“The Inquest heard evidence that Mr”

The coroner’s concerns

The Inquest heard evidence that Mr. Starbuck’s care and treatment for his skin cancers was initially provided privately. National guidance published by the National Institute for Health and Care Excellence (NICE) sets out that any patient with a high risk Squamous Cell Carcinoma (SCC) should be referred to a specialist skin MDT (SSMDT.) Specifically, this is something which should have occurred following excision of a SCC. This is mandated practice within the NHS and the overwhelming evidence before me was that this applied to clinicians practicing in NHS. The situation in relation to patients being treated privately was less clear; evidence Regulation 28 – After Inquest Document Template Updated 30/07/2021 from several witnesses ranged from the position that this guidance was as binding on clinicians treating patients privately as in NHS, to the guidance was just that ‘guidance’ to be applied by the clinician within the framework of care being provided privately. The latter was relevant in the context of how clinicians treating patients privately would access the SSMDT. The evidence received was that normally this was via the treating clinician taking the patient to the relevant NHS SSMDT or in less frequent occasions where the Hospital had a private SSMDT to deal with patients being treated privately. No mandatory policy exists beyond the NICE guidance. As a consequence, whilst the policy is mandated for patients in receipt of NHS Care and Treatment, it is not mandatory for patients being treated for the same conditions privately. There are many clinicians who import the NICE Guidelines into their private practice, along with NHS Trusts who accept referrals from clinicians treating patients privately into the SSMDT for consideration. However, as this is not mandated practice for either clinicians or convenors of SSMDT’s, the consequence is that patients treated privately are at risk of receiving inferior care to those treated under the NHS, often within the same physical hospital setting. I am concerned that there is a lacuna in mandated care standards for patients treated privately by clinicians within the regulatory framework which gives rise to a risk of death.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0204

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0