An independent inquiry into how rogue breast surgeon Ian Paterson was able to go on performing unnecessary operations for years has uncovered a healthcare system “dysfunctional at almost every level”.
The Paterson Inquiry, launched in May 2018, published 15 recommendations on Tuesday after hearing 181 first-hand accounts from the surgeon’s former patients.
Among the recommendations, it urges both the NHS trust which employed Paterson and private health firm Spire Healthcare to check all Paterson’s patients had been recalled.
The Government should introduce reforms, including regulation of insurance protection for patients as a “nationwide safety net”, the report said.
Inquiry chairman the Rt Rev Graham James, Bishop of Norwich, said that “patients were let down over many years” by both the NHS and independent providers.
As part of the Inquiry’s terms of reference, it was allowed to refer individuals considered to have committed a “disciplinary or criminal offence” to the relevant authorities.
Following the investigation, five health professionals have been referred to either the General Medical Council (GMC) or Nursing and Midwifery Council (NMC).
Another case has been referred to West Midlands Police.
Responding to the report, one of Paterson’s victims, Deborah Douglas, who was instrumental in getting the public inquiry established, said the report’s recommendations “must be implemented”.
The inquiry report urges the creation of an “accessible and intelligible” single repository of consultants’ key performance data, as a one-stop shop for patients.
Patients were let down over many yearsInquiry chairman the Rt Rev Graham James
Paterson carried out unnecessary operations in NHS and private hospitals, exaggerating or inventing cancer risks and claiming payments for more expensive procedures.
The consultant breast surgeon was employed by the Heart of England NHS Foundation Trust (HEFT) but had practising privileges in the independent sector at both 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 of his victims.
Initially handed a 15-year prison term, 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.
Among other recommendations, the inquiry says it should be made standard practice for consultants writing to patients about procedures to copy the letter to the patient’s GP.
The inquiry also states that when hospitals investigate a health professional’s behaviour, if there is a perceived risk to patient safety, that individual should be suspended and other employers informed.
Commenting on the report Mrs Douglas, a mother-of-three who underwent an entirely unnecessary operation which left her in “horrendous” pain, said: “What was really really shocking were the numbers of patients affected.
“Instead of talking hundreds, you’re talking over 6,000 Ian Paterson patients – so huge numbers that I wasn’t really expecting.”
Mrs Douglas, who runs the Breast Friends Solihull support group, continued: “What you’re going to see in this inquiry report are over 200 statements.
“It’s going to be horrific because it tells how they were failed in both the NHS and the private sector – these recommendations must be implemented.”
Presenting the 232-page report, the Rt Rev James praised the victims who had campaigned for an inquiry and for their courage in giving often “harrowing” accounts of their experiences.
The bishop added: “Many of them were lied to, deceived or exploited.”
He added that “many” of the more than 100 corporate witnesses who also gave evidence to the inquiry team 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.