Recurring concern

Failure to investigate prolonged unexplained symptoms

First to latest report 22 Dec 2015 — 19 Jun 2024

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
3

What this concern includes

Includes failures to recognise persistent or unexplained symptoms as requiring further investigation, second opinion, specialist review or escalation, including delays in investigating unexplained abdominal pain and comparable symptom presentations.

What is not included
  • Excludes failures involving a named disease-specific diagnostic pathway where that condition supplies the more specific supported concern.
  • Excludes failures occurring after appropriate investigation has been completed, including treatment or follow-up deficiencies unrelated to the investigation decision.
  • Excludes generic clinical-record, staffing, communication or continuity-of-care deficiencies unless they directly cause failure to investigate prolonged or unexplained symptoms.
  • Excludes isolated diagnostic disagreement or an adverse outcome without an asserted continuing failure to investigate, reconsider or escalate prolonged or unexplained symptoms.

Reports and published responses 5 reports

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

  1. Essex

    AI-generated summary

    Chloe HUNT · 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

    Chloe Hunt died in hospital on 15 March 2022 after swallowing pens that caused gastrointestinal obstruction and a fatal cardiac arrhythmia secondary to metabolic derangement. The concerns included insufficient consideration of her trauma-related difficulties in hospital, delays and inadequate planning for removal of the pens, and failure to recognise and respond to her deteriorating clinical condition.

    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 investigate the underlying cause of persistent tachycardia and low blood pressure

    Wider context from the report

    “d. Chloe was tachycardic throughout her admission with low blood pressure and there was no investigation of the underlying cause in a young otherwise physically healthy woman. NEWS Scores should not replace consideration of the whole clinical picture for a patient. ”

    Source location

    Chloe HUNT · Prevention of Future Deaths report
    Page 2 · 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

    Discuss the case with ward and governance staff to promote recognition of underlying causes of abnormalities in apparently stable patients.

    Verbatim wording from the response

    “Chloe’s case has been discussed with staff members, through the daily ward huddle and the Two at the Top meeting (outlined below) as well as at the joint governance meeting to promote learning from Chloe’s case and highlight additional actions that can be taken to help establish potential underlying causes for abnormalities in an otherwise seemingly stable patient.”

    Source location

    Response from East Suffolk and North Essex NHS Foundation Trust
    Page 3 · response
    Published 26 June 2024

    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

    Circulate learning on persistent tachycardia and the need for further investigations to identify its underlying cause.

    Verbatim wording from the response

    “The Trust has however reviewed the case and acknowledge that a further electrocardiogram could have been undertaken during the admission to provide further clinical insight into Chloe’s condition.”

    Source location

    Response from East Suffolk and North Essex NHS Foundation Trust
    Page 3 · response
    Published 26 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Concerns about care at Colchester General Hospital fall outside NHS England’s remit.

    Verbatim wording from the response

    “Your Report raises concerns with the care provided to Chloe whilst she was a patient at Colchester General Hospital. It is appropriate that East Suffolk & North Essex NHS Foundation Trust respond to your concerns, which do not fall under NHS England’s remit.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 26 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    East Suffolk & North Essex NHS Foundation Trust is responsible for responding to concerns about care at Colchester General Hospital.

    Verbatim wording from the response

    “Your Report raises concerns with the care provided to Chloe whilst she was a patient at Colchester General Hospital. It is appropriate that East Suffolk & North Essex NHS Foundation Trust respond to your concerns, which do not fall under NHS England’s remit.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 26 June 2024

    Open published response

  2. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    John Robert Maltby Worthington · 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

    John Robert Maltby Worthington fell down stairs in late March or early April 2017 and was treated for a head injury, with back and neck pain noted. He was later found to have spinal and rib fractures and pneumonia, and died in hospital on 29 June 2017 from bronchopneumonia, osteomyelitis of the spine and traumatic spinal fracture. The concerns included not undertaking further imaging after the initial fall and not recording a full set of observations or conducting further investigations when he later saw his GP with persistent back pain.

    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 investigate persistent back pain and tenderness

    Wider context from the report

    “(2) Mr Worthington persistently complained of back pain. He saw his GP on the 13th April 2017. He was tender on his back. No further investigation was recommended and a full set of observations were not taken or recorded. He presented to the hospital 3 days later with irreversible bronchopneumonia. A full set of observations may have given an earlier indication of the developing problem. ”

    Source location

    John Robert Maltby Worthington · Prevention of Future Deaths report
    Page 2 · 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

    Consider or make x-ray referrals for older patients after significant trauma.

