Recurring concern

Failure to obtain clinically indicated repeat investigations

First to latest report 20 Jan 2015 — 30 Jan 2026

Reports that mention this concern: 12
Times this concern has been raised: 14
Stated actions linked to this concern: 13

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.

What is 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.

Trends

Reports over time

Reports mentioning this concern, 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.

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

Reports and published responses 12 reports

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

16 May2016
Surrey
Concerns raised1
1. Failure to request repeat inflammatory markers
This report raised 22 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Circle Health Group Limited
Stated actions 2
1. Circle Health Group Limited
  Incorporate British Thoracic Society diagnostic guidance into the pathway for managing patients with pleural infection.
2. Circle Health Group Limited
  Develop a consultant pathway presenting the patient’s clinical condition to support decisions about proceeding with interventional procedures.
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
20 Jan2015
London (East)
Concerns raised2
1. Delays in repeating arterial blood gas tests
2. Failure to repeat blood tests within the required timeframe
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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