First reported 20 Aug 2013•Latest report 29 Aug 2025
Definition
What this concern includes
Includes failures of assessment, training, monitoring or other competence-assurance controls specifically concerning doctors performing clinical procedures.
Not included
Excludes competence deficiencies unrelated to doctors performing clinical procedures.
Excludes failures concerning non-procedural prescribing, treatment, care planning or general professional performance.
Excludes generic staffing, documentation or training deficiencies not explicitly tied to doctors' procedural competence.
Reports
8
Distinct published reports
Individual concerns
9
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
15
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.
Department of Health and Social Care3
NHS England2
Aston Medical School1
Birmingham Medical School1
Care Quality Commission1
Chief Medical Officer for England and Wales1
General Medical Council1
HM Prison and Probation Service1
Ministry of Justice1
Pennine Acute Hospitals NHS Trust1
Queen Victoria Hospital NHS Foundation Trust1
Recipient name withheld1
Royal College of Paediatrics and Child Health1
Sandwell and West Birmingham Hospitals NHS Trust1
Stockport NHS Foundation Trust1
Ministerial department4
NHS trust4
Type not available3
Executive non-departmental public body2
Executive agency1
Health and care professional regulator1
Health and social care service regulator1
Prison or young offender institution1
Professional body1
University faculty or school1
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.
Manchester South
Concerns raised1
Lack of competency training enabling ward doctors to undertake lumbar puncture
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 concerns
Each 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
Action
Deliver registrar lumbar-puncture training through completed simulation and ongoing supervised procedural sign-off.
Stated by Stockport NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 September 2025.
Manchester South
Concerns raised1
Lack of compulsory direct observed training for paediatric middle grades performing neonatal intubation
Responses linked to these concerns
Each 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
Action
Provide neonatal airway management training through Progress+ neonatology placements.
Stated by Royal College of Paediatrics and Child HealthStated completedThe respondent said that this action was complete when they made their response on 14 February 2025.
Action
Strengthen the Progress+ curriculum's neonatal airway capabilities, emphasizing non-invasive airway management and specialty-level safe intubation and difficult-airway management.
Stated by Royal College of Paediatrics and Child HealthStated completedThe respondent said that this action was complete when they made their response on 14 February 2025.
Action
Develop a neonatal airway safety standard with BAPM addressing skills maintenance and ongoing training.
Stated by Royal College of Paediatrics and Child HealthStated completedThe respondent said that this action was complete when they made their response on 14 February 2025.
Action
Signpost members to the neonatal airway safety standard and its skills-maintenance resources.
Stated by Royal College of Paediatrics and Child HealthStated plannedThe respondent said that this action was planned when they made their response on 14 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Removing mandatory neonatal intubation DOPS does not necessarily increase risk because non-invasive airway management is safer and the former DOPS provided false reassurance.
Stated by Royal College of Paediatrics and Child HealthDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Operational delivery networks are responsible for supporting airway and resuscitation skill maintenance across neonatal units, particularly where skills are infrequently used.
Stated by Royal College of Paediatrics and Child HealthRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Insufficient PAO experience among surgeons performing the procedure
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 concerns
Each 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.4
Position
Trusts and orthopaedic surgeons should already recognise PAO as a specialist procedure requiring suitably trained and experienced clinicians.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Further comment on the specific concerns is not appropriate based on the information provided and matters addressed by the Trust.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Relevant clinical and professional standards and guidance are outside NHS England’s responsibility.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Further information on relevant clinical and professional standards and guidance should be sought from the RCS of England or BOA.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised2
Failure to formally assess junior doctors' competence to take bloods from central lines
Failure to formally assess and monitor doctors' procedural competence
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.8
Action
Write to UK Postgraduate Deans requesting protected-time induction, best practice and reinforcement of Foundation Professional Capability 18.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Cascade learning from the report to Postgraduate Deans and Foundation Schools, reinforcing competency, training and supervision requirements.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Reinforce to Trust trainees that central-line procedures are restricted to appropriately trained specialist settings and that Foundation doctors must not perform them.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Provide Foundation doctors theoretical central-line education, including simulation of air embolism during blood sampling.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Liaise with Health Education England to determine competency-assignment and supervision arrangements for clinical skills.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Forward clinical-skills competence summaries between rotations and require supervisors to check competency before assigning procedures.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Require documented competency and prohibit unsupervised procedures until trainees are signed off as competent.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Continue working with employers, Health Education England and medical schools to monitor actions and ensure sustainable training-environment safety changes.
Stated by General Medical CouncilStated in progressThe respondent said that this action was in progress when they made their response on 1 April 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Central-line blood sampling should not be required of all Foundation doctors because it is specialist work requiring specific authorisation, training and direct supervision.
Stated by General Medical CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
At the Trust, blood sampling from central venous catheters is assigned to competent nursing staff, outreach teams or medical registrars rather than Foundation doctors.
Stated by Sandwell and West Birmingham Hospitals NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
National standard operating procedures for central-line blood sampling are matters for national service and education providers such as Health Education England and NHS England.
Stated by General Medical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Sussex
Concerns raised1
Lack of assured competence for peri-operative PEG insertion
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Review alternative pathways and external oversight for PEG placement, including competency-based training and accreditation.
Stated by Queen Victoria Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
QVH considers its consultants’ experience and existing PEG practice sufficient to continue PEG placement, although continuation remains under review.
Stated by Queen Victoria Hospital NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
NHS Improvement, NHS England, and the Care Quality Commission, working with the Trust and commissioners, were responsible for ensuring appropriate action.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local competency assessments, experience checks and supervised practice are considered sufficient because no nationally recognised PEG training courses exist.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Portsmouth and South East Hampshire
Concerns raised1
Lack of formal monitoring schemes for inexperienced surgeons carrying out surgical procedures
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Swansea and Neath Port Talbot
Concerns raised1
Failure to ensure ACCT health-screening doctors are trained in required procedures
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester North
Concerns raised1
Failure to ensure current competence for suprapubic procedures
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 concerns
Each 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
Action
Implement urology training and competency sign-off for clinicians inserting suprapubic catheters outside urology.
Stated by Pennine Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 December 2013.
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Includes failures of assessment, training, monitoring or other competence-assurance controls specifically concerning doctors performing clinical procedures.
