A View from the Paterson Inquests

Introduction

HH Richard Foster, a former circuit judge and Deputy High Court Judge, is conducting a series of inquests into the deaths of patients treated by Ian Paterson. Readers will remember that Paterson was a high-profile breast cancer surgeon convicted in 2017 of 17 counts of wounding with intent and sentenced to 15 years’ imprisonment, increased on appeal to 20 years. He had carried out medically unnecessary cancer surgery on ten patients between 1997 and 2011. His motives were unclear.

Following these convictions, HM Senior Coroner for Birmingham and Solihull began inquiries to determine whether there was reason to suspect that any former patient of Paterson in his private or NHS practice died an unnatural death as a result of his actions. The investigation involved a review of the medical records for each patient by a multi-disciplinary team of surgeons and oncologists [‘the MDT’], who then reported whether there appeared to have been any culpable act or omission in the patient’s treatment and whether, on the balance of probabilities, the failing more than minimally, trivially or negligibly contributed to death. At present 62 inquests have been opened and adjourned as a result of these inquiries.

HM Deputy Coroner is now conducting a lengthy series of hearings expected to last into 2026 and beyond. The first module consists of ‘normal’ inquests into the death of each patient to determine the cause of death. Later modules will deal with systemic issues, the response of regulators and other NHS bodies, the patient recall process initiated once concerns about Paterson’s treatment were raised, and the question of a prevention of future deaths report.

These hearings are unusual not only because of the sheer number of individual inquests involving the same issues and cohort of interested persons, but also because the Coroner will be called upon to examine factual issues dating as far back as the 1990s. As well as the inevitable difficulties of fading recollections caused by the passage of time, the Coroner will also have to contend with identifying the relevant guidelines, the state of scientific knowledge, and generally accepted standards of care that applied in any given case at any given time.

Progress of the Inquests

The hearings to date have not run altogether smoothly. The intention was to hear evidence in relation to each patient sequentially, with Paterson attending each separate inquest to give evidence as well as other clinicians involved. It was hoped that the entire series of Module 1 hearings would be concluded within a year beginning in autumn 2024.

In fact, the proceedings have been beset by delays from the outset. As the module 1 hearings were scheduled to begin, submissions were filed on behalf of Paterson arguing that the Coroner had the power to grant Paterson funding for legal costs and should do so, and that he should adjourn the inquests. HM Coroner gave this application pretty short shrift, finding that neither the Coroners Allowances, Fees and Expenses Regulations 2013 nor the Coroners and Justice Act 2009 gave him power to grant funding to an interested person for legal representation. Paterson had made three failed applications for legal aid and his remedy was judicial review. The application for adjournment was refused. The Coroner did not accept that Paterson had inadequate time or facilities to prepare for the hearings. He was in the same position as any other IP and arrangements had been made for him to access documentary materials in prison and to give evidence remotely. Despite efforts to assist him he had refused to make a statement.

Very shortly afterward there followed an application to revoke the Schedule 5 notice served on Paterson, that being the notice requiring Paterson to attend to give evidence. The Coroner refused the application, observing that he would “do [his] utmost to use [his] powers to the fullest extent to ensure the attendance of Mr Paterson”. This application was renewed orally and refused again.

Somewhat to the surprise of all concerned, following the refusal of these applications Paterson has for the most part made himself available to give evidence when required to do so by the Coroner. Paterson’s participation is a particularly unusual feature of these inquests as his evidence may expose him to new legal action. As the coroner examines whether any deaths could amount to unlawful killing, there is a clear risk that his testimony could lead to further criminal charges  – most notably, gross negligence manslaughter.

Although Paterson was ultimately willing to give evidence, the proceedings suffered a further setback when submissions were made on his behalf in relation to the independence of HM Deputy Coroner’s MDT. That same panel of medics who conducted the initial triage of Paterson’s patients have now formed a team giving expert evidence to the Coroner in each inquest in relation to the surgical and oncological treatment given. Paterson’s defence team argued that the MDT had shown actual and/or unconscious bias against Paterson and that their evidence was so unreliable that the Coroner should exclude it. Reliance was placed on emails from one member of the MDT, Professor Dixon, which described Paterson as a “liar”. Observing that Paterson was proved during his trial to have told lies, the Coroner found that no member of the MDT had expressed an irrational or unreasonable view and that there was no evidence of actual or unconscious bias. Nevertheless, he concluded that it would be in the best interests of Prof Dixon to withdraw from the MDT.

These submissions took time to resolve and the wider context was an ongoing discussion about the extent to which the MDT’s views on causation are supported by medical literature and research material. The result is that all inquests have been paused and a new phase scheduled, in which overarching causation issues will be explored through the evidence of the four remaining MDT members and two further experts instructed by Spire, the private healthcare provider for whom Paterson worked outside his NHS practice. The most recent indication is that the module 1 individual inquests will not be completed before April 2026.

Conclusion

The Paterson inquests are likely to run for years to come and may have consequences not only for Paterson himself but also for the wider management of NHS and private healthcare.

Sarah Przybylska and Paul Renteurs are representing Dr Andrew Stockdale, the lead oncologist giving evidence to the Inquests, instructed by Adam Weston, Claire Petts and Patrick Smith at Clyde & Co on behalf of the Medical Protection Society.