It is still possible for a rogue surgeon to operate in both the NHS and private sectors today, a report about jailed cancer doctor Ian Paterson has said.
The inquiry team has found that checks and balances put in place since Paterson practised, and which may have detected his malpractice, are not universal or uniform across the NHS and independent sectors.
Paterson was jailed for 20 years in 2017 for wounding patients after a criminal investigation found he performed unnecessary surgery – including mastectomies – on patients.
They conclude: “It is our opinion that it remains possible for poor or unsafe practice to be undetected today.”
The team, led by The Right Reverend Graham James, has found that patients were failed by “a healthcare system that proved itself dysfunctional at almost every level when it came to keeping patients safe”.
It has also discovered that concerns raised by healthcare professionals in the NHS were missed on many occasions and there was a “culture of avoidance and denial” within both the NHS and private sector.
It concluded that Paterson could have been stopped from practising in 2003 and should have been stopped in 2007 rather than 2011.
Since then it has emerged that as many as a thousand patients were victims of unnecessary or unsafe procedures that he carried out over more than a decade at the Heart of England Foundation Trust and private Spire hospitals in the West Midlands.
The inquiry team has spoken to hundreds of patients who were harmed by Paterson.
A subsequent recall of patients did not put safety and care first and lacked transparency in both the NHS and independent sectors, the report found.
The inquiry team say they remain unconvinced that all patients who should have been recalled have been contacted.
The report lays out 15 recommendations that include the creation of a single repository of consultants’ practice, setting out their practising privileges and key performance data that is accessible and clear to the public.
It also says the government needs to address gaps in responsibility and liability between the NHS and the independent sector as a priority.
Debbie Douglas was diagnosed with breast cancer by Ian Paterson in 2003. She recalls the fear she felt when told by him that she needed a mastectomy and chemotherapy, and the anxiety it caused her then teenage children.
It was only later, when she was recalled, that she discovered her cancer had been of a low grade and the mastectomy and reconstruction had been unnecessary.
She was also told that not all of her breast tissue had been removed, as she had thought, because Ian Paterson had performed a “cleavage sparing mastectomy” without informing her.
“Down the line I realise none of this was necessary, I should have had a lumpectomy,” she told Sky News.
“Not only has he left me scarred physically and mentally but he’s left me at risk of a reoccurance of breast cancer. If I needed a mastectomy he should have removed all the breast tissue.”
She was treated at the private Spire Parkway hospital in Solihull.
The report found that “where good practice is implemented in the NHS it is often voluntary in the independent sector”.
It continues: “Where the independent sector does adopt best practice it is often slow and decisions to adopt such practice focus on innovation and flexibility rather than keeping patients safe.”
Health Minister, Nadine Dorries said: “I deeply regret the failures of the NHS and the independent sector to protect patients from the devastating impact of Paterson’s malpractice.
“It is essential we all respond quickly and effectively to the lessons of this inquiry, giving every patient the confidence that the care they receive is safe and meets the highest standards.
“We will give thorough and detailed consideration to this report and its findings and will provide a full response in due course.”