Is the NHS doing enough to protect us from rogue surgeons?

'Having surgery so many times was exhausting,' said Carole Johnson. She did not have cancer

Carole Johnson used to regard herself as one of the lucky ones. True, she’d been ‘shattered’ to develop breast cancer not once, but seven times over a decade. But each time she found a new lump, Carole had her rock: the breast cancer surgeon Ian Paterson. Each time Mr Paterson diagnosed another tumour, he was able to arrange her speedy admission to hospital so he could perform a lumpectomy to remove the cancerous tissue.

‘Of course, having surgery so many times was exhausting,’ says Carole, 60, who runs a busy pub in Yardley, Birmingham, with her husband Barry and their three adult children. ‘It terrified my family and left my breasts covered in scars. Each time, it took me weeks, sometimes months, before I was well enough to work again. But it made all the difference that Mr Paterson was always there for me. He really cared about me. Or so I thought.’

Two weeks ago, though, Carole got the worst shock of her life. Far from being a cancer survivor, she discovered that she’d never actually had cancer. Astonishingly, she was one of 450 healthy women on whom Mr Paterson had carried out surgery they didn’t need.  The surgeon — widely seen as charming and charismatic — had also performed unorthodox partial mastectomies on a further 700 women. Known as ‘cleavage sparing mastectomy’, this procedure, which leaves breast tissue around the central chest area, was invented by Mr Paterson and has never been properly tested.  The technique breaches national guidelines, which state that leaving excess tissue could increase the risk of the cancer returning.

The question is why it took so long for Ian Paterson to be stopped

In fact, the medical review carried out on every woman Mr Paterson performed the procedure on has identified a number of cases where this has already happened. On October 29 — just four days after Carole Johnson heard the truth about her ‘lovely’ surgeon — Mr Paterson’s 28-year career in NHS and private hospitals across the Midlands came to an abrupt halt when he was suspended from practising medicine by the General Medical Council, the doctors’ regulatory body. He now faces a disciplinary inquiry, as well as a possible criminal investigation.

The question is why it took so long for Mr Paterson to be stopped. It now appears that the Heart of England NHS Foundation Trust he worked for was aware of the problems associated with his procedure back in 2003, with further concerns reported in 2007. Yet Mr Paterson was still operating on women until July 2011, when he was ordered to stop breast cancer surgery by the GMC, though he was still permitted to see patients. It was only at this point that the patients themselves were invited to have their cases reviewed. Initially deeply hurt by the revelations about her surgeon, Carole’s feelings soon turned to anger that he could be allowed to deliver substandard care to so many women for so long. ‘Why weren’t we told? she asks. ‘Why did I have to find out the hard way through seven operations?’

A SCANDAL THAT'S HAPPENED BEFORE

Why indeed? Nearly 20 years ago, the same question was being asked by dozens of parents whose babies had died or been left brain-damaged after heart surgery at Bristol Royal Infirmary between 1988 and 1995. In a case that has shocking parallels with today’s scandal, for seven years two surgeons at the Bristol hospital persisted in carrying out complex cardiac surgery that was way beyond their capabilities.

Astonishingly, while managers and a growing number of hospital staff were aware that twice as many babies were dying in the hospital’s paediatric operating theatre compared to the national norm, the surgeons were never directly challenged. Indeed, managers saw a need to be ‘discrete and supportive’ of the surgeons, who complained of ‘a run of unusually complex cases’.

For years, the parents of the tiny victims were only aware of their own individual tragedy — never for a moment realising that within the hospital the child heart surgery unit was dubbed ‘the Killing Fields’. In 2001, a report found that at least 35 babies had died unnecessarily, and estimated that 170 more might have been saved if they’d been operated on elsewhere. The report blamed the scandal on the ‘old boys’ culture’ among doctors, a lax approach to safety, secrecy about doctors’ performance, and a lack of monitoring by management.

Determined to ensure that no such scandal would ever happen again, the Department of Health began immediately to promote a ‘Safety First’ approach, with a rack of measures to protect patients — particularly in the operating theatre. This approach is based on the recognition that doctors and nurses are as capable of human error as anyone else — whether it’s forgetting to wash their hands regularly or, less commonly, