First reported 15 May 2014•Latest report 8 Jun 2026
Definition
What this concern includes
Includes failures in the process for identifying due laboratory monitoring, arranging and completing clinically required tests, reviewing results, flagging clinically significant findings and initiating appropriate follow-up or action.
Not included
Excludes diagnostic investigations and their completion tracking where the test is not part of ongoing or clinically required laboratory monitoring.
Excludes generic clinical-record, staffing or communication deficiencies unless they directly impair laboratory-test monitoring or follow-up.
Excludes failures to treat or manage a condition after relevant laboratory results have been reliably reviewed and acted upon.
Excludes non-laboratory investigations, physiological observations and imaging unless the assertion explicitly concerns the same laboratory-test monitoring process.
Reports
28
Distinct published reports
Individual concerns
34
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
66
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.
Department of Health and Social Care5
NHS England3
Medicines and Healthcare products Regulatory Agency2
Pennine Care NHS Foundation Trust2
Amgen Limited1
Ayurvedic Professionals Association1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Barts Health NHS Trust1
Belmont Health Centre1
Betsi Cadwaladr University LHB1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Cann House Care Home1
Care First Homes1
Davyhulme Medical Centre1
Grosvenor Medical Centre1
NHS trust15
Healthcare site9
Ministerial department5
Executive non-departmental public body3
Private limited company3
Health professional body2
Integrated care board2
Local health board2
Medicines and medical devices regulator2
Multi-service care provider2
Care-home operator1
Company limited by guarantee1
English metropolitan district council1
Nursing home1
Professional body1
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.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Failure to follow up abnormal blood test results
This report raised 15 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.
Carmarthenshire and Pembrokeshire
Concerns raised1
Failure to undertake requested liver function tests when clinically required
This report raised 2 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
Remind medical staff to undertake clinically justified tests and discuss provider-declined investigations with the ordering consultant.
Stated by Hywel Dda University LHBStated completedThe respondent said that this action was complete when they made their response on 27 July 2016.
East London
Concerns raised1
Failure to obtain baseline bloods and subsequent APTT monitoring for heparin administration
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
Introduce an unfractionated-heparin chart and weight-based guideline with six-hour APTT checks and consultant escalation for abnormal results at extreme weights.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 30 October 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Weight-based dosing, six-hour APTT checks and conditional haematology advice are considered sufficient safeguards without routine consultation for extreme patient weights.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Newcastle upon Tyne
Concerns raised1
Failure to action crucial blood analysis results
This report raised 2 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
Use blood-result sheets in patient notes to record individual results and trends.
Stated by Northumbria Healthcare NHS Foundation TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 9 October 2015.
Manchester South
Concerns raised3
Failure of biochemistry laboratories to escalate blood test results
Delays in recognising serious blood-test results
Failure to admit patients as emergencies despite serious blood-test results
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.7
Action
Lower the creatinine alert threshold to 400 µmol/L and telephone qualifying results on the same day.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2015.
Action
Implement the Trust-wide acute kidney injury alert system, with same-day telephone escalation for Stage 3 alerts and case-by-case review of Stage 1 and 2 alerts.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2015.
Action
Review the practice policy for allocating and checking incoming test results in light of the case.
Stated by Davyhulme Medical CentreStated completedThe respondent said that this action was complete when they made their response on 25 March 2015.
Action
Have all practice GPs read NICE guidance on acute kidney injury to improve management and awareness.
Stated by Davyhulme Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 25 March 2015.
Action
Deliver acute kidney injury recognition and management training for junior and other relevant staff.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2015.
Action
Implement and disseminate acute kidney injury guidelines through Acute Medical Unit displays and the locum doctor handbook.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2015.
Action
Disseminate the case and its lessons through staff debriefing, Medical Grand Round and divisional audit and clinical effectiveness presentations.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The practice relies on the laboratory to telephone urgent abnormal results, which are passed to the on-call doctor and dealt with that day.
Stated by Davyhulme Medical CentreExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The practice considers it impractical to guarantee that all results are checked continuously as they arrive.
Stated by Davyhulme Medical CentreUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The practice cannot automatically see hospital results and would need to search for them using a named-patient basis.
Stated by Davyhulme Medical CentreUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
London (East)
Concerns raised2
Failure to ensure communication of requests for clinically required tests
Failure to repeat blood tests within the required timeframe
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.1
Action
Add signing and dating requirements to orthopaedic handover sheets and retain them for audit and transparency.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2015.
Surrey
Concerns raised1
Failure to consider chemical pathology flagging of particularly concerning results
This report raised 13 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 of the laboratory to flag blood-calcium levels from 3.0mmol/l
This report raised 11 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
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
NICE does not stipulate laboratory reference values or alert thresholds because this falls outside its remit.
Stated by Department of Health and Social CareOutside remitThe respondent said that this matter was outside its role or authority.
Position
Individual NHS Trusts are responsible for reviewing their own standards for laboratory result reporting and alerts.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures in the process for identifying due laboratory monitoring, arranging and completing clinically required tests, reviewing results, flagging clinically significant findings and initiating appropriate follow-up or action.
