Concerns raised 11 Lack of robust clinical governance and multidisciplinary team processes for community urology services View source Delays in assessment, diagnosis, treatment and transfer of postoperative sepsis View source Lack of robust assessment and guidelines for independent private-sector practising privileges View source Lack of appraisal and mandatory assessment of community urology clinicians View source Lack of multidisciplinary assessment and senior consultant oversight of community urology patients View source Lack of independent review of deaths for learning and practice change View source Failure of senior clinicians to retain responsibility for patients throughout private hospital care View source Lack of regular morbidity and mortality review of community urology complications View source Failure to assess whether patients are fit for operative procedures at the hospital View source Failure to fully inform patients of clinicians’ relevant experience View source Failure to integrate community urology services with hospital-based consultant-led urology services View source See 8 more concerns
Responses linked to these concerns
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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. The report was sent to Goring Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of robust clinical governance and multidisciplinary team processes for community urology services
Wider context from the report “1. Lack of clinical governance of the Community Urology Service (CUS) by the Integrated Care Board (ICB) who commissioned the service and Sussex Medical Chambers (SMC) who were responsible for providing the service
The Integrated Care Board contracted Sussex Medical Chambers to provide a Community Urology Service through any qualified provider in 2015 and renewed the contract through a competitive tendering process twice subsequently. The ICB used a generic contract supplied by NHS England to contract the service. Neither the IB nor SMC were able to provide any evidence of robust clinical governance or multi-disciplinary team processes to ensure best practice of urology services from inception to date.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Goring Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in assessment, diagnosis, treatment and transfer of postoperative sepsis
Wider context from the report “6. Management of Mr Hankin at Goring Hall Hospital
There were multiple omissions in the pre-operative, intra-operative and post operative care provided by Goring Hall Hospital which individually and collectively contributed to Mr Hankin’s death. This included a failure to recognise Mr Hankin underlying medical co-morbidities rendered him unfit to have his operative procedure at the hospital. More specifically the post-operative assessment and support provided by the consultant anaesthetist and surgeon led to a delay in assessing and diagnosing sepsis and thereafter giving appropriate and timely antibiotics and facilitating an earlier transfer to the NHS Hospital for further management . This gives rise to a concern that there was a lack of understanding by the senior clinicians (in the absence of any local and national guidelines provided at the inquest) requiring them to remain responsible for the care of patients throughout their time in a private hospital rather than delegating the care to a Resident Medical Officer who is more likely than not to be insufficiently experienced in managing such critical situations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Goring Hall Hospital; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Goring Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of appraisal and mandatory assessment of community urology clinicians
Wider context from the report “3. Lack of appraisal and mandatory assessment of clinicians employed by CUS
There was an absence of any appraisal and/or mandatory assessments within the CUS or the ICB and SMC for the associate specialist clinicians who were working extra-contractually outside of their NHS work. No evidence was provided as to their experience and competency. This gives rise to a concern that their working practices are insufficiently assessed and fails to fulfil GMC ‘good practice’ guidelines. Likewise, no evidence was provided regarding regular morbidity and mortality reviews of complications by the ICB, CUS and SMC such as when patients re-present to NHS hospitals with complications arising from the CUS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Goring Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of multidisciplinary assessment and senior consultant oversight of community urology patients
Wider context from the report “2. Lack of Integration of the Community Urology service with NHS Hospital Urology Services
The CUS provided community-based urology services with non-consultant grade urologists without any oversight or integration with hospital-based consultant led urology services. Whilst there was an opportunity for CUS to refer more complex patients to NHS Hospital Trusts the ‘silo’ effect of these 2 services was such that they effectively worked independently of each other. The absence of a robust multidisciplinary team assessment within the CUS and the lack of senior clinical oversight of community urology patients by NHS consultant clinicians leads to a concern that the urology service is fragmented and does not effectively support urology patients within the region to confirm best practice and optimal treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Goring Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of independent review of deaths for learning and practice change
Wider context from the report “5. Learning from Mr Hankin’s death
