Providing Medical Treatment to a Non-English-Speaking Patient

Please note that this article was first published in AvMA Lawyers Service Newsletter in July 2025. Details of AvMA can be found here.
 

Paragraph 32 of the General Medical Council’s Good medical practice 2024 states:
 

You must take steps to meet patients’ language and communication needs, so you can support them to engage in meaningful dialogue and make informed decisions about their care. The steps you take should be proportionate to the circumstances, including the patient’s needs and the seriousness of their condition(s), the urgency of the situation and the availability of resources.

This paragraph is of particular importance when doctors are assessing and providing treatment to a patient who does not speak English. In this article I summarise a recent settlement in a case I conducted involving a 62-year-old Portuguese man who does not speak English but found himself communicating with his GP via Google Translate and, for whatever reason, failed to understand that he had dangerously high blood pressure requiring immediate treatment in the form of anti-hypertensive medication.

In the text that follows I attempt to set the scene of what was an unusual case and identify practice points that AvMA members may find of interest.

Factual Background
 

The case concerned medical treatment provided to a 62-year-old Portuguese man (who I will simply refer to as ‘the Claimant’) who moved to the UK with his wife in 2011. His stepdaughters, both of whom spoke fluent English, had already relocated to the UK. The Claimant and his wife spoke no English but could understand a few words. Their understanding was not sufficient to have a conversation in English.

Upon moving to the UK, the Claimant and his wife initially lived with one of their stepdaughters before relocating to a borough of South London which has a large Portuguese population.

In early 2015 one of the Claimant’s stepdaughters set about registering her mother and the Claimant with a GP. Upon researching local GP services, a practice was chosen because it was highly rated, and they made it very clear they were welcoming to non-English speakers and would provide interpretation services. The Claimant and his wife duly registered with the practice in April 2015. Upon registering the Claimant’s details, the practice computer system (EMIS) was used to record his specific requirements, namely – “Main spoken Language Portuguese – Interpreter needed”.

Following registration at the practice the Claimant and his wife were invited for NHS Health Check appointments with one of the practice’s Healthcare Assistants (HCA). The wife’s appointment was scheduled first but had to be re-arranged to facilitate telephone interpretation services via an authorised provider – Language Line. When the rearranged Health Check appointment took place, the Claimant’s wife was able to follow and, more importantly, understand what was being discussed during the appointment.

To ensure the practice was aware of the Claimant’s interpretation needs, the Claimant’s stepdaughter attached a Post-it note to his appointment letter which stated, in English, “Only speak Portuguese, I’d like an interpreter” so he could present this note to reception staff when attending the practice in June 2015 for his NHS Health Check.

On the day of his NHS Health Check the Claimant attended the practice alone but had with him his appointment letter and the Post-it note written by his stepdaughter. The Health Check was carried out by an HCA who, as was the case with the Claimant’s wife’s appointment, relied upon a telephone interpreter provided via Language Line. The HCA measured the Claimant’s blood pressure and obtained a reading of 218/118mmHg. Based on the HCA’s records, it was not clear the extent to which this information was relayed to the Claimant. The HCA was appropriately concerned about the Claimant’s blood pressure that she asked one of the GPs within the practice to see the Claimant as an emergency patient, i.e. fitting him in between scheduled patients. This is where the GP (referred to as D2 – Second Defendant) enters the arena.

D2 saw the Claimant in his consulting room but did not use Language Line to communicate with him. Instead D2 relied upon Google Translate as a means of communication. D2 in his witness evidence confirmed that he could not picture the Claimant or remember seeing him. He explained that when using Google Translate, he would ask basic closed questions to assess how much the patient understood. He had two screens on his desk. One would show the practice computer system (EMIS), the other had internet access and was used for Google Translate. D2 would use the keyboard on his desk and type out closed questions to the patient. The patient then took over the keyboard and typed in a response. D2 typed in English and Google Translate would interpret his words into the language selected. The patient would do the same in reverse.

Upon physical examination by D2 the Claimant’s blood pressure was measured again. This time the reading was 210/110mmHg. D2 arranged for blood tests, an ECG and urine sample for ACR (albumin to creatinine ratio – used to explore signs of kidney damage). All of these involved D2 handing a piece of paper to the Claimant to take away with him and organise the investigations. D2 also prescribed Amlodipine, an anti hypertensive, but the prescription was sent electronically to the pharmacy across the road from the practice. Therefore, a traditional paper-based green prescription was not handed to the Claimant. Instead, according to D2’s witness evidence, D2 pointed to the pharmacy building from the window of his consulting room suggesting to the Claimant that is where he should go next.

D2 also arranged a follow up appointment to take place four days later. He wrote the appointment date and time on the envelope containing the NHS Health Check appointment letter and the Post-it note written by the Claimant’s stepdaughter.

The Claimant left the surgery and went about having the blood test, ECG and depositing a urine sample. He returned to the surgery for the review appointment four days later, this time accompanied by his wife. Despite attempting to communicate with a Spanish speaking receptionist the Claimant and his wife did not understand where they should go and who would be seeing the Claimant. They remained in the waiting area for some time, but the Claimant’s name was not announced. Being unable to communicate with staff, the Claimant and his wife lost patience and left the practice without being seen by D2. No further follow up was attempted by the practice or D2 from this point.

Approximately eleven weeks later (late August 2015), the Claimant suffered a severe haemorrhagic stroke which left him with significant brain damage. His mobility is severely restricted, he is almost completely unable to speak and requires a high level of care. Upon being admitted to A&E via emergency ambulance on the day of stroke, A&E staff questioned whether the Claimant had been taking his anti-hypertensive medication. This was the first time the Claimant’s wife and stepdaughters were made aware of the prescription issued by D2 in June 2015. It was this information that led the Claimant’s stepdaughters to request their father’s GP records and consult with solicitors.

Peculiarities of the Case

This was an unusual case in the sense that the individuals present during the index consultations (the Claimant, the HCA and D2) were not able to give their recollection of events. As a result of his injuries the Claimant lacks capacity and was unable to give evidence on what was said during the consultations with the HCA and D2, and what he understood his medical condition to be. D2, on the other hand, could not picture the Claimant or remember seeing him. All he had to go on was his contemporaneous note and his standard practice. The HCA in question had left the practice and their solicitors were unable to locate her. No witness evidence was served from the HCA.

The Claimant had not discussed with his wife or stepdaughter the outcome of his NHS Health Check and subsequent consultation with D2. The Claimant did take brief notes, in Portuguese, in his diary during the Health Check and D2’s consultation. The notes were limited and only went so far to shed light on what the Claimant had understood from the assessments.

Therefore, the Claimant’s factual evidence was limited to:

1. His family’s account of how health conscious he was and that had he been aware of his high blood pressure and the prescription he would have acted upon, not ignored, the advice and taken the Amlodipine. He would not have played Russian roulette with his health by not taking the medication, and
2. His family’s retrospective piecing together of the Claimant’s contemporaneous handwritten notes in his diary.

As for expert opinion, the evidence from the Claimant’s GP expert was that D2 was an above average GP and he could not criticise D2’s examination of the Claimant, the tests and investigations ordered, the prescription issued and his treatment plan. Therefore, the case boiled down to the adequacy of interpretation services available, and whether appropriate steps were taken by the HCA and D2 to ensure the Claimant understood and could follow the advice being giving to him during the consultations.

The Pleadings

The claim was advanced against two Defendants: D1 was the company managing the practice (hence liable for the actions of the HCA); D2 was the GP who saw the Claimant as an emergency consultation.

It was alleged on behalf of the Claimant that the HCA should have informed the GP of the need for a Portuguese interpreter as well as the fact that the Health Check had been conducted with the assistance of Language Line. It was the Claimant’s case that the GP should have used Language Line (asking the call to be transferred to his consulting room) rather than relying upon Google Translate which, we claimed, was an inadequate means of communication in the circumstances.

Both Defendants denied all allegations of breach of duty asserting that appropriate translation services were in place. D1 further asserted that it is not the duty of an HCA to direct a GP as to which form of translation services should be used. D2’s position was that Google Translate is an appropriate means of communicating with a non-English speaking patient and D2 took reasonable steps to ensure that the Claimant could follow the consultation and understood what was being said to him. Interestingly, D2 in his witness evidence stated that he had stopped using Google Translate when he was notified of the Claimant’s claim because it “seemed a prudent and sensible thing to do.”

The Defendants made a late amendment to their pleading, alleging contributory negligence on the part of the Claimant stating inter alia, the Claimant either understood the advice given but for whatever reason chose to ignore it, or in the alternative failed to take reasonable steps to alert the HCA and D2 that he did not understand what was being said to him during the consultations.

Causation involved a complicated analysis of whether taking Amlodipine on its own, or in combination with other anti-hypertensive medication, during the intervening eleven-week period would have prevented the stroke from occurring. General physicians and neurologists were instructed by all parties to address these issues which resulted in a lengthy group experts’ discussion and Joint Statement setting out a detailed analysis of the literature behind the efficacy of anti-hypertensive medication. This debate was made more challenging by the fact the literature referenced was primarily designed to assess whether anti-hypertensive medication works rather than the timeframe within which the medication is able to reduce blood pressure to a ‘target level’. Causation could be the subject of a standalone article and will not be covered in this piece. Suffice to say, the parties could not agree on causation – the Defendants’ case being given the severity of the Claimant’s high blood pressure the stroke would always have occurred; the Claimant’s position was that the stroke on balance would have been avoided had anti-hypertensive medication been commenced within a day or two of the Claimant’s consultation with D2.

Outcome

This case settled shortly after a roundtable meeting and approximately two months before trial. In respect of the case against D1, it was agreed between the respective nursing experts that the HCA should have explained to the Claimant that he had dangerously high blood pressure and that was the reason he needed to see a doctor urgently. There was no evidence in the records that this information was given to the Claimant and as noted above, a witness statement from the HCA was not served.

