Recurring concern
Failure to recognise and manage post-endoscopy complications
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Request correctionFirst reported 16 Nov 2015•Latest report 21 Jun 2021
What this concern includes
Includes only assertions that directly instantiate the manually reviewed condition ‘Failure to recognise and manage post-endoscopy complications’ and satisfy this evidence boundary: Two distinct reports directly support absent post-ERCP complication pathways and failure to act on an endoscopy report indicating a dangerous complication. The separate formal ERCP case-review assertion concerns retrospective governance after cases, not direct recognition or management of a patient's complication; exclude that seed.
Not included
- Excludes generic failures to review clinical reports or investigation results where no endoscopy-related complication is identified.
- Excludes routine endoscopy access, scheduling, consent or technical-performance failures when no post-endoscopy complication-management deficiency is asserted.
- Excludes failures in managing complications after unrelated procedures unless the assertion explicitly concerns the same post-endoscopy complication process.
- Excludes failures occurring after an endoscopy complication has been reliably recognised and appropriately escalated when the remaining issue is unrelated downstream care.
- Excludes manifestations outside the manually reviewed boundary: Two distinct reports directly support absent post-ERCP complication pathways and failure to act on an endoscopy report indicating a dangerous complication. The separate formal ERCP case-review assertion concerns retrospective governance after cases, not direct recognition or management of a patient's complication; exclude that seed.
- Reports
- 3
- Individual concerns
- 3
- Date range
- 2015–2021
- Stated actions
- 2
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 act on an endoscopy report indicating a possible dangerous complication
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 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
Lack of protocol guidance for identifying post-endoscopy rebleeding
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of a pathway or guideline for post-ERCP patients who develop complications
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.2
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Action
Implement a pathway for managing suspected post-endoscopy complications, perforations or leaks.
Stated by Maidstone and Tunbridge Wells NHS Trust -
Action
Review the implemented pathway after six months to determine whether staff require further clarity.
Stated by Maidstone and Tunbridge Wells NHS 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 implemented post-endoscopy complication pathway is considered sufficient to address escalation concerns across Trust sites.
Stated by Maidstone and Tunbridge Wells NHS Trust
Data last updated 7 September 2026