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
Failure of sodium valproate blood test reference ranges to clearly indicate the therapeutic range
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
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.
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
Use ward patient plans and boards to track investigations, tests and urgent treatment, with daily nursing and medical review.
Stated by University Hospitals Plymouth NHS Trust -
Action
Require review of outstanding tests and verbal and written handover before transferring MAU patients to wards.
Stated by University Hospitals Plymouth NHS Trust -
Action
Conduct formal handovers for every on-call team to transfer information and identify outstanding tests and concerns.
Stated by University Hospitals Plymouth NHS Trust
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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.
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.2
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Action
Enable clinicians to electronically check all outpatient tests ordered in their name.
Stated by Stockport NHS Foundation Trust -
Action
Require consultants to follow up, or establish systems to follow up, every blood test and other investigation they order.
Stated by Stockport NHS Foundation Trust
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
Individual NHS Trusts are responsible for reviewing their own standards for laboratory result reporting and alerts.
Stated by Department of Health and Social Care
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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
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
Monitor emergency CT scan reporting times through routine sampling.
Stated by Hywel Dda University LHB -
Action
Ensure test results are available to all relevant clinical teams when patients are under the care of multiple teams.
Stated by Hywel Dda University LHB -
Action
Remind staff to ensure requesting clinical teams review diagnostic results and document review and resulting actions.
Stated by Hywel Dda University LHB
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Concerns raised1
Failure to communicate recent haemoglobin test results to clinicians assessing fitness for surgery
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
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.
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 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.
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 laboratory to inform ward staff of abnormal potassium results
Failure of medical staff to recognise the significance of potassium results
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.
Data last updated 7 September 2026