Recurring concern
Unreliable recognition and management of pulmonary embolism
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Request correctionFirst reported 24 Feb 2016•Latest report 15 Sep 2025
What this concern includes
Includes failures in the dedicated pulmonary-embolism process, including application of PE assessment policies, interpretation of clinical scores and symptoms, recognition of suspected PE, investigation, escalation and treatment decisions where these directly concern pulmonary embolism.
Not included
- Excludes venous-thromboembolism prevention or thromboprophylaxis failures where pulmonary-embolism recognition or management is not the deficient control.
- Excludes generic diagnostic, training, communication or documentation deficiencies unless they directly impair recognition or management of pulmonary embolism.
- Excludes treatment or follow-up failures after pulmonary embolism has been reliably recognised and managed, unless the asserted deficiency remains part of the PE management process.
- Excludes other causes of chest pain, breathlessness or clinical deterioration where pulmonary embolism is not a material part of the asserted concern.
- Reports
- 9
- Individual concerns
- 11
- Date range
- 2016–2025
- Stated actions
- 19
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 to recognise that a low Wells score does not exclude DVT or PE
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.2
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Action
Develop an e-learning module highlighting correct interpretation of the DVT Wells score.
Stated by Royal College of General Practitioners -
Action
Promote the e-learning module through the members’ network and the Chair’s blog.
Stated by Royal College of General Practitioners
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Concerns raised2
Failure to apply an evidence-based pulmonary embolism diagnostic pathway
Failure to use or document structured pulmonary embolism risk assessments
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.
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.4
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Action
Provide Ardens templates integrated with SystmOne to support structured Wells pulmonary embolism assessment, risk stratification and escalation.
Stated by Milton Keynes Urgent Care Services (MKUCS -
Action
Deliver clinician information sharing and case-based training on Wells PE, Ardens templates, clinical context and NICE-aligned use of decision tools.
Stated by Milton Keynes Urgent Care Services (MKUCS -
Action
Audit and provide feedback on clinicians’ application of Wells PE and related clinical decision tools.
Stated by Milton Keynes Urgent Care Services (MKUCS
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Action
Conduct regular audits of NEWS2, POPS, risk assessments and decision tools, with monthly KPI reporting and quarterly commissioner review.
Stated by Milton Keynes Urgent Care Services (MKUCS
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Ardens templates in SystmOne and Wells PE risk assessment are considered sufficient to provide structured pulmonary embolism assessment and escalation.
Stated by Milton Keynes Urgent Care Services (MKUCS
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Position
PERC is considered inappropriate for primary care because it is not validated in that setting; Wells scoring is preferred for suspected pulmonary embolism.
Stated by Milton Keynes Urgent Care Services (MKUCS
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Concerns raised1
Failure to investigate suspected pulmonary embolism in accordance with NICE guidance
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.2
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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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Position
The Trust considers its current CTPA screening approach broadly appropriate and balanced against investigation risks.
Stated by Milton Keynes University Hospital NHS Foundation Trust
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Concerns raised1
Failure to establish whether VQ or CTPA is the appropriate scan modality for suspected pulmonary embolism
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
Complete and approve a focused After-Action Review of the decision to discharge despite raised troponin and d-dimer results.
Stated by Bolton NHS Foundation Trust -
Action
Complete and approve an addendum addressing further investigations and the lack of observations before discharge.
Stated by Bolton NHS Foundation Trust -
Action
Share learning about considering CTPA instead of VQ scans for suspected pulmonary embolism with Radiology through governance processes.
Stated by Bolton NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Replacing V/Q scans with CTPA scans for all suspected pulmonary embolism patients was considered inappropriate because it departed from national guidance.
Stated by Bolton NHS Foundation Trust
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Position
The established PE referral pathway and radiologist-led modality selection were considered sufficient; clinician-radiologist discussion is required only when departing from protocol or guidance.
Stated by Bolton NHS Foundation Trust
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Concerns raised1
Failure to apply the PE policy in accordance with its specific wording
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
Failure to perform a point-of-care ultrasound scan to exclude intra-abdominal bleeding when pulmonary embolism is suspected
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.
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.4
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Action
Emphasise ultrasound use during advanced life support to identify reversible causes, including haemorrhage, across cardiac-arrest guidance.
Stated by Resuscitation Council UK -
Action
Include pregnancy-specific guidance to identify and treat reversible causes, with focused ultrasound available for skilled operators.
Stated by Resuscitation Council UK -
Action
Include guidance on abdominal ultrasound and massive-haemorrhage protocols for suspected haemorrhage during pregnancy-related cardiac arrest.
Stated by Resuscitation Council UK
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Action
Discuss with emergency-medicine and radiology educators the need to check for intra-abdominal bleeding before anticoagulating a collapsed patient.
Stated by Royal College of Obstetricians and Gynaecologists
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Existing RCUK guidance and teaching materials already address ultrasound use and reversible causes, including haemorrhage, during cardiac arrest in pregnancy.
Stated by Resuscitation Council UK
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Position
Universal ultrasound requirements are limited because skilled operators and equipment may be unavailable and ultrasound could delay time-critical treatment.
Stated by Resuscitation Council UK
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Concerns raised1
Failure to correctly diagnose pulmonary embolism
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.
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Concerns raised1
Delays in medical assessment of patients with classical DVT/PE symptoms
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.
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
Provide consultant-led senior assessment in the START emergency assessment hub during its operating hours.
Stated by Barnsley Hospital NHS Foundation Trust
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Concerns raised2
Failure to recognise and accurately record an abnormal ECG indicating a potential pulmonary embolism
Failure to undertake further diagnostic testing for a possible pulmonary embolism
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.2
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Action
Provide Emergency Department training on identifying and treating pulmonary embolism, including ECG abnormalities.
Stated by the Royal Wolverhampton NHS Trust -
Action
Provide individual pulmonary embolism-focused ECG interpretation training to the directly involved clinical staff.
Stated by the Royal Wolverhampton NHS Trust
Data last updated 7 September 2026