BRIS-99

Mandate direct supervision for clinicians performing new clinical procedures until expert

Bristol Heart Inquiry · Bristol Heart Inquiry — Final Report · Issued 18 July 2001

Government responseNot tracked (historical inquiry)

DeliveryDHSC and NHS England say in progress (Feb 2026)

Recommendation, verbatim from the inquiry

●Inquiry 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.

Bristol Heart Inquiry, Bristol Heart Inquiry — Final Report · 18 Jul 2001 Source PDF →

Government response

●No formal government response recorded

The Index has not yet recorded a verbatim government response to this recommendation.

Delivery

●DHSC and NHS England say in progress · 27 Feb 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.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025)

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.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024)

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.

How this page is built

The recommendation and the government responses are verbatim from primary documents. Delivery statements and other bodies' findings are shown in their own words, each with its source. The summary is written by this site and labelled as such. The Index does not paraphrase sources or characterise intent; it records what has been published.