Recurring concern
Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
- Reports that mention this concern
- 108
- Times this concern has been raised
- 138
- Stated actions linked to this concern
- 168
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.
What is 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.
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 108 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure of sodium valproate blood test reference ranges to clearly indicate the therapeutic range
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Delays in medical review of investigation results
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals Plymouth NHS 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.3
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University Hospitals Plymouth NHS Trust
Use ward patient plans and boards to track investigations, tests and urgent treatment, with daily nursing and medical review.
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University Hospitals Plymouth NHS Trust
Require review of outstanding tests and verbal and written handover before transferring MAU patients to wards.
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University Hospitals Plymouth NHS Trust
Conduct formal handovers for every on-call team to transfer information and identify outstanding tests and concerns.
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Concerns raised1
Misinterpretation of blood or urine test results communicated to the General Practitioner
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- Stockport 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
-
Stockport NHS Foundation Trust
Enable clinicians to electronically check all outpatient tests ordered in their name.
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Stockport NHS Foundation Trust
Require consultants to follow up, or establish systems to follow up, every blood test and other investigation they order.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Department of Health and Social Care
Individual NHS Trusts are responsible for reviewing their own standards for laboratory result reporting and alerts.
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Concerns raised2
Failure to make CT scan results promptly available to departments involved in patient care
Failure to act on CT scan results without delay within a reasonable time-scale
Linked response
- Hywel Dda University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Hywel Dda University LHB
Monitor emergency CT scan reporting times through routine sampling.
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Hywel Dda University LHB
Ensure test results are available to all relevant clinical teams when patients are under the care of multiple teams.
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Hywel Dda University LHB
Remind staff to ensure requesting clinical teams review diagnostic results and document review and resulting actions.
-
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
Delays in receiving ECG and blood test results
This report raised 8 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.
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Concerns raised1
Failure to provide urgent admission and further investigation after significant test results
This report raised 4 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 raised2
Failure of the laboratory to inform ward staff of abnormal potassium results
Failure of medical staff to recognise the significance of potassium results
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