Imogen Nunn

Karin Smyth MP 
Minister of State for Health (Secondary Care) 

39 Victoria Street 
London 
SW1H 0EU 

19th January 2026 

Our ref: PFD – 25-10-07 - NUNN 

HM Coroner Penelope Schofield 
West Sussex, Brighton & Hove Coroner Service 
County Hall North, 
Chart Way, 
Horsham, 
West Sussex, 
RH12 1XH 
033 022 25560 

By email: coronersofficers@westsussex.gov.uk  

Dear Ms Schofield,  

Thank you for the Regulation 28 report of 07 October 2025 sent to the Secretary of State 
about the death of Imogen Alice Nunn. I am replying as the Minister with responsibility for 
Secondary Care.       

Firstly, I would like to say how saddened I was to read of the circumstances of Ms Nunn’s 
death and I offer my sincere condolences to her family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to 
my attention.  

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  report  raises  concerns  over  a  shortage  of  BSL-proficient  clinicians,  and 
insufficient efforts being made to recruit and retain these professionals.  

In preparing this response, my officials have made enquiries within this department and NHS 
England to ensure we adequately address your concerns. 

I have carefully considered the situation. The safety of all patients is a top priority for the 
government. All providers of healthcare are regulated by the CQC and follow a set of 
fundamental standards of safety and quality, below which care should never fall. 

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 

 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 services within their budgets and planning frameworks, ensuring provision is tailored to the 
health priorities and population requirements of their area. 

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.  

ICBs and other care providers already have a duty through the Health and Social Care Act 
20081 to regularly review the number of staff and skill mix needed to safely meet the needs 
of people using their services. Given Ms Nunn’s tragic death and the experience of other 
deaf service users, that may include access to a variety of interpreters. 

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.  

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,  

MINISTER OF STATE FOR HEALTH 

1 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Regulation 18

From 

  Minister of State for Care   

39 Victoria Street   
London   
SW1H 0EU  

29 May 2025  

Our ref: 

HM Coroner Penelope Schofield  
The Coroner’s Office,  
Woodvale,  
Lewes Road,  
Brighton  
BN2 3QB  

By email: 

Dear Ms Schofield,   

Thank you for the Regulation 28 report of 24th March 2025 sent to the Department of Health 
and Social Care about the death of Imogen Alice (“Immy”) Nunn. I am replying as the Minister 
with responsibility for disability policy in the Department of Health and Social Care. 

Firstly, I would like to say how saddened I was to read of the circumstances of Immy’s death, 
and I offer my sincere condolences to her family and loved ones. The circumstances your 
report describes are concerning and I am grateful to you for bringing these matters to my 
attention. 

The  report  raises  concerns  over  the  lack  of  availability  of  British  Sign  Language  (BSL) 
interpreters. This meant that meetings and assessments with mental health practitioners had 
to  take  place  without  an  interpreter  present  to  provide  support  for  Immy.  This  proved 
particularly difficult when an interpreter was needed at short notice during times of crisis. 

In preparing this response, my officials have made enquiries with NHS England to ensure 
we adequately address your concerns. 

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. 

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 

   
  
  
 
  
  
  
  
  
  
 
 
 
 
 to enable health and care workers to record, share and view details of reasonable adjustment 
across the NHS, wherever the person is treated. 

NHS England has issued guidance in respect of the Reasonable Adjustments Flag. The 
Flag is designed to provide staff with information on their duties under the Equality Act 2010. 
The Flag provides basic context about a patient; key adjustments and the details related to 
this and further information to aid health and care workers. 

To address these concerns at a national level the Cabinet Office’s Disability Unit, alongside 
members  of  the  Government’s  BSL  Advisory  Board,  met  with  the  National  Registers  of 
Communication Professionals working with Deaf and Deafblind People (NRCPD) at the end 
of April to discuss the barriers for Deaf people accessing mental health care. 

The BSL Advisory Board was created to advise the Government on key issues impacting the 
Deaf community in their everyday life. The Board also established subgroups to focus on 
particular  priorities  which  includes  a  group  focusing  on  health  and  social  care.  They  will 
publish a report in the autumn which will make recommendations for health and social care 
settings. 

I hope this response is helpful. Thank you for bringing these concerns to my attention.    

Yours sincerely,   

MINISTER OF STATE FOR CARE

Ms Penelope Schofield 
Senior Coroner  
West Sussex, Brighton and Hove 
Record Office 
Orchard Street 
Chichester 
PO19 1DD 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

19 May 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Imogen Alice Nunn who 
died on 1 January 2023.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  24 
March  2025  concerning  the  death  of  Imogen  Alice  Nunn  (known  as  “Immy”)  on  1 
January 2023. In advance of responding to the specific concerns raised in your Report, 
I would like to express my deep condolences to Immy’s family and loved ones. NHS 
England are keen to assure the family and the Coroner that the concerns raised have 
been listened to and reflected upon.   

