Recurring concern
Unreliable pre-operative assessment arrangements delaying or compromising surgery
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Request correctionFirst reported 27 Oct 2014•Latest report 10 May 2022
What this concern includes
Includes failures in pre-operative assessment arrangements that cause avoidable delay, impose unnecessary attendance or approval requirements, omit required preparation, or fail to ensure that material assessment information reaches the clinicians responsible for the procedure.
Not included
- Excludes deficiencies in assessing surgical suitability or operative risk where the pre-operative assessment arrangements themselves are not unreliable; those belong to the existing surgical-risk assessment concern.
- Excludes generic staffing shortages, consultant availability or communication failures unless they directly concern the pre-operative assessment process.
- Excludes delays or information failures occurring after the pre-operative assessment has been completed and transferred to the operating team.
- Excludes postoperative assessment, treatment, monitoring and discharge processes.
- Reports
- 7
- Individual concerns
- 7
- Date range
- 2014–2022
- Stated actions
- 8
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
Unavailability of designated permanent room space for a high-risk anaesthetic pre-operative assessment clinic
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.
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
Establish four protected consultant-led high-risk anaesthetic pre-assessment clinics weekly, including specialist orthopaedic expertise, dedicated rooms and appropriate medical equipment.
Stated by Ashford and St Peter'S Hospitals NHS Foundation Trust
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Concerns raised1
Unnecessary Junior Doctor attendance requirement delaying operations
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 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
Develop a nurse-led pre-operative assessment model and continue work to improve identification and escalation of abnormal blood results.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure to include relevant DVT investigations and treatment in the second pre-operative assessment
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
The available investigations did not identify DVT, so it would not have affected pre-operative assessment or the operating team’s decisions.
Stated by University Hospitals Coventry and Warwickshire NHS Trust
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Concerns raised1
Failure to establish MRSA history before surgery
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
Introduce new admission and transfer documentation to record patient infection status.
Stated by The Trust -
Action
Disseminate the new infection-status documentation through twice-monthly infection-control update sessions.
Stated by The Trust -
Action
Check completion of infection-status documentation during daily patient reviews and provide nursing feedback.
Stated by The Trust
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Action
Amend the surgical safety checklist to verify MRSA status and history with patients and staff before induction and at theatre sign-in.
Stated by The Trust
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Concerns raised1
Lack of pre-operative orthogeriatric review for high-risk patients requiring hemiarthroplasty
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.
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Concerns raised1
Failure to ensure the operating consultant is informed of vital information during pre-operative assessment
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
Take steps with the operating surgeon to prevent recurrence of consultant-unaware pre-operative assessment.
Stated by Stockport NHS Foundation Trust -
Action
Discuss the case at General Surgery Morbidity and Mortality meetings and with the assessing junior doctor.
Stated by Stockport 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
Junior doctors conducting pre-operative assessments is not standard organisational practice and was unique to the operating surgeon concerned.
Stated by Stockport NHS Foundation Trust
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Concerns raised1
Inadequate pre-operative anaesthetic assessment of high-risk patients
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026