Recurring concern

Failure to ensure clinical investigation results are reliably available, interpreted and acted upon

First to latest report 11 Sep 2013 — 25 Jun 2026

Reports that mention this concern
108
Times this concern has been raised
138
Stated actions linked to this concern
168

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.

What is 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 and published responses 108 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Brighton and Hove

    AI-generated summary

    Kalma RAM-HENMAN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kalma RAM-HENMAN died on 7 June 2018 after presenting to A&E in a precarious state and later being found to have a perforated gastric ulcer. The report identified concerns about incomplete fluid monitoring, failure to administer prescribed potassium and sufficient intravenous fluids, missed ECG abnormalities, inadequate repeat blood testing, and delays in responding to her deterioration and providing planned treatment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to review and identify abnormal ECG results

    Wider context from the report

    “(2) An ECG was ordered which showed abnormalities likely associated with her low potassium level. This was not seen by the doctor who requested it. The signature on it is illegible. A second ECG should have been requested. It was not. She was written up for potassium in A&E as well as intravenous fluids but was given no potassium and only half a litre of intravenous fluids in her entire 24 hour admission. It was the view of the Doctors giving the evidence that she should have received at least four litres to deal with her depleted state. So instructions given within three to four hours of her arrival in A&E (at 12.12pm on 6/6/2018) were not implemented. Why not? ”

    Source location

    Kalma RAM-HENMAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Liverpool and the Wirral

    AI-generated summary

    Tom Cribley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to escalate monitoring and management after grossly abnormal blood results

    Wider context from the report

    “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017. Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness. The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions. Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area. ”

    Source location

    Tom Cribley · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Black Country

    AI-generated summary

    Mrs Natalie Billingham · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs Natalie Billingham was admitted to hospital with worsening foot pain, later developed necrotising fasciitis, underwent emergency surgery including a through-knee amputation, and died on the evening of 2 March 2018. The report identified concerns about inadequate communication and delays in reviewing abnormal blood results, recognising sepsis, and administering antibiotics.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in assessing available blood results

    Wider context from the report

    “1. Evidence emerged during the inquest that there was inadequate communication and delays in assessing the blood results when available. There were also missed opportunities for administering antibiotics at an earlier stage and recognising the development of sepsis. ”

    Source location

    Mrs Natalie Billingham · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  4. London (East)

    AI-generated summary

    William George BARTRAM · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    William Bartram was born with a chordee and hydrocele and was reported to have an inadequate urine stream from shortly after birth. Raised creatinine results and concerns about his urine output were not acted upon, and he died from septic shock on 12 March 2017 after deteriorating in hospital. The principal concerns were unclear processes for repeat blood samples, failure to highlight or act on abnormal results, and inadequate advice to his parents about what constituted a healthy urine stream.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a clear process for repeat blood samples in babies and subsequent checking and actioning of results

    Wider context from the report

    “(1) The Trust’s investigation report noted that on the 2 March 2017, the parents should not have been advised to attend outpatients for repeat bloods. They should have been advised to return to the emergency department. The A&E registrar who gave evidence during the course of the Inquest, confirmed that staff are not advised to ensure that babies return to the emergency department for repeat bloods. The process for repeat samples is not clear. A clear process for the taking of repeat blood samples for babies would be helpful. A process which would maximise the chances of the results being checked and actioned would be most desirable. ”

    Source location

    William George BARTRAM · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of capillary blood gas printouts to highlight abnormal results to clinical staff

    Wider context from the report

    “(2) A grossly raised creatinine was found on a capillary blood gas sample taken in A&E on 2 March 2017. It was not noted by the clinical staff. It does not appear that the print out from the machine highlighted the result in any way. If abnormal results could be highlighted to clinical staff, this may reduce the risk of abnormal readings being missed. ”

    Source location

    William George BARTRAM · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Surrey

