Unreliable recognition and management of pulmonary embolism
First to latest report 24 Feb 2016 — 15 Sep 2025
Reports that mention this concern
9
Times this concern has been raised
11
Stated actions linked to this concern
19
What this concern includes
Includes failures in the dedicated pulmonary-embolism process, including application of PE assessment policies, interpretation of clinical scores and symptoms, recognition of suspected PE, investigation, escalation and treatment decisions where these directly concern pulmonary embolism.
What is not included
Excludes venous-thromboembolism prevention or thromboprophylaxis failures where pulmonary-embolism recognition or management is not the deficient control.
Excludes generic diagnostic, training, communication or documentation deficiencies unless they directly impair recognition or management of pulmonary embolism.
Excludes treatment or follow-up failures after pulmonary embolism has been reliably recognised and managed, unless the asserted deficiency remains part of the PE management process.
Excludes other causes of chest pain, breathlessness or clinical deterioration where pulmonary embolism is not a material part of the asserted concern.
Trends
Reports over time
Reports mentioning this concern, 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.
Barnsley Hospital NHS Foundation Trust1
Barts Health NHS Trust1
Dartford and Gravesham NHS Trust1
Department of Health and Social Care1
Milton Keynes University Hospital1
Milton Keynes Urgent Care Services CIC1
New Cross Hospital1
Resuscitation Council UK1
Royal Bolton Hospital1
Royal College of General Practitioners1
Royal College of Obstetricians and Gynaecologists1
Healthcare site3
NHS trust3
Health professional body2
Ministerial department1
Type not available1
Reports and published responses 9 reports
See individual reports that have raised this concern, and the actions taken in response
East Riding and Hull
Concerns raised1
Failure to recognise that a low Wells score does not exclude DVT or PE
Linked response
Royal College of General Practitioners
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Royal College of General Practitioners
Develop an e-learning module highlighting correct interpretation of the DVT Wells score.
Royal College of General Practitioners
Promote the e-learning module through the members’ network and the Chair’s blog.
Milton Keynes
Concerns raised2
Failure to apply an evidence-based pulmonary embolism diagnostic pathway
Failure to use or document structured pulmonary embolism risk assessments
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Milton Keynes Urgent Care Services (MKUCS
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Milton Keynes Urgent Care Services (MKUCS
Provide Ardens templates integrated with SystmOne to support structured Wells pulmonary embolism assessment, risk stratification and escalation.
Milton Keynes Urgent Care Services (MKUCS
Deliver clinician information sharing and case-based training on Wells PE, Ardens templates, clinical context and NICE-aligned use of decision tools.
Milton Keynes Urgent Care Services (MKUCS
Audit and provide feedback on clinicians’ application of Wells PE and related clinical decision tools.
Milton Keynes Urgent Care Services (MKUCS
Conduct regular audits of NEWS2, POPS, risk assessments and decision tools, with monthly KPI reporting and quarterly commissioner review.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Milton Keynes Urgent Care Services (MKUCS
Ardens templates in SystmOne and Wells PE risk assessment are considered sufficient to provide structured pulmonary embolism assessment and escalation.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Milton Keynes Urgent Care Services (MKUCS
PERC is considered inappropriate for primary care because it is not validated in that setting; Wells scoring is preferred for suspected pulmonary embolism.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Milton Keynes
Concerns raised1
Failure to investigate suspected pulmonary embolism in accordance with NICE guidance
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Milton Keynes University Hospital NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Milton Keynes University Hospital NHS Foundation Trust
Held cross-departmental discussions to review and optimise pulmonary embolism screening and triage systems across patient groups.
Milton Keynes University Hospital NHS Foundation Trust
Undertake an audit of pulmonary embolism pick-up rates against recorded Wells scores and D-dimer use, including appropriateness of scoring-system application.
Milton Keynes University Hospital NHS Foundation Trust
Trial and evaluate for six months a process escalating unapproved CTPA requests to the duty radiologist, with requester contact when further information or investigation is needed.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Milton Keynes University Hospital NHS Foundation Trust
The Trust considers management reasonable and says earlier D-dimer or CTPA would not probably have changed the outcome.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Milton Keynes University Hospital NHS Foundation Trust
The Trust considers its current CTPA screening approach broadly appropriate and balanced against investigation risks.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester West
Concerns raised1
Failure to establish whether VQ or CTPA is the appropriate scan modality for suspected pulmonary embolism
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Bolton NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Bolton NHS Foundation Trust
Complete and approve a focused After-Action Review of the decision to discharge despite raised troponin and d-dimer results.
Bolton NHS Foundation Trust
Complete and approve an addendum addressing further investigations and the lack of observations before discharge.
Bolton NHS Foundation Trust
Share learning about considering CTPA instead of VQ scans for suspected pulmonary embolism with Radiology through governance processes.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Bolton NHS Foundation Trust
Replacing V/Q scans with CTPA scans for all suspected pulmonary embolism patients was considered inappropriate because it departed from national guidance.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Bolton NHS Foundation Trust
The established PE referral pathway and radiologist-led modality selection were considered sufficient; clinician-radiologist discussion is required only when departing from protocol or guidance.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Failure to apply the PE policy in accordance with its specific wording
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring 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 perform a point-of-care ultrasound scan to exclude intra-abdominal bleeding when pulmonary embolism is suspected
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Resuscitation Council UK
Royal College of Obstetricians and Gynaecologists
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Resuscitation Council UK
Emphasise ultrasound use during advanced life support to identify reversible causes, including haemorrhage, across cardiac-arrest guidance.
Resuscitation Council UK
Include pregnancy-specific guidance to identify and treat reversible causes, with focused ultrasound available for skilled operators.
Resuscitation Council UK
Include guidance on abdominal ultrasound and massive-haemorrhage protocols for suspected haemorrhage during pregnancy-related cardiac arrest.
Royal College of Obstetricians and Gynaecologists
Discuss with emergency-medicine and radiology educators the need to check for intra-abdominal bleeding before anticoagulating a collapsed patient.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Resuscitation Council UK
Existing RCUK guidance and teaching materials already address ultrasound use and reversible causes, including haemorrhage, during cardiac arrest in pregnancy.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Resuscitation Council UK
Universal ultrasound requirements are limited because skilled operators and equipment may be unavailable and ultrasound could delay time-critical treatment.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
North West Kent
Concerns raised1
Failure to correctly diagnose pulmonary embolism
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Yorkshire (Western)
Concerns raised1
Delays in medical assessment of patients with classical DVT/PE symptoms
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Barnsley Hospital NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Barnsley Hospital NHS Foundation Trust
Provide consultant-led senior assessment in the START emergency assessment hub during its operating hours.
Black Country
Concerns raised2
Failure to recognise and accurately record an abnormal ECG indicating a potential pulmonary embolism
Failure to undertake further diagnostic testing for a possible pulmonary embolism
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
the Royal Wolverhampton NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
the Royal Wolverhampton NHS Trust
Provide Emergency Department training on identifying and treating pulmonary embolism, including ECG abnormalities.
the Royal Wolverhampton NHS Trust
Provide individual pulmonary embolism-focused ECG interpretation training to the directly involved clinical staff.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.