Recurring concern
Failure to supervise clinicians during clinical work
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Request correctionFirst reported 13 Dec 2013•Latest report 17 Dec 2025
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.
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
- 22
- Individual concerns
- 23
- Date range
- 2013–2025
- Stated actions
- 29
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised2
Poor ward-level leadership and supervision of nurses
Inadequate on-call consultant supervision of junior colleagues
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to supervise staff grade anaesthetists
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Establish electronic rota and induction arrangements identifying anaesthetic supervision, consultants and emergency contact routes for staff-grade, trainee and locum anaesthetists.
Stated by Maidstone and Tunbridge Wells NHS Trust
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Concerns raised1
Failure to ensure consultant knowledge of manual cervical replacement
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 concernsEach 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.2
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Action
Provide initial supervisory feedback to the two trainee doctors involved in the delivery.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Hold formal feedback meetings involving the trainee doctors and their former and new educational supervisors.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Lack of supervision or retraining for RMNs remaining in clinical posts
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to provide effective senior support for abnormal CTG monitoring
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Strengthen newly qualified midwives’ preceptorship through supernumerary supported practice with experienced senior midwives.
Stated by Milton Keynes University Hospital NHS Foundation Trust -
Action
Provide two-hourly Band 7 coordinator rounding for patients receiving one-to-one care.
Stated by Milton Keynes University Hospital NHS Foundation Trust -
Action
Clarify staff responsibilities for patient reviews, senior-help escalation and upward-escalation timescales in writing.
Stated by Milton Keynes University Hospital NHS Foundation Trust
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Action
Introduce ‘fresh eyes/ears’ stickers to ensure hourly senior review of intermittent and continuous fetal monitoring.
Stated by Milton Keynes University Hospital NHS Foundation Trust
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Concerns raised1
Failure to supervise an operating surgeon during a complex twin delivery
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Implement the comprehensive junior-doctor obstetrics and gynaecology induction programme, including orientation, competency assessments, guidance access, support contacts, follow-up and supernumerary work.
Stated by United Lincolnshire Teaching Hospitals NHS Trust
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Concerns raised1
Failure to provide appropriate supervision for EU-trained doctors
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 concernsEach 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.2
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Position
Health Education England is the appropriate body to comment on St George’s training and supervision programme.
Stated by Dr Dan Poulter MP
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Position
Primary responsibility for induction arrangements for clinical staff rests with individual employers.
Stated by Dr Dan Poulter MP
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Concerns raised1
Failure to account for junior doctor unfamiliarity during senior review
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 concernsEach 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
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Action
Remind senior clinicians to exercise extreme caution when reviewing patients assessed by unfamiliar or locum junior staff without personally seeing them.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Inadequate supervision of out-of-hours urology trainees
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.2
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Action
Provide weekend urology review and supervision through consultant ward rounds, registrar emergency assessments, case discussion and consultant availability.
Stated by Frimley Health NHS Foundation Trust -
Action
Review the three-hospital urology on-call services and develop an action plan toward seven-day compliance.
Stated by Frimley Health NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Existing arrangements provide safe, supervised out-of-hours trainee practice through registrar discussions and consultant advice or review when required.
Stated by Frimley Health NHS Foundation Trust
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Position
Consultant-delivered emergency services with regular inpatient ward rounds require additional consultant appointments before compliance can be achieved.
Stated by Frimley Health NHS Foundation Trust
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Concerns raised1
Failure to provide supervision proportionate to identified competence concerns for locum consultants
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026