Recommendation BRIS-99: Mandate direct supervision for clinicians performing new clinical procedures until expert
From Bristol Heart Inquiry — Final Report, published 18 July 2001.
Recommendation
Any clinician carrying out any clinical procedure for the first time must be directly supervised by colleagues who have the necessary skill, competence and experience until such time as the relevant degree of expertise has been acquired.
Government response
No government response to this recommendation is on the record yet.
Delivery
DHSC and NHS England say in progress (27 February 2026)
When the Care Quality Commission assess providers, it will look for evidence that providers have systems in place to ensure that staff are recruited appropriately, operating within the limits of their capability, scope of practice and competency and provided with the appropriate information, support and supervision to enable them to carry out their role. (Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014)
NHS Employers also recently published a guide on Clinical supervision models.
Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Implemented – Ongoing”. Table row: section 6.2 No. 99, PDF page 115.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry legal team (15 May 2024)
The Government agreed with this recommendation.
In its January 2002 response, the Department of Health said that job plans for consultants included responsibility for the supervision of their staff as well as for themselves when carrying out procedures for the first time. The Department referred to the appraisal process for consultants as identifying professional development needs.
Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 6.2 No. 99, PDF page 104.
Themes and tags
Who has spoken
- DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding