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.
South Yorkshire (West)
Concerns raised2
Delays in following up requested blood tests
Failure to communicate and follow up abnormal blood 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.8
Action
Flag all abnormal results within MEDITECH.
Stated by the Rotherham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Introduce and communicate a Trust-wide standard operating procedure for managing investigation results.
Stated by the Rotherham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Review and update the standard operating procedure for critically abnormal pathology results in clinical areas.
Stated by the Rotherham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Conduct a Pathology audit of documentation for time-critical results telephoned to clinical areas.
Stated by the Rotherham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Conduct an additional 50-result audit of documentation and appropriate action for time-critical results.
Stated by the Rotherham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Action
Develop a Power BI module to monitor acknowledgement of results.
Stated by the Rotherham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Launch an Urgent and Emergency Care Centre pilot using the alertive bleep system to flag critical blood results.
Stated by the Rotherham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2026.
Action
Include learning from the incident in the Quality Newsletter, focusing on acting upon time-critical blood results.
Stated by the Rotherham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing face-to-face handover arrangements require follow-up tasks to be transferred to the out-of-hours team.
Stated by the Rotherham NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Black Country
Concerns raised2
Failure to adequately scrutinise laboratory blood test results
Failure to prominently flag abnormal laboratory results
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.11
Action
Pilot safe transmission and ingestion of DAPB4101 pathology reports between laboratories and GP practices.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2026.
Action
Publish guidance and resources supporting safe clinical messaging, test-result handling, clinical decision support and digital clinical safety.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Notify the laboratory of missing NT-proBNP alerts and request corrected reporting.
Stated by Quarry Bank Medical CentreStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Implement the MY Bot AI triage system to segregate results and alert the duty doctor to urgent abnormal findings.
Stated by Quarry Bank Medical CentreStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Reissue the Results Management SOP, retaining requesting-clinician responsibility and escalating results unfiled beyond 24 hours.
Stated by Quarry Bank Medical CentreStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Introduce mandatory same-day review and documented action for NT-proBNP values exceeding 400.
Stated by Quarry Bank Medical CentreStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Introduce an EMIS Web abnormal-alert framework for critical biomarkers and require documented acknowledgment or reasons for not following referral recommendations.
Stated by Quarry Bank Medical CentreStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Introduce cross-filing tasks and secondary review safeguards for results filed by another clinician and specified critical cardiac biomarkers.
Stated by Quarry Bank Medical CentreStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Develop and operate a clinical audit programme for significant results and referral completion, including fortnightly, monthly-governance, and quarterly NT-proBNP audits.
Stated by Quarry Bank Medical CentreStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Monitor revised-protocol compliance through monthly clinical governance meetings and formally review change effectiveness at three and six months.
Stated by Quarry Bank Medical CentreStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2026.
Action
Promote wider standardisation of pathology result-flagging conventions.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Individual GP practices manage operational arrangements for reviewing, assigning and acting on pathology results.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Laboratory and GP system suppliers are primarily responsible for pathology result formatting, structure, presentation and display of abnormal results.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS England may review national laboratory guidance on abnormal-result flagging and standardise laboratory alert protocols.
Stated by Quarry Bank Medical CentreRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Devon, Plymouth and Torbay
Concerns raised1
Failure to carry out regular blood tests
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
Action
Enforce the hospital discharge and clinical follow-up procedure, including review, action logging, GP confirmation and management audit.
Stated by Premiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Berkshire
Concerns raised1
Lack of guidance requiring consideration of CT scanning when CRP is high and not decreasing or rising after major abdominal surgery
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.3
Action
Provide existing guidance on postoperative CRP monitoring and CT investigation triggers.
Stated by The Association of Coloproctology of Great Britain and IrelandStated completedThe respondent said that this action was complete when they made their response on 24 April 2025.
Action
Contact ACPGBI to support its assessment of guidance needs and dissemination of any resulting guidance or communications.
Stated by Royal College of Surgeons of EnglandStated plannedThe respondent said that this action was planned when they made their response on 24 April 2025.
Action
Share the case details with NICE’s prioritisation team for consideration of whether further action is needed.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 24 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Existing guidance on CRP monitoring and CT investigation makes further ACPGBI guidance unnecessary at this time.
Stated by The Association of Coloproctology of Great Britain and IrelandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
ACPGBI is best placed to consider whether guidance is needed on recognising deterioration after bowel surgery.
Stated by Royal College of Surgeons of EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Clinical guidance is primarily the responsibility of NICE and relevant Royal Colleges, while Trusts should implement appropriate local processes or guidance.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Further guidance on CT scanning after abdominal surgery with raised CRP is not required because existing guidance and evidence address anastomotic leaks.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing NICE guidance, clinical judgement, local protocols and relevant professional guidance are relied upon instead of standalone CRP-based postoperative imaging guidance.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure to ensure urgent blood results are acted upon immediately
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.
North Wales (East and Central)
Concerns raised1
Failure to complete or communicate required repeat blood tests
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.
Lincolnshire
Concerns raised1
Failure to investigate a significantly abnormal respiratory acidosis blood gas result
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.2
Action
Require ED clinicians acknowledging blood gas results to document abnormalities requiring management and the planned further management.
Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 10 July 2023.
Action
Have clinical audit teams in both ULHT departments audit blood gas results and documentation to assess whether the learning and actions are embedded.
Stated by United Lincolnshire Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 10 July 2023.
Birmingham and Solihull
Concerns raised1
Delays in reviewing available blood test results
This report raised 4 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.
Derby and Derbyshire
Concerns raised1
Failure of the laboratory-results display to show all results in minimised mode
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
Reset the results-view scroll bar to the top when selecting another result and release the change to all users.
Stated by The Phoenix Partnership (Leeds) LtdStated completedThe respondent said that this action was complete when they made their response on 24 March 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The system displays scrollbars when information cannot fit on screen, and the table layout used to review results has no issue.
Stated by The Phoenix Partnership (Leeds) LtdDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner South London
Concerns raised1
Delays in review and follow-up of crucial blood test results
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.2
Action
Implement a virtual environment for tracking outstanding patient investigations, including blood test results.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Action
Establish a Gastroenterology hot clinic to ensure jaundice patients are referred after initial assessment and ultrasound, with Registrar and Consultant support.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
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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.
