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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 (1)

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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