Recurring concern
Unreliable laboratory notification of safety-critical problems and results
Pin
Get email alerts
Request correctionFirst reported 11 Sep 2013•Latest report 6 Feb 2026
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.
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.
- Reports
- 10
- Individual concerns
- 10
- Date range
- 2013–2026
- Stated actions
- 10
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.
-
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.
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
-
Action
Promote wider standardisation of pathology result-flagging conventions.
Stated by NHS England -
Action
Notify the laboratory of missing NT-proBNP alerts and request corrected reporting.
Stated by Quarry Bank Medical Centre
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
Laboratory and GP system suppliers are primarily responsible for pathology result formatting, structure, presentation and display of abnormal results.
Stated by NHS England
-
Position
NHS England may review national laboratory guidance on abnormal-result flagging and standardise laboratory alert protocols.
Stated by Quarry Bank Medical Centre
-
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.
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
-
Action
Emphasise the need to agree local critical-result cut-offs with clinicians in the next document revision.
Stated by Royal College of Pathologists
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Responsibility for communicating clinical staff obligations on reviewing electronic results lies with organisations and NHS England or devolved health services.
Stated by Royal College of Obstetricians and Gynaecologists
-
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.
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
-
Action
Improve Emergency Department blood-result turnaround through process changes spanning booking, sample transport and laboratory processing.
Stated by Royal Berkshire NHS Foundation Trust -
Action
Upgrade the laboratory information management system to improve the reliability and connectivity of result reporting.
Stated by Royal Berkshire NHS Foundation Trust
-
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.
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
-
Action
Implement automatic transfer of laboratory results into the primary patient record and display them on the Trust-wide system home screen.
Stated by Calderdale and Huddersfield NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
-
Position
The internal investigation could not pursue why laboratory results were not passed on because the recipient could not be identified.
Stated by Calderdale and Huddersfield NHS Foundation Trust
-
Position
Automatic laboratory-result availability in the primary record is considered sufficient, removing the need for results to be phoned through or verbally passed on.
Stated by Calderdale and Huddersfield NHS Foundation Trust -
Position
The Trust considers the doctor’s changed practice, including proactive information review and communication training, sufficient to address handover and record-review concerns.
Stated by Calderdale and Huddersfield NHS Foundation Trust
-
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.
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.
-
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.
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
-
Action
Change the laboratory IT system and issue staff instructions on revised standard operating procedures for haemoglobin reporting.
Stated by Wirral University Teaching Hospital NHS Foundation Trust
-
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.
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
-
Action
Implement an automated paracetamol phone-trigger and ALT alert prompting laboratory staff to telephone critical results to requesting clinicians.
Stated by Medway NHS Foundation Trust -
Action
Audit compliance with SBAR reporting and associated critical-result protocols.
Stated by Medway NHS Foundation Trust
-
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.
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
-
Action
Discuss the delayed laboratory-result notification at a microbiology and infection clinical governance meeting as training for registrars prioritising urgent follow-up.
Stated by University Hospitals Sussex NHS Foundation Trust
-
Concerns raised1
Failure to communicate recent haemoglobin test results to clinicians assessing fitness for surgery
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.
-
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.
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.
Data last updated 7 September 2026