admissions left deaf patients feeling vulnerable and confused.

80. We understand it would have been distressing for Mrs R to witness her father being unable to communicate properly. We understand this led her to be concerned about whether this impacted his care.

81. We think this distress was further exacerbated by the Trust’s failure to provide an interpreter to meet Mrs R’s needs. This meant Mrs R was also limited in her ability to communicate on behalf of her father, or herself. We understand this impacted her access to information about her father’s health. We acknowledge this would have frustrating, worrying, stressful and upsetting for her.

82. Mrs R said using her children as interpreters caused her and her children additional stress and distress which had an impact on their grief. She has told us of the profound emotional impact these events had, and continues to have, on her children.

83. The BMJ article on family members being used as interpreters says clinicians should be aware that over-reliance on minors (under 18 years of age) as translators can cause them harm. It says minors could be traumatised by their exposure to a complex medical communication scenario.

84. As detailed above, the Trust used Mrs R’s children, O and I, as interpreters for sensitive discussions. In doing so, it failed to act in line with the NHS guidance on interpreters.

85. We acknowledge having to translate sensitive and upsetting information would have caused O and I trauma and distress. As described in the BMJ article using minors as translators can cause harm to the individuals.

86. We recognise the emotional distress it would have caused O having to translate information that his grandfather may not survive the night, and the discussion surrounding escalation of his care and resuscitation.

87. The SignHealth report found that using family members as interpreters raised the risk of errors in translation due to the individual not being a qualified interpreter. We recognise the distress caused to I in having to translate information she recognised was important, but included medical terms she did not understand and struggled to translate.

88. We acknowledge the trauma and distress O and I experienced at the time may have contributed to the ongoing impact on her children that Mrs R has told us about. We also acknowledge this would have impacted on their ability to grieve for their grandfather.

89. We understand how witnessing this, and also not having regular access to a registered interpreters herself, also caused Mrs R additional distress at what was already a difficult time.

90. We are sorry to hear that Mrs R, O and I continue to experience ongoing distress as a result of the Trust’s failings. We have set out our recommendations in recognition of this impact, and to try and put things right, in the recommendations section of our report, which can be found at paragraph 110.

Complaint Meeting

91. Mrs R said information was not correctly interpreted by the BSL translator during the resolution meeting and she became aware of this when she read the meeting summary. Mrs R said she knew who the interpreter was and knows they do not have the skill level to interpret such a meeting.

92. PHSO principles of good complaint handling says public bodies should communicate with the complainant in a way that is appropriate to them and their circumstances.

93. We can see the Trust completed a booking request for a BSL interpreter on 12 August 2022 through an external company it used for interpreters. On 16 August the company requested further information regarding the nature of the meeting that the interpreter was required for. We can see the Trust responded on 12 September and advised the interpreter was required to translate the Trust’s response to the concerns Mrs R raised in her complaint.

94. We can see the interpreter used by the Trust has a BSL level 6 qualification which they have held for over five years. Signature, which is the leading awarding body for deaf communication and language qualifications in the UK, details level 6 as the highest qualification available.

95. From the evidence we have seen, we have found the Trust has acted in line with PHSO principles of good complaint handling which says public bodies should communicate in a way that is appropriate for the complainant. We can see the Trust booked an interpreter with the highest qualification available and provided information regarding what the interpreter would need to translate.

96. We understand Mrs R has informed us the interpreter was not correctly translating information. We understand this would have been frustrating and upsetting for Mrs R. We are not able to say this was due to a failing of the Trust. This is because we can see the Trust did request an interpreter to translate for a local resolution meeting and the interpreter was qualified to the highest level. We would therefore expect the interpreter to be able to correctly interpret the information provided in the complaint meeting. We understand Mrs R has told us that sadly this did not happen.

97. We recognise Mrs R will be disappointed by our decision. We can understand why Mrs R was concerned the Trust had not provided a suitably qualified interpreter. Mrs R informed us the meeting summary did not accurately reflect what was translated to her and we recognise this would have been concerning for her. We have found the Trust acted in line with PHSO principles of good complaint handling in the steps it took to procure an interpreter.

Complaint Response

98. Mrs R said she felt the Trust’s response was very general and did not really address the issues she had raised. Mrs R said the response was unclear and the Trust did not provide clear answers on what it would implement to stop this happening to anybody else. Mrs R said the written response she received exacerbated her grief as the response was unclear and had not fully addressed the issues she had raised, and she felt she was being dismissed by the Trust.

99. The Trust’s patient relations procedure says if the complainant requires a meeting, the respondents should attend to address the issues raised, and the Trust should provide a brief written summary of the meeting to the complainant.

100. We can see in an email to the Trust on 28 October 2021 Mrs R raised concerns that on 27 September she informed two staff members that her father wasn’t feeling well. She said the staff members did not review Mr R and three hours later he deteriorated significantly and sadly died the next day. Mrs R explained she felt her father would have survived if there had been an earlier intervention.

