Clinicians and health-care managers displayed “a capacity for wilful blindness” that allowed Ian Paterson to hide in plain sight—that is the uncomfortable opening statement of the independent inquiry
into Paterson’s malpractice, published on Feb 4, 2020. Paterson worked as a consultant surgeon from 1993 to 2011 in both private and National Health Service hospitals in West Midlands, UK. During that period, he treated thousands of patients, many of whom had surgery. Paterson demonstrated an array of abhorrent and unsafe activities over this time, including exaggerating patients’ diagnoses to coerce them into having surgery, performing his own version of a mastectomy, which goes against internationally agreed oncological principles, and inappropriate conduct towards patients and staff.
The inquiry makes a range of valuable recommendations that cover regulatory reform, corporate accountability, information for patients, informed consent, complaints, and clinical indemnity. The crucial message is that these reforms must occur across both the NHS and the private sector and must be implemented earnestly and urgently. But many of the issues in the Paterson case cannot be regulated and flow from the murky waters of medical professionalism. At times during the 87 pages of patient testimony, patients suggested in hindsight they could see that other clinicians knew there was a problem with Paterson but did not say anything. The hurt and disappointment that patients felt with the medical profession are chilling.
Paterson is not the first rogue doctor to go unchecked. He was only suspended by the General Medical Council (GMC) in 2012, but he had been suspended by Good Hope Hospital (Birmingham, UK) in 1996 for exposing a patient to harm in one of his operations. He moved to the Heart of England NHS Foundation Trust (HEFT) in 1998, where again concerns about his conduct were raised as early as 2003. A senior clinician was tasked with investigating at this time, but the report was not acted on by the HEFT. Again in 2007, further concerns were raised by senior clinicians. An investigation was undertaken, and a breast surgeon from another trust was asked to review Paterson’s surgical performance. A further six health-care professionals raised concerns that year and Paterson was finally asked to stop performing some of the concerning surgical procedures. In 2008, Paterson was again subject to external observation of his surgical practice. Despite the observation, he continued to operate on patients for another 5 years.
During his years in practice, Paterson must have worked with hundreds of health-care professionals, most of whom would have had enough experience to discern his unusual practice, if not malpractice. Yet for the few who dared to speak up, their voice was drowned out by the complicit silence of other colleagues and hospital management.
Health-care workers reporting concerns often come under substantial pressure from health-care management, and sometimes have to justify their own practice and reasons for speaking out. Four of the health-care professionals who did report Paterson were subject to fitness to practice scrutiny by the GMC during the later investigation because they had worked alongside him. Many doctors reported to the inquiry that they were fearful of reporting Paterson because they did not want to draw attention to themselves. Others tried to avoid working with him, and trainees commented that the unusual nature of his surgical practice was well known in the region.
Apprenticeship, camaraderie, trust, and hierarchy have long been part of medical training and clinical practice. But re-examining the Paterson inquiry report, these qualities clearly also underpinned a system that allowed a doctor to perform procedures that, when examined independently, were clearly harmful. When professionals failed to speak out, they built a web of silence that ultimately was permissive of serious malpractice.
In 2013, the GMC introduced a duty of candour, which puts a duty on any clinician involved in a patient’s care to be open and honest when harm or near harm occurs. Only through building a system in which hospital management and senior clinicians encourage and demonstrate frank dialogue at all levels, from minor issues to larger problems, will serious cases like Paterson’s be avoided again.
Will this duty be enough to crack the nebulous dynamics of a doctor’s allegiance to their colleagues, the obligation they have to their patients, and the fear and ambition they have for themselves?