Latest News

Press Release: Stage 2 of the disclosure process

Monday 4th March 2024

HM Coroner has received written submissions from solicitors on behalf of Mr Paterson indicating that Mr Paterson will be challenging the conclusions of the multi-disciplinary team of medical experts.

In those circumstances Module One of the Inquests (“medical cause of death”) will take considerably longer than previously envisaged to enable HM Coroner to perform his duty to fully, fairly and fearlessly investigate the facts.

Although the substantive hearings of the Inquests will still commence on 7th October 2024 It is now expected that Module One will not conclude until April 2025, with the remaining modules following thereafter.

This has consequences for the timetable for stage 2 of the disclosure process and therefore for the proposed directions for the forthcoming planned Pre-Inquest Review Hearing (PIRH).

In all the circumstances HM Coroner has decided to postpone the PIRH fixed for 6th March 2024.  HM Coroner will re-list the PIRH for the earliest possible date and notice of the date will be issued.

It is hoped that this will give all Interested Persons and their legal teams additional time to make written submissions if necessary.

Press Release: HM Coroner Investigations and Inquests into the Deaths of Patients of Ian Paterson

Tuesday 27th February 2024

A further Pre Inquest Review Hearing to take place on Wednesday 6 March 2024 at 11am at Birmingham Coroners Court, Steelhouse Lane, Birmingham B4 6BJ. HM Coroner will give further consideration to his Article 2 European Court of Human Rights investigation into the deaths of patients of Mr Ian Paterson, former Consultant Breast Surgeon who were treated for breast cancer and died from a breast cancer related illness.

This hearing will give all those concerned the opportunity to make representations and for HM Coroner to give directions in advance of the final hearings. The final hearings are scheduled to commence on 7 October 2024.

Press Release: A further 5 inquests shall be opened on Wednesday 17 January 2024

Tuesday 9th January 2024

On Wednesday 17 January 2024 at 11am a further 6 inquests shall be opened in relation to the following former patients of Mr Ian Paterson:

Linda Cotterill

Claire Hawthorne

Sylvia Atterbury

Janet Law

Marjorie Taylor

Catherine Harrow

Preliminary investigations under section 1(7) of the Coroners and Justice Act 2009 have been carried out to identify whether there is reason to suspect that any former patients of Mr Paterson died an unnatural death as a result his care and treatment.

Following preliminary investigations, HH Richard Foster who is appointed as HM Coroner to conduct these investigations believes there is evidence to have reason to suspect that some of those deaths may be unnatural.

Preliminary investigations are ongoing into the deaths of other patients of Mr Paterson, and it is anticipated that further inquests will be opened in due course.  Any next of kin of former patients of Mr Paterson should come forward and make contact with the Solicitors to the Inquests via the dedicated website   www.coronerspatersoninvestigation.org

Once opened the inquests will be adjourned and it is anticipated that a pre inquest review hearing will be listed for early 2024.  Final hearings are expected to begin in late 2024.

Should you wish to attend the hearings of the openings please contact us on the details below or visit http://coronerspatersoninvestigation.org/ for more information. Higgs LLP has been appointed to assist.  If you need any further information contact Higgs on enquiries@coronerspatersoninvestigation.org or 01384 327113

Press Release: A further 10 inquests shall be opened on Friday 6 October 2023

Date: Thursday 28th September

On Friday 6 October 2023 at 11am a further 10 inquests shall be opened in relation to the following former patients of Mr Ian Paterson:

Veronica James

Elaine Morris

Sheila Rideal

Tracey Taylor

Pauline Tomkinson

Pauline Wale

Winifred Worrall

Karen Warren

Christine Baker

Doreen Marvin

Preliminary investigations under section 1(7) of the Coroners and Justice Act 2009 have been carried out to identify whether there is reason to suspect that any former patients of Mr Paterson died an unnatural death as a result his care and treatment.

Following preliminary investigations, HH Richard Foster who is appointed as HM Coroner to conduct these investigations believes there is evidence to have reason to suspect that some of those deaths may be unnatural.

