Rachael Grimaldi
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As World Patient Safety Day approaches on 17 September, with its focus on safe care for every newborn and every child, it's a stark reminder of how communication barriers in healthcare can exacerbate risks and inequalities. In my view, exclusive communication—where language, literacy or accessibility needs are overlooked—poses a significant threat to patient safety, particularly for vulnerable children and their families. Embracing inclusive communication isn't just an ethical imperative; it's a practical pathway to safer outcomes. Drawing from years of observing these disparities, I believe we need to confront the scale of this challenge head-on and commit to dismantling it through systemic changes and supportive tools. This blog is part of our World Patient Safety Day 2025 series - Safe care for every newborn and every child. The scale of the challenge: why inclusive communication matters for children Health inequalities in the UK are a persistent crisis, costing the NHS an estimated £4.8 billion annually in avoidable hospital costs alone.[1] Patients in the most deprived areas live nearly a decade less than those in affluent regions, often enduring fewer years in good health. When we narrow this to children and newborns, the picture is even more alarming. Consider the evidence: non-English-speaking mothers face a 25-fold increased risk of maternal mortality,[3] directly impacting newborns. Black women are nearly four times more likely to die during pregnancy or childbirth compared to white women, with poor communication frequently cited as a contributing factor.[4] These risks extend to children, where misunderstandings can lead to delayed diagnoses or mismanaged care. For instance, unreported or misunderstood symptoms in maternity settings contribute to 55% of stillbirths linked to undetected foetal movements.[5] The NHS allocates around £75.5 million yearly to interpreting services,[6] yet the true demand could reach £250–£300 million, underscoring how under-resourced and fragmented our systems remain. In paediatric care, where children's voices are often mediated through parents, these gaps can result in higher readmission rates and preventable harm, perpetuating cycles of inequality from the earliest stages of life. The challenges for parents, children and staff For parents, navigating healthcare for their child amid language or accessibility barriers can be isolating and terrifying. Imagine a non-English-speaking parent trying to convey subtle changes in their newborn's behaviour, only to be met with confusion or reliance on ad-hoc solutions, like family members translating. These are methods that often introduce errors and breach confidentiality. Children themselves, especially those with cognitive or hearing challenges, may struggle to express pain or discomfort, leading to overlooked conditions. Healthcare staff face their own challenges. Time pressures in busy wards mean interpreters aren't always available promptly, forcing reliance on gestures, louder speech or generic online translation tools that lack clinical accuracy. This not only heightens the risk of misdiagnosis but also erodes trust, contributing to inefficiencies like wasted appointments and increased litigation. In essence, exclusive communication creates a vicious cycle where staff burnout rises, parental anxiety escalates and children's safety is compromised. The safety benefits of breaking down communication barriers In my opinion, prioritising inclusive communication provides transformative safety benefits. By ensuring information is accessible through multilingual resources, simplified language or sign language, we empower parents to report concerns early. This enables timely interventions that prevent deterioration. For children, this means fewer neonatal readmissions and better management of chronic conditions. Tools like CardMedic demonstrate how barriers can be broken down effectively: offering pre-scripted clinical dialogues in multiple formats, it supports immediate, accurate exchanges when live interpreters are unavailable. Integrating such approaches aligns with legal standards like the Accessible Information Standard, reducing risks and fostering equity. The result? Measurable improvements, such as early detection of issues in maternity care, lower stillbirth rates and enhanced patient satisfaction, ultimately redirecting resources to frontline services. Tools for a safer future To truly advance safe care for every newborn and child, we must embed inclusive communication as standard practice, not an afterthought. This requires a cultural shift: training staff to default to accessible tools, investing in hybrid solutions that blend technology with human support and tracking outcomes to prove the return on investment. Innovations that bridge gaps in real-time exemplify how we can dismantle these barriers, supporting better safety and outcomes for children. On this World Patient Safety Day, let's commit to a healthcare system where every voice, whether it’s a parent, child or clinician, is heard equally, turning potential tragedies into preventable successes. References Asaria M, Doran T, Cookson R. The costs of inequality: whole-population modelling study of lifetime inpatient hospital costs in the English National Health Service by level of neighbourhood deprivation. Journal of Epidemiology and Community Health. 