The two-year independent inquiry into the malpractice of breast surgeon Ian Paterson has found that a culture of “avoidance and denial” allowed him to perform botched and unnecessary operations on hundreds of women.
Paterson is serving 20 years in prison after he was found guilty of 17 counts of wounding with intent and 3 counts of unlawful wounding. He worked with cancer patients over 14 years at hospitals in the West Midlands. Three were NHS hospitals – Heartlands, Solihull and the Good Hope – and two were run by private firm Spire Healthcare, Spire Parkway and Spire Hospital Little Aston.
Medically unjustified operations
Paterson performed unregulated ‘cleavage sparing’ mastectomies on his breast cancer patients, in which not all breast tissue was removed, meaning that the cancer returned in many of the women he operated on.
Opportunities to stop him carrying out these medically unjustified operations were missed because staff and management at the hospitals he worked in displayed a “wilful blindness” to his behaviour, despite many being concerned by it and some even making complaints.
The inquiry has now recommended the recall of Paterson’s 11,000 patients for their surgery to be assessed. A colleague of his has been referred to the police by the inquiry, and five more to health watchdogs. The coroner and West Midlands Police are also looking into the deaths of 23 of Paterson's patients.
Chair of the inquiry, Rt Revd Graham James, identified “multiple individual and organisational failures". He said:
"There was a culture of avoidance and denial, an alarming loss of corporate memory and an offloading of responsibility at every level…
"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 few must have known."
He also suggested that although there are currently more than enough regulators with sufficient resources, they still are not doing enough collectively to keep patients safe. He added that “to a surprising degree he was ‘hiding in plain sight’”.
Tracey Smith is one of Paterson’s victims, she welcomed the recommendations for the health service – of which there were 15 in total. She said:
"Paterson was claiming that there was some sort of cancer hotspot in Solihull. The only problem in Solihull was Ian Paterson,
"Now we will continue to fight so that the recommendations are put in place to stop this from ever happening in the NHS or the Spire or any private hospital in the country."
The independent inquiry has highlighted just how vulnerable we are as patients when we are given medical advice and required to make informed choices about treatment; and how difficult it is for any of us to trust the quality of the advice and treatment being proposed when healthcare watchdogs are not maintaining the required level of scrutiny. Sadly, in the majority of clinical negligence cases I deal with, even with the Duty of Candour now in place which requires hospitals to be open and honest with patients, the shutters are still going down and the patient is the last to know what has gone wrong.
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