Ian Paterson, a consultant breast surgeon, who was employed by the Heart of England NHS Foundation Trust and practised in the independent sector at Spire Parkway and Spire Little Aston, was convicted of 17 counts of wounding with intent and 3 counts of unlawful wounding. He was sentenced in 2017 to a 20 year custodial sentence.

In January 2020, H M Senior Coroner for Birmingham and Solihull, Louise Hunt, and Area Coroner Emma Brown commenced preliminary inquiries to identify whether there is any evidence that gives reason to suspect that any of the former patients of Mr Paterson died an unnatural death as a result of Ian Paterson’s actions. Those inquiries involve the review of medical records by a multi-disciplinary team of doctors. 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, this triggering the statutory duty to conduct an investigation (and ultimately an inquest) pursuant to section 1 of the Coroners and Justice Act 2009.

As a result of those inquiries, which are continuing, 54 Inquests in relation to the former patients of Mr Paterson have been opened and adjourned so far.

On 1 April 2023 His Honour Richard Foster was nominated by the Lord Chief Justice to conduct the Investigations and Inquests in view of their complexity, scale and time commitment. At a Pre Inquest Review Hearing on 9 June, 2023 he ruled that he will sit without a jury and that Article 2 of the European Convention on Human Rights (the “right to life”) is engaged by these Inquests, and so by virtue of section 5(2) of the Coroners and Justice Act 2009 the scope of the Inquests will include:
(a) Any failings in the recruitment and supervision of Mr Paterson by his colleagues, management and corporate governance. This will include considering whether Mr Paterson’s clinical colleagues should have been put on notice that Mr Paterson was treating patients improperly and informed the appropriate authorities.
(b) Systemic failing by the hospital management and corporate governance in addressing and responding to concerns raised about Mr Paterson.
(c) Any inaction or failure of supervision by the regulatory agencies and other NHS bodies.
(d) Any failings in the culture at the hospitals where Mr Paterson worked in addressing and preventing substandard medical treatment while Mr Paterson worked at each hospital.
(e) Any failings in the establishment and scope of the respective recall systems adopted.

He will also consider Reports to Prevent Future Deaths pursuant to Schedule 5 Paragraph 7 of the Coroners and Justice Act 2009.

A further Pre Inquest Review Hearing will be held on 25 April, 2024. The substantive hearings will commence on 7 October, 2024 and it is estimated that they will take up to 11 months. The hearings will be divided into five modules:

  1. The cause of death
  2. Systemic issues
  3. Regulatory and other NHS bodies
  4. The patient recall process
  5. Prevention of Future Deaths

In accordance with Section 85A of the Courts Act 2003 and the Remote Observation and Recordings (Courts and Tribunals) Regulations 2022 members of the press and the public as well as Interested Persons and their legal representatives may apply to attend a hearing remotely. Any such person member of the public or press wishing to attend the hearings remotely needs to contact us on enquiries@coronerspatersoninvestigation.org no later than midday on the day before the hearing, giving reasons why they should be granted remote access.