Recurring concern
Failure to communicate clinically significant diagnostic findings to patients and care providers
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Request correctionFirst reported 4 Apr 2017•Latest report 20 Apr 2026
What this concern includes
Includes failures to communicate clinically significant diagnostic findings or suspected serious pathology to the affected patient and/or the clinicians responsible for ongoing care, including findings from imaging, pathology or comparable diagnostic investigations where communication is needed for follow-up or treatment.
Not included
- Excludes failures limited to identifying, interpreting or reporting a diagnostic finding when the finding was otherwise communicated reliably.
- Excludes generic clinical communication, record-keeping or handover deficiencies where no clinically significant diagnostic finding is the material object.
- Excludes failures to arrange follow-up or treatment after the finding was communicated, unless the communication of the finding itself was also deficient.
- Excludes neutral delays or omissions involving routine, non-safety-critical diagnostic information.
- Reports
- 10
- Individual concerns
- 14
- Date range
- 2017–2026
- Stated actions
- 22
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 report or urgently highlight clinically significant incidental ED findings to the GP
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 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.1
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Action
Review all Emergency Department imaging reports, follow up incidental or relevant findings, and inform GPs where appropriate.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised2
Failure to include relevant diagnostic findings in the patient history
Failure to inform patients of potential malignancy findings
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 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
Provide patients with copies of their radiology reports through the NHS App, including summaries of clinical findings.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Implement changes and processes to ensure patients are properly informed of their imaging results.
Stated by Mid and South Essex NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Existing radiology alerts, communication procedures and annual audits provide sufficient arrangements for timely review and patient communication of significant findings.
Stated by Mid and South Essex NHS Foundation Trust
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Position
The referring clinician is responsible for delivering requested radiology results and communicating significant findings to patients.
Stated by Mid and South Essex NHS Foundation Trust
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Concerns raised1
Failure to report potentially clinically significant vascular calcification in x-ray reports
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Mild vascular calcification does not correlate with peripheral vascular disease symptoms or severity, and knee X-rays are not used to diagnose it.
Stated by Warrington and Halton Teaching Hospitals NHS Foundation Trust
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Position
Not reporting mild vascular calcification without clinical information suggesting peripheral vascular disease complies with national radiology standards and practice.
Stated by Warrington and Halton Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure to alert requesting teams to suspicious radiological findings treated as expected findings
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 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.6
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Action
Alert referrers electronically to expected, unexpected, and newly detected cancers and critical or significant non-cancer findings, with verbal escalation for emergency findings.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Launch the Aptvision radiology referral system during the week commencing 30 October 2023.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Provide an electronic acknowledgement function for referrers to confirm receipt of finalised radiology reports and urgent notifications, supported by user training.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Action
Require specialties to create shared mailboxes receiving imaging-report notifications alongside named consultants’ individual worklists.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Add the radiological requesting, review, and expectation process to the Chief Medical Officer’s three-day induction programme for new consultants.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Develop a unified North-East London cancer-alert policy through collaborative clinical leadership work.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Concerns raised2
Lack of a process for adding alerts to normal communication methods for significant radiological findings
Failure to highlight significant, unexpected, and important radiological findings to the referring clinician
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.4
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Action
Update the Medica Alerts policy to require urgent notification of referrers for potential new TB diagnoses and advise that treatment changes may be needed.
Stated by Medica -
Action
Circulate the updated Medica Alerts policy to all reporters.
Stated by Medica -
Action
Work with clients to enact the 2022 Academy of Royal Colleges and RCR Alerts guidelines within local processes.
Stated by Medica
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Action
Raise Urgent Findings for relevant cases until clients adjust their internal alert processes.
Stated by Medica
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
Clients are responsible for integrating the 2022 Alerts guidelines into local processes; until then, Medica will raise Urgent Findings.
Stated by Medica
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Concerns raised1
Failure to communicate the iliac artery aneurysm diagnosis to treating clinicians
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 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.4
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Action
Implement and expand Sunrise digital clinical documentation, results access and patient-observation recording across the organisation.
Stated by East Kent Hospitals University NHS Foundation Trust -
Action
Continue improving Sunrise to support record-keeping quality and patient safety.
Stated by East Kent Hospitals University NHS Foundation Trust -
Action
Revisit clinician training so staff can access all parts of the clinical record.
Stated by East Kent Hospitals University NHS Foundation Trust
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Action
Ensure surgical clinicians understand their medical-record access responsibilities and include this requirement in new-staff induction.
Stated by East Kent Hospitals University NHS Foundation Trust
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Concerns raised1
Failure of the laboratory to ring through significant downward haemoglobin trends for urgent clinical review
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.1
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Action
Change the laboratory IT system and issue staff instructions on revised standard operating procedures for haemoglobin reporting.
Stated by Wirral University Teaching Hospital NHS Foundation Trust
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Concerns raised1
Failure to document significant findings and required follow-up investigations in discharge information
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 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.4
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Action
Send formal discharge notifications to GPs after self-discharge, including relevant tests, assessments and follow-up arrangements.
Stated by King'S College Hospital NHS Foundation Trust -
Action
Implement mandatory suspected and confirmed diagnoses, author and senior clinician fields on Emergency Department discharge letters to GPs.
Stated by King'S College Hospital NHS Foundation Trust -
Action
Develop a Trust-wide best-practice guide for discharge notifications and clinic letters, including self-discharge requirements, with local CCG collaboration.
Stated by King'S College Hospital NHS Foundation Trust
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Action
Upgrade the Emergency Department tracking system to distinguish completed, booked and pending investigations on GP discharge notifications.
Stated by King'S College Hospital NHS Foundation 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 concerns raised did not cause or contribute to the death, and the inquest found no failures of care contributed to it.
Stated by King'S College Hospital NHS Foundation Trust
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Concerns raised1
Lack of a radiology protocol for non-cancerous significant and potentially life-threatening findings
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.
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
Existing Guidance and ICE electronic reporting systems are considered sufficient to significantly reduce the risk of similar radiological communication failures and future deaths.
Stated by Barnsley Hospital NHS Foundation Trust
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Concerns raised3
Failure to communicate identified thoracic aneurysms to patients and GPs
Failure to inform GPs of identified thoracic aneurysms
Failure to inform patients of identified thoracic aneurysms
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 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.
Data last updated 7 September 2026