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 named or responsible consultant review before child discharge
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.1
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Action
Complete weekly assurance audits of clinical records across acute areas, covering sepsis assessment and related discharge and communication safeguards.
Stated by Doncaster and Bassetlaw Teaching Hospitals 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
Consultant handovers, case discussion and retrospective attendance-note review provide sufficient safeguards for children discharged without admission.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure to escalate deteriorating postoperative patients to senior clinicians
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.6
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Action
Require the consultant anaesthetist to define postoperative care and NEWS thresholds for escalation to critical care outreach.
Stated by Leeds Teaching Hospitals NHS Trust -
Action
Implement defined daytime and out-of-hours escalation using consultant contacts, NEWS2 and applicable deteriorating-patient and transfer policies.
Stated by Leeds Teaching Hospitals NHS Trust -
Action
Develop a dedicated policy for deteriorating patients cared for at peripheral hospital sites.
Stated by Leeds Teaching Hospitals NHS Trust
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Action
Establish a dedicated on-call consultant rota for Chapel Allerton Hospital.
Stated by Leeds Teaching Hospitals NHS Trust -
Action
Extend on-site anaesthetic and recovery-unit cover until 21:00.
Stated by Leeds Teaching Hospitals NHS Trust -
Action
Provide rolling staff education and mandatory escalation-pathway and resuscitation training, recording junior doctors’ training on Electronic Staff Records.
Stated by Leeds Teaching Hospitals NHS Trust
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Concerns raised1
Lack of senior review of patients for anticoagulant management
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.1
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Action
Require senior-doctor discussion and full documentation before changing an existing warfarin plan.
Stated by Sherwood Forest Hospitals NHS Foundation Trust
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Concerns raised1
Failure to provide senior doctor review for deteriorating patients
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
Ratify and implement an updated ED standard operating policy defining responsibility for each patient and escalation arrangements.
Stated by Kettering General Hospital NHS Foundation Trust -
Action
Increase daily senior decision-making capacity by adding middle-grade shifts and a second consultant shift in the Emergency Department.
Stated by Kettering General Hospital NHS Foundation Trust -
Action
Create a new EDU operating policy specifying consultant ward-round responsibility, patient ownership and risks identified in the report before recommissioning.
Stated by Kettering General Hospital NHS Foundation Trust
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Concerns raised1
Failure to provide adequate senior specialist support to junior medical staff
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.
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
Reiterate consultant support and escalation expectations to junior hepatology doctors, and update switchboard and ward whiteboard contact details.
Stated by Barts Health NHS Trust -
Action
Repeat consultant-support and escalation information during induction training for new junior doctors.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to provide senior clinician review after admission
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.1
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Action
Escalate cases without an enacted management plan to the Nurse in Charge or senior decision-maker and record the escalation in nursing documentation and Datix.
Stated by University Hospitals of North Midlands 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 absence of consultant review was not a separate error because existing senior-review mechanisms were robust; it resulted from misunderstanding responsibility for the patient.
Stated by University Hospitals of North Midlands NHS Trust
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Concerns raised3
Failure to exercise professional curiosity in high-risk discharge decisions
Failure of senior clinicians to review patients referred for advice
Lack of a system ensuring senior review of cases referred by junior doctors
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
Delays in senior clinician review of reported chest X-rays
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 raised1
Failure to require senior clinical reference before discharge by very junior 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
Audit discharge records to examine whether senior doctors or Consultants participated in discharge decisions.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Provide learning to Consultant Psychiatrists about senior involvement in discharge decisions.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Provide junior doctors with discharge-related teaching during Trust induction.
Stated by Norfolk and Suffolk NHS Foundation Trust
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Concerns raised1
Failure of senior clinician coordination for complex care decisions
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.
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
Use daily multidisciplinary board rounds and safety huddles to review treatment, discharge plans, patient needs and emerging concerns.
Stated by Mid Yorkshire Teaching NHS Trust
Data last updated 7 September 2026