Report evidence summary
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 12
Action
Publish personal profiles for consultants on the hospital website, alongside GMC Specialist Register information, to provide patients with transparent experience information.
Stated by Circle Health Group and Goring Hall Hospital Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
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 Hospital Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
Action
Require consultants to retain responsibility for patients throughout their clinical pathway under the Practising Privileges policy.
Stated by Circle Health Group and Goring Hall Hospital Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
Action
Implement a Care of the Deteriorating Patient policy defining consultant and Resident Medical Officer responsibilities and requiring escalation when consultants fail to respond appropriately.
Stated by Circle Health Group and Goring Hall Hospital Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
Action
Follow up completion of serious-incident recommendations through enhanced contract quality meetings.
Stated by NHS Surrey and Sussex Integrated Care Board Stated plannedThe respondent said that this action was planned when they made their response on 19 September 2025. View source
Action
Set clinical governance, effectiveness, patient safety and experience expectations for all commissioned services in 2026/2027 contract negotiations.
Stated by NHS Surrey and Sussex Integrated Care Board Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
Action
Issue a Contract Performance Notice to Sussex Medical Chambers requiring evidence of its clinical governance framework.
Stated by NHS Surrey and Sussex Integrated Care Board Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
Action
Serve a Contract Performance Notice on Goring Hall Hospital concerning clinical governance, serious-incident learning and quality assurance failures.
Stated by NHS Surrey and Sussex Integrated Care Board Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
Action
Review the serious incident and identify all associated learning and recommendations.
Stated by NHS Surrey and Sussex Integrated Care Board Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
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 Care Stated in progressThe respondent said that this action was in progress when they made their response on 19 September 2025. View source
Action
Implement a Managing Clinical Incidents Plan to reinforce policies, strengthen incident reviews, and increase confidence and learning.
Stated by Sussex Medical Chambers Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
Action
Implement a Communication Improvement Plan, including a referral risk assessment checklist for selecting appropriate secondary providers.
Stated by Sussex Medical Chambers Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source See 9 more actions Respondent positions A position is what a recipient says about a concern when it does not describe a specific action. 29
Position
CHG considers no additions or changes to its current practising-privileges and transparency processes necessary.
Stated by Circle Health Group and Goring Hall Hospital No action considered necessaryThe respondent said that no further action was needed. View source
Position
Existing policies sufficiently establish consultants’ continuing responsibility for patients and define RMO and consultant responsibilities during deterioration.
Stated by Circle Health Group and Goring Hall Hospital Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
CHG considers its consultant-responsibility policies clear and effective, requiring no revision or further action at this time.
Stated by Circle Health Group and Goring Hall Hospital No action considered necessaryThe respondent said that no further action was needed. View source
Position
CHG disputes breaching the statutory duty of candour, relying on consultant profiles and GMC registration information as transparent disclosures to patients.
Stated by Circle Health Group and Goring Hall Hospital Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
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 Hospital Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Appraisal and mandatory assessment of clinicians are the responsibility of their employers, Sussex Medical Chambers and Goring Hall Hospital.
Stated by NHS Surrey and Sussex Integrated Care Board Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
The ICB monitors commissioned services organisationally and does not review individual patient-level information.
Stated by NHS Surrey and Sussex Integrated Care Board Outside remitThe respondent said that this matter was outside its role or authority. View source
Position
The ICB does not employ clinicians and is therefore not responsible for their appraisal or mandatory assessment.
Stated by NHS Surrey and Sussex Integrated Care Board Outside remitThe respondent said that this matter was outside its role or authority. View source
Position
The ICB has no power over which clinicians receive practising privileges or admitting rights.
Stated by NHS Surrey and Sussex Integrated Care Board Unable to actThe respondent said that a constraint prevented them from taking the relevant action. View source
Position
The ICB is not responsible for investigating serious incidents involving individual patient care.