Your Report raised the concern that there is a lack of British Sign Language (BSL) 
interpreters available to help support deaf patients in the community with mental health 
difficulties. In Immy’s case, interpreters were not always available to attend meetings 
and assessments with mental health practitioners, particularly at short notice, and so 
they went ahead without an interpreter present. 

is 

important,  both 

to  support  patients  and 

NHS England recognises that the provision of interpreters within community mental 
health  services 
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 that 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.  

to  ensure 

NHS Shared Business Services (SBS) have a national framework agreement in place 
for Interpretation and Translation Services. The agreement covers all language service 
needs for the NHS and wider public sector organisations, with Lot 2 specifically aimed 
at BSL face to face, video and document services. It is not clear from your Report if 
Sussex Partnership NHS Foundation Trust (SPFT) were using the national framework 
or if there were issues with the nominated provider.  

Since 1 August 2016, all organisations that provide NHS care and/or publicly funded 
adult  social  care  have  been  legally  required  to  follow  the  Accessible  Information 
Standard (AIS), which sets out the information and communication support needs of 
patients,  service  users,  carers  and  parents  with  a  disability,  impairment  or  sensory 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
  
 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.  

My regional Patient Safety colleagues in the South East have also been engaging with 
NHS Sussex Integrated Care Board, the responsible commissioner for SPFT, on the 
concerns  raised  in  your  Report.  They  have  asked  for  assurance  from  the  Trust 
regarding  reasonable  adjustments  being  made,  and  are  expecting  a  formal  update 
from  the  Trust  by  June  2025.  We  are  happy  to  update  the  Coroner  further  in  this 
regard, if this would assist. 

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.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director

NRCPD Response to the Regulation 28 Report regarding Imogen Nunn 

Introduction 

The National Registers of Communication Professionals working with Deaf and Deafblind 
People (NRCPD) acknowledges receipt of the Regulation 28 Report issued by HM Coroner 
and wishes to express its sincere condolences to the family and friends of Imogen Nunn. 

We are deeply saddened by the circumstances that have led to this report and recognise 
the significance of Imogen’s life and advocacy. From the accounts shared publicly, and 
through her own presence online, it is evident that Imogen was a powerful advocate not 
only for her own rights but also for the rights and visibility of other Deaf young people, 
including  those  within  the  LGBTQ+  community.  We  honour  her  memory  and  the 
continuing advocacy of her family and loved ones. 

NRCPD  accepts  the  Coroner’s  matter  of  concern,  specifically  regarding  the  lack  of 
availability  of  British  Sign  Language  (BSL)  interpreters  to  support  Deaf  patients 
experiencing  mental  health  difficulties  in  the  community,  particularly  during  times  of 
crisis.  

We agree that this issue has serious implications for the safety, dignity, and wellbeing of 
Deaf individuals. 

In  preparing  this  response,  NRCPD  has  taken  time  to  seek  input  from  our  registrants, 
reflect  on  the  regulatory  responsibilities  we  hold,  and  consider  how  NRCPD  can 
contribute meaningfully to the wider effort to address the systemic challenges raised in 
this case.  

This  document  offers  a  contextual  overview  of  the  national  landscape  surrounding 
interpreter provision in mental health care, followed by specific ways in which NRCPD 
will seek to support improvements in response to the matter of concern. 

We are committed to working collaboratively with Public Bodies, service providers, Deaf-
led organisations and our Registrants to reduce the risk of recurrence and ensure that 
Deaf individuals in crisis receive safe, accessible, and timely care. 

Actions Undertaken by NRCPD in Response to the Regulation 28 Report 

Following receipt of the Regulation 28 Report issued by HM Coroner, NRCPD undertook 
a series of actions to understand the systemic and practical issues contributing to the 
matter of concern: namely, the lack of availability of qualified British Sign Language (BSL) 
interpreters to support Deaf individuals in mental health crisis situations. 

We  began  by  seeking  to  understand  the  current  professional  landscape  from  the 
perspective  of  those  working  directly  within  it.  A  survey  was  distributed  to  all  NRCPD 

1 

 
 
 
 Registrants,  receiving  over  450  responses.  Respondents  provided  detailed  feedback 
about  the  structural  and  practical  barriers  they  experience  when  engaging  with 
healthcare  interpreting,  particularly  within  mental  health  services  and  crisis  settings. 
in  shaping  our  understanding  of  where 
This  feedback  has  been 
interventions may be most effective. 

instrumental 

In  addition  to  direct  engagement  with  our  Registrants,  NRCPD  consulted  with  key 
stakeholder organisations, including professional associations such as the Association 
of Sign Language Interpreters (ASLI) and Visual Language Professionals (VLP), as well as 
Deaf-led  and  representative  bodies  including  the  British  Deaf  Association  (BDA)  and 
members of the BSL Advisory Board.  

