NHSE told to review how labs flag abnormal results to GPs following patient death
NHS England should review guidance for laboratories flagging abnormal results to GPs, a coroner has said following a patient’s death.
Stephen Rhodes, 66, saw his GP on 13 September 2024 presenting ‘with symptoms of progressive shortness of breath’, according to a prevention of future deaths report, published following an inquest.
The GP requested routine blood tests, including NT-Brain Natriuretic Peptide and the reading was ‘significantly raised’ at 3473.
The advice from the laboratory was to refer for specialist assessment and transthoracic echocardiography within two weeks, and a chest x-ray was also ordered.
In the report, Zafar Siddique, senior coroner for the Black Country, said that the blood test results ‘were then filed in the mistaken belief there was no abnormal result findings’.
The report said: ‘The blood test results reported on the 17 September 2024 showed normal renal function, normal liver function and bone metabolism.
‘However, the NT-Brain Natriuretic Peptide results which are a marker of increased left atrial pressure and screen for heart failure was markedly raised at 3473 (normal expected for this age group < 400).
‘This was reported to the practice and noted in the practice record with the advice from the laboratory to “refer for specialist assessment and transthoracic echocardiography within 2 weeks”.’
Mr Rhodes continued to work as a delivery driver and died on 11 March 2025 after collapsing and suffering a cardiac arrest.
At the inquest, a GP giving evidence ‘could not adequately explain how the error occurred’ but suggested the results were not flagged on the front page of the report or highlighted in red.
Since the incident, the laboratory has updated their reporting to ensure that abnormal results are flagged on the first page of the report.
But the report argued that NHS England should review any guidance for laboratories flagging up abnormal results.
Mr Siddique said: ‘The GP giving evidence, described that the practice could have up to several hundred reports a day. They could not adequately explain how the error occurred. However, one suggestion was that the abnormal results were not found on the front page of the report or highlighted in red.
‘I also heard, evidence that since this incident the laboratory involved has now updated their reporting to ensure that anormal results are flagged on the first page of the report.
‘Given the concerns identified, the GP surgery may wish to review their current processes and at a national level, NHS England may wish to review any guidance for laboratories flagging up abnormal results.’
Current NHS England guidance on clinical messaging and test results suggests ensuring ‘results are reviewed promptly’ and that systems are in place to ‘action any abnormal results’.
The guidance said: ‘Clinical staff, along with the organisations that they work for, have a responsibility to understand the capabilities and limitations of the clinical communication tools they use.
‘Understanding these factors, and staying up to date, may form part of staff mandatory training.
‘There must be adequate preparation and continuing awareness in dealing with digital faults.’
This page was updated on 17 February, after the coroner’s report was published, but NHS England told Pulse that its diagnostics team did not initiate the update and that it appears not to be related to the prevention of future death’s report.
The inquest into Mr Rhodes’ death concluded he had died of ‘natural causes contributed to by neglect’.
Mr Siddique added that there was a ‘missed opportunity’ to make a cardiological referral which if it had been made in the suggested two-week period, further tests and treatment could have been initiated.
‘It is likely he would have possibly survived with earlier intervention with a diagnosis of hypertensive heart and aortic stenosis,’ the report added.
The report has been sent to NHS England and the GP practice, Quarry Bank Medical Centre, who have a statutory duty to respond in writing within 56 days of its publication – 6 April.
An NHS England spokesperson told Pulse: ‘NHS England extends its deepest sympathies to the friends and family of Stephen Rhodes. We are carefully considering the Prevention of Future Deaths Report sent to us by HM Coroner and will respond in due course.’
Quarry Bank Medical Centre declined to comment.
Last year, Optum (formerly EMIS) was issued a prevention of future deaths report after death of a patient whose prescription was automatically removed from repeats and recategorised as a past prescription.
However, it challenged the coroner’s warning that a feature of its software posed a potential patient safety risk.
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READERS' COMMENTS [7]
Please note, only GPs are permitted to add comments to articles
Hardly the labs fault if the requesting clinician doesn’t read the report.
So sadly GPs get to appear in coroners court. BNP wasn’t even done in GP til recently. Admissions teams won’t accept BNP>x and instantly admit for echo /revasculularisation. Our waiting times for heart failure services and echo are months.
Not sure why there’s a problem getting to the bottom of the practice’s error. Who ever looked at laboratory report and filled it in patient’s computer records will be recorded in dead Patient’s computer records – surely Coroner’s know about clinical systems audit trails? The mistake lies with the GP who mistakenly filed the abnormal report without letting patient know result was abnormal and needed action.
One has to ask – was the, presumably severe, aortic stenosis not audible? One might surmise that “New SOBOE + new ESM” = ECG +refer either echo or cardiology irrespective of what a blood test may or may not have shown. But them I may be missing something.
Perhaps the relentless tide of “you can’t be too careful” routine blood tests for everyone and everything makes it too easy to miss problematic results; the needle in the haystack?
Particularly as so many results are flagged as “abnormal” but most of these “abnormal ” results are benign.
Nigel they mean they couldn’t explain why the GP thought it was normal and it sounds like usually abnormal results are flagged in red and I suspect this one wasn’t and came in the usual black font (I have heard of other similar errors and a datix we submitted for a pancreatic elastase which was mistakenly filed as normal when it was severely abnormal actually led to a change in how it is reported by the lab)
Does anywhere in the UK have access to outpatient echo within 2 weeks if referred by a GP? We can’t get direct echos except for murmurs so this would have been a HF clinic referral. They take around 3 months.