Paterson inquiry recommendations for improving patient safety delayed again

17 December 2021

On 4 February 2020 the independent inquiry, led by Reverend Graham James, into rogue breast surgeon Ian Paterson who was jailed in 2017 published its findings.

Between 1997 and 2011 Paterson saw 6,617 patients of whom 4,077 underwent unnecessary and harmful surgical procedures in the independent sector, and between 1998 and 2011 Paterson saw 4,424 patients in the NHS, of whom 1,207 underwent similarly unnecessary and unapproved surgery.

The inquiry’s report  concluded that Paterson was able to continue his criminal malpractice over a 14 year period due to a dysfunctional health system and the wilful blindness of managers. Rev James in the report’s introduction said: 

“This report is not simply a story about a rogue surgeon. It would be tragic enough if that was the case, given the thousands of people whom Ian Paterson treated. But it is far worse. It is the story of a healthcare system which proved itself dysfunctional at almost every level when it came to keeping patients safe, and where those who were the victims of Paterson’s malpractice were let down time and time again.”

The report made 15 recommendations. A year on from publication, Nadine Dorries set out the government’s initial response which directly addressed only three of those recommendations (those concerning patient recall were actioned by the University Hospitals Birmingham NHS Foundation Trust board and Spire Healthcare). Recommendations immediately addressed were:

  • that it should be standard practice for consultants in both the NHS and the independent sector write to patients, outlining their condition and treatment, in simple language, and copy this letter to the patient’s GP, rather than writing to the GP and sending a copy to the patient
  • that there should be a short period introduced into the process of patients giving consent for surgical procedures to allow them time to reflect on their diagnosis and treatment options
  • that the Care Quality Commission (CQC) should assure itself that all hospital providers are complying effectively with up-to-date national guidance on Multi Disciplinary Team (MDT) meetings, including in breast cancer care

The government had promised to consider all the recommendations and produce a full response to the inquiry’s 15 recommendations during 2021. Instead, today Paterson’s victims had to make do with a statement from Health Secretary Sajid Javid, maintaining that the government is "as committed as ever" to learning lessons. 

Mr Javid said the implementation of the inquiry’s recommendations had been delayed by the coronavirus pandemic and that while the government accepts most suggestions in principle, some "require further consideration and consultation to ensure that we can deliver real and lasting change".

His statement made it clear that two of the 15 recommendations made by the inquiry have been rejected by the government:

  • that an investigation into a healthcare professional's behaviour should trigger a suspension if there was a perceived risk to safety
  • that private providers should not be eligible for NHS contracted work unless they had implemented all the recommendations

Mr Javid said it would be wrong to impose a ‘blanket rule’ and on eligibility of private providers he said that this requirement could reduce the capacity available to the NHS for providing care. It’s estimated that the NHS sent as many as three million patients to private hospitals in the wake of the coronavirus pandemic. 

Mr Javid said that a plan has been produced  for the implementation of the recommendations and what he described as ‘another progress report’ will be delivered in 12 months' time. Many victims have asked ‘why don't they just get on with it?’ 

Kashmir Uppal, a specialist medical negligence solicitor who investigated and brought the first civil case against Paterson in 2010 and is widely considered as the lead solicitor in claims against Paterson, particularly for patients he treated in private practice, said:

“We are concerned that not taking action now to level the liability and indemnity position of private hospitals with the NHS could lead to even greater cost to the NHS in rectifying problems caused in the private sector. People have worked tirelessly on the inquiry and the sooner all the recommendations can be implemented, the better protection will be afforded to patients treated in the private sector.”



This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2024

Contact our experts

Sorry, there are a few problems with the information you have entered. Please correct these before continuing.


One moment please...

Thank You

Your submission has been received. We'll be in touch soon.

Who we work with

  • Brain Injury Group
  • Child Brain Injury Trust
  • Headway
  • SIA
  • Back Up
  • Macmillan
  • Danielles Flutterbyes
  • Forces
  • Bens Heroes Trust

Our accreditations

  • Accredited Personal Injury
  • Apil
  • Ama
  • Clinical Negligence
  • Legal 500
  • UK Chambers
  • The Society Of Clinical Injury Lawyers