101. Mrs R also raised concerns that BSL interpreters were not being provided regularly and explained her father had limited vision and both her and her father had limited English. Mrs R also raised concerns the bereavement service was not accessible to deaf people.

102. We can see Mrs R raised further concerns by email on 24 November and complained about a note that was written on the ward by staff and that her children were used as interpreters.

103. We can see the complaints meeting took place in September 2022 and the Trust issued its written response in March 2023. We have reviewed the Trust’s response, and we can see the Trust did provide a written response to each concern raised. We think the Trust did provide clear responses to each point, but the responses were not a full explanation of what happened.

104. We have found the Trust has acted in line with its patient relations procedure. We can see the Trust said it’s letter of March 2023 was to serve as a brief summary of the issues discussed in the meeting. Therefore, we understand the Trust was not providing full explanations to each point but was summarising what was discussed. This is in line with the Trust’s patient relations procedure.

105. We think the issue here is that Mrs R has told us information was not being translated correctly during the meeting. This means when the Trust has summarised the meeting, Mrs R has still not received the answers she needed as the explanations were summarised instead of being written in full. As the meeting was not recorded, we are not able to determine what was said in the meeting.

106. It is difficult for us to say the Trust has not acted in line with guidance as we understand the Trust would have provided full responses within the complaint meeting and this would also have allowed Mrs R to ask any follow-up questions. Following the meeting the Trust has provided a brief written summary of what was discussed which is in line with its patient relations procedure.

107. We can understand why Mrs R is concerned the Trust has not fully addressed each concern in the letter it sent. In line with the Trust’s patient relations procedure all concerns should have been addressed within the meeting. The letter it sent was not a formal written response but a meeting summary. We are not able to say the Trust providing a brief summary was a failing of the Trust as it acted in line with its own guidance.

108. We understand Mrs R will be disappointed by our decision, specifically as she has told us the Trust’s response exacerbated her grief.

109.  In summary, we have seen no failings in the letter the Trust sent in March 2023 following the complaint meeting.

1. Mrs R has complained to us about the care her father, Mr R, received from the Trust. We do not underestimate the difficult time Mrs R has been through, and we recognise the death of her father was an emotional and distressing time.

2. We have not found any failings in the actions of the Trust on 26 September 2021 in its management of Mr R’s deterioration. We have also found no failings in the interpreter provided by the Trust for the complaint meeting, or in the Trust’s written response following this meeting.

3. We have found failings in the Trust not providing regular interpreters and using Mrs R’s children as interpreters. We have found this did not affect the care and treatment the Trust provided to Mr R.

4. We have found this failing caused Mrs R distress, frustration, worry and distress. We also think this caused both Mrs R and her children additional stress and distress at an already difficult time and impacted their ability to grieve.

5. For the above failings we consider the Trust should take action to put things right. We recommend the Trust acknowledge the failings we have found and apologise for the impacts we have identified. We also recommend the Trust to provide £900 each, to both I and O. We also recommend the Trust to provide £750 to Mrs R. This in recognition of the impact caused by these failings. We also recommend the Trust produce an action plan to explain how it will stop similar failings from occurring in the future.

110. We have considered the impact caused by the Trust failing to arrange regular interpreters for Mr R and Mrs R in line with the guidance. We have also considered the impact of the Trust using Mrs R’s children to interpret, which was not in line with the guidance.

111. We have found this caused Mrs R distress, frustration, worry and distress. We have also found this caused both Mrs R and her children additional stress and distress at an already difficult time, and it impacted their ability to grieve.

112. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

113. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

114. In line with this we recommend the Trust write to Mrs R within one month of our final report to acknowledge the failings that occurred. We also recommend the Trust apologise for the linked impacts, as set out above. We would ask the Trust to send us a copy of this letter.

115. We recommend the Trust provides details of the actions it will take to address these failings. It should produce an action plan setting out what it has done or intends to do to prevent similar events from occurring. The action plan should also explain who is responsible for the action, when it will be completed by, and how it will monitor the changes to ensure an improvement is maintained.

116. We would ask the Trust to produce this action plan within three months of our final report, and to share this with Mrs R, ourselves, the Care Quality Commission, and NHS Improvement.

117. To decide on a level of financial remedy, we review similar cases where the person has experienced similar injustice, along with our severity of injustice scale. Our scale allows us to ensure the recommendations we make are consistent and transparent for everyone who uses our service.

118. Following this review, we recommend the Trust should pay both O and I ​​£900 each. This is in recognition of the impact on I of having to translate important medical information at the age of 12. This is also in recognition of the impact on O of having to translate upsetting and distressing information to his mother regarding Mr R’s prognosis and the ceiling of care.

119. We would also recommend the Trust pay Mrs R £750. This is in recognition of the impact Mrs R experienced as a result of the Trust not providing regular interpreters and using her children to translate.