Recurring concern

Failure to supervise clinicians during clinical work

First to latest report 13 Dec 2013 — 17 Dec 2025

Reports that mention this concern
22
Times this concern has been raised
23
Stated actions linked to this concern
29

What this concern includes

Includes failures of supervision dedicated to overseeing clinicians during clinical work, including supervision of operating surgeons, locum clinicians, staff-grade anaesthetists and preceptee nurses during medication administration.

What is not included
  • Excludes supervision of patients, residents, service users or members of the public.
  • Excludes failures of clinical assessment, handover, communication, referral or escalation where inadequate clinician supervision is not the shared unsafe condition.
  • Excludes generic workforce, staffing or training deficiencies not explicitly tied to supervision of clinicians during clinical work.

Reports and published responses 22 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Surrey

    AI-generated summary

    Jackson J Chadd · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jackson became unwell at home with fever, poor feeding, diarrhoea, a rash and abnormal observations, and was discharged from A&E with a diagnosis of gastroenteritis. He returned in septic shock and died despite resuscitation; the medical cause of death was fulminant meningococcal infection. Concerns included inadequate supervision and assessment, failure to apply fever guidelines, and failure to act on a parent’s concerns.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of effective supervision of non-career grade paediatricians without previous experience

    Wider context from the report

    “1. Lack of effective supervision of a non-career grade paediatrician with no previous experience ”

    Source location

    Jackson J Chadd · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide a paediatric consultant responsible for Emergency Department supervision alongside an Emergency Department consultant with paediatric interest.

    Verbatim wording from the response

    “• There is a Consultant responsible for Paediatric A&E working alongside an A&E consultant with a Paediatric interest to supervise junior medical staff”

    Source location

    2014-0137-Response-by-Frimley-Park-Hospital
    Page 2 · response
    Published 24 March 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Consider further work to strengthen consultant-delivered paediatric cover towards 24/7 service.

    Verbatim wording from the response

    “• Further work is being considered by the Trust to strengthen a Paediatric Consultant delivered service in moving towards 24/7 cover in line with the Keogh Standards.”

    Source location

    2014-0137-Response-by-Frimley-Park-Hospital
    Page 2 · response
    Published 24 March 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Require paediatric SHOs to notify the consultant when senior review is delayed more than one hour.

    Verbatim wording from the response

    “• In place at the time of Jackson’s death there was an Escalation Policy whereby if a child was in the A&E Department for more than 3 hours waiting for Paediatric opinion, the Consultant should be informed. The SHO should now notify the Consultant if there is more than an hour delay in senior review of a child.”

    Source location

    2014-0137-Response-by-Frimley-Park-Hospital
    Page 2 · response
    Published 24 March 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Audit compliance with the Facing the Future paediatric service standards across UK units.

    Verbatim wording from the response

    “The ‘Facing the Future’ standards were audited in 2012 by RCPCH for compliance by units across the UK. We found standard 1 was met by 77.4% of units and standard 2 by 87.7%. 99.2% met standard 3. Although this case may have been compliant with our existing standards, our audit report indicated that we were proposing to reconsider standard 2 amongst others with a view to increasing the frequency of consultant review to twice rather than once in 24 hours. This review has now commenced and will take around three months during which we will collate any evidence available to support the recommendations made. In parallel I have discussed this matter with Professor Reid at Health Education England, and as a result our workforce team is working with HEE to model the implications for medical staffing across the country were we to recommend twice daily consultant review.”

    Source location

    2014-0137-Response-by-Royal-College-of-Paediatrics-Child-Health
    Page 3 · response
    Published 24 March 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the consultant-review standard, collate supporting evidence, and consider increasing consultant reviews from once to twice daily within 24 hours.

    Verbatim wording from the response

    “The ‘Facing the Future’ standards were audited in 2012 by RCPCH for compliance by units across the UK. We found standard 1 was met by 77.4% of units and standard 2 by 87.7%. 99.2% met standard 3. Although this case may have been compliant with our existing standards, our audit report indicated that we were proposing to reconsider standard 2 amongst others with a view to increasing the frequency of consultant review to twice rather than once in 24 hours. This review has now commenced and will take around three months during which we will collate any evidence available to support the recommendations made. In parallel I have discussed this matter with Professor Reid at Health Education England, and as a result our workforce team is working with HEE to model the implications for medical staffing across the country were we to recommend twice daily consultant review.”

    Source location

    2014-0137-Response-by-Royal-College-of-Paediatrics-Child-Health
    Page 3 · response
    Published 24 March 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Model with Health Education England the national medical-staffing implications of recommending twice-daily consultant review.

    Verbatim wording from the response

    “The ‘Facing the Future’ standards were audited in 2012 by RCPCH for compliance by units across the UK. We found standard 1 was met by 77.4% of units and standard 2 by 87.7%. 99.2% met standard 3. Although this case may have been compliant with our existing standards, our audit report indicated that we were proposing to reconsider standard 2 amongst others with a view to increasing the frequency of consultant review to twice rather than once in 24 hours. This review has now commenced and will take around three months during which we will collate any evidence available to support the recommendations made. In parallel I have discussed this matter with Professor Reid at Health Education England, and as a result our workforce team is working with HEE to model the implications for medical staffing across the country were we to recommend twice daily consultant review.”

