Why do test results go missing in general practice?
Practices handle a large volume of results every day: blood tests, urine and swab results, imaging, histology, screening and results in hospital letters. Most are normal and some need urgent action. Failures are a recognised cause of delayed diagnosis, particularly of cancer, kidney disease, diabetes and serious infection, and they appear regularly in complaints, claims and coroners' reports.
Results errors are rarely caused by a lack of clinical knowledge. They happen in the gaps: a result filed with no action, a test that was never processed, a patient told 'no news is good news', a locum's results not reassigned, or a repeat test that nobody checked was done.
The results cycle: where does it break?
Thinking of results as a cycle helps you see where things go wrong. A failure at any stage can lead to harm.
| Stage | What should happen | Common failure |
|---|---|---|
| Request | Clear indication, correct test, patient told why and how they will hear | Missing clinical details; patient not told to chase |
| Sample | Taken, labelled correctly and reaches the laboratory | Sample lost, unlabelled or rejected without anyone noticing |
| Return | Result arrives and is matched to the right patient | Unmatched, sent to the wrong practice, or arrives on paper |
| Review | A clinician reviews it in the context of the patient | Reviewed without context, or not reviewed because the requester is away |
| Action | A specific action is recorded | Filed as normal when abnormal, or filed with no action |
| Communication | The patient is told the result and the plan | Message not passed on or patient not reached |
| Follow-up | The repeat test, referral or appointment happens | Not booked, or the patient does not attend and nobody notices |
Helen, a practice nurse, sends a FIT kit to a 67-year-old woman with a change in bowel habit and sets a three-week reminder. When the reminder appears there is no result. Helen phones the patient, who had not returned the kit because she was unsure how to use it. Helen explains again, sends a new kit and sets another reminder. Without that reminder, nobody would have known.
How should you review and file a result?
Reviewing a result is not just reading a number. You are deciding what it means for this patient and what happens next. A value within the reference range can still matter, and an out-of-range value may be expected and harmless.
- Read it in context: Check why the test was requested, the history, current medicines and previous results. Look at the trend, not only the latest value.
- Decide what it means: Normal and expected; abnormal but known and stable; a new abnormality needing routine follow-up; or something needing urgent action.
- Record a specific action: Use your system's filing options and add a short comment explaining the decision, written so that a colleague, or the patient reading it online, would understand.
- Say who does what and by when: Use a task with a deadline rather than relying on memory. State who will contact the patient, how and how urgently.
- Update linked records: If the result changes the plan, such as stopping a medicine, update the medication list and problem list.
| Result | Weak filing comment | Stronger filing comment |
|---|---|---|
| eGFR fallen from 65 to 42 in six months, on ramipril and an NSAID | Abnormal | Significant fall in eGFR. Stop NSAID. Phone patient today. Repeat U&E in 2 weeks; task sent. |
| PSA raised for age, no symptoms | Seen | Raised PSA for age. Needs assessment for suspected cancer referral in line with NG12. Appointment within a week; patient to be called today. |
| Normal FBC in a patient with fatigue | Normal, no action | Normal FBC and TFTs. Inform patient by text; offer review if symptoms persist. |
What should you do with an urgent or critical result?
Laboratories phone some results through because they may need same-day action, for example markedly abnormal potassium, sodium, INR, glucose or haemoglobin. The exact thresholds are set by your local laboratory or pathology network, so learn what yours phones through and how.
- Take the call properly: Record the patient's details, the result, the time and the caller's name, and read the result back.
- Pass it to a clinician immediately: Non-clinical staff should not decide what to do. Tell the duty clinician straight away.
- Assess urgency: Check the record. Is it new? Is there an explanation, such as a delayed or haemolysed sample? Is the patient at risk now?
- Contact the patient the same day: If they are unwell they may need emergency assessment. Record each attempt and the outcome.
- Escalate if you cannot reach them: Follow your practice protocol, which may include other numbers, next of kin where appropriate, community teams, or a police welfare check in serious cases.
- Hand over late results: If the result arrives late in the day, hand it to the out-of-hours service with clear instructions.
How should results be communicated to patients?
Patients should know when and how they will receive their results. 'No news is good news' is unsafe, because a lost result produces no news. The CQC says practices should not rely only on patients calling in, should communicate in a way that matches the level of risk, and should keep a record of contact.
Receptionist, reading a message: 'Your blood test is abnormal, you need to see the doctor.' The patient asks what is wrong and is told, 'I don't know, I just pass on messages.' The patient is anxious and does not book.
GP, by phone: 'Your kidney test has dropped compared with six months ago. This is often caused by medicines, and I think your anti-inflammatory tablets may be part of it. Please stop them, and we'll repeat the test in two weeks; I've booked it for the 14th. If you feel unwell, pass much less urine or get very short of breath, call us or NHS 111 straight away. Does that make sense?'
- Significant or unexpected results should usually be discussed by a clinician.
- Non-clinical staff can pass on many results safely if the clinician provides exact written wording and the patient can speak to a clinician if needed.
