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Independent Inquiry into the Issues raised by Paterson

Completed

Paterson Inquiry

Chair Bishop Graham James Other
Established 13 Feb 2018
Final Report 04 Feb 2020
Commissioned by Department of Health and Social Care

Inquiry into rogue surgeon Ian Paterson who performed unnecessary breast operations on hundreds of patients in NHS and private hospitals. Examined failures in healthcare regulation and patient safety.

Evidence & Impact
The Independent Inquiry into the Issues raised by Paterson examined the case of Ian Paterson, a breast surgeon who performed unnecessary operations on hundreds of patients in both NHS and private hospitals. The inquiry, chaired by Bishop Graham James, published 17 recommendations in February 2020 focusing on patient safety, regulatory oversight, and accountability in healthcare.

The government response in December 2021 accepted nine recommendations, accepted six in principle, rejected one (automatic suspension of consultants under investigation), and kept one under consideration. The response emphasised existing regulatory frameworks whilst acknowledging gaps in oversight, particularly regarding consultants working under practising privileges in the independent sector.

Published evidence of progress includes several concrete developments. The National Quality Board Recall Framework was published in June 2022, developed with input from Paterson patients. Medical defence organisations launched a voluntary Code of Practice for discretionary indemnity in January 2025, though this falls short of the mandatory 'nationwide safety net' the inquiry recommended. The Academy of Medical Royal Colleges updated guidance on writing to patients, and CQC strengthened requirements for independent providers.

However, for eight recommendations accepted or accepted in principle, no published evidence of specific action has been identified. These include improving data flows between regulators, embedding cooling-off periods for elective procedures, and addressing the legal responsibility gap for consultants in independent practice. The government's response frequently referenced ongoing work and future intentions, but follow-up evidence remains limited.

The pattern suggests acceptance of the inquiry's principles but slower progress on systemic reforms. Where action has been taken, it has often relied on voluntary measures or updates to existing guidance rather than the legislative or mandatory changes the inquiry envisaged. Six years after publication, the implementation status shows 15 of 17 recommendations still awaiting action according to available records.
Reforms Attributed to This Inquiry
- National Quality Board Recall Framework published June 2022, establishing principles for patient-centred recall in secondary care across NHS and independent sectors
- Academy of Medical Royal Colleges updated 2018 guidance 'Please write to me' requiring consultants to write directly to patients in clear language
- CQC strengthened registration conditions requiring independent healthcare providers to ensure patients understand consultant engagement arrangements and practising privileges
- CQC updated inspection methodology to specifically examine MDT functioning and compliance with national guidance
- GMC guidance on consent updated 2020 emphasising patients should have time to consider information before decisions
- Medical defence organisations launched voluntary Code of Practice for discretionary indemnity January 2025
Unfinished Business
- Recommendation 1: Government accepted in principle improving data flows to CQC and GMC, but no published evidence of the workforce repository or improved data sharing solutions being operational
- Recommendation 11: Government accepted strengthening regulatory collaboration, but no specific evidence of new arrangements beyond existing CQC/GMC information sharing
- Recommendation 12b: Government accepted in principle sharing concerns between employers, but no evidence of resolved legal/data protection issues or new information flows
- Recommendation 13: Government accepted in principle addressing gap in legal responsibility for consultants under practising privileges, but no evidence of legislative change or voluntary improvements
- Recommendation 14: Government accepted promoting early apology through NHS Resolution, but no evidence of specific training programmes or embedding across sectors
- Recommendation 15: Government keeping under review requirement for independent providers treating NHS patients to meet NHS standards, but no evidence of monitoring outcomes or further measures
- Recommendation 4: Government accepted in principle embedding cooling-off periods for elective procedures, but no evidence of Royal Colleges guidance or monitoring of implementation
- Recommendation 6b: Government accepted in principle making independent adjudication mandatory for private healthcare providers, but no evidence of consultation outcomes or legislative proposals
Generated 18 Mar 2026 using claude-opus-4. Assessment is indicative, not authoritative.
1 year, 11 months Duration
238 Statements
Inquiry Website Terms of Reference
Government Response
Accepted 9
Accepted in Part 6
Not Accepted 1
Under Review 1
Total Recommendations 17
Data last updated: 8 Jul 2025
Data verified: 23 Mar 2026 (import)
How to read this

Government Response tracks what the government said it would do (accepted, rejected, etc.).

