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
Inconsistent implant site checks during clinic visits
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.2
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Action
Introduce a clinical history sheet requiring red-flag assessment and documented inspection of device implantation sites during device-check appointments.
Stated by Cardiff & Vale University LHB -
Action
Require clinic entries to document clinical findings, implant-site observations, red flags, patient symptoms, device data, and associated tests.
Stated by Cardiff & Vale University LHB
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Concerns raised1
Failure to conduct an independent physical assessment
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.5
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Action
Share CFT’s MIU ambulance-receiving procedure with LML and reinforce ambulance-based assessment, handover, family involvement and suitability decisions through staff communications and learning forums.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation Trust -
Action
Require CFT MIU teams to assess ambulance arrivals and obtain handover, history and records before accepting or booking patients into the unit.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation Trust -
Action
Reinforce CFT requirements to obtain complete histories and documentation, exercise professional curiosity, and independently assess patients rather than rely on previous assessments or handovers.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation Trust
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Action
Disseminate inquest learning on ambulance patient assessment, family and carer involvement, handover and safe escalation through CFT meetings, forums, staff communications and governance groups.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation Trust -
Action
Require CFT MIU clinicians to complete a full physical assessment after ambulance-based triage and continue monitoring implementation through documentation audits and observations of care.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation Trust
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Concerns raised1
Failure to undertake vascular examination of a limb when a foot wound and leg pain are reported
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
Hold a multidisciplinary learning event reviewing peripheral vascular disease, differential diagnosis of foot and lower-limb pain, clinical assessment, red flags and referral criteria.
Stated by Alexandra & Crestview Surgeries
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Concerns raised1
Failure to carry out basic examinations for learning disabled adults at risk of pneumonia in the emergency department
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.2
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Action
Implement the Diamond Standard acute-care pathway for learning-disabled and autistic people across emergency, planned-admission and outpatient services.
Stated by NHS Humber Health Partnership -
Action
Adopt the Royal College of Emergency Medicine Learning Disabilities Toolkit in the Emergency Department.
Stated by NHS Humber Health Partnership
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The Emergency Department has not identified evidence that basic examinations are omitted specifically for patients with learning disabilities.
Stated by NHS Humber Health Partnership
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Position
Without direct clinical involvement or access to Trust records, NHS England cannot comment directly on David’s care.
Stated by NHS England -
Position
Hull University Teaching Hospitals NHS Trust should respond to concerns about David’s care and treatment.
Stated by NHS England
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Concerns raised1
Failure to remove footwear for foot inspection
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.
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 undertake a detailed history and full neurological examination in general practice
This report raised 9 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
Ask colleagues from seven NHS regions to share learning and available guidance with Integrated Care Boards for cascading to relevant healthcare professionals.
Stated by NHS England -
Action
Replace the epilepsy guideline with updated recommendations on referral and information and support after a first seizure.
Stated by National Institute for Health and Care Excellence
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
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Position
NICE is responsible for producing clinical guidance on the diagnosis, treatment and management of febrile seizures.
Stated by NHS England
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Position
Existing national guidance is considered sufficient for managing febrile seizures.
Stated by NHS England -
Position
Existing national guidance and the Clinical Knowledge Summary are considered sufficient to support timely assessment, investigation and referral for febrile seizures.
Stated by National Institute for Health and Care Excellence -
Position
RCEM will not lead development of further guidance because the project would be a significant undertaking, but can contribute with other organisations.
Stated by Royal College of Emergency Medicine
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Concerns raised1
Failure to arrange an in-person physical examination
This report raised 11 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 further abdominal examination before discharge
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 provide physical examination during telephone GP consultations where clinically needed
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.
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 provide physical examination during GP consultations
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
Produce and iteratively update standard operating procedures for safe remote triage and selection of consultation methods in general practice.
Stated by NHS England -
Action
Develop and maintain joint NHS England–RCGP guidance and learning resources on choosing remote or face-to-face consultations, patient safety and shared decision-making.
Stated by NHS England
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
Existing remote-triage procedures and consultation guidance address patient safety and require face-to-face review where clinically appropriate.
Stated by NHS England
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Position
Existing guidance, procedures, training and safety resources are considered sufficient to support safe remote general practice consultations.
Stated by Department of Health and Social Care
Data last updated 7 September 2026