Hospital staff used a teenage boy to tell his Deaf mother that her father might die that day, an investigation by England’s Health Ombudsman has found.

 The boy’s grandfather, Alan Graham, 75, was born Deaf and his first language was British Sign Language (BSL).

After a fall, he was admitted to hospital and diagnosed with heart failure.

Hospital clinicians asked his grandson Connor Petty, who was 16 at the time and knew some BSL, to tell his mother that Alan may not survive the night and that CPR should not be provided if the need arose. Alan died the following day.

Alan’s daughter Jennifer Graham-Petty, 52, who was born Deaf and uses BSL, complained to the Parliamentary and Health Service Ombudsman (PHSO) about her father’s care and the use of her children as interpreters.

PHSO found that the University Hospitals Birmingham NHS Foundation Trust failed to comply with national guidance by repeatedly using Connor and his sister Mia, who was 12 years old at the time, to relay information to Alan about his care and treatment. This caused distress to the family and affected their ability to grieve.

The Ombudsman is urging healthcare leaders to make sure services are accessible to all and that providers make reasonable adjustments, such as BSL interpreters, to remove any barriers to services.

Rebecca Hilsenrath KC (Hon), Chief Executive at the PHSO, said:

"Public services must be accessible to everyone for the system to be fair and equitable. Deaf patients and their families should have access to the same healthcare as everyone else without facing additional barriers.

 

“This is recognised by national clinical guidelines which say that interpreters should be provided to those who face difficulties in speaking and understanding English. It is also enshrined in standards and legislation, such as the Accessible Information Standard and the Equality Act, which both set out that service providers should make reasonable adjustments for Deaf people to access their services.”

Alan Graham was a former furniture maker and keen fisherman from Dundee who moved to Birmingham to be closer to his grandchildren.

In June 2021 he had a fall at home and was admitted to Queen Elizabeth Hospital in Birmingham. Alan suffered swelling in his legs and chest pain and was diagnosed with right side heart failure before being discharged in August.

In September 2021, he was admitted again after experiencing similar symptoms and was diagnosed with heart failure. Alan died two weeks later.

During the 11 weeks that he was in hospital, the Trust provided professional interpreters on only three occasions. PHSO found that the Trust was regularly using two of his grandchildren to communicate with Alan, asking them to translate medical information and details about his prognosis.

Rebecca added:

"In this case, by not consistently providing BSL interpreters to Alan, the Trust caused unnecessary distress in the weeks before his death. Healthcare leaders and professionals must learn from this to make sure that another family does not go through the same experience.”

Jennifer said: 

"It was extremely frustrating, every day I was asking for an interpreter. My children just wanted to visit their grandad and be there for him as family members but they were constantly being asked to translate by the staff.

 

“While they know some BSL, they are hearing so it is not their first language and they don’t have the same level of knowledge as a professional to interpret the medical jargon that staff were asking them to. Having to deliver the bad news about my dad’s prognosis was totally unacceptable and very upsetting for all of us.

 

“Too often there is a lack of interpreters in healthcare settings all over the UK, I have experienced it myself when being referred by GPs. There needs to be more awareness about the barriers faced by Deaf people and things need to change. A good place to start would be more joint working and better communication between health professionals so that interpreters are automatically provided for those who need them.”

The Ombudsman found that while a lack of interpreters did not impact the care and treatment Alan received, it caused worry and stress to Connor, Mia, and Jennifer, whose ability to communicate with medical staff about her father’s treatment was also affected.

PHSO recommended that the Trust create an action plan detailing how it will prevent this from happening again. It also recommended that the Trust apologise and pay Alan’s grandchildren £900 each and pay Jennifer £750 for the impact of the failings on them. The Trust has complied.

PHSO has raised its concerns about access to BSL interpreters with NHS England and RNID (Royal National Institute for Deaf People).

Victoria Boelman, Director of Insight and Policy at RNID, said: 

The details of this case are entirely unjust and unacceptable, yet sadly unsurprising. We know from our research and campaigning work in this area that the levels of communication support and access to healthcare information for deaf communities and those with hearing loss are often woefully lacking.

“This is not an isolated incident – our recent report co-written with SignHealth, Still ignored: The fight for accessible healthcare, reveals seven out of ten deaf people and people with hearing loss have never been asked about their information and communication needs when accessing NHS care – something which providers are obliged to do under the Accessible Information Standard.