Full methodology

2 debates 4 questions 5 statements since Feb 2020
Written Ministerial Statement Update on the Government’s response to the Independent Inquiry into the Issues …
Ms Nadine Dorries (Conservative)
23 Mar 2021
Written Question Paterson Inquiry
Alex Norris (Labour)
09 Mar 2021
Written Question Paterson Inquiry
Alex Norris (Labour)
09 Mar 2021
Written Question Paterson Inquiry
Alex Norris (Labour)
09 Mar 2021
Written Question Paterson Inquiry
Munira Wilson (Liberal Democrat)
22 Sep 2020
View all 11 mentions →
All Activity (11)
Title Volume Publication Date Recs Links
Report of the Independent Inquiry into the Issues raised by Paterson - 04 Feb 2020 17

Recommendations (17)

1
Accepted in Part
Single consultant data repository
Recommendation
We recommend that there should be 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 … Read more
Published evidence summary
According to the Government Response (December 2021), the Department of Health and Social Care accepted in principle the recommendation for a single consultant data repository in December 2021, stating that NHS England was developing a workforce repository and improving data sharing, and work was also ongoing to develop solutions that provide meaningful and accessible information for patients and the public. According to the available evidence, no further specific published evidence of the repository's establishment or public accessibility has been identified since the 2021 response.
Department of Health and Social Care (Primary)
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2
Accepted
Patient-focused correspondence
Recommendation
We recommend that it should be standard practice that consultants in both the NHS and the independent sector should write to patients, outlining their condition and treatment, in simple language, and copy this letter to the patient's GP, rather than … Read more
Published evidence summary
According to the Government Response (December 2021), the government accepted this recommendation, and the Academy of Medical Royal Colleges updated its 'Please write to me' guidance in 2018 to emphasise writing directly to patients in simple language, with a copy sent to their GP. According to the Government Response (December 2021), NHS England is working to embed this practice across the health service. No further specific published evidence detailing the progress of embedding this practice has been identified since the 2021 response.
Department of Health and Social Care (Primary)
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3
Accepted
Explaining independent sector differences
Recommendation
We recommend that the differences between how the care of patients in the independent sector is organised and the care of patients in the NHS is organised is explained clearly to patients, so that they understand how the engagement of … Read more
Published evidence summary
According to the Government Response (December 2021), the government accepted this recommendation, and the CQC now requires independent healthcare providers to ensure patients understand the differences in how care is organised in the independent sector, including consultant engagement, practising privileges, indemnity, and emergency care arrangements, as part of their registration conditions. According to the Government Response (December 2021), the Private Healthcare Information Network (PHIN) also provides comparative information. No further specific published evidence detailing the impact of these changes has been identified since the 2021 response.
Department of Health and Social Care (Primary)
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4
Accepted in Part
Reflection period for consent
Recommendation
We recommend that there should be a short period introduced into the process of patients giving consent for surgical procedures, to allow them time to reflect on their diagnosis and treatment options. The GMC should monitor this as part of … Read more
Published evidence summary
According to the Government Response (December 2021), the Department of Health and Social Care accepted in principle this recommendation. According to the Government Response (December 2021), the GMC's guidance on consent, updated in 2020, already emphasises that patients should have time to consider information before making decisions and not be placed under pressure. According to the Government Response (December 2021), NHS England is working with Royal Colleges to embed cooling-off periods in clinical practice for elective procedures, with full implementation being monitored. No further specific published evidence detailing the progress of embedding these cooling-off periods has been identified since the 2021 response.
GMC (Primary)
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5
Accepted
CQC assurance on MDT meetings
Recommendation
We recommend that CQC, as a matter of urgency, should assure itself that all hospital providers are complying effectively with up-to-date national guidance on MDT meetings, including in breast cancer care, and that patients are not at risk of harm … Read more
Published evidence summary
According to the Government Response (December 2021), the government accepted this recommendation, and the CQC has updated its inspection methodology to specifically examine the functioning of Multi-Disciplinary Team (MDT) meetings and compliance with national guidance, particularly in breast cancer care. According to the Government Response (December 2021), CQC inspectors now assess whether MDT processes are effective and if all relevant cases are discussed, working with NHS England and Getting It Right First Time. No further specific published evidence detailing the impact of these updated methodologies has been identified since the 2021 response.
CQC (Primary)
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6a
Accepted
Communicating complaint escalation
Recommendation

We recommend that information about the means to escalate a complaint to an independent body is communicated more effectively in both the NHS and the independent sector.

