Opportunities to Stop Unregulated Breast Cancer Surgery Missed-Kennedy Report Finds

19 December 2013

Opportunities to Stop Unregulated Breast Cancer Surgery Missed-Kennedy Report Finds

An independent review by Sir Ian Kennedy has identified that a breast cancer surgeon was allowed to carry out incomplete surgeries on hundreds of women with the NHS trust in question missing a number of opportunities to stop him from doing so.

Ian Paterson carried out incomplete mastectomies for 15 years through an unregulated ‘cleavage-sparing’ procedure at Solihull Hospital and Good Hope Hospital in Sutton Coldfield, West Midlands. The operation-which is against national guidelines-leaves breast tissue behind for cosmetic reasons.

Sir Ian Kennedy, who called the missed opportunities to censure Ian Peterson as ‘depressingly familiar’, carried out an independent review looking at how the Heart of England NHS Foundation Trust responded to concerns raised by both patients as well as staff.

The review found that the trust missed a number of chances to stop Mr Paterson performing the unauthorised surgical procedure, which led to hundreds of women being left with the risk that cancerous cells remained within their breast tissue despite undertaking the procedure specifically to entirely remove all cancerous tissue.

"Lessons for the future cannot be learned unless the past is understood," Sir Ian said.

"The story is complex but the themes are depressingly familiar. The fundamental theme is one of culture. When culture fails, care fails.

"Concerns were expressed as early as 2003 but were not treated with sufficient seriousness, nor looked into with sufficient rigour and care."

He added: "Various colleagues in the breast unit raised concerns, an investigation was launched and a report produced ... but nothing came of it.

"Mr Paterson was not an easy colleague. He was not a team player. The focus of managers, however, was on man management when it should have been on Mr Paterson's surgical practices and competence."

The procedure itself was identified as potentially risky in 2004 when Solihull Hospital first carried out an internal report; it identified in 2007 that Mr Paterson should cease performing the operations after a close review of breast care services at the hospital.

Yet the report undertaken by Sir Ian, and the evidence of solicitors collated within it, suggested Mr Paterson continued to perform the unregulated procedure for three more years after than until 2010.

Sir Ian said the trust must "make its peace with patients, staff and the community".

"There is much anger and a strong sense of betrayal," he added.

Lord Philip Hunt, chairman of the Heart of England NHS Foundation Trust, said: "I wish to give a full and unreserved apology to all of the patients and their relatives for the way in which they were mistreated by Mr Paterson ... and also how they were subsequently let down by the trust management team at the time in their failure to properly intervene into his practices and his behaviour in terms of patient safety and quality of care.

"This was completely unacceptable and I'm very sorry indeed."

If you have undergone breast cancer surgery at the trusts mentioned above, or are concerned about the treatment for breast cancer you may have undergone at any other trust or hospital, Mistreatment.com is able to provide you with advice, support and guidance about your patient and healthcare rights. Mistreatment.com has specialists in the fields of breast cancer and surgical errors who can provide you with assistance about your patient care rights.