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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 18 questions 10 statements since Feb 2020
Written Question Paterson Inquiry
Baroness Maclean of Redditch (Conservative)
07 Jul 2026
Written Question Paterson Inquiry
Baroness Maclean of Redditch (Conservative)
07 Jul 2026
Written Question Patients: Safety
Baroness Maclean of Redditch (Conservative)
07 Jul 2026
Written Question Paterson Inquiry
Baroness Maclean of Redditch (Conservative)
29 Jun 2026
Written Question Paterson Inquiry
Baroness Maclean of Redditch (Conservative)
29 Jun 2026
View all 30 mentions →
All Activity (30)
Title Volume Publication Date Tracked recs Links
Report of the Independent Inquiry into the Issues raised by Paterson - 04 Feb 2020 17
Clear

Recommendations (6)

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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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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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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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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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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