Stated by NHS Surrey and Sussex Integrated Care Board Outside remitThe respondent said that this matter was outside its role or authority. View source
Position
Statutory provider choice, professional standards and referral pathways allow community urology services to manage suitable patients safely.
Stated by NHS Surrey and Sussex Integrated Care Board Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Providers are responsible for conducting serious incident investigations under the applicable Serious Incident Framework.
Stated by NHS Surrey and Sussex Integrated Care Board Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
Goring Hall Hospital is responsible for decisions about practising privileges and admitting rights.
Stated by NHS Surrey and Sussex Integrated Care Board Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
Integrated Care Boards are responsible for enforcing contracts and ensuring independent-sector providers meet patients’ needs.
Stated by Department of Health and Social Care Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
Existing governance processes, quality oversight and provider review were considered sufficient for the Community Urology Service.
Stated by Department of Health and Social Care Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
The existing urology pathway, referral routes and service specification were considered sufficient to address concerns about siloing.
Stated by Department of Health and Social Care Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
The GMC is responsible for doctors’ registration and standards, while designated bodies oversee appraisals and related fitness-to-practise concerns.
Stated by Department of Health and Social Care Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
The provider’s serious-incident review and ICB scrutiny were considered sufficient; an independent review would be considered only if learning was inadequate.
Stated by Department of Health and Social Care Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
The Integrated Care Board is responsible for commenting on actions taken following Mr Hankin's death.
Stated by Sussex Medical Chambers Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
The claim that SMC provided no evidence of robust clinical governance is rejected.
Stated by Sussex Medical Chambers Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
Further information about clinicians' experience and competency cannot be provided because of confidentiality constraints.
Stated by Sussex Medical Chambers Unable to actThe respondent said that a constraint prevented them from taking the relevant action. View source
Position
Primary-employer appraisals, annual SMC reviews and mandatory training checks are considered sufficient clinician assessment arrangements.
Stated by Sussex Medical Chambers Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Existing SMC governance structures, meetings and CQC-assessed systems are considered comprehensive and ongoing.
Stated by Sussex Medical Chambers Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Goring Hall Hospital is responsible for explaining practising-privileges processes and addressing the duty-of-candour concern.
Stated by Sussex Medical Chambers Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
Oversight and governance of Integrated Care Boards fall outside the regulatory scope of this respondent.
Stated by Care Quality Commission Outside remitThe respondent said that this matter was outside its role or authority. View source
Position
Existing appraisal and performance-review arrangements for Community Urology Service clinicians were considered consistent with nationally recognised independent-sector arrangements.
Stated by Care Quality Commission Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Sussex Medical Chambers’ clinical governance and multidisciplinary arrangements were considered acceptable under Regulation 17.
Stated by Care Quality Commission Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Failures by individual clinicians fall outside prosecutorial remit because prosecutorial powers extend only to registered providers or registered managers.
Stated by Care Quality Commission Outside remitThe respondent said that this matter was outside its role or authority. View source
Position
The Integrated Care Board is best placed to address concerns about its oversight, governance and performance.
Stated by Care Quality Commission Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source See 28 more positions
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
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 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
×
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
×
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
×
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
×
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 Follow up completion of serious-incident recommendations through enhanced contract quality meetings.
Verbatim wording from the response “Following the Inquest Goring Hall Hospital have submitted the final version of the Serious Incident which has followed the Serious Incident Framework. NHS Sussex have reviewed the incident and have identified that all learning and recommendations have been identified. NHS Sussex through enhanced contract quality meetings will follow up to ensure that recommendations are complete. The next meeting is on 14th November 2025.” Source location Response from NHS Sussex
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 Set clinical governance, effectiveness, patient safety and experience expectations for all commissioned services in 2026/2027 contract negotiations.
Verbatim wording from the response “• For 2026/2027 NHS Contract negotiations, NHS Sussex has set out its expectations in relation to quality standards which includes Clinical Governance and Effectiveness, Patient Safety and Experience for all commissioned services.” Source location Response from NHS Sussex
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 Issue a Contract Performance Notice to Sussex Medical Chambers requiring evidence of its clinical governance framework.
