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2.2.3. Language or other comms barrier; no reasonable adjustments made
Less frequent than the failure to communicate with other professionals, but no less disturbing.
This category specifically covers failure to make reasonable adjustments for communication needs.
It reflects the message in a recent report by Healthwatch that NHS England's Accessible Information Standard is not being properly followed - a standard which exists precisely to prevent these problems from arising.
PFD reports citing this issue
sent to
MH team (community healthcare trust)
Linda had learning difficulties and a mental health condition. She was under the care of the MH team, but they failed to notice her LD and made no reasonable adjustments. Linda overdosed on her medication, and died as a result of the acute complications of paracetamol overdose on a background of alcohol related liver disease
sent to
Local authority: Children's Services (inc social care and education/SEND)
Fern committed suicide after being told that her baby was going to be placed for adoption. This followed a catalogue of failings by Children's Social Care, rooted in their failure to recognise Fern's clinically diagnosed autism, to make any reasonable adjustments for it, or to provide her with an independent advocate while they carried out the s.17 investigation on her baby.
The PFD report itself is addressed to the ambulance service and refers to the delay in getting her to hospital after taking an overdose. However, as with Jessie Eastland-Seares, there's a great deal of further detail in the report from georgejulian.co.uk, which paints a clear picture of the communication failures which led her to overdose.
sent to
Hospitals and other NHS acute settings
Karmchand was admitted to hospital with acute intestinal obstruction. He was placed on the wrong referral pathway, resulting in severe delay to the surgery he needed. Observations were not carried out properly while he was awaiting surgery.
Karmchand was unable to communicate the pain he was feeling to hospital staff. His family raised concerns, as did hospital staff who knew him, "but adequate notice does not appear to have been taken."
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