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'
Summary written by the tracker with AI assistance, 26 March 2026. Not part of the inquiry record; indicative, not authoritative.
Implementation Reviewed By
Thirlwall Inquiry legal team
(Feb 2026)
The Thirlwall Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026) sets out 17 of this inquiry's recommendations that this site holds, with its own notes on implementation. It colours a recommendation's Extent of Implementation cell green where it found evidence that the recommendation had been clearly implemented: 14 not coloured green; 3 coloured green.
DHSC and NHS England (commentary provided to the Thirlwall Inquiry, September 2024)
(Feb 2026)
DHSC and NHS England gave the Thirlwall Inquiry their own account of progress on 17 of this inquiry's recommendations that this site holds, printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). This is the government's own account, not a finding of the Inquiry. Their reviewed extent of implementation: 6 Implemented - Ongoing; 4 In progress; 2 Partially implemented – Ongoing; 2 Implemented – Ongoing; 2 Not accepted; 1 Implemented – Closed.
Thirlwall Inquiry legal team
(May 2024)
The Thirlwall Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024) sets out 17 of this inquiry's recommendations that this site holds, with its own notes on implementation. It colours a recommendation's Extent of Implementation cell green where it found evidence that the recommendation had been clearly implemented: 14 not coloured green; 3 coloured green.
DHSC (comments provided to the Thirlwall Inquiry, February 2024)
(May 2024)
DHSC gave the Thirlwall Inquiry their own account of progress on 16 of this inquiry's recommendations that this site holds, printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). This is the government's own account, not a finding of the Inquiry.