We also drew upon evidence and data published in recent research and sector reports, 
notably Sick of It (SignHealth, 2014)and Still Ignored (SignHealth and RNID, 2025), which 
continue to evidence longstanding issues in access to communication within healthcare 
settings. 

As the largest national register and voluntary regulator, we also reflected critically on our 
own  role  in  relation  to  the  confidence  and  preparedness  of  Registrants  who  accept 
bookings within complex, high-risk domains such as mental health.  

We  asked  ourselves  whether  NRCPD  is  providing  sufficient  information,  guidance,  or 
frameworks  to  support  interpreters  in  making  informed  and  ethical  decisions  in 
accordance  with  the  NRCPD  Code  of  Conduct.  Mental  health  interpreting  can  involve 
high  levels  of  emotional,  ethical,  and  linguistic  complexity.  It  is  imperative  that 
interpreters are adequately prepared, both in terms of specialist knowledge and access 
to information before accepting such assignments. 

Contextualising  the  Coroner’s  Concerns:  A  National  Perspective  on  Systemic 
Barriers to Healthcare for Deaf Individuals 

The  tragic  and  preventable  death  of  Imogen  underscores  systemic  challenges  in  the 
provision  of  accessible  healthcare  for  Deaf  individuals.  The  issues  identified  by  HM 
Coroner  are  not  isolated  incidents  but  reflect  longstanding,  documented  challenges 
within the National Health Service (NHS) and broader healthcare systems across the UK. 

2 

 
 
 
 
 
 
 
 
 Persistent Health Inequalities and Communication Barriers 

In 2014, SignHealth’s Sick of It report revealed that Deaf people experience significant 
health  disparities,  including  higher  rates  of  obesity,  hypertension,  and  diabetes, 
compared  to  the  general  population.  These  disparities  are  attributed  to  inadequate 
access  to  healthcare  information,  misdiagnoses,  and  poor  treatment  stemming  from 
communication barriers. The report estimated that misdiagnosis and poor treatment of 
Deaf patients cost the NHS approximately £30 million annually. 

A  decade  later,  the  Still  Ignored  report  (RNID  &  SignHealth  2025)  indicates  minimal 
progress. The study found despite clear legal obligations under the Equality Act and the 
Accessible Information Standard, 70% of Deaf individuals and those with hearing loss 
have  never  been  asked  about  their  communication  needs  when  accessing  NHS  care, 
despite  the  legal  requirements  of  the  Accessible  Information  Standard  (AIS).  This  has 
resulted in the frequent absence of qualified, registered communication professionals, 
particularly British Sign Language (BSL) interpreters, during medical consultations and 
emergency health situations. 

Furthermore,  only  24%  of  NHS  staff  reported  always  being  able  to  meet  the 
communication  needs  of  Deaf  patients,  with  barriers  including  lack  of  training  (34%), 
time constraints (32%), and inadequate IT systems (30%) . 

These  failures  are  not  new  and  are  not  rare.  They  represent  a  structural  problem  that 
remains largely unresolved despite over a decade of clear evidence. 

National, representative organisations like the British Deaf Association (BDA) have now 
embedded  these  concerns  into  their  long-term  strategic  planning.  The  BDA’s  strategic 
vision sets out a comprehensive response, including: 

•  Support  for  NHS  bodies—particularly 

Integrated  Care  Boards  (ICBs)—to 
implement national recommendations for accessible communication, including 
those resulting from NHS England’s review of BSL interpreting. 

•  The promotion of real-time, digital interpreting solutions like those offered during 

the pandemic, to avoid unnecessary delays in urgent care. 

•  A call for the NHS to take responsibility for training interpreters in highly specialist 

domains such as mental health, where need is high and risk is significant. 

•  Clearer  progression  pathways  for  BSL/English  interpreters  and  recognition  of 

specialist skills within regulated frameworks. 

NRCPD  wholeheartedly  supports  these  strategic  aims  and  note  that  they  reflect  a 
consensus  across  the  Deaf  community:  that  the  failure  to  provide  appropriate 
communication in healthcare is not just a practical inconvenience it is a breach of human 
rights and a threat to life. 

3 

 
 
 Barriers Created by Interpreter Procurement Models 

In many regions, interpreting services are procured via multi-provider frameworks where 
several agencies hold contracts simultaneously. While intended to ensure flexibility and 
value  for  money,  these  frameworks  often  result  in  a  fragmented  and  inconsistent 
approach to service provision. Interpreters frequently report a lack of clarity about which 
agency  is  coordinating  a  given  booking,  who  holds  clinical  responsibility,  or  what 
information, if any, will be provided in advance of the assignment. 

This  uncertainty  can  significantly  impact  interpreter  confidence,  particularly  when  the 
assignment involves crisis care or mental health assessment. As the only individual in 
the room fluent in both BSL and English and culturally aware of both Deaf and hearing 
contexts,  the  interpreter  plays  a  critical,  delegated  role  in  facilitating  effective 
communication. Without access to adequate background information about the patient, 
clinical concerns, and setting, interpreters are unable to assess the ethical or practical 
viability  of the assignment. This creates risk for the patient, the clinical team, and  the 
interpreter themselves. 

