Independent Inquiry into the Issues raised by Paterson
Completed
· Chair: Bishop Graham James
· Established December 2017
· 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.
More about this inquiry
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.
Not accepted · DHSC and NHS England say not accepted
Recommended
We recommend that if, when a hospital investigates a healthcare professional's behaviour, including the use of an HR process, any perceived risk to patient safety should result in the suspension of that healthcare professional.
Since then (summary written by this site)
In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England maintained that the recommendation was not accepted, stating that its underlying goals could be met through clear guidance and robust investigations (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team recorded in its February 2026 review that the recommendation had not been accepted by the government (The Thirlwall Inquiry legal team, Feb 2026). In their September 2024 update, the bodies noted that policy frameworks for raising concerns were being developed, alongside national people policy frameworks for providers to adopt locally, which will include a resolution framework (DHSC and NHS England, Feb 2026).
Addressed to Department of Health and Social Care · Full record
Not accepted · DHSC and NHS England say not accepted
Recommended
We recommend that, if the Government accepts any of the recommendations concerned, it should make arrangements to ensure that these are to be applicable across the whole of the independent sector's workload (i.e. private, insured and NHS-funded) if independent sector providers are to be able to qualify for NHS-contracted work.
Since then (summary written by this site)
In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England confirmed that the recommendation was not accepted, explaining that differences in operational and governance models between the sectors require different approaches (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team noted in May 2024 that the recommendation was not accepted by the government and was due to be reviewed further (The Thirlwall Inquiry legal team, May 2024). The department had stated in February 2024 that "no further action has been taken in relation to this recommendation" (The Department of Health and Social Care, May 2024).
Addressed to Department of Health and Social Care · Full record
Written QuestionHouse of LordsBaroness Maclean of Redditch · Conservative
Asked: To ask His Majesty's Government, further to the Written Answer by Baroness Merron on 29 April (HL16567), whether the National Consultant Information Programme (1) is publicly accessible to patients, (2) includes data on consultants practising in the independent sector, and (3) records the practising privileges …
Answered by Department of Health and Social Care: The National Consultant Information Programme (NCIP) is publicly accessible to patients on the Getting It Right First Time website. The NCIP portal is a free data platform containing consultant and provider-level activity and outcomes data for over 500 procedures in 13 surgical specialties. It covers National Health Service practices, NHS funded work in the independent sector, and privately funded work …
Written QuestionHouse of LordsBaroness Maclean of Redditch · Conservative
Asked: To ask His Majesty's Government, further to the Written Answer by Baroness Merron on 29 April (HL16570), what data they hold on compliance with the General Medical Council's guidance Decision making and consent; how many fitness to practise cases since November 2020 have involved a …
Answered by Department of Health and Social Care: The General Medical Council (GMC) is independent of the Government, directly accountable to Parliament, and is responsible for operational matters concerning the discharge of its statutory duties. The United Kingdom’s model of healthcare professional regulation is founded on the principle of regulators operating independently from the Government. The Department does not hold national datasets on what audits of consent practice …
Written QuestionHouse of LordsBaroness Maclean of Redditch · Conservative
Asked: To ask His Majesty's Government, further to the Written Answer by Baroness Merron on 29 April (HL16569), when they expect the information explaining to patients how care in the independent sector differs from NHS care to be published; and what has caused the delay in …
Answered by Department of Health and Social Care: The Department recognises the importance of ensuring that patients have clear information about their care in the National Health Service, whether delivered by NHS providers or independent sector providers. We have recently published a set of patient experience minimum standards setting out our expectations of providers of NHS funded elective care while patients are on the waiting list. We will …
Written QuestionHouse of LordsBaroness Maclean of Redditch · Conservative
Asked: To ask His Majesty's Government, for each of the 17 recommendations arising from the Paterson Inquiry report as set out in their response of 16 December 2021, (1) whether the recommendation was accepted, accepted in principle, or not accepted, (2) its current implementation status, and …
Answered by Department of Health and Social Care: In October 2021, the Professional Record Standards Body (PRSB) updated its guidance on standard outpatient letters to make it clear that it is best practice for most outpatient letters to be written directly to the patient. The NHS Standard Contract states that outpatient letters should be consistent with PRSB’s standards. All National Health Service and independent sector providers are regulated …
Written QuestionHouse of LordsBaroness Maclean of Redditch · Conservative
Asked: To ask His Majesty's Government what assessment they have made of compliance in (1) the NHS, and (2) the independent healthcare sector, with the Paterson Inquiry recommendation that consultants write to patients in plain language outlining their condition and treatment, with a copy of that …
Answered by Department of Health and Social Care: In October 2021, the Professional Record Standards Body (PRSB) updated its guidance on standard outpatient letters to make it clear that it is best practice for most outpatient letters to be written directly to the patient. The NHS Standard Contract states that outpatient letters should be consistent with PRSB’s standards. All National Health Service and independent sector providers are regulated …
Written QuestionHouse of LordsBaroness Maclean of Redditch · Conservative
Asked: To ask His Majesty's Government on what date the Paterson Inquiry Response Programme Board last met; who its current members are; whether representatives of former patients of Ian Paterson sit on it; and whether they intend to publish the Board's minutes.
