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. 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 obtain repeat blood tests for clinical comparison

    Wider context from the report

    “(5) Mrs RAM-HENMAN only had one set of bloods done. At Inquest I was told that she should have had more bloods for comparison. These would undoubtedly have shown her deteriorating condition and would have acted as an additional reminder of the failings in her care. ”

    Source location

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

    Open source report

  2. Dorset

    AI-generated summary

    Rosemary Scott · 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

    Rosemary Scott suffered a fall, developed a chest flail segment and pneumonia, and died in hospital on 30 December 2017 after deterioration requiring respiratory support. Concerns included the absence of venous blood gas measurements and a reminder system, and insufficient availability of machines to provide the required positive end-expiratory pressure.

    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 reminder system for required venous blood gas measurements

    Wider context from the report

    “2. I have concerns with regard to the following: i. Due to the lack of a reminder system in relation to measuring venous blood gases it was not known whether the respiratory support being provided to Mrs Scott should have been escalated to a BiPAP or CPAP. I request that a review is undertaken to assess whether there should be a system installed to ensure the staff caring for patients where venous blood gases should have been measured are “reminded” of the need to do so. ii. The insufficient number of machines to provide PEEP to patients who require it. ”

    Source location

    Rosemary Scott · 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

    Existing handover and clinical monitoring systems are considered sufficient; a blanket venous blood gas reminder cannot accommodate individual clinical judgment.

    Verbatim wording from the response

    “I have been informed that it would be clearly indicated in the medical records that staff within the emergency department had been unable to access veins to gain venous gases. The decision, as to whether these would be clinically necessary would lie with the clinicians. As a patient’s condition changes, the clinical review of tests required can change. This is part of the individual clinician’s judgement and assessment of the patient.”

    Source location

    2018-0172-Response-by-Dorset-County-Hospital-NHS-Trust
    Page 1 · response
    Published 8 July 2018

    Open published response

  3. West Sussex

    AI-generated summary

    Dennis Allen Teesdale · 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

    Dennis Allen Teesdale underwent surgery including insertion of a PEG tube on 17 October 2016 and subsequently developed severe abdominal pain, multi-organ failure and septic shock. He was found to have peritonitis caused by leakage of bowel contents from the PEG tube passing through the bowel, and died on 20 October 2016. Concerns included the insertion and post-operative management of the PEG, delayed recognition and treatment of deterioration, delayed transfer, and limitations in specialist, diagnostic and laboratory services at Queen Victoria Hospital.

    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 timely on-site emergency laboratory testing and results

    Wider context from the report

    “12. There are no haematology or biochemistry services at QVH. A courier service is required for emergency laboratory tests. This has the potential to either not request ‘bloods’ and/or a delay in obtaining results. ”

    Source location

    Dennis Allen Teesdale · 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 existing laboratory network and urgent courier arrangements are considered sufficient, with no evidence they reduce blood-test requests or breach processing requirements.

    Verbatim wording from the response

    “Blood pathology services are provided by Princess Royal Hospital, Haywards Heath. There are seven routine transits of blood samples per day during the week, and four at weekends. If urgent blood results are required outside of these routine transits, an urgent courier service is available at any time, day or night, seven days per week. There is no evidence that this network arrangement impacts on the likelihood of requesting bloods. No concerns regarding this long standing arrangement have been raised by NHS England or the Care Quality Commission in their reviews. As part of the SLA with BSUH for blood pathology services, the Trust requires that urgent specimens can be received and processed at the lab ready for testing within one hour of leaving QVH. This is an essential pass/fail requirement.”

    Source location

    Dennis-Teesdale-Response-1
    Page 6 · response
    Published 28 July 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

    NHS Improvement, NHS England, and the Care Quality Commission, working with the Trust and commissioners, were responsible for ensuring appropriate action.

    Verbatim wording from the response

    “Finally, I am satisfied that the regulators are alert to the risks you have highlighted, and it is for NHS Improvement, NHS England and the Care Quality Commission, working with the Trust and its commissioners, to ensure sufficient and appropriate action is taken to address the concerns raised. My officials have asked to be kept informed of developments.”

