Clinical Governance

We aim to attain exceptional outcomes through healthcare services supported by robust governance

Fostered by experience

Our clinical governance (CG) leads hold the same positions in their local trusts. As a result, our framework is designed to uphold the highest standards of patient care, safety, staff wellbeing and continued professional development, and are aligned with the NHS’s Patient Safety Incident Response Framework (PSIRF).

Dedicated governance leads

Each specialty has a CG Lead overseeing project safety, incident management, and Datix investigations. Monthly meetings review incidents, assign risks, and agree on actions like duty of candour. Incident boards offer transparent visibility, forming the basis of shared Trust reports.

Performance monitoring

Audit showcases our dedication to enhancing patient care and safety while monitoring clinical competencies e.g. we track excision margins in skin cancer surgeries, comparing our consultants' rates with national standards.

Feedback & mentorship

Feedback is provided to surgeons and CG Lead. All surgeons consistently exceed national averages. If an outlier is found, a mentorship process pairs surgeons to maintain best practices. Individual surgeon reports are discussed at annual appraisals to ensure compliance with revalidation requirements.

Continuous improvement

Our nurses and surgeons are urged to attend relevant national and international meetings to stay updated on current standards and uphold clinical excellence.


Governance framework

Clinical governance is a multifaceted framework that ensures healthcare organisations maintain the highest standards of quality, safety, and ethical conduct.

Clinical Incident Management

Incidents managed promptly by nurse-in-charge and consultant-in-charge, with clear escalation guidelines. Consultant-in-charge ensures patient safety. Reports documented, uploaded, and discussed at CG meetings. Each incident investigated by specialty's CG Lead, findings shared with Trust. Dialogue with patients includes duty of candour. Changes audited for effectiveness. Incident boards aid management, accessible to partner Trusts.

Complaint Handling

Complaints addressed within 24 hours, initiated by CG Lead and Medical Director. Presented at Clinical Governance meetings, with outcomes recorded and actioned. Multidisciplinary team collaborates for fair responses, aiming for service improvement and stakeholder trust.

Incident Reporting

Centralised systems streamline incident reporting, documentation, and tracking. Incident boards aid team communication and coordination. Account managers handle complaints directly. The Director of Operations supervises complaint handling and ensures compliance. The Medical Director provides clinical guidance and ensures standards adherence.

Complication Management

Complications are promptly addressed with patient safety prioritised. Patients receive dedicated consultant care until resolution. A 24/7 CNS line facilitates triage for post-operative issues. Comprehensive documentation is presented at monthly meetings for review. Reports ensure Trust accountability and transparency.

Ethical conduct & compliance

At The Surgical Consortium, we steadfastly uphold ethical conduct and compliance as the cornerstones of our commitment to healthcare excellence.


We operate with the highest level of integrity, ensuring that every action and decision is grounded in honesty and ethical behavior

Patient-centric ethics

Our ethical framework is deeply patient-centered, placing the well-being, autonomy, and rights of patients at the forefront of our practices

Regulatory adherence

We diligently adhere to healthcare regulations, policies, and legal standards, ensuring full compliance at all levels