An “opportunity was missed” to stop a rogue surgeon continuing to carry out unsafe surgical procedures because nurses ignored their training and accepted his false assurances, according to an independent report.
Overall, the report found that “weak and indecisive leadership” from senior managers at Heart of England Foundation Trust allowed Ian Paterson to flout clinical guidance by leaving behind tissue for cosmetic reasons during mastectomy operations.
Mr Paterson’s procedure, which became known as a “cleavage sparing mastectomy”, was not a recognised procedure and increased the risk of cancer recurrence.
The surgeon – described as charismatic and charming – worked at Good Hope and Solihull hospitals from 1998 until his suspension in 2011. He was also suspended from the medical register last year by the General Medical Council and his case has been referred to West Midlands Police.
The review into Heart of England Foundation Trust was carried out by lawyer Sir Ian Kennedy, former chair of the Healthcare Commission – the forerunner of the Care Quality Commission.
His review, which was commissioned by the trust, found that while clinicians working with Mr Paterson raised concerns about his surgery, they were either pacified by the surgeon himself or were not treated with sufficient seriousness by managers.
Key opportunities were missed by the trust to stop him, the report said.
Oncologists, pathologists and nurses became concerned as early as 2003, according to the report. These sparked an internal investigation, which made recommendations on improving multi-disciplinary working and “only referred in passing” to the key concern of tissue being left behind.
It was not until four years later that a further investigation in 2007 imposed some conditions on Mr Paterson, and he continued to operate until mid-2011.
Sir Ian’s report said breast care nurses at the trust who expressed concern were reassured by Mr Paterson that any tissue was fatty tissue, which was left so patients could have a “more satisfying aesthetic appearance after surgery”.
“Quite whether the nurses should have accepted that assurance is an issue of some importance,” Sir Ian’s report said. “After all, the assurance was being given by the person whose operation was being questioned. It might be expected that he would justify it.”
He said: “The breast care nurses went along with Mr Paterson’s assurances that there was no need to be concerned at what they were seeing, even though their training had told them that a mastectomy involved a flat chest wall.”
Sir Ian was told by a breast cancer nurse, who was not part of the Solihull team, that the nurses should have gone to another surgeon to share their concerns and taken advice.
“That they did not do so can probably be explained by the regard in which they held Mr Paterson initially, and because of his charismatic personality. But, it meant that another avenue of challenge was not opened. An opportunity was missed,” he said.
Although the report questioned the level of action taken by breast cancer nurses at the trust, its most scathing criticism was levelled at managers.
Sir Ian concluded “the culture in the trust was not conducive to raising concerns about a leading surgeon”.
Even when managers finally stopped Mr Paterson from operating, the report said the trust embarked upon a “hopelessly flawed approach” of only recalling some of his patients to check for cancer recurrence and not all of them.
The report added: “The fact that the recall was managed and operated by staff who had previously looked after them at the trust created difficulties for some patients, and for some nurses. Efforts were made to engage outside specialists, doctors and nurses, but with very limited success.”
Overall sir Ian, who also chaired the 2001 public inquiry into children’s heart surgery at the Bristol Royal Infirmary, described the events at the trust as a “tragic story”.
“It is a story of clinicians going along with what they knew to be poor performance. 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,” he said.
Up to 400 women are thought to be seeking compensation from the trust.
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