Recurring concern
Unreliable completion and tracking of requested clinical investigations
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Request correctionFirst reported 25 Feb 2014•Latest report 22 Aug 2025
What this concern includes
Includes failures of the dedicated process for initiating, conducting, recording, tracking or verifying requested clinical investigations, including investigations prompted by episodes of loss of consciousness, where the deficiency risks an investigation being missed or its completion being misunderstood.
Not included
- Excludes failures limited to interpretation, communication or clinical action after an investigation has been reliably completed unless the report also identifies a completion or tracking failure.
- Excludes investigation-result management concerns where the investigation was completed but its result was delayed, lost, misinterpreted or not acted upon.
- Excludes generic clinical record-keeping, staffing or documentation deficiencies that are not specifically tied to completion or tracking of requested clinical investigations.
- Excludes formal incident, complaint, police or inquest investigations that are not clinical investigations for patient care.
- Reports
- 9
- Individual concerns
- 11
- Date range
- 2014–2025
- Stated actions
- 7
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure of systems and documentation to identify whether requested investigations had been performed
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Implement the identified communication and documentation immediate safety actions in the Emergency Department under senior-doctor oversight.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Develop and implement a chest-pain standing operating procedure defining required clinical assessment and investigations in the Emergency Department.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Introduce a local Emergency Department quality-improvement initiative focused on communication and contemporaneous documentation.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure to complete D-dimer testing during pulmonary embolism investigation
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 concernsEach 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
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Action
Held cross-departmental discussions to review and optimise pulmonary embolism screening and triage systems across patient groups.
Stated by Milton Keynes University Hospital NHS Foundation Trust -
Action
Undertake an audit of pulmonary embolism pick-up rates against recorded Wells scores and D-dimer use, including appropriateness of scoring-system application.
Stated by Milton Keynes University Hospital NHS Foundation Trust -
Action
Trial and evaluate for six months a process escalating unapproved CTPA requests to the duty radiologist, with requester contact when further information or investigation is needed.
Stated by Milton Keynes University Hospital NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The Trust considers management reasonable and says earlier D-dimer or CTPA would not probably have changed the outcome.
Stated by Milton Keynes University Hospital NHS Foundation Trust
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Concerns raised1
Delays in CTA being performed
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of a pathway for investigating dysphagia caused by an oesophageal stricture
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 concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Developing clinical pathways for oesophageal stricture is outside NHS England and NHS Improvement’s role.
Stated by NHS England
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Concerns raised1
Failure to record blood-test requests, reasons and outstanding results
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Audit ED staff compliance with documentation requirements and repeat the audit monthly.
Stated by the Shrewsbury and Telford Hospital NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The alert facility existed; failure to complete it was attributed to human factors rather than a system failure.
Stated by the Shrewsbury and Telford Hospital NHS Trust
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Concerns raised1
Failure to ensure completion or handover and documentation of outstanding A & E investigations
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to ensure requested blood tests are taken and reported back to GP practices
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Inadequate documentation confirming completion and clinical review of requested investigations
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised3
Failure to fully investigate prisoners’ reported episodes of loss of consciousness
Failure to conduct NICE-compliant investigations of loss of consciousness
Failure to conduct clinical investigations of prisoners experiencing loss of consciousness
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026