On February 4, 2020, a report entitled “Report of the Independent Inquiry into the Issues raised by Paterson” (“Report”) was printed pursuant to an order of the U.K. House of Commons. Ian Paterson, the subject of the Report, had graduated from medical school in the U.K. in 1981. He was trained as a general surgeon, initially specializing in vascular surgery, but was nonetheless appointed as a specialist breast surgeon in 1998 at Solihull Hospital, part of the Heart of England NHS Foundation Trust (HEFT).
Paterson had been suspended for a time in 1996, while he was employed at Good Hope Hospital, after he had exposed a patient to harm in one of his operations. Good Hope Hospital arranged for Paterson’s surgical work to be supervised until there was confidence that he could operate again without such oversight.
Paterson also practiced as a surgeon in the independent sector. He treated patients at the Bupa Little Aston Hospital from 1993 and at the Bupa Parkway Hospital in Solihull from 1998. Both hospitals were taken over by Spire Healthcare (Spire) in 2007. Over time, Paterson increasingly treated most of his private patients at Spire Parkway Hospital. There were concerns about Paterson’s clinical practice over many years. Clinical colleagues first raised serious questions about his surgical procedures and medical practice in 2003. Ultimately, he was suspended by HEFT in 2011 and Spire suspended his right to practise at its hospitals later that year.
In April 2017, Paterson was convicted of 17 counts of wounding with intent and three counts of unlawful wounding relating to nine women and one man, whom he had treated as private patients between 1997 and 2011. Paterson was sent to prison for 15 years. His jail sentence was felt to be too lenient and was increased by the Court of Appeal to 20 years in August 2017.
Despite the conviction of Paterson, many of his patients felt that there were still unanswered questions about his malpractice and called for a public inquiry into the case. On October 5, 2017, a group of 11 former patients of Paterson met Philip Dunne MP, Minister of State for Health, to ask him to set up an inquiry. The Inquiry was announced in Parliament on December 7, 2017, under the chairmanship of Bishop Graham James. On December 7, 2017, Philip Dunne MP, Minister of State for Health, announced that there would be an independent, non-statutory inquiry into the malpractice of Paterson and associated issues.
The Report opens with a statement from the Chairman, which states, in part: “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. They were initially let down by a consultant surgeon who performed inappropriate or unnecessary procedures and operations. They were then let down both by an NHS trust and an independent healthcare provider who failed to supervise him appropriately and did not respond correctly to well-evidenced complaints about his practice. Once action was finally taken, patients were again let down by wholly inadequate recall procedures in both the NHS and the private sector. The recall of patients did not put their safety and care first, which led many of them to consider the Heart of England NHS Foundation Trust and Spire were primarily concerned for their own reputation. Patients were further let down when they complained to regulators and believed themselves frequently treated with disdain. They then felt let down by the Medical Defence Union which used its discretion to avoid giving compensation to Paterson patients once it was clear his malpractice was criminal. Only by taking their cases to sympathetic lawyers did some patients find themselves heard. By that stage many others found their exhaustion was too great and their sense of rejection so complete that they scarcely had the emotional or physical strength to fight any further. Even today, many patients, especially those treated within Spire hospitals, have no individual care plan. Thousands of people are still living with the consequences of what happened. It is wishful thinking that this could not happen again.”
“But in Paterson’s years of practice, there were many regulations and guidelines in place which were disregarded or simply ignored, and not just by him. It was striking that regulators testified to major improvements which they thought would identify another Paterson, while the clinicians we met believed that, despite the changes, it was entirely possible that something similar could happen now. The testimony of those on the front line is telling … This report is primarily about poor behaviour and a culture of avoidance and denial. These are not necessarily improved by additional regulation. The sheer number of regulatory bodies and the complexity of their areas of responsibility meant that Paterson’s patients thought the system unfocused and scarcely possible to navigate, while many clinicians seemed to feel the same, and so avoided engagement with it.”
“This capacity for wilful blindness is illustrated by the way in which Paterson’s behaviour and aberrant clinical practice was excused or even favoured. Many simply avoided or worked round him. Some could have known, while others should have known, and a few must have known. At the very least a great deal more curiosity was needed, and a broader sense of responsibility for safety in the wider healthcare system by both clinicians and managers alike. However, some seem to have been inhibited from complaining because they had seen colleagues appearing to get nowhere by doing so (and in some cases finding themselves under investigation). A few of Paterson’s more junior colleagues commented that the unusual character of his surgical practice (compared with other breast surgeons) was well known. To a surprising degree he was “hiding in plain sight.””
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