The Paterson Inquiry: Are there any new lessons for patient safety? Will there be any action?

  • 11th February 2020

The Independent Inquiry into the Issues raised by Paterson, published on Tuesday 4 February 2020, was prompted by the case of Ian Paterson, a breast surgeon who was convicted of wounding with intent some of the 11,000 patients he treated and jailed for 20 years in 2017. More than 200 patients and family members gave evidence as part of the Inquiry and it is estimated that he could have harmed more than 1000 patients.[1]

The Inquiry gave those involved an opportunity to be heard and to learn how this happened, in both the NHS and the independent sector. It found that this “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”.[2]

At Patient Safety Learning we have reflected on some of the key patient safety themes that have emerged from this Inquiry and the actions required to address these issues. You can read our full response here.

The Government’s response and action needed

The Government’s response to the publication of the Inquiry’s report advised that they would look at these recommendations and report back ”in three to four months’ time”.[3] When doing this it is vital that these recommendations are considered holistically as part of the wider change that is needed, where patient safety is treated as a strategic purpose of healthcare. Patient safety is currently treated as one of many priorities to be weighed against each other. We think it is wrong that safety is negotiable. Patient safety must be core to the purpose of healthcare, reflected in everything that it does.

We look forward to the Government’s response to the Inquiry recommendations. This must include action for change, including:

Culture change

  • Creating a culture in healthcare where staff feel safe and secure in reporting patient safety concerns, knowing their concerns will be actively welcomed, listened to and acted upon.
  • Healthcare organisations should regularly and independently assess their organisational culture and have programmes of action to ensure a just and learning culture is in place.

Staff reporting concerns

  • An open and learning culture clearly signposting staff on how to raise concerns and that these concerns are acted upon.

Harmed patients are supported

  • Patients receive the support they need when things go wrong.
  • ‘Harmed patient care pathways’ outline the provision of advice, guidance, practical and psychological support to patients and families.

Learning from complaints

  • All private patients have the right to mandatory independent resolution of their complaint. Patient safety applies to all, irrespective of whether care is provided for in the NHS or independent sector.


  • Organisations develop systems and measurements to improve patient safety, collecting data on patient safety and sharing learning. We strongly support the recommendation made by the Inquiry that where a healthcare professional is suspended with a perceived risk to patient safety, these concerns should be communicated to other providers that they work for.

Leading and owning patient safety

  • A new model for leadership and governance for patient safety that operates in both the NHS and independent sector. There should be high standards and behaviours set for our leaders and they should be supported by specialist patient safety experts in executive and non-executive board roles. Organisations need clear and published goals for patient safety with board focus and effectively oversight on reducing patient harm.
  • The healthcare system operates as one coordinated system with patient safety as a core purpose.

If action isn’t taken, then the Paterson Inquiry will become yet another report of unsafe care where sympathetic noises are made but no real learning and change occurs. If Government and leaders say that ‘lessons have been learned’ then they need to tell us what those lessons are, what actions they are taking, and publish updated reports on their progress and share these publicly. Without having these measures in place, how can the public and patients be assured that there won’t be future reports of unsafe care? As the Inquiry Chair said, “it is wishful thinking that this could not happen again”.

[1] The Guardian, Ian Paterson inquiry: more than 1,000 patients had needless operations, 4 February 2020.

[2]The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, February 2020.

[3]House of Commons Debate, Paterson Inquiry, 4 February 2020, Volume 671.

Paterson Inquiry


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