Recurring concern

Unreliable supervision and competence assurance for trainee medical staff

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First reported 26 Jan 2016•Latest report 13 Jan 2025

Definition

What this concern includes

Includes failures in arrangements that select or verify suitable mentors or supervisors, document trainee experience and competence, and maintain reliable supervision and competence assurance as trainees move between training providers or hospital trusts.

Not included

  • Excludes general clinician credentialing or verification before independent practice where the concern is not trainee supervision or training-stage competence assurance.
  • Excludes generic staffing, training or education deficiencies without a direct trainee medical-staff supervision or competence-assurance connection.
  • Excludes failures limited to the quality of clinical care after a trainee has received suitable supervision and competence assurance.
  • Excludes ordinary disagreements about mentor preference or trainee progression where no continuing failure in the supervision or competence-assurance process is identified.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2016–2025

First to latest report issue date

Stated actions
3

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 Care3
Birmingham Women'S and Children'S NHS Foundation Trust1
Care Quality Commission1
Lifeskills Medical (UK) Limited1
NHS England1
Queen Victoria Hospital NHS Foundation Trust1

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.

  1. Birmingham and Solihull

    AI-generated summary

    Aarav Pal CHOPRA · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Aarav Pal CHOPRA died on 22 November 2023 after an intercostal artery was damaged during a liver biopsy, causing a haemothorax, cardiac arrest and hypoxic brain injury. The report identified concerns about inadequate planning and communication, delayed recognition and treatment of the haemothorax, unclear decision-making, trainee competence, consent, patient risk factors, prophylactic antibiotics, learning from deaths and access to complete electronic records.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a mechanism to evidence trainees' experience and competence across hospital trusts

    Wider context from the report

    “2. Experience and competence of trainees: The inquest heard evidence that there was confusion around the experience and level of the trainee involved. He was thought to be an ST6 when he was an ST4. My concern is that there is no mechanism to evidence trainees experience and competence when they travel to various different hospital trusts as part of their training. ”

    Source location

    Aarav Pal CHOPRA · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Share trainee competence and support information in local faculty group meetings.

    Verbatim wording from the response

    “We will ensure that this process is strengthened further:”

    Source location

    Response from Birmingham Women's and Children's NHS Foundation Trust
    Page 2 · response
    Published 13 January 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Require trainers to discuss trainee competence and support with the named educational or clinical supervisor before procedures or treatment.

    Verbatim wording from the response

    “We will ensure that this process is strengthened further:”

    Source location

    Response from Birmingham Women's and Children's NHS Foundation Trust
    Page 2 · response
    Published 13 January 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Communicate strengthened trainee oversight arrangements to consultants and monitor them through postgraduate education governance.

    Verbatim wording from the response

    “4. The Chief Medical Officer has communicated with the consultant body in the recent Senior Medical and Dental Staff Committee meeting and has followed this up with an email.”

    Source location

    Response from Birmingham Women's and Children's NHS Foundation Trust
    Page 2 · response
    Published 13 January 2025

    Open published response
  2. West Sussex

    AI-generated summary

    Dennis Allen Teesdale · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Dennis Allen Teesdale underwent surgery including insertion of a PEG tube on 17 October 2016 and subsequently developed severe abdominal pain, multi-organ failure and septic shock. He was found to have peritonitis caused by leakage of bowel contents from the PEG tube passing through the bowel, and died on 20 October 2016. Concerns included the insertion and post-operative management of the PEG, delayed recognition and treatment of deterioration, delayed transfer, and limitations in specialist, diagnostic and laboratory services at Queen Victoria Hospital.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of assured general surgical competence in out-of-hours cover

    Wider context from the report

    “9. Mr Teesdale was cared for ‘out of hours’ by a trainee oral-maxillo-facial surgeon with unknown general surgical experience who did not recognise or manage the severity of a surgical complication. ”

    Source location

    Dennis Allen Teesdale · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    NHS Improvement, NHS England, and the Care Quality Commission, working with the Trust and commissioners, were responsible for ensuring appropriate action.

    Verbatim wording from the response

    “Finally, I am satisfied that the regulators are alert to the risks you have highlighted, and it is for NHS Improvement, NHS England and the Care Quality Commission, working with the Trust and its commissioners, to ensure sufficient and appropriate action is taken to address the concerns raised. My officials have asked to be kept informed of developments.”

    Source location

    2017-0202-Response-by-Department-of-Health
    Page 3 · response
    Published 28 July 2017

    Open published response
  3. South London

    AI-generated summary

    Rio Andrew · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Rio Andrew became unwell after taking MDMA at an illegal rave and was taken to the event medical providers. The inquest concluded that he died from multiple organ failure due to acute MDMA intoxication. Concerns included the lack of regulation of medical assistance at temporary events, poor medical knowledge among private medical staff, the unregulated use of the title “ambulance technician”, and inadequate oversight of training mentors.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure the suitability of mentors for trainee medical staff

    Wider context from the report

    “(3) Individuals undergoing training at Lifeskills UK Ltd (and possibly other private training providers) are left to find their own mentor(s) without checks being made by the company as to their suitability or any register or panel from which the choice can be made. ”

    Source location

    Rio Andrew · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026