Independent Inquiry into the Issues raised by Paterson

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.