As to the case against D2, the GP experts instructed by the Claimant and D2 (each Defendant had their own GP expert) agreed that the Claimant should have been given a green paper-based prescription rather than the GP sending the prescription electronically to the pharmacy. This, according to the GP experts, would have alerted the Claimant to the fact that a prescription needed to be dispensed, and would have been seen by his stepdaughters both of whom spoke English and would have collected the prescription on their father’s behalf.

Causation remained heavily contested between the parties with the experts taking diametrically opposed views on whether the stroke would have been avoided.

There were significant litigation risks in respect of breach of duty, causation and the late allegations of contributory negligence. The parties agreed a lump sum only settlement reflecting a significant discount for litigation risk. Notwithstanding this, the settlement consisted of a seven-figure sum and was approved by the Court in November 2024.

Practice Points
 

Upon reflecting on what was an unusual and hard-fought case against two Defendants with different indemnifiers and legal teams, points of potential interest are:

Analysis of the Claimant’s GP records
 

In this case the practice’s EMIS records gave a lot of information. It was clear the Claimant’s communication needs had been captured during the registration process. This included not only interpreter requirements but also contact details for one of the Claimant’s stepdaughters. The EMIS records made it clear that D1 knew of the Claimant’s specific communication and language needs.

Analysis of the Claimant’s wife’s GP records 
 

GP records of family members are not obtained as a matter of course in a clinical negligence claim. In this case the Claimant’s wife’s GP records were very helpful. They documented that upon attending D1’s practice for her NHS Health Check and subsequent GP appointments Language Line or a Portuguese speaking member of staff provided interpretation services. Google Translate was not used.

Disclosure
 

Disclosure from D1 was particularly enlightening. D1 provided details of interpretation services available within their practice and provided data on how often Language Line had been used during the time in question. The data confirmed the HCA used Language Line during the Health Check assessment and how long the Portuguese interpreter remained on the line. This level of detail helped build a picture of what happened on the day in question. It cannot be assumed that typed clinical notes will detail the method of interpretation service used and how long the consultation/assessment lasted.

Witness evidence
 

This case was rare in the sense that a non-English speaking patient attended a GP surgery on his own without being accompanied by a member of his family. Evidence (factual and documentary) of the Claimant’s health-conscious lifestyle and his contemporaneous handwritten notes helped to unravel how the Claimant is likely to have acted had he been aware of his life threatening condition. Extensive searches for documents – including the Claimant’s diary – took place. Without this level of detail it would have been difficult to advance the Claimant’s narrative that notwithstanding the fact he was examined by a HCA and GP on the same day, he left D1’s practice unaware of his dangerously high blood pressure and that a prescription for anti hypertensive medication had been issued.

Standard of care
 

Is using Google Translate negligent per se? I think not. It depends on the circumstances of the case and the severity of the patient’s condition. Free to access online translation platforms may be appropriate when communicating with a non-English speaking patient regarding a minor aliment or dealing with a request of an administrative nature. When dealing with a potentially life-threatening condition – such as dangerously high blood pressure – I would argue doctors and healthcare practitioners should tailor their approach. Language Line (available across the NHS) is the gold standard. If Language Line is not an option, an English-speaking member of the patient’s family can be contacted to act as interpreter, or a member of staff at a GP practice / NHS hospital or treatment centre fluent in the relevant language can be called upon as a last resort. One of the issues raised by the Claimant’s family was whether D2 selected the correct dialect of Portuguese (European Portuguese being significantly different from Brazilian Portuguese) upon using Google Translate. By using online interpretation platforms, it introduces the risk of the wrong dialect being selected, an error that will immediately be identified upon using Language Line or a member of staff to interpret in-person.

Cost budgeting
 

As the Claimant’s wife did not speak English her witness statement needed to be taken in Portuguese, with the assistance of an official independent interpreter, and translated into English. The process of obtaining a witness statement in a foreign language is lengthy in relation to solicitor drafting time but also interpreter input. A specialist interpreter (who is able to interpret medical and legal terminology) will have a higher rate than a standard interpreter who will be more equipped to translate general everyday conversations. Every document that is translated requires to be verified by a statement of authenticity. Specialist interpreters will charge by the word or per one hundred words. My advice when preparing a Precedent H costs budget for cases involving non-English speakers is, whatever figure is estimated for interpretation/translation fees – double it.

Kingsley Napley LLP were instructed by the Claimant; Counsel was Neil Sheldon KC of 1 Crown Office Row.

About the author

Richard Lodge is a Partner in the Medical Negligence and Personal Injury practice and is an individually ranked lawyer within the field of clinical/medical negligence in both the Chambers UK and Legal 500 directories. Richard is accredited for clinical negligence work by the Law Society and by the charity Action against Medical Accidents (AvMA).