First reported 17 Sep 2013•Latest report 9 Feb 2026
Definition
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
Distinct published reports
Individual concerns
20
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
21
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.
Barts Health NHS Trust2
Care Quality Commission2
Department of Health and Social Care2
NHS England2
Abbotsbury Residential Home1
Audlem Medical Practice1
Blackpool Teaching Hospitals NHS Foundation Trust1
County Durham and Darlington NHS Foundation Trust1
Croft House Rest Home1
East and North Hertfordshire Teaching NHS Trust1
East Lancashire Hospitals NHS Trust1
Grosvenor Park Care Home1
Lancashire Teaching Hospitals NHS Foundation Trust1
Medway NHS Foundation Trust1
Mersey Care NHS Foundation Trust1
NHS trust11
Executive non-departmental public body2
Health and social care service regulator2
Ministerial department2
Multi-service care provider2
Residential care home2
Healthcare site1
Nursing home1
Private limited company1
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.
Northumberland
Concerns raised1
Failure to consider altered gastric anatomy and investigate potential perforation when complications arise
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Failure to detect iatrogenic injury despite clinical assessment and investigation
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
Expand Martha’s Rule to all acute inpatient sites.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The consultant surgeon’s CT interpretation was a reasonable differential diagnosis given the evidence available at the time.
Stated by Barts Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Lack of DGH Emergency Department protocols and staff awareness for recognising potential silver trauma cases at arrival
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
NHSE and local integrated care bodies are responsible for addressing the concerns about treatment at Wythenshawe Hospital.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Greater Manchester Integrated Care provides the relevant services, while its Integrated Care Board decides commissioned health services.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Mid Kent and Medway
Concerns raised2
Failure to consider fracture or internal bleeding during continued deterioration
Failure to consider potential fracture injury
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.5
Action
Deliver staff teaching and simulated training on evidence-based trauma care for elderly patients.
Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 February 2021.
Action
Resume the suspended staff teaching and simulated training programme on elderly trauma care.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 February 2021.
Action
Implement ED silver trauma screening for frail patients with low-energy trauma, including senior-clinician assessment where red flags require escalation.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 February 2021.
Action
Adopt the London Major Trauma System elderly-trauma screening and triage pathway prompting immediate senior-doctor assessment.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 February 2021.
Action
Provide a specialist-nurse front-door team to assess frail elderly patients arriving in ED and expedite transfer, escalation or discharge.
Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 February 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The ambulance record documented a shortened leg without rotation, contrary to the inquest evidence.
Stated by Medway NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Hertfordshire
Concerns raised1
Failure to identify serious injuries following road traffic collisions
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
Review the care provided on 4 May 2018.
Stated by East and North Hertfordshire Teaching NHS TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 22 November 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Clinical findings did not require head or forearm imaging; assessment and national guidance supported no further investigation.
Stated by East and North Hertfordshire Teaching NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Failure to undertake further imaging in borderline presentations of significant head injury
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
No further investigations were considered necessary because there were no clinical signs indicating a need at the time.
Stated by Recipient name withheldNo action considered necessaryThe respondent said that no further action was needed.
Black Country
Concerns raised1
Failure to correctly assess and diagnose injuries in the Emergency Department
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.
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
Action
Revise the head-injury guideline to align with NICE guidance and add head-and-neck imaging prompts to the proforma.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 March 2018.
Action
Require all clinicians to use the head-injury proforma for hospital falls and Emergency Department presentations.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 March 2018.
Action
Adopt the approved head-injury guideline within one month and address identified implementation challenges.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 March 2018.
Action
Monitor implementation of the approved head-injury guideline, including imaging, observation duration, specialist referrals and follow-through of requested actions.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 March 2018.
Inner North London
Concerns raised2
Failure to obtain detailed symptom information after head injury
Failure to consider the potential for serious consequences from head injury in vulnerable older people
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
Introduce a formal trust-wide policy for managing head injury in patients and staff.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 4 February 2018.
Bedfordshire and Luton
Concerns raised1
Failure of night shift staff to consider and exclude possible head injury in residents with confusion
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.
Liverpool and the Wirral
Concerns raised1
Failure to take physiological readings when assessing physiological response to fracture
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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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.
