Paul Stemman

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Home > Policy > Special Inquiries > Daniel Joseph Inquiry (page 2)

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3. The Inquiry’s Conclusions


Having examined all the available evidence, the Inquiry concluded that no professionals could be blamed for what happened (i.e. no doctor, nurse, social worker). There had been growing concern that Daniel’s mental health was deteriorating. However, there was confusion about which doctors and which teams should be doing what. This was partly because Daniel had moved to a new address, which meant he was in a different health team’s area. The Inquiry team felt that Daniel was failed by the system.


Indeed, the Inquiry team said that Daniel was also a victim. They had heard many people say what a charming and likeable person Daniel was.



4. The Inquiry’s recommendations


The Inquiry team’s report made 32 recommendations. Some of these related to the procedures of the professionals involved (such as recording and communicating information). Other recommendations were far more wide-reaching and included:

  1. Specialist services for deaf people do not currently have the priority they deserve on the NHS Executive Agenda. They should be given a much higher priority. Without this the strategic work the Inquiry believes is necessary cannot be implemented and integrated into the wider National Service Framework for mental health.
  2. Except in an emergency, or where it is known that the patient communicates other than by sign language, no assessment of a deaf person by a non-specialist mental health professional should be undertaken without a sign language interpreter.
  3. Training should be provided to all health care and social services professionals as part of their basic professional training on how to understand the complexities of working with deaf people and how to use interpreters.
  4. Health and Social Services should review their commissioning of sign language interpreters and develop collaborations with neighbouring services and other voluntary and independent agencies to improve the recruitment, availability and competencies of such interpreters.
5. The Sign of the Times Consultation Document


The Department of Health responded to the Inquiry’s findings by publishing the Sign of the Times consultation document. This set out to look at mental health services for deaf people, and see what improvements could be made.


Having consulted with various Deaf groups and services, the Department of Health then followed this with another Report, Towards Equity and Access. This was a guidance document for health services, and included recommendations on how to improve services for Deaf patients. Although it specifically looked at Deaf people with a mental health problem, many of the report’s conclusions applied to all health services.


Along with these recommendations, there was an increase in funding for Deaf mental health services. For further information see the Towards Equity and Access page.


A copy of the full Inquiry report can be downloaded from here pdf icon