Recurring concern

Unsafe delegation of clinical duties and decisions

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First reported 16 Sep 2016•Latest report 4 Dec 2023

Definition

What this concern includes

Includes failures of controls specifically governing delegation of clinical duties or decisions, including defining delegable responsibilities, matching delegated work to competence and seniority, retaining appropriate supervision, and preventing unsuitable delegation to junior or otherwise inappropriate staff.

Not included

  • Excludes generic staffing, training or supervision deficiencies that do not concern the delegation of clinical duties or decisions.
  • Excludes failures of staff qualification or competence where no delegation decision or delegation control is identified.
  • Excludes failures occurring after appropriately delegated work has been accepted and supervised, unless the delegation arrangement itself was unsafe.
  • Excludes non-clinical delegation, administrative task allocation or general organisational responsibility gaps without a direct clinical-care delegation concern.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2016–2023

First to latest report issue date

Stated actions
2

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.

Aneurin Bevan University LHB1
Anglian Community Enterprise (ACE) Community Interest Company1

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. Gwent

    AI-generated summary

    Catriona Ellen Martin · 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

    Catriona Ellen Martin was admitted to hospital with autoimmune encephalitis and died on 25 December 2020 after developing dehydration, acute kidney injury and uncontrolled seizures. The report identified inadequate nursing care, including failures to observe her and administer medication, and noted concerns about reliance on her mother to provide care without clear guidance on delegation and nursing staff support.

    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 guidelines establishing the level of delegation of nursing duties

    Wider context from the report

    “At the inquest I determined that the level of care that Catriona’s mother was expected to provide was unacceptable but was informed that there are no guidelines to establish the level of delegation of nursing duties in such circumstances, and the requirement of the nursing team to not only continue to supervise care but to support and intervene as required. ”

    Source location

    Catriona Ellen Martin · 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

    Deliver staff education and training on safe delegation of care, family involvement and use of the enhanced observation framework.

    Verbatim wording from the response

    “Following the raising of the matters of concern, it is recognised that additional training and education is required to ensure staff are clear in their responsibilities in regards appropriate delegation of care to family members. This can include patient care that is not only prescribed through cognitive impairment but is associated with acuity and complexity associated with intervention such as, post operative procedures. Education and training will be delivered via Patient Safety and Quality focused study sessions, supported by a bespoke programme of work with the Person-Centred Care Team. Throughout this work increased emphasis will be placed on appropriate and safe delegation, family involvement and utilising the framework not only for those patients with cognitive impairment but for those patients with complex medical acuity.”

    Source location

    Response from Aneurin Bevan University Health Board
    Page 2 · response
    Published 11 December 2023

    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

    Revise the enhanced observation framework to document family discussions, delegation responsibilities and collaborative care planning.

    Verbatim wording from the response

    “The Health Board is currently in the process of revising the Person-Centred Enhanced Observational Framework. The revised version will include the following requirements to be documented:”

    Source location

    Response from Aneurin Bevan University Health Board
    Page 2 · response
    Published 11 December 2023

    Open published response

  2. Essex

    AI-generated summary

    Martha Ann Davies · 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

    Martha Ann Davies, a 98-year-old woman, fell at home, underwent surgery for a fractured hip, was transferred for rehabilitation, suffered a further fall, and died in hospital on 29 November 2015. The report identified concerns including communication failings, reliance on agency and junior staff, delayed response to deterioration, lack of engagement by ward staff and management, and documentation failings; the inquest concluded that she did not receive adequate care and appropriate treatment at Clacton District Hospital, which may have contributed to her death.

    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 appropriately senior staff make decisions

    Wider context from the report

    “(2) Over reliance upon agency staff and on junior staff to make decisions ”

    Source location

    Martha Ann Davies · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026