Preliminary investigations are ongoing into the deaths of other patients of Mr Paterson, and it is anticipated that further inquests will be opened in due course.  Any next of kin of former patients of Mr Paterson should come forward and make contact with the Solicitors to the Inquests via the dedicated website   www.coronerspatersoninvestigation.org

Once opened the inquests will be adjourned and it is anticipated that a pre inquest review hearing will be listed for late 2023 / early 2024.  Final hearings are expected to begin in late 2024.

Should you wish to attend the hearings of the openings please contact us on the details below or visit http://coronerspatersoninvestigation.org/ for more information.

Higgs LLP has been appointed to assist.  If you need any further information contact Higgs on enquiries@coronerspatersoninvestigation.org or 01384 327113

Press Release: Decision where breast cancer appears in part 2 of death certificates

Date: Wednesday 27th September

In the Birmingham & Solihull Coroner’s Court

Before HM Coroner his honour Richard Foster

In the matter of multiple Inquests touching the death of patients of Mr Ian Paterson for treatment for breast cancer

Decision where breast cancer appears in part 2 of death certificates

  1. The initial phase of the preliminary enquiries pursuant to section 1(7) of the Coroners and Justice Act 2009 have concentrated on those cases where breast cancer is shown as a cause of death in Part 1 of the Death Certificate. Those enquiries are now complete.
  2. In all cases where Breast Cancer appears in Part 2 HM Coroner had not previously called for the medical records or referred them to the Multi-Disciplinary Team (MDT) unless on the face of the certificate there could potentially be seen to be a clear link between the Part 1 cause of death and the breast cancer shown in Part 2. That policy will continue with those cases where the cause of death of Paterson patients has been unknown, but Death Certificates are now being obtained from Registry Offices.
  3. At my direction the MDT of medical experts have also considered a random sample of 20 other cases where breast cancer appears in Part 2 so that I can consider whether it would be necessary and proportionate to consider all Part 2 cases.
  4. The outcome of this exercise has informed my decision that it would NOT be necessary or proportionate to continue with further enquiries with Part 2 cases, unless, as I have already indicated, there is on the face of the Death Certificate potentially a clear link between the Part 1 cause of death and the breast cancer shown in Part 2. Of those 20 cases selected there was one where an Inquest has already been opened for other reasons unconnected with Mr Paterson, and another where Breast Cancer was incorrectly recorded in Part 2. In all other cases there was no reason to suspect an unnatural death.

Press Release: A further 11 inquests shall be opened on Friday 14 July.

Date: Monday 10th July 2023

On Friday 14 July 2023 at 11am a further 11 inquests shall be opened in relation to former patients of Mr Ian Paterson.

Preliminary investigations under section 1(7) of the Coroners and Justice Act 2009 have been carried out to identify whether there is reason to suspect that any former patients of Mr Paterson died an unnatural death as a result his care and treatment.

Following preliminary investigations, HH Richard Foster who is appointed as HM Coroner to conduct these investigations believes there is evidence to have reason to suspect that some of those deaths may be unnatural.

Preliminary investigations are ongoing into the deaths of other patients of Mr Paterson, and it is anticipated that further inquests will be opened in due course.  There are 294 further deaths where the cause of death is unknown because it has not been possible to trace a death certificate, despite enormous efforts by the  Coroner’s Officers. Any next of kin of former patients of Mr Paterson should come forward and  make contact with the Solicitors to the Inquests via the dedicated website www.coronerspatersoninvestigation.org

Once opened the inquests will be adjourned and  it is anticipated that a pre inquest review hearing will be listed for late 2023 / early 2024.  Final hearings are expected to begin in late 2024.

Should you wish to attend the hearings of the openings please contact us on the details below or visit http://coronerspatersoninvestigation.org/ for more information.

Higgs LLP has been appointed to assist.  If you need any further information contact Higgs on enquiries@coronerspatersoninvestigation.org or 01384 327113

Press Release: Opening remarks by His Honour Richard Foster at the Pre Inquest Review Hearing On 9th June 2023

Date: Friday 9th June 2023

This the first hearing since my nomination to conduct the investigations and inquests into the deaths of the patients of Ian Paterson and is also the first hearing when the wider systemic issues will be considered. There have been previous inquiries and reports into Mr Paterson’s practice, including the report by Bishop James as well as his criminal trial. However, these inquests will be the first opportunity for matters to be explored in connection with deceased patients by evidence on oath and subject to challenge by those interested following full disclosure.