“Change is urgently needed as lives are being seriously disrupted, and even lost in some cases, because vital health information is not being communicated in a way that is accessible to all, and this should not be the case. We are calling on the Department of Health and Social Care to make a series of improvements, such as mandatory deaf awareness training to be introduced to all NHS staff.”

Read the investigation report. 

The Local Government and Social Care Ombudsman (LGSCO) has appointed James Strachan as its new Director of Corporate Services.

James joins from Eastleigh Borough Council in Hampshire, where he has served as Chief Executive for the past four years. He brings a wealth of experience from across local and central government, having previously held the role of Business Development Director at Southampton City Council and a range of senior positions at Hampshire County Council.

James also has significant Whitehall experience, having worked at the Cabinet Office and served as a Director at the National Archives.

In this newly-created role, James will join the Ombudsman’s Executive Team and lead the corporate services function, overseeing the organisation’s Policy and Communications, Human Resources, IT, Operational Support, Projects and Committee & Governance teams.

Local Government and Social Care Ombudsman, Mrs Amerdeep Clarke, said:

"After a thorough recruitment process, we are delighted to have appointed James as our new Director of Corporate Services. 

“His extensive experience across local and central government, combined with his strong track record of leadership, makes him ideally placed to drive forward our corporate services and support the vital work we do for the public. 

“James has demonstrated throughout his career an ability to lead teams effectively while delivering real improvements to services. His understanding of both local government and central government will be invaluable as we continue to develop as an organisation. We very much look forward to working with him.”

Mr Strachan said:

"I'm delighted to be joining the Local Government and Social Care Ombudsman.  I've always been impressed with the professionalism and dedication of the LGSCO and its mission not just to resolve individual disputes, but also to learn lessons that can be applied across the sector.  

“I look forward to joining a great team and contributing what I've learned from my own career in public services."

James will take up his new post on 1 April.

An investigation by England’s Health Ombudsman following the death of a 67-year-old woman has triggered a systemic review of cancer treatment and diagnosis wait times at Mid and South Essex NHS Foundation Trust.

The Parliamentary and Health Service Ombudsman (PHSO) recently investigated the care of Mrs S who was treated at Broomfield Hospital, run by the Trust, in 2023.

The retired history teacher and mother-of-two from Chelmsford, had terminal ovarian cancer and died in April that year. Her son, who was 29 when his mother died, raised concerns about her care. PHSO’s subsequent investigation found there had been a delay in diagnosing and treating his mother’s cancer.

Mrs S’s diagnosis took 49 days and her treatment did not start for 81 days after the referral. NHS England targets at the time were for cancer to be diagnosed within 28 days of referral and treatment to begin within 62 days. After her son complained about his mother’s treatment, the Trust said that it had improved its performance on cancer wait times. However, PHSO’s investigation found the Trust’s performance against its treatment targets had declined.

In 2023, at the time Mrs S was being treated, the Trust failed to meet all of the NHS England cancer wait time targets. Only 47.6% of patients were treated within 62 days, compared to the national target of 85%. By July 2025, that had dropped to 46.1%. Trust figures show that at the end of August, 664 patients were waiting longer than 62 days to confirm a cancer diagnosis, or rule it out, and begin treatment.

Following its investigation, PHSO took the unusual step of asking the Trust to systemically review its performance against national cancer wait time targets, and develop a robust plan to help it meet treatment targets. 

The action plan has been received and the Trust has committed to look at how it can better allocate resources and increase capacity to reduce wait times. The Trust will use new technology to improve efficiency by standardising and digitising processes, and specialist software to analyse cancer pathways and identify delays.

The Trust will also hold weekly meetings to track progress and ensure the longest waiting patients are prioritised and implement a one-stop menopausal bleeding clinic which will offers scans and a consultant review at the first appointment to help with timely diagnosis.

Paula Sussex, Parliamentary and Health Service Ombudsman, said, 

Every day, hundreds of people receive a diagnosis of cancer. It is vital that they can trust in the system to deliver the quality treatment they need for their survival, recovery, or, in terminal conditions, to allow them to spend precious time with loved ones.

 

“Learning from past failings and continually improving services should be the lifeblood of the NHS. I am aware that the Trust has faced organisational challenges that exacerbated pressures brought by the pandemic, and they have worked to find an effective operating model, including leadership changes and a new programme to better listen to frontline voices. 

