Recurring concern

Failure to provide feedback and learning to clinicians after safety-relevant clinical errors

First to latest report 19 Oct 2015 — 5 Dec 2023

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
3

What this concern includes

Includes failures of the clinical feedback and learning process after safety-relevant clinical errors or consequential clinical decisions, including explaining the rationale for a consultant overruling a junior doctor and providing direct feedback or learning opportunities to clinicians after identified errors.

What is not included
  • Excludes generic organisational learning, incident investigation or action-implementation failures where direct feedback or learning to clinicians after a clinical error is not the unsafe condition.
  • Excludes feedback concerning non-clinical staff, criminal-justice decisions, patient explanations or routine performance development unrelated to a safety-relevant clinical error or consequential clinical decision.
  • Excludes deficiencies in supervision, training or clinical decision-making where no failure to provide post-error or post-decision feedback and learning is identified.

Reports and published responses 3 reports

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

  1. South Yorkshire (Western)

    AI-generated summary

    Kyra Ali Aslam · 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

    Kyra Ali Aslam was admitted to Sheffield Children's Hospital for a planned procedure to reverse a stoma, deteriorated over two days after surgery, and died on 13 August 2022. The substantive concerns relate to whether medics adequately considered the views of parents and nursing staff, and whether junior doctors receive sufficient explanation when overruled by a consultant.

    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

    Failure to adequately explain learning to junior doctors after consultant overruling

    Wider context from the report

    “2. Where a junior doctor is over ruled by a Consultant, is that learning adequately explained to that junior doctor to learn for next time? ”

    Source location

    Kyra Ali Aslam · Prevention of Future Deaths report
    Page 3 · 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 additional time for specialty clinical tutor posts supporting educational faculty and trainee development.

    Verbatim wording from the response

    “We have invested in additional time for speciality clinical tutor posts which support the development of educational faculty for doctors in training and as a local support for trainees to discuss their training and training needs. Any trainee placed at Sheffield Children’s has a personal clinical supervisor assigned to them, their role is to provide learning through case-based discussions and review of their experiences (and address unmet learning needs or concerns).”

    Source location

    Response from Sheffield Children's NHS Foundation Trust
    Page 3 · response
    Published 8 December 2023

    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

    Introduce appraisal-linked requirements for consultants to evidence Clinical and Educational Supervisor upskilling.

    Verbatim wording from the response

    “As a Trust we have introduced a new way for consultants to evidence their upskilling as a Clinical and Educational Supervisor. This is now linked to their appraisal process within their Scope of Work and gives very clear suggestions on how to meet the seven domains required by the GMC. We believe that this will maintain high standards amongst our trainers, increase their accountability and ensure they receive regular training to improve their approach to teaching and give them confidence to challenge colleagues who are not meeting the same standards. Acute medicine can at times require fast decision making by the most senior colleague present which can be appropriate in emergency situations, however embedding improved supervision training for all supervisors will work towards ensuring that all clinical contacts are viewed as learning opportunities.”

    Source location

    Response from Sheffield Children's NHS Foundation Trust
    Page 3 · response
    Published 8 December 2023

    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

    Embed improved supervision training for all supervisors to make clinical contacts learning opportunities.

    Verbatim wording from the response

    “As a Trust we have introduced a new way for consultants to evidence their upskilling as a Clinical and Educational Supervisor. This is now linked to their appraisal process within their Scope of Work and gives very clear suggestions on how to meet the seven domains required by the GMC. We believe that this will maintain high standards amongst our trainers, increase their accountability and ensure they receive regular training to improve their approach to teaching and give them confidence to challenge colleagues who are not meeting the same standards. Acute medicine can at times require fast decision making by the most senior colleague present which can be appropriate in emergency situations, however embedding improved supervision training for all supervisors will work towards ensuring that all clinical contacts are viewed as learning opportunities.”

    Source location

    Response from Sheffield Children's NHS Foundation Trust
    Page 3 · response
    Published 8 December 2023

    Open published response

  2. Inner North London

    AI-generated summary

    Roy Elton TRAVERS · 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

    Roy Travers died on 6 June 2022 from a spontaneous cerebral bleed after admission to Whittington Hospital on 2 June, where he was not initially scanned and the bleed was not diagnosed. Concerns included delayed review after melaena was noted, failure to withhold apixaban, uncertainty about whether identified learning actions took place, and concerns about the treatment of Mr Travers and the late disclosure of the hospital’s review to the coroner and family.

    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

    Uncertainty about provision of direct feedback and learning opportunities after identified clinical errors

    Wider context from the report

    “2. As identified at the Whittington 72 hour review, the reviewing doctor who later considered Mr Travers’ condition in the light of the melaena, then failed to withhold his anti-coagulation therapy, apixaban. It is unclear from the review whether that doctor has since been given direct feedback and a learning opportunity. ”

    Source location

    Roy Elton TRAVERS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Inner North London

    AI-generated summary

    Vasilis KTORAKIS · 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

    Baby Vasilis was born in an extremely poor condition following a long labour at Whittington Hospital on 23 May 2015 and died shortly thereafter. The report identified concerns about the timing of Syntocinon, inadequate recording of a management plan, a registrar’s decision regarding passive descent, and failures to involve staff in the investigation and communicate its findings for learning.

    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

    Failure to provide appropriate feedback after a clinical error

    Wider context from the report

    “3. At ten past midnight on Saturday, 23 May, a different registrar took the decision to allow two hours passive descent before pushing. This was an error of judgement that the registrar had not appreciated even by the time of the inquest, over four months after death, indicating that she had not received appropriate feedback. It is therefore unclear whether this particular registrar, and others on the unit, might be likely to make this same mistake again. ”

    Source location

    Vasilis KTORAKIS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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