    AI-generated summary

    Doris Mary Ridgwell · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Doris Mary Ridgwell was admitted to hospital with knee swelling and pain, with an INR of 8.1 that was not successfully communicated to the ward or acted upon before her discharge. She was later admitted with a large subdural haematoma and intraventricular bleed, and the inquest determined that she died as a consequence of over-anticoagulation. Concerns included unclear procedures for communicating abnormal coagulation results, delays in making results available to healthcare professionals, and discharge summaries that did not include blood test results.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in authorising abnormal results onto the Clinical Manager system

    Wider context from the report

    “Abnormal results are not authorised onto the Clinical Manager system to be viewed by Healthcare professionals by Laboratory staff until they have telephoned the results through to the ward, which can potentially cause a delay in these being available on the system; ”

    Source location

    Doris Mary Ridgwell · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Omission of blood test results from discharge summaries

    Wider context from the report

    “The Discharge summaries provided to GPs following discharge from Hospital do not include blood tests results, meaning a potential safeguard to check these results is missed; ”

    Source location

    Doris Mary Ridgwell · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficiently clear procedures for telephoning abnormal coagulation results

    Wider context from the report

    “The Trust’s Standard Operating Procedure for Telephoning of Coagulation Results is not sufficiently clear regarding what action should be taken by staff in the Blood Sciences Department to ensure abnormal coagulation results are made known to the treating Healthcare professionals; - A new Standard Operating Procedure has been prepared, but having had sight of this, I do not believe this clearly outlines for Laboratory staff the steps to be taken in telephoning through abnormal Coagulation Results; ”

    Source location

    Doris Mary Ridgwell · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise the coagulation-results procedure to require escalation, prompt Clinical Manager release, documented communication, and shift handover when urgent abnormal results cannot be promptly telephoned.

    Verbatim wording from the response

    “The Root Cause Analysis investigation carried out following this incident identified the fact that the Trust’s Standard Operating Procedure for the telephoning of clinically urgent abnormal coagulation results was not robust enough and that the procedure required strengthening. As a result of the investigation the Standard Operating Procedure was revised to make it clear that where it is not possible to get hold of a clinician who has requested a blood result which has been deemed clinically urgent, this needs to be handed over to those working the next shift in the Blood Sciences Department so that continues attempts to contact this clinician can be made. This strengthened the process but following the concerns raised at the inquest hearing we have strengthened the process even further.”

    Source location

    2018-0151-Response-by-Epsom-St-Helier-University-Hospital
    Page 3 · response
    Published 8 July 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Including hospital blood results in discharge summaries is not considered necessary because GPs can access those results through Telepath.

    Verbatim wording from the response

    “The possibility of including blood results from hospitals within hospital discharge summaries was discussed with a GP representative from the local area at the Clinical Quality Review Group on 24 May 2018. They did not feel they would be able to review blood results within patient’s discharge summaries. Moreover, it is not felt that it would be appropriate to rely on GP’s to act as a potential safeguard for abnormal results. Blood results taken in hospital can be accessed by GP’s via a computerised patient management system, Telepath.”

    Source location

    2018-0151-Response-by-Epsom-St-Helier-University-Hospital
    Page 5 · response
    Published 8 July 2018

    Open published response

  6. Inner North London

    AI-generated summary

    Freddie Oliver DOBINSON-EVANS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Freddie Dobinson-Evans had undiagnosed Dravet syndrome and died from causes recorded as post-cardiac arrest syndrome and Dravet syndrome. A genetic test report was communicated to his father as “absolutely normal”, although Freddie had a pathogenic SCN1A gene mutation; the report identified the potential for significant consequences for another child.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to communicate genetic test results accurately

    Wider context from the report

    “Following a testing request made for Freddie on 20 February 2017, a report was issued from the laboratory at Great Ormond Street Hospital on 7 June 2017. It was headlined: No clearly pathogenic variant detected. Diagnosis not confirmed. ████████ spoke to Freddie’s father the following day and told him that Freddie’s genetic test results were “absolutely normal”. In fact, Freddie did have a pathogenic gene mutation in the SCN1A gene and died as a result of Dravet Syndrome. By the time the report was issued, Freddie had already sadly died and so of course the misdiagnosis had no consequences for him, but such a situation could have significant consequences for another child. ”

    Source location

    Freddie Oliver DOBINSON-EVANS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ensure effective ongoing communication between the paediatric neurology team and clinical scientists to clarify genetic test results.

