A tragedy for doctors too
The Paterson Inquiry: Chairman’s statement
‘This report is not simply a story about a rogue surgeon. It would be tragic enough if that was the case, given the thousands of people whom Ian Paterson treated. But it is far worse.’
These are the opening words of the Paterson Inquiry report by its chairman, The Rt Revd Graham James.
In a damning synopsis, he said: ‘It is the story of a healthcare system which proved itself dysfunctional at almost every level when it came to keeping patients safe, and where those who were the victims of Paterson’s malpractice were let down time and time again.
‘They were initially let down by a consultant surgeon who performed inappropriate or unnecessary procedures and operations. They were then let down both by an NHS trust and an independent healthcare provider who failed to supervise him appropriately and did not respond correctly to well-evidenced complaints about his practice.
‘Once action was finally taken, patients were again let down by wholly inadequate recall procedures in both the NHS and the private sector. The recall of patients did not put their safety and care first, which led many of them to consider the Heart of England NHS Foundation Trust and Spire were primarily concerned for their own reputation.
Treated with disdain
‘Patients were further let down when they complained to regulators and believed themselves frequently treated with disdain. They then felt let down by the Medical Defence Union which used its discretion to avoid giving compensation to Paterson patients once it was clear his malpractice was criminal.
‘Only by taking their cases to sympathetic lawyers did some patients find themselves heard. By that stage, many others found their exhaustion was too great and their sense of rejection so complete that they scarcely had the emotional or physical strength to fight any further.’
The Bishop said that, even today, many patients, especially those treated within Spire hospitals, had no individual care plan.
Thousands of people were still living with the consequences of what happened and it would be wishful thinking that this could not happen again.
He continued: ‘The Inquiry team were told by regulators and other witnesses that procedures and processes had tightened up considerably in the past decade. We were informed that the regulatory system was more vigilant, and patient safety was now given a much higher priority so that another Paterson would be unlikely.
Guidelines ignored
‘We acknowledge many areas of improvement in processes and procedures. But in Paterson’s years of practice, there were many regulations and guidelines in place which were disregarded or simply ignored, and not just by him.
‘It was striking that regulators testified to major improvements which they thought would identify another Paterson, while the clinicians we met believed that, despite the changes, it was entirely possible that something similar could happen now.
‘The testimony of those on the front line is telling. It is tempting for inquiries to recommend fresh layers of regulation. But our healthcare system does not lack regulation or regulators. The resources they possess, both human and financial, are very considerable.
Culture of denial
‘There is no process, procedure or regulation which can prevent malpractice on its own. This report is primarily about poor behaviour and a culture of avoidance and denial. These are not necessarily improved by additional regulation.’
The Bishop said the sheer number of regulatory bodies and the complexity of their areas of responsibility meant that Paterson’s patients thought the system unfocused and scarcely possible to navigate, while many clinicians seemed to feel the same, and so avoided engagement with it.
‘We were told that if there was more accessible data about a consultant’s whole practice, then the events described in this report would have been stopped more quickly. We have made a recommendation in this area, but it is important to recognise that the collection of data and information is insufficient alone to prevent what has been described here.
‘It is how information is analysed and used, and then made available to the public, which determines its value.’
He said managers seemed to look for patterns which reassured rather than disturbed.
Wilful blindness
This capacity for ‘wilful blindness’ was illustrated by the way in which Paterson’s behaviour and aberrant clinical practice was excused or even favoured.
The Inquiry chairman added: ‘Many simply avoided or worked round him. Some could have known, while others should have known, and a few must have known.
‘At the very least, a great deal more curiosity was needed, and a broader sense of responsibility for safety in the wider healthcare system by both clinicians and managers alike.
‘However, some seem to have been inhibited from complaining because they had seen colleagues appearing to get nowhere by doing so – and in some cases finding themselves under investigation.
‘A few of Paterson’s more junior colleagues commented that the unusual character of his surgical practice – compared with other breast surgeons – was well known. To a surprising degree he was “hiding in plain sight”.’
Enormous impact on clinicians
The impact of what is described in the report has been enormous for many clinicians and others who either worked with Paterson or came into contact with him, the Bishop said.
‘Those who did take action but were then poorly served by those to whom they reported, have themselves been traumatised. Some who should have taken action now live with the guilt. Others are in a state of denial.
‘Many patients felt that some of those who worked closely with Paterson should answer for their actions or negligence.’
He has reported five health professionals to either the GMC or the Nursing & Midwifery Council and referred one matter for investigation by the West Midlands Police.