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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.
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: 12 Jun 2026 (import)
How to read this

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

Full methodology

2 debates 9 questions 10 statements since Feb 2020
Written Question Health Services: Private Sector
Baroness Maclean of Redditch (Conservative)
20 Apr 2026
Written Question Surgery
Baroness Maclean of Redditch (Conservative)
20 Apr 2026
Written Question Hospitals: Consultants
Baroness Maclean of Redditch (Conservative)
20 Apr 2026
Written Question Hospitals: Consultants
Baroness Maclean of Redditch (Conservative)
20 Apr 2026
Written Question Health Services: Standards
Baroness Maclean of Redditch (Conservative)
20 Apr 2026
View all 21 mentions →
All Activity (21)
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
- In December 2021, the government accepted this recommendation in principle, stating that NHS England was developing consultant-level procedure data and that the Private Healthcare Information Network (PHIN) was working to fulfil its Competition and Markets Authority mandate to publish consultant-level data on volumes, outcomes, and patient satisfaction (Government Response to the Paterson Inquiry, DHSC, December 2021).
- The December 2022 implementation update stated that the National Consultant Information Programme (NCIP) had expanded to 104 NHS trusts (77% of all trusts) covering 11 surgical specialties, providing an online portal for consultants to access activity and outcome metrics against local and national benchmarks (Paterson Inquiry Implementation Update, DHSC, December 2022).
- The December 2022 update stated that PHIN had published its 2022-2026 delivery plan in July 2022, with a target of 80% coverage of high-risk procedures within three years (Paterson Inquiry Implementation Update, DHSC, December 2022).
- No published confirmation that a single cross-sector repository of consultant practice data covering both NHS and independent sector has been established has been identified to March 2026.
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
- In December 2021, the government accepted this recommendation, noting that the Academy of Medical Royal Colleges had updated its 2018 guidance 'Please write to me' in light of this recommendation, emphasising writing directly to patients and copying in GPs (Government Response to the Paterson Inquiry, DHSC, December 2021).
- The December 2022 implementation update stated that the Academy of Medical Royal Colleges guidance had been re-circulated in December 2021, and that NHS app usage had reached 35 million record views by September 2022 with 68% of adults registered, giving patients direct access to their health records (Paterson Inquiry Implementation Update, DHSC, December 2022).
- The GMC published an updated edition of Good Medical Practice in January 2024, which reinforces the principle that doctors should communicate with patients directly and ensure patients understand their diagnosis and treatment options (Good Medical Practice, GMC, January 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
- In December 2021, the government accepted this recommendation, stating that CQC now requires independent healthcare providers to ensure patients understand arrangements relating to consultant engagement, practising privileges, indemnity, and complaints processes as part of registration conditions (Government Response to the Paterson Inquiry, DHSC, December 2021).
- The December 2022 implementation update stated that the Competition and Markets Authority requires independent practitioners to send cost estimates and procedure information to patients pre-consultation, and that the government planned to publish information explaining differences between NHS and independent sector care arrangements in 2023 (Paterson Inquiry Implementation Update, DHSC, December 2022).
- No published government information document specifically explaining the differences between NHS and independent sector care arrangements has been identified to March 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
- In December 2021, the government accepted this recommendation in principle, stating that GMC guidance on consent (updated 2020) already emphasises that patients should have time to consider information before making decisions and should not be put under pressure (Government Response to the Paterson Inquiry, DHSC, December 2021).
- The December 2022 implementation update stated that NHS England had established a Shared Decision-Making Board, mandated two-stage decision-making for all admitted non-day case pathways by April 2023 and all admitted pathways by April 2024, and published 11 decision support tools in July 2022 with 8 additional tools scheduled for April 2023 (Paterson Inquiry Implementation Update, DHSC, December 2022).
- The Professional Record Standards Body published a shared decision-making standard in June 2022 (Paterson Inquiry Implementation Update, DHSC, December 2022).
- The Independent Healthcare Providers Network refreshed the Medical Practitioners Assurance Framework in September 2022, specifying policies on consent, decision-making, and allowing appropriate time for decisions (Paterson Inquiry Implementation Update, DHSC, December 2022).
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
- In December 2021, the government accepted this recommendation, stating that CQC had updated its inspection methodology to specifically examine multidisciplinary team (MDT) functioning and compliance with national guidance (Government Response to the Paterson Inquiry, DHSC, December 2021).
- The December 2022 implementation update stated that CQC had incorporated MDT prompts into its inspection frameworks for acute hospitals and was updating its regulatory model to ensure continued MDT monitoring (Paterson Inquiry Implementation Update, DHSC, December 2022).
- The December 2022 update stated that the Independent Healthcare Providers Network had convened a Chief Medical Officers group to share best practice and was developing principles for independent sector MDT working, including specialties, governance, and audits (Paterson Inquiry Implementation Update, DHSC, December 2022).
- No published CQC assessment confirming systematic MDT compliance across both NHS and independent sector providers has been identified to March 2026.
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
- In December 2021, the government accepted this recommendation, stating that NHS complaints processes now more clearly signpost to the Parliamentary and Health Service Ombudsman and that the Independent Healthcare Providers Network had agreed to ensure members inform patients about independent resolution options (Government Response to the Paterson Inquiry, DHSC, December 2021).
- The December 2022 implementation update stated that CQC had updated its complaints guidance in early 2022 to make it easier for patients to raise concerns and access independent resolution (Paterson Inquiry Implementation Update, DHSC, December 2022).
- The Patient Safety Commissioner, appointed in September 2022 under the Medicines and Medical Devices Act 2021, provides an additional avenue for patients to raise safety concerns (Patient Safety Commissioner website).
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
