Rogue surgeon carried out dangerous breast cancer operations "for years"

Solihull hospital in the West Midlands, in which Ian Paterson worked until finally 2011, seven many years soon after worries about his function were 1st raised. Photograph: Colin Underhill/Alamy

A rogue surgeon who carried out a hazardous breast cancer method on patients without having their consent for many years was able to do so simply because of a failure of culture at his NHS believe in, a damning review has located.

Ian Paterson was not banned from carrying out cleavage-sparing mastectomies (CSMs), which leave tissue behind and so raise the danger of breast cancer returning, until December 2007, and carried on surgical treatment until mid-2011, in spite of a number of warnings about the process dating back to 2004.

In his overview, published on Thursday, of what took place at Solihull hospital, Prof Sir Ian Kennedy explained the Heart of England NHS basis trust had failed to place sufferers very first. “It is a story of ladies faced with a lifestyle-threatening ailment who have been harmed,” he said. “It is a story of clinicians at their wits’ ends trying for many years to get the trust to tackle what was going on. It is a story of clinicians going along with what they knew to be poor efficiency. It is a story of weak and indecisive leadership from senior managers. It is a story of secrecy and containment. It is a story of a board which did not carry out its responsibilities.”

Following considerations were raised by other clinicians and nurses, an inner investigation of Paterson’s work was carried out and published in 2004 but produced no recommendation on leaving behind tissue right after what was supposed to be a mastectomy. It also failed to take into account the crucial situation of patient consent, which was absent as sufferers had been not effectively informed. If the lack of consent had been identified earlier, Paterson might have been stopped from working sooner, Kennedy mentioned.

When one more investigation was launched in 2007, senior managers invoked the Division of Health’s disciplinary procedures, doing work through the HR division, which meant it was shrouded in secrecy. The decision “was to have profound implications for many years to come”, said Kennedy. “Individuals have been unaware of considerations about the surgeon in whose hands they were putting their hopes for the greatest possible care,” he stated. “Mr Paterson’s colleagues did not know what was going on.”

It also meant that the target was on how to integrate Paterson into the team, and on his needs, rather than on patients.

Kennedy also criticised the recall procedure for patients, which Paterson was involved in, and which Kennedy mentioned involved identifying individuals most at danger of recurrence even however all were at increased risk. Data did not show on which sufferers Paterson had employed CSM, so all patients should rightly have been recalled, said Kennedy. He identified one purpose for the restricted recall was “a desire to have and management the fallout from the worries and therefore defend the reputation of the trust”. He said that as more sufferers were recalled they were subjected to delays, which could have put them at higher danger.

Ian Cunliffe, healthcare director during the time of the 2007 investigation, and the trust’s then chief executive, Mark Goldman, were singled out for “clamping down” on communication, searching for to contain the fallout and not stopping Paterson operating on breast cancer patients.

Kennedy said: “Senior managers did not respond effectively to considerations expressed about Mr Paterson’s surgical practice till late December 2007 and then their response was neither sufficiently robust nor rigorous. Other clinicians in the breast team, fellow surgeons, oncologists, radiologists and pathologists, continued to function with Mr Paterson for years. They did not go to the GMC or the regulator, even though they felt that they were receiving nowhere in the trust.”

He explained that while it was not a story about the complete of the NHS “it has lessons for the complete of the NHS”.

Shena Mason, a patient of Paterson quoted in the report, explained: “Some of us will always have rotten bad luck and carry on and the condition will produce, that is going to occur, but rotten bad luck is less complicated to live with than the thought that your surgeon may possibly have damaged you … You have this gnawing suspicion that maybe if you had woken up with a good flat chest wall the day after the operation, perhaps you would be feeling nicely now, but I am in no way going to know.”

Rogue surgeon carried out dangerous breast cancer operations "for years"