Recurring concern
Failure to provide effective senior clinical oversight of patient care
Pin
Get email alerts
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.
-
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.
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.4
-
Action
Change the patient whiteboard to record the doctor-review time for suspicious CTG traces.
Stated by Milton Keynes University Hospital NHS Foundation Trust -
Action
Clarify staff responsibilities for patient reviews, senior-help escalation and upward-escalation timescales in writing.
Stated by Milton Keynes University Hospital NHS Foundation Trust -
Action
Embed a revised SBAR handover communication tool in practice.
Stated by Milton Keynes University Hospital NHS Foundation Trust
-
Action
Recirculate the written escalation policy to all staff.
Stated by Milton Keynes University Hospital NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
-
Position
The concerns were identified and appropriately escalated; junior midwives are qualified and understand how to summon emergency assistance.
Stated by Milton Keynes University Hospital NHS Foundation Trust
-
Position
The CTG did not require immediate intervention, and staff escalated appropriately when the doctor did not attend within a reasonable timescale.
Stated by Milton Keynes University Hospital NHS Foundation Trust -
Position
Clear escalation instructions already exist for all midwifery and medical staff, including escalation to a consultant.
Stated by Milton Keynes University Hospital NHS Foundation Trust
-
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.
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
-
Action
Strengthen senior medical review requirements, including consultant reviews, daily review of sick patients, junior attendance and documentation of discussions.
Stated by University Hospitals Sussex NHS Foundation Trust
-
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.
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
-
Action
Increase permanent Acute Medical Unit staffing, including matron input, an additional senior nurse and a support assistant role.
Stated by University Hospitals Sussex NHS Foundation Trust
-
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.
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
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.
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
-
Action
Continue recruiting senior medical staff to reduce out-of-hours registrar-cover gaps.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Consider alternative ways to deploy senior Trust staff to provide out-of-hours support.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
-
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.
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
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.
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 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.
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
-
Action
Remind consultants and shift leaders to require a detailed management plan and shift-leader confirmation before transferring patients.
Stated by University Hospitals Sussex NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
The consultant’s undated signature on transfer documentation was not relevant to the patient’s clinical care.
Stated by University Hospitals Sussex NHS Foundation Trust
-
Position
The failure to countersign the initial observations was considered a documentation oversight without adverse effect on clinical assessment.
Stated by University Hospitals Sussex NHS Foundation Trust
-
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.
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 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.
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.
Data last updated 7 September 2026