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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 carried out unnecessary operations on hundreds of patients in NHS and private hospitals. The inquiry, chaired by Bishop Graham James, published 17 recommendations in February 2020 focusing on patient safety, consent processes, regulatory oversight, and redress mechanisms.

The government's December 2021 response accepted nine recommendations, accepted six in principle, rejected one, and kept one under consideration. The single rejected recommendation (12a) concerned automatic suspension of consultants under investigation, with the government stating this should remain a case-by-case decision based on risk assessment to avoid deterring reporting.

Published evidence indicates some concrete changes have emerged. NHS England published the National Quality Board Recall Framework 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 safety net recommended by the inquiry. The CQC has strengthened registration conditions and updated inspection methodologies, while professional bodies have revised guidance on patient communication and consent.

However, six years after publication, the implementation status shows 15 of 17 recommendations as 'awaiting action', with only one 'in progress'. Multiple recommendations accepted or accepted in principle show limited published evidence of completion. Work on improving data flows between regulators remains 'ongoing', embedding cooling-off periods is still being worked on with Royal Colleges, and decisions on legislative changes for consultant liability under practising privileges remain under consideration.

The government's approach appears characterised by accepting principles while deferring concrete implementation mechanisms. Several responses indicate ongoing consultations, monitoring of voluntary improvements, or work to address legal and data protection considerations, but published evidence of completed actions remains limited for most recommendations.
Reforms Attributed to This Inquiry
- NHS England published the National Quality Board Recall Framework on 1 June 2022, establishing principles for patient-centred recall in secondary care across NHS and independent sectors
- Medical defence organisations launched a voluntary Code of Practice for discretionary indemnity on 6 January 2025, establishing seven core principles
- The Academy of Medical Royal Colleges updated their 2018 guidance 'Please write to me' to emphasise writing 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) emphasises patients should have time to consider information before making decisions
Unfinished Business
- Recommendation 1: Government response indicates work is 'ongoing' to develop solutions for improving data flows between CQC, GMC and NHS England regarding consultants' full scope of practice
- Recommendation 4: While GMC guidance exists, government response indicates NHS England is still 'working with Royal Colleges to embed cooling-off periods in clinical practice'
- Recommendation 6b: Government response states 'further work needed on implementation mechanism' and 'consultation ongoing' regarding mandatory independent adjudication for private healthcare complaints
- Recommendation 10: The voluntary Code of Practice falls short of the 'mandatory nationwide safety net' the Inquiry recommended, with government 'continuing to consider further policy options'
- Recommendation 12b: Government response indicates NHS England is 'working with independent sector to improve information flows' with 'legal and data protection considerations being addressed'
- Recommendation 13: Government response states 'consideration being given to whether legislative change needed' regarding legal responsibility when consultants work under practising privileges
- Recommendation 15: Government rejected but kept under review, stating it is 'monitoring whether voluntary improvements by independent sector are sufficient'
AI-generated narrative. Generated 26 Mar 2026 using claude-opus-4. Assessment is indicative, not authoritative.
Implementation Reviewed By
DHSC and NHS England (implementation update provided to the Thirlwall Inquiry) (Apr 2025)
DHSC and NHS England provided the Thirlwall Inquiry with an update on the implementation of this inquiry's recommendations (April 2025). This is the government's own account of progress, submitted to the inquiry, rather than an independent assessment by the inquiry. Across 17 recommendation(s) the reviewed extent of implementation was stated as: 8 Implemented – Ongoing; 4 In progress; 2 Partially implemented – Ongoing; 2 Not accepted; 1 Implemented – Closed.
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: 29 Apr 2026
Data verified: 5 Feb 2026 (Claude)
How to read this