Compounding this is a wider lack of consistent guidance available to NHS staff and other 
public sector commissioners on how to procure BSL interpreting services effectively. The 
absence  of  standardised  information  about  working  conditions,  ethical  requirements, 
and terms of engagement for interpreters leads to additional uncertainty, both for those 
booking the services and those delivering them. 

NRCPD’s Ongoing Role and Contribution to Systemic Reform 

In  light  of  these  findings,  NRCPD  recognises  its  responsibility  to  contribute  to  the 
development of sector-wide improvements.  

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. 

We will work directly with the BSL Advisory Board to ensure that the statutory guidance 
being developed is informed by professional standards and is practically implementable. 
This includes advocating for greater awareness among commissioners and NHS bodies 
about  the  professional  requirements  of  BSL  interpreters,  and  how  these  can  be 
embedded at the contract level.  

4 

 
 
 
 
 
 Areas of focus will include minimum notice periods, access to preparatory information, 
booking transparency, and appropriate remuneration for high-risk or specialist settings. 

The Procurement Act 2023: A Catalyst for Reforming Language Service Provision in 
Health and Care Settings 

The Procurement Act (2023) provides a unique opportunity to reform how interpreting and 
language services are commissioned, particularly for British Sign Language (BSL) users 
and other Deaf and deafblind people whose access to care is intrinsically dependent on 
these language services. 

Current Challenges in Language Service Procurement 

As outlined in earlier sections of this report, the current procurement structures for BSL 
interpreting are often fragmented and, at times, inconsistent. This has led to widespread 
uncertainty among interpreters regarding terms and  conditions, access to preparatory 
information, and their role in risk-sensitive or urgent contexts. 

Furthermore, language access is frequently treated as an ancillary rather than essential 
function.  This  results  in  reactive,  last-minute  bookings  that  lack  continuity,  clinical 
integration,  or  respect  to  patient-centred  principles  of  care.  As  the  only  professionals 
able  to  navigate  both  BSL  and  English  with  cultural  fluency,  interpreters  must  be 
resourced  to  carry  out  their  responsibilities  ethically  and  effectively.  Current 
commissioning models often prevent this. 

Embedding Interpreters into the “Team Around the Patient” Model 

During the preparation of this response, NRCPD consulted with a range of practitioners 
and  stakeholders,  including  interpreters  working  in  community  and  mental  health 
contexts.  In  doing  so,  we  were  made  aware  of  agencies  operating  a  person-centred 
approach to language provision, where Registered Sign Language Interpreters (RSLIs) are 
included  in  service  planning  with  a  focus  on  continuity  and  clear  communication 
pathways. RSLIs working within this model reported a more structured and supportive 
working  environment,  with  improved  access  to  information  and  clearer  expectations 
about  their  role.  While  not  representative  of  all  current  practice,  this  example 
demonstrates how embedding Sign Language Interpreter provision more closely within 
care teams can support both professional confidence and service consistency. 

Building on this evidence and the goals of the Procurement Act, NRCPD has looked to 
multi-agency  safeguarding  frameworks  like  Team  Around  the  Child  (DfES,  2003),  this 

5 

 
 
 
 
 
 model re-frames interpreting not as an external booking but as an embedded function 
within the care pathway. 

Originally  developed  under  the  Every  Child  Matters  policy  agenda  (DfES,  2003)  and 
formalised in response to the Laming Report (2003), TAC/TAF established the need for 
multi-agency  collaboration,  early  intervention,  shared  responsibility,  and  coordinated 
planning, particularly where there is complexity or vulnerability. These models have been 
widely endorsed across education, social care, and early help services and serve as a 
proven  foundation  for  ensuring  joined-up  support  around  individuals  with  multiple  or 
specialised needs. 

In the context of mental health and community care, this model does not suggest that 
interpreters  are  contributors  to  clinical  decision-making  or  care  planning  content. 
Rather, it recognises interpreter provision as a central communication function, integral 
to the infrastructure of inclusive care. When a Deaf or deafblind individual identifies that 
their language preference is BSL and, as such,  require BSL interpretation, Intralingual 
interpretation or any other language service, the interpreter or interpreting team must be 
embedded  from  the  earliest  stages  of  care  planning.  This  includes  ensuring  Sign 
Language  Interpreter  access  is  in  place  for  all  planning,  review,  and  multidisciplinary 
meetings, and that continuity is maintained throughout the patient’s engagement with 
services. 

