First reported 23 Sep 2013•Latest report 9 May 2025
Definition
What this concern includes
Includes failure to consider life-threatening or organic alternatives during initial assessment and failure to revisit a diagnosis when symptoms, investigations or treatment response are inconsistent.
Not included
Diagnostic-test availability where differential diagnosis was appropriate
Failure to act on a confirmed result where diagnostic reconsideration is not deficient
Condition-specific pathways that provide a narrower supported recurring concern
Reports
17
Distinct published reports
Individual concerns
18
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
29
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Care Quality Commission3
NHS England3
Department of Health and Social Care2
General Medical Council2
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Cardiff & Vale University LHB1
Frimley Health NHS Foundation Trust1
Frimley Park Hospital1
Herefordshire and Worcestershire Health and Care NHS Trust1
Leicestershire Partnership NHS Trust1
Liverpool University Hospitals NHS Foundation Trust1
London Ambulance Service NHS Trust1
Metropolitan Police Service1
Milton Keynes University Hospital1
NHS trust11
Healthcare site5
Health professional body5
Executive non-departmental public body3
Health and social care service regulator3
Integrated care board3
Health and care professional regulator2
Ministerial department2
Professional body2
Executive agency1
Local health board1
Multi-service care provider1
Police force1
Prison or young offender institution1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Manchester South
Concerns raised1
Failure to revisit and holistically reassess an exercise-related asthma diagnosis
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner South London
Concerns raised1
Inadequate training of doctors to consider appendicitis as a differential diagnosis for generalised abdominal pain
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9
Action
Run regular courses developing safe, comprehensive history-taking and triage skills for telephone consultations.
Stated by Royal College of General PractitionersStated completedThe respondent said that this action was complete when they made their response on 8 November 2024.
Action
Embed telephone consultation, triage, and urgent-care knowledge and skills within the GP Curriculum, training, and clinical topic guides.
Stated by Royal College of General PractitionersStated completedThe respondent said that this action was complete when they made their response on 8 November 2024.
Action
Continue supporting educational resources on appendicitis and managing diagnostic uncertainty through the GP Curriculum and continuing professional development.
Stated by Royal College of General PractitionersStated in progressThe respondent said that this action was in progress when they made their response on 8 November 2024.
Action
Signpost members to the Best Practice Pathway Resource for paediatric acute abdominal pain and appendicectomy.
Stated by Royal College of Paediatrics and Child HealthStated plannedThe respondent said that this action was planned when they made their response on 8 November 2024.
Action
Share the report with Specialty Advisory Committee Chairs for consideration in upcoming curriculum reviews.
Stated by Royal College of Surgeons of EnglandStated completedThe respondent said that this action was complete when they made their response on 8 November 2024.
Action
Review CCRISP course content to determine whether it should explicitly refer to retrocaecal appendicitis.
Stated by Royal College of Surgeons of EnglandStated in progressThe respondent said that this action was in progress when they made their response on 8 November 2024.
Action
Launch the updated CCRISP course version incorporating the completed content review.
Stated by Royal College of Surgeons of EnglandStated plannedThe respondent said that this action was planned when they made their response on 8 November 2024.
Action
Redevelop the Clinical Skills in Emergency Surgery course while reviewing whether to explicitly refer to retrocaecal appendicitis.
Stated by Royal College of Surgeons of EnglandStated in progressThe respondent said that this action was in progress when they made their response on 8 November 2024.
Action
Publish an anonymised educational Surgical Safety vignette about the case in the specified surgical journals and disseminate it to a wide surgical audience.
Stated by Royal College of Surgeons of EnglandStated plannedThe respondent said that this action was planned when they made their response on 8 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Current surgical curricula adequately cover retrocaecal appendicitis, so no additional curriculum change is considered necessary beyond ongoing review.
Stated by Royal College of Surgeons of EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner South London
Concerns raised1
Failure to assess potentially life-threatening non-cardiac causes alongside cardiac causes of pain
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Update the guideline on asthma diagnosis, monitoring and chronic asthma management for publication.
Stated by National Institute for Health and Care ExcellenceStated in progressThe respondent said that this action was in progress when they made their response on 2 September 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Insufficient information about the UTC’s role and STREAMing Model prevents a specific response to concerns about prioritising chest pain.
Stated by Royal College of Emergency MedicineUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The STREAMing pathway does not unduly prioritise cardiac-sounding chest pain, and directing this patient to MedOCC was appropriate after low-risk assessment.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The prioritisation system and acute-care organisation concerns fall outside NICE’s remit.
Stated by National Institute for Health and Care ExcellenceOutside remitThe respondent said that this matter was outside its role or authority.
Position
NHS England is responsible for addressing concerns about its STREAMing prioritisation system.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Rutland and North Leicestershire
Concerns raised1
Failure to revisit working diagnoses and explore potential severe depressive disorder
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Sussex
Concerns raised1
Failure to consider and exclude tension pneumothorax during PEA cardiac arrest
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Provide multidisciplinary training for obstetric, anaesthetic and midwifery staff covering obstetric emergencies, maternal collapse and the 4H’s and 4T’s.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 January 2023.
Action
Include tension pneumothorax and surgical emphysema management in regular anaesthetic trainee simulation sessions.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 January 2023.
Action
Develop and deliver simulation demonstrations of national anaesthetic Regulation 28 notices through teaching and clinical governance meetings.
Stated by University Hospitals Sussex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Review guidance on managing increased airway pressure in ventilated patients, including its relevance to surgical emphysema and tension pneumothorax.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 January 2023.
Action
Share learning that non-traumatic bilateral pneumothoraces can cause failure to ventilate and cardiac arrest through safety updates, education and events.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Share learning that bilateral pneumothoraces can cause cardiac arrest without trauma or thoracic surgery through safety updates, education and events.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The Trust disputes that the team unreasonably delayed identifying tension pneumothorax or surgical emphysema during the cardiac arrest.
Stated by University Hospitals Sussex NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The existing ALS course adequately covers the resuscitation algorithm and cardiac arrest in pregnancy, so no course change is required.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Surrey
Concerns raised1
Failure to complete investigation of suspected bowel perforation
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Milton Keynes
Concerns raised1
Failure to reassess possible correctable causes when the patient fails to improve
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Failure to consider Covid-19 in patients with consistent symptoms
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Maintain and update monthly the local GP guidance providing routes for managing patients with and without Covid symptoms.
Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 14 June 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
National and local guidance already required remote triage, risk stratification, oximetry and escalation pathways for potentially high-risk Covid-19 patients.
Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Lack of clinical curiosity and failure to reconsider a queried diagnosis when findings are inconsistent
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Develop a guideline with Radiology and General Surgery to replace plain abdominal radiographs with CT for specified acute abdominal presentations.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
Action
Provide weekly virtual teaching on radiographic assessment and related diagnostic issues.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2021.
Action
Deliver teaching on diagnostic overshadowing and senior escalation, and add safeguarding and diagnostic overshadowing to the induction pack.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2021.
Lincolnshire
Concerns raised1
Failure to consider differential diagnoses and exacerbation of pre-existing co-morbidities
This report raised 17 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failure to consider life-threatening or organic alternatives during initial assessment and failure to revisit a diagnosis when symptoms, investigations or treatment response are inconsistent.
