Recurring concern
Failure to provide effective senior clinical oversight of patient care
- Reports that mention this concern
- 59
- Times this concern has been raised
- 64
- Stated actions linked to this concern
- 63
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 59 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked responses
- HM Prison and Probation Service
- Midlands Partnership University NHS Foundation Trust
- Practice Plus Group
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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HM Prison and Probation Service
Practice Plus Group is responsible for responding to concerns about healthcare delivery at HMP Hewell.
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Midlands Partnership University NHS Foundation Trust
The clinical presentation did not indicate a need for more urgent psychiatric assessment.
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Midlands Partnership University NHS Foundation Trust
Active clinical observation through ACCT and food refusal processes was sufficient before psychiatric assessment.
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Practice Plus Group
The food and fluid refusal pathway is considered robust and fit for purpose regardless of the reason for refusal.
-
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.
Linked response
- Kent and Medway Mental Health NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Kent and Medway Mental Health NHS Trust
Revise the Trust-wide Home Treatment and Rapid Response procedures to require senior clinical oversight before declining referrals and agreement of alternative care.
-
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.
Linked responses
- NHS England
- the Princess Alexandra Hospital NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
the Princess Alexandra Hospital NHS Trust
Provide restorative clinical supervision and professional nurse advocate learning on controlled drugs, communication, challenge and escalation.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
NHS England
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked responses
- Care Quality Commission
- Circle Health Group
- Goring Hall Hospital
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Circle Health Group and Goring Hall Hospital
Require consultants to retain responsibility for patients throughout their clinical pathway under the Practising Privileges policy.
-
Circle Health Group and Goring Hall Hospital
Implement a Care of the Deteriorating Patient policy defining consultant and Resident Medical Officer responsibilities and requiring escalation when consultants fail to respond appropriately.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
-
Circle Health Group and Goring Hall Hospital
Existing policies sufficiently establish consultants’ continuing responsibility for patients and define RMO and consultant responsibilities during deterioration.
-
Circle Health Group and Goring Hall Hospital
CHG considers its consultant-responsibility policies clear and effective, requiring no revision or further action at this time.
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Care Quality Commission
Failures by individual clinicians fall outside prosecutorial remit because prosecutorial powers extend only to registered providers or registered managers.
-
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.
Linked response
- Essex Partnership University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Essex Partnership University NHS Foundation Trust
Review the Liaison Service Standard Operating Procedure to incorporate the described consultant-oversight provisions, completing the review by May 2026.
-
Essex Partnership University NHS Foundation Trust
Monitor the consultant-oversight provisions to assess whether they contribute to patient safety and therapeutic care.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Essex Partnership University NHS Foundation Trust
Existing Core 24, multidisciplinary review, referral, escalation and on-call arrangements provide sufficient Consultant oversight for liaison patients.
-
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.
Linked response
- Royal College of Obstetricians and Gynaecologists
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Royal College of Obstetricians and Gynaecologists
Provide guidance on reducing venous thromboembolism risk during pregnancy and the puerperium, including anticoagulation decisions when bleeding risk exists.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked response
- Manchester University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Manchester University NHS Foundation Trust
Deliver regular ECG interpretation teaching and promote second opinions from appropriately qualified clinicians or cardiologists.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Manchester University NHS Foundation Trust
Registrar review is considered an appropriately senior arrangement, so consultant oversight of every ECG is not considered reasonable.
-
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.
Linked response
- Sherwood Forest Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Sherwood Forest Hospitals NHS Foundation Trust
Establish a Children and Young People’s Working Group to review related policies and procedures, including joint working, pathways, recruitment and operations.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026