 

“In this case, we recommended that the Trust should investigate its performance against national targets and make a robust plan for how it will improve. The Trust has committed to carrying out this work and will be rolling out new technology to help it allocate resources more efficiently and increase capacity for cancer appointments. 

 

“While this will sadly not change what happened in this case, it highlights how one complaint can make a difference. Because of this investigation, other patients and families should experience wait times that are in line with national guidance.”

Mrs S visited her GP in January 2023 as she had uncomfortable abdominal bloating. After receiving concerning blood test results, the GP referred her to the Trust. 

A CT scan on 16 February showed the presence of cancer but clinicians could not identify the type of cancer until a biopsy on 15 March. Mrs S was diagnosed with ovarian cancer on 21 March. She was told that while it was not survivable, chemotherapy may extend her life.

Chemotherapy was scheduled for 21 April but due to the delays in diagnosis and treatment, Mrs S was no longer fit for the treatment. This meant she lost the opportunity to engage in chemotherapy, and her family will never know whether or not this could have improved her quality of life or extended her life to give her more time with her family. This is a serious injustice to them.

PHSO found that had the Trust met the national cancer standard for referral to treatment, Mrs S’s palliative care should have begun on or before 3 April. At that point, her medical records indicate that she would have been fit for treatment. 

When the Trust told her that her cancer was not survivable, it should have considered starting a palliative care pathway. There is no evidence this happened and there was no coordination of her palliative care between the hospital and the hospice, delaying her access to this care.

The Ombudsman found further failings in care including delays draining her ascites (fluid build up in the abdomen) which caused avoidable distress. 

The Trust also unsafely discharged Mrs S from hospital on 18 April. She was readmitted three days later in a serious condition. She died the next day.

PHSO found the failings by the Trust caused distress to Mrs S and her family. The Trust had not acknowledged the extent of its failings or taken appropriate action to address them.

Along with the cancer wait times review, PHSO recommended the Trust create an action plan detailing how it will improve its discharge planning, palliative care planning, and communication between staff and patients approaching the end of their life. The Trust was also told to apologise to her family. The Trust has complied.

Mrs S’s son described his mother as someone who was heavily involved in the local community. She sang in two local choirs, played tennis twice a week and volunteered teaching English to female refugees in Chelmsford.

Her son, a 31-year-old chartered surveyor, said, 

I had trust in the NHS, so whenever they told us things, like scans, would happen we believed them. But it was just delay after delay. My mother and I kept asking questions and for updates but never got anywhere and the whole situation was just confusing and frustrating.

 

“There was clearly something wrong with my mum and we had a feeling it could be cancer, but we needed a diagnosis and this took too long to get. After we finally had the diagnosis, we were almost relieved and we expected treatment to start straight away. But again, it took too long to confirm the chemotherapy date. 

 

“Then there were issues with my mum being unsafely discharged from hospital. I was basically just handed a bag of medication with no instructions, advice or support. My mum was incredibly weak during that time and I feel like that week where she came home and I was trying to look after her with no support took 10 years off my life. I still have nightmares about it.

 

“There was nothing that could be done for my mum because her cancer was terminal. But if she had received the care she should have had, then her quality of life would have improved and we may have had more time together.

 

"I’m grateful the Ombudsman provided the answers I couldn’t get from the Trust, I just want the Trust to be held to account. I don’t want another family to go through something like this.

 

"The service failures the Ombudsman has identified should be another driver for the Government to address substantial reforms required in the NHS. Time and time again, we hear politicians go on about reducing wait times but nothing seems to be improving on the ground. I cannot fault the frontline staff but there seems a general consensus around the country that without a substantial shake-up by policymakers, the quality of NHS care will continue to decline.”

Dawn Scrafield, Chief Executive of Mid and South Essex NHS Foundation Trust, said:

We know that waiting for cancer diagnosis and treatment is a worrying time and we offer sincere apologies to Mrs S’s family for the delay in her treatment. Demand has increased, and we are reviewing how we manage the need for more diagnostic services. We have begun an integrated improvement plan, working with our health and care system partners to speed up treatment times and get patients to the right place at the right time.

 

“We have invested in new technologies to help us treat cancer faster and have recently opened new a Community Diagnostic Centre in Thurrock, which is improving access to scans and diagnostic tests.

 

 “Cancer care is one of our key priorities, and we can already see our wait times reducing in some cancers as we deliver extra clinics and theatre scheduling.”