Answered by Department of Health and Social Care: In October 2021, the Professional Record Standards Body (PRSB) updated its guidance on standard outpatient letters to make it clear that it is best practice for most outpatient letters to be written directly to the patient. The NHS Standard Contract states that outpatient letters should be consistent with PRSB’s standards. All National Health Service and independent sector providers are regulated …
Written QuestionHouse of LordsBaroness Maclean of Redditch · Conservative
Asked: To ask His Majesty's Government how many of the recommendations made by the Independent Inquiry into the issues raised by Paterson, published in February 2020, have been fully implemented; which recommendations remain outstanding; and what timeline they h
Answered by Department of Health and Social Care: As referenced in the answer to HL960, the Government accepted 13 of the 15 recommendations set out in the 2020 Paterson Inquiry Report. Of these, nine recommendations have been implemented or partially implemented, and four recommendations are in progress...
Written QuestionHouse of LordsBaroness Maclean of Redditch · Conservative
Asked: To ask His Majesty's Government what cross-departmental mechanism exists between the Ministry of Justice and the Department of Health and Social Care to monitor and report on the implementation of the Paterson Inquiry recommendations; and how progress aga
Answered by Department of Health and Social Care: As referenced in the answer to HL960, the Government accepted 13 of the 15 recommendations set out in the 2020 Paterson Inquiry Report. Of these, nine recommendations have been implemented or partially implemented, and four recommendations are in progress...
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.
Reforms attributed to this inquiry · AI-generated- NHS England published the National Quality Board Recall Framework on 1 June 2022, establishing principles for patient-centred recall in secondary care across NHS and independent sectors - Medical defence organisations launched a voluntary Code of Practice for discretionary indemnity on 6 January 2025, establishing seven core principles - The Academy of Medical Royal Colleges updated their 2018 guidance 'Please write to me' to emphasise writing directly to patients in clear language - CQC strengthened registration conditions requiring independent healthcare providers to ensure patients understand consultant engagement arrangements and practising privileges - CQC updated inspection methodology to specifically examine MDT functioning and compliance with national guidance - GMC guidance on consent (updated 2020) emphasises patients should have time to consider information before making decisionsUnfinished business · AI-generated- Recommendation 1: Government response indicates work is 'ongoing' to develop solutions for improving data flows between CQC, GMC and NHS England regarding consultants' full scope of practice - Recommendation 4: While GMC guidance exists, government response indicates NHS England is still 'working with Royal Colleges to embed cooling-off periods in clinical practice' - Recommendation 6b: Government response states 'further work needed on implementation mechanism' and 'consultation ongoing' regarding mandatory independent adjudication for private healthcare complaints - Recommendation 10: The voluntary Code of Practice falls short of the 'mandatory nationwide safety net' the Inquiry recommended, with government 'continuing to consider further policy options' - Recommendation 12b: Government response indicates NHS England is 'working with independent sector to improve information flows' with 'legal and data protection considerations being addressed' - Recommendation 13: Government response states 'consideration being given to whether legislative change needed' regarding legal responsibility when consultants work under practising privileges - Recommendation 15: Government rejected but kept under review, stating it is 'monitoring whether voluntary improvements by independent sector are sufficient'
The Thirlwall Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026) sets out 17 of this inquiry's recommendations that this site holds, with its own notes on implementation. It colours a recommendation's Extent of Implementation cell green where it found evidence that the recommendation had been clearly implemented: 14 not coloured green; 3 coloured green.
DHSC and NHS England (commentary provided to the Thirlwall Inquiry, September 2024)(Feb 2026)↗
DHSC and NHS England gave the Thirlwall Inquiry their own account of progress on 17 of this inquiry's recommendations that this site holds, printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). This is the government's own account, not a finding of the Inquiry. Their reviewed extent of implementation: 6 Implemented - Ongoing; 4 In progress; 2 Partially implemented – Ongoing; 2 Implemented – Ongoing; 2 Not accepted; 1 Implemented – Closed.
The Thirlwall Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024) sets out 17 of this inquiry's recommendations that this site holds, with its own notes on implementation. It colours a recommendation's Extent of Implementation cell green where it found evidence that the recommendation had been clearly implemented: 14 not coloured green; 3 coloured green.
DHSC (comments provided to the Thirlwall Inquiry, February 2024)(May 2024)↗
DHSC gave the Thirlwall Inquiry their own account of progress on 16 of this inquiry's recommendations that this site holds, printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). This is the government's own account, not a finding of the Inquiry.