Recurring concern

Unreliable verification of clinicians’ competence before independent clinical practice

Get email alerts

Request correction

First reported 13 Apr 2014•Latest report 17 Sep 2025

Definition

What this concern includes

Includes failures of credentialing, practising-privileges, competence-verification or cross-Trust training-record processes where they determine whether a clinician may practise independently or undertake clinical duties without direct scrutiny, including assessment of prior experience, evidence of competence and approval by the responsible hospital or credentialing body.

Not included

Excludes general professional registration or fitness-to-practise checks where the specific concern is not verification of competence or suitability for independent clinical practice.
Excludes supervision, training quality or staffing deficiencies where no failure to verify competence before independent work is identified.
Excludes failures limited to permanent employment, appraisal or post-appointment performance monitoring when the unsafe condition is not the initial or continuing authorisation to practise independently.
Excludes patient disclosure, consent or duty-of-candour concerns that do not concern clinician credentialing or competence verification.

Reports: 2
Individual concerns: 2
Date range: 2014–2025
Stated actions: 2

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2

Care Quality Commission1

Goring Hall Hospital1

NHS Surrey and Sussex Integrated Care Board1

Sussex Medical Chambers Limited1

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.

17 Sep2025
West Sussex, Brighton and Hove
Concerns raised1
1. Lack of robust assessment and guidelines for independent private-sector practising privileges
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Apply a Practising Privileges policy requiring evidence of clinicians’ qualifications, experience, competencies and procedural activity before independent practice.
  Stated by Circle Health Group and Goring Hall HospitalStated completed
2. Action
  Complete clear, patient-focused guidance explaining NHS and independent-sector care, private-hospital consultant arrangements, emergency provision, handovers and questions for providers.
  Stated by Department of Health and Social CareStated in progress
Respondent positions 5
1. Position
  Existing practising-privileges requirements and governance arrangements sufficiently assess clinicians’ qualifications, experience and competence for independent practice.
  Stated by Circle Health Group and Goring Hall HospitalExisting arrangements considered sufficient
1. Position
  CHG considers no additions or changes to its current practising-privileges and transparency processes necessary.
  Stated by Circle Health Group and Goring Hall HospitalNo action considered necessary
2. Position
  Goring Hall Hospital is responsible for decisions about practising privileges and admitting rights.
  Stated by NHS Surrey and Sussex Integrated Care BoardRedirects responsibility
3. Position
  The ICB has no power over which clinicians receive practising privileges or admitting rights.
  Stated by NHS Surrey and Sussex Integrated Care BoardUnable to act
4. Position
  Goring Hall Hospital is responsible for explaining practising-privileges processes and addressing the duty-of-candour concern.
  Stated by Sussex Medical ChambersRedirects responsibility
AI-generated summary

Keith James Hankin · 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

Keith James Hankin was admitted for an elective optical urethrotomy on 8 September 2023, developed sepsis shortly after the procedure, was transferred to Worthing Hospital, and died there on 11 September 2023. The report identifies concerns about poor clinical governance and lack of integration, oversight and clinician assessment within the Community Urology Service, as well as multiple omissions in his pre-operative, intra-operative and post-operative care at Goring Hall Hospital, including delays in recognising and treating sepsis and transferring him for further management.

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 robust assessment and guidelines for independent private-sector practising privileges
Wider context from the report
“4. Practicing Privileges within the private sector ████████ set up and led the CUS under the auspices of SMC. The ICB contractually required this service to be run by a consultant urologist. ████████ had not held a formal consultant urologist position within the NHS prior to tendering for this work. It remains unclear as to how ████████ was provided with practicing privileges at a private hospital as a consultant and was therefore able to practice independently and without scrutiny. This gives rise to a concern that there is a lack of robust assessment and guidelines, both locally and nationally, as to how clinicians are given practising privileges to work independently outside of the NHS to the potential detriment of patient care. It also gives rise to a concern that patients are not being fully informed of the relevant experience of such clinicians thereby breaching the statutory duty of candour responsibility of all hospitals. ”
Source location
Keith James Hankin · 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
Apply a Practising Privileges policy requiring evidence of clinicians’ qualifications, experience, competencies and procedural activity before independent practice.

Verbatim wording from the response
“It should also be noted that CHG has in place, and stringently applies, a Practising Privileges policy which requires those seeking practising privileges to provide robust evidence of their qualifications, experience and competencies to ensure it is suitable for them to practise at our hospitals using the title of “consultant”. These include a requirement to provide evidence of:”

Source location
Response from Circle Health Group
Page 2 · response
Published 19 September 2025
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
Complete clear, patient-focused guidance explaining NHS and independent-sector care, private-hospital consultant arrangements, emergency provision, handovers and questions for providers.