The ICB did not independently review the circumstances of Mr Hankin’s death to confirm if there was any learning or changes in practice to prevent further deaths. Likewise, SMC relied on ████████ to inform them and investigate Mr Hankin’s death without considering the inherent conflict of interest in so doing . The lack of an independent review prevented any proactive learning and changes in practice following the death of Mr Hankin. This gives rise to a concern that the system within the ICB and SMC are insufficiently robust and could – as it was with Mr Hankin – prevent transparency and openness as to the circumstances of his death and limit any learning and or necessary changes in practice to prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Goring Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of senior clinicians to retain responsibility for patients throughout private hospital care
Wider context from the report “6. Management of Mr Hankin at Goring Hall Hospital
There were multiple omissions in the pre-operative, intra-operative and post operative care provided by Goring Hall Hospital which individually and collectively contributed to Mr Hankin’s death. This included a failure to recognise Mr Hankin underlying medical co-morbidities rendered him unfit to have his operative procedure at the hospital. More specifically the post-operative assessment and support provided by the consultant anaesthetist and surgeon led to a delay in assessing and diagnosing sepsis and thereafter giving appropriate and timely antibiotics and facilitating an earlier transfer to the NHS Hospital for further management. This gives rise to a concern that there was a lack of understanding by the senior clinicians (in the absence of any local and national guidelines provided at the inquest) requiring them to remain responsible for the care of patients throughout their time in a private hospital rather than delegating the care to a Resident Medical Officer who is more likely than not to be insufficiently experienced in managing such critical situations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Goring Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of regular morbidity and mortality review of community urology complications
Wider context from the report “3. Lack of appraisal and mandatory assessment of clinicians employed by CUS
There was an absence of any appraisal and/or mandatory assessments within the CUS or the ICB and SMC for the associate specialist clinicians who were working extra-contractually outside of their NHS work. No evidence was provided as to their experience and competency. This gives rise to a concern that their working practices are insufficiently assessed and fails to fulfil GMC ‘good practice’ guidelines. Likewise, no evidence was provided regarding regular morbidity and mortality reviews of complications by the ICB, CUS and SMC such as when patients re-present to NHS hospitals with complications arising from the CUS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Goring Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to assess whether patients are fit for operative procedures at the hospital
Wider context from the report “6. Management of Mr Hankin at Goring Hall Hospital
There were multiple omissions in the pre-operative, intra-operative and post operative care provided by Goring Hall Hospital which individually and collectively contributed to Mr Hankin’s death. This included a failure to recognise Mr Hankin underlying medical co-morbidities rendered him unfit to have his operative procedure at the hospital . More specifically the post-operative assessment and support provided by the consultant anaesthetist and surgeon led to a delay in assessing and diagnosing sepsis and thereafter giving appropriate and timely antibiotics and facilitating an earlier transfer to the NHS Hospital for further management. This gives rise to a concern that there was a lack of understanding by the senior clinicians (in the absence of any local and national guidelines provided at the inquest) requiring them to remain responsible for the care of patients throughout their time in a private hospital rather than delegating the care to a Resident Medical Officer who is more likely than not to be insufficiently experienced in managing such critical situations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Goring Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to fully inform patients of clinicians’ relevant experience
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Goring Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to integrate community urology services with hospital-based consultant-led urology services
Wider context from the report “2. Lack of Integration of the Community Urology service with NHS Hospital Urology Services
The CUS provided community-based urology services with non-consultant grade urologists without any oversight or integration with hospital-based consultant led urology services . Whilst there was an opportunity for CUS to refer more complex patients to NHS Hospital Trusts the ‘silo’ effect of these 2 services was such that they effectively worked independently of each other . The absence of a robust multidisciplinary team assessment within the CUS and the lack of senior clinical oversight of community urology patients by NHS consultant clinicians leads to a concern that the urology service is fragmented and does not effectively support urology patients within the region to confirm best practice and optimal treatment.
” Open source report
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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 Publish personal profiles for consultants on the hospital website, alongside GMC Specialist Register information, to provide patients with transparent experience information.
