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. Manchester South

    AI-generated summary

    Rachal Marie Murphy · 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

    Rachal Marie Murphy died at home on 8 September 2015 after taking medication prescribed to other family members; the medical cause of death was recorded as acute hypoxia due to morphine overdose, and the conclusion was that she had taken her own life. The report identified concerns about fragmented inter-agency care, failures and delays in referrals and investigations, overlooked CAF documentation, and delays in Early Help case allocation.

    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 EEGs

    Wider context from the report

    “3. There was as significant delay in the reporting of Rachals EEG and the Court heard that this remained the case in respect of reporting of EEGs at the time of the Inquest. ”

    Source location

    Rachal Marie Murphy · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    The Trust cannot control reporting times or delivery of specialist EEG results performed exclusively by another NHS Trust.

    Verbatim wording from the response

    “As indicated to you, in a letter from our solicitors dated 30 August 2016, 24 and 72 hour EEGs are performed and reported exclusively by Manchester Children’s Hospital (operated by Central Manchester University Hospitals NHS Trust). Whilst the Trust can chase up the results, they are not in control of the timeframes for reporting and delivery of EEG results, although given their specialist nature a period of analysis is expected. A patient’s care is also not affected whilst awaiting the EEG result.”

    Source location

    2016-0401-Responses
    Page 7 · response
    Published 19 February 2017

    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

    Responsibility for action on delayed EEG reporting should be directed to the organisation controlling specialist EEG reporting and results delivery.

    Verbatim wording from the response

    “As indicated to you, in a letter from our solicitors dated 30 August 2016, 24 and 72 hour EEGs are performed and reported exclusively by Manchester Children’s Hospital (operated by Central Manchester University Hospitals NHS Trust). Whilst the Trust can chase up the results, they are not in control of the timeframes for reporting and delivery of EEG results, although given their specialist nature a period of analysis is expected. A patient’s care is also not affected whilst awaiting the EEG result.”

    Source location

    2016-0401-Responses
    Page 7 · response
    Published 19 February 2017

    Open published response

  2. Manchester West

    AI-generated summary

    Karen Ann Thorne · 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

    Karen Ann Thorne died at Salford Royal Hospital on 13 June 2016 following complications associated with Natalizumab treatment for Multiple Sclerosis and subsequent Plasma Exchange treatment for Progressive Multifocal Leukoencephalopathy. PML identified on scans in May and October 2015 was not reported or diagnosed until February 2016, with delays in reporting and treatment adversely affecting her response and prognosis. The report raised concerns about delays in neuroradiology reporting and the national shortage of Radiologists and training positions.

    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 neuroradiology and radiology

    Wider context from the report

    “1. During the Inquest evidence was heard that:- i. There are delays in reporting neuroradiology within the Salford Royal NHS Foundation Trust and at the present time the longest wait is 60 days, which is a slight improvement from the end of 2015 when the Scan conducted on the Deceased was not reported for 65 days but a delay of 60 days is still unacceptable. ii. There is an increasing demand for neuroradiology, and radiology in general, and there is a national shortage of Radiologists. iii. The delay in reporting radiology is of greater concern in cases where a patient is receiving treatment on a regular basis, namely every 28 days in the case of the Deceased, and the Scans are not reported for a period in excess of 60 working days, during which time the Deceased received 2 or 3 additional Natalizumab infusions, which would have been stopped had the Scan been reported and identified PML before the next infusion. iv. Evidence was given at the Inquest, on the basis of information received from the Royal College of Radiologists, that the national shortage of Radiologists was due to the fact that there are a fixed number of training positions for Radiologists each year and the number is insufficient to produce the number of Radiologists required to give an appropriate service and to report radiology within a reasonable, necessary and expected time period. The information referred to the fact that there was no shortage of clinicians prepared to train as Radiologists and that there were more applicants than training positions. The evidence given to the Inquest was that an increase in the number of training positions would increase the number of Radiologists to address the national shortage of Radiologists, which is creating the delays in reporting radiology and delays in the diagnosis of conditions requiring either immediate treatment or the cessation of treatment with recognised complications. 2. I request you to consider the above concerns in relation to a national shortage of Radiologists and to review the number of training positions to address the national shortage of Radiologists and to address delays in the reporting of radiology and the diagnosis of disease, either requiring treatment or the cessation of treatment. ”

    Source location

    Karen Ann Thorne · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Norman Arthur BEARD · 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

    Norman Arthur BEARD suffered a fall, was admitted to hospital, and later transferred to Daisy Bank Nursing Home, where he developed serious pressure sores, dehydration and significant weight loss. He died at Abbey Court Nursing Home on 14 February 2015. Concerns included delayed referral and inadequate treatment of pressure sores, shortages of staff and essential supplies, incomplete care records, inadequate response to weight loss and minimal GP involvement.