    Source location

    2017-0202-Response-by-Department-of-Health
    Page 3 · response
    Published 28 July 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

    Pre-operative assessment considers suitability for surgery based on available facilities, while the laboratory agreement requires urgent specimens to be processed within one hour.

    Verbatim wording from the response

    “All patients having major surgery at QVH have an individual pre-operative assessment with a surgeon. This determines their suitability for surgery at the hospital, in view of the available on-site facilities. This is recorded in the patient record.”

    Source location

    2017-0202-Response-by-Care-Quality-Commission
    Page 10 · response
    Published 28 July 2017

    Open published response

  4. Black Country

    AI-generated summary

    Mr Vinod Kumar · 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

    Mr Vinod Kumar became seriously ill after developing flu-like symptoms and sustaining a graze to his right arm in a fall. He was diagnosed with sepsis secondary to necrotising fasciitis and died shortly after surgery on 10 August 2016. The concerns related to the initial emphasis on the fall, the lack of further observations or blood tests for about three hours, and whether he should have remained under observation before triage categorisation.

    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 observations and blood tests when potential infection is present

    Wider context from the report

    “1. Evidence emerged during the inquest that when he was seen initially by the Triage nurse, that too much emphasis and reliance was placed on the significance of the fall/trauma. Evidence of potential infection (swelling to his arms) resulted in no further observations or blood tests done until some three hours later. ”

    Source location

    Mr Vinod Kumar · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Carmarthenshire and Pembrokeshire

    AI-generated summary

    Cerith Wyn Pugh · 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

    Cerith Wyn Pugh underwent surgery for bowel obstruction in March 2013, experienced a cardiac arrest and further surgery, and had subsequent hospital readmissions. He died on 20 May 2014 after developing bleeding from his ileostomy; the inquest recorded multi-organ failure, ischaemic bowel disease, and cholelithiasis with mechanical jaundice. Concerns included consultant referrals being handled initially by middle grade doctors and liver function tests being declined because testing had been conducted less than three days earlier, without evidence of a mechanism to override that guidance when clinically appropriate.

    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 undertake requested liver function tests when clinically required

    Wider context from the report

    “That liver function tests were requested but the Health Board declined to undertake these for reasons of demand management on the basis that had been done some three days earlier. Expert evidence received at the inquest was highly critical of this practice. Whilst 72 hour testing is in accordance with guidance contained in guidance from the Association for Clinical Biochemistry and the Royal College of Pathologists both documents are clear that the guidance must be capable of being overridden if clinically appropriate. There was no evidence of any mechanism to override the guidance or, if such guidance existed, that it was known to staff. ”

    Source location

    Cerith Wyn Pugh · 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

    Remind medical staff to undertake clinically justified tests and discuss provider-declined investigations with the ordering consultant.

    Verbatim wording from the response

    “We have also reminded medical staff that where test requests are made on clinically justifiable grounds these should be undertaken regardless of guidance regarding repeating tests and in the event of an investigation being declined by a provider the matter must be discussed with the Consultant whose team has ordered the request.”

    Source location

    2016-0271-Response-by-University-health-Board
    Page 1 · response
    Published 27 July 2016

    Open published response

  6. Staffordshire South

    AI-generated summary

    Alan George Stead · 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

    Alan George Stead, a serving prisoner at HMP Dovegate, became ill late on 20 January 2016 and died shortly after arriving at hospital. The principal concern was delays in taking and testing prisoners’ blood samples at HMP Dovegate, which could have serious consequences in some cases.

    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 testing blood samples from prisoners

    Wider context from the report

    “(1) The medical review has identified delays with the taking and testing of blood samples from prisoners at HMP Dovegate. This was not something included in a recommendation in the PPO report but was expressed as a concern by the family at the Inquest. This could have serious consequences in some cases. I wonder if you have looked at this and have done or can do anything to improve the situation with this at HMP Dovegate and indeed at any other prisons where you provide healthcare if this is an issue. ”

    Source location

    Alan George Stead · 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

    Conduct required blood tests promptly, using same-day testing where possible and a short waiting list when same-day testing is unavailable.