Verbatim wording from the response “Turning to the second part of the concern, which suggests a breach of the statutory duty of candour placed on all hospitals regulated by the CQC. This duty requires healthcare providers to be open and transparent with their patients. For the reasons stated above, I have found no basis on which it can fairly be asserted that CHG is breaching the statutory duty of candour or otherwise failing to be transparent. It should also be noted that CHG’s website publishes personal profiles for all consultants who provide services at CHG facilities. This is in addition to the detail provided on the GMC Specialist Register, which confirms their registration and any restrictions on it. Taking the example of the treating surgeon in Mr Hankin’s case, the personal profile on CHG’s website is detailed and fully transparent about his extensive experience.” Source location Response from Circle Health Group
Open published response
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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
Open published response
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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 Require consultants to retain responsibility for patients throughout their clinical pathway under the Practising Privileges policy.
Verbatim wording from the response “I can confirm that GHH, as with all CHG sites, operates a consultant-led care model which is adopted across the private sector. Consultants’ responsibilities are clearly and robustly identified in CHG’s Practising Privileges policy, which draws upon the GMC’s Good Medical Practice and associated national guidance with which all doctors are expected to comply. CHG’s policy explicitly states: “The practitioner retains responsibility for patients they have treated during the patient’s entire clinical pathway in the relevant CHG hospital”.” Source location Response from Circle Health Group
Open published response
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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 Implement a Care of the Deteriorating Patient policy defining consultant and Resident Medical Officer responsibilities and requiring escalation when consultants fail to respond appropriately.
Verbatim wording from the response “Consultants’ responsibilities are further reiterated within the comprehensive suite of clinical policies that are implemented across the CHG estate. Of particular relevance in this case is CHG’s Care of the Deteriorating Patient policy, which plainly sets out the expectations of both consultants and RMOs when managing patient deteriorations, and is incontrovertibly clear that consultants remain responsible for clinical care throughout a patient’s stay in a CHG hospital. Further, the policy mandates that a failure by a consultant to respond in line with their responsibilities must be escalated to the senior management team within the hospital.” Source location Response from Circle Health Group
Open published response
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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
Open published response
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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 policies sufficiently establish consultants’ continuing responsibility for patients and define RMO and consultant responsibilities during deterioration.
Verbatim wording from the response “I can confirm that GHH, as with all CHG sites, operates a consultant-led care model which is adopted across the private sector. Consultants’ responsibilities are clearly and robustly identified in CHG’s Practising Privileges policy, which draws upon the GMC’s Good Medical Practice and associated national guidance with which all doctors are expected to comply. CHG’s policy explicitly states: “The practitioner retains responsibility for patients they have treated during the patient’s entire clinical pathway in the relevant CHG hospital”.” Source location Response from Circle Health Group
Open published response
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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 its consultant-responsibility policies clear and effective, requiring no revision or further action at this time.
Verbatim wording from the response “Consultant compliance with their responsibilities is monitored and ensured through a combination of incident reporting and monitoring, appraisal, biennial review, a wider-reaching and robust audit programme and Freedom to Speak Up escalation channels. Any concerns about consultant performance are addressed appropriately under CHG’s Responding to Concerns about Medical Practitioners policy. I can therefore confirm that CHG has given careful consideration to the concerns identified and is satisfied that its policies are clear, effective in their aim, and that no revision or further action is required at this time. As is the case with all policies, and as mentioned above, these are reviewed regularly to ensure ongoing compliance with best practice.” Source location Response from Circle Health Group
Open published response
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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 disputes breaching the statutory duty of candour, relying on consultant profiles and GMC registration information as transparent disclosures to patients.
Verbatim wording from the response “Turning to the second part of the concern, which suggests a breach of the statutory duty of candour placed on all hospitals regulated by the CQC. This duty requires healthcare providers to be open and transparent with their patients. For the reasons stated above, I have found no basis on which it can fairly be asserted that CHG is breaching the statutory duty of candour or otherwise failing to be transparent. It should also be noted that CHG’s website publishes personal profiles for all consultants who provide services at CHG facilities. This is in addition to the detail provided on the GMC Specialist Register, which confirms their registration and any restrictions on it. Taking the example of the treating surgeon in Mr Hankin’s case, the personal profile on CHG’s website is detailed and fully transparent about his extensive experience.” Source location Response from Circle Health Group
Open published response
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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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations