Recurring concern
Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
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Request correctionFirst reported 11 Sep 2013•Latest report 25 Jun 2026
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
- Individual concerns
- 138
- Date range
- 2013–2026
- Stated actions
- 168
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.
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Concerns raised1
Delays in making lumbar puncture results available
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.
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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Position
The viral lumbar puncture results were received within the normal turnaround time for this outsourced investigation.
Stated by Medway NHS Foundation Trust
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Concerns raised1
Failure to accurately categorise RAST test 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 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.
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Concerns raised2
Failure of the results-routing system to send results to the referring clinician
Failure of the results-routing system to prevent sending results to uninvolved doctors
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.
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Concerns raised2
Lack of a system for escalating blood test results to the consultant
Failure to act on high clozapine blood test results through repeat testing and dose adjustment
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 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.5
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Action
Send pharmacy reports of clozapine results above 600 to the Clozapine Lead for direct escalation to the Consultant and Divisional Pharmacist.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Audit all patients prescribed clozapine on the identified doctor’s caseload for unconsidered anomalous results.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Issue a practice alert to doctors reminding them to review anomalous clozapine results.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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Action
Strengthen multidisciplinary meeting focus on physical health and include clozapine in quality-improvement checks of testing and abnormal-result actions.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Draft and send a clozapine safety alert to clinicians to support immediate action where necessary.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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Concerns raised1
Failure to accurately report smear test 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.
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Concerns raised1
Failure to act on urine test results after patient discharge
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.
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 of laboratory abnormal-result repeating, alerting and follow-up
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.3
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Action
Highlight to Emergency Department medical staff the importance of reviewing abnormal blood results and arranging appropriate follow-up.
Stated by King'S College Hospital NHS Foundation Trust -
Action
Prepare a Safety Net communication on raised protein or globulin and its association with multiple myeloma.
Stated by King'S College Hospital NHS Foundation Trust -
Action
Use the Screening Diagnostic Improvement Group to review systems for prompt test-result review and reduced clinical risk.
Stated by King'S College Hospital NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The Trust disputes that every elevated globulin requires extensive investigation, citing multiple causes and poor clinical utility.
Stated by King'S College Hospital NHS Foundation Trust
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Position
Critical-result telephone notification follows professional recommendations, which do not classify elevated total protein as requiring communication.
Stated by King'S College Hospital NHS Foundation Trust
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Concerns raised3
Intermittent systems errors delaying D-Dimer results
Unclear telephone-reporting arrangements for A&E patients
Failure to record blood-test requests, reasons and outstanding results
This report raised 9 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
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Action
Audit ED staff compliance with documentation requirements and repeat the audit monthly.
Stated by the Shrewsbury and Telford Hospital NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Because ED patients are classified as in-patients, pathology does not telephone D-Dimer results; the requester must check the system.
Stated by the Shrewsbury and Telford Hospital NHS Trust
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Position
The alert facility existed; failure to complete it was attributed to human factors rather than a system failure.
Stated by the Shrewsbury and Telford Hospital NHS Trust
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Concerns raised1
Failure to recognise worsening condition from blood 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 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.
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Concerns raised2
Inadequate processes for recording test results in electronic patient records
Inadequate processes for reviewing 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 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
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Action
Use updated diagnostic-result processes to action results on receipt, arrange follow-up for results requiring it, notify patients appropriately, and audit actions in clinical records.
Stated by Stonefield Street Surgery
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Test results were clearly visible in the electronic record, contrary to the concern that results were not appearing within patient records.
Stated by Stonefield Street Surgery
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Position
Existing diagnostic-result processes ensure tests are actioned on receipt, abnormal results are followed up, and actions are auditable.
Stated by Stonefield Street Surgery
Data last updated 7 September 2026