Public Inquiry
Independent Inquiry into the Issues raised by Paterson
Status: Completed
Chair: Bishop Graham James
Established: Feb 2018
Report: Feb 2020
Commissioned by: Department of Health and Social Care
Inquiry into rogue surgeon Ian Paterson who performed unnecessary breast operations on hundreds of patients in NHS and private hospitals. Examined failures in healthcare regulation and patient safety.
Response breakdown
Data last updated: 29 Apr 2026 · Data verified: 5 Feb 2026 (Claude)
Evidence & impact
The Independent Inquiry into the Issues raised by Paterson examined the case of Ian Paterson, a breast surgeon who carried out unnecessary operations on hundreds of patients in NHS and private hospitals. The inquiry, chaired by Bishop Graham James, published 17 recommendations in February 2020 focusing on patient safety, consent processes, regulatory oversight, and redress mechanisms.
The government's December 2021 response accepted nine recommendations, accepted six in principle, rejected one, and kept one under consideration. The single rejected recommendation (12a) concerned automatic suspension of consultants under investigation, with the government stating this should remain a case-by-case decision based on risk assessment to avoid deterring reporting.
Published evidence indicates some concrete changes have emerged. NHS England published the National Quality Board Recall Framework in June 2022, developed with input from Paterson patients. Medical defence organisations launched a voluntary Code of Practice for discretionary indemnity in January 2025, though this falls short of the mandatory safety net recommended by the inquiry. The CQC has strengthened registration conditions and updated inspection methodologies, while professional bodies have revised guidance on patient communication and consent.
However, six years after publication, the implementation status shows 15 of 17 recommendations as 'awaiting action', with only one 'in progress'. Multiple recommendations accepted or accepted in principle show limited published evidence of completion. Work on improving data flows between regulators remains 'ongoing', embedding cooling-off periods is still being worked on with Royal Colleges, and decisions on legislative changes for consultant liability under practising privileges remain under consideration.
The government's approach appears characterised by accepting principles while deferring concrete implementation mechanisms. Several responses indicate ongoing consultations, monitoring of voluntary improvements, or work to address legal and data protection considerations, but published evidence of completed actions remains limited for most recommendations.
The government's December 2021 response accepted nine recommendations, accepted six in principle, rejected one, and kept one under consideration. The single rejected recommendation (12a) concerned automatic suspension of consultants under investigation, with the government stating this should remain a case-by-case decision based on risk assessment to avoid deterring reporting.
Published evidence indicates some concrete changes have emerged. NHS England published the National Quality Board Recall Framework in June 2022, developed with input from Paterson patients. Medical defence organisations launched a voluntary Code of Practice for discretionary indemnity in January 2025, though this falls short of the mandatory safety net recommended by the inquiry. The CQC has strengthened registration conditions and updated inspection methodologies, while professional bodies have revised guidance on patient communication and consent.
However, six years after publication, the implementation status shows 15 of 17 recommendations as 'awaiting action', with only one 'in progress'. Multiple recommendations accepted or accepted in principle show limited published evidence of completion. Work on improving data flows between regulators remains 'ongoing', embedding cooling-off periods is still being worked on with Royal Colleges, and decisions on legislative changes for consultant liability under practising privileges remain under consideration.
The government's approach appears characterised by accepting principles while deferring concrete implementation mechanisms. Several responses indicate ongoing consultations, monitoring of voluntary improvements, or work to address legal and data protection considerations, but published evidence of completed actions remains limited for most recommendations.
Implementation reviewed by
DHSC and NHS England (implementation update provided to the Thirlwall Inquiry)
(Apr 2025)
↗
DHSC and NHS England provided the Thirlwall Inquiry with an update on the implementation of this inquiry's recommendations (April 2025). This is the government's own account of progress, submitted to the inquiry, rather than an independent assessment by the inquiry. Across 17 recommendation(s) the reviewed extent of implementation was stated as: 8 Implemented – Ongoing; 4 In progress; 2 Partially implemented – Ongoing; 2 Not accepted; 1 Implemented – Closed.
Key facts
Duration: 1 year, 11 months
Statements: 238
Reports & milestones
Reports
04 Feb 2020
17 tracked recs
Report of the Independent Inquiry into the Issues raised by Paterson
· Tracked recommendations
· PDF
Timeline
No milestones recorded.
Recommendations
| Code | Recommendation | Addressed to | Response | |
|---|---|---|---|---|
| 12a |
We recommend that if, when a hospital investigates a healthcare professional's behaviour, including the use of an HR process, any perceived risk …
|
Department of Health and Social Care | Not Accepted | View → |
Parliamentary activity
2 debates
18 questions
10 statements