Accordingly, I wish to make some preliminary remarks.

I wish to pay tribute to Louise Hunt, Senior Coroner, and Emma Brown, Area Coroner for Birmingham and Solihull for the systems which they set up for the preliminary enquiries which have been and are being carried out pursuant to section 1(7) of the Coroners and Justice Act 2009. Those enquiries involve the review of medical records by a multi-disciplinary team. That team then reports to HM Coroner having applied a two stage test in each case – first to identify whether there appears to have been any culpable human failing or system failing in the medical management of a person’s breast cancer, and secondly whether, on the balance of probabilities, that failing has more than minimally, trivially or negligibly contributed to death. The report from the multi-disciplinary team informs HM Coroner as to whether there is reason to suspect that the deceased has died an unnatural death, thus triggering the statutory duty to conduct an investigation (and ultimately an inquest) pursuant to section 1 of the Act.

The members of the multi-disciplinary team are:

Professor Nigel Bundred (Professor of Surgical Oncology and Consultant Surgeon at University Hospital, South Manchester)

Professor Mike Dixon (Professor of Breast Surgery and Consultant Surgeon at Western General Hospital, Edinburgh)

Rick Linforth (Consultant Oncoplastic Breast and Reconstructive Surgeon at the Bradford Teaching Hospitals)

David Dodwell (Consultant Clinical Oncologist at Oxford University Hospitals NHS Trust and Senior Clinical Research Fellow at the University of Oxford)

Simon Russell (Clinical Oncologist at Addenbrooke’s Hospital, Cambridge)

Professor Ian Ellis (Professor of Cancer Pathology and Honorary Consultant Pathologist at Nottingham Teaching Hospitals)

Steve Allen (Consultant Radiologist at the Royal Marsden Hospital).

Mr Paterson practised within the NHS at hospitals which are now all part of University Hospitals Birmingham NHS Foundation Trust, and within the private sector at hospitals in Solihull and Sutton Coldfield run by Spire Healthcare Group PLC. So far the multi-disciplinary team have reviewed 417 cases. These constitute all the cases reported of patients of Mr Paterson  where breast cancer is shown as a cause of death in part 1 of the death certificate. 27 of those have resulted in inquests being opened and adjourned, with a further 9 to be opened on 14th July, 2023. In each of these cases the reports to HM Coroner from the multi-disciplinary team has resulted in a reason for HM Coroner to suspect that the deceased had died an unnatural death. Of those 36 cases, 29 were NHS patients and 7 were private patients. There are a further 21 cases where the multi-disciplinary team have expressed a preliminary view that their two-stage test has been met, but I am awaiting formal reports before I decide whether inquests should be opened. There are a further 36 cases at this stage for the multi-disciplinary team to review.

Additionally, there have been reported to HM Coroner 130 cases where breast cancer is included as a cause of death in part 2 of the death certificate. The multi-disciplinary team are considering a selection of these so as to inform me whether it would be proportionate to review all these cases.

There are further deaths where the cause of death is unknown because it has not been possible to trace a death certificate, despite enormous efforts by the  Coroner’s Officers. I urge any next of kin of former patients of Mr Paterson to come forward and to make contact with the Solicitors to the Inquests via the dedicated website www.coronerspatersoninvestigation.org

The statutory purpose of the inquests will be to determine who each deceased was, and how, when and where she came by her death. Who, when and where are obviously uncontroversial and will be dealt with at the opening of each inquest. I have received no submissions to the contrary to my provisional view that the circumstances of these inquests will engage the state’s obligations under Article 2 of the European Convention on Human Rights, and I anticipate giving such a direction later as part of this Pre Inquest Review Hearing. In those circumstances “how” will be interpreted as by what means and in what circumstances in accordance with section 5(2) of the Coroners and Justice Act 2009. This means that systemic failings will form part of my investigations.  My duty is to ensure that the relevant facts are fully, fairly and fearlessly investigated. It is also likely that I will be considering Reports to Prevent Future Deaths pursuant to regulation 28 of the Coroners (Investigations) Regulations 2013.

