Recurring concern

Failure to provide timely clinically required blood tests

First to latest report 25 Jul 2014 — 7 Feb 2026

Reports that mention this concern
22
Times this concern has been raised
23
Stated actions linked to this concern
16

What this concern includes

Includes failures to arrange, collect, process or complete clinically required blood tests promptly, including delays occurring overnight, in emergency care or in prison healthcare, where the blood-testing delay can impair diagnosis, monitoring or treatment.

What is not included
  • Excludes non-blood diagnostic investigations, such as ECGs, imaging or urine tests, unless the assertion also specifically identifies a deficient blood-testing control.
  • Excludes failures to communicate or act on blood-test results when the blood test itself was completed and made available on time.
  • Excludes generic laboratory, staffing or communication deficiencies unless they directly cause delayed, omitted or unavailable clinically required blood tests.
  • Excludes routine blood tests where no clinically required timeframe or safety consequence is identified.

Reports and published responses 22 reports

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

  1. Manchester West

    AI-generated summary

    Patricia Edge · 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

    Patricia Edge died at Royal Bolton Hospital on 20 July 2014 after bowel cancer, bowel obstruction and ischaemic bowel, with paracetamol liver toxicity also identified in the inquest conclusion. An excessive dose of paracetamol was prescribed and dispensed between 14 and 19 July 2014, and the report raised concerns about prescribing and dispensing procedures, review of the dose, and the absence of blood tests.

    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 carry out blood tests to identify excessive paracetamol dosing

    Wider context from the report

    “(3) The apparent failure to carry out blood tests between 14ᵗʰ and 19ᵗʰ July, which would have revealed/confirmed the possibility of the dose of paracetamol being excessive, again considering issues of training and procedures. ”

    Source location

    Patricia Edge · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Sunderland

    AI-generated summary

    Nathan James Healer · 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

    Nathan James Healer was born on 03/02/2014 and died on 05/02/2014 after developing signs including low temperature, poor feeding and jittering arms. His first blood glucose measurement, taken almost five hours after birth, was 0.2 mmol/L. The principal concern was that the severity of his condition was not appreciated and he was not given a more timely blood glucose test, in the context of existing clinical guidance.

    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 provide timely blood glucose testing for newborns

    Wider context from the report

    “I was made aware of :- a) the 2008 NICE Clinical Guidance 63 “Diabetes in Pregnancy” which in essence recommended a pre 2nd Feed Blood Glucose test at between 2-4 hours; b) the hospital Guidance for “Hypothermia in the newborn Infant” 2014; c) the hospital Guidance for “Prevention, detection and management of hypoglycaemia in the newborn 2012 (Blood glucose test at around 4 hours). Although the severity of Nathans’s condition was not appreciated and he was not given the opportunity of a more timely blood glucose test I heard evidence that although new guidance from NICE is in contemplation it has not yet been finalised. If that is the case then it would be helpful to know what stage this is at and whether any steps can be taken to expedite it’s production. If no new guidance is in contemplation then it may be an opportune moment to revisit the guidance in any event. ”

    Source location

    Nathan James Healer · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

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