The  model  supports  and  operationalises  the  principles  of  Person-Centred  Care,  a 
framework  enshrined  in  the  NHS  Five  Year  Forward  View  (2014),  NHS  Long  Term  Plan 
(2019),  and  supported  by  NICE  guidelines  on  service  user  experience  in  adult  mental 
health (CG136). These principles emphasise the right of individuals to be seen, heard, 
and involved in decisions about their care in ways that are accessible and respectful of 
their communication preferences, cultural identity, and lived experience. For Deaf and 
deafblind  individuals,  such  involvement  is  only  meaningful  if  interpreting  support  is 
familiar,  consistent,  and  planned,  not  arranged  reactively  or  delivered  by  unfamiliar 
professionals at the last minute. 

This approach also reflects and supports the Accessible Information Standard (AIS), The 
AIS requires all health and adult social care services to identify, record, flag, share, and 
meet  individuals'  communication  and  information  needs.  Embedding  interpreting 
provision as part of the structural design of a patient’s care pathway, rather than as an 
add-on,  ensures  that  AIS  is  implemented  not  just  technically,  but  meaningfully, 
throughout a person’s contact with services. 

In practical terms, this model requires that interpreter provision is confirmed as part of 
initial care planning. A consistent team of Registered Sign Language Interpreters should 
be identified, by the contracted agency, wherever possible, and their availability should 
be  factored  into  scheduling  decisions.  Where  a  Deaf  patient  is  attending  a  planning 

6 

 
 
 meeting, the RSLI or interpreting agency should be included in the logistics of setting the 
meeting date. 

For patients using remote or hybrid services, remote interpreting services (VRI/VRS) must 
be built into contingency and routine access plans. 

For  emergency  and  out-of-hours  situations,  interpreter  continuity  may  not  always  be 
possible.  However,  where  a  language  service  need  is  known,  care  plans  and  crisis 
protocols  should  include  communication  contingency  planning;  pre-identified  access 
routes to qualified, registered sign language interpreters (including remote interpreting 
providers)  who  can  respond  quickly  and  safely  within  the  clinical  governance 
requirements  of  the  setting.  This  prevents  dangerous  delays,  promotes  continuity  of 
communication,  and  ensures  that  critical  interactions  such  as  Mental  Health  Act 
assessments,  safeguarding  interventions,  or  urgent  care  reviews  are  not  conducted 
without accessible language provision. 

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.  

It also requires that only Registered Professionals are used, ensuring that practitioners 
are subject to a code of conduct, complaints procedures, and continued professional 
development requirements. 

Expanding Access Through Remote Interpreting Provision (VRI/VRS) 
Remote interpreting services (VRI/VRS) are a vital component of a modern, responsive 
approach to language access for Deaf people, particularly in situations where 
immediate support is needed and an in-person interpreter cannot be secured.  

While remote interpreting is not a substitute for face-to-face interpreting in complex 
or ongoing care scenarios, such as mental health assessments or therapeutic 
interventions, it plays a crucial role in ensuring that Deaf individuals are not left without 
language support in urgent, unplanned, or short-notice interactions. 

The success of BSL Health Access, a 24/7 Video Relay Service launched during the 
COVID-19 pandemic, provides clear evidence of the value of such provision. Funded by 
SignHealth and delivered in partnership with InterpreterNow, the service supported 
over 25,000 health-related conversations in its first year, primarily with GP 
appointments. 

7 

 
 
 
 Deaf users frequently reported a significant increase in their ability to manage their own 
health independently and in real time. One service user described the experience as 
“empowering” and highlighted the contrast between instant access to remote 
interpreting services and the previous delays caused by having to wait days or even 
weeks for an in-person interpreter to be booked, even in urgent situations. 

Despite its proven value and a recommendation in a Rapid Review that the service be 
maintained, BSL Health Access was discontinued due to a lack of long-term funding. Its 
closure represents a step backwards in equitable access and highlights the fragility of 
ad hoc or charity-funded solutions to what is ultimately a statutory responsibility. 

As part of a wider language access strategy, remote interpreting services should be 
embedded within commissioning frameworks, service-level agreements, and care 
planning pathways. This includes ensuring that access to qualified, registered sign 
language interpreters, whether in person or via remote interpreting provision, is 
designed into services rather than added reactively.  

Opportunities Under the Procurement Act 2023 

The  Procurement  Act  introduces  principles  that  directly  support  a  more  strategic  and 
ethical approach to commissioning language access services, including: 

•  Public  Benefit:  This  includes  the  advancement  of  equality  and  social  value 

through public procurement decisions. 

•  Value for Money: Not only measured by financial cost, but also through improved 
outcomes  and  effectiveness,  relevant  in  ensuring  that  care  is  genuinely 
accessible. 

•  Transparency and Accountability: Enabling clearer standards for the quality and 

consistency of contracted interpreting services. 

•  Supplier Engagement: Encouraging co-design and greater flexibility in contract 

specifications to meet diverse user needs. 

These  provisions  provide  a  policy  foundation  upon  which  NHS  commissioners  and 
Integrated  Care  Boards  (ICBs)  can  develop  bespoke  commissioning  models  for  BSL 
services that centre the person and safeguard continuity. 

