Prevention of Future Deaths Report: Keith Hankin (19 September 2025)

Summary

On the 8 September 2023 Keith James Hankin was admitted to Goring Hall Hospital for an elective surgical optical urethrotomy for long standing urethral strictures. Shortly after the procedure Mr Hankin developed sepsis and was transferred to Worthing Hospital later that afternoon. Despite supportive intensive care management Mr Hankin died at the hospital on the 11 September 2023.

The Coroner’s report into his death identifies failings in the community management, pre-operative assessment, intra-operative and post operative care at Goring Hall Hospital on a background of poor clinical governance of the Community Urology Service (CUS) materially contributed to his death. She states that there was a gross failure to provide basic medical attention to Mr Hankin when he was dependent on it and concludes that Mr Hankin died from a recognised complication of a surgical procedure contributed to by neglect.

Content

The report identifies the following matters of concern:

• 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 Coroner states that neither the ICB 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.
• Lack of Integration of the CUS with NHS Hospital Urology Services. The Coroner said that the ‘silo’ effect of these two services was such that they effectively worked independently of each other.
• 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.
• The Coroner notes that this case 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 practicing privileges to work independently outside of the NHS to the potential detriment of patient care.
• The lack of an independent review prevented any proactive learning and changes in practice following the death of Mr Hankin. The Coroner stated that 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.
• 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.