Coroner’s Inquest finds that there are systemic, longstanding and well documented challenges in the provision of mental health services for deaf patients and a national shortage of BSL interpreters, which makes it difficult for deaf patients to communicate their distress when their mental health is deteriorating, or they are in crisis.
The failures in the care provided by mental health services which were found to have contributed to the death included:
- Failing to review the care plan.
- Failing to put in place safeguarding measures being advised.
- Failing to have a face-to-face appointment to assess risk.
The coroner concluded that deaf mental health patients face systemic, longstanding and well documented challenges in accessing treatment they need. Despite over a decade of clear evidence, these barriers to deaf patients accessing healthcare remain.