Recurring concern

Failure to provide timely urgent diagnostic investigations

First to latest report 29 Sep 2013 — 18 Dec 2025

Reports that mention this concern
24
Times this concern has been raised
27
Stated actions linked to this concern
66

What this concern includes

Includes failures in the process for providing clinically urgent diagnostic investigations, including ordering or initiation, scheduling, performance, reporting and timely availability for clinical review, across diagnostic modalities and clinical settings.

What is not included
  • Excludes routine or non-urgent diagnostic waiting times where urgency is not identified.
  • Excludes failures limited to interpretation or clinical action after a result was timely available, unless the investigation's reporting or availability was also deficient.
  • Excludes generic staffing, communication, capacity or documentation deficiencies unless they directly cause delay or unreliability in providing an urgent diagnostic investigation.
  • Excludes a separately named diagnostic pathway or modality concern where that named system supplies the more specific supported parent boundary.
  • Excludes delays in treatment, referral or specialist review where no urgent diagnostic-investigation failure is identified.

Reports and published responses 24 reports

See individual reports that have raised this concern, and the actions taken in response

  1. North Wales (East and Central)

    AI-generated summary

    Sally Ellison · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sally Ellison contracted legionella while on holiday in Tunisia in mid-May 2012 and died on 1 June 2012 from cardiac arrest, multi-organ failure and legionella pneumonia. Concerns were raised that testing for legionella was not undertaken until 31 May, with confirmation on 1 June, and that this may have delayed optimal treatment; the report also identified the need for earlier testing and a rapid testing and reporting service.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to expedite urgent blood test samples for laboratory analysis

    Wider context from the report

    “1. That urgent blood tests were requested By ████████ (GP) at lunchtime on the 28th of April 2012, yet, despite these being noted as urgent, the samples were not conveyed to the laboratory for analysis after collection by the district nurse, until a routine collection of samples was undertaken from Colwyn Bay Community Hospital later that afternoon. As a result the delay in an analysis meant that results were not provided to surgery until the following morning. Whilst the evidence indicates that changes have been made within the laboratory at Glan Clwyd to enable the immediate reporting of all cases where the CRP is greater than 300, there was no evidence available to confirm that all urgent tests could be expedited by district nurses thus alleviating potentially life threatening delays in treatment. ”

    Source location

    Sally Ellison · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review primary-care urgent-sample requesting processes and prepare a memorandum covering sample labelling, transport and laboratory notification.

    Verbatim wording from the response

    “From this, you have requested that actions should be taken to prevent future deaths. Because of this, the Pathology Clinical Programme Group (CPG), and in particular the Governance section of the CPG, has reviewed the process for the requesting of urgent samples from primary care across BCUHB. This process has been explained in a memorandum ████████ that will be distributed electronically to all GPs and Practice Managers supported by BCUHB. The memorandum includes the correct process for the labeling of samples and its transportation to minimise delay. It also includes the relevant departmental telephone numbers for the laboratories across North Wales to ensure that the sample requester can warn the relevant department of the samples imminent arrival.”

    Source location

    2015-0163-Response-by-NHS-Wales
    Page 1 · response
    Published 27 April 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Distribute the urgent-sample process memorandum electronically to all BCUHB-supported GPs and practice managers.

    Verbatim wording from the response

    “From this, you have requested that actions should be taken to prevent future deaths. Because of this, the Pathology Clinical Programme Group (CPG), and in particular the Governance section of the CPG, has reviewed the process for the requesting of urgent samples from primary care across BCUHB. This process has been explained in a memorandum ████████ that will be distributed electronically to all GPs and Practice Managers supported by BCUHB. The memorandum includes the correct process for the labeling of samples and its transportation to minimise delay. It also includes the relevant departmental telephone numbers for the laboratories across North Wales to ensure that the sample requester can warn the relevant department of the samples imminent arrival.”

    Source location

    2015-0163-Response-by-NHS-Wales
    Page 1 · response
    Published 27 April 2015

    Open published response

  2. Plymouth, Torbay and South Devon

    AI-generated summary

    Audrey Christine DAWS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Audrey Christine Daws was admitted to Derriford Hospital with chest pain and other symptoms, but her chest X-ray was delayed and its result was not identified promptly. The X-ray eventually showed air under the diaphragm indicating a perforation; she underwent surgery, deteriorated and died. The principal concerns were inadequate handover of outstanding investigations and delays in ordering, performing and reviewing the X-ray.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to identify and address prolonged delays in urgent investigations

    Wider context from the report

    “2. A chest X-ray should have been ordered at the time of Mrs Daws admission into the emergency department. One was ordered approximately four hours later but it was not performed for nearly 17 hours. This was described as “inexplicable” during the Inquest hearing. It is plainly undesirable for an investigation that is considered urgent to be delayed for so long without anyone identifying the issue. Related to this issue is that once the X-ray was performed, the result was not seen by medical staff for over 24 hours. No satisfactory explanation was put forward as to why this occurred. ”

    Source location

    Audrey Christine DAWS · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in performing urgent investigations

    Wider context from the report

    “2. A chest X-ray should have been ordered at the time of Mrs Daws admission into the emergency department. One was ordered approximately four hours later but it was not performed for nearly 17 hours. This was described as “inexplicable” during the Inquest hearing. It is plainly undesirable for an investigation that is considered urgent to be delayed for so long without anyone identifying the issue. Related to this issue is that once the X-ray was performed, the result was not seen by medical staff for over 24 hours. No satisfactory explanation was put forward as to why this occurred. ”

    Source location

    Audrey Christine DAWS · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Use ward patient plans and boards to track investigations, tests and urgent treatment, with daily nursing and medical review.

