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.
Cumbria
Concerns raised1
Failure to record recognition of the significance of critical blood-test results
This report raised 9 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 North London
Concerns raised1
Delay in responding to markedly abnormal blood test results
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Warwickshire
Concerns raised2
Failure to act on significant hypothyroidism identified by thyroid blood tests
Failure to flag significant hypothyroidism on thyroid blood tests
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.5
Action
Complete a results-management service-improvement review and produce its report.
Stated by South Warwickshire University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2021.
Action
Establish a clinically represented steering group to develop results-requesting and acknowledgement arrangements.
Stated by South Warwickshire University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2021.
Action
Select the clinical systems to use for requesting, reporting and acknowledging results before the new electronic patient record.
Stated by South Warwickshire University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2021.
Action
Further develop and approve a Trust-wide policy covering results requesting, reporting, review, acknowledgement, action, escalation, responsibilities and compliance monitoring.
Stated by South Warwickshire University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2021.
Action
Review technical and operational issues, develop standard operating procedures, and implement the selected clinical results systems.
Stated by South Warwickshire University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Laboratory flagging of suppressed thyroxine results is not recommended or proportionate because most results do not require urgent action.
Stated by South Warwickshire University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Directly flagging every low or suppressed thyroxine result would impose significant resource demands on the laboratory.
Stated by South Warwickshire University NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Birmingham and Solihull
Concerns raised1
Lack of a system for escalating blood test results to the consultant
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
Send pharmacy reports of clozapine results above 600 to the Clozapine Lead for direct escalation to the Consultant and Divisional Pharmacist.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2020.
Inner South London
Concerns raised1
Failure of laboratory abnormal-result repeating, alerting and follow-up
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
Highlight to Emergency Department medical staff the importance of reviewing abnormal blood results and arranging appropriate follow-up.
Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 May 2019.
Action
Prepare a Safety Net communication on raised protein or globulin and its association with multiple myeloma.
Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 May 2019.
Action
Use the Screening Diagnostic Improvement Group to review systems for prompt test-result review and reduced clinical risk.
Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 May 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Trust disputes that every elevated globulin requires extensive investigation, citing multiple causes and poor clinical utility.
Stated by King'S College Hospital NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Critical-result telephone notification follows professional recommendations, which do not classify elevated total protein as requiring communication.
Stated by King'S College Hospital NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester North
Concerns raised1
Failure to ensure required blood tests for individuals under specialist secondary care for renal failure
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.12
Action
Modify patient letters to explain blood-test arrangements clearly and provide an SRFT contact for monitoring difficulties.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Ask GPs before ESA treatment whether they can monitor bloods, record responses electronically, agree monitoring plans, and follow up non-responses.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Assume responsibility for taking bloods until the GP responds, ensuring clinically necessary ESA treatment can begin.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Develop and implement a standard operating policy covering ESA blood-monitoring arrangements, outstanding responses, and negative responses.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Update the electronic record to track ESA blood results due, missing results requiring follow-up, and the latest haemoglobin results.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Allocate prescriber job-plan time for ESA monitoring and prescribing.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Write to existing ESA patients to identify difficulties accessing monitoring and manage identified difficulties under the agreed policy.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Explore a Greater Manchester commissioned shared-care protocol for ESA monitoring through CCGs and the Medicines Management Group.
Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 June 2019.
Action
Establish an operating procedure requiring direct GP communication and a provider response before confirming monitoring-dependent treatment plans.
Stated by NHS Oldham CCGStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Describe the shared-care model in a business case for consideration by the Greater Manchester Medicines Management Group and local commissioners.
Stated by NHS Oldham CCGStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Identify patients receiving or potentially requiring shared-care ESA pathways and write to GP practices to promote robust monitoring.
Stated by NHS Oldham CCGStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Notify the CCG that the Practice was asked to monitor a red-status medication and report the associated significant event.
Stated by St Chads Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The SPoA and District Nursing service followed due process and acted appropriately on the referral based on the information available.
Stated by Pennine Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The community nursing service was commissioned to provide phlebotomy only for housebound patients, and this patient was not housebound.
Stated by Pennine Care NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Practice should not accept responsibility for monitoring EPO; the CCG will liaise directly with the Trust and medicines management.
Stated by St Chads Medical PracticeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Brighton and Hove
Concerns raised1
Failure to obtain repeat blood tests for clinical comparison
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Cornwall and Isles of Scilly
Concerns raised1
Failure to complete quarterly kidney function and lithium-level monitoring
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
Highlight lithium monitoring requirements to GPs and practices and remind them that current BNF and local CCG prescribing guidance is available.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 7 March 2018.
Mid Kent and Medway
Concerns raised1
Failure of haematology laboratory alerting for abnormal ALT and toxic paracetamol 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 an automated paracetamol phone-trigger and ALT alert prompting laboratory staff to telephone critical results to requesting clinicians.
Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 November 2017.
Action
Audit compliance with SBAR reporting and associated critical-result protocols.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 November 2017.
Manchester South
Concerns raised1
Failure to undertake annual liver function tests
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.
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 annual liver-function monitoring for patients prescribed sodium valproate, with due-date alerts, prescription checks and escalation of missed tests.
Stated by Grosvenor Medical CentreStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Action
Search current sodium-valproate patients’ records and invite those overdue for liver-function testing to attend for blood tests.
Stated by Grosvenor Medical CentreStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
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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.
