First reported 11 Sep 2013•Latest report 25 Jun 2026
Definition
What this concern includes
Includes failures in the end-to-end process for managing clinical investigation results when the result is not reliably made available to, brought to the attention of, correctly checked or interpreted by, and acted upon by the responsible clinical team.
Not included
Excludes failures concerning treatment monitoring or prescribing unless the assertion specifically concerns management of the resulting investigation result.
Excludes generic documentation, staffing, training or communication deficiencies that are not explicitly tied to the management of an investigation result.
Excludes administrative or test-ordering failures where no result-management deficiency is identified.
Excludes failures involving non-clinical items, equipment or processes unrelated to clinical investigation results.
Reports
108
Distinct published reports
Individual concerns
138
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
168
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.
Department of Health and Social Care15
NHS England12
Care Quality Commission7
Betsi Cadwaladr University LHB5
Mid and South Essex NHS Foundation Trust4
Royal College of Obstetricians and Gynaecologists4
University Hospitals Sussex NHS Foundation Trust4
Barts Health NHS Trust3
Medicines and Healthcare products Regulatory Agency3
Recipient name withheld3
Royal London Hospital3
Ashford and St Peter'S Hospitals NHS Foundation Trust2
Birmingham and Solihull Mental Health NHS Foundation Trust2
Bristol NHS Foundation Trust2
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust2
NHS trust61
Healthcare site28
Ministerial department15
Executive non-departmental public body13
Health and social care service regulator7
Local health board7
Health professional body6
Private limited company5
Type not available5
Integrated care board4
Medicines and medical devices regulator3
Multi-service care provider3
Health and care professional regulator2
Health-system partnership2
Professional body2
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.
City of London
Concerns raised1
Lack of a system for checking access to and reading of important test results
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 concerns
Each 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
Revise the abnormal-results process to categorise urgency, specify response routes and timeframes, escalate unacknowledged findings, and document communication and clinical action.
Stated by East Kent Hospitals University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 August 2026.
Action
Review implementation of the revised abnormal-results escalation process and compliance with completion of Devices MDT actions through governance arrangements.
Stated by East Kent Hospitals University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 August 2026.
Essex
Concerns raised1
Failure to provide clinicians caring for transplant patients with reliably up-to-date blood test results
Responses linked to these concerns
Each 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
Standardise transplant blood-sample routing through a single contact offering daily tacrolimus assays and sample prioritisation on request.
Stated by East Suffolk and North Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 September 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Responsibility for assuring tacrolimus sample testing and reporting rests with the General Hospital and testing laboratory.
Stated by Cambridge University Hospitals NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
CUH cannot require the General Hospital to send tacrolimus samples exclusively to CUH laboratories.
Stated by Cambridge University Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Delayed or intermittent tacrolimus results are outside CUH’s direct control, so CUH is not the appropriate organisation to address the identified risk.
Stated by Cambridge University Hospitals NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
The renal unit cannot process specialist transplant tests, so samples must be sent elsewhere for processing and results.
Stated by East Suffolk and North Essex NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Failure to review, act on, and escalate abnormal blood results
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Yorkshire (West)
Concerns raised2
Failure to communicate and follow up abnormal blood results
Failure to review and act on clinical records and recent investigation results
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 concerns
Each 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.8
Action
Flag all abnormal results within MEDITECH.
Stated by the Rotherham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Introduce and communicate a Trust-wide standard operating procedure for managing investigation results.
Stated by the Rotherham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Review and update the standard operating procedure for critically abnormal pathology results in clinical areas.
Stated by the Rotherham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Conduct a Pathology audit of documentation for time-critical results telephoned to clinical areas.
Stated by the Rotherham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Conduct an additional 50-result audit of documentation and appropriate action for time-critical results.
Stated by the Rotherham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Action
Develop a Power BI module to monitor acknowledgement of results.
Stated by the Rotherham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Launch an Urgent and Emergency Care Centre pilot using the alertive bleep system to flag critical blood results.
Stated by the Rotherham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2026.
Action
Include learning from the incident in the Quality Newsletter, focusing on acting upon time-critical blood results.
Stated by the Rotherham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing face-to-face handover arrangements require follow-up tasks to be transferred to the out-of-hours team.
Stated by the Rotherham NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Sussex, Brighton and Hove
Concerns raised1
Failure of policies, systems and electronic records to proactively drive infection testing and follow-up
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Develop and implement clinical decision support within phase three of the electronic patient record implementation.
Stated by University Hospitals Sussex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 August 2026.
City of London
Concerns raised2
Lack of a system ensuring timely review and consideration of echocardiography results
Lack of a pathway for echocardiography teams to flag results to clinical teams
Responses linked to these concerns
Each 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.4
Action
Operate and update the echocardiography escalation protocol, including senior review routes and a new criterion for pulmonary hypertension findings.
Stated by North Middlesex University HospitalStated completedThe respondent said that this action was complete when they made their response on 12 March 2026.