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

Full methodology

2 debates 12 questions 10 statements since Feb 2020
Written Question Health Services: Private Sector
Baroness Maclean of Redditch (Conservative)
17 Jun 2026
Written Question Health Professions: Insurance
Baroness Maclean of Redditch (Conservative)
15 Jun 2026
Written Question Health Services: Standards
Baroness Maclean of Redditch (Conservative)
15 Jun 2026
Written Question Surgery
Baroness Maclean of Redditch (Conservative)
20 Apr 2026
Written Question Health Services: Private Sector
Baroness Maclean of Redditch (Conservative)
20 Apr 2026
View all 24 mentions →
All Activity (24)
Title Volume Publication Date Tracked 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
- The Department of Health and Social Care stated in December 2021 that it was improving data flows to the CQC and GMC to provide oversight of consultants' full scope of practice (Government Response to the independent inquiry into the issues raised by Ian Paterson, DHSC, December 2021).
- NHS England launched the Medical Devices Outcomes Registry (MDOR) in April 2024 to collect data on responsible, supervising, and lead consultants (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
- NHS England mandated data submission to the Outcome Registries Platform for all providers, including the independent sector, with a deadline of March 2025 (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
- The National Consultant Information Programme (NCIP) portal provides a platform for consultants to review their own clinical data (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
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
- The Academy of Medical Royal Colleges (AoMRC) updated its 'Please write to me' guidance in 2018, stipulating that outpatient letters should be written directly to patients (Please write to me, AoMRC, 2018).
- The Professional Record Standards Body (PRSB) updated its guidance on standard outpatient letters in October 2021 to reflect that letters should be addressed to the patient (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
- The GMC's updated 'Good Medical Practice' guidance, which came into effect in January 2024, includes requirements for doctors to communicate effectively and directly with patients (Good Medical Practice, GMC, 2024).
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
- The available evidence indicates that implementation is in progress but not complete. The government remains committed to publishing the information requested by the recommendation, but the April 2026 answer says only that publication will occur in due course.
- The Independent Healthcare Provider Network (IHPN) and the Patients Association published a video in January 2020 explaining what patients should expect from independent healthcare (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
- The Department of Health and Social Care stated in April 2025 that it intended to publish information on the differences in care organization between the NHS and independent sector, but work was halted during the 2024 pre-election period (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
- The Department of Health and Social Care stated that it remained committed to the recommendation and that information would be published in due course, without giving a publication date (Written Question HL16569, UK Parliament, 29 April 2026).
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
- The GMC revised its "Decision making and consent" guidance, effective 9 November 2020, which requires doctors to give patients time to consider information before making a decision (Decision making and consent, GMC, 2020).
- The Royal College of Surgeons published "Good Surgical Practice" guidance in 2018 stating that patients should sign a consent form at the end of the discussion once they have decided to proceed (Good Surgical Practice, RCS, 2018).
- The Independent Healthcare Providers Network updated the Medical Practitioners Assurance Framework (MPAF) to include standards for patient consent (Implementation update to Thirlwall Inquiry, DHSC/NHS England, April 2025).
- NHS England stated in April 2025 that it is implementing a two-stage shared decision-making process to introduce a period of reflection for patients (Implementation update to Thirlwall Inquiry, DHSC/NHS England, April 2025).
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
- The government stated in December 2021 that the CQC had updated its inspection methodology to examine MDT functioning and compliance with national guidance (Government Response to the Report of the Independent Inquiry into the Issues raised by Ian Paterson, DHSC, December 2021).
- NHS England, the Information Commissioner’s Office, and the National Data Guardian developed guidance on information sharing within MDTs (Implementation update to Thirlwall Inquiry, DHSC/NHS England, April 2025).
- The NHS Long Term Workforce Plan includes a focus on optimising multi-disciplinary teams (NHS Long Term Workforce Plan, NHS England, 2023).
- No further published evidence regarding CQC's specific assurance of breast cancer MDTs has been identified since 2021.
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
- The Parliamentary and Health Service Ombudsman issued NHS Complaints Standards in December 2022, which include a model procedure to increase awareness of independent resolution (NHS Complaints Standards, PHSO, December 2022).
- The NHS Standard Contract (Service Condition 16) requires providers of NHS-funded care to follow the NHS Complaint Standards (NHS Standard Contract, NHS England, 2023).
- The Independent Healthcare Providers Network agreed to ensure members inform patients about the Independent Sector Complaints Adjudication Service (Government Response to the Report of the Independent Inquiry into the Issues raised by Ian Paterson, DHSC, December 2021).
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
- The government stated in December 2021 that it was considering whether legislative change is needed to make independent adjudication mandatory for all private healthcare providers (Government Response to the Report of the Independent Inquiry into the Issues raised by Ian Paterson, DHSC, December 2021).
- In April 2025, the government reported that CQC assesses all registered providers against Regulation 16 regarding receiving and acting on complaints (Implementation update to Thirlwall Inquiry, DHSC/NHS England, April 2025).