For example, new contracts could require providers to deliver: 

•  Tailored  language  service  provision,  focused  on  the  language  preferences 

identified by the Deaf person, themselves 

8 

 
 
 
 •  Dedicated interpreter teams for ongoing care (including mental health cases), 

•  Evidence of meeting Accessible Information Standard (AIS) requirements, 

•  Transparent scheduling protocols that involve interpreters in planning, 

•  Digital and remote access services such as Video Relay Service (VRS) for crisis or 

out-of-hours care, 

NRCPD’s Role in Supporting Procurement Reform 

NRCPD  recognises  our  role  in  supporting  a  shift  towards  person-centred,  ethically 
commissioned interpreting services. 

We commit to: 

•  Supporting  NHS  England  and  ICBs  in  designing  new  procurement  frameworks 

aligned with the Procurement Act 2023, 

•  Providing detailed guidance on quality assurance and ethical conditions for BSL 

interpreter provision, 

•  Contributing to the development of statutory guidance under the BSL Act 

These actions will support the long-term integration of interpreting into care models—not 
as a reactive cost, but as an ethical and clinical necessity. The failings that prompted this 
Regulation 28 report demand a systemic, sustained, and standards-based response. We 
believe the Procurement Act 2023 presents a critical opportunity to deliver it. 

NRCPD’s Commitment to Addressing Systemic Barriers 

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

We  are  committed  to  playing  an  active  role  in  addressing  the  systemic  barriers  that 
contributed to the circumstances of Imogen’s death. 

In  response  to  the  Coroner’s  concerns,  and  in  alignment  with  the  national  picture 
outlined above, NRCPD will: 

•  Continue to uphold and enforce rigorous registration standards that include 
safeguarding  awareness,  professional  ethics,  and  mandatory  CPD  for  all 
registrants. 

9 

 
 
 
 
 
 •  Work  collaboratively  with  health  and  social  care  providers  to  promote 

understanding of the importance of using NRCPD-registered professionals. 

•  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. 

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

• 

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. 

•  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. 

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. 

Supporting Interpreter Readiness in Mental Health Settings 

NRCPD  recognises  its  regulatory  responsibility  to  ensure  that  all  of  our  registrants, 
including  Registered  Sign  Language  Interpreters  and  Registered  Sign  Language 
Intralingual  Interpreters,  are  appropriately  supported  to  make  informed,  ethical 
decisions when accepting bookings, particularly in high-risk, complex contexts such as 
mental health settings. 

Amongst  our  registrant  population  are  highly  skilled,  motivated,  and  values-led 
practitioners who demonstrate a clear commitment to ethical practice and to delivering 
safe, high-quality services. NRCPD expects all interpreters on our register to operate in 
accordance  with  our  Code  of  Conduct,  which  includes  duties  to  work  within  one’s 
competence, to ensure effective communication, and to act in the best interests of the 
people they work with. 

Despite  the  professionalism  of  our  registrants,  the  evidence  gathered  from  our  recent 
survey  and  engagement  with  professional  associations  (ASLI,  VLP),  community 
feedback, and independent research reveals a range of challenges faced by interpreters 
in  undertaking  work  within  mental  health  contexts.  These  include  a  lack  of  structured 
preparation, inconsistent access to appropriate training, limited opportunities to observe 

10 

 
 
 
 or  work  alongside  experienced  peers,  and  variability  in  the  information  provided  by 
agencies and public bodies about the nature and complexity of assignments. 

Studies such as Hetherington (2012) and Dean & Pollard (2013) highlight that interpreters 
working  in  mental  health  contexts  report  higher  emotional  demands,  greater  ethical 
complexity,  and  increased  risks  of  vicarious  trauma.  They  also  note  the  challenge  of 
interpreting  for  service  users  in  acute  distress  while  navigating  the  needs  and 
expectations of multidisciplinary professionals unfamiliar with interpreting processes. A 
review by Bontempo & Malcolm (2012) stresses that interpreters in healthcare may be 
underprepared for clinical environments, particularly without specialised training. 

The  feedback  from  our  Registrants  supports  best  practice  recommendations  from 
professional  bodies  such  as  ASLI  and  international  counterparts  like  the  Registry  of 
Interpreters for the Deaf (RID, USA), which advocate that interpreters should not work in 
mental health or similarly complex environments until they have acquired at least three 
years of post-qualification experience (RID, 2007).  

However, Registrants have told us that what constitutes relevant experience during that 
three-year period is not clearly defined by NRCPD. As a result, while more experienced 
Registered  Sign  Language  Interpreters  are  generally  confident  in  taking  on  this  work, 
other  qualified  interpreters,  even  after  completing  three  years  of  experience,  may  be 
hesitant to accept assignments in complex settings. This, in turn, affects the pipeline and 
risks reducing the number of registered sign language interpreters willing or prepared to 
work in areas such as mental health. 

