Recurring concern

Failure to supervise clinicians during clinical work

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First reported 13 Dec 2013•Latest report 17 Dec 2025

Definition

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

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care8

NHS England4

Care Quality Commission3

General Medical Council2

Greater Manchester Mental Health NHS Foundation Trust2

Royal College of Anaesthetists2

University Hospitals Sussex NHS Foundation Trust2

Alternative Futures Group Limited1

Association Of Anaesthetists (Great Britain & Ireland)1

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1

Difficult Airway Society1

East Kent Hospitals University NHS Foundation Trust1

Faculty of Intensive Care Medicine1

Frimley Health NHS Foundation Trust1

Frimley Park Hospital1

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.

20 Mar2014
Surrey
Concerns raised1
1. Lack of effective supervision of non-career grade paediatricians without previous experience
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 6
1. Action
  Provide a paediatric consultant responsible for Emergency Department supervision alongside an Emergency Department consultant with paediatric interest.
  Stated by Frimley Health NHS Foundation TrustStated completed
2. Action
  Consider further work to strengthen consultant-delivered paediatric cover towards 24/7 service.
  Stated by Frimley Health NHS Foundation TrustStated in progress
3. Action
  Require paediatric SHOs to notify the consultant when senior review is delayed more than one hour.
  Stated by Frimley Health NHS Foundation TrustStated planned
1. Action
  Audit compliance with the Facing the Future paediatric service standards across UK units.
  Stated by Royal College of Paediatrics and Child HealthStated completed
2. Action
  Review the consultant-review standard, collate supporting evidence, and consider increasing consultant reviews from once to twice daily within 24 hours.
  Stated by Royal College of Paediatrics and Child HealthStated in progress
3. Action
  Model with Health Education England the national medical-staffing implications of recommending twice-daily consultant review.
  Stated by Royal College of Paediatrics and Child HealthStated in progress
Respondent positions 2
1. Position
  The hospital Trust is responsible for addressing local policies, their implementation, staff practice and competence, including parental concerns.
  Stated by Royal College of Paediatrics and Child HealthRedirects responsibility
1. Position
  The case may have complied with existing paediatric supervision standards, although review of those standards is being undertaken.
  Stated by Royal College of Paediatrics and Child HealthDisputes the concern
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
13 Dec2013
Manchester City
Concerns raised1
1. Lack of clinical supervision and guidance for junior medical staff
This report raised 8 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 2
1. Action
  Provide weekly supervision for CT1–3 and ST4–6 trainees and reinforce its importance with trainees and consultants.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
2. Action
  Review junior-doctor induction and consultant timetables to strengthen enforcement and documentation of clinical and educational supervision.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Trust-level policy and procedural concerns are assigned to the NTDA and Manchester Health and Social Care Trust.
  Stated by Department of Health and Social CareRedirects responsibility
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

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

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.6

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of clinical supervision and guidance for junior medical staff

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 6

Respondent positions 2

Actions described in response 2

Respondent positions 1