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
Delays and unsafe processes in investigation reporting and results access
This report raised 14 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
Conduct a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 6 March 2024.
Berkshire
Concerns raised1
Delays in notification of abnormal blood test results to clinicians
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.2
Action
Improve Emergency Department blood-result turnaround through process changes spanning booking, sample transport and laboratory processing.
Stated by Royal Berkshire NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024.
Action
Upgrade the laboratory information management system to improve the reliability and connectivity of result reporting.
Stated by Royal Berkshire NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024.
Teesside and Hartlepool
Concerns raised1
Failure to review pre-surgery urine test results
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 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
Implement an electronic patient record and scan historical records into it, including electronically signed, dated and timed clinical notes.
Stated by South Tees Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 January 2024.
Avon
Concerns raised2
Failure of specialty teams to communicate investigation information and share results in a timely manner
Failure of 2-week urgent cancer pathway timeframes to include investigation reporting and referring-clinician review
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.10
Action
Scope administrative review of patient lists to identify parallel clinical pathways before endoscopy and assess a possible pilot.
Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 November 2023.
Action
Discontinue paper radiology reports from 1 May 2024.
Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 November 2023.
Action
Set up specialty-specific radiology reporting systems within existing digital platforms.
Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 November 2023.
Action
Launch a joint digital strategy to converge provider-collaborative IT systems and centralise clinical information digitally.
Stated by Bristol NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 November 2023.
Action
Reformed cancer waiting-time standards by introducing the 28-day Faster Diagnosis Standard and consolidating nine reporting standards into three.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 21 November 2023.
Action
Recruit radiologists to fill vacancies and increase reporting capacity.
Stated by Bristol NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 November 2023.
Action
Use outsourced radiology reporting to maximise reports completed within the target timeframe.
Stated by Bristol NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 November 2023.
Action
Provide locum radiology cover and additional reporting sessions for existing radiologists.
Stated by Bristol NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 November 2023.
Action
Scope increased radiographer resource to support radiologists.
Stated by Bristol NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 November 2023.
Action
Add radiology turnaround times to the divisional risk register.
Stated by Bristol NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 November 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Local management and implementation of national policies and procedures is assigned to NHS England and the responsible Integrated Care Board.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing clinician checks provide a robust process for identifying relevant investigations for patients on parallel clinical pathways.
Stated by Bristol NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The Faster Diagnosis Standard is considered to address concerns by including diagnostic reporting and review times within the cancer waiting-time standard.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Radiology reporting cannot consistently meet the three-day cancer-pathway timeframe because of national staffing shortages, despite mitigation measures.
Stated by Bristol NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner West London
Concerns raised1
Failure to implement periodic clinician-led review of abnormal diagnostic 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 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
Publish national standards for communicating diagnostic test results after hospital discharge.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Trusts are responsible for procedures following national guidance and for responding on handover arrangements and clinician-led review of abnormal blood results.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East London
Concerns raised1
Delays in reporting radiological chest x-rays
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.
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
Increase Emergency Department imaging-reporting radiologists and radiographers to near-full capacity.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 30 October 2023.
Action
Recruit further imaging reporters to reduce reporting turnaround times.
Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The chest radiograph was reported within the department’s ten-working-day timeframe, despite being completed outside normal working hours.
Stated by Barts Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
North Yorkshire and York
Concerns raised1
Failure to ensure swab results are reviewed
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 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
Require staff to record recent post-discharge contacts, advice, investigations and clinicians in PPM+, and forward review requests to outpatient teams.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Birmingham and Solihull
Concerns raised1
Failure to highlight high clozapine results in routinely used clinical notes
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing ICE access, abnormal-result indicators and pharmacy reporting provide the strongest safeguards for recording and responding to high clozapine levels.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Lincolnshire
Concerns raised1
Failure to investigate a significantly abnormal respiratory acidosis blood gas result
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
Require ED clinicians acknowledging blood gas results to document abnormalities requiring management and the planned further management.
Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 10 July 2023.
Action
Have clinical audit teams in both ULHT departments audit blood gas results and documentation to assess whether the learning and actions are embedded.
Stated by United Lincolnshire Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 10 July 2023.
West Yorkshire Eastern
Concerns raised1
Delays in urgent blood sample delivery and reporting
This report raised 14 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.
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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.