    Verbatim wording from the response

    “6. I will ensure that myself and the paediatric neurology team members keep effective communication with the Clinical scientists shall there remain in clarities.”

    Source location

    2018-0078-Response-by-Barts-Health-NHS-Trust
    Page 2 · response
    Published 16 June 2018

    Open published response

  7. Inner South London

    AI-generated summary

    Rastislav Petrisko · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Rastislav Petrisko, who had a history of suicide attempts, drug and alcohol misuse, and mental health admissions, took a fatal overdose after being granted unescorted leave from a mental health ward. The concerns included an apparently unsuitable low-risk assessment, inappropriate unescorted leave, delayed notification of police when he failed to return, and differing approaches to risk assessment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of recorded drug-screening results on return from leave

    Wider context from the report

    “The responsible clinician (RC) assessed the patient as low risk on granting an hour’s unescorted leave in the local area from 13th. He said that he was not mentally unstable, which would trigger an escort. He was no longer expressing suicidal thoughts. The RC did not consider that Mr Petrisko was an immediate risk to himself, although the past medical history established a higher long term risk. He had already taken leave several times without self-harming (although unknown to the doctor he had returned drunk on 8th whilst in another unit). Although there was reference to recent or pending drug testing there was no record of the result of any drug screening on return from leave in this admission. A nurse indicated that being high risk made no difference to the likelihood of drug screening and the RC indicated that he may still be given leave if he was high risk. However a mental health nurse on the ward said that he was given leave as he was low risk. The risk assessments were guided by the statutory guidance of the Mental Health Act and were not subject to further local guidance. In retrospect the RC did not change his risk assessment. A missing persons form was completed by the ward. His risk was described as concern he would take large amount of drugs and alcohol, which would affect his mental state and that it was not out of character. In answer to the question whether he was likely to commit suicide, was written: “Was admitted with overdose cocaine and medication with suicidal intent”. The police were called at 21.56 and attended at 23.30, by which time emergency services were already in attendance to him in the car park, following a 999 call. As he was low risk the local policy on handling patients who had absconded at the time indicated that he could be given a period of grace before the police were notified, if he did not return at the allotted time. This was given as he had a history of being late back from leave. The ward notified the police 1 hour 49 minutes after he was due back, a period of time acknowledged to be too long. The policy in place made clear that a high risk patient should be reported immediately. The revised Trust policy continues that requirement, removes the period of grace but leaves it to the discretion of the clinicians when to call the police, if the patient is deemed not to be high risk. The DI from the Metropolitan Police Service indicated on reviewing the case, that he would be classed as medium risk, not low risk. High risk is an immediate risk to life, when a DI is deployed immediately to investigate and search. Medium Risk is that the risk to life is not immediate, but is a concern. An investigation and search is begun within the hour. Low risk is where there are no immediate concerns. The investigation may not begin straight away but take a few days. She further said that an immediate action would be to identify the places from which he had been admitted before. The medical records indicated that of the last three admissions he had been brought in from the Calderwood Street Car Park on two occasions (13.12.16 and 05.01.17). That was the site where he took the final fatal overdose. Thus if the police had been rung immediately, and assuming they took no action for the whole of the first hour, they would have had at least 49 minutes to find him in this site, which on the facts of the present case would enable an inference to be drawn that his life would have been saved. Thus the risk assessment by the police would seem to enable some deaths to be prevented, which would not necessarily on application of the assessment of the responsible physician, as immediate reporting only occurs if the patient is high risk. It is of concern that there are two different methods of assessing the risk when a vulnerable patient is granted leave, both in operation, one with greater potential of saving his life than the other. ”

    Source location

    Rastislav Petrisko · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. London (East)

    AI-generated summary

    Caliel Arlington SMITH-KWAMI · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Caliel Arlington Smith-Kwami suffered a profound hypoglycaemic episode around 28 hours after birth and later died on 17 August 2016 from persistent neonatal hyperinsulinaemic hypoglycaemia. He was discharged before key test results were obtained, and concerns included failures to notify clinicians that results were delayed or available, unclear responsibility for chasing results, and a missed opportunity to involve community midwives.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to chase outstanding test results before discharge