No conclusion can be framed in any way so as to appear to determine any question of civil or criminal liability. Nevertheless I am mindful of my obligations under the agreement between the CPS and the Chief Coroner of March 2016 as well as regulation 25(4) of the Coroners (Investigations) Regulations 2013 and I will not hesitate to refer any evidence of further criminal liability to the Director of Public Prosecutions.

I will now proceed to the agenda for this hearing, a copy of which has been circulated to all next of kin and other potential Interested Persons.

Press Release: Inquests into deaths of patients of Ian Paterson, Consultant Breast Surgeon

Date: Monday 22nd May 2023

So that he can consider the scope and extent of the investigations HM Coroner has decided to bring forward the first case management hearing. Accordingly, a Pre Inquest Review Hearing will take place at Birmingham Coroner’s Court, Steelhouse Lane, Birmingham B4 6BJ on Friday, 9th June 2023 commencing at 11am. This will give all those concerned the opportunity to make any representations and for HM Coroner to give directions.

Press Release: His Honour Richard Foster to continue the investigations

Date: Wednesday 26th April 2023

Upon the request of the Chief Coroner under schedule 10 paragraph 3 of the Coroners and Justice Act 2009 the Lord Chief Justice has nominated His Honour Richard Foster to continue the investigations and to conduct the inquests into the deaths of patients of the consultant, Ian Paterson. The nomination took effect on 1st April. 2023. The appointment of a Judge is necessary due to the scale and complexity of the investigations.  This is not unusual for those exceptional cases that cannot be accommodated alongside the regular caseload of the Coroner’s Court.

Preliminary enquiries continue to be carried out pursuant to section 1(7) of the Coroners and Justice Act 2009 to consider whether the duty to investigate any death pursuant to section 1(2) arises. If it does arise, then inquests are opened and then adjourned pending the conclusion of all preliminary enquiries.

To assist with the preliminary enquiries and any subsequent investigation Higgs LLP remains appointed as Solicitors to the Inquest. Counsel to the Inquest have also been appointed.

The preliminary enquiries were triggered by the West Midlands Police who approached the Coroner following the conviction and sentencing of Ian Paterson for a number of offences relating to his treatment of patients.  As a result, a process was set up to identify and to carry out preliminary enquiries on patients who had been treated by Mr Paterson and had subsequently died of breast cancer.  Enquiries were made of patients treated in both the NHS and in the private sector.

An independent Multi-Disciplinary Team of medical experts made up of Consultant Breast Surgeons and Consultant Oncologists has been instructed to meet and review the patient records.  A Consultant Pathologist and Consultant Radiologist are included as required.

A two-stage test is applied before proceeding to open an inquest into a death. This involves first identifying whether there appears to have been any culpable human failing or system failing in the medical management of the patient’s breast cancer and, if so, secondly to establish whether, on the balance of probabilities, that failing has more than minimally, trivially or negligibly contributed to death. This is the established legal criteria for triggering the coroner’s duty to investigate under section 1(2) and therefore to open an inquest. Inquests can only be opened where there is reason to suspect that this two-stage test is satisfied.

So far 27 inquests have been opened and adjourned. The preliminary enquiries on individual cases are continuing. Further Inquests will be opened if there is reason to suspect the two-stage test is satisfied. This process will be completed by early 2024. Thereafter, it is anticipated that the first case management hearing will take place in the Spring of 2024 when HM Coroner will give Directions on the scope of the Inquests.  It is anticipated the final hearings will take place over a 9-month period commencing in the autumn of 2024.

For any further information please make contact on enquiries@coronerspaterson.org or 01384 327113

Press Release: H M Coroner of Birmingham and Solihull Ian Paterson investigation

On Friday March 24 2023 at 10am a further 7 inquests shall be opened in relation to former patients of Mr Ian Paterson.

The Senior Coroner Mrs Louise Hunt and Area Coroner Ms Emma Brown have been carrying out preliminary investigations under section 1(7) of the Coroners and Justice Act 2009 to identify whether there is reason to suspect that any former patients of Mr Paterson died an unnatural death as a result of the care they received.

Following preliminary investigations, the Senior and Area Coroner believe there is evidence to have reason to suspect that some of those deaths may be unnatural.

