Unsafe assurance of doctors' procedural competence
First to latest report 20 Aug 2013 — 29 Aug 2025
Reports that mention this concern
8
Times this concern has been raised
9
Stated actions linked to this concern
15
What this concern includes
Includes failures of assessment, training, monitoring or other competence-assurance controls specifically concerning doctors performing clinical procedures.
What is not included
Excludes competence deficiencies unrelated to doctors performing clinical procedures.
Excludes failures concerning non-procedural prescribing, treatment, care planning or general professional performance.
Excludes generic staffing, documentation or training deficiencies not explicitly tied to doctors' procedural competence.
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.
Department of Health and Social Care3
NHS England2
Aston Medical School1
Birmingham Medical School1
Care Quality Commission1
Chief Medical Officer for England and Wales1
General Medical Council1
HM Prison and Probation Service1
Ministry of Justice1
Pennine Acute Hospitals NHS Trust1
Queen Victoria Hospital NHS Foundation Trust1
Recipient name withheld1
Royal College of Paediatrics and Child Health1
Sandwell and West Birmingham Hospitals NHS Trust1
Stockport NHS Foundation Trust1
Ministerial department4
NHS trust4
Type not available3
Executive non-departmental public body2
Executive agency1
Health and care professional regulator1
Health and social care service regulator1
Prison or young offender institution1
Professional body1
University faculty or school1
Reports and published responses 8 reports
See individual reports that have raised this concern, and the actions taken in response
Manchester South
Concerns raised1
Lack of competency training enabling ward doctors to undertake lumbar puncture
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Stockport NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Stockport NHS Foundation Trust
Deliver registrar lumbar-puncture training through completed simulation and ongoing supervised procedural sign-off.
Manchester South
Concerns raised1
Lack of compulsory direct observed training for paediatric middle grades performing neonatal intubation
Linked response
Royal College of Paediatrics and Child Health
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Royal College of Paediatrics and Child Health
Provide neonatal airway management training through Progress+ neonatology placements.
Royal College of Paediatrics and Child Health
Strengthen the Progress+ curriculum's neonatal airway capabilities, emphasizing non-invasive airway management and specialty-level safe intubation and difficult-airway management.
Royal College of Paediatrics and Child Health
Develop a neonatal airway safety standard with BAPM addressing skills maintenance and ongoing training.
Royal College of Paediatrics and Child Health
Signpost members to the neonatal airway safety standard and its skills-maintenance resources.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Royal College of Paediatrics and Child Health
Removing mandatory neonatal intubation DOPS does not necessarily increase risk because non-invasive airway management is safer and the former DOPS provided false reassurance.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Royal College of Paediatrics and Child Health
Operational delivery networks are responsible for supporting airway and resuscitation skill maintenance across neonatal units, particularly where skills are infrequently used.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Insufficient PAO experience among surgeons performing the procedure
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
NHS England
Trusts and orthopaedic surgeons should already recognise PAO as a specialist procedure requiring suitably trained and experienced clinicians.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
NHS England
Further comment on the specific concerns is not appropriate based on the information provided and matters addressed by the Trust.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
NHS England
Relevant clinical and professional standards and guidance are outside NHS England’s responsibility.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS England
Further information on relevant clinical and professional standards and guidance should be sought from the RCS of England or BOA.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised2
Failure to formally assess junior doctors' competence to take bloods from central lines
Failure to formally assess and monitor doctors' procedural competence
This report raised 4 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
General Medical Council
Sandwell and West Birmingham Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Department of Health and Social Care
Write to UK Postgraduate Deans requesting protected-time induction, best practice and reinforcement of Foundation Professional Capability 18.
Department of Health and Social Care
Cascade learning from the report to Postgraduate Deans and Foundation Schools, reinforcing competency, training and supervision requirements.
Sandwell and West Birmingham Hospitals NHS Trust
Reinforce to Trust trainees that central-line procedures are restricted to appropriately trained specialist settings and that Foundation doctors must not perform them.
Sandwell and West Birmingham Hospitals NHS Trust
Provide Foundation doctors theoretical central-line education, including simulation of air embolism during blood sampling.
Sandwell and West Birmingham Hospitals NHS Trust
Liaise with Health Education England to determine competency-assignment and supervision arrangements for clinical skills.
Sandwell and West Birmingham Hospitals NHS Trust
Forward clinical-skills competence summaries between rotations and require supervisors to check competency before assigning procedures.
Sandwell and West Birmingham Hospitals NHS Trust
Require documented competency and prohibit unsupervised procedures until trainees are signed off as competent.
General Medical Council
Continue working with employers, Health Education England and medical schools to monitor actions and ensure sustainable training-environment safety changes.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
General Medical Council
Central-line blood sampling should not be required of all Foundation doctors because it is specialist work requiring specific authorisation, training and direct supervision.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Sandwell and West Birmingham Hospitals NHS Trust
At the Trust, blood sampling from central venous catheters is assigned to competent nursing staff, outreach teams or medical registrars rather than Foundation doctors.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
General Medical Council
National standard operating procedures for central-line blood sampling are matters for national service and education providers such as Health Education England and NHS England.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Sussex
Concerns raised1
Lack of assured competence for peri-operative PEG insertion
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission
Department of Health and Social Care
Queen Victoria Hospital NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Queen Victoria Hospital NHS Foundation Trust
Review alternative pathways and external oversight for PEG placement, including competency-based training and accreditation.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Queen Victoria Hospital NHS Foundation Trust
QVH considers its consultants’ experience and existing PEG practice sufficient to continue PEG placement, although continuation remains under review.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Department of Health and Social Care
NHS Improvement, NHS England, and the Care Quality Commission, working with the Trust and commissioners, were responsible for ensuring appropriate action.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Care Quality Commission
Local competency assessments, experience checks and supervised practice are considered sufficient because no nationally recognised PEG training courses exist.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Portsmouth and South East Hampshire
Concerns raised1
Lack of formal monitoring schemes for inexperienced surgeons carrying out surgical procedures
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Swansea and Neath Port Talbot
Concerns raised1
Failure to ensure ACCT health-screening doctors are trained in required procedures
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.
Manchester North
Concerns raised1
Failure to ensure current competence for suprapubic procedures
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Pennine Acute Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Pennine Acute Hospitals NHS Trust
Implement urology training and competency sign-off for clinicians inserting suprapubic catheters outside urology.
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.