This gap in clarity and support needs to be addressed by NRCPD to ensure that, during 
those  first  three  years,  both  Registered  Sign  Language  Interpreters  and  Intralingual 
Interpreters acquire the core competencies necessary to work in complex settings. 

Doing so will better enable them to undertake this work effectively and ethically, with the 
appropriate  supportive  structures  in  place,  such  as  professional  membership  and 
professional supervision, to sustain their practice over the long term.  

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. 

Specifically, NRCPD commits to: 

•  Commissioning  a  programme  of  work  led  by  expert  mental  health 
practitioners  and  experienced  interpreters  to  develop  detailed,  practical 
guidance on what constitutes readiness for mental health interpreting. 

11 

 
 
 •  Producing  clear  guidance 

registrants,  agencies,  and  service 
commissioners  that  defines  the  types  of  experience  and  training  that  support 
safe practice in complex or high-risk interpreting contexts. 

for 

•  Exploring  the  feasibility  of  structured  pathways  to  specialisation  in  mental 
for  healthcare 
includes  supervised  practice,  mentorship,  and  formal 

health,  similar  to  RID's  Alternative  Pathway  Programme 
interpreting,  which 
assessment. 

•  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. 

•  Consulting  with  Deaf  community-led  organisations  and  Deaf  individuals  to 
ensure that guidance and training incorporate the lived experience of Deaf people 
who use mental health services. 

These  actions  are  intended  not  only  to  increase  the  number  of  interpreters  who  are 
confident and competent to work in mental health settings but also to ensure that those 
already  undertaking  this  work  are  better  supported  through  robust  guidance  and 
recognised training frameworks. 

Ultimately, this approach forms part of a broader strategy to enhance interpreter access 
and quality within health and social care, ensuring linguistic inclusion and safeguarding 
remain central to care for Deaf and deafblind people. 

12 

 
 
 
 
 
 Deaf People as Primary Rights Holders and Experts in their Care 

NRCPD  acknowledges  that  while  this  response  to  the  Regulation  28  report  has 
necessarily  focused  on  professional  regulation,  interpreter  standards,  and  systemic 
recommendations, it is essential to recognise the individuality and agency of Deaf people 
when considering language services provision.  

In particular, we acknowledge the importance of positioning Deaf individuals not simply 
as stakeholders, but as agents and primary rights holders and experts in their own care.  

Too  often,  discussions  about  access  and  safety  are  centred  on  professionals, 
commissioners,  or  services,  rather  than  on  the  lived  experience,  autonomy,  and 
leadership of Deaf people themselves. In the context of Imogen’s death, this imbalance 
is especially significant.  

Imogen was an articulate advocate for her language rights and, the Regulation 28 report 
suggests  that  she  made  clear  requests  for  BSL  interpretation,  which  were  not 
consistently upheld. Although Imogen was able to lipread, in all of her public posts, she 
was clear that her language preference was BSL.  Therefore, her ability to lipread should 
not  have  been  taken  as  a  substitute  for  her  requested  professional  language  service 
provision,  BSL  interpretation.  Lipreading  is  cognitively  demanding,  especially  during 
moments  of  acute  mental  distress.  It  requires  the  Deaf  BSL  user  to  interpret  and 
complete incomplete information, often in their second language, at significant cost to 
their energy and, at times, wellbeing.  

The capacity to “code-switch”, to move between different language modes such as BSL, 
lipreading  and,  at  other  times,  requiring  intralingual  interpretation  is  not  a  sign  of 
inconsistency but rather a reflection of a Deaf individuals’ deep understanding of their 
own  language  access  needs  in  different  settings.  It  is  therefore  imperative  that  public 
services,  including  healthcare,  respect  and  respond  to  these  self-identified  needs 
without making assumptions based on surface-level assessments of language ability.  

Flexibility in provision, led by the Deaf person’s expressed preference, must be central to 
safe and effective communication access. 

NRCPD further acknowledges the need for deeper co-production with Deaf communities 
in  shaping  policy,  guidance,  and  regulatory  improvements.  This  includes  actively 
involving  Deaf  advisors,  Deaf  professionals,  and  those  with  lived  experience  of  the 
systems we seek to influence.  

The rights of Deaf people, as outlined in the UN Convention on the Rights of Persons with 
Disabilities, particularly Articles 9 (Accessibility) and 25 (Health), must underpin both the 
language  and  substance  of  our  work.  Accessible  care  must  not  only  include  qualified 

13 

 
 
 
 registered language professionals, but also reflect Deaf culture, identity, and the right to 
be understood on one’s own terms. 

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.  

Conclusion and Summary of Actions 

NRCPD  acknowledges  the  matter  of  concern  raised  in  this  Regulation  28  Report  and 
accepts its seriousness. We recognise that the lack of timely and appropriate interpreting 
provision for Deaf individuals in mental health crisis can have grave consequences and 
must be addressed as a matter of urgency 

In response to the concerns raised by HM Coroner, NRCPD commits to a programme of 
meaningful  and  collaborative  action  aimed  at  improving  the  safety,  accessibility,  and 
quality of interpreting provision for Deaf individuals in mental health and community care 
settings. 

