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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 & Sons solicitors 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 & Sons solicitors 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