- Inquiry accuses NHS and private sector of “wilful blindness” over rogue surgeon
- Calls for new database of consultants with key performance data
- Government says it will give “detailed consideration” to findings
A single database publicising consultants’ practising privileges and performance is among the recommendations from the inquiry into the rogue surgeon Ian Paterson.
The Paterson Inquiry, which accused the NHS and private sector of “wilful blindness” over the convicted surgeon who performed unnecessary and damaging operations on breast cancer patients, added the new database should be available online and should be “accessible and understandable to the public”.
The report calls for “a single repository of the whole practice of consultants across England, setting out their practising privileges and other critical consultant performance data, for example, how many times a consultant has performed a particular procedure and how recently… It should be mandated for use by managers and healthcare professionals in both the NHS and independent sector”.
The inquiry, which was led by Bishop of Norwich Graham James, has also called for healthcare professionals to be suspended if they are under investigation and there is a perceived risk to patient safety, and for this to be communicated to any other providers they work for.
Mr Paterson, who operated at the Heart of England Foundation Trust (now part of University Hospitals Birmingham Foundation Trust) and the Spire Parkway and Spire Little Aston private hospitals in Solihull, was jailed for 20 years in 2017 after being convicted of 13 counts of wounding with intent and three counts of unlawful wounding.
At a press conference in Birmingham to launch the inquiry report, Bishop Graham said opportunities to spot Mr Paterson’s malpractice were missed and his colleagues displayed “wilful blindness” in relation to his behaviour.
He said: “This would be tragic enough if it was simply about a rogue surgeon. It is much more than that. 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.
“Colleagues avoided him or worked around him. Some could have known, while others should have known, and a few must have known.”
The inquiry has reported five healthcare professionals to either the General Medical Council or the Nursing and Midwifery Council, while one referral has been made to West Midlands Police.
More than 1,000 patients
A total of 211 patients and relatives gave the inquiry detailed accounts of the treatment of 177 patients — 80 were NHS patients, 92 were private sector, and five were NHS patients who were treated in the private sector.
The patient accounts given to the inquiry span between 1998 and 2011. In that time, Mr Paterson performed breast surgery on 2,399 patients at Spire and had a further 4,424 breast patients in the NHS at the Heart of England FT. The review of Mr Paterson’s patients at Spire also uncovered “procedures on minors where other tests revealed no abnormalities”.
Bishop Graham, who told the press conference the number of patients who had suffered inappropriate surgery at the hands of Mr Paterson “almost certainly” exceeded 1,000, has also called for changes in the way care is organised in the NHS and private sector to be clearly explained to patients.
He called on government to address gaps in responsibility and liability between the NHS and independent sector as a priority, and argued it should be standard practice that consultants write to patients outlining their conditions and treatment while copying in their GPs, rather than the other way around.
Bishop Graham said patients were “unsupported” when they learned they were victims of serious malpractice. His inquiry recommended all private patients have a right to mandatory independent resolution of their complaints.
The recommendations should be made across the independent sector as well as the NHS, as a “condition” for the independent sector continuing to deliver NHS-funded care, Bishop Graham has said.
The report was also critical of the Care Quality Commission, noting the chief executive did not attend the evidence session with the inquiry.
“This was out of line with other regulators whose chief executives fully engaged with us,” the report added. “We do not believe the CQC approached the inquiry with the level of seriousness and priority we would expect from an organisation that was in existence when [Mr] Paterson was practising, and which patients felt had let them down.”
The CQC said in a statement: “At the time the inquiry was inviting witnesses to give evidence, CQC’s chief executive, Ian Trenholm, had been in post for six weeks.
“Following discussion with the inquiry secretariat, it was agreed that it would be more beneficial if Professor Ted Baker, chief inspector of hospitals, who has been with the organisation for a number of years, gave evidence on behalf of CQC. Throughout the course of the inquiry, we have remained committed to cooperating in any way we could in order to ensure learning for all parts of the system so that people are not harmed in this way again.”
Junior 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.
“It is essential we all respond quickly and effectively to the lessons of this inquiry, giving every patient the confidence that the care they receive is safe and meets the highest standards.
“We will give thorough and detailed consideration to this report and its findings and will provide a full response in due course.”