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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: 25 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
Clear

Recommendations (9)

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 Department of Health and Social Care (DHSC) accepted this recommendation in December 2021. The Academy of Medical Royal Colleges updated its 2018 guidance 'Please write to me' to emphasise writing directly to patients in simple language, with a copy sent to their GP (Government Response, December 2021). NHS England was working to embed this practice across the health service (Government Response, December 2021). No further specific published evidence has been identified since December 2021 detailing the extent to which this practice has been embedded across the health service.
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 Department of Health and Social Care (DHSC) accepted this recommendation in December 2021. CQC registration conditions now require independent healthcare providers to ensure patients understand how consultant engagement, practising privileges, indemnity, and emergency and intensive care arrangements work (Government Response, December 2021). The Private Healthcare Information Network (PHIN) also provides comparative information to patients (Government Response, December 2021). No further specific published evidence has been identified since December 2021 detailing the impact or enforcement of these CQC requirements.
Department of Health and Social Care (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 CQC updated its inspection methodology to specifically examine the functioning of Multi-Disciplinary Team (MDT) meetings and compliance with national guidance, including whether all relevant cases are discussed (Government Response, December 2021). The CQC also works with NHS England and Getting It Right First Time to ensure national guidance on MDTs is followed (Government Response, December 2021). No further specific published evidence detailing the updated methodology or its outcomes has been identified since December 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
NHS complaints processes now more clearly signpost patients to the Parliamentary and Health Service Ombudsman (Government Response, December 2021). The Independent Healthcare Providers Network (IHPN) agreed to ensure its members inform patients about the Independent Sector Complaints Adjudication Service (ISCAS) (Government Response, December 2021). The CQC monitors complaints handling as part of its inspections, but no further specific published evidence detailing these improvements or monitoring outcomes has been identified since December 2021.
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 (UHB) undertook extensive patient recall programmes, resulting in over 12,000 patients being recalled for review (Government Response, December 2021). The Trust confirmed that all identifiable patients of Ian Paterson were contacted and offered a review, with ongoing support provided to affected patients (Government Response, December 2021). No further specific published evidence has been identified since December 2021, but the government response indicated the action was completed.
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 undertook a comprehensive patient recall programme, contacting all identifiable former patients of Ian Paterson and offering them a clinical review (Government Response, December 2021). Spire also provided ongoing treatment plans and support to affected patients, consistent with the NHS approach (Government Response, December 2021). No further specific published evidence has been identified since December 2021, but the government response indicated the action was completed.
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
NHS England published the National Quality Board Recall Framework on 1 June 2022, which was developed with input from Paterson patients (Government 12-month Implementation Update, December 2022). This framework establishes principles for patient-centred recall in secondary care, applicable across both the NHS and independent sectors (Government 12-month Implementation Update, December 2022). This action directly addresses the recommendation for a national framework or protocol for patient recall.
NHS England (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 (DHSC) accepted this recommendation in December 2021. The government stated it was strengthening regulatory collaboration, with the CQC and GMC having improved information sharing arrangements (Government Response, December 2021). The Professional Standards Authority oversees healthcare regulators, and a regulatory reform programme was underway to ensure patient safety is paramount. The Health and Care Act 2022 includes provisions to improve regulatory effectiveness (Government Response, December 2021). No further specific published evidence has been identified since December 2021 detailing the outcomes or ongoing progress of the regulatory reform programme or the impact of the Health and Care Act 2022 in ensuring patient safety as the top priority.
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 Department of Health and Social Care (DHSC) accepted this recommendation in December 2021. Duty of Candour regulations require healthcare providers to be open when things go wrong (Government Response, December 2021). NHS Resolution promotes early apology and has clarified that sincere apologies do not constitute an admission of liability. Professional Standards Authority guidance supports early acknowledgment of harm, and training on candour was being embedded across the NHS and independent sector (Government Response, December 2021). No further specific published evidence has been identified since December 2021 detailing the completion or impact of the candour training.
Department of Health and Social Care (Primary)
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