Recurring concern
Failure to perform clinically indicated physical examinations
- Reports that mention this concern
- 23
- Times this concern has been raised
- 23
- Stated actions linked to this concern
- 31
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.
What is 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.
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
Most frequent recipients
Reports about this concern sent to each recipient.
Reports and published responses 23 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked response
- Medway NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Medway NHS Foundation Trust
Implement ED silver trauma screening for frail patients with low-energy trauma, including senior-clinician assessment where red flags require escalation.
-
Medway NHS Foundation Trust
Adopt the London Major Trauma System elderly-trauma screening and triage pathway prompting immediate senior-doctor assessment.
-
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.
Linked response
- Recipient name withheld
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Recipient name withheld
Discuss more patient details with the on-call consultant and obtain advice when uncertain about management.
-
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.
Linked responses
- Birmingham and Solihull Mental Health NHS Foundation Trust
- Birmingham Community Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham Community Healthcare NHS Foundation Trust
Review national guidance and local protocols for DVT management and examination of intravenous injection sites.
-
Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham Community Healthcare NHS Foundation Trust
Remind all healthcare staff to complete appropriate observations during physical examinations of injection and DVT sites.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham Community Healthcare NHS Foundation Trust
Existing local protocols for examining injection and DVT sites reflect national guidelines, so no new examination protocol is required.
-
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.
Linked response
- Stonefield Street Surgery
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Stonefield Street Surgery
Use a written internal-referral policy directing patients to a more appropriate clinician for examinations or procedures.
-
Stonefield Street Surgery
Enable some male GPs to undertake further training in female pelvic examination techniques.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked response
- Wells Road Surgery
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Wells Road Surgery
Conduct all medically relevant patient conversations in a consulting room to enable private physical examination.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Wells Road Surgery
The patient refused to wait for a formal consultation, so the clinician assessed him informally between booked urgent patients.
-
Wells Road Surgery
The patient lacked features of acute severe asthma or severe chest infection, making home antibiotics with safety-netting clinically appropriate.
-
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.
Linked response
- Lifeshield Medical Service Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Lifeshield Medical Service Limited
Apply a no-medical, failed-medical, or failed-drug-test rule prohibiting participation in boxing events.
-
Lifeshield Medical Service Limited
Maintain separate medical paperwork for participants, even when organisers provide their own records.
-
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.
Linked response
- The Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
The Trust
Issue guidance requiring thorough rupture-of-membranes histories and appropriate speculum examinations.
-
Concerns raised1
Failure to carry out physical examinations during home visits
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked responses
- Royal College of Anaesthetists
- The British Thoracic Society
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
The British Thoracic Society
Publish and make freely accessible updated pleural disease guidance covering safe chest-drain insertion.
-
Royal College of Anaesthetists
Work with colleagues to identify, learn from and share lessons from the chest-drain incident.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Royal College of Anaesthetists
Responsibility for reviewing and potentially reissuing the chest-drain safety alert lies with NHS England’s safety department.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026