A culture of “avoidance and denial” allowed a breast surgeon to perform botched and unnecessary operations on hundreds of women, a report has found.
An independent inquiry into Ian Paterson’s malpractice has recommended the recall of his 11,000 patients for their surgery to be assessed.
Paterson is serving a 20-year jail term for 17 counts of wounding with intent.
One of Paterson’s colleagues has been referred to police and five more to health watchdogs by the inquiry.
The disgraced breast surgeon worked with cancer patients at NHS and private hospitals in the West Midlands over 14 years.
His unregulated “cleavage-sparing” mastectomies, in which breast tissue was left behind, meant the disease returned in many of his patients. Others had surgery they did not need – some even finding out years later they did not have cancer.
Patients were let down by the healthcare system “at every level” said the inquiry chair, Bishop of Norwich the Rt Revd Graham James, who identified “multiple individual and organisational failures”.
One of Paterson’s victims, Tracey Smith, welcomed the 15 recommendations for the health service made by the inquiry.
“Paterson was claiming that there was some sort of cancer hotspot in Solihull. The only problem in Solihull was Ian Paterson,” she said.
“Now we will continue to fight so that the recommendations are put in place to stop this from ever happening in the NHS or the Spire or any private hospital in the country.”
In his report, Bishop James said: “The suffering described; the callousness; the wickedness; the failures on the part of individuals and institutions as well as Paterson himself – these are vividly described in what patients told us.
“The scale of what happened, the length of time this malpractice went on; the terrible legacy for so many families; it is difficult to exaggerate the damage done, including to trust in medical organisations.”
The coroner and West Midlands Police are looking into the deaths of 23 of Paterson’s patients.
Hugh Pym, health editor, BBC News
The opening words of the Paterson inquiry are striking. The chair, Rt Revd Graham James, says this was “far worse” than simply a story about a rogue surgeon though that itself was tragic.
He says the healthcare system was dysfunctional at every level when it came to keeping patients safe. And this was less than a decade ago.
He suggests there are currently more than enough regulators with sufficient budgets, but they still aren’t doing enough collectively to keep patients safe.
Chillingly he says that based on evidence from clinicians as opposed to regulators something similar could happen now.
Paterson began working at Spire private hospital in Solihull in 1997 and was appointed at Solihull Hospital, part of the Heart of England NHS Trust, a year later.
Between then and 2011, he had 11,000 patients across the two sites. He was suspended by the General Medical Council (GMC) in 2012 while his practices were being investigated.
An independent report by lawyer Sir Ian Kennedy found concerns about Paterson had been raised as early as 2003, but hospital management missed several opportunities to stop him.
Following a trial at Nottingham Crown Court, Paterson, of Altrincham in Greater Manchester, who grew up in County Down, Northern Ireland, was jailed for 15 years in May 2017 after being found guilty of wounding with intent on nine women and one man.
His sentence was later increased to 20 years.
Later that year, minister of state for health Philip Dunne established the independent inquiry.
“There was a culture of avoidance and denial, an alarming loss of corporate memory and an offloading of responsibility at every level,” Bishop James said in his conclusions.
“This capacity for wilful blindness is illustrated by the way in which Paterson’s behaviour and aberrant clinical practice was excused or even favoured.
“Many simply avoided or worked round him. Some could have known, while others should have known, and a few must have known.”
Those referred to the health watchdog and the police were not named in the report.
Jacqui Smith, chair of University Hospitals Birmingham NHS Foundation Trust which now runs Solihull Hospital, said it “wholly condemns” Paterson’s practices and acknowledged “many of Paterson’s patients received appalling treatment whilst under the care of the NHS”.
Spire Healthcare’s chief executive, Justin Ash, apologised for the “significant distress” suffered by patients and accepted “missed opportunities to challenge Ian Paterson’s criminal behaviour”.
Debbie Douglas, one of Paterson’s patients spearheading the campaign for an inquiry, said: “The fight goes on until the legislation has changed.
“We don’t want somebody from the Government giving us lip service and saying that lessons will be learned. It sickens me.
“Lessons aren’t learned unless legislations change.”
Other recommendations made by the inquiry are the suspension of healthcare professionals who are under investigation over patient safety, and that gaps in responsibility and liability between the NHS and the private sector are improved by the government.
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.”