    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 follow up abnormal blood test results

    Wider context from the report

    “(7) The involvement of the GP was minimal and there was no follow up when blood tests revealed an abnormality. ”

    Source location

    Norman Arthur BEARD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Inner North London

    AI-generated summary

    Ana Geanina SIRGHI-MARIN · 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

    Ana Geanina Sirghi-Marin died on 29 July 2016 from Escherichia coli sepsis associated with a naturally occurring uterine infection while sixteen weeks pregnant, after undergoing amniocentesis. The principal concern was that unusually dark yellow, non-blood-stained amniotic fluid was not sent for immediate microbiological analysis and promptly followed up, despite the absence of fever or another infection indicator at the time.

    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 promptly follow up microbiological results from unusually discoloured amniotic fluid

    Wider context from the report

    “The amniotic fluid drawn off at amniocentesis two days before death was neither purulent nor blood stained, but was discoloured dark yellow. Given the rarity of such non blood stained discolouration, I heard evidence that it would be a wise precaution in this situation always to send a sample for immediate microbiological analysis, and quickly to follow up the result. I say always because, at the time of the amniocentesis, there was no fever or other indicator of infection, yet when Ms Sirghi-Marin presented at the emergency unit the following afternoon she was very unwell, and she died the next morning. Such action would not have changed the outcome in this instance, because presentation to the emergency unit took place approximately 26 hours after the amniocentesis. However, it might in another case. And given the rarity of such non blood stained discoloured amniotic fluid, a guideline that this action is necessary does not seem onerous. ”

    Source location

    Ana Geanina SIRGHI-MARIN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Surrey

    AI-generated summary

    Rhi anne Anoushka Florence BARTON · 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

    Rhi anne Barton developed severe abdominal pain and vomiting at 35 weeks of pregnancy after previous bariatric surgery and was later found to have a small bowel obstruction. She aspirated during induction of anaesthesia before surgery, developed severe physiological compromise and died in the early hours of 13 February 2015. The principal concerns included delays in investigation, diagnosis and surgical management, lack of consultant supervision, inadequate documentation and fluid monitoring, and insufficient consideration of surgical causes associated with previous bariatric surgery.

    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 on markedly abnormal urine glucose findings

    Wider context from the report

    “4. Evidence was presented of poor documentation of routine observations and an incomplete fluid balance chart. No accurate records were kept with regard to fluid intake and urine output. It was not possible to assess the amount, frequency and volume of the vomitus. There was no evidence of diarrhoea despite a diagnosis of gastroenteritis. A urine dipstick was undertaken which revealed 4+ of glucose but no action was undertaken with regard to the finding. ”

    Source location

    Rhi anne Anoushka Florence BARTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester South

    AI-generated summary

    Antony Edmund Briggs · 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

    Antony Edmund Briggs developed a very aggressive bladder tumour, with delays in treatment; the inquest recorded natural causes and a medical cause involving pulmonary embolism, deep venous thrombosis, immobility and pelvic obstruction due to bladder carcinoma, with ischaemic heart disease. Concerns included differences between the Buxton and Stepping Hill information systems, failure of information to be acted on, and the infiltrating adenocarcinoma not being identified as soon as it could have been.

    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 make Buxton urology test results viewable at Stepping Hill

    Wider context from the report

    “1. The “system” which operates at Buxton is different from that at Stepping Hill Hospital, and therefore he cannot look at the test results on his screen at Stepping Hill. 2. The urologists see patients at Stockport, Tameside, Macclesfield and Buxton. At all of these locations, the data can be input so as to be viewable at Stepping Hill, save and except for Buxton. 3. When the Urologist’s view is not available on screen at Stepping Hill, it should, apparently, fail to the Local GP's in Buxton to act on the information, but they either cannot or do not, thus the patient falls into a lacuna and no action is pursued. This is always of importance, but especially so with a very aggressive malignancy. ”

    Source location

    Antony Edmund Briggs · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Brighton and Hove

    AI-generated summary

    Geoffrey John MOYSE · 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

    Geoffrey John MOYSE’s death was the subject of an inquest that concluded with a finding of Medical Misadventure. The report raised concerns about an eight-month delay in referral, poor communication between providers, and failures to transfer investigation results into the NHS system, leaving him unwell, undiagnosed and untreated for too long.