Verbatim wording from the response “Following the conclusion of the inquest which highlighted HM Coroner’s concerns about Sussex Medical Chamber (SMC) clinical governance NHS Sussex took the following action:” Source location Response from NHS Sussex
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 Serve a Contract Performance Notice on Goring Hall Hospital concerning clinical governance, serious-incident learning and quality assurance failures.
Verbatim wording from the response “Management of Mr Hankin at Goring Hall Hospital.
NHS Sussex ICB have served a contract performance notice to Goring Hall Hospital (Circle Health Group) in respect of services delivered at Goring Hall Hospital, following concerns about the governance and response to a serious patient safety incident. The CPN cited breaches of the NHS Standard Contract, including failure to meet clinical standards, failure to act meaningfully on serious incident learning, and lack of transparent quality assurance.” Source location Response from NHS Sussex
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 Review the serious incident and identify all associated learning and recommendations.
Verbatim wording from the response “Learning from Mr Hankin’s death.
NHS Sussex ICB is not responsible for conducting serious incident (SI) investigations regarding individual patient care this is the responsibility of the providers in line with National NHSSE Serious Incident Framework which was in place in 2023. Goring Hall Hospital completed the appropriate notifications to NHS Sussex.” Source location Response from NHS Sussex
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
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 Implement a Managing Clinical Incidents Plan to reinforce policies, strengthen incident reviews, and increase confidence and learning.
Verbatim wording from the response “In addition to the Communication Improvement Plan, SMC has implemented a Managing Clinical Incidents Plan. This plan includes provision for reinforcing policies, strengthening incident reviews and increasing confidence and learning. It was sent to you on 1 August 2025 along with our three action plans which will be reviewed in January 2026.” Source location Response from Sussex Medical Chambers
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 Implement a Communication Improvement Plan, including a referral risk assessment checklist for selecting appropriate secondary providers.
Verbatim wording from the response “I understand that your concern arises from ████████ decision to refer Mr Hankin to Goring Hall Hospital (a private provider) and not to Worthing Hospital (an NHS hospital) given his co-morbidities. SMC fully accepts this concern and, as a result of this, is trialling the referral risk assessment checklist which was sent to you on 1 August 2025. This requires all clinicians working within the CUS to complete a checklist for all surgical referrals. It is designed to ensure that all patients are referred appropriately and receive optimal treatment.” Source location Response from Sussex Medical Chambers
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
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 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
×
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
×
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
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 Appraisal and mandatory assessment of clinicians are the responsibility of their employers, Sussex Medical Chambers and Goring Hall Hospital.
Verbatim wording from the response “Lack of appraisal and mandatory assessment of clinicians employed by CUS.
NHS Sussex ICB does not directly employ the clinicians and is therefore not responsible for the appraisal or mandatory assessment of individual clinicians who are working either for the NHS or extra-contractually outside their NHS work. It is compulsory for a medical clinician to have valid GMC registration and to belong to a medical defence organisation. Appraisal and mandatory assessment are the responsibility of the employer which in this case was Sussex Medical Chambers and Goring Hall Hospital.” Source location Response from NHS Sussex
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 monitors commissioned services organisationally and does not review individual patient-level information.
Verbatim wording from the response “The role of NHS Sussex ICB through contractual management processes is to ensure that the organisational quality assurance, oversight and clinical governance processes are in place and to seek assurance where improvements are required. ICBs are required to monitor at an organisational level and do not review individual patient level information.” Source location Response from NHS Sussex
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 The ICB does not employ clinicians and is therefore not responsible for their appraisal or mandatory assessment.
Verbatim wording from the response “Lack of appraisal and mandatory assessment of clinicians employed by CUS.
