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
Lack of effective consultant input into inpatient care
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.2
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Action
Maintain a 24-hour, seven-day MERIT service staffed by senior anaesthetic clinicians to provide emergency critical-care support.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Maintain a critical-care referral policy defining consultant-to-consultant and urgent medical-registrar referral pathways.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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
The concerns fall under the Trust’s remit rather than NHS England’s functions.
Stated by NHS England
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Position
The Trust is the appropriate organisation to respond, with the Greater Manchester Integrated Care Board responsible for commissioning.
Stated by NHS England -
Position
The consultant on-call rota had no staffing deficit during the admission, contrary to concerns about ineffective consultant input over Christmas and New Year.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Failure of senior healthcare leadership oversight of care planning and deterioration
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.
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 dedicated Resus Lead support, onsite training, scenario coaching, code-call shadowing and feedback for deteriorating-patient care.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
-
Concerns raised1
Failure to alert senior clinicians to unexpected patient deterioration
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.3
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Action
Provide NEWS refresher training to relevant colleagues and conduct regular audits of NEWS compliance.
Stated by Spire Healthcare Limited -
Action
Deliver training to RMOs on recognising deteriorating patients and signs of gastric perforation.
Stated by Spire Healthcare Limited -
Action
Introduce deteriorating-patient stickers for clinical use.
Stated by Spire Healthcare Limited
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Concerns raised1
Failure to provide appropriate senior oversight of patient assessment
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.3
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Action
Amend the senior doctor rota to increase substantive Emergency Department staffing.
Stated by Wye Valley NHS Trust -
Action
Provide specialty doctors with enhanced departmental oversight and leadership training through the rolling training programme.
Stated by Wye Valley NHS Trust -
Action
Increase the substantive establishment of Band 6 nurses to strengthen Emergency Department leadership and support.
Stated by Wye Valley 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
Existing electronic monitoring, consultant cover, on-call arrangements and senior nursing and medical oversight are relied on to address senior supervision.
Stated by Wye Valley NHS Trust
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Concerns raised1
Failure to provide effective senior review of deteriorating patients
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.
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 easy access to input from more experienced doctors
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.
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.3
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Action
Require consultant assessment and review before transferring inpatients to Linden Lodge.
Stated by Nottingham University Hospitals NHS Trust -
Action
Develop induction guidelines and an escalation process for junior doctors managing patients at risk of deterioration in Linden Lodge.
Stated by Nottingham University Hospitals NHS Trust -
Action
Use a specialty referral and escalation procedure for City Campus patients based on their presenting condition.
Stated by Nottingham University Hospitals NHS Trust
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Concerns raised1
Failure to escalate critical A&E blood-test abnormalities to the senior clinician
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Lack of senior clinical oversight
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.
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 senior HBTT clinician risk-review planning and monitoring after disclosure of access to lethal means
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.3
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Action
Update inpatient and HBTT procedures to require risk assessments at entry, discharge, identified intervals, and when risks change.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Hold daily HBTT multidisciplinary meetings to share new information and risks and assign responsibility for the next 24 hours.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Introduce a structured HBTT note format prompting documentation of visit purpose, presentation, and risk to self and others.
Stated by Greater Manchester Mental Health 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
The patient's disclosure about obtaining medication was reviewed, incorporated into a management plan and followed up by HBTT staff.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Insufficient senior clinical input into policy-holder medical management
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.
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.3
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Action
Expand senior clinical capacity by employing two doctors, including a Medical Director and an additional doctor available on call.
Stated by Mayday Group Ltd -
Action
Implement an internal escalation process for very sick and seriously ill patients to the senior clinical team.
Stated by Mayday Group Ltd -
Action
Conduct virtual weekly ward rounds to review patients of concern and formally review complex cases presenting clinical or logistical challenges.
Stated by Mayday Group Ltd
Data last updated 7 September 2026