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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.
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”.
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 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”. 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:
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”.
 The Guardian, Ian Paterson inquiry: more than 1,000 patients had needless operations, 4 February 2020. https://www.theguardian.com/society/2020/feb/04/ian-paterson-inquiry-culture-of-denial-allowed-rogue-breast-surgery
The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, February 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/863211/issues-raised-by-paterson-independent-inquiry-report-web-accessible.pdf
House of Commons Debate, Paterson Inquiry, 4 February 2020, Volume 671. https://hansard.parliament.uk/Commons/2020-02-04/debates/560C88B9-4C75-483D-ABF2-12951326AE28/PatersonInquiry