System failed to keep patients safe from rogue surgeon

Author: Louise Prime

Independent as well as NHS providers must write directly to patients explaining their condition and treatment in easy to understand terms, copying in their GP, the official inquiry into disgraced surgeon Ian Paterson has recommended. It heard that Paterson lied in letters he sent to patients’ GPs about them, as well as keeping inadequate notes and even asking a colleague to destroy many patients’ notes – and also that he provided local GPs with hospitality and “built a strong local reputation which appeared to influence referral behaviour”. It also found that the regulatory system had been ineffective.

Nadine Dorries MP (Parliamentary under-secretary of state for mental health, suicide prevention and patient safety) presented to Parliament yesterday afternoon the report* of the independent inquiry into the issues raised by Paterson, who worked for Heart of England NHS Foundation Trust (HEFT) and Spire. She apologised to patients and their families on behalf of the government and the NHS, and said the government is “absolutely committed to ensuring that lessons are learned and acted upon… in both the NHS and the independent sector”.

The inquiry was chaired by The Right Reverend Graham James, Bishop of Norwich. In his opening statement to the report, he wrote: “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. 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.”

The inquiry report said [p.98] it was told Paterson saw 6,617 patients from 1997-2011 at Spire hospitals, of whom 4,077 underwent a surgical procedure, of which 2,399 were breast surgery. During his tenure at HEFT from 1998-2001 he treated 4,424 patients for breast symptoms and performed mastectomies on 1,207. More than 130 patients, or relatives of patients, gave evidence that included specific references to poor quality of care from Paterson, both at HEFT and Spire hospitals. It said that an earlier report from Spire in 2016 “contains shocking examples of Paterson’s treatment, including procedures on minors where other tests revealed no abnormalities. The report also refers to other healthcare professionals, who did not question Paterson’s clinical practice”.

The inquiry heard that Paterson’s notes were generally of poor quality and with insufficient detail to show what procedure had been undertaken, particularly if it had been a cleavage-sparing mastectomy (terminology used by Paterson, but not a recognised procedure); some patients gave evidence that Paterson had lied in the letters he sent to GPs about them; and other witnesses said Paterson lied in patient letters and notes. About a dozen patients told the inquiry that some or all their notes were missing; and a witness who worked with Paterson at Spire said she had been instructed to destroy a substantial number of patient notes.

The inquiry heard that neither GPs nor patients routinely had access to information about the care they received while at hospital. The report said [p.177]: “Failure to provide information to both the patient and their GP disempowered them, removing their ability to have full control over their care. Writing letters directly to patients is in keeping with both the NHS Constitution and GMC’s [General Medical Council’s] Good Medical Practice.”

The report also noted: “Many patients were referred to Paterson specifically by their GP, both in the NHS and independent sector. Their GP’s personal recommendation built their trust in Paterson in advance of meeting him. We heard that Paterson built a strong local reputation which appeared to influence referral behaviour. We also heard that he would provide local GPs with hospitality, such as tickets for rugby matches.”

The inquiry’s recommendations include:

  • 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 example, how many times a consultant has performed a particular procedure and how recently – for use by managers and healthcare professionals in both the NHS and the independent sector
  • 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, and copy this letter to the patient’s GP, rather than writing to the GP and sending a copy to the patient.
  • 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 treatment options. The GMC should monitor this as part of ‘Good Medical Practice’.
  • Care Quality Commission (CQC), as a matter of urgency, should assure itself that all hospital providers are complying effectively with up-to-date national guidance on multidisciplinary team meetings, including in breast cancer care, and that patients are not at risk of harm due to non-compliance in this area.
  • 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 the inquiry, and introduce a nationwide safety net to ensure patients are not disadvantaged.
  • 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 system identified in this inquiry.
  • If, when a hospital investigates a healthcare professional’s behaviour, including the use of a human resources process, any perceived risk to patient safety should result in the suspension of that healthcare professional. If the healthcare professional also works at another provider, any concerns about them should be communicated to that provider.

CQC pointed out that since the time when Paterson was practising, it has developed its regulatory model to require providers to strengthen medical governance and oversight of clinical care in both the NHS and private hospitals. Its chief executive Ian Trenholm said: “We must continue to promote a culture, both in the NHS and the private sector, where people feel able to raise concerns without fear of retribution and where the voices of staff, patients and their families are listened to and acted on without exception.”

Action Against Medical Accidents (AvMA) advised some of the patients and their families affected by Paterson, and gave evidence to the inquiry. The charity called last night for major changes to the way in which private healthcare is regulated in order to protect future patients, and said it has been campaigning for many years on issues including:

  • Bringing regulations of private healthcare up to the level applied to the NHS, with regular audits and supervision and appraisal of health staff
  • A single robust complaints procedure for patients in private healthcare with the right to appeal to an ombudsman or equivalent and independent advice/advocacy
  • A statutory requirement for any private healthcare organisation to take responsibility and have indemnity cover for any legal claim made in relation to the treatment provided under its auspices.

AvMA chief executive Peter Walsh said: “The inquiry failed to recommend that patients/families have access to a funded independent advice service to help them take forward concerns. This is a major gap in private healthcare where injured patients are often left to fend for themselves against large corporations or on rare occasions, rogue doctors.”

*Paterson Inquiry report. Prepared by the Department of Health and Social Care, 4 February 2020.