Recurring concern

Unreliable access to blood testing for patients with difficult venous access

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First reported 1 Sep 2023•Latest report 8 Dec 2023

Definition

What this concern includes

Includes failures of arrangements specifically intended to provide or enable blood testing for patients whose venous access is difficult, including absence of a specialist referral service, lack of a suitable facility in primary or out-of-hours care, and missing or uncommissioned pathways for referral to an accessible blood-testing service.

Not included

  • Excludes general delays or omissions in blood testing where difficult venous access is not a material part of the asserted concern.
  • Excludes failures in interpreting, communicating or acting on blood-test results after the blood sample has been successfully obtained.
  • Excludes generic laboratory staffing, equipment or commissioning deficiencies unless they directly prevent access to blood testing for patients with difficult venous access.
  • Excludes failures involving other diagnostic tests or patients who do not require an alternative or specialist blood-testing arrangement.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2023–2023

First to latest report issue date

Stated actions
7

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.

NHS Greater Manchester Integrated Care Board2
Medicines and Healthcare products Regulatory Agency1
NHS England1
Royal College of Psychiatrists1

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.

  1. Manchester North

    AI-generated summary

    Charlene Roberts · 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

    Charlene Roberts died at Fairfield General Hospital on 12 January 2023 after suffering cardiac arrest during an inpatient admission; her cause of death was confirmed as cyclizine toxicity, with aspiration pneumonia, anorexia and factitious disorder also recorded. The principal concerns included the availability and prescribing of cyclizine, limited professional understanding of cyclizine dependence and the use of local intelligence systems for non-controlled drugs, and the lack of a commissioned community pathway for obtaining blood samples from compromised patients.

    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

    Absence of a commissioned pathway for GPs to refer compromised community patients requiring blood tests

    Wider context from the report

    “During the course of the evidence the court heard evidence from the GP who was responsible for obtaining weekly bloods to monitor her eating disorder. There is no commissioned pathway in Rochdale for GPs to refer patients who require bloods but who are compromised and therefore hard to obtain blood from. As a result patients are attending A&E departments for these to be taken. ”

    Source location

    Charlene Roberts · 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

    Reiterate the process for arranging supported blood testing to all GP practices through GP communications.

    Verbatim wording from the response

    “There are a very small group of people who may be more difficult to take blood than others due to clinical presentation. Rochdale GPs do have the ability to arrange, on a case-by-case basis, where a compromised patient needs to have bloods taken with support from ultrasound.”

    Source location

    Response from Greater Manchester NHS
    Page 2 · response
    Published 12 December 2023

    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

    Complete a Greater Manchester review of phlebotomy provision to identify variation and support more consistent patient access.

    Verbatim wording from the response

    “In addition to the locality-specific actions as set out above, a GM level review of phlebotomy provision has been undertaken recently which has identified the variation in provision and sets out the intention to improve the consistency of offer to patients across Greater Manchester. This is also a priority deliverable of the Greater Manchester Primary Care Blueprint.”

    Source location

    Response from Greater Manchester NHS
    Page 2 · response
    Published 12 December 2023

    Open published response

  2. Manchester North

    AI-generated summary

    Stephen Ratcliffe · 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

    Stephen Ratcliffe, who had a history of illicit drug and alcohol use and mental health conditions, was found deceased at home on 6 February 2023 after last being contacted when he collected methadone on 10 January 2023. The medical cause of death was recorded as respiratory depression due to combined drug toxicity, with developing liver cirrhosis and anxiety and depression also recorded; the principal concern was that no diabetes test was obtained because of difficult venous access and the absence of a specialist blood-taking service for GPs to refer to.

    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

    Lack of a specialist blood-testing referral service for patients with difficult venous access

    Wider context from the report

    “1. The court heard that due to the deceased having compromised venous access as a result of his drug use, the GP practice were unable to take his bloods. The evidence before the court was that there is no specialist service for GPs to refer a patient to for bloods when venous access is difficult. Evidence was heard that this had been raised previously to the CCG. As a result, in this case no test for diabetes was obtained. ”

    Source location

    Stephen Ratcliffe · Prevention of Future Deaths report
    Page 1 · 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

    Establish a Bury pathway enabling GPs to refer patients with difficult venous access to Same Day Emergency Care.

    Verbatim wording from the response

    “Bury Clinical Senate has reviewed this incident and a new pathway has been confirmed for Bury general”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 1 · response
    Published 8 December 2023

    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

    Promote the Bury difficult-venous-access referral pathway through targeted communications.

    Verbatim wording from the response

    “practices in relation to patients where venous access is difficult. Where venous access is difficult general practitioners (GPs) will be able to refer into the Same Day Emergency Care (SDEC) service. This new pathway will be promoted through targeted communications across Bury.”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 2 · response
    Published 8 December 2023

    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 briefing to check and challenge difficult-venous-access arrangements across Greater Manchester localities.

    Verbatim wording from the response

    “To better understand the pathways across the other localities we will be developing a briefing, highlighting this event and using this to check and challenge what arrangements each locality has in place for access for patients where it is difficult to obtain blood.”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 2 · response
    Published 8 December 2023

    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

    Complete a Greater Manchester review of phlebotomy provision and identified variation in services.

    Verbatim wording from the response

    “In addition to the locality-specific actions as set out above, a GM level review of phlebotomy provision has been undertaken recently which has identified the variation in provision and sets out the intention to improve the consistency of offer to patients across Greater Manchester. This is also a priority deliverable of the Greater Manchester Primary Care Blueprint.”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 2 · response
    Published 8 December 2023

    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

    Present and share learning from the locality check-and-challenge exercise with the Greater Manchester System Quality Group.

    Verbatim wording from the response

    “1. Learning from the check and challenge exercise to be presented/shared with the Greater Manchester System Quality Group on the 18th of January 2024. This meeting is attended by commissioners, including commissioners of specialist services, localities, regulators, Healthwatch and NICE. Through sharing in this forum, we expect members to review and ensure learning is incorporated into their commissioned services. There will be a follow up review of implementation in July 2024.”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 2 · response
    Published 8 December 2023

    Open published response
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Data last updated 7 September 2026