First reported 17 Apr 2015•Latest report 8 Jun 2026
Definition
What this concern includes
Includes failures in the dedicated process for identifying, handing over, authorising, tracking or completing a scheduled investigation and ensuring its result or required action is followed up within the clinically required timeframe.
Not included
Excludes investigations that were never scheduled or indicated.
Excludes generic staffing, communication, documentation or handover deficiencies not explicitly tied to failure to follow up a scheduled investigation.
Excludes unrelated discharge-planning failures, outpatient appointment failures and general delays in clinical review.
Reports
8
Distinct published reports
Individual concerns
8
A report can raise multiple concerns
Date range
2015–2026
First to latest report issue date
Stated actions
19
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 Trust1
Blackpool Teaching Hospitals NHS Foundation Trust1
Department of Health and Social Care1
Egton Medical Information Systems Limited1
Guy'S and St Thomas' NHS Foundation Trust1
Medway NHS Foundation Trust1
Mersey and West Lancashire Teaching Hospitals NHS Trust1
Rotherham General Hospital1
Southport and Ormskirk Hospital NHS Trust1
Tameside and Glossop Integrated Care NHS Foundation Trust1
the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust1
NHS trust6
Healthcare site1
Ministerial department1
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.
South Yorkshire (West)
Concerns raised1
Delays in following up requested blood tests
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.
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.
Berkshire
Concerns raised1
Failure of the practice follow-up system to ensure investigations are completed at the correct time
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.
Norfolk
Concerns raised1
Lack of escalation arrangements for outstanding x-ray requests
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
Upgrade the Emergency Department two-hourly-round checklist to prompt escalation of outstanding investigations, including imaging and blood tests.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 May 2022.
Liverpool and the Wirral
Concerns raised1
Failure to follow up missed appointments for investigation of neutropenia
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.6
Action
Schedule and clinically annotate ward-attender appointments electronically to track attendance and record outcomes.
Stated by Mersey and West Lancashire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Require consultant clinical review and documented follow-up for every child not brought to a scheduled outpatient or ward-attender appointment.
Stated by Mersey and West Lancashire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Audit the outpatient non-attendance pathway and review cases where children were not clinically reviewed.
Stated by Mersey and West Lancashire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Revise the Did Not Attend policy into a corporate Was Not Brought policy incorporating required safeguards and best-practice principles.
Stated by Mersey and West Lancashire Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2021.
Action
Conduct monthly audits of adherence to the updated Was Not Brought policy and processes, escalating breaches through governance and incident-management arrangements.
Stated by Mersey and West Lancashire Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
Action
Amend paediatric staff induction to cover communication with families, communication with other organisations, and responses when children are not brought to appointments.
Stated by Mersey and West Lancashire Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2021.
Manchester South
Concerns raised1
Lack of a clear system to follow up required OGD before the next-day AMU ward round
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.
Inner South London
Concerns raised1
Lack of checks to ensure review of requested investigations and appropriate action in line with guidelines
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.2
Action
Review compliance with ESC 2014 guidelines for diagnosing and managing hypertrophic cardiomyopathy.
Stated by Guy'S and St Thomas' NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2018.
Action
Report Holter recordings through trained physiology technicians, communicate concerning findings to referring consultants, and upload reports to electronic patient records.
Stated by Guy'S and St Thomas' NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing GMC and NHS England guidance provides an adequate framework for safe communication with patients and handling test results.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Blackpool and the Fylde
Concerns raised1
Failure of the clinical team to follow up missing CTPA procedures
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.
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
Create a standard operating procedure for recording and tracing diagnostic-request status changes, messages, requested actions and authorisation.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 May 2015.
Action
Ratify the procedure within the directorate, submit it to the electronic Trust document library, and provide paper copies in key radiology areas.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 May 2015.
Mid Kent and Medway
Concerns raised1
Failure to identify scheduled investigations before hospital discharge
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.
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 in the dedicated process for identifying, handing over, authorising, tracking or completing a scheduled investigation and ensuring its result or required action is followed up within the clinically required timeframe.
