The rogue breast surgeon Ian Paterson subjected more than 1,000 patients to unnecessary and damaging operations over 14 years before he was stopped, an independent inquiry has found.
Paterson was free to perform harmful surgery on mainly female patients in NHS and private hospitals because of “a culture of avoidance and denial” in a “dysfunctional” healthcare system where there was “wilful blindness” to his behaviour.
The inquiry found that victims were “lied to, deceived and exploited” by Paterson, who is serving a 20-year jail sentence imposed in 2017 for wounding with intent and unlawfully wounding nine women and one man whom he treated between 1997 and 2011.
A scathing report by the inquiry into Paterson said his victims “were let down time and time again”, first by him, then by the hospitals where he worked and then – once the harm they had suffered was known – by healthcare regulators who treated them with disdain. An array of “individuals, organisations and institutions … should have kept patients safe but failed to do so”, it concluded.
The inquiry, chaired by the Rt Rev Graham James, a former bishop of Norwich, called on ministers, NHS bosses and the private healthcare industry to introduce a series of measures to reduce the risk that another health professional could inflict such life-changing harm on a patient.
Scores of patients who gave evidence to the inquiry vividly described their suffering at the surgeon’s hands and failures by individuals and institutions to protect them. Their testimony, detailed in 87 of the report’s 232 pages, makes clear the “devastating consequences” for their physical and mental health.
“The scale of what happened; the length of time this malpractice went on; the terrible legacy for so many families: it is difficult to exaggerate the damage done, including to trust in medical organisations and clinicians,” James said.
Most of the people on whom Paterson inflicted medically unjustified procedures were women who had found a lump in their breast, which may have indicated breast cancer, or who had already been diagnosed with the disease. In many cases the surgeon invented or exaggerated the risk of breast cancer to persuade them to have surgery, which sometimes involved several operations.
“The overwhelming majority of patients were distressed to discover, usually at recall appointments, that they should not have had any surgery at all or that they had had the wrong procedure,” James said.
Debbie Douglas, who helps runs the victims’ support group Breast Friends, told the Guardian: “I was left with only 50% of my breast to remove a lump that was less than 2cm. I was cut from hip to hip, I had my belly button removed, I had unnecessary chemotherapy – it’s left me completely scarred.”
The government commissioned the inquiry in late 2017. Some of the behaviour James and his expert advisers heard about was so troubling that he has referred five unnamed doctors and nurses to either the General Medical Council or Nursing and Midwifery Council, which regulate those professions, for possible disciplinary action. James has also referred one “matter” , which he declined to detail, to West Midlands police to investigate as a possible crime.
Victims have previously called Paterson “a monster” and compared him to Harold Shipman, the GP who killed at least 250 elderly patients by giving them lethal doses of morphine. Shipman was jailed for life in 2000 after being convicted of 15 murders. A colleague of Paterson said he had “a very aggressive, bullying sort of personality, which allowed him to get his way.”
By playing up the risk of cancer, Paterson began persuading patients to undergo a version of the mastectomy that he had developed, called a “cleavage-sparing mastectomy”. He said that not removing all the breast tissue would help women psychologically. However, the surgery was unapproved and breached national guidelines, which say that in a mastectomy all breast tissue should be removed in order to reduce the risk of cancer returning.
Paterson treated huge numbers of patients in both the NHS and private practice. Between 1997 and 2011 he treated 6,617 patients at the privately run Spire Parkway hospital and Spire Little Aston hospital in the West Midlands, on top of his work at three NHS hospitals run by the Heart of England NHS trust. Of his Spire patients, 4,077 had some form of surgery, including 2,399 who underwent breast surgery. Over the same period he also had 4,424 breast patients in his work for the NHS.
Pressed to clarify how many had gone under Paterson’s knife unnecessarily or inappropriately, James said it was “well over 1,000, but it’s impossible to know. It’s a frightening number.”
Paterson operated unnecessarily on two under-18s, it emerged. A previously secret report on the surgeon compiled by Spire, which it released to the inquiry, “contains shocking examples of Paterson’s treatment, including procedures on minors where other tests revealed no abnormalities”, said James’s report.
Despite colleagues voicing fears about Paterson from 2003, he was allowed to continue working and was not suspended by the NHS and Spire until 2011.
“It’s bewildering that he continued to practice for so long,” said James. “Wilful blindness in relation to Paterson’s behaviour and aberrant clinical practice” included colleagues avoiding him and “keeping heads down”, the report said. Complaints did not lead to action, which discouraged others from reporting him.
Despite his conviction, Paterson denies any wrongdoing. In a statement issued through his lawyers, he maintained that he was innocent of all the charges he faced during his trial in 2017 and was preparing an appeal against his conviction. Paterson chose not to give evidence to the inquiry, James said.
The inquiry’s 15 recommendations include that:
The NHS should stop sending patients for NHS-funded treatment at private hospitals until the for-profit sector implements the changes recommended by James.
The NHS and private hospital groups set up a website where members of the public can see what types of procedures every surgeon in England is qualified to do, to help guide them where to be treated.
Surgeons should have to write to patients outlining in plain English the procedure they are proposing.
Patients should have time to think through whether to have surgery before undergoing it.
Complaints made by people treated in private hospitals should be resolved by someone independent of the care provider.
Action against Medical Accidents (AvMA), which represents victims of medical negligence, said the recommendations did not go far enough to protect patients being treated in the private sector.
It welcomed James’s demand that ministers close a loophole whereby patients injured while undergoing private healthcare have to sue the doctor or other health professional involved, because the hospitals where the incidents happen are not held legally liable.
AvMA’s chief executive, Peter Walsh, said: “The inquiry failed to recommend that patients and families have access to a funded independent advice service to help them take forward concerns. This is a major gap in private healthcare where injured patients are often left to fend for themselves against large corporations or on rare occasions, rogue doctors.”