    Verbatim wording from the response

    “When ████████ examined Dr Worthington she did not feel that an x-ray of the ribs/lumbar spine was indicated given that Dr Worthington was not suffering from any midline lumbar spine bony tenderness. In retrospect however, ████████ accepts that an x-ray may well have picked up the fractures sustained by Dr Worthington which in turn may have led to a different outcome. Having reflected on this aspect of the case, ████████ is now more likely to send patients of a similar age for x-rays in future after any significant trauma.”

    Source location

    2018-0204-Response-by-MDDUS
    Page 2 · response
    Published 14 August 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    An x-ray was not considered indicated at the time because there was no midline lumbar spine bony tenderness, although this assessment was later reconsidered.

    Verbatim wording from the response

    “When ████████ examined Dr Worthington she did not feel that an x-ray of the ribs/lumbar spine was indicated given that Dr Worthington was not suffering from any midline lumbar spine bony tenderness. In retrospect however, ████████ accepts that an x-ray may well have picked up the fractures sustained by Dr Worthington which in turn may have led to a different outcome. Having reflected on this aspect of the case, ████████ is now more likely to send patients of a similar age for x-rays in future after any significant trauma.”

    Source location

    2018-0204-Response-by-MDDUS
    Page 2 · response
    Published 14 August 2018

    Open published response

  3. Surrey

    AI-generated summary

    Rhi anne Anoushka Florence BARTON · 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

    Rhi anne Barton developed severe abdominal pain and vomiting at 35 weeks of pregnancy after previous bariatric surgery and was later found to have a small bowel obstruction. She aspirated during induction of anaesthesia before surgery, developed severe physiological compromise and died in the early hours of 13 February 2015. The principal concerns included delays in investigation, diagnosis and surgical management, lack of consultant supervision, inadequate documentation and fluid monitoring, and insufficient consideration of surgical causes associated with previous bariatric surgery.

    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 undertaking appropriate investigations for unexplained abdominal pain

    Wider context from the report

    “3. I also heard evidence that whilst the rarity of an omental band may make it difficult to diagnose there was still a responsibility to exclude other causes of abdominal pain in the absence of an obstetric cause, by undertaking appropriate investigations in a timely fashion. ”

    Source location

    Rhi anne Anoushka Florence BARTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Black Country

    AI-generated summary

    Baby Ryan Singh Bhogal · 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

    Ryan was a healthy baby and toddler who experienced increasingly frequent medical visits and multiple symptoms before being diagnosed with acute myeloid leukaemia and dying on 11 September 2015. The principal concerns were a lack of continuity and overall ownership in GP care, possible missed red flags and opportunities for earlier testing, and hospital systems for reviewing GP medical records.

    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 identify red flags and obtain second opinions or further tests for prolonged unexplained symptoms

    Wider context from the report

    “1. There was a lack of continuity and overall ownership in terms of treatment Ryan received at the GP practice. He was seen by different Doctor’s including Locum staff with no overall holistic approach. This surgery may wish to consider reviewing their policy and management of children who appear excessively for treatment to ensure that there is continuity of care and appropriate measures are in place. In addition you may wish to consider reviewing the systems in place in identifying “Red Flags” and seeking a second opinion or requesting further tests where symptoms or unexplained illnesses are identified for an extended period. ”

    Source location

    Baby Ryan Singh Bhogal · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. Inner North London

    AI-generated summary

    Shalini GANESH-RAM · 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

    Shalini Ganesh-Ram died in the Royal London Hospital on 11 August 2015 after developing Ogilvie’s syndrome following a Caesarean section, which led to a perforated caecum. The concerns included delayed diagnosis of the perforation, delays in CT scanning and surgical consultation, and inappropriate use of the modified obstetric early warning score to identify sepsis.

    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 escalate concerning postoperative symptoms for CT imaging

    Wider context from the report

    “1. Whilst Ms Ganesh-Ram underwent many consultant reviews, a raised pulse, abdominal pain and lack of urine output on Saturday the 8ᵗʰ and the morning of Sunday the 9ᵗʰ did not prompt a CT scan. Reassurance was drawn from the fact that her pain was controlled, but I wonder whether this was false reassurance, given that it was controlled by Oramorph, dihydrocodeine and paracetamol. (Abdominal distension was not noted until the middle of the day on Sunday the 9ᵗʰ, probably because it was masked by a high body mass index.) ”

    Source location

    Shalini GANESH-RAM · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026