Recurring concern
Unreliable laboratory notification of safety-critical problems and results
- Reports that mention this concern
- 10
- Times this concern has been raised
- 10
- Stated actions linked to this concern
- 10
What this concern includes
Includes failures of laboratory processes to promptly notify responsible clinicians about analyser or service failures affecting testing, materially abnormal or urgent laboratory results, and related safety-critical information requiring alternative arrangements, urgent review or escalation.
What is not included
- Excludes general laboratory capacity, test-completion, interpretation or result-follow-up failures where the notification control is not itself deficient.
- Excludes generic clinical communication, documentation or electronic-system failures unless they directly impair laboratory-to-clinician notification of safety-critical information.
- Excludes notifications to patients, regulators or other recipients where laboratory-to-clinician safety notification is not the shared condition.
- Excludes routine laboratory results or equipment problems without an identified need for prompt clinical notification or a safety consequence.
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 10 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to prominently flag abnormal laboratory results
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
- NHS England
- Quarry Bank Medical Centre
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
-
NHS England
Promote wider standardisation of pathology result-flagging conventions.
-
Quarry Bank Medical Centre
Notify the laboratory of missing NT-proBNP alerts and request corrected reporting.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
NHS England
Laboratory and GP system suppliers are primarily responsible for pathology result formatting, structure, presentation and display of abnormal results.
-
Quarry Bank Medical Centre
NHS England may review national laboratory guidance on abnormal-result flagging and standardise laboratory alert protocols.
-
Concerns raised1
Failure to communicate grossly abnormal liver function test results from laboratory staff to clinical staff
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Royal College of Obstetricians and Gynaecologists
- Royal College of Pathologists
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
-
Royal College of Pathologists
Emphasise the need to agree local critical-result cut-offs with clinicians in the next document revision.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Royal College of Obstetricians and Gynaecologists
Responsibility for communicating clinical staff obligations on reviewing electronic results lies with organisations and NHS England or devolved health services.
-
Concerns raised1
Delays in notification of abnormal blood test results to clinicians
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Royal Berkshire 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
-
Royal Berkshire NHS Foundation Trust
Improve Emergency Department blood-result turnaround through process changes spanning booking, sample transport and laboratory processing.
-
Royal Berkshire NHS Foundation Trust
Upgrade the laboratory information management system to improve the reliability and connectivity of result reporting.
-
Concerns raised1
Failure to communicate laboratory results to treating clinicians
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Calderdale and Huddersfield 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.1
-
Calderdale and Huddersfield NHS Foundation Trust
Implement automatic transfer of laboratory results into the primary patient record and display them on the Trust-wide system home screen.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
-
Calderdale and Huddersfield NHS Foundation Trust
The internal investigation could not pursue why laboratory results were not passed on because the recipient could not be identified.
-
Calderdale and Huddersfield NHS Foundation Trust
Automatic laboratory-result availability in the primary record is considered sufficient, removing the need for results to be phoned through or verbally passed on.
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Calderdale and Huddersfield NHS Foundation Trust
The Trust considers the doctor’s changed practice, including proactive information review and communication training, sufficient to address handover and record-review concerns.
-
Concerns raised1
Failure of the laboratory to notify clinicians when the analyser is not functioning
This report raised 5 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 of the laboratory to ring through significant downward haemoglobin trends for urgent clinical review
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Wirral University Teaching Hospital 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.1
-
Wirral University Teaching Hospital NHS Foundation Trust
Change the laboratory IT system and issue staff instructions on revised standard operating procedures for haemoglobin reporting.
-
Concerns raised1
Failure of haematology laboratory alerting for abnormal ALT and toxic paracetamol results
This report raised 1 other concern. 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 an automated paracetamol phone-trigger and ALT alert prompting laboratory staff to telephone critical results to requesting clinicians.
-
Medway NHS Foundation Trust
Audit compliance with SBAR reporting and associated critical-result protocols.
-
Concerns raised1
Delays in reporting important microbiology results to clinicians
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals Sussex 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.1
-
University Hospitals Sussex NHS Foundation Trust
Discuss the delayed laboratory-result notification at a microbiology and infection clinical governance meeting as training for registrars prioritising urgent follow-up.
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Concerns raised1
Failure to communicate recent haemoglobin test results to clinicians assessing fitness for surgery
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure of the laboratory to inform ward staff of abnormal potassium results
This report raised 1 other concern. 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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026