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 …

- The Department of Health and Social Care stated in December 2021 that it was improving data flows to the CQC and GMC to provide …

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, …

- The Academy of Medical Royal Colleges (AoMRC) updated its 'Please write to me' guidance in 2018, stipulating that outpatient letters should be written directly …

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 …

- The available evidence indicates that implementation is in progress but not complete. The government remains committed to publishing the information requested by the recommendation, …

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 …

- The GMC revised its "Decision making and consent" guidance, effective 9 November 2020, which requires doctors to give patients time to consider information before …

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 …

- The government stated in December 2021 that the CQC had updated its inspection methodology to examine MDT functioning and compliance with national guidance (Government …

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.

- The Parliamentary and Health Service Ombudsman issued NHS Complaints Standards in December 2022, which include a model procedure to increase awareness of independent resolution …

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.

- The government stated in December 2021 that it was considering whether legislative change is needed to make independent adjudication mandatory for all private healthcare …

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 …

- University Hospitals Birmingham NHS Foundation Trust stated that all known living patients of Ian Paterson had been contacted by August 2020 (Implementation update to …

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 …

- Spire Healthcare stated in April 2025 that it had contacted all known living patients of Ian Paterson and completed a comprehensive review (Implementation update …

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 …

- The National Quality Board published the "Patient-Centred Framework for NHS-Led Recalls" on 1 June 2022 to provide guidance on conducting recall processes (Patient-Centred Framework …

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 March 2024, the government announced that Medical Defence Organisations (MDOs) intended to implement a sector-led Code of Practice for discretionary indemnity by the …

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 …

- The Department of Health and Social Care stated in April 2025 that professional regulators are members of the Joint Strategic Oversight Group (JSOG) to …

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 …

- The government did not accept the recommendation for automatic suspension, stating that suspension should be based on individual risk assessments (Government Response to the …

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.

- The GMC updated its guidance to state that patient safety is paramount when deciding whether to share information about doctors with other providers (DHSC …

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.

- The Independent Healthcare Providers Network (IHPN) refreshed the Medical Practitioners Assurance Framework (MPAF) to clarify that independent providers are responsible for the quality of …

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 …

- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 established a statutory duty of candour for NHS trusts in 2014 and all …

15 Under Consideration

Paterson Inquiry (2020)

Independent sector NHS contract qualification

We recommend that, if the Government accepts any of the recommendations concerned, it should make arrangements to ensure that these are to be applicable across the whole of the independent …

- The government did not accept this recommendation, stating that different governance models in the NHS and independent sectors require different approaches to achieving change …