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Learning from invited reviews 2014-2021

The RCP Invited Reviews service has gained a wealth of experience dealing with demanding situations involving individuals, teams, departments and services. We have recently published our learning from invited reviews report. It brings together our experiences across multiple specialities, identifying common themes and crystallising some of our generic findings, which we hope will prove useful to all in clinical leadership roles. (Link to download report below)

Key learning from invited reviews

Service design

Concerns relating to service design often concentrate on two issues:

  • whether the service reflects best practice in that specialty area
  • the sustainability of the service.

Patient safety

Patient safety issues highlighted across the reviews varied widely. Often healthcare organisations were aware of potential patient safety concerns and had already taken steps to improve care.

Consultant oversight of inpatient care

This was not always clearly visible from patient records, where there was sometimes inadequate documentation to establish which clinician and clinical team was taking ownership and responsibility for patient care. This reflects the complexity of emergency care pathways, with many patients undergoing multiple ward moves and being referred from one clinician and team to another without a clearly articulated and documented plan.

Patient experience and communication

Evidence of communication with patients and their families was often stronger when patients were on an end-of-life care pathway and weak at earlier stages of care. Some reviews identified a lack of evidence that patients had been counselled adequately regarding ‘aggressive’ or ‘risky’ treatments.

Clinical record keeping

Common omissions in clinical records included documentation of conversations with patients and their families regarding treatment options and evidence of their involvement in the management plan.

Clinical governance

Many organisations have well-established clinical governance processes, but these systems tend to operate in ‘silos’ within specialty professional groups, which undermines the sharing of learning across multi-professional teams.

Leadership and culture

A recurring concern has been that organisations have not allocated adequate time for individuals to deliver clinical leadership roles within job plans.


Physicians frequently communicated to review teams that there was a need to increase consultant numbers. More often, however, the way physicians organised their working patterns and practices held the key to addressing many of the pressures faced by the service.


Issues arising from clinical record reviews with respect to teamworking tended to focus on a lack of evidence of multidisciplinary team collaboration and discussion regarding a patient’s care, including nurse/doctor communication and the involvement of allied health professionals.