Recurring concern
Failure to perform clinically indicated physical examinations
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Request correctionFirst reported 28 Feb 2014•Latest report 6 Mar 2026
What this concern includes
Includes failures of the clinical physical-examination process where an indicated examination is omitted, incomplete, inadequately adapted to the patient or circumstances, or based on an unsafe substitute such as absence of reported pain; include relevant examination components such as vascular, limb, top-to-toe, internal or home-visit examinations.
Not included
- Excludes diagnostic imaging, laboratory testing or treatment failures where no physical-examination deficiency is identified.
- Excludes failures limited to recording, communicating or escalating examination findings when the examination itself was completed adequately.
- Excludes generic clinical assessment or diagnostic reasoning deficiencies that do not specifically concern performing or completing a clinically indicated physical examination.
- Excludes factual pain, DVT or other hazard assertions without an identified failure in the physical-examination process.
- Reports
- 23
- Individual concerns
- 23
- Date range
- 2014–2026
- Stated actions
- 31
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
Over-reliance on absence of reported pain during physical examination
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.2
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Action
Implement ED silver trauma screening for frail patients with low-energy trauma, including senior-clinician assessment where red flags require escalation.
Stated by Medway NHS Foundation Trust -
Action
Adopt the London Major Trauma System elderly-trauma screening and triage pathway prompting immediate senior-doctor assessment.
Stated by Medway NHS Foundation Trust
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Concerns raised1
Failure to carry out a further vaginal examination after an hour before deciding how to proceed with delivery
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.1
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Action
Discuss more patient details with the on-call consultant and obtain advice when uncertain about management.
Stated by Recipient name withheld
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Concerns raised1
Failure to examine injection sites and DVT sites
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
Review national guidance and local protocols for DVT management and examination of intravenous injection sites.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham Community Healthcare NHS Foundation Trust -
Action
Remind all healthcare staff to complete appropriate observations during physical examinations of injection and DVT sites.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham Community Healthcare 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
Existing local protocols for examining injection and DVT sites reflect national guidelines, so no new examination protocol is required.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham Community Healthcare NHS Foundation Trust
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Concerns raised1
Reluctance by male doctors to carry out internal examinations on female patients
This report raised 7 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
Use a written internal-referral policy directing patients to a more appropriate clinician for examinations or procedures.
Stated by Stonefield Street Surgery -
Action
Enable some male GPs to undertake further training in female pelvic examination techniques.
Stated by Stonefield Street Surgery
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Concerns raised1
Failure to remove leg bandages for full top-to-toe examination
This report raised 7 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.
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Concerns raised1
Failure to perform chest examinations
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
Conduct all medically relevant patient conversations in a consulting room to enable private physical examination.
Stated by Wells Road Surgery
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
The patient refused to wait for a formal consultation, so the clinician assessed him informally between booked urgent patients.
Stated by Wells Road Surgery
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Position
The patient lacked features of acute severe asthma or severe chest infection, making home antibiotics with safety-netting clinically appropriate.
Stated by Wells Road Surgery
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Concerns raised1
Failure to ensure that all boxers receive complete medical examinations before fighting
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
Apply a no-medical, failed-medical, or failed-drug-test rule prohibiting participation in boxing events.
Stated by Lifeshield Medical Service Limited -
Action
Maintain separate medical paperwork for participants, even when organisers provide their own records.
Stated by Lifeshield Medical Service Limited
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Concerns raised1
Failure to carry out speculum examination to establish rupture of membranes
This report raised 13 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
Issue guidance requiring thorough rupture-of-membranes histories and appropriate speculum examinations.
Stated by The Trust
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Concerns raised1
Failure to carry out physical examinations during home visits
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 examine patients prior to chest drain insertion
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.2
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Action
Publish and make freely accessible updated pleural disease guidance covering safe chest-drain insertion.
Stated by The British Thoracic Society -
Action
Work with colleagues to identify, learn from and share lessons from the chest-drain incident.
Stated by Royal College of Anaesthetists
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
Responsibility for reviewing and potentially reissuing the chest-drain safety alert lies with NHS England’s safety department.
Stated by Royal College of Anaesthetists
Data last updated 7 September 2026