    Verbatim wording from the response

    “On 14 December 2015 a programme was introduced at HMP Dovegate for all nurses and HCAs to be trained in phlebotomy. This programme was completed and all of the staff were deemed competent and signed off in March 2016. Now, blood tests are conducted as soon as required and on the same day whenever possible or if flagged urgent. If they are not performed on the day, patients are added onto a waiting list of a few days. Blood samples are sent to the hospital laboratory the day each afternoon.”

    Source location

    2016-0261-Response-by-Care-UK
    Page 2 · response
    Published 22 July 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

    Send blood samples to the hospital laboratory each afternoon on the day they are taken.

    Verbatim wording from the response

    “On 14 December 2015 a programme was introduced at HMP Dovegate for all nurses and HCAs to be trained in phlebotomy. This programme was completed and all of the staff were deemed competent and signed off in March 2016. Now, blood tests are conducted as soon as required and on the same day whenever possible or if flagged urgent. If they are not performed on the day, patients are added onto a waiting list of a few days. Blood samples are sent to the hospital laboratory the day each afternoon.”

    Source location

    2016-0261-Response-by-Care-UK
    Page 2 · response
    Published 22 July 2016

    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

    The delayed blood test would not have affected Mr Stead’s death or resulted in different treatment.

    Verbatim wording from the response

    “As noted by the independent clinical reviewer, this blood test would not have had an impact on Mr Stead’s death on 21 January and an earlier test would not have resulted in Mr Stead receiving any different treatment.”

    Source location

    2016-0261-Response-by-Care-UK
    Page 2 · response
    Published 22 July 2016

    Open published response

  7. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Mr Ronald Francis Bonfield · 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

    Mr Ronald Francis Bonfield sustained a head injury at home on 29 September 2014, was admitted to Prince Charles Hospital on 1 October, and died there on 2 October 2014. The inquest recorded that he was taking Warfarin, was over-anticoagulated, and that his INR levels were not being monitored as required. The substantive concerns related to inconsistent procedures for monitoring delegated INR testing and the risk of unmonitored over-anticoagulation.

    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

    Unmonitored over-anticoagulation following omitted delegated INR testing

    Wider context from the report

    “(3) Until such action is taken there remains a risk that a future death(s) could occur in similar circumstances to Mr Bonfield’s, where delegated INR testing has not been done leading to unmonitored over anti-coagulation ”

    Source location

    Mr Ronald Francis Bonfield · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Brighton and Hove

    AI-generated summary

    MR. ANTHONY GEERTS · 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

    Mr. Anthony Geerts sustained a fractured neck of femur, underwent surgery and was transferred for rehabilitation before being moved to a nursing home. He later returned to hospital with hospital-acquired pneumonia and a possible urinary tract infection, and died on 21 November 2014. The concerns included inadequate rehabilitation, incomplete records and monitoring, poor communication and discharge planning, and failures in managing his continence, fluid restriction and possible chest infection; the inquest concluded that neglect at Princess Royal Hospital contributed to his death.

    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 complete requested blood tests

    Wider context from the report

    “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly. In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for. His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as (a) There was insufficient physiotherapy staff to do so and (b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th. Neither Mr. GEERTS nor his family were involved in this decision. Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th. Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio. For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection. No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st. Specifically at Princess Royal Hospital: • Notes not completed. • No nursing notes and no NEWS for 10th or 11th • Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded. • No plan for physiotherapy • No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented. • No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented. • No referral of lack of urinary continence. Therefore no plan regarding this. • Failed Trial without catheter on 3rd November 2014. • Bowel monitoring chart not complete • Discharge planning non-existent or inadequate • Communication with patient and family virtually non-existent • No senior review from 4th November 2014; possibility of chest infection not followed up. • Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction. • Discharge lounge information incorrect. ”

    Source location

    MR. ANTHONY GEERTS · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. North Wales (East and Central)

    AI-generated summary

    Sally Ellison · 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

    Sally Ellison contracted legionella while on holiday in Tunisia in mid-May 2012 and died on 1 June 2012 from cardiac arrest, multi-organ failure and legionella pneumonia. Concerns were raised that testing for legionella was not undertaken until 31 May, with confirmation on 1 June, and that this may have delayed optimal treatment; the report also identified the need for earlier testing and a rapid testing and reporting service.