2016;70(10):990. The Health Foundation. Major study outlines wide health inequalities in England, 15 August 2022. National Register of Public Service Interpreters. Hear Me, April 2024. Birthrights. Systemic racism, not broken bodies An inquiry into racial injustice and human rights in UK maternity care, May 2022. Sands. Stillbirth study investigates fetal movements in pregnant women, 28 September 2018. NHS England. Community languages translation and interpreting services, December 2024. Further reading on the hub CardMedic: Empowering staff and patients to communicate across any barrier Improvement framework: community language translation and interpreting services Blog - 12 tips for communicating with deaf patients Opinions expressed in blogs and other content are those of the author. Patient Safety Learning welcomes sharing content and opinions that promotes safer patient care and for the reduction of avoidable harm. The views expressed on the hub however do not necessarily represent Patient Safety Learning's views or values. References to a specific product or service does not imply a recommendation or endorsement. -
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The story behind CARDMEDIC (updated 28 May 2020)
Rachael Grimaldi posted an article in Blogs
Having read an article about a critically ill intensive care patient terrified when they couldn’t understand what the healthcare team were saying through their personal protective equipment (PPE), Rachael Grimaldi, an NHS anaesthetist, was inspired to create a simple communication tool: CARDMEDICTM. Update from Rachael: Since writing this blog, we have been accepted onto The Hill Accelerator Program, run by Oxford University, Oxford University Hospitals NHS Foundation Trust and Oxford Brookes University. We have also been selected to be a part of the Healthcare UK Digital Health Offer for Export for 2020. Healthcare UK is a joint initiative of The Department for International Trade (DIT), The Department of Health and Social Care (DHSC) and NHS England, which promotes the UK healthcare sector to overseas markets. We now have over 30,000 users in over 100 countries, alongside 11,500 app downloads. Version 2 of the app is out now, with a 'free notes' section so the patient and healthcare staff can communicate directly. Text can either be dictated or typed into the notes box, the language auto-detected and then translated into one of 10 languages available and read aloud to the patient if necessary. We are working on enhancing accessibility through the addition of sign language videos and images / illustrations / makaton signs. An independent academic evaluation by University of Brighton using simulated patients demonstrated 25% increased confidence in understanding a healthcare worker in PPE with CARDMEDIC than without. Overall, confidence improved by 28% to 95%. Results likely significantly higher for those unwell/communication needs. I am an NHS anaesthetist at Brighton and Sussex University Hospitals NHS Trust, on maternity leave (with three children under the age of 4 years), and currently stuck abroad in the US. Unable to be patient-facing during the COVID-19 pandemic, I have had to re-evaluate my initial plans to return to work. I have felt desperate to do something to help, and while keeping up with the news I was inspired by an article I read about a critically ill intensive care patient who was terrified when he couldn’t understand what the healthcare team were saying to him through their PPE (face masks, visors, hoods, etc). PPE creates a barrier to communication. So much is lost through this barrier. Not only verbal communication, but also non-verbal cues, which form the basis of the majority of communication – the ability to lip read for those that rely on it and the human connection behind the mask. As such, there is a significant risk of miscommunication of vital information between the patient and healthcare provider, presenting a considerable patient safety issue. What started out as a simple thought, “would healthcare staff be able to write down what they need to say on a piece of paper and show it to the patient?”, within 72 hours turned into an A–Z index of digital flashcards covering a wide range of topics, and www.cardmedic.com was launched. A free online resource for all to use, CARDMEDICTM launched on 1 April 2020. Prior to being shared on national news platforms, the site already had over 8000 users in 50 countries across 6 continents in just over 3 weeks, including across Europe, Australia, New Zealand, United States, Canada, Asia and Africa. It was shared by the Defence Medical Services to over 70 senior clinicians across all specialties in multiple Trusts across the UK. Since being featured in The Guardian and various other media outlets, the site has now had over 10,000 visits and 60,000 page views in less than 8 hours! I have been inundated with support, positive feedback and offers of help ranging from translation to illustrations and more. CARDMEDICTM is simple to use. Healthcare providers can access www.cardmedic.com/flashcards either on their institution’s or their patient’s smart phone, tablet or desktop. Choose the flashcard you would like to talk to the patient about and display it on the screen to the patient. Just ensure the website is displayed in the relevant language, there are 10 to choose from at the moment (thanks to Weglot) – this option is currently at the bottom right hand side of the page. If your patient is too unwell or unable to read, or partially