NHS Sussex ICB does not directly employ the clinicians and is therefore not responsible for the appraisal or mandatory assessment of individual clinicians who are working either for the NHS or extra-contractually outside their NHS work. It is compulsory for a medical clinician to have valid GMC registration and to belong to a medical defence organisation. Appraisal and mandatory assessment are the responsibility of the employer which in this case was Sussex Medical Chambers and Goring Hall Hospital.” Source location Response from NHS Sussex
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
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 is not responsible for investigating serious incidents involving individual patient care.
Verbatim wording from the response “Learning from Mr Hankin’s death.
NHS Sussex ICB is not responsible for conducting serious incident (SI) investigations regarding individual patient care this is the responsibility of the providers in line with National NHSSE Serious Incident Framework which was in place in 2023. Goring Hall Hospital completed the appropriate notifications to NHS Sussex.” Source location Response from NHS Sussex
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 Statutory provider choice, professional standards and referral pathways allow community urology services to manage suitable patients safely.
Verbatim wording from the response “Lack of Integration of the Community Urology service with the NHS Hospital Urology Services.
Through legislation, patients have a statutory right at the point of referral from general practice to choose any available consultant-led provider able to deliver the care they require (NHS Commissioning Board and CCG (Responsibilities and Standing Rules) Regulations 2012). For non-complex Urology cases, this choice includes community providers, able to deliver more timely care for a range of minor conditions than local NHS providers.” Source location Response from NHS Sussex
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 Providers are responsible for conducting serious incident investigations under the applicable Serious Incident Framework.
Verbatim wording from the response “Learning from Mr Hankin’s death.
NHS Sussex ICB is not responsible for conducting serious incident (SI) investigations regarding individual patient care this is the responsibility of the providers in line with National NHSSE Serious Incident Framework which was in place in 2023. Goring Hall Hospital completed the appropriate notifications to NHS Sussex.” Source location Response from NHS Sussex
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 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
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 Integrated Care Boards are responsible for enforcing contracts and ensuring independent-sector providers meet patients’ needs.
Verbatim wording from the response “Those providers in receipt of NHS contracts must meet additional requirements, including meeting the provisions of the NHS Provider License and the NHS Standard Contract. These additional measures put in place specific standards which must be met. Contracts to private providers can be and are terminated where these are not met. ICBs are responsible for enforcing contracts with providers, including independent sector providers in their area, and are best placed to ensure providers are meeting the needs of their patients.” Source location Response from Department for Health and Social Care
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 governance processes, quality oversight and provider review were considered sufficient for the Community Urology Service.
Verbatim wording from the response “Regarding the commissioning of the CUS, Care Quality Commission (CQC) Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires effective governance processes are in place to complete registration of a regulated service, and the ICB have a contracting checklist that confirms provider governance is in place. As such, SMC have these processes in place, but this was unfortunately not shared at the inquest. Their current overall CQC rating is good.” Source location Response from Department for Health and Social Care
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 The existing urology pathway, referral routes and service specification were considered sufficient to address concerns about siloing.
Verbatim wording from the response “With view to the siloing of CUS and NHS hospital urology work, the CUS is part of the Urology Pathway and manages “low risk” individuals. There are referral routes to the NHS pathway as clinically required. An issue was raised by the NHS Consultant giving evidence at the inquest for University Hospitals Sussex, but no formal concerns were raised to the ICB and this remains the case. The CUS service specification was met by the Provider, and all recruitment checks are managed by the Providers of the service.” Source location Response from Department for Health and Social Care
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 GMC is responsible for doctors’ registration and standards, while designated bodies oversee appraisals and related fitness-to-practise concerns.
Verbatim wording from the response “The General Medical Council (GMC) is responsible for ensuring that doctors have the necessary skills and knowledge to join its UK registers. All doctors must register with the GMC, and meet the expected standards set out in the GMC’s Good medical practice to work in the UK: https://www.gmc-uk.org/professional-standards/standards-for-doctors/good-medical-practice. Doctors must also hold a licence to practice medicine.” Source location Response from Department for Health and Social Care
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 The provider’s serious-incident review and ICB scrutiny were considered sufficient; an independent review would be considered only if learning was inadequate.