- Confirm identity and contact details before giving results.
- Use text messages only for normal or minor results with clear instructions; phone for significant ones.
- Check that the follow-up was booked and attended, using a task with a deadline.
Most patients in England can now see new entries in their GP record, including many results, through the NHS App or other online services. They may see an abnormal value before a clinician has contacted them. Write filing comments that make sense to a patient, consider whether a significant result needs a conversation promptly, and follow your practice policy on the limited circumstances in which information may be withheld.
Locums, absences and results requested by hospitals
Many results errors happen because the requester is not there when the result arrives. Every practice should have a clear process for redirecting results when a clinician is on leave, part-time or has left. If you are a locum, check before you leave how your results will be handled, and make sure every test you request has a named person responsible for reviewing it.
Results for tests requested by hospital teams often arrive in the practice. The BMA's position is that the requesting clinician remains responsible unless responsibility has been explicitly handed over, for example in a clinic letter. However, if you see a seriously abnormal result, you cannot simply ignore it because someone else ordered it. Check whether the requesting team is aware, contact them if in doubt, act directly if the patient is at immediate risk, and record what you did.
The CQC does not prescribe a particular results policy, but expects practices to show their system works across the whole pathway, including absences, locums, communication, follow-up of abnormal results, training and supervision for whoever reviews results, and regular audit.
Reflecting on a results incident
If a result was missed or delayed, make sure the patient is now safe, be open with them under the duty of candour, report the incident and take part in a significant event or learning review. A strong reflection describes which stage of the cycle failed and your part in it, without blaming reception staff or the system alone.
The result was filed by mistake during a busy session. I will be more careful in future.
I filed a falling eGFR as 'abnormal, no action' because I was reviewing a large batch of results without opening the patient's record. I missed that he had started an NSAID. His kidney function fell further before it was noticed at a later review. I phoned him, apologised and arranged an urgent repeat. I now open the record for every abnormal result, write a specific action and a task with a deadline, and my results filing has been audited by a partner over three months. I also helped the practice add a weekly check of outstanding results tasks.
If your regulator becomes involved, seek advice from your defence organisation, trade union or professional body before responding.
Learning more
Our course Test Results Management in Primary Care works through the full results cycle, filing decisions on normal, abnormal and borderline results, urgent results, communicating with patients, and how results are lost, with worked examples and a guided reflection. It is written for GPs, locums, practice nurses, advanced nurse practitioners and clinical pharmacists, including those new to UK general practice and its clinical systems.
Frequently asked questions
Who is responsible for acting on a test result?
The clinician who requests the test is responsible for making sure the result is reviewed and acted on, unless responsibility has been explicitly handed to someone else. Practice systems support this by redirecting results when clinicians are absent. If you see a seriously abnormal result requested by someone else, check the requester is aware, act if the patient is at immediate risk, and document what you did.
Is 'no news is good news' acceptable for test results?
No. A lost or unprocessed result produces no news at all, so the patient may wrongly assume everything is fine. Patients should be told when and how they will get their result and what to do if they have not heard. The CQC says practices should not rely only on patients contacting them for results.
Can receptionists give test results?
Non-clinical staff can safely give many results, usually normal or minor ones, if the reviewing clinician has written clear instructions about what to say and the patient can speak to a clinician if they have questions. Significant or unexpected abnormal results should usually be discussed with the patient by a clinician. Staff must confirm the patient's identity before sharing results.
What does CQC look for in GP results management?
The CQC does not mandate a specific policy, but expects practices to show their system covers the whole pathway: tracking tests, handling results when clinicians are away or are locums, timely communication matched to risk, follow-up of abnormal results, training and supervision for staff who review results, safeguards for correspondence, and regular audit to show the system works.
What should I write when filing an abnormal result?
Write a short comment that explains your decision and the action: what the result means, what will happen, who will do it and by when. For example: 'New mild anaemia. Appointment within two weeks; repeat FBC, ferritin and coeliac screen.' Avoid comments such as 'seen' or 'abnormal' on their own, and set a task so follow-up is not left to memory.
What should a locum GP do about test results?
Before leaving a practice, check how the results of tests you have requested will be reviewed, and make sure a named clinician will take responsibility for them. Record clear clinical details on requests so whoever reviews the result understands why it was done. If the practice has no clear process for locum results, raise it with the practice manager.
What should I do if I cannot contact a patient about an urgent result?
Follow your practice protocol. Try all recorded numbers and contact methods, document each attempt, and consider contacting next of kin where appropriate, involving community teams, or asking the police for a welfare check if the patient may be at serious risk. If the result arrives late, hand it over to the out-of-hours service with clear instructions.
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Sources and further reading
- GP mythbusters: managing test results and correspondence. Care Quality Commission.
- Receiving results ordered by another clinician. British Medical Association.
- Suspected cancer: recognition and referral (NG12). National Institute for Health and Care Excellence.
- Good Medical Practice (2024). General Medical Council.
- The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Nursing and Midwifery Council.
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulations 12 and 17. Care Quality Commission.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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