sighted or blind, there is also a read-aloud option (thanks to SiteSpeaker) – choose the blue “play” button at the top right of the screen. Devices can be placed in freezer bags that are compatible with gloves and can be disposed of between patients, although we are aware of the environmental impact of this. Alternatively, some places have devices that they disinfect by wiping clean between patients. For those who prefer a paper-based approach, the cards can be printed and laminated; write-on, wipe-off. We are working on making these available as downloadable PDFs. With the re-deployment of vast numbers of healthcare and allied healthcare professionals, together with those returning to practice, there are a large number working outside their usual realm of clinical practice. This presented a further issue; staff may feel uncertain of how to talk to patients about certain aspects of their care in simple language if it is an area they are not familiar with working. The flashcards can also act as a reminder or prompt in these circumstances and another layer of maintaining patient safety. We have also just launched a free app on 25 April, compatible with android and iOS/Apple, improving accessibility for those with difficult internet access and ease of access for all..A huge thanks to Phil at A Million Monkeys for working tirelessly over the last couple of weeks on this. The app should not only improve accessibility for those in areas with little or no internet access, but also provide an immediately available source of flashcards that will be continually updated, without having to repeatedly download new versions from the app store. Based upon my training in anaesthetics and, as a part of this, experience in critical care, I wrote the majority of the CARDMEDICTM content. I have had significant contribution both in terms of content and resources from specialist colleagues in critical care nursing, end of life and palliative care, radiography, DNAR, obstetrics, midwifery, speech and language therapists and learning disability nurses, with more to come. Whilst what we have prepared is not professing to be a “gold standard” in communication, it is based upon a wealth of combined experience, knowledge and an acceptable standard in clinical practice. There is much planned in way of development, in part shaped by the feedback we have received. For example, we are collaborating with Signly on integrating British Sign Language videos and also working on integrating illustrations to improve accessibility for users. I am delighted to have Scarlett Brandley, a Leeds University Medical School student, spending her elective with me working on it. Some incredible suggestions have also been put forward about using it in refugee camps in Greece, Iran and Afghanistan. CARDMEDICTM has been developed through a combination of extreme generosity of colleagues, friends, family, contacts, word of mouth and Twitter, as well as very much burning the candle at both ends seven days a week. When I started this, I thought I would share the site with a few friends and colleagues and it would hopefully help make a difference to a few patients. I never envisaged it would have grown so rapidly and at such pace. I am so overwhelmed by the time, advice, services donated free of charge from so many different people – organisations, colleagues, friends and family. There are too many people to thank here! To mention a few – Patient Safety Learning have been championing it and have been a great source of support. My friends and colleagues at Brighton and Sussex University Hospitals NHS Trust and the University of Brighton have been incredibly supportive and proactive – I am very grateful. The Department for International Trade has been fantastic and introduced me to so many different contacts across a wide range of organisations, including Grow Global and Signly. A Million Monkeys has worked tirelessly on developing the app. The Defence Medical Services have shared it across the UK. The Academic Health Sciences Network (AHSN) have also been a really useful resource, especially with advice on possible funding streams. Dr Andy Tagg at Don’t Forget the Bubbles in Australia has been brilliant and we are looking forward to working together, along with Jane Stokes, to translate it into a further 15–20 languages. Having never been on Twitter before, the networking opportunities have been phenomenal and so many people have come forward too, to offer their time and expertise with various clinical sections of the site. I could go on! I am humbled to think my idea could have such far reaching purpose and value as this. It has been and continues to be, an enormous team effort to pull this together. We have applied for government funding and are yet to hear back. If this doesn’t come through, I am going to take the anaesthetics department at Brighton and Sussex University Hospitals NHS Trust up on their incredible offer of financial start-up support to aid further development, as well as a private donor up on their unbelievably generous offer to pay for the app development. All else has been without funding. It is so important for this to remain free for the end users: the patients and the staff. We are constantly looking to develop and improve. It is essential this works on the frontline and we are very grateful for your thoughts and feedback. If you have a moment, please either contact us via the website (www.cardmedic.com/contact) or via Twitter (@cardmedic).
