The national investigation worth reading #
This is one of the few areas of clinic admin that has been formally investigated in the UK. The Healthcare Safety Investigation Branch published Failures in communication or follow-up of unexpected significant radiological findings on 21 October 2022. The case that prompted it was a 76 year old woman whose chest X-ray showed a possible lung cancer that was not followed up, leading to a delayed diagnosis.
Its findings are about process, not about clinical skill. The report described wide variation in how unexpected significant findings are communicated to clinicians and acknowledged. Multiple handovers between teams create opportunities for a finding to be lost when a patient moves between them.
High workload and email volume mean a result can simply be passed over. And a delay in reporting can mean the patient has already been discharged before the result exists.
On scale, the report cites these figures.
41
Serious incidents reported nationally between April 2017 and May 2018, involving delayed lung cancer diagnosis from radiological findings that were not acted on
Healthcare Safety Investigation Branch, 21 October 2022
662
Radiology claims identified by NHS Resolution over two years
Healthcare Safety Investigation Branch, 21 October 2022
Over £2.5m
Paid on settled cases involving failure to act on abnormal results
NHS Resolution, cited by the Healthcare Safety Investigation Branch, 21 October 2022
Read the caveat with the figures. This is an NHS investigation of NHS systems, focused on radiology and largely on emergency departments. A private physiotherapy or aesthetics clinic is not the setting it describes. What carries across is the mechanism, and the mechanism is embarrassingly simple: a result exists, and nobody can prove a person saw it.
The chain, and where it breaks #
| Step | How it fails | Is the failure visible? |
|---|---|---|
| Test ordered | Never taken, or taken elsewhere | No, unless somebody reconciles orders to results |
| Result returned | Arrives in a shared inbox with no owner | No |
| Result seen | Opened by nobody in particular | Only if acknowledgement is recorded |
| Result interpreted | Clinical, and correctly so | Yes, in the record |
| Patient told | Assumed to have happened at the next appointment that never came | No |
| Follow up booked | Agreed verbally, never entered | No |
Four of the six failures are invisible, and all four are invisible for the same reason: the absence of a record is not itself a record. Nothing arrives in an inbox to say a result never came back. That is precisely the class of problem a rule catches, because a rule can be asked to look for nothing where something should be.
Which parts run on rules #
- A test ordered with no result returned after a defined period.
- A result received with no acknowledgement by a named person.
- An acknowledged result with no action recorded against it.
- A result flagged as needing a follow up appointment, with none booked.
- A patient told a result would be discussed, with no contact since.
- A result that arrived after the patient's last appointment, so was never discussed.
Every one of those is an absence check against dates and states. None of them involves reading the result. That is the whole distinction, and it is the same one drawn on referral letters and reports: watching the envelope is admin, reading the contents is clinical.
The line that does not move #
Nothing here should be read as suggesting a system triage results, decide which are normal, decide which are urgent, or send a result to a patient on its own judgement.
The General Medical Council's Good medical practice, in effect since 30 January 2024, carries duties on recording work clearly and accurately that do not transfer to a supplier.
A clinic that let a rule decide which results mattered would have automated the care, not the admin, and that is the one thing this site consistently says not to do. The general version of the argument is on jobs that are not worth automating.
Telling the patient #
When a result is communicated in writing, the Academy of Medical Royal Colleges guidance Please write to me applies as much as it does to a clinic letter: everyday language rather than jargon, any medical term explained, and a record of whether the patient has accessibility needs affecting how they read and process information.
The guidance was updated in April 2026 and its underlying argument has not changed since 2018, which is that patients want to be written to directly.
Whether a particular result should be delivered in writing at all is a judgement about that result and that person. A page cannot make it and neither can a rule.
The data protection footnote #
A result is health data in its purest form, which makes it special category data under UK GDPR, so a lawful basis and an Article 9 condition are both required. Your practice stays the controller for it whichever supplier moves it around. Misdirection is the risk that matters most here, as it is with letters. The patient data page points at the ICO rather than interpreting the law.
What to look at first #
Take a month of tests ordered and reconcile them against results received. Then take a month of results received and count how many carry a named acknowledgement. Most clinics have never run either count, and the second one tends to be the uncomfortable one. If you want to put hours against the reconciliation before talking to anybody, the free tools work from your own numbers.