First reported 13 Dec 2013•Latest report 17 Dec 2025
Definition
What this concern includes
Includes failures of supervision dedicated to overseeing clinicians during clinical work, including supervision of operating surgeons, locum clinicians, staff-grade anaesthetists and preceptee nurses during medication administration.
Not included
Excludes supervision of patients, residents, service users or members of the public.
Excludes failures of clinical assessment, handover, communication, referral or escalation where inadequate clinician supervision is not the shared unsafe condition.
Excludes generic workforce, staffing or training deficiencies not explicitly tied to supervision of clinicians during clinical work.
Reports
22
Distinct published reports
Individual concerns
23
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
29
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.
Department of Health and Social Care8
NHS England4
Care Quality Commission3
General Medical Council2
Greater Manchester Mental Health NHS Foundation Trust2
Royal College of Anaesthetists2
University Hospitals Sussex NHS Foundation Trust2
Alternative Futures Group Limited1
Association Of Anaesthetists (Great Britain & Ireland)1
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1
Difficult Airway Society1
East Kent Hospitals University NHS Foundation Trust1
Faculty of Intensive Care Medicine1
Frimley Health NHS Foundation Trust1
Frimley Park Hospital1
NHS trust16
Ministerial department8
Healthcare site5
Executive non-departmental public body4
Health and social care service regulator3
Health professional body3
Health and care professional regulator2
Private limited company2
Registered charity2
Company limited by guarantee1
Education sector body1
Integrated care board1
Medicines and medical devices regulator1
Multi-service care provider1
Professional body1
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.
Sunderland
Concerns raised1
Failure to supervise preceptee nurses during medication administration
This report raised 9 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.1
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Surrey
Concerns raised1
Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients
This report raised 9 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.7
Action
Assess providers’ arrangements for safe recruitment, adequate staffing, supervision, accountability, governance, information-sharing and inclusive care involving Physician Associates.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 26 February 2025.
Action
Issue a position statement setting standards for Physician Associate supervision, identification, patient selection and regulation.
Stated by Royal College of Emergency MedicineStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Update workforce-tier guidance to classify Physician Associates at Tier 1 and recommend discussion or review of their patients by Tier 4 or 5 doctors.
Stated by Royal College of Emergency MedicineStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Issue updated clinical-governance guidance supporting supervision, board-level responsibility and local governance of physician associates and anaesthesia associates.
Stated by General Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Develop and publish website materials supporting doctors who supervise physician associates and applying relevant supervision guidance.
Stated by General Medical CouncilStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2025.
Action
Commission an independent review of Physician Associate and Anaesthesia Associate roles and their contribution to multidisciplinary healthcare teams.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Issue and implement an Emergency Department Physician Associate scope of practice requiring senior doctor oversight, appropriate patient selection, escalation, and medical review before discharge or admission.
Stated by Surrey and Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
Existing CQC guidance and provider governance, supervision and competence requirements apply to Physician Associates in secondary care.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The supervising doctor decides whether a patient seen by a physician associate requires face-to-face review or discussion.
Stated by Royal College of Emergency MedicineRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Employers, clinical leaders and supervisors must determine PAs’ permitted activities and required supervision through local clinical governance.
Stated by General Medical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The GMC is responsible for regulating physician associates, while national system leaders should develop their scope of practice and supervision framework.
Stated by Royal College of PhysiciansRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The right to seek a second opinion should be addressed locally.
Stated by Royal College of PhysiciansRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
GMC regulation and existing NHS guidance already govern PA regulation, competence, scope, supervision and employer clinical governance.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Leicester City and South Leicestershire
Concerns raised1
Lack of independent checks and challenge in single-surgeon emergency operating 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 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.2
Action
Introduce and roll out Stop the Line across the Trust, incorporating concerns into Datix reporting and daily team huddles.
Stated by Kettering General Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Continue reviewing existing routes for raising concerns and challenging clinical decisions to reinforce the Trust’s safety culture.
Stated by Kettering General Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The round table panel concluded that no further action was necessary regarding the concerns about the patient's care.
Stated by Kettering General Hospital NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.
Milton Keynes
Concerns raised1
Failure to provide adequate support and supervision to junior doctors
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 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
Lack of appropriate clinical supervision of nurses and support workers
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 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.
North East Kent
Concerns raised1
Failure to assess and supervise locum clinicians
This report raised 19 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The CQC is responsible for deciding and providing further detail on regulatory action concerning the Trust’s maternity-service safety risks.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Trust is responsible for setting out and implementing actions to address the identified maternity-service safety risks.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
London (East)
Concerns raised1
Failure to supervise staff delegated to provide asthma care
This report raised 23 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 London
Concerns raised1
Inadequate supervision of Primary Nurses
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.
Gloucestershire
Concerns raised1
Failure to provide adequate senior supervision of junior doctors before patient discharge
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
Failure to provide timely senior supervision in A&E
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 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.
Pin
Get email alerts
Request correction
Includes failures of supervision dedicated to overseeing clinicians during clinical work, including supervision of operating surgeons, locum clinicians, staff-grade anaesthetists and preceptee nurses during medication administration.