Verbatim wording from the response “Regarding reviewing the causes of Mr Hankin’s death and the risk of a lack of transparency, Mr Hankin’s case was reviewed by the provider under the National Serious Incident (SI) framework as it occurred in 2023. NHS Sussex have reviewed the SI as per ICB scrutiny process and the SI has been closed. This provider review is the same process that any provider would undertake following the SI Framework. The ICB would consider an independent review if the quality of the provider report was an issue or did not elicit appropriate learning. The provider SI identified appropriate learning and subsequent actions.” Source location Response from Department for Health and Social Care
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 Integrated Care Board is responsible for commenting on actions taken following Mr Hankin's death.
Verbatim wording from the response “We will leave it to the ICB to comment on any actions it took following Mr Hankin's death. Insofar as your concerns regarding SMC's review of his death are concerned, it is incorrect to say that ████████ allegedly investigated Mr Hankin's death. The circumstances of his death were reviewed at a clinical governance meeting on 1 November 2023 at which I was present along with ████████ who is a consultant in renal medicine at University Hospitals Sussex NHS Foundation Trust, ████████ (Director), ████████ (Operations Managers). We discussed the events leading up to Mr Hankin's death and the fact that Goring Hall Hospital was conducting its own investigation into Mr Hankin's care. We wrote to Goring Hall Hospital offering to input into their investigation, as is usual when treatment spans multiple providers.” Source location Response from Sussex Medical Chambers
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 The claim that SMC provided no evidence of robust clinical governance is rejected.
Verbatim wording from the response “Your concerns regarding how the ICB commissioned CUS will no doubt be addressed by the ICB. I strongly refute your comment that SMC has provided no evidence of robust clinical governance however. In my evidence I answered your questions about the quarterly meetings that take place between the ICB and SMC. I expanded on my oral evidence in my letter of 1 August 2025 by explaining that these are contract review meetings that are held and chaired by the ICB. I confirmed that during these meetings, metrics and performance data is reported and discussed and governance issues are addressed. I offered to request the minutes of these meetings from the ICB so that you could reassure yourself about the nature and content of our discussions, however you chose not to request these.” Source location Response from Sussex Medical Chambers
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 Further information about clinicians' experience and competency cannot be provided because of confidentiality constraints.
Verbatim wording from the response “In the absence of you requesting further information as to experience and competency, CUS was not in a position to address your concerns and is unable to do so in this response for confidentiality reasons.” Source location Response from Sussex Medical Chambers
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 Primary-employer appraisals, annual SMC reviews and mandatory training checks are considered sufficient clinician assessment arrangements.
Verbatim wording from the response “the appraisal process in my statement of 27 June 2025. I confirmed in that all clinicians employed in the CUS are employed in a primary clinical role elsewhere and work for our organisation as a secondary role. The primary role is usually within an NHS Trust but occasionally is within another regulated health care provider. Each primary organisation is required to carry out an annual appraisal which involves considering previous appraisals, checking CPD is kept up to date, ensuring all mandatory training has been completed, considering feedback and looking into serious events and complaints, as well as other internal processes. It is standard practice for the primary appraiser to ask the CUS to input into these appraisals, which we always do on request.” Source location Response from Sussex Medical Chambers
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 SMC governance structures, meetings and CQC-assessed systems are considered comprehensive and ongoing.
Verbatim wording from the response “I also gave evidence about the quarterly clinical governance meetings held within SMC. I provided you with the minutes of these meetings from 2020 onwards in the bundle of documents that accompanied my letter of 1 August 2025. CUS's clinical governance arrangements are reviewed and assessed by the CQC and, following our last inspection, in November 2022 it was determined that the structures, processes and systems to support good management were clearly set out and understood, leaders held regular update meetings to discuss and review the service and there was effective staff meeting structure and systems for cascading information within the organisation.” Source location Response from Sussex Medical Chambers
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 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
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 Oversight and governance of Integrated Care Boards fall outside the regulatory scope of this respondent.
