2025

Disputed (AI summary) The Cabinet Secretary disagrees that GPs should be engaged in recalling individuals or that their clinical record systems should be amended to include prompts to recommend surveillance and suggests the health board should investigate the surveillance waiting list management.

Disputed (AI summary) The MPS expresses condolences and acknowledges the concerns. However, they dispute the coroner's view that the failure to update the facility was a conduct/performance/learning matter, stating that the DSI review was appropriate.

Disputed (AI summary) Circle Health Group disputes the need for further action regarding consultant responsibilities and practicing privileges, stating that their existing policies and monitoring systems are clear, effective, and compliant with national guidance, and that consultants' responsibilities are clearly identified in their Practicing Privileges policy. The CQC reviewed Goring Hall Hospital's updated investigation and action plan following the inquest, finding that the hospital had implemented most of the planned actions, including sharing the coroner's findings with governance committees, introducing documentation for recording antimicrobials, updating patient materials, clarifying consultant responsibilities, implementing a digital report summarising procedures, and strengthening training with sepsis scenarios and escalation protocols. They will continue to monitor the provider’s compliance. NHS Sussex has served a contract performance notice to Goring Hall Hospital following concerns about governance and response to a serious patient safety incident; Goring Hall Hospital submitted a comprehensive reply, including a revised and updated Post-Inquest Action Plan, and the finalized Serious Incident Investigation Report. NHS England has taken steps to ensure effective governance processes are in place for regulated services, NHS Sussex have visited Goring Hall and are following up on the recommendation that they refer themselves to GMC. The ICB would consider an independent review if the quality of the provider report was an issue or did not elicit appropriate learning. Sussex Medical Chambers outlines actions it will take, including reviewing and updating its Clinical Governance Policy to reflect the coroner's comments, considering further guidance for consultant appointments, and ensuring consultant indemnity insurance coverage. They will also ensure that all doctors undergo annual appraisals, provide evidence of GMC registration, and ensure policy implementation across all clinics.