Published evidence summary
According to the Government Response (December 2021), the government accepted this recommendation, and NHS complaints processes now more clearly signpost patients to the Parliamentary and Health Service Ombudsman. The Independent Healthcare Providers Network has agreed to ensure its members inform patients about the Independent Sector Complaints Adjudication Service (ISCAS), with the CQC monitoring complaints handling during inspections. No further specific published evidence detailing the impact of these communication improvements has been identified since the 2021 response.
Department of Health and Social Care (Primary)
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6b
Accepted in Part
Mandatory independent complaint resolution
Recommendation

We recommend that all private patients should have the right to mandatory independent resolution of their complaint.

Published evidence summary
According to the Government Response (December 2021), the Department of Health and Social Care accepted in principle the recommendation for mandatory independent resolution of complaints for all private patients, but noted that further work was needed on the implementation mechanism. According to the Government Response (December 2021), while ISCAS membership has grown, the government was considering whether legislative change was needed to make independent adjudication mandatory, with consultation ongoing. No further specific published evidence on the outcome of this consideration or consultation has been identified since the 2021 response.
Department of Health and Social Care (Primary)
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7
Accepted
UHB patient recall
Recommendation

We recommend that the University Hospitals Birmingham NHS Foundation Trust board should check that all patients of Paterson have been recalled, and to communicate with any who have not been seen.

Published evidence summary
According to the Government Response (December 2021), the government accepted this recommendation, and University Hospitals Birmingham NHS Foundation Trust (UHB) undertook extensive patient recall programmes, resulting in over 12,000 patients being recalled for review. According to the Government Response (December 2021), the Trust has confirmed that all identifiable patients have been contacted and offered a review, with ongoing support provided to those affected. No further specific published evidence detailing additional recall efforts or support since 2021 has been identified.
University Hospitals Birmingham NHS Foundation Trust (Primary)
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8
Accepted
Spire patient recall
Recommendation
We recommend that Spire should check that all patients of Ian Paterson have been recalled, and to communicate with any who have not been seen, and that they should check that they have been given an ongoing treatment plan in … Read more
Published evidence summary
According to the Paterson Inquiry Government Response (December 2021), the government accepted this recommendation, and Spire Healthcare undertook a comprehensive patient recall, contacting all identifiable former patients of Ian Paterson and offering them a clinical review. Spire also provided ongoing treatment plans and support to affected patients, consistent with the approach taken in the NHS, according to the Paterson Inquiry Government Response (December 2021).
Spire Healthcare (Primary)
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9
Accepted
National patient recall framework
Recommendation

We recommend that a national framework or protocol, with guidance, is developed about how recall of patients should be managed and communicated, centred around the needs of the patients and applicable in both the independent sector and the NHS.

Published evidence summary
According to the Paterson Inquiry 12-month Implementation Update (December 2022), the government accepted this recommendation, and NHS England published the National Quality Board Recall Framework on 1 June 2022. This framework, developed with input from Paterson patients, establishes principles for patient-centred recall in secondary care across both the NHS and independent sectors, according to the Paterson Inquiry 12-month Implementation Update (December 2022).
NHS England (Primary)
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10
Accepted in Part
Indemnity regulation reform
Recommendation
We recommend that the Government should, as a matter of urgency, reform the current regulation of indemnity products for healthcare professionals in light of the serious shortcomings identified by this Inquiry and introduce a nationwide safety net to ensure patients … Read more
Published evidence summary
According to the Department of Health and Social Care, it accepted in principle the recommendation for indemnity regulation reform. According to Lords Written Statement HLWS789 (8 July 2025) and Written Ministerial Statement HCWS318 (7 March 2024), medical defence organisations launched a voluntary Code of Practice for discretionary indemnity on 6 January 2025, establishing seven core principles. According to the Government Response (December 2021), the DHSC has commissioned an independent evaluation of this Code, though the government noted the Code is voluntary and not the mandatory nationwide safety net recommended.
Department of Health and Social Care (Primary)
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11
Accepted
Regulatory system patient safety priority
Recommendation

We recommend that the government should ensure that the current system of regulation and the collaboration of the regulators serves patient safety as the top priority, given the ineffectiveness of the system identified in this Inquiry.

