Recurring concern

Failure to provide timely urgent diagnostic investigations

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First reported 29 Sep 2013•Latest report 18 Dec 2025

Definition

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.

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: 24
Individual concerns: 27
Date range: 2013–2025
Stated actions: 66

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care4

NHS England2

Ashford and St Peter'S Hospitals NHS Foundation Trust1

Barts Health NHS Trust1

Bedfordshire Hospitals NHS Foundation Trust1

Betsi Cadwaladr University LHB1

Care Quality Commission1

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1

Doncaster Royal Infirmary1

East Lancashire Hospitals NHS Trust1

Glan Clwyd Hospital1

Glangwili General Hospital1

Husband of the deceased1

King's College Hospital1

Maidstone and Tunbridge Wells NHS Trust1

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.

27 Apr2015
North Wales (East and Central)
Concerns raised1
1. Failure to expedite urgent blood test samples for laboratory analysis
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 2
1. Action
  Review primary-care urgent-sample requesting processes and prepare a memorandum covering sample labelling, transport and laboratory notification.
  Stated by Betsi Cadwaladr University LHBStated completed
2. Action
  Distribute the urgent-sample process memorandum electronically to all BCUHB-supported GPs and practice managers.
  Stated by Betsi Cadwaladr University LHBStated planned
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
9 Jun2014
Plymouth, Torbay and South Devon
Concerns raised2
1. Failure to identify and address prolonged delays in urgent investigations
2. Delays in performing urgent investigations
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 5
1. Action
  Use ward patient plans and boards to track investigations, tests and urgent treatment, with daily nursing and medical review.
  Stated by University Hospitals Plymouth NHS TrustStated completed
2. Action
  Conduct formal handovers for every on-call team to transfer information and identify outstanding tests and concerns.
  Stated by University Hospitals Plymouth NHS TrustStated completed
3. Action
  Establish radiography performance standards for MAU and ward requests and monitor compliance monthly.
  Stated by University Hospitals Plymouth NHS TrustStated completed
1. Action
  Radiograph patients with chest pain during transfer from the Emergency Department to the MAU.
  Stated by University Hospitals Plymouth NHS TrustStated completed
2. Action
  Request overnight radiographs for relevant patients regardless of whether they are asleep.
  Stated by University Hospitals Plymouth NHS TrustStated completed
Respondent positions 1
1. Position
  Radiography delays are within established standards, and patients transferred from the Emergency Department to the MAU receive radiographs without delay.
  Stated by University Hospitals Plymouth NHS TrustDisputes the concern
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
20 Mar2014
Carmarthenshire and Pembrokeshire
Concerns raised1
1. Failure to make CT scan results promptly available to departments involved in patient care
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 2
1. Action
  Monitor emergency CT scan reporting times through routine sampling.
  Stated by Hywel Dda University LHBStated planned
2. Action
  Ensure test results are available to all relevant clinical teams when patients are under the care of multiple teams.
  Stated by Hywel Dda University LHBStated planned
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
29 Sep2013
Manchester South
Concerns raised1
1. Lack of shared understanding between the GP and District Nurses about requesting urgent blood tests
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to expedite urgent blood test samples for laboratory analysis

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

Concerns raised2

Failure to identify and address prolonged delays in urgent investigations

Delays in performing urgent investigations

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

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

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

Concerns raised1

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

Actions described in response 2

Actions described in response 5

Respondent positions 1

Actions described in response 2