    Wider context from the report

    “(2)Test results do not appear to have been chased up before Caliel’s discharge from hospital. It was unclear from the evidence who had the responsibility for chasing up test results prior to discharge. ”

    Source location

    Caliel Arlington SMITH-KWAMI · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Lancashire and Blackburn with Darwen

    AI-generated summary

    Kristina CROSS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kristina Cross, aged 72, was admitted on 28 August 2016 after an unwitnessed fall and was later found to have a displaced fracture of the neck of the femur. The fracture was initially misdiagnosed, delaying surgical fixation; she subsequently suffered wound complications and joint dislocations, deteriorated after further surgery, and died on 20 November 2016. The principal concerns were unfilled consultant radiologist posts and delays, or failures, in reporting radiological investigations needed for diagnosis and clinical decision-making.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in reporting plain radiology within required timescales

    Wider context from the report

    “Evidence from the Lead Consultant Radiologist of the University Hospitals of Morecambe Bay NHS Foundation Trust was that whilst there was an initial misdiagnosis of the hip fracture there was a subsequent significant delay in reporting on plain radiology, due to a shortage of Consultant Radiologists. Furthermore evidence was heard that non-urgent plain radiology is not being reported at all unless specifically requested by clinicians. Evidence was heard that a quarter of positions within the Trust are currently unfilled. The Dalton Review of July 2014 identified that such is a national position, with comparatively low levels of radiologist training and retention with 41% of unfilled consultant radiological posts remaining unfilled for more than 12 months. In brief the concerns arising from the evidence are that a substantial number of consultant posts are unfilled, and that due to shortages of qualified radiologists, radiological investigations, crucial for diagnostic and clinical decision making purposes, are not reported on within the timescales set out within Professor Sir Bruce Keogh's report of 2013, or at all. ”

    Source location

    Kristina CROSS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Liverpool and the Wirral

    AI-generated summary

    Paul James Maddox · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Paul James Maddox was admitted to hospital with vomiting and subsequently developed severe internal bleeding after a fall in haemoglobin was not acted upon. He underwent emergency surgery after deteriorating, but died from massive gastrointestinal bleeding with disseminated intravascular coagulopathy. The principal concern was the missed opportunity to detect, investigate and treat the bleeding, with strategies to prevent recurrence still described as work in progress at the inquest.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to act upon a reducing trend in a haemoglobin result

    Wider context from the report

    “In spite of a Trust Root Cause Analysis Report identifying a missed opportunity before 13th April 2017 the court has been told at inquest that strategies to avoid a repeated failure were still work in progress. The missed opportunity was not acting upon a reducing trend in a haemoglobin result. This is simply not good enough as this issue should have been fixed during the Root Cause analysis investigation and before the report was approved as soon as the error became evident. During the course of the inquest evidence was heard from several doctors including a surgeon and it was suggested that “when there is a downward trend in haemoglobin of 10% or more the laboratory should always ring through the result as a potential surgical emergency for the urgent review of clinicians” The court brings this to the attention of the Trust and for confirmation as to when a solution to this problem has been implemented ”

    Source location

    Paul James Maddox · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Change the laboratory IT system and issue staff instructions on revised standard operating procedures for haemoglobin reporting.

    Verbatim wording from the response

    “• Changes to the lab IT system have been made and an action notice has been issued to all staff informing them of the agreed changes to our standard operating procedure around Hb reporting”

    Source location

    2017-0220-Response-by-Wirral-University-Teaching-Hospital
    Page 2 · response
    Published 24 September 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reduce the haemoglobin delta-check threshold from 25% to 20%.

    Verbatim wording from the response

    “• The delta check value for Hb has changed from 25% to 20%. There is currently no delta check in the Royal College guidance.”

    Source location

    2017-0220-Response-by-Wirral-University-Teaching-Hospital
    Page 2 · response
    Published 24 September 2017

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026