Recurring concern
Failure to reliably assess and diagnose injuries
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Request correctionFirst reported 17 Sep 2013•Latest report 9 Feb 2026
What this concern includes
Includes failures of clinical assessment, investigation, diagnostic reasoning or review specifically concerning recognition and diagnosis of traumatic or other physical injuries, including missed or delayed fracture diagnosis and Emergency Department injury-assessment failures.
Not included
- Excludes failures concerning diagnosis of medical diseases or conditions without an injury-diagnosis component.
- Excludes treatment, referral, follow-up or discharge failures where the injury was correctly diagnosed and the deficiency concerns a later care step.
- Excludes generic staffing, training, communication or documentation deficiencies unless they directly result in unreliable injury assessment or diagnosis.
- Excludes isolated limitations of a diagnostic test or imaging modality unless the report identifies the resulting failure to assess or diagnose an injury.
- Reports
- 17
- Individual concerns
- 20
- Date range
- 2013–2026
- Stated actions
- 21
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to report a visible hip fracture on an x-ray report
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 concernsEach 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
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Action
Put specific measures in place to reduce the risk of further radiology reporting errors.
Stated by East Lancashire Hospitals NHS Trust
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Concerns raised1
Failure to consider intracranial bleeding when assessing new confusion after a fall
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Discuss serious incidents and morbidity and mortality issues through governance meetings and disseminate learning points to the acute admissions team.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to assess injuries after a significant uncontrolled fall before repositioning the patient
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 concernsEach 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
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Action
Instruct all staff not to move a person after a fall until a suitably trained person completes a full assessment.
Stated by Rch Care Homes Limited
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Concerns raised1
Delays in diagnosing fractures during regular clinical visits and examinations
Responses linked to these concernsEach 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.4
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Action
Introduce 24-hour falls observation charts to support closer post-fall monitoring and evidence-based escalation.
Stated by Four Seasons Health Care -
Action
Refer residents with osteoporosis to the Community Matron after a low-impact fall for review.
Stated by Four Seasons Health Care -
Action
Initiate prompt ambulance referral for assessment and x-ray when an elderly frail person falls, recognising that minor trauma may cause fracture.
Stated by Partners of Neasham Road Surgery
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Action
Include dementia, osteoporosis and other relevant factors in care plans to prompt and support appropriate post-fall assessment.
Stated by Partners of Neasham Road Surgery
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Concerns raised2
Failure of triage to undertake further and detailed assessment of spinal injury risk
Delays in diagnosing suspected spinal cord injury
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 concernsEach 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
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Action
Review triage nurse training to require grip assessment for specified elderly patients with head injury.
Stated by the Dudley Group NHS Foundation Trust -
Action
Develop a business case and risk assessment for a medical rapid-assessment service for ambulance-borne patients.
Stated by the Dudley Group NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The investigation concluded that earlier immobilisation and diagnosis would not have prevented this patient’s death.
Stated by the Dudley Group NHS Foundation Trust
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Concerns raised1
Unrecognised incorrect assumptions about the cause of a patient’s injury
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to diagnose fractures in the Emergency Department
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026