Verbatim wording from the response “We are unable to comment on the aspects of this concern that relate to the Integrated Care Board (ICB) as it falls outside the scope of our regulatory responsibilities. The Integrated Care Board (ICB), as a named respondent in this case, would be best placed to address this point and provide further clarification.” Source location Response from Care Quality Commission
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 appraisal and performance-review arrangements for Community Urology Service clinicians were considered consistent with nationally recognised independent-sector arrangements.
Verbatim wording from the response “We were satisfied that this demonstrated that appraisals were performed in line with nationally recognised arrangements for individuals working in the independent sector.” Source location Response from Care Quality Commission
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 Sussex Medical Chambers’ clinical governance and multidisciplinary arrangements were considered acceptable under Regulation 17.
Verbatim wording from the response “We were satisfied that the evidence provided demonstrated acceptable arrangements under Regulation 17: Good Governance.” Source location Response from Care Quality Commission
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 Failures by individual clinicians fall outside prosecutorial remit because prosecutorial powers extend only to registered providers or registered managers.
Verbatim wording from the response “CQC’s prosecutorial powers only extend to registered persons. A registered person means either the provider or their registered manager. Failures by individuals are not within our remit; therefore, we cannot pursue this matter any further.” Source location Response from Care Quality Commission
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 The Integrated Care Board is best placed to address concerns about its oversight, governance and performance.
Verbatim wording from the response “While the Care Quality Commission (CQC) has statutory powers to regulate providers of health and social care services, we do not hold regulatory authority over Integrated Care Boards (ICBs). Responsibility for the oversight, governance, and performance of ICBs lies with NHS England.” Source location Response from Care Quality Commission
Open published response
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 5 1 Monitor consultant compliance through incident reporting, appraisal, biennial review, audit and Freedom to Speak Up escalation channels.
Stated by Circle Health Group and Goring Hall Hospital Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source 2 Review the three action plans in January 2026.
Stated by Sussex Medical Chambers Stated plannedThe respondent said that this action was planned when they made their response on 19 September 2025. View source 3 Establish a Specific Incident Progression Team and strengthen support for inspection teams to ensure consistent incident follow-up.
Stated by Care Quality Commission Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source 4 Request and review Goring Hall Hospital’s updated action plan to verify full implementation of incident-related actions.
Stated by Care Quality Commission Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source 5 Continue monitoring provider compliance with regulatory standards and ensure learning from the case is embedded into practice.
Stated by Care Quality Commission Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source Recipient positions A position is what a recipient says about a concern when they do not describe a specific action. 4 1 The surgeon’s use of the title “consultant” in private practice was not inappropriate because his GMC registration permitted work at consultant grade.
Stated by Circle Health Group and Goring Hall Hospital Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source 2 The claim that the clinical lead was a non-consultant-grade urologist is rejected.
Stated by Sussex Medical Chambers Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source 3 Goring Hall Hospital is responsible for addressing concerns about management at that hospital.
Stated by Sussex Medical Chambers Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source 4 The General Medical Council is responsible for professional registration and qualifications and is best placed to address that aspect.
Stated by Care Quality Commission Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
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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 Monitor consultant compliance through incident reporting, appraisal, biennial review, audit and Freedom to Speak Up escalation channels.
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 action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the three action plans in January 2026.
Verbatim wording from the response “In addition to the Communication Improvement Plan, SMC has implemented a Managing Clinical Incidents Plan. This plan includes provision for reinforcing policies, strengthening incident reviews and increasing confidence and learning. It was sent to you on 1 August 2025 along with our three action plans which will be reviewed in January 2026.” Source location Response from Sussex Medical Chambers
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 Establish a Specific Incident Progression Team and strengthen support for inspection teams to ensure consistent incident follow-up.
