'Dysfunctional' System Allowed Rogue Surgeon to Hide in Plain Sight

Peter Russell

February 04, 2020

A rogue breast surgeon was allowed to perform unnecessary procedures on hundreds of women in NHS and private hospitals because of a healthcare system "which proved itself dysfunctional at almost every level", an independent inquiry report concluded.

Opportunities to prevent Ian Paterson, a consultant specialist breast surgeon practising in the West Midlands, carrying out medically unjustified operations were missed because of "a culture of avoidance and denial", it said.

The Government said the report was "a shocking and sobering analysis" of failure in the NHS, the independent sector, and the regulatory system, as well as clinical malpractice by one individual.

Cleavage Sparing Mastectomy

Paterson was jailed for 20 years after being convicted in April 2017 of 17 counts of wounding with intent, and three counts of unlawful wounding, relating to nine women and one man, whom he had treated between 1997 and 2011.

Paterson had treated patients at three NHS hospitals – Heartlands, Solihull, and the Good Hope – and at two run by the private firm Spire Healthcare, called Parkway Hospital and Little Aston Hospital.

The disgraced breast surgeon exaggerated or invented the risk of cancer to patients before persuading them – mainly women – to undergo what he called a 'cleavage sparing mastectomy'. His technique, in which some breast tissue remained in situ, was not approved and risked the cancer returning.

A number of Inquiry witnesses described having undergone surgery by Paterson even though pathology results indicated they did not have cancer.

One patient discovered at a recall meeting that Paterson had coded her lumps as cancerous so that he could charge her insurance company more for treatment, even though pathology results did not indicate cancer.

A consultant who reviewed some patients pursuing legal claims told the Inquiry: "I think the one thing we haven't really talked about is the fact that Paterson blatantly lied and misrepresented the results of radiology and pathology. And in fact, you only needed to read one of Paterson's notes to tell he was lying about the results."

Hiding in Plain Sight

Hospital managers demonstrated "wilful blindness" to Paterson's surgical results, the independent inquiry chair Rt Revd Graham James said, while fellow clinicians either avoided or worked round him.

A reluctance to complain about Paterson's "unusual" surgical practices resulted in him "hiding in plain sight", he said.

As a consequence of the Inquiry, five health professionals were reported to either the General Medical Council or the Nursing and Midwifery Council, and one matter was referred for investigation by the West Midlands Police.

In total 211 patients or their relatives gave evidence to the Inquiry.


Among the 15 recommendations in the report was the recall of all Paterson's estimated 11,000 patients in order for their surgery to be assessed.

Other recommendations included:

  • A single repository of practice information for all consultants in England, setting out their practising privileges and other critical consultant performance data

  • Making it standard practice for consultants in both the NHS and the independent sector to write to patients, outlining their condition and treatment, in simple language

  • That the Government should ensure "as a top priority" that the current system of regulation and the collaboration of the regulators serves patient safety

In a statement to Parliament, Nadine Dorries, Parliamentary Under-Secretary at the Department of Health and Social Care, apologised on behalf of the Government and the NHS. She said she had been particularly struck "that the various regulatory bodies failed in their main tasks, and the absence of curiosity by those in positions of authority in the healthcare providers in the face of concerns voiced by other healthcare professionals".

The Government would make a formal response to the recommendations in a few months' time, she told MPs.

The General Medical Council (GMC) also apologised to affected patients, saying they had been "let down".

Charlie Massey, the GMC's chief executive, said: "We welcome the Inquiry's recommendations to protect patients and strengthen local oversight of doctors. We will reflect on these and look at how we act on them as we continue our work to progress genuine cultural and regulatory change.

"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."

'Important for Patient Care'

Commenting on the report, Prof Derek Alderson, president of the Royal College of Surgeons England, said: "The horrific experience of patients at Paterson’s hands is laid bare in today's report. The healthcare system has failed hundreds of patients and their families, and we must learn from what went wrong. 

"Following their thorough investigation, we welcome the Inquiry's recommendations today, designed to improve patient safety."

Dr Rinesh Parmar, chair of The Doctors' Association UK, and an intensive care doctor in the West Midlands, said: "Whilst there is no doubt that the harm caused to patients was due to a rogue individual, a private hospital must not be allowed to simply wash their hands of this case without taking any accountability for this happening right under their nose.

"The private system as a whole must learn from the mistakes made in this tragic case to give the patients and families affected true justice."

Spire Healthcare said it wanted to apologise again for the "significant distress" caused to those treated in its hospitals by Paterson. It accepted that there had been missed opportunities to challenge the consultant's criminal behaviour prior to his suspension in 2011.

Justin Ash, Spire's chief executive, said: "Significant investment and progress has already been made in many of the areas highlighted today.

"I would reiterate that we have learned lessons from this incident and implemented change. A strong indicator of this is that 83% of our hospitals are now rated 'Good' or 'Outstanding' by the regulators, the Care Quality Commission (CQC) or their equivalents in Wales and Scotland."

Editor's Note, 4th February 2020: This article was updated to include a revised quote from the Royal College of Surgeons England, 5th February 2020 the article was updated to include inquiry information on pathology and a comment from the GMC.


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