Practice · 7 min read

If a patient cannot communicate, have we listened to them?

Accessible communication is not only a question of patient experience. It sits at the heart of patient safety – and it points to a question that should be in every business case.

By Dr Rachael Grimaldi, NHS Consultant Anaesthetist, co-founder and Chief Medical Officer of CardMedic.

Conversations really are at the heart of excellent patient care – I could not agree more with Stockport CNIO Pam Fearns on that. I am proud that our work on equality and inclusivity across acute and community care has been recognised with two finalist places at this year’s Picker Experience Network National Awards, alongside Stockport NHS Foundation Trust.

But conversations are only the start. Can we really say we have listened to a patient who could not communicate with the people looking after them?

For millions of people, the honest answer is no. It might be a language barrier, hearing loss, a learning disability, cognitive impairment or health literacy. Someone might need Easy Read, sign language, or content read aloud. Any of these makes it harder to describe symptoms, understand information, give consent, ask questions or raise a concern.

When that happens it is not only a poor experience. It affects diagnosis, consent, escalation and, above all, safety. Communication failure appears repeatedly in patient safety investigations, and NHS England’s own work on safety-critical spoken communication recognises as much.

What Ockenden and Amos put in front of us

The Ockenden review described families who were brushed aside, ignored and not listened to. Baroness Amos’s independent investigation has since made maternity and neonatal reform an urgent national priority.

NHS England’s response begins with a call to listen. Three of its commitments depend directly on whether a patient can communicate at all.

1. 01 Listen Roll-out of Martha’s Rule begins across all maternity and neonatal services in 2026/27, extending an escalation right that already exists in acute inpatient settings.
2. 02 Measure Trusts should collect and analyse real-time patient experience data in monthly cycles at public boards, with explicit attention to women from minority backgrounds.
3. 03 Address inequity National roll-out of the Perinatal Equity and Anti-discrimination Programme by the end of 2026.

Listening is vital. But how can we genuinely listen to everyone if our processes make it hard for some people to speak up?

Women and birthing people with limited English are at the forefront of this. NHS England’s improvement framework for community language translation and interpreting services reviewed MBRRACE-UK cases involving migrant women with limited English proficiency. Professional interpretation was not documented in 73% of them. In half, no interpretation was used at all.

Those are safety signals. We should treat them as such.

Martha’s Rule raises the stakes

Martha’s Rule exists for the moment a patient, family member or carer notices deterioration before the observations do. It gives them a clear route to escalate.

Escalation only works when communication is clear. If a patient cannot understand the question, how can they answer it? If they cannot describe what has changed, how can they raise a concern? If a relative cannot follow the clinical conversation, how can they advocate for the person they know best?

Giving people a voice only matters if they have the means to use it. That is why I believe accessible communication is a foundation of patient safety rather than a nice-to-have.

The obligation is already written down

The revised Accessible Information Standard, DAPB1605, is explicit. Organisations must identify, record, flag, share, meet and review patients’ information and communication needs – including communication support such as interpreters, sign language, communication aids and accessible formats.

For most Trusts the gap is not the obligation. It is delivery, at three in the morning, in a busy emergency department.

What happens when staff have the tools

An independent evaluation of CardMedic in urgent care surveyed 32 frontline staff at a single site. The evidence base is promising but still developing, and one site is one site – I would not present it as more than that.

Every member of staff surveyed said communication improved compared with their previous practice. All of them rated it valuable, and 96% reported faster consultations.

What strikes me most, though, is confidence. One senior health officer described the confidence of knowing their patient had understood them in a time-critical moment. Others said it was the clinically validated content that let them trust what was in front of them instead of having to improvise.

That difference matters. Clinicians do not just need to believe communication has happened. They need to know the patient has understood.

The alternative is already happening

Where support is hard to reach, staff turn to family members, to colleagues, or to generic online translation tools. Those workarounds carry obvious risks to accuracy, confidentiality, dignity and governance. Staff are doing it to meet the need in front of them – but it does not meet everyone’s needs, and it leaves no record that a need existed at all.

The department in that evaluation sees around 31,000 patients a month. Based on local data, the study estimated there should be roughly 849 interpreter interactions each month if everyone who needed one received one. In June 2025, before CardMedic, there were about 90 bookings, costing £3,500 to £4,000.

The real question is not “what are we spending on interpreters?” It is “how many people needed communication support and quietly went without it?”

Technology can identify unmet need. It can also help meet it. Sometimes a clinician needs one specific question answered. Sometimes it is an interpreter for a complex consultation – and that is what an interpreter is for. Sometimes it is Easy Read, sign language, or text read aloud. The same evaluation logged 647 uses of Read Aloud, 62 of Easy Read and 59 sign language videos: needs that no interpreter booking would ever have recorded.

The question I would add to every business case

Boards are right to ask what problem a technology solves, what evidence supports it, what it costs and how impact will be measured. I would add one more.

What happens to the patient when we do not have it?

Sometimes it is a delayed consultation. A repeat appointment. A decision made without the full history. A consent conversation someone did not fully follow. A family member speaking for a patient who should never have had to rely on them. And sometimes it is a concern that was never raised at all.

Ockenden, Amos and Martha’s Rule all point to the same thing: people need to be heard. Our job is to make sure every patient has a way to be heard in the first place.