    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 transmit private-sector diagnostic results into the local NHS system

    Wider context from the report

    “(1) Please see the attached letter dated the 19th December 2014 which explains the system which was put in place by the CCG. Please refer to Part 3 of the attached Record of Inquest to learn what happened in Mr Moyse’s case. It is clear to me from the evidence I heard at the Inquest that there was a huge delay in referring him (its right to say that some of that delay was due to Mr Moyse being unable to help speed the process up). Nonetheless, it took eight months from referral to seeing the appropriate Surgeon and I should imagine a referral direct to Digestive Diseases would have been substantially quicker than that. There was no understanding it seems by the people involved in the arrangements that it was probably possible to try and short circuit them. For example, why did the Consultant Gastroenterologist not contact the colorectal clinic himself or even copy his letter and his histology report sent to the GP on the 29th June 2015? Why did BICS, who were sent a copy of the histology report, not forward this to anyone else e.g. the colo-rectal clinic to see whether it would produce the urgent result which the GP was seeking to achieve? Could the GP have done a two week referral at the very beginning? Would that have come within Code 2 on the letter of the 19th December 2015? If he had, perhaps the whole system would have worked. One of the problems in existence appears to be that because the initiative involves private hospitals, some private hospitals will use their own histo-pathologists to analyse results of procedures such as colonoscopies instead of using the National Health laboratories. This means that the results do not automatically feed in to the local NHS system. Surely it would be possible to insist that all x-ray results, MRI scans, CT scans, histopathology reports etc. etc. which arise in this way as part of an NHS initiative involving the private sector must be transmitted back into the NHS system at the earliest possible opportunity. It just seems to me that this system broke down because these processes seem to work with any reference to a joined up approach and the person who suffers is the patient. In this case I was eventually satisfied that this did not adversely affect the outcome with Mr Moyse but certainly it meant that the whole process for him was hugely delayed and he was left unwell, undiagnosed and untreated for far, far too long. I would like to see a complete review of this process and I am sure that Mrs Moyse would be happy, suitably anonymised, if Mr Moyse’s case could be used to ensure that this does not happen again to another patient where this delay might have been fatal on its own. ”

    Source location

    Geoffrey John MOYSE · 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

    Maintain service specifications for independent providers covering onward referrals, results tracking and relevant best practice.

    Verbatim wording from the response

    “In your report you highlighted a possible disconnect between independent sector hospitals and NHS provision relating to results of investigations and questioned whether they are routinely made available to clinicians within NHS provision. The CCG currently has service specifications in place with all independent sector providers which cover commissioners’ expectations regarding onwards referrals, tracking results and highlight best practice and national guidelines.”

    Source location

    Moyse-Response
    Page 5 · response
    Published 19 February 2016

    Open published response

  8. South Yorkshire (Eastern)

    AI-generated summary

    Marc Jason Stephen Poole · 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

    Marc Jason Stephen Poole, aged 6, was admitted to hospital on 16 May 2015 with suspected infection and died in Sheffield Children’s Hospital on 18 May 2015 from the effects of pneumococcal septicaemia. The report identified concerns about delayed antibiotic treatment, poor communication, inaccurate observation and warning-score recording, inadequate paediatric sepsis guidance, dissemination of medical information, and poor record keeping.

    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 communicating microbiology results to staff responsible for assessment

    Wider context from the report

    “(1) Poor communication on a number of levels Insufficient discussion with the parents regarding history, insufficient weight attached to the information they did provide at the time of admission and subsequently. Absence of any protocols of guidance as to how best to communicate with children with disabilities such as autism as MJ had. Communications between staff were poor, HCAs to nurses, nurses to doctors and between junior doctors and senior doctors. Ineffective communication of microbiology results which had been phoned through to the ward but not immediately passed on to those who needed to undertake assessment. ”

    Source location

    Marc Jason Stephen Poole · 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

    Require clinical handovers to access microbiology results through ICE and document outstanding results for follow-up and action.

    Verbatim wording from the response

    “With respect to ineffective communication of microbiology results, the team has considered the issue of outstanding test results and confirmed that during clinical handovers the results should be accessed through ICE. Any outstanding matters will form part of the documentation in the handover process in order to confirm that they are followed up and acted upon. In respect of receipt of urgent blood results from the laboratory via telephone, staff have been made aware that it is the responsibility of the individual taking the call to record the results on the IPOC and to verbally share the results with the medical staff as well as date, time and sign the entry and record the member of medical staff that the results have been shared with.”

    Source location

    Marc-Poole-Response
    Page 2 · response
    Published 2 February 2016

    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

    Require staff receiving urgent blood results by telephone to record, sign, date, time and verbally communicate them to medical staff.