Preliminary investigations are ongoing into the deaths of other patients of Mr Paterson and it is anticipated that further inquests will be opened in due course.  All the inquests will be adjourned until a conclusion has been reached on all preliminary investigations when a pre inquest review hearing will be listed.

Should you wish to attend please contact us on the details below or visit http://coronerspatersoninvestigation.org/ for more information.

Higgs LLP has been appointed to assist.  If you need any further information contact Higgs on enquiries@coronerspatersoninvestigation.org or 01384 327113

Announcement of appointment of HHJ Richard Foster

Date: 28 February 2023

Following consultation with the Lord Chancellor, the Lord Chief Justice has nominated His Honour Judge Richard Foster to conduct the investigations and inquests into the deaths of patients of the consultant surgeon, Ian Paterson.

The nomination will take effect on 1st April, 2023. Judge Foster qualified as a solicitor in 1979, and has a professional background in medical negligence. He was appointed a Deputy High Court Judge in 2003 and a Circuit Judge in 2004

Press Release: H M Coroner of Birmingham and Solihull Ian Paterson investigation

Date: 20 October 2022


On Friday October 28 2022 at 10am a further 13 inquests shall be opened in relation to former patients of Mr Ian Paterson.

The Senior Coroner Mrs Louise Hunt and Area Coroner Ms Emma Brown have been carrying out preliminary investigations under section 1(7) of the Coroners and Justice Act 2009 to identify whether there is reason to suspect that any former patients of Mr Paterson died an unnatural death as a result of the care they received.

Following preliminary investigations, the Senior and Area Coroner believe there is evidence to have reason to suspect that some of those deaths may be unnatural.

Preliminary investigations are ongoing into the deaths of other patients of Mr Paterson and it is anticipated that further inquests will be opened in due course.  All the inquests will be adjourned until a conclusion has been reached on all preliminary investigations when a pre inquest review hearing will be listed.

Should you wish to attend please contact us on the details below or visit http://coronerspatersoninvestigation.org/ for more information.

Higgs LLP has been appointed to assist.  If you need any further information contact Higgs on enquiries@coronerspatersoninvestigation.org or 01384 327113

Date: 20 July 2020


On 22 July 2020 at 9am a further three inquests shall be opened in relation to former patients of Mr Ian Paterson.

The Senior Coroner Ms Louise Hunt and Area Coroner Ms Emma Brown have been carrying out preliminary investigations under section 1(7) of the Coroners and Justice Act 2009 to identify whether there is reason to suspect that any former patients of Mr Paterson have died an unnatural death as a result of any of the care they received.

Following preliminary investigations, the Senior and Area Coroner believe there is evidence to have reason to suspect that some of those deaths may be unnatural.

Preliminary investigations are ongoing into the deaths of other patients of Mr Paterson and it is anticipated that further inquests will be opened in due course. All the inquests will be adjourned until a conclusion has been reached on all preliminary investigations when a pre inquest review hearing will be listed.

The opening of the inquests shall follow the same format as the inquests opened on 6 July 2020.  All attendance shall be via Microsoft Teams due to social distancing requirements. Should you wish to attend please contact us on the details below or visit http://coronerspatersoninvestigation.org/ for more information.

We have appointed Higgs LLP to assist. If you need any further information you should contact them at enquiries@coronerspatersoninvestigation.org or on 01384 327113.

Press Release: H M Coroner of Birmingham and Solihull Ian Paterson investigation

Date: 2 July 2020


The Senior Coroner Ms Louise Hunt and Area Coroner Ms Emma Brown have been carrying out preliminary investigations under section 1(7) of the Coroners and Justice Act 2009 to identify whether there is reason to suspect that any former patients of Mr Paterson have died an unnatural death as a result of any of the care they received.

Following preliminary investigations, the Senior and Area Coroner believe there is evidence to have reason to suspect that some of those deaths may be unnatural.

In accordance with the Coroners and Justice Act 2009, inquests will now be opened in relation to four former patients of Mr Paterson.

Preliminary investigations are ongoing into the deaths of other patients of Mr Paterson and it is anticipated that further inquests will be opened in due course. All the inquests will be adjourned until a conclusion has been reached on all preliminary investigations when a pre inquest review hearing will be listed.

