First reported 23 Aug 2013•Latest report 10 Mar 2026
Definition
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
Distinct published reports
Individual concerns
64
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
63
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.
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
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.
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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.
Responses linked to these concerns
Each 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
Action
Update the Intrapartum Care clinical guideline, including fetal assessment and monitoring recommendations.
Stated by National Institute for Health and Care ExcellenceStated in progressThe respondent said that this action was in progress when they made their response on 25 February 2014.
Action
Consult stakeholders on the draft Intrapartum Care guideline recommendations between 13 May and 24 June 2014.
Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 25 February 2014.
Action
Publish the final updated Intrapartum Care clinical guideline in October 2014.
Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 25 February 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The regulator cannot offer a view on models of private and NHS midwifery care because this falls outside its regulatory role.
Stated by Nursing and Midwifery CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Position
References concerning private and NHS midwifery care should be addressed to the Department of Health.
Stated by Nursing and Midwifery CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Clinicians retain responsibility for treatment decisions and may depart from NICE guidelines for appropriate, documented clinical reasons.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The private midwifery-led service model was discontinued and no longer operates, so further action on that model is not indicated.
Stated by Department of Health and Social CareExisting 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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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.