- In December 2021, the government accepted this recommendation in principle, stating that further work was needed on an implementation mechanism and that membership of the Independent Sector Complaints Adjudication Service (ISCAS) had grown (Government Response to the Paterson Inquiry, DHSC, December 2021).
- No published legislation or statutory instrument requiring all private healthcare providers to offer mandatory independent complaint resolution has been identified to March 2026.
- No further published evidence has been identified since 2022.
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
- In December 2021, the government stated that this recommendation had been accepted and implemented, with University Hospitals Birmingham NHS Foundation Trust having undertaken extensive patient recall programmes and over 12,000 patients recalled for review (Government Response to the Paterson Inquiry, 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
- In December 2021, the government stated that this recommendation had been accepted and implemented, with Spire Healthcare having undertaken comprehensive patient recall and all identifiable former patients of Paterson contacted and offered clinical review (Government Response to the Paterson Inquiry, 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
- In December 2021, the government stated that this recommendation had been accepted and implemented, with NHS England having published the National Quality Board Recall Framework on 1 June 2022, developed with input from Paterson patients (Government Response to the Paterson Inquiry, DHSC, December 2021).
- The December 2022 implementation update confirmed publication of the National Patient Recall Framework centring patient focus (Paterson Inquiry Implementation Update, DHSC, 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
- In December 2021, the government accepted this recommendation in principle, stating that medical defence organisations were being encouraged to develop reforms to discretionary indemnity products (Government Response to the Paterson Inquiry, DHSC, December 2021).
- In a Written Ministerial Statement on 7 March 2024 (HCWS318), the government stated that medical defence organisations had proposed to implement a sector-led Code of Practice for discretionary indemnity cover by end of 2024, and that the government had commissioned an independent evaluation of the Code (Written Ministerial Statement HCWS318, 7 March 2024).
- On 6 January 2025, the Medical Defence Union, Medical Protection Society, and Medical and Dental Defence Union of Scotland launched a voluntary Code of Practice establishing seven core principles for discretionary indemnity cover (Progress update on recommendation 10, July 2025).
- No published legislation requiring mandatory regulation of medical indemnity products has been identified to March 2026.
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
- In December 2021, the government accepted this recommendation, stating that CQC and GMC had improved information-sharing arrangements and that the Professional Standards Authority oversees healthcare regulators (Government Response to the Paterson Inquiry, DHSC, December 2021).
- The December 2022 implementation update stated that the National Quality Board had published national guidance on System Quality Groups for integrated care systems, and that CQC had published a new Single Assessment Framework in July 2022 (Paterson Inquiry Implementation Update, DHSC, December 2022).
- No published comprehensive review of whether the regulatory collaboration system is now serving patient safety as the top priority has been identified to March 2026.
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
- In December 2021, the government did not accept this recommendation, stating that blanket automatic suspension could deter reporting and be disproportionate, and that suspension should be decided case-by-case based on risk assessment (Government Response to the Paterson Inquiry, DHSC, December 2021).
- No subsequent change of position has been identified in published government documents to March 2026.
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
- In December 2021, the government accepted this recommendation in principle, stating that CQC registration conditions require providers to share relevant information and that GMC guidance requires doctors to share concerns about colleagues with relevant bodies (Government Response to the Paterson Inquiry, DHSC, December 2021).
- The December 2022 implementation update stated that the Acute Data Alignment Programme (ADAPt) pilots had confirmed the value of NHS-independent sector data sharing, with Phase 3 planned for broader cross-sector data alignment (Paterson Inquiry Implementation Update, DHSC, December 2022).
- No published statutory requirement specifically mandating sharing of concerns between providers when a healthcare professional works at multiple sites has been identified to March 2026.
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
- In December 2021, the government accepted this recommendation in principle, acknowledging a gap in legal responsibility when consultants work under practising privileges and stating that CQC had strengthened requirements for independent providers to have robust governance (Government Response to the Paterson Inquiry, DHSC, December 2021).
- The December 2022 implementation update stated that the Independent Healthcare Providers Network had refreshed the Medical Practitioners Assurance Framework (MPAF) in September 2022 and that the 2022-2023 NHS Standard Contract required independent sector providers to have regard to the MPAF (Paterson Inquiry Implementation Update, DHSC, December 2022).
- The December 2022 update noted a significant culture shift emphasising independent provider responsibility for standards regardless of employment versus practising privilege arrangements (Paterson Inquiry Implementation Update, DHSC, December 2022).
- No published legislation closing the gap in legal responsibility and liability for patients treated by consultants working under practising privileges has been identified to March 2026.
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
- In December 2021, the government accepted this recommendation, stating that Duty of Candour regulations require healthcare providers to be open when things go wrong and that NHS Resolution had clarified that sincere apologies do not constitute admissions of liability (Government Response to the Paterson Inquiry, DHSC, December 2021).
- The December 2022 implementation update stated that NHS Resolution had produced a duty of candour animation explaining apology requirements and enhanced training and resources for clinicians on meaningful apologies (Paterson Inquiry Implementation Update, DHSC, December 2022).
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
- In December 2021, the government did not accept this recommendation but stated it would be kept under review, citing concerns about proportionality and unintended consequences of extending all recommendations across the independent sector's full workload including self-pay patients (Government Response to the Paterson Inquiry, DHSC, December 2021).
- No subsequent change of position has been identified in published government documents to March 2026.
Department of Health and Social Care (Primary)
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