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.
Black Country
Concerns raised1
Failure to await blood test results before discharge
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.4
Action
Incorporate proactive blood-result review into postgraduate induction training and disseminate the requirement to postgraduate staff.
Stated by the Royal Wolverhampton NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 10 October 2022.
Action
Use the ED clerking form’s investigations-and-results section to document blood-result review before discharge.
Stated by the Royal Wolverhampton NHS TrustStated completedThe respondent said that this action was complete when they made their response on 10 October 2022.
Action
Allocate consultant work-plan time to review blood results in the ICE system within 24 hours.
Stated by the Royal Wolverhampton NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 10 October 2022.
Action
Review and include the discharge blood-result process in ED policy and guidance.
Stated by the Royal Wolverhampton NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 10 October 2022.
Manchester South
Concerns raised1
Failure to act on abnormal clinical imaging reports and provide indicated 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.
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.4
Action
Introduce and test an electronic RAG-priority radiology reporting and alerting system for Emergency Department findings.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2022.
Action
Implement a reporting and escalation SOP covering responsibilities, documentation, monitoring, oversight and escalation of unread or unacknowledged findings.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
Action
Prioritise and monitor daily Emergency Department Consultant review of radiology reports, with administrative processing of required actions.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2022.
Action
Require Consultant review on the day for specified X-rays received by the Emergency Department before 22:00.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
An audit found that the small number of fractures missed by Emergency Department clinicians were acted upon appropriately when radiology reports were received.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Cumbria
Concerns raised1
Failure to record recognition of the significance of critical blood-test 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 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.
Inner North London
Concerns raised1
Delay in responding to markedly abnormal blood 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Yorkshire (Western)
Concerns raised2
Failure to obtain available laboratory results for treatment planning
Failure to communicate laboratory results to treating clinicians
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
Implement automatic transfer of laboratory results into the primary patient record and display them on the Trust-wide system home screen.
Stated by Calderdale and Huddersfield NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 March 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The internal investigation could not pursue why laboratory results were not passed on because the recipient could not be identified.
Stated by Calderdale and Huddersfield NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Automatic laboratory-result availability in the primary record is considered sufficient, removing the need for results to be phoned through or verbally passed on.
Stated by Calderdale and Huddersfield NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The Trust considers the doctor’s changed practice, including proactive information review and communication training, sufficient to address handover and record-review concerns.
Stated by Calderdale and Huddersfield NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cumbria
Concerns raised2
Failure of the result-filing function to prevent multiple-click filing of subsequent results without clinician review
Lack of a failsafe for abnormal radiology results to prompt clinician review
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.7
Action
Test a workable EMIS solution and continue collaborating with EMIS on system fixes, user communication and escalation of identified risks.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2022.
Action
Return the Cockermouth Hospital community ward to the ICE Order Comms system after assessing the affected functionality.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Increase Neurology team vigilance when reviewing results and stop using “file no comment” in favour of “File and Comment” to require clinician review.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Implement a separate Rad Alert system that emails referrers about significant radiology findings and escalates unacknowledged alerts to alternative clinicians.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2022.
Action
Notify Primary Care colleagues using EMIS about the risk and required precautions through the CCG Chief Clinical Information Officer.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Continue collaborating with NHS Digital on modern messaging standards to improve normal and abnormal result flagging.
Stated by EMIS GroupStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2022.
Action
Review results-filing training materials to emphasise detailed review of radiology and other results that may lack abnormal flags.
Stated by EMIS GroupStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Existing EMIS Web failsafes, combined with appropriate user diligence, are considered sufficient to prevent inadvertent filing of multiple results.
Stated by EMIS GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Clinicians are responsible for reviewing, filing and archiving results at a speed and diligence appropriate to their clinical nature and patient context.
Stated by EMIS GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
EMIS cannot develop abnormal radiology flagging until NHS Digital standards provide identifiers distinguishing normal from abnormal results.
Stated by EMIS GroupUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The Neurology Service cannot revert to ICE because transferring data from ICE to EMIS could introduce transcription errors and other risks.
Stated by North Cumbria Integrated Care NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Adding flagging codes to ICE cannot affect results because source systems bypass ICE and interface directly with EMIS Web.
Stated by North Cumbria Integrated Care NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
North Wales (East and Central)
Concerns raised1
Failure to implement procedures mitigating risks from failure to act on diagnostic results within the stated timeframe
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.1
Action
Implement the ratified procedure defining staff roles and processes for communicating critical and unexpected pathology results.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 2 November 2021.
Manchester South
Concerns raised1
Delays in returning inpatient swab results
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.
Nottinghamshire
Concerns raised1
Absence of an alert and review system for ICE results across the paediatric team
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.1
Action
Train paediatric consultants to review ICE results electronically and operate the electronic ICE system alongside a paper safety net.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 August 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Electronic ICE access, paper records and radiology red-and-amber alerts provide sufficient safeguards for reviewing paediatric investigation results.
Stated by Doncaster and Bassetlaw Teaching Hospitals 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 raised1
Failure to approve the updated procedure for direct communication of life-threatening blood 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 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
Update, approve and activate the SOP for telephoning reports and life-threatening results, and discuss it in team briefings.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.
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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.
