When Healthcare Communication Fails Patients Pay The Price

A deaf woman receiving the wrong vaccine after being denied effective British Sign Language (BSL) support has highlighted a much wider problem in healthcare: communication is not an optional extra. It is part of safe, effective treatment.

According to a report from the Parliamentary and Health Service Ombudsman (PHSO), the woman, identified as Samantha, had booked a flu vaccination. She had arranged her flu and Covid vaccinations for different weeks and even showed a note on her phone stating that she was there for the flu jab only.

Despite this, she was given a Covid vaccine.

The PHSO found that the GP practice had failed to provide the accessible communication support she needed. A BSL video that could have helped confirm which vaccination she had requested was not shown to her. The practice also believed it had established her consent through her grandmother, who was not in the treatment room and had early-stage dementia.

The consequences went beyond receiving the wrong injection. Samantha told the ombudsman that the experience had a “profound impact” on her.

The case illustrates a fundamental principle: patients cannot give meaningful consent if they cannot properly understand what is being offered to them.

Accessibility is a patient-safety issue

It can be tempting to think of interpreters, subtitles, large-print documents, audio information and other adjustments as additional services that make healthcare more convenient.

They are much more important than that.

When a patient cannot access information about a diagnosis, medication, procedure or vaccination, the risk of misunderstanding increases. That can affect consent, treatment decisions and ultimately patient safety.

The PHSO said disabled people were being let down because public services were not consistently meeting their accessible communication needs. These needs can arise because of disability, neurodivergence or because English is not someone’s first language.

Its figures are striking. Since April 2020, the ombudsman said it had concluded 623 investigations involving reasonable adjustments. Of those, 496 were upheld or partly upheld.

That suggests this is not simply a story about one unfortunate mistake.

Families should not have to become interpreters

The report also highlighted the experience of Alan Graham, a deaf patient being treated at University Hospitals Birmingham NHS Trust.

When an interpreter was unavailable, hospital staff asked his teenage grandson to interpret for the family and communicate extremely serious information, including that Graham might die.

That places an extraordinary burden on a young family member.

Medical conversations can involve complex terminology, distressing information and difficult decisions. Expecting relatives—particularly children or teenagers—to interpret such conversations can create emotional pressure while also increasing the possibility that important information is misunderstood or lost.

Following an ombudsman investigation, the trust apologised and said it had introduced measures intended to improve communication and accessibility for deaf patients.

There are examples of better practice

The PHSO’s report was not solely critical. It highlighted North Cheshire and Mersey NHS Foundation Trust as an example of how services can improve.

The trust worked with local advocacy groups and deaf people to understand why patients felt excluded. It subsequently provided guides explaining how patients could access interpreting and translation services.

The result was a 50% increase in the use of interpreters over one year.

That is an important lesson. Accessibility works best when services listen directly to the people who use them rather than simply assuming that existing arrangements are adequate.

Trust depends on being heard

Healthcare relies heavily on trust. Patients need to believe that professionals understand them, that their choices are respected and that important information will be communicated clearly.

When communication breaks down, that trust can quickly disappear.

Rebecca Hilsenrath, chief executive of the PHSO, said that when people feel they are not listened to and their needs are not met, they lose trust in the very services designed to support them.

That is why accessible communication should not be treated as a bureaucratic requirement. It is fundamental to dignity, informed consent and safe care.

The Department of Health and Social Care has described the experiences highlighted in the report as completely unacceptable, while NHS England has said it is unacceptable for deaf people or those with visual loss to face barriers to understanding or accessing healthcare.

The challenge now is turning those statements into consistent practice.

What should change?

The lesson from these cases is straightforward: healthcare organisations need to identify communication needs before treatment begins and make sure the appropriate support is actually available.

That means providing qualified interpreters where necessary, using accessible written and visual information, checking understanding directly with the patient and avoiding assumptions about what a patient has consented to.

Most importantly, accessibility needs to be built into healthcare rather than treated as something that is arranged only when a problem occurs.

Samantha’s case should never have happened. Nor should a teenager have been put in the position of interpreting potentially life-changing medical information for a family member.

Good healthcare is about more than the medicine itself. It is also about making sure every patient can understand what is happening to them, communicate their wishes and participate in decisions about their own care.

When that communication fails, the consequences can be far more serious than a misunderstanding. They can undermine safety, dignity and trust—the very foundations on which healthcare depends.