Action
Automatically book cancelled appointments into the next available follow-up slot and escalate repeated service cancellations for senior clinical review.
Stated by North Middlesex University HospitalStated completedThe respondent said that this action was complete when they made their response on 12 March 2026.
Action
Operate and annually review the echocardiography escalation pathway, including escalation of significant abnormalities and the added criterion for new pulmonary hypertension.
Stated by North Middlesex University HospitalStated completedThe respondent said that this action was complete when they made their response on 12 March 2026.
Action
Automatically book cancelled appointments into the next available follow-up slot and escalate repeated service cancellations to the Cardiology service manager for senior review.
Stated by North Middlesex University HospitalStated completedThe respondent said that this action was complete when they made their response on 12 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
An established echocardiography escalation pathway and protocol adequately address significant abnormal findings.
Stated by North Middlesex University HospitalExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
An established echocardiography escalation pathway and protocol are considered sufficient to address significant abnormal findings.
Stated by North Middlesex University HospitalExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Essex
Concerns raised1
Delays in official radiologist reporting of chest X-rays showing cardiomegaly
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 concerns
Each 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
Complete and formalise the radiology policy review to document how clinical teams can expedite imaging reports for clinical concerns.
Stated by Mid and South Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 March 2026.
Action
Share the updated radiology escalation guidance with paediatric teams and publish it on the Trust intranet.
Stated by Mid and South Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Formal chest X-ray reporting delays lie outside the respondent’s control.
Stated by Royal College of Paediatrics and Child HealthUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Black Country
Concerns raised2
Failure to adequately scrutinise laboratory blood test results
Failure to prominently flag abnormal laboratory results
Responses linked to these concerns
Each 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.11
Action
Pilot safe transmission and ingestion of DAPB4101 pathology reports between laboratories and GP practices.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2026.
Action
Publish guidance and resources supporting safe clinical messaging, test-result handling, clinical decision support and digital clinical safety.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Notify the laboratory of missing NT-proBNP alerts and request corrected reporting.
Stated by Quarry Bank Medical CentreStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Implement the MY Bot AI triage system to segregate results and alert the duty doctor to urgent abnormal findings.
Stated by Quarry Bank Medical CentreStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Reissue the Results Management SOP, retaining requesting-clinician responsibility and escalating results unfiled beyond 24 hours.
Stated by Quarry Bank Medical CentreStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Introduce mandatory same-day review and documented action for NT-proBNP values exceeding 400.
Stated by Quarry Bank Medical CentreStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Introduce an EMIS Web abnormal-alert framework for critical biomarkers and require documented acknowledgment or reasons for not following referral recommendations.
Stated by Quarry Bank Medical CentreStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Introduce cross-filing tasks and secondary review safeguards for results filed by another clinician and specified critical cardiac biomarkers.
Stated by Quarry Bank Medical CentreStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Develop and operate a clinical audit programme for significant results and referral completion, including fortnightly, monthly-governance, and quarterly NT-proBNP audits.
Stated by Quarry Bank Medical CentreStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Monitor revised-protocol compliance through monthly clinical governance meetings and formally review change effectiveness at three and six months.
Stated by Quarry Bank Medical CentreStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2026.
Action
Promote wider standardisation of pathology result-flagging conventions.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Individual GP practices manage operational arrangements for reviewing, assigning and acting on pathology results.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Laboratory and GP system suppliers are primarily responsible for pathology result formatting, structure, presentation and display of abnormal results.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS England may review national laboratory guidance on abnormal-result flagging and standardise laboratory alert protocols.
Stated by Quarry Bank Medical CentreRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Lack of sharing pacemaker wound test results with the surgical team
Responses linked to these concerns
Each 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
Strengthen the wound-swab tracking and review documentation to record swab timing, result review, clinician notification and associated treatment.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2025.
Action
Add wound-swab results to the WHO checklist, using an interim sticker until the revised form is approved, redesigned and printed.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Microbiology telephone notification was not required because the superficial wound swab result did not meet critical-result reporting criteria.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Harris Flex cannot automatically alert clinicians to pathology results, limiting automated result notification while IT work continues.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Failure of blood gas machines to clearly indicate unrecordably low blood glucose levels
Responses linked to these concerns
Each 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.3
Action
Investigate whether interpretation of glucose and other out-of-range point-of-care analyser results presents a wider safety issue.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 20 May 2025.
Action
Share applicable report details with the manufacturer for review through its ongoing post-market surveillance.
Stated by Medicines and Healthcare products Regulatory AgencyStated plannedThe respondent said that this action was planned when they made their response on 20 May 2025.
Action
Work with the trust to resolve any identified training issues relating to interpretation of analyser results.
Stated by Medicines and Healthcare products Regulatory AgencyStated plannedThe respondent said that this action was planned when they made their response on 20 May 2025.
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Includes failures in the end-to-end process for managing clinical investigation results when the result is not reliably made available to, brought to the attention of, correctly checked or interpreted by, and acted upon by the responsible clinical team.
