The report following the inquiry into the actions taken by Ian Paterson was published on Tuesday 4 February 2020. In April 2017, Ian Paterson was convicted of 17 counts of wounding with intent and three counts of unlawful wounding. He was given a prison sentence of 15 years that was increased to 20 years in August 2017. The factual background to the events leading up to the conviction are well known and not rehearsed here. The inquiry did not focus on the offences themselves, rather, the inquiry considered how it was possible that the so called ‘rogue surgeon’ was able to commit so many offences apparently undetected while ‘hiding in plain sight’.

While the report concludes with a number of recommendations (set out below), the reader is reminded that there are numerous regulators within the healthcare system. The implication is that patients would be better served by a simplification of the regulatory processes rather than yet more regulation/regulators and/or complicating an already complex process.

1. Information to patients

These recommendations stem from the concerns raised by patients, organisations and regulators as to the quality and amount of information available to the public.

Single repository of all consultants (whether practising in the public and/or private sector): This repository should include the respective consultant’s practising privileges and other ‘critical consultant data’ (i.e. the procedures undertaken by the consultant, the frequency and how recently). This database should be accessible and understandable to the public.

Consultants to write to patients, copying in the patient’s GP, following a consultation: Current practice is to write to the patient’s GP, copying the patient. The recommended change in focus is to ensure that correspondence is patient focused and easy for patients to understand, rather than correspondence with medical terminology.

Clarity of the distinction between the NHS and independent sector: The recommendations are for patients to be clearly advised who is providing treatment and how it is funded. This should include details of practising privileges and indemnity as well as the arrangements for emergency provision and intensive care.

2. Consent

A cooling-off period: Patients should be given a short period to be able to reflect on treatment options. This is, in any event, good practice and would need to be considered based on the urgency of need.

3. MDT discussions

CQC to ensure compliance with up-to-date national guidance on MDT meetings: The CQC should be ensuring that the MDT process is across the healthcare sector within the ‘safe’ and ‘effective’ parts of its investigatory framework.

4. Complaints

Independent complaint reviews: Patients should be given clear advice as to who to complain to in the event that they are not satisfied with the response from the healthcare organisation. All private patients should have the opportunity to an independent resolution of their complaint.

5. Patient recall and ongoing care

While the recommendations under this heading were addressed to those organisations specifically involved, the principles apply across the healthcare sector. In the event of an incident requiring patients to be recalled, it is important that organisations have a clear system to identify those patients, communicate with them timeously, and ensure that they are given an appropriate care plan.

National framework: It is recommended that a national framework is established to provide clear guidance as to how patients are recalled and how this recall should be communicated.

6. Clinical indemnity

Wholescale review of indemnity products for healthcare professionals: The government is advised to review the current regulation to ensure patients are not disadvantaged by, for example, discretionary cover which may be withdrawn in certain circumstances and which leaves patients without the possibility of financial recompense.

7. Regulatory system

Government review: The government should review the current regulatory system to ensure that patient safety is the priority. This recommendation recognises the numerous organisations, with at times competing aims, regulating the healthcare sector.

8. Investigating a healthcare professional's behaviour

Suspension of healthcare professionals: If, following an investigation, there is a perceived risk to patient safety, suspension of the healthcare professional in question would follow. This will include the use of an HR process, rather than specific patient safety investigation.

Communication: Concerns about practitioners working for/with another provider(s) should also be communicated to that other provider(s).

9. Corporate accountability

Accountability in the independent sector: the investigation found that there was a gap in the responsibility and liability of consultants in the private sector. It is recommended that this lacuna is addressed by the government as a matter of urgency.

Apologies: Where there are failings, boards should apologise at the earliest possibility. This echoes the requirements of the statutory duty of candour, however, organisations should be reminded that this applies equally to ‘one off’ incidents as it does to systemic and widespread failings.

10. Adoption into the independent sector

Joined-up responsibility: The government should ensure that the regulatory framework in place for NHS organisations should apply equally to the independent sector, particularly those undertaking NHS-funded work.


The report concludes that while the index offences were, largely, the actions taken by one man, the failings within the healthcare sector are wholesale and widespread. While the inquiry’s recommendations are just that – recommendations – and are not obligatory, it is important that organisations consider these findings carefully. Quite rightly, the actions taken by Ian Paterson were considered to be a national disgrace and widely condemned. The onus is on all working in the healthcare industry to ensure a similar situation is not replicated.