Public Inquiry Recommendations

1 Accepted in Part

Paterson Inquiry (2020)

Single consultant data repository

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 …

- In December 2021, the government accepted this recommendation in principle, stating that NHS England was developing consultant-level procedure data and that the Private Healthcare …

2 Accepted

Paterson Inquiry (2020)

Patient-focused correspondence

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, …

- In December 2021, the government accepted this recommendation, noting that the Academy of Medical Royal Colleges had updated its 2018 guidance 'Please write to …

3 Accepted

Paterson Inquiry (2020)

Explaining independent sector differences

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 …

- In December 2021, the government accepted this recommendation, stating that CQC now requires independent healthcare providers to ensure patients understand arrangements relating to consultant …

4 Accepted in Part

Paterson Inquiry (2020)

Reflection period for consent

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 …

- In December 2021, the government accepted this recommendation in principle, stating that GMC guidance on consent (updated 2020) already emphasises that patients should have …

5 Accepted

Paterson Inquiry (2020)

CQC assurance on MDT meetings

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 …

- In December 2021, the government accepted this recommendation, stating that CQC had updated its inspection methodology to specifically examine multidisciplinary team (MDT) functioning and …

6a Accepted

Paterson Inquiry (2020)

Communicating complaint escalation

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.

- In December 2021, the government accepted this recommendation, stating that NHS complaints processes now more clearly signpost to the Parliamentary and Health Service Ombudsman …

6b Accepted in Part

Paterson Inquiry (2020)

Mandatory independent complaint resolution

We recommend that all private patients should have the right to mandatory independent resolution of their complaint.

- In December 2021, the government accepted this recommendation in principle, stating that further work was needed on an implementation mechanism and that membership of …

7 Accepted

Paterson Inquiry (2020)

UHB patient recall

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 …

- In December 2021, the government stated that this recommendation had been accepted and implemented, with University Hospitals Birmingham NHS Foundation Trust having undertaken extensive …

8 Accepted

Paterson Inquiry (2020)

Spire patient recall

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 …

- In December 2021, the government stated that this recommendation had been accepted and implemented, with Spire Healthcare having undertaken comprehensive patient recall and all …

9 Accepted

Paterson Inquiry (2020)

National patient recall framework

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 …

- In December 2021, the government stated that this recommendation had been accepted and implemented, with NHS England having published the National Quality Board Recall …

10 Accepted in Part

Paterson Inquiry (2020)

Indemnity regulation reform

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 …

- In December 2021, the government accepted this recommendation in principle, stating that medical defence organisations were being encouraged to develop reforms to discretionary indemnity …

11 Accepted

Paterson Inquiry (2020)

Regulatory system patient safety priority

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 …

- In December 2021, the government accepted this recommendation, stating that CQC and GMC had improved information-sharing arrangements and that the Professional Standards Authority oversees …

12a Not Accepted

Paterson Inquiry (2020)

Suspension during investigation

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 …

- In December 2021, the government did not accept this recommendation, stating that blanket automatic suspension could deter reporting and be disproportionate, and that suspension …

12b Accepted in Part

Paterson Inquiry (2020)

Information sharing between providers

We recommend that if the healthcare professional also works at another provider, any concerns about them should be communicated to that provider.

- In December 2021, the government accepted this recommendation in principle, stating that CQC registration conditions require providers to share relevant information and that GMC …

13 Accepted in Part

Paterson Inquiry (2020)

Independent sector provider responsibility

We recommend that the government addresses, as a matter of urgency, this gap in responsibility and liability.

- In December 2021, the government accepted this recommendation in principle, acknowledging a gap in legal responsibility when consultants work under practising privileges and stating …

14 Accepted

Paterson Inquiry (2020)

Board apologies

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 …

- In December 2021, the government accepted this recommendation, stating that Duty of Candour regulations require healthcare providers to be open when things go wrong …

15 Under Consideration

Paterson Inquiry (2020)

Independent sector NHS contract qualification

We recommend that if the government accepts any of the recommendations set out above, it should make arrangements to ensure that these are to be applicable across the whole of …

- In December 2021, the government did not accept this recommendation but stated it would be kept under review, citing concerns about proportionality and unintended …