Recurring concern
Failure to provide effective senior clinical oversight of patient care
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Request correctionFirst reported 23 Aug 2013•Latest report 10 Mar 2026
What this concern includes
Includes failures of senior clinical oversight of patient care, including absent or delayed senior input at presentation, early or daily senior review, review of patients referred for advice, and ongoing senior clinical direction or challenge where senior involvement is required for safe care.
Not included
- Excludes generic organisational, corporate or regulatory oversight where senior clinical oversight of patient care is not the unsafe condition.
- Excludes senior review of incident investigations, documentation quality, policies or safety governance unless the assertion directly concerns oversight of a patient's clinical care.
- Excludes failures of junior staff competence, staffing capacity or clinical treatment where senior clinical oversight is not itself deficient.
- Excludes delays or failures in specialist review where the concern is access to a named specialty rather than the broader senior clinical oversight of patient care.
- Reports
- 59
- Individual concerns
- 64
- Date range
- 2013–2026
- Stated actions
- 63
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 raised1
Delays in full medical assessment by a senior healthcare professional
This report raised 7 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
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Position
Practice Plus Group is responsible for responding to concerns about healthcare delivery at HMP Hewell.
Stated by HM Prison and Probation Service
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Position
The clinical presentation did not indicate a need for more urgent psychiatric assessment.
Stated by Midlands Partnership University NHS Foundation Trust -
Position
Active clinical observation through ACCT and food refusal processes was sufficient before psychiatric assessment.
Stated by Midlands Partnership University NHS Foundation Trust -
Position
The food and fluid refusal pathway is considered robust and fit for purpose regardless of the reason for refusal.
Stated by Practice Plus Group
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Concerns raised1
Lack of clear senior clinical oversight and decision-making accountability for Rapid Response Team referrals
This report raised 9 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
Revise the Trust-wide Home Treatment and Rapid Response procedures to require senior clinical oversight before declining referrals and agreement of alternative care.
Stated by Kent and Medway Mental Health NHS Trust
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Concerns raised1
Failure to escalate medication concerns to appropriately senior clinicians
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.1
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Action
Provide restorative clinical supervision and professional nurse advocate learning on controlled drugs, communication, challenge and escalation.
Stated by the Princess Alexandra Hospital NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Stated by NHS England
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Concerns raised1
Failure to escalate significant clinical changes for review by appropriately senior clinicians
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Lack of multidisciplinary assessment and senior consultant oversight of community urology patients
Failure of senior clinicians to retain responsibility for patients throughout private hospital care
This report raised 9 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
Require consultants to retain responsibility for patients throughout their clinical pathway under the Practising Privileges policy.
Stated by Circle Health Group and Goring Hall Hospital -
Action
Implement a Care of the Deteriorating Patient policy defining consultant and Resident Medical Officer responsibilities and requiring escalation when consultants fail to respond appropriately.
Stated by Circle Health Group and Goring Hall Hospital
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Existing policies sufficiently establish consultants’ continuing responsibility for patients and define RMO and consultant responsibilities during deterioration.
Stated by Circle Health Group and Goring Hall Hospital
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Position
CHG considers its consultant-responsibility policies clear and effective, requiring no revision or further action at this time.
Stated by Circle Health Group and Goring Hall Hospital -
Position
Failures by individual clinicians fall outside prosecutorial remit because prosecutorial powers extend only to registered providers or registered managers.
Stated by Care Quality Commission
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Concerns raised1
Lack of Consultant Psychiatrist oversight for vulnerable patients
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 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
Review the Liaison Service Standard Operating Procedure to incorporate the described consultant-oversight provisions, completing the review by May 2026.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Monitor the consultant-oversight provisions to assess whether they contribute to patient safety and therapeutic care.
Stated by Essex Partnership University NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing Core 24, multidisciplinary review, referral, escalation and on-call arrangements provide sufficient Consultant oversight for liaison patients.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to obtain consultant obstetric input, medical review and imaging before therapeutic anticoagulation
This report raised 15 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
Provide guidance on reducing venous thromboembolism risk during pregnancy and the puerperium, including anticoagulation decisions when bleeding risk exists.
Stated by Royal College of Obstetricians and Gynaecologists
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Concerns raised1
Failure to refer patients to a senior medical practitioner in line with the NEWS algorithm
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 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
Lack of required senior review when diagnostic results are incongruous or unexpected in context
This report raised 6 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
Deliver regular ECG interpretation teaching and promote second opinions from appropriately qualified clinicians or cardiologists.
Stated by Manchester University NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Registrar review is considered an appropriately senior arrangement, so consultant oversight of every ECG is not considered reasonable.
Stated by Manchester University NHS Foundation Trust
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Concerns raised1
Failure to provide joint assessment by senior Emergency Department and Paediatric staff
This report raised 6 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 a Children and Young People’s Working Group to review related policies and procedures, including joint working, pathways, recruitment and operations.
Stated by Sherwood Forest Hospitals NHS Foundation Trust
Data last updated 7 September 2026