    Verbatim wording from the response

    “• Each ward has a plan for every patient (this involves a whiteboard with a clear plan of daily investigations together with the tests ordered and expected for each patient, which can be tracked by nursing and medical staff). A second board, which includes tests or treatment which are urgent for the on-call doctors is evident by the nurses station. The plans for each patient are discussed on a daily basis with nursing and medical staff.”

    Source location

    2014-0318-Plymouth-Hospital-NHS-Trust
    Page 1 · response
    Published 9 July 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct formal handovers for every on-call team to transfer information and identify outstanding tests and concerns.

    Verbatim wording from the response

    “• There are now formal shift handovers for every on-call team, both within the week and weekend, which manage the transfer of information between shifts and identify outstanding tests and cases of concern.”

    Source location

    2014-0318-Plymouth-Hospital-NHS-Trust
    Page 2 · response
    Published 9 July 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish radiography performance standards for MAU and ward requests and monitor compliance monthly.

    Verbatim wording from the response

    “Within the last 18 months, we have established strict standards which define a level of expectation for the performance of tests requested by various services. In relation to the MAU, there is a 4 hour standard which is monitored monthly – this shows that there is currently a median delay of 2 hours between request and performance of the examination. It is also worth noting that a significant number of tests are performed in less than an hour, with very few at 4 hours and no extreme outliers over the last year. In relation to patients on the ward, there is a 24 hour standard. Irrespective of either of these standards, any patient can be identified as urgent and the examination expedited by telephone or personal communication with the inpatient radiographic team.”

    Source location

    2014-0318-Plymouth-Hospital-NHS-Trust
    Page 2 · response
    Published 9 July 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Radiograph patients with chest pain during transfer from the Emergency Department to the MAU.

    Verbatim wording from the response

    “• All patients with chest pain are now radiographed on the way to the MAU, rather than the test being requested on the MAU and the patient having to return to the Emergency Department for the test.”

    Source location

    2014-0318-Plymouth-Hospital-NHS-Trust
    Page 2 · response
    Published 9 July 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Request overnight radiographs for relevant patients regardless of whether they are asleep.

    Verbatim wording from the response

    “As indicated previously, many of the patients have their radiographs in transition between the Emergency Department and MAU. There is no delay in these patients receiving their radiograph whatsoever and these patients have been excluded from the data, which would in effect reduce the median time, were they to be included. With regard to patients being requested for radiograph that might have their examinations overnight I have asked that these examinations be performed irrespective of whether or not the patient is sleeping, on account of the fact that these patients may have been administered opiates.”

    Source location

    2014-0318-Plymouth-Hospital-NHS-Trust
    Page 2 · response
    Published 9 July 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Radiography delays are within established standards, and patients transferred from the Emergency Department to the MAU receive radiographs without delay.

    Verbatim wording from the response

    “Within the last 18 months, we have established strict standards which define a level of expectation for the performance of tests requested by various services. In relation to the MAU, there is a 4 hour standard which is monitored monthly – this shows that there is currently a median delay of 2 hours between request and performance of the examination. It is also worth noting that a significant number of tests are performed in less than an hour, with very few at 4 hours and no extreme outliers over the last year. In relation to patients on the ward, there is a 24 hour standard. Irrespective of either of these standards, any patient can be identified as urgent and the examination expedited by telephone or personal communication with the inpatient radiographic team.”

    Source location

    2014-0318-Plymouth-Hospital-NHS-Trust
    Page 2 · response
    Published 9 July 2014

    Open published response

  3. Carmarthenshire and Pembrokeshire

    AI-generated summary

    Robert Erryl Jones · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Robert Erryl Jones was admitted for bowel surgery and remained in hospital as his health declined. Delays in reporting and acting on the results of an emergency CT scan led to a significant delay in further surgery. The principal concern was that CT scan results should be made available promptly to the relevant departments and acted upon without delay where appropriate.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to make CT scan results promptly available to departments involved in patient care

    Wider context from the report

    “That when a CT scan is performed the results should be made available promptly to the departments involved in the care of the patient and where appropriate the results should be acted upon without delay and within a reasonable time-scale. ”

    Source location

    Robert Erryl Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Monitor emergency CT scan reporting times through routine sampling.

    Verbatim wording from the response

    “The Health Board fully recognises the need to ensure CT scan results should be made available promptly and will ensure that this is routinely monitored. The Radiology department will be undertaking sampling of the scan to report time for emergency CT scans.”

    Source location

    2014-0190-Response
    Page 1 · response
    Published 20 March 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ensure test results are available to all relevant clinical teams when patients are under the care of multiple teams.

    Verbatim wording from the response

    “Any test results which are given verbally, as maybe the case in an emergency situation, must also be appropriately documented in the patient record. We will also ensure that where patients may be under the care of several different clinical teams that test results are made available to any members of those teams.”

    Source location

    2014-0190-Response
    Page 1 · response
    Published 20 March 2014

    Open published response

  4. Manchester South

    AI-generated summary

    Dorothy Townley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Dorothy Townley sustained burns after spilling tea at home on 28 September 2012; the burns became infected and she was admitted to hospital on 11 October. Despite active treatment, she died on 20 October 2012. Concerns included communication between District Nurses and the GP, limited knowledge and training in burn treatment, inadequate wound assessment documentation, and unclear processes for requesting urgent blood tests.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of shared understanding between the GP and District Nurses about requesting urgent blood tests

    Wider context from the report

    “5. There was a lack of understanding between the GP and District Nurses as to how to request urgent blood tests. It was assumed by the GP that his request for a blood test would be treated as urgent and done that day (on 10th); the District Nurses indicated it would only be carried out as ‘urgent’ if requested. ”

    Source location

    Dorothy Townley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026