An independent inquiry into how rogue breast surgeon Ian Paterson was able to go on performing unnecessary operations for years has uncovered a “dysfunctional” healthcare system that failed patients.
The Paterson Inquiry, launched in May 2018, published 15 recommendations on Tuesday after hearing 177 first-hand accounts from the surgeon’s former patients.
Among the recommendations it urged the NHS trust that employed Paterson and private health firm Spire Healthcare to check that all of more than 11,000 patients he treated had been recalled.
The Government should introduce reforms, including regulation of insurance protection for patients as a “nationwide safety net”, the report said.
It also called for the creation of an “accessible and intelligible” single repository of consultants’ key performance data, as a one-stop shop for patients.
It is the story of a healthcare system which proved itself dysfunctional at almost every level when it came to keeping patients safeThe Rt Rev Graham James
Inquiry chairman the Rt Rev Graham James, retired Bishop of Norwich, said patients were “let down over many years” by the NHS and independent providers, and there was “a culture of avoidance and denial”.
He said there were “missed opportunities” to stop Paterson, describing the failure to suspend him in 2003, when an NHS colleague first raised concerns, as “inexplicable”.
“It is the story of a healthcare system which proved itself dysfunctional at almost every level when it came to keeping patients safe,” he added.
The disgraced surgeon was eventually suspended eight years later – what the Bishop called an “appallingly long time”.
The inquiry has referred a health professional to West Midlands Police and five others to the General Medical Council (GMC) or Nursing and Midwifery Council (NMC).
Last month, police announced they had asked the senior coroner for Birmingham and Solihull to examine a sample of 23 deaths of former Paterson patients.
Deb Douglas, who suffered “needless” surgery at the hands of Paterson, said all the recommendations must be implemented.
Paterson carried out unnecessary operations in NHS and private hospitals, exaggerating or inventing cancer risks and claiming payments for more expensive procedures.
He was employed by Heart of England NHS Foundation Trust (HEFT) but had practising privileges in the independent sector at Spire Parkway and Spire Little Aston in Birmingham.
In 2017 he was jailed after being found guilty of 17 counts of wounding patients with intent, against 10 victims.
He was handed a 15-year prison term, but Court of Appeal judges later increased his tariff to 20 years.
In September 2017, more than 750 patients treated by Paterson received compensation payouts from a £37 million fund.
Presenting the 232-page report, the Rt Rev James praised the victims who campaigned for an inquiry and for their courage in giving often “harrowing” accounts.
He added: “Many of them were lied to, deceived or exploited.”
He added that many of more than 100 corporate witnesses who gave evidence were part of a system that “should have kept patients safe, but failed to do so”.
The senior clergyman said: “Opportunities to stop him (Paterson) were missed, time after time.”
He added there was “wilful blindness” to what Paterson was doing.
“Some could have known, some should have known – and a few must have known,” he said.
“We did give Ian Paterson an opportunity, if he wished, to meet me and other inquiry members and he declined to do so.”
Asked if there could be a repeat of the failures that allowed the disgraced surgeon to get away with malpractice for so long, he said: “We believe our range of recommendations, implemented all together, can begin to change the culture.”
A statement issued on behalf of Paterson, through his lawyers, said he had written to the inquiry and “answered all questions put to him”.
The statement said he “maintains his innocence of all of the criminal charges of which he was convicted and is actively working on an appeal against those convictions”.
Mrs Douglas provided her first-hand account to the inquiry as well as NHS figures showing that of Paterson’s 1,206 mastectomy patients, 675 had died by 2017.
She added: “If you look at the stats alone, if you were a Paterson patient you were 50% more likely to get a recurrence of breast cancer because you’ve been left with breast tissue, basically a time bomb, in your chest, ready to explode and ready to give you cancer because he didn’t remove it.”
Mrs Douglas welcomed the inquiry’s referral of individuals to authorities including the police.
Tracey Smith, another former patient, said: “I’ve always been angry, from 2012 when I was told my breast cancer surgery was unnecessary – hence why myself and Deb (Douglas) went to Whitehall and fought for this inquiry.
“We will continue to fight so that the recommendations are put in place to stop this from ever happening in the NHS or the Spire or any private hospital in the country.”
Professor Derek Alderson, president of the Royal College of Surgeons England, said: “Together, the measures outlined could help prevent another rogue surgeon in the future from getting away with the appalling and criminal behaviour the inquiry has exposed.
“However, the test will be whether Government and regulators act on these recommendations.”
Charlie Massey, GMC chief executive, said he was sorry patients were let down and welcomed the recommendations.
He added: ���A system-wide approach is needed to build on the safeguards now in place since Ian Paterson’s actions first came to light.
“We must continue to challenge problematic workplace cultures, encourage transparency, and work collaboratively to protect patients.”
Justin Ash, Spire Healthcare chief executive, said: “We once again apologise for the significant distress suffered by patients who were treated by Ian Paterson in our hospitals.
“We accept that there were a number of missed opportunities to challenge Ian Paterson’s criminal behaviour when these incidents happened prior to his suspension in 2011.
“We welcome the report and the voice it has given to patients.
“We fully support its recommendations and we will work with Government and the healthcare sector to ensure their implementation.”
Health minister Nadine Dorries said: “I deeply regret the failures of the NHS and the independent sector to protect patients from the devastating impact of Paterson’s malpractice.
“We will give thorough and detailed consideration to this report and its findings and will provide a full response in due course.”