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
Suffolk
Concerns raised1
Failure to conduct and document senior clinician–senior radiologist discussions for further out-of-hours investigation justification
This report raised 3 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.
Essex
Concerns raised1
Lack of input from senior clinical staff at patient presentation
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 raised1
Failure to seek early senior review
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.
Inner South London
Concerns raised1
Inconsistent thresholds for review and intervention between private and NHS maternity care
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care
National Institute for Health and Care Excellence
Nursing and Midwifery Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
National Institute for Health and Care Excellence
Update the Intrapartum Care clinical guideline, including fetal assessment and monitoring recommendations.
National Institute for Health and Care Excellence
Consult stakeholders on the draft Intrapartum Care guideline recommendations between 13 May and 24 June 2014.
National Institute for Health and Care Excellence
Publish the final updated Intrapartum Care clinical guideline in October 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Nursing and Midwifery Council
The regulator cannot offer a view on models of private and NHS midwifery care because this falls outside its regulatory role.
Outside remitThe respondent said that this matter was outside its role or authority.
Nursing and Midwifery Council
References concerning private and NHS midwifery care should be addressed to the Department of Health.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
National Institute for Health and Care Excellence
Clinicians retain responsibility for treatment decisions and may depart from NICE guidelines for appropriate, documented clinical reasons.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Department of Health and Social Care
The private midwifery-led service model was discontinued and no longer operates, so further action on that model is not indicated.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Brighton and Hove
Concerns raised1
Lack of early senior review
This report raised 10 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.
Surrey
Concerns raised1
Delays in senior clinical review
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.
Manchester City
Concerns raised1
Failure of senior clinical review to recognise seriousness and plan urgent treatment
This report raised 4 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.
South Yorkshire (Western)
Concerns raised2
Failure to contact a consultant when Early Warning Scores indicate clinical deterioration
Failure to refer patients to consultant level when Early Warning Scores indicate escalation
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.
West Yorkshire (East)
Concerns raised1
Failure to arrange necessary General Practitioner review or Consultant Psychiatrist referral
This report raised 4 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.