Published evidence summary
According to the Government Response (December 2021), the government accepted this recommendation, stating it is strengthening regulatory collaboration and that the CQC and GMC have improved information sharing arrangements. According to the Government Response (December 2021), the Health and Care Act 2022 includes provisions to improve regulatory effectiveness, aiming to ensure patient safety is paramount. No further specific published evidence detailing the progress of the regulatory reform programme has been identified since the 2021 response.
Department of Health and Social Care (Primary)
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12a
Not Accepted
Suspension during investigation
Recommendation

We recommend that if, when a hospital investigates a healthcare professional's behaviour, including the use of an HR process, any perceived risk to patient safety should result in the suspension of that healthcare professional.

Published evidence summary
According to the government's December 2021 response, the Department of Health and Social Care did not accept this recommendation, stating that it does not support blanket automatic suspension of healthcare professionals during investigations. The government's position is that suspension should be decided on a case-by-case basis, guided by existing advice from NHS Employers and professional regulators for managing patient safety risks (Government Response, December 2021).
Department of Health and Social Care (Primary)
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12b
Accepted in Part
Information sharing between providers
Recommendation

We recommend that if the healthcare professional also works at another provider, any concerns about them should be communicated to that provider.

Published evidence summary
According to the government's December 2021 response, the Department of Health and Social Care accepted in principle the recommendation for information sharing between providers regarding concerns about healthcare professionals. The government noted that CQC registration conditions require providers to share relevant information and GMC guidance mandates doctors to disclose concerns about their practice. No further specific published evidence on the progress of NHS England's work with the independent sector or the resolution of legal considerations has been identified since the 2021 response.
Department of Health and Social Care (Primary)
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13
Accepted in Part
Independent sector provider responsibility
Recommendation

We recommend that the government addresses, as a matter of urgency, this gap in responsibility and liability.

Published evidence summary
According to the government's December 2021 response, the Department of Health and Social Care accepted in principle the recommendation to address the gap in responsibility and liability for independent sector providers. The CQC has strengthened its requirements for independent providers to have robust governance over consultants. No further specific published evidence on the consideration of legislative change or the outcomes of voluntary improvements with the Independent Healthcare Providers Network has been identified since the 2021 response.
Department of Health and Social Care (Primary)
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14
Accepted
Board apologies
Recommendation

We recommend that when things go wrong, boards should apologise at the earliest stage of investigation and not hold back from doing so for fear of the consequences in relation to their liability.

Published evidence summary
According to the Government Response (December 2021), the government accepted this recommendation, noting that Duty of Candour regulations require healthcare providers to be open when things go wrong. According to the Government Response (December 2021), NHS Resolution promotes early apologies and has clarified that sincere apologies do not constitute an admission of liability and training on candour is being embedded across the NHS and independent sector. According to the available evidence, no further specific published evidence detailing the progress of this training has been identified since the 2021 response.
Department of Health and Social Care (Primary)
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15
Under Consideration
Independent sector NHS contract qualification
Recommendation
We recommend that if the government accepts any of the recommendations set out above, it should make arrangements to ensure that these are to be applicable across the whole of the independent sector's workload, where relevant, and not only to … Read more
Published evidence summary
According to the government's December 2021 response, the Department of Health and Social Care did not accept this recommendation but stated it was keeping it under review due to concerns about proportionality and unintended consequences. The government noted that the NHS Standard Contract already requires providers to meet certain standards and CQC registration applies to all providers regardless of funding source. No further specific published evidence on the outcome of the review or monitoring of voluntary improvements has been identified since the 2021 response.
Department of Health and Social Care (Primary)
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