    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 expedite urgent blood test samples for laboratory analysis

    Wider context from the report

    “1. That urgent blood tests were requested By ████████ (GP) at lunchtime on the 28th of April 2012, yet, despite these being noted as urgent, the samples were not conveyed to the laboratory for analysis after collection by the district nurse, until a routine collection of samples was undertaken from Colwyn Bay Community Hospital later that afternoon. As a result the delay in an analysis meant that results were not provided to surgery until the following morning. Whilst the evidence indicates that changes have been made within the laboratory at Glan Clwyd to enable the immediate reporting of all cases where the CRP is greater than 300, there was no evidence available to confirm that all urgent tests could be expedited by district nurses thus alleviating potentially life threatening delays in treatment. ”

    Source location

    Sally Ellison · 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 primary-care urgent-sample requesting processes and prepare a memorandum covering sample labelling, transport and laboratory notification.

    Verbatim wording from the response

    “From this, you have requested that actions should be taken to prevent future deaths. Because of this, the Pathology Clinical Programme Group (CPG), and in particular the Governance section of the CPG, has reviewed the process for the requesting of urgent samples from primary care across BCUHB. This process has been explained in a memorandum ████████ that will be distributed electronically to all GPs and Practice Managers supported by BCUHB. The memorandum includes the correct process for the labeling of samples and its transportation to minimise delay. It also includes the relevant departmental telephone numbers for the laboratories across North Wales to ensure that the sample requester can warn the relevant department of the samples imminent arrival.”

    Source location

    2015-0163-Response-by-NHS-Wales
    Page 1 · response
    Published 27 April 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

    Distribute the urgent-sample process memorandum electronically to all BCUHB-supported GPs and practice managers.

    Verbatim wording from the response

    “From this, you have requested that actions should be taken to prevent future deaths. Because of this, the Pathology Clinical Programme Group (CPG), and in particular the Governance section of the CPG, has reviewed the process for the requesting of urgent samples from primary care across BCUHB. This process has been explained in a memorandum ████████ that will be distributed electronically to all GPs and Practice Managers supported by BCUHB. The memorandum includes the correct process for the labeling of samples and its transportation to minimise delay. It also includes the relevant departmental telephone numbers for the laboratories across North Wales to ensure that the sample requester can warn the relevant department of the samples imminent arrival.”

    Source location

    2015-0163-Response-by-NHS-Wales
    Page 1 · response
    Published 27 April 2015

    Open published response

  10. London (East)

    AI-generated summary

    Mrs Awa Jeng · 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 Awa Jeng was admitted after a fall that caused a fractured left hip and underwent surgery. She subsequently required dialysis but was not adequately monitored on the ward, and tests were delayed until her potassium was at a life-threatening level. She deteriorated, suffered cardiac arrest during intubation, and could not be resuscitated; the inquest concluded that inadequate monitoring and delayed haemofiltration contributed to her death.

    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 repeating arterial blood gas tests

    Wider context from the report

    “2. The ITU consultant gave a clear direction to the FY2 on Tayberry Ward during the afternoon of the 19th December 2013 that the arterial blood gases should be repeated that evening and she should be checked for signs of pulmonary oedema and fluid overload. ”

    Source location

    Mrs Awa Jeng · 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 to repeat blood tests within the required timeframe

    Wider context from the report

    “3. The blood tests were not repeated until the following morning when they had deteriorated to a life threatening level. 4. It was not clear from the evidence why the blood tests were not repeated. The FY2 did write a retrospective note confirming that she had asked the on-call doctor to perform the test. Evidence from the on-call doctor denied that this information was passed on to her. ”

    Source location

    Mrs Awa Jeng · Prevention of Future Deaths report
    Page 2 · 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