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.
Essex
Concerns raised1
Failure to follow up potential malignancy findings
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The presentation and symptom resolution were more consistent with adhesive than malignant small bowel obstruction, making malignancy an unexpected outcome.
Stated by Mid and South Essex NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Essex
Concerns raised1
Delays in making CT scan results available
This report raised 12 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
Use one comprehensive patient-tracking system across hospital sites to monitor cancer pathways, diagnostic reporting, timescales and required escalations.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 January 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Weekly specialist MDT meetings and centralised tracking are considered sufficient to prevent delays in scan review and treatment planning.
Stated by Mid and South Essex NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Avon
Concerns raised2
Failure of urgent liver function test reporting thresholds to account for pregnancy-specific conditions
Failure to communicate grossly abnormal liver function test results from laboratory staff to clinical staff
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
Request that the Royal Colleges consider the report and develop national guidance on urgent LFT reporting reference ranges in pregnancy.
Stated by Bristol NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 November 2024.
Action
Raise the issue with the regional obstetric lead for liaison with the national obstetric lead.
Stated by Bristol NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 November 2024.
Action
Set up a task and finish group to implement nationally recommended urgent LFT reporting reference ranges safely across the Trust.
Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 November 2024.
Action
Review the Royal College of Pathologists’ response to the report regarding pregnancy-specific thresholds for urgent liver-function-test reporting.
Stated by Royal College of Obstetricians and GynaecologistsStated plannedThe respondent said that this action was planned when they made their response on 13 November 2024.
Action
Communicate the review outcome to members and incorporate relevant learning into clinical guidance.
Stated by Royal College of Obstetricians and GynaecologistsStated plannedThe respondent said that this action was planned when they made their response on 13 November 2024.
Action
Emphasise the need to agree local critical-result cut-offs with clinicians in the next document revision.
Stated by Royal College of PathologistsStated plannedThe respondent said that this action was planned when they made their response on 13 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Changing urgent LFT reference ranges in one Trust alone may create risk through inconsistent guidance and would not address the national issue.
Stated by Bristol NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The Royal Colleges are asked to consider and develop national guidance on urgent LFT reference ranges in pregnancy.
Stated by Bristol NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local pathology providers and clinicians are responsible for agreeing communication cut-offs; the guidance does not prescribe universal thresholds.
Stated by Royal College of PathologistsRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Responsibility for communicating clinical staff obligations on reviewing electronic results lies with organisations and NHS England or devolved health services.
Stated by Royal College of Obstetricians and GynaecologistsRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner West London
Concerns raised1
Failure of ultrasound reporting to avoid false reassurance regarding malrotation
This report raised 7 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
Formalise the paediatric abdominal reporting standard in local radiology protocols and audit reports for quality assurance.
Stated by St George'S University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 July 2025.
Suffolk
Concerns raised1
Failure of patient handover processes to ensure significant clinical findings are available to receiving 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.
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 IT support linking ambulance and emergency department systems to improve electronic clinical information sharing.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 4 September 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Implementation and oversight of clinical handover protocols across England are the responsibility of local organisations.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local process improvements and ambulance information systems provide an adequate response to clinical handover and patient-record concerns.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure to recognise the need for follow-up medical review after a negative x-ray
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 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.3
Position
The GP surgery is responsible for responding to concerns about the care it provided and appointment access arrangements.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The GP practice contact concerned care outside the Trust’s remit because it was not delivered by East Cheshire NHS Trust.
Stated by East Cheshire NHS TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
The GP practice’s provider, gtd healthcare, is responsible for responding to concerns about that primary care contact.
Stated by East Cheshire NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised2
Lack of required senior review when diagnostic results are incongruous or unexpected in context
Lack of minimum standards for obtaining clinical context when reviewing isolated test or 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.
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
Deliver regular ECG interpretation teaching and promote second opinions from appropriately qualified clinicians or cardiologists.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 June 2024.
Action
Expand simulation and Human Factors training through a rolling programme for junior doctors across MFT sites.
Stated by Manchester University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Registrar review is considered an appropriately senior arrangement, so consultant oversight of every ECG is not considered reasonable.
Stated by Manchester University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
North Wales (East and Central)
Concerns raised3
Lack of an electronic laboratory-to-emergency-department alert system for abnormal results
Failure to act on abnormal blood results
Failure to document abnormal blood results in emergency department records
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
Review, revise and update telephone-alert procedures across all three emergency departments, establishing a clear mechanism for receiving and acting on abnormal laboratory results.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 25 June 2024.
Action
Cascade learning from the case across all three emergency departments and ensure staff are aware of the updated telephone-alert procedures.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 25 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Telephone alerts remain an adequate safety arrangement and are unlikely to be replaced by a future electronic alert system.
Stated by Betsi Cadwaladr University LHBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure to ensure urgent blood results are acted upon immediately
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.
Manchester South
Concerns raised1
Delays in specialist reporting of X rays
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 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
Expand Clinical Radiology specialty training places to increase the trained reporting workforce.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2024.
Action
Continue international recruitment of radiologists to support diagnostic capacity, with demand planning underway for further recruitment.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2024.
Action
Deliver the Long Term Workforce Plan, including expanded domestic education, training and recruitment and workforce retention measures.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
NHS Trusts are responsible for ensuring safe staffing levels in hospitals’ current day-to-day operations.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local A&E procedures require follow-up of X-ray reports because general X-rays may not receive 24/7 imaging-service reporting.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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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.
