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.
Mid Kent and Medway
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 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
Implement an automated paracetamol phone-trigger and ALT alert prompting laboratory staff to telephone critical results to requesting clinicians.
Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 November 2017.
Action
Audit compliance with SBAR reporting and associated critical-result protocols.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 November 2017.
South Wales Central
Concerns raised1
Failure of the hospital-to-GP DVT result communication system
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.6
Action
Undertake a review of discharge arrangements, focusing on communication and documentation supporting discharge from secondary to primary healthcare.
Stated by Healthcare Inspectorate WalesStated in progressThe respondent said that this action was in progress when they made their response on 2 December 2017.
Action
Implement a streamlined DVT pathway directing suspected cases to radiology, initiating primary treatment before ultrasound, and ensuring positive and negative results receive appropriate follow-up.
Stated by Hywel Dda University LHBStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Record all suspected DVT referrals and follow up 48 hours later to confirm receipt of results.
Stated by RHAYADER GROUP PRACTICEStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Review how inspections assess timely information transfer between services, using policy, medicines and clinical expertise.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Revise and improve the wording of the Key Lines of Enquiry on information sharing during transfers between services.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Have inspectors use two specific information-sharing questions when reviewing practice safety from November 2017.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 2 December 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Welsh Clinical Portal access was considered sufficient for the GP to review the patient's A&E attendance outcome despite the discharge summary issue.
Stated by Hywel Dda University LHBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Including scan results with transferred patient records was considered sufficient, so no additional regulatory input was required.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Current inspection methodology was considered to cover the relevant care elements, so no additional policy change was required.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Black Country
Concerns raised1
Failure to take previous abnormal ECG results into account during paramedic handover
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.3
Action
Summarise electronic ambulance handover information into one or two sheets and attach it to emergency department documentation.
Stated by the Royal Wolverhampton NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.
Action
Incorporate a clinician confirmation that pre-hospital information was reviewed into the emergency department discharge documentation.
Stated by the Royal Wolverhampton NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2017.
Action
Audit compliance with the emergency department discharge checklist monthly.
Stated by the Royal Wolverhampton NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 4 August 2017.
Birmingham and Solihull
Concerns raised2
Failure to act on identified missing blood gas results
Failure to ensure arterial blood gas results remain available to clinicians
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.
Surrey
Concerns raised1
Delays in obtaining 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Failure to act on requested clinical 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Brighton and Hove
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 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
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 TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.
North Wales (Eastern and Central)
Concerns raised1
Lack of a reliable system for delivering histology results to named consultants
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
Implement Procedure MD23 to mitigate risks from failure to act on diagnostic results.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Action
Develop the CHAI Ping electronic reporting solution to alert requesting clinicians, record action taken, and reduce printing of WCP results.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Following up and acting on histology results remains the ultimate responsibility of the health professional who ordered the investigation.
Stated by Betsi Cadwaladr University LHBRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester West
Concerns raised1
Lack of policies governing notification of investigative test results to responsible Consultants
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.2
Action
Complete a joint review of policies governing radiological investigation requests and communication of results to requesting clinicians.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Action
Disseminate radiology notification protocols by email and discuss them at the Orthopaedic clinical governance meeting.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing radiology notification protocols and communication arrangements are considered sufficient to support timely review and appropriate treatment.
Stated by Northern Care Alliance NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised2
Unavailability of computer systems delaying access to blood results
Failure to review blood results promptly before emergency transfer
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.1
Action
Reiterate to all medical staff the availability of point-of-care tests for deteriorating patients.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 February 2017.
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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.