    Source location

    2014-0137-Response-by-Royal-College-of-Paediatrics-Child-Health
    Page 3 · response
    Published 24 March 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The hospital Trust is responsible for addressing local policies, their implementation, staff practice and competence, including parental concerns.

    Verbatim wording from the response

    “Given that we do not have all the details of the case presented the RCPCH is unable to comment on the specifics of the case. We have presumed that the hospital Trust will be responding on local policies and procedures and their implementation relating to the above, and will be reviewing and addressing any issues pertaining to the personal practice and competence of the staff involved.”

    Source location

    2014-0137-Response-by-Royal-College-of-Paediatrics-Child-Health
    Page 1 · response
    Published 24 March 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The case may have complied with existing paediatric supervision standards, although review of those standards is being undertaken.

    Verbatim wording from the response

    “The ‘Facing the Future’ standards were audited in 2012 by RCPCH for compliance by units across the UK. We found standard 1 was met by 77.4% of units and standard 2 by 87.7%. 99.2% met standard 3. Although this case may have been compliant with our existing standards, our audit report indicated that we were proposing to reconsider standard 2 amongst others with a view to increasing the frequency of consultant review to twice rather than once in 24 hours. This review has now commenced and will take around three months during which we will collate any evidence available to support the recommendations made. In parallel I have discussed this matter with Professor Reid at Health Education England, and as a result our workforce team is working with HEE to model the implications for medical staffing across the country were we to recommend twice daily consultant review.”

    Source location

    2014-0137-Response-by-Royal-College-of-Paediatrics-Child-Health
    Page 3 · response
    Published 24 March 2014

    Open published response

  2. Manchester City

    AI-generated summary

    STEPHANIE DANIELS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Stephanie Daniels, who had a history of serious mental health problems and repeated self-harm, was admitted to the Safire unit on 22 March 2012 after a delay in securing an inpatient bed. She died there on 24 March 2012 after being found unconscious with a ligature around her neck. The principal concerns included inadequate observation and handover, failure to clerk her in, medication-recording and supervision problems, failures in the emergency response, and deficiencies in the subsequent internal investigation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of clinical supervision and guidance for junior medical staff

    Wider context from the report

    “5. Supervision of Junior Medical Staff I am concerned about the lack of appropriate clinical supervision and guidance for junior medical staff. Two junior doctors were asked to attend the ward and made no appropriate clinical records of the reason for their attendance, reviewing the records, seeing the patient and explaining any clinical decision to prescribe medication. It is appreciated that they are busy with a number of duties but it is a matter of concern that they did not undertake basic clinical recording duties for a patient who clearly should have been seen. They did not notice that the patient had not been clerked in. Medication was being prescribed without adequate consideration of the relevant clinical history. They did not notice the named Consultant in charge of the patient was unaware of the admission. Appropriate clinical supervision would be expected to ensure an appropriate standard of performance. I understand that supervision may be delegated by the North West Deanery to the relevant NHS Trust but there has to be some basic accepted levels of interaction, communication and supervision between the junior Doctors and their Consultants to ensure an appropriate standard and continuity of care. This may be a joint responsibility between the Deanery and the NHS trust involved. ”

    Source location

    STEPHANIE DANIELS · Prevention of Future Deaths report
    Page 10 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide weekly supervision for CT1–3 and ST4–6 trainees and reinforce its importance with trainees and consultants.

    Verbatim wording from the response

    “I appreciate you have also sent your Regulation 28 Report to the Deanery at Manchester University. From a Trust perspective, all trainees graded CT1-3 and StR 4-6 have weekly supervision. Trainees and Consultants have been reminded of the importance of this and a discussion has taken place with the Deanery. This will be additionally monitored through the annual handover and supervision survey data completed by junior medical staff.”

    Source location

    2013-0353-Response-by-Manchester-Mental-Health-NHS
    Page 2 · response
    Published 13 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review junior-doctor induction and consultant timetables to strengthen enforcement and documentation of clinical and educational supervision.

    Verbatim wording from the response

    “All trainees in the grades CT1–3 and ST4–6 have weekly supervision. Trainees and consultants have been reminded of the importance of this, and supervision will take place with the deanery on this. Supervision will be enforced at all times and the juniors’ induction and seniors’ timetables will be reviewed.”

    Source location

    2013-0353-Response-by-Manchester-Mental-Health-NHS
    Page 5 · response
    Published 13 December 2013

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Trust-level policy and procedural concerns are assigned to the NTDA and Manchester Health and Social Care Trust.

    Verbatim wording from the response

    “As many of the concerns you raise are issues to be dealt with at Trust level, I have ensured that your concerns have been sent to the National Trust Development Authority (NTDA) which provides support, oversight and governance for all NHS Trusts. The NTDA is in contact with MHSCT Trust and has received an action plan which seeks to address the points you have raised.”

    Source location

    2013-0353-Response-by-Department-of-Health
    Page 1 · response
    Published 13 December 2013

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026