First reported 18 Oct 2013•Latest report 12 Nov 2025
Definition
What this concern includes
Includes failures to assess surgical suitability, comorbidity, operative risk or the need for preoperative investigation or optimisation.
Not included
Excludes generic medication prescribing, monitoring or supply failures not directly part of preoperative surgical assessment or consent.
Excludes standalone VTE, anticoagulation or diagnostic-testing failures when they are not tied to a preoperative surgical decision or consent process.
Excludes postoperative care, discharge planning and treatment-selection failures outside the preoperative assessment and consent process.
Excludes generic staffing, communication, documentation or training deficiencies unless the source explicitly connects them to the safety of preoperative assessment or consent.
Reports
13
Distinct published reports
Individual concerns
17
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
9
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care4
St Peter's Hospital2
Barts Health NHS Trust1
British Society For Dermatological Surgery1
Care Quality Commission1
East Kent Hospitals University NHS Foundation Trust1
Goring Hall Hospital1
NHS Blood and Transplant1
NHS Surrey and Sussex Integrated Care Board1
Regenesis Health Travel Ltd1
Royal College of Anaesthetists1
Royal College of Surgeons of England1
Royal London Hospital1
Sandwell and West Birmingham Hospitals NHS Trust1
Stepping Hill Hospital1
Healthcare site4
Ministerial department4
NHS trust4
Registered charity2
Health and social care service regulator1
Health professional body1
Independent healthcare provider1
Integrated care board1
Multi-service care provider1
Private limited company1
Special health authority1
Type not available1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Inner West London
Concerns raised1
Failure to review relevant blood tests before surgery and incorporate them into surgical risk assessment and consent
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Include hypoalbuminaemia in peri-operative transplant assessment and suspend affected patients until investigations and stability support reactivation.
Stated by St George’s, Epsom and St Helier University Hospitals and Health GroupStated plannedThe respondent said that this action was planned when they made their response on 14 November 2025.
Action
Review acute and historic investigations and incorporate results into transplant risk-benefit analysis and consent.
Stated by St George’s, Epsom and St Helier University Hospitals and Health GroupStated completedThe respondent said that this action was complete when they made their response on 14 November 2025.
Action
Implement a revised transplant-offer pathway requiring base-hospital nephrology contact, recent blood-test review, communication checkpoints, and regular audit.
Stated by St George’s, Epsom and St Helier University Hospitals and Health GroupStated completedThe respondent said that this action was complete when they made their response on 14 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Relevant blood tests were reviewed, and hypoalbuminaemia was not considered an absolute contraindication to transplantation under applicable guidelines.
Stated by St George’s, Epsom and St Helier University Hospitals and Health GroupDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
West Sussex, Brighton and Hove
Concerns raised1
Failure to assess whether patients are fit for operative procedures at the hospital
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Implement a Communication Improvement Plan, including a referral risk assessment checklist for selecting appropriate secondary providers.
Stated by Sussex Medical ChambersStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Failures by individual clinicians fall outside prosecutorial remit because prosecutorial powers extend only to registered providers or registered managers.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Rutland and North Leicestershire
Concerns raised1
Failure to establish fitness for surgery before operating
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Sussex, Brighton and Hove
Concerns raised3
Insufficiently robust guidance on maintaining anti-thrombotic medication before dermatological excision
Failure to conduct preoperative assessment before dermatological surgery
Failure to undertake risk-benefit analysis for surgery during anti-thrombotic treatment
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Integrate any amended British Society of Dermatological Surgery guidance on anticoagulants into service policy.
Stated by Sussex Community Dermatology ServiceStated plannedThe respondent said that this action was planned when they made their response on 29 July 2024.
Action
Implement documented preoperative assessments to identify risks of complications from skin surgery.
Stated by Sussex Community Dermatology ServiceStated plannedThe respondent said that this action was planned when they made their response on 29 July 2024.
Action
Provide advanced consent and schedule procedures to allow appropriate adjustment of anticoagulation.
Stated by Sussex Community Dermatology ServiceStated plannedThe respondent said that this action was planned when they made their response on 29 July 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Responsibility for responding to the concern about BSDS guidance rests with BSDS; SCDS will await any revised guidance.
Stated by Sussex Community Dermatology ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The guidelines are not intended for community surgery, where other guidance may be more appropriate and hospital facilities and expertise differ.
Stated by British Society For Dermatological SurgeryDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
There is no known dermatological surgery evidence that the condition of excised skin affects bleeding risk or should be included in the guideline.
Stated by British Society For Dermatological SurgeryDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The existing antithrombotic and skin-surgery guidelines are considered sufficiently robust as drafted, based on clinical expertise and published evidence.
Stated by British Society For Dermatological SurgeryExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Norfolk
Concerns raised2
Failure to ensure preoperative review by a surgeon
Limited preoperative psychological and physical assessment
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Cheshire
Concerns raised1
Failure to independently assess patient fitness before arranging surgery
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Surrey
Concerns raised1
Failure to complete requested pre-operative echocardiographic assessment for pulmonary hypertension or Cor Pulmonale
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Establish four protected consultant-led high-risk anaesthetic pre-assessment clinics weekly, including specialist orthopaedic expertise, dedicated rooms and appropriate medical equipment.
Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 May 2022.
East London
Concerns raised1
Lack of a formal preoperative risk assessment tool requirement
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised1
Lack of routine screening for Strongyloides stercoralis forms before transplant surgery
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Write to SaBTO about the case and request a clear position on donor screening.
Stated by NHS Blood and Transplant and The British Transplantation SocietyStated plannedThe respondent said that this action was planned when they made their response on 23 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Local transplant hospitals and organisations are responsible for setting recipient screening policies under local protocols.
Stated by NHS Blood and Transplant and The British Transplantation SocietyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Black Country
Concerns raised2
Failure to highlight patients as high risk before major surgery
Inadequate consent discussions about major-surgery risks
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures to assess surgical suitability, comorbidity, operative risk or the need for preoperative investigation or optimisation.
