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.
Inner South London
Concerns raised1
Failure to ensure immediate ambulance transfer when abnormal blood results require urgent transfer
This report raised 4 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
Continue collaboration with Kings College Hospital to improve access to medical care and support rapid access from the Maudsley site.
Stated by South London and Maudsley NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 July 2015.
Inner North London
Concerns raised1
Lack of Out of Hours access to previous medical history and clinical test results
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 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.
Manchester South
Concerns raised5
Failure of biochemistry laboratories to escalate blood test results
Failure to provide radiologists with current blood results before scanning
Failure to escalate blood test results
Delays in recognising serious blood-test results
Failure to admit patients as emergencies despite serious blood-test results
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 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
Lower the creatinine alert threshold to 400 µmol/L and telephone qualifying results on the same day.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2015.
Action
Implement the Trust-wide acute kidney injury alert system, with same-day telephone escalation for Stage 3 alerts and case-by-case review of Stage 1 and 2 alerts.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2015.
Action
Check for later renal-function results before administering intravenous contrast to patients with known chronic kidney disease.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2015.
Action
Review the practice policy for allocating and checking incoming test results in light of the case.
Stated by Davyhulme Medical CentreStated completedThe respondent said that this action was complete when they made their response on 25 March 2015.
Action
Have all practice GPs read NICE guidance on acute kidney injury to improve management and awareness.
Stated by Davyhulme Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 25 March 2015.
Action
Deliver acute kidney injury recognition and management training for junior and other relevant staff.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2015.
Action
Implement and disseminate acute kidney injury guidelines through Acute Medical Unit displays and the locum doctor handbook.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2015.
Action
Disseminate the case and its lessons through staff debriefing, Medical Grand Round and divisional audit and clinical effectiveness presentations.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The practice relies on the laboratory to telephone urgent abnormal results, which are passed to the on-call doctor and dealt with that day.
Stated by Davyhulme Medical CentreExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The practice considers it impractical to guarantee that all results are checked continuously as they arrive.
Stated by Davyhulme Medical CentreUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The practice cannot automatically see hospital results and would need to search for them using a named-patient basis.
Stated by Davyhulme Medical CentreUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester West
Concerns raised2
Failure of hospitals to inform General Practitioners of GDH positive results
Lack of awareness of the significance of GDH positive results for future antibiotic prescribing
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.5
Action
Explore methods to support local health communities in reporting and sharing patients’ C. difficile status.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 6 March 2015.
Action
Develop hospital-to-primary-care information sharing on patient discharge, informed by local best practice and consultation with relevant partners and experts.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 6 March 2015.
Action
Deliver national antimicrobial-resistance workshops and a national C. difficile study day promoting testing and appropriate antibiotic prescribing.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 6 March 2015.
Action
Make national workshop and study-day materials available on the NHS England Patient Safety Domain webpage.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 6 March 2015.
Action
Work with partners to develop wider understanding of C. difficile testing and the implications of results, including GDH testing.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 6 March 2015.
Norfolk
Concerns raised1
Delayed availability of echocardiogram 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 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 an electronic reporting system for test results, including echocardiography.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 December 2014.
Cardiff & the Vale of Glamorgan
Concerns raised1
Failure to record first lumbar puncture test results in the core donor data form
This report raised 8 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.4
Action
Develop and implement an electronic system for specialist nurses to record and transmit donor data to transplant centres.
Stated by NHS Blood and TransplantStated plannedThe respondent said that this action was planned when they made their response on 18 December 2014.
Action
Continue reminding specialist nurses to capture and provide key donor information accurately and fully during the interim period.
Stated by NHS Blood and TransplantStated in progressThe respondent said that this action was in progress when they made their response on 18 December 2014.
Action
Share the case and its learning through specialist nurse, transplant surgeon and intensive care governance channels, including case-study presentations and NHSBT communications.
Stated by NHS Blood and TransplantStated completedThe respondent said that this action was complete when they made their response on 18 December 2014.
Action
Audit organ-donor primary records to assess the accuracy and completeness of transferring information from medical case notes to donor files and EOS.
Stated by NHS Blood and TransplantStated in progressThe respondent said that this action was in progress when they made their response on 18 December 2014.
Portsmouth and South East Hampshire
Concerns raised1
Failure to properly check returned specialist investigation 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing prison healthcare specifications and appointment, referral, attendance, and follow-up systems address healthcare investigation and continuity concerns.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Delays in reporting imaging results
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Birmingham and Solihull
Concerns raised3
Lack of timely review of abnormal blood test results
Failure to provide treatment after abnormal blood test results
Failure to review the patient after abnormal blood test results
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.
Surrey
Concerns raised1
Failure to consider chemical pathology flagging of particularly concerning results
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 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.
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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.