- No published evidence of a mandatory independent resolution requirement for non-NHS funded private patients has been identified.
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
- University Hospitals Birmingham NHS Foundation Trust stated that all known living patients of Ian Paterson had been contacted by August 2020 (Implementation update to Thirlwall Inquiry, DHSC/NHS England, April 2025).
- The Trust reported that by June 2021, all known former patients had their care reviewed and outstanding concerns addressed (Implementation update to Thirlwall Inquiry, DHSC/NHS England, April 2025).
- The government stated in December 2021 that over 12,000 patients had been recalled for review (Government Response to the Report of the Independent Inquiry into the Issues raised by Ian Paterson, DHSC, December 2021).
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
- Spire Healthcare stated in April 2025 that it had contacted all known living patients of Ian Paterson and completed a comprehensive review (Implementation update to Thirlwall Inquiry, DHSC/NHS England, April 2025).
- Spire Healthcare reported in April 2025 that it had completed more than three quarters of its reviews for deceased patients (Implementation update to Thirlwall Inquiry, DHSC/NHS England, April 2025).
- The government stated in December 2021 that Spire had provided ongoing treatment plans and support consistent with the NHS approach (Government Response to the Report of the Independent Inquiry into the Issues raised by Ian Paterson, DHSC, 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
- The National Quality Board published the "Patient-Centred Framework for NHS-Led Recalls" on 1 June 2022 to provide guidance on conducting recall processes (Patient-Centred Framework for NHS-Led Recalls, National Quality Board, June 2022).
- The CQC stated in April 2025 that it has incorporated the Recall Framework into its assessment process (Implementation update to Thirlwall Inquiry, DHSC/NHS England, April 2025).
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
- In March 2024, the government announced that Medical Defence Organisations (MDOs) intended to implement a sector-led Code of Practice for discretionary indemnity by the end of 2024 (Written Ministerial Statement HCWS318, March 2024).
- A voluntary Code of Practice for discretionary indemnity was launched by the Medical Defence Union, Medical Protection Society, and Medical and Dental Defence Union of Scotland on 6 January 2025 (Lords Written Statement HLWS789, July 2025).
- The Department of Health and Social Care stated in July 2025 that it had commissioned an independent evaluation of the voluntary Code of Practice (Lords Written Statement HLWS789, July 2025).
- The Department of Health and Social Care published a survey report in 2024 regarding healthcare professionals' indemnity arrangements to inform future policy options (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
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
- The Department of Health and Social Care stated in April 2025 that professional regulators are members of the Joint Strategic Oversight Group (JSOG) to share intelligence and coordinate regulatory action (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
- The CQC, Nursing and Midwifery Council (NMC), and GMC launched strategies focused on collaboration and patient safety, including a shared data platform for maternity services (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
- The National Quality Board published guidance on System Quality Groups (SQGs) which includes independent sector providers within the scope of local risk surveillance (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
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
- The government did not accept the recommendation for automatic suspension, stating that suspension should be based on individual risk assessments (Government Response to the independent inquiry into the issues raised by Ian Paterson, DHSC, December 2021).
- NHS Resolution published a suite of resources in April 2022 to support provider decisions relating to the exclusion of healthcare professionals (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
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
- The GMC updated its guidance to state that patient safety is paramount when deciding whether to share information about doctors with other providers (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
- The Department of Health and Social Care stated in April 2025 that it was considering legislative changes to the Medical Profession (Responsible Officers) Regulations 2010 to strengthen information-sharing systems (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
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
- The Independent Healthcare Providers Network (IHPN) refreshed the Medical Practitioners Assurance Framework (MPAF) to clarify that independent providers are responsible for the quality of care in their facilities (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
- The CQC stated it assesses independent sector providers on their governance mechanisms, taking the MPAF into account during inspections (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
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
- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 established a statutory duty of candour for NHS trusts in 2014 and all other CQC-registered providers in 2015 (The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, SI 2014/2936).
- CQC guidance on the duty of candour states that an apology is a required component of the duty and does not constitute an admission of civil liability (CQC Guidance: Regulation 20: Duty of candour, CQC, March 2021).
- NHS Resolution provides resources and training to healthcare providers emphasizing that sincere apologies should be offered as soon as possible following an incident (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
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
- The government did not accept this recommendation, stating that different governance models in the NHS and independent sectors require different approaches to achieving change (Government Response to the independent inquiry into the issues raised by Ian Paterson, DHSC, December 2021).
- The Department of Health and Social Care confirmed in April 2025 that the recommendation remains not accepted (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
Department of Health and Social Care (Primary)
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