Failure to provide effective senior clinical oversight of patient care
First to latest report 23 Aug 2013 — 10 Mar 2026
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.
University Hospitals Sussex NHS Foundation Trust7
Department of Health and Social Care4
NHS England4
Royal Sussex County Hospital4
Care Quality Commission3
Greater Manchester Mental Health NHS Foundation Trust3
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust2
Medway NHS Foundation Trust2
Mid and South Essex NHS Foundation Trust2
National Institute for Health and Care Excellence2
Nottingham University Hospitals NHS Trust2
Recipient name withheld2
Sherwood Forest Hospitals NHS Foundation Trust2
Aneurin Bevan University LHB1
Ashford and St Peter'S Hospitals NHS Foundation Trust1
NHS trust42
Healthcare site18
Executive non-departmental public body6
Ministerial department5
Health and social care service regulator3
Independent healthcare provider2
Local health board2
Type not available2
Company1
Coronial office1
Health and care professional regulator1
Health professional body1
Integrated care board1
Medicines and medical devices regulator1
Non-ministerial department1
Reports and published responses 59 reports
See individual reports that have raised this concern, and the actions taken in response
Milton Keynes
Concerns raised1
Lack of leadership authority to require timely doctor attendance and CTG review
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Milton Keynes University Hospital 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.4
Milton Keynes University Hospital NHS Foundation Trust
Change the patient whiteboard to record the doctor-review time for suspicious CTG traces.
Milton Keynes University Hospital NHS Foundation Trust
Clarify staff responsibilities for patient reviews, senior-help escalation and upward-escalation timescales in writing.
Milton Keynes University Hospital NHS Foundation Trust
Embed a revised SBAR handover communication tool in practice.
Milton Keynes University Hospital NHS Foundation Trust
Recirculate the written escalation policy to all staff.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Milton Keynes University Hospital NHS Foundation Trust
The concerns were identified and appropriately escalated; junior midwives are qualified and understand how to summon emergency assistance.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Milton Keynes University Hospital NHS Foundation Trust
The CTG did not require immediate intervention, and staff escalated appropriately when the doctor did not attend within a reasonable timescale.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Milton Keynes University Hospital NHS Foundation Trust
Clear escalation instructions already exist for all midwifery and medical staff, including escalation to a consultant.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Brighton and Hove
Concerns raised1
Failure to provide senior review and follow up suspected infection
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Sussex 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
University Hospitals Sussex NHS Foundation Trust
Strengthen senior medical review requirements, including consultant reviews, daily review of sick patients, junior attendance and documentation of discussions.
Brighton and Hove
Concerns raised1
Failure to provide senior clinical review
This report raised 24 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Sussex 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
University Hospitals Sussex NHS Foundation Trust
Increase permanent Acute Medical Unit staffing, including matron input, an additional senior nurse and a support assistant role.
Mid Kent and Medway
Concerns raised1
Failure to conduct renal or urological consultations through appropriately senior clinicians
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Nottinghamshire
Concerns raised1
Unavailability of senior medical review when a registrar is absent
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Doncaster and Bassetlaw Teaching 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.2
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Continue recruiting senior medical staff to reduce out-of-hours registrar-cover gaps.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Consider alternative ways to deploy senior Trust staff to provide out-of-hours support.
Manchester City
Concerns raised1
Lack of suitably senior psychiatric clinician attendance at discharge case reviews
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Yorkshire (Western)
Concerns raised1
Failure to obtain appropriate senior medical review or support when deterioration is identified
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Brighton and Hove
Concerns raised2
Failure to formulate a detailed and complete senior clinical plan
Failure of Senior Nurse verification and completion of N.E.W.S. scores
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Sussex 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
University Hospitals Sussex NHS Foundation Trust
Remind consultants and shift leaders to require a detailed management plan and shift-leader confirmation before transferring patients.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
University Hospitals Sussex NHS Foundation Trust
The consultant’s undated signature on transfer documentation was not relevant to the patient’s clinical care.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
University Hospitals Sussex NHS Foundation Trust
The failure to countersign the initial observations was considered a documentation oversight without adverse effect on clinical assessment.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
North Wales (East and Central)
Concerns raised1
Unavailability of senior clinicians for overnight second opinions
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Brighton and Hove
Concerns raised1
Lack of Senior Pharmacist review of Medical Administration Record charts
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.