Verbatim wording from the response
“You also raised concerns about privileges to practice in private hospitals. In response to Recommendation 3 of the Paterson Inquiry report (published in 2020), this Department is currently completing clear, patient-focused information that explains the differences”

Source location
Response from Department for Health and Social Care
Page 2 · response
Published 19 September 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing practising-privileges requirements and governance arrangements sufficiently assess clinicians’ qualifications, experience and competence for independent practice.

Verbatim wording from the response
“It should also be noted that CHG has in place, and stringently applies, a Practising Privileges policy which requires those seeking practising privileges to provide robust evidence of their qualifications, experience and competencies to ensure it is suitable for them to practise at our hospitals using the title of “consultant”. These include a requirement to provide evidence of:”

Source location
Response from Circle Health Group
Page 2 · response
Published 19 September 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
CHG considers no additions or changes to its current practising-privileges and transparency processes necessary.

Verbatim wording from the response
“Having considered your concerns carefully, CHG is satisfied that no additions or changes to its current processes are required, and that medical practitioners working within its facilities have the necessary qualifications, expertise and experience to do so, and that this is fully transparent to CHG patients.”

Source location
Response from Circle Health Group
Page 2 · response
Published 19 September 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Goring Hall Hospital is responsible for decisions about practising privileges and admitting rights.

Verbatim wording from the response
“Goring Hall Hospital is responsible for decisions regarding Practising Privileges and NHS Sussex ICB has no power over the system of who is granted admitting rights.”

Source location
Response from NHS Sussex
Page 3 · response
Published 19 September 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The ICB has no power over which clinicians receive practising privileges or admitting rights.

Verbatim wording from the response
“Goring Hall Hospital is responsible for decisions regarding Practising Privileges and NHS Sussex ICB has no power over the system of who is granted admitting rights.”

Source location
Response from NHS Sussex
Page 3 · response
Published 19 September 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Goring Hall Hospital is responsible for explaining practising-privileges processes and addressing the duty-of-candour concern.

Verbatim wording from the response
“We note that you have issued a Prevention of Future Deaths report to Goring Hall Hospital and we will therefore leave it to Goring Hall Hospital to explain its processes in relation to the practising privileges provided to ████████. We will also leave it to Goring Hall Hospital to address the point you raised regarding duty of candour, since it references hospitals and not the SMC.”

Source location
Response from Sussex Medical Chambers
Page 4 · response
Published 19 September 2025
Open published response
13 Apr2014
Leicester City and South Leicestershire
Concerns raised1
1. Failure to use robust processes for signing off locum consultants as competent for independent practice
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Lalitab en Jayantibhai Patel · 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

Mrs Patel underwent elective laparoscopic cholecystectomy on 4 May 2012, during which inappropriate dissection damaged a vessel near the common bile duct. The vessel ruptured, causing a massive secondary haemorrhage, subsequent complications and hypoxic brain injury, followed by her death on 20 December 2012; the principal concern was inadequate systems for assessing and supervising locum consultant surgeons, creating a risk of similar events elsewhere.

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 use robust processes for signing off locum consultants as competent for independent practice
Wider context from the report
“(1) The surgeon who had responsibility for the elective cholecystectomy was a Locum Consultant Surgeon and was in the second week of his 4 weeks contract. Evidence was heard that he had been appointed via an agency following which he undertook two practical assessments at the University Hospitals Leicester. In summary, there were two main issues highlighted by both assessing Consultants on two separate days resulting in a decision to restrict the Locum Consultant Surgeon to conducting routine laparoscopic cholecystectomies. However, as this was a Consultant grade Locum, no other supervision was provided in respect of the cases under his clinical management. Evidence revealed that the systems in place at the material time for signing off a locum Consultant as competent to undertake independent practice were not as robust as they should have been. The inquest heard that University Hospitals Leicester have now changed their recruitment process for Locums and that Locums must be recruited by the ‘Locum Bookers’ team in accordance with Trust policy. In addition the processes for signing off a locum consultant as competent are more robust. However, it is understood that in other areas the practice for appointing locums is not so robust and mirrors the practice undertaken at the material time. Accordingly, there is a real risk that what happened in this case could happen elsewhere. ”
Source location
Lalitab en Jayantibhai Patel · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of robust assessment and guidelines for independent private-sector practising privileges

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5

Concerns raised1

Failure to use robust processes for signing off locum consultants as competent for independent practice

Actions described in response 2

Respondent positions 5