We will commit to: 

•  Support  the  development  of  person-centred, 

inclusive 
procurement models by working with commissioners, interpreting agencies, and 
statutory bodies to ensure interpreting provision is embedded from the outset of 
care planning. 

linguistically 

•  Advocate for clear national guidance, aligned with the Accessible Information 
Standard  and  the  BSL  Act  2022,  on  the  commissioning  and  delivery  of 
interpreting  services,  including  terms  and  working  conditions  that  enable 
interpreters to work safely and effectively. 

•  Contribute  to  the  development  of  statutory  guidance  under  the  BSL  Act, 
ensuring  that  the  requirements  for  high-quality,  regulated  interpreting  provision 
are reflected in service specifications and contracts. 

•  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. 

•  Commission  expert  Deaf  and  practitioner-led  work  to  define  interpreter 
readiness  for  mental  health  and  other  complex  contexts  and  to  produce 
guidance on safe practice, experience requirements, and routes to specialisation. 

14 

 
 
 
 •  Collaborate  with  NHS  England  and  training  providers  to  develop  endorsed, 
interpreter  confidence  and 

that  support 

specialist  training  pathways 
competence in complex settings. 

•  Engage with Deaf-led organisations, professional associations, and our own 
registrants  to  ensure  that  all  actions  taken  are  informed  by  lived  experience, 
ethical standards, and professional realities. 

•  Champion  Deaf-led  principles  across  national  policy,  commissioning,  and 

professional standards through its regulatory role. 

NRCPD  recognises  that  improving  access  to  interpreters  in  mental  health  settings 
requires  both  systemic  and  professional-level  change.  We  are  committed  to  playing  a 
central role in that change through regulation, guidance, and partnership, so that Deaf 
people can receive the care they need, in the language they use, with safety, dignity, and 
equity. 

We extend our condolences once again to Imogen’s family and loved ones. In responding 
to this matter of concern, we aim to honour her advocacy and contribute to the systemic 
changes needed to safeguard others. 

Chief Executive Officer  

NRCPD 

15 

 
 
 
 
 
 
 
 Timetable of Actions

16 

 
 
 Academic References 

Bontempo, K. and Malcolm, K., 2012. An ounce of prevention is worth a pound of cure: 
Educating interpreters about the risk of vicarious trauma in healthcare settings. In: L. 
Swabey and K. Malcolm, eds. In our hands: Educating healthcare interpreters. 
Washington, DC: Gallaudet University Press, pp.105–130. 

Dean, R.K. and Pollard, R.Q., 2013. The demand-control schema: Interpreting as a 
practice profession. North Charleston: CreateSpace Independent Publishing. 

Hetherington, A., 2012. Interpreting for mental health professionals: Researching the 
interpreter’s perspective on working in mental health settings. International Journal of 
Mental Health, 41(2), pp.70–87. 

Registry of Interpreters for the Deaf (RID), 2016. Standard Practice Paper: Interpreting in 
Mental Health Settings. [online] Available at: Standard Practice Paper - working in 
mental health settings [Accessed 8 May 2025]. 

Government & Policy References 

Department for Education and Skills (DfES), 2003. Every Child Matters. London: The 
Stationery Office. 

Department of Health and Social Care (DHSC), 2016. Accessible Information Standard 
– Specification. [online] Available at: 
https://www.england.nhs.uk/ourwork/accessibleinfo/ [Accessed 8 May 2025]. 

NHS England, 2014. Five Year Forward View. London: NHS England. 

NHS England, 2019. The NHS Long Term Plan. London: NHS England. 

National Institute for Health and Care Excellence (NICE), 2011. Service user experience 
in adult mental health: improving the experience of care for people using adult NHS 
mental health services (CG136). London: NICE. 

UK Parliament, 2022. Health and Care Act (2022) [online] Available at: 
https://www.legislation.gov.uk/ukpga/2022/31/contents/enacted  

UK Parliament, 2023. Procurement Act 2023. : Procurement Act 2023 - Guidance 
documents - GOV.UK  

UK Parliament, 2022.  BSL Act 2022: British Sign Language Act 2022 

17 

 
 
 
 
 
 
 National Deaf Organisation References 

British Deaf Association (BDA), 2023. Strategic Vision 2023–2028. 
https://bda.org.uk/strategic-vision/  

SignHealth, 2014. Sick of It. SignHealth Sick of It report  

SignHealth, 2021One Year On, 25,000 Conversations Later – What Has BSL Health 
Access Achieved? Available at: https://signhealth.org.uk/blog/one-year-on-25000-
conversations-later-what-has-bsl-health-access-achieved/  

SignHealth & RNID 2025 Still Ignored: Still Ignored Report 

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