    Verbatim wording from the response

    “With respect to ineffective communication of microbiology results, the team has considered the issue of outstanding test results and confirmed that during clinical handovers the results should be accessed through ICE. Any outstanding matters will form part of the documentation in the handover process in order to confirm that they are followed up and acted upon. In respect of receipt of urgent blood results from the laboratory via telephone, staff have been made aware that it is the responsibility of the individual taking the call to record the results on the IPOC and to verbally share the results with the medical staff as well as date, time and sign the entry and record the member of medical staff that the results have been shared with.”

    Source location

    Marc-Poole-Response
    Page 2 · response
    Published 2 February 2016

    Open published response

  9. Newcastle upon Tyne

    AI-generated summary

    Patrick Joseph Carrick · 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

    Patrick Joseph Carrick underwent laparoscopic high anterior resection for colorectal cancer on 23 January 2012 and subsequently deteriorated, later dying from a rare but recognised complication of the surgery. Concerns included a significant unexplained departure from his management plan during rapid deterioration, failure to action blood analysis results, inadequate monitoring, delays in administering antibiotics, and inadequate completion of nursing and medical notes.

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    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 action crucial blood analysis results

    Wider context from the report

    “(1) There was a significant departure from a patients management plan without explanation (2) The above was compounded as it occurred in a period of rapid deterioration (3) Crucial blood analysis results were not actioned (4) Inadequate completion of nursing and medical notes ”

    Source location

    Patrick Joseph Carrick · 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

    Use blood-result sheets in patient notes to record individual results and trends.

    Verbatim wording from the response

    “"Actioning" of bloods on ICE requires that an action button is pressed on the ICE system for each blood result. This presents a conscious statement from the member of the medical team that they have viewed, interpreted and where clinically necessary, actioned the blood results. The key to the "actioning" of results is interpretation and integration into the patient's management plan and the following initiatives have or are being implemented to ensure that this continues to happen in a safe, consistent and effective manner:”

    Source location

    2015-0374-Response-by-Northumbria-Health-Care-NHS-Trust
    Page 2 · response
    Published 9 October 2015

    Open published response

  10. Cardiff and the Vale of Glamorgan

    AI-generated summary

    Geoffrey Parry · 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

    Geoffrey Parry underwent major surgery for aggressive bladder cancer on 1 May 2015, developed infection and pneumonia, and died on 29 June 2015. Concerns included an ECG result being unavailable to anaesthetists before surgery and an unlabelled intravenous noradrenaline line becoming disconnected in intensive care, causing a significant drop in blood pressure and the need for cardiopulmonary resuscitation.

    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 keep investigative test and scan results with patients' medical notes

    Wider context from the report

    “During the evidence it transpired that an ECG test which was undertaken on 21st April 2015 was not available to the reviewing consultant anaesthetists prior to surgery. The evidence suggested that there was a problem within the hospital, not specific to ECG tests whereby results from investigative tests and scans are not kept with the patient's medical notes. In this instance, it appeared that there was a facility for the result of the ECG to be electronically uploaded onto the hospital computer system but this had not happened. The evidence at the hearing suggested that this was not an uncommon problem. In this case the unavailability of the scan was not in any way causative of Mr Parry's death but could have been. ”

    Source location

    Geoffrey Parry · Prevention of Future Deaths report
    Page 1 · 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

    Review systems and processes for storing ECG investigations.

    Verbatim wording from the response

    “• An ECG test undertaken on 21 April 2015 was not available to the reviewing consultant anaesthetist prior to surgery. The evidence suggested that there was a problem within the hospital, not specific to ECG tests whereby results from investigative tests and scans are not kept with the patient’s medical notes. In this instance, it appeared that there was a facility for the result of the ECG to be electronically uploaded onto the hospital computer system but this had not happened.”

    Source location

    2015-0400-Response-by-University-Health-Board
    Page 1 · response
    Published 7 October 2015

    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

    Review ECG machines for MUSE connectivity and improved patient identification.

    Verbatim wording from the response

    “In order to strengthen use of the MUSE system across the Health Board a number of actions are planned. An improvement plan to support this is in development and will address numerous areas including:”

    Source location

    2015-0400-Response-by-University-Health-Board
    Page 2 · response
    Published 7 October 2015

    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

    Review MUSE usage and supporting infrastructure capacity for increased ECG activity.

    Verbatim wording from the response

    “In order to strengthen use of the MUSE system across the Health Board a number of actions are planned. An improvement plan to support this is in development and will address numerous areas including:”

    Source location

    2015-0400-Response-by-University-Health-Board
    Page 2 · response
    Published 7 October 2015

    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