Verbatim wording from the response “In addition, CQC have taken steps to strengthen support for inspection teams to ensure the Specific Incident process is consistently followed in future cases in line with CQC’s Specific Incident guidelines. To enhance our oversight of Specific Incidents, we have established a Specific Incident Progression Team. This team supports inspection staff in meeting our responsibilities for incident follow-up and ensures alignment with our enforcement powers. As you may be aware, since 1 April 2015, the Commission has held responsibility for prosecuting registered persons for failures to provide safe care and treatment where service users have been exposed to or sustained avoidable harm, under Regulations 12(1) and 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” Source location Response from Care Quality Commission
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 Request and review Goring Hall Hospital’s updated action plan to verify full implementation of incident-related actions.
Verbatim wording from the response “Since receiving the Regulation 28 Report, we have reflected on our regulatory response and have acknowledged that while the majority of actions had already been completed, we did not follow up with Goring Hall Hospital (GHH) to confirm full implementation of their actions. We have since asked GHH for their updated action plan to ensure full implementation.” Source location Response from Care Quality Commission
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 Continue monitoring provider compliance with regulatory standards and ensure learning from the case is embedded into practice.
Verbatim wording from the response “I trust that the considered response provided, alongside the actions undertaken by the Care Quality Commission, offers the necessary assurance in accordance with our regulatory responsibilities. We will continue to monitor the provider’s compliance with regulatory standards and ensure that learning from this case is embedded into practice. We remain committed to supporting improvements in patient safety and care quality across all services.” Source location Response from Care Quality Commission
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 The surgeon’s use of the title “consultant” in private practice was not inappropriate because his GMC registration permitted work at consultant grade.
Verbatim wording from the response “While the first of the above listed concerns was not specifically directed to GHH, we understand it was prompted by the use of the title “consultant” by Mr Hankin’s treating surgeon at GHH when he had not held a consultant post in the NHS. As was clarified at the inquest hearing, the surgeon in question had worked in the NHS for approximately 18 years, prior to retiring to focus on his private practice. He has been registered on the GMC Specialist Register since 23 April 2008. The GMC-designated terms of the surgeon’s registration confirm that he “may work at any grade in the NHS including consultant”. We therefore see no fair basis on which it can be deemed inappropriate for the surgeon to adopt the title of “consultant” for his private 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 The claim that the clinical lead was a non-consultant-grade urologist is rejected.
Verbatim wording from the response “As I confirmed in my letter of 1 August 2025, when the CUS was first established in 2011, the clinical lead was a professor in urology. The professor led the service until 2014 following which ████████ took over as the lead clinician. ████████ had been given an honorary consultant position by Western Sussex Hospitals NHS Foundation Trust in May 2009 having been accepted onto the GMC Specialist Register in April 2008 and having practised in a consultant urologist role at BMI Goring Hall Hospital from December 2008. The ICB had been provided with ████████ CV and were fully aware of his background and experience. We do not accept that he is a "non-consultant grade urologist" as per your report. ████████ GMC registration states he may work at any grade including consultant.” Source location Response from Sussex Medical Chambers
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 Goring Hall Hospital is responsible for addressing concerns about management at that hospital.
Verbatim wording from the response “This concern is for Goring Hall Hospital to address.” Source location Response from Sussex Medical Chambers
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 The General Medical Council is responsible for professional registration and qualifications and is best placed to address that aspect.
Verbatim wording from the response “We recognise that the General Medical Council (GMC) is responsible for ensuring that all doctors, physician associates (PAs), and anaesthesia associates (AAs) practising in the UK have the appropriate knowledge, skills, qualifications, and experience. They fulfil this role by maintaining official registers of these professionals. We are unable to comment on the GMC regulatory responsibilities. The GMC is best placed to respond to this aspect of this question. However, we note that the GMC is not a named respondent.” Source location Response from Care Quality Commission
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