Recurring concern

Failure to obtain clinically indicated repeat investigations

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First reported 20 Jan 2015•Latest report 30 Jan 2026

Definition

What this concern includes

Includes failures to request, arrange or complete a clinically indicated repeat laboratory, imaging, physiological or cardiac investigation, including repeat inflammatory markers, blood tests and ECGs, where the repeat investigation is needed to reassess a patient's condition or guide treatment.

Not included

  • Excludes failures limited to reviewing, communicating or acting on an investigation result when the repeat investigation itself was obtained as required.
  • Excludes investigations that were never clinically indicated or scheduled for repeat assessment.
  • Excludes generic staffing, documentation, communication or follow-up deficiencies unless they directly cause failure to obtain a clinically indicated repeat investigation.
  • Excludes failures involving an initial investigation rather than a required repeat investigation.
Reports
12

Distinct published reports

Individual concerns
14

A report can raise multiple concerns

Date range
2015–2026

First to latest report issue date

Stated actions
13

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.

Barts Health NHS Trust2
Department of Health and Social Care2
Betsi Cadwaladr University LHB1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Cann House Care Home1
Care Quality Commission1
Circle Health Group Limited1
General Medical Council1
Isle of Wight NHS Trust1
NHS England1
Pennine Acute Hospitals NHS Trust1
Premiere Health Limited1
Royal College of Radiologists1
Royal London Hospital1
Royal Surrey County Hospital1

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.

  1. Surrey

    AI-generated summary

    Mr Critall · 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

    Mr Critall, an 80-year-old man, developed a haemothorax after insertion of a chest drain while being treated for pneumonia and died on 6 July 2014 after further deterioration and emergency treatment. The report raised concerns about the necessity and technique of the drain insertion, the failure to confirm its position, inadequate monitoring and resuscitation, and the hospital’s lack of appropriate emergency facilities and protocols. It also recorded that his family were not contacted after he became unwell or died.

    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 request repeat inflammatory markers

    Wider context from the report

    “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist. ”

    Source location

    Mr Critall · Prevention of Future Deaths report
    Page 3 · 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

    Incorporate British Thoracic Society diagnostic guidance into the pathway for managing patients with pleural infection.

    Verbatim wording from the response

    “5. Following the feedback from the coroner we have further strengthened the process for the management of patients with pleural infection, utilising the diagnostic algorithm for the management of such patients as described in the BTS guidelines 2010.”

    Source location

    2016-0187-Response-by-Mount-Alvernia-Hospital
    Page 2 · response
    Published 16 May 2016

    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

    Develop a consultant pathway presenting the patient’s clinical condition to support decisions about proceeding with interventional procedures.

    Verbatim wording from the response

    “3. We have developed a pathway which provides consultants with a clear picture of the patient’s clinical condition which will support any decision regarding the progression to an interventional procedure.”

    Source location

    2016-0187-Response-by-Mount-Alvernia-Hospital
    Page 4 · response
    Published 16 May 2016

    Open published response

  2. London (East)

    AI-generated summary

    Mrs Awa Jeng · 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

    Mrs Awa Jeng was admitted after a fall that caused a fractured left hip and underwent surgery. She subsequently required dialysis but was not adequately monitored on the ward, and tests were delayed until her potassium was at a life-threatening level. She deteriorated, suffered cardiac arrest during intubation, and could not be resuscitated; the inquest concluded that inadequate monitoring and delayed haemofiltration contributed to her death.

    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

    Delays in repeating arterial blood gas tests

    Wider context from the report

    “2. The ITU consultant gave a clear direction to the FY2 on Tayberry Ward during the afternoon of the 19th December 2013 that the arterial blood gases should be repeated that evening and she should be checked for signs of pulmonary oedema and fluid overload. ”

    Source location

    Mrs Awa Jeng · Prevention of Future Deaths report
    Page 2 · 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

    Failure to repeat blood tests within the required timeframe

    Wider context from the report

    “3. The blood tests were not repeated until the following morning when they had deteriorated to a life threatening level. 4. It was not clear from the evidence why the blood tests were not repeated. The FY2 did write a retrospective note confirming that she had asked the on-call doctor to perform the test. Evidence from the on-call doctor denied that this information was passed on to her. ”

    Source location

    Mrs Awa Jeng · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026