The Inquests will be opened on Monday 6 July 2020 from 9am onwards. All attendance shall be via Microsoft Teams due to social distancing requirements. Should you wish to attend please contact us on the details below or visit http://coronerspatersoninvestigation.org/ for more information.

We have appointed Higgs LLP to assist. If you need any further information you should contact them at enquiries@coronerspatersoninvestigation.org or on 01384 327113.


Press Release: H M Coroner of Birmingham and Solihull Ian Paterson Investigation

Date: 24 January 2020


West Midlands Police have asked the Birmingham and Solihull Coroner to review a number of cases where patients have died from breast cancer and who were previously treated by Mr Paterson.

Mr Paterson was convicted of the assault of a number of his patients as he was found to have been undertaking breast operations that did not conform to approved standards.

The Senior Coroner Mrs Louise Hunt and the Area Coroner Ms Emma Brown are jointly carrying out a preliminary investigation into the cases under s 1(7) of the Coroners and Justice Act 2009. The preliminary investigation is to identify whether there is any evidence that gives reason to suspect that any of the former patients of Mr Paterson have died an unnatural death as a result of his potentially substandard treatment.

These preliminary investigations will take some time due to the volume of patients and complexity of the cases. As a starting point the Birmingham and Solihull coroners have selected 23 cases at random to investigate in more detail to try to understand whether the required legal threshold will be met. With assistance from West Midlands Police, we have tried to locate and notify the families of the women selected for the 23 test cases and our enquiries in this regard are ongoing.

We understand that this will cause anxiety for a lot of families and we would ask at this stage that families do not contact us.

We have set up a website which contains some useful information about what is happening and would ask that you refer to that website.


We have appointed Higgs LLP to assist us in our preliminary investigations.

If you need any further information you should contact them at: enquiries@coronerspatersoninvestigation.org or 01384 327113

Findings of the Independent Inquiry published

February 4, 2020

The findings of the independent Inquiry into breast surgeon Ian Paterson have now been published.

The two year Inquiry heard 181 first-hand accounts from the surgeon’s former patients with evidence gathered over several hundred sessions with patients, families and other witnesses.

In the report, the Rt Rev Graham James, who chaired the Inquiry said there was a culture of “avoidance and denial”, which allowed Paterson to carry out unnecessary and sub-standard operations on hundreds of women.

A number of recommendations were made in the report which found that “patients were let down over many years” by the NHS and private hospitals, and opportunities to stop Paterson were “missed, time after time”.

The recommendations of the Inquiry report are:

  • Complete recall of all patients of Ian Paterson from NHS trust and Spire Healthcare
  • A national framework or protocol is developed about how recall of patients should be managed and communicated
  • “Accessible and intelligible” single repository of consultants’ key performance data
  • Standard practice for consultants in NHS and private hospitals to send a letter to patients outlining condition and treatment and copy letter to patient’s GP
  • The difference between how NHS and private care is organised, is explained clearly to patients receiving private healthcare
  • Introduction of short period of time for patients to reflect on diagnosis and treatment before consenting to surgical procedures
  • CQC should assure all hospital providers are complying with national guidance on multi-disciplinary team meetings
  • Information on how to complain to an independent body is communicated more effectively in NHS and private sector
  • The Government should, as a matter of urgency, reform the current regulation of indemnity products for healthcare professionals
  • Current system of regulation and the collaboration of the regulators serves patient safety as the top priority
  • When a hospital investigates a healthcare professional’s behaviour, any perceived risk to patient safety should result in the suspension of the healthcare professional
  • When NHS or private hospitals do not take responsibility for what has happened, the Government addresses, as a matter of urgency, this gap in irresponsibility and liability
  • When things go wrong, boards should apologise at the earliest stage of investigation
  • If the Government accepts any of the recommendations concerned, it should make arrangements to ensure that these are to be applicable across the whole of the independent sector’s workload (i.e. private, insured and NHS-funded) if independent sector providers are to be able to qualify for NHS contracted work.

The full report can be accessed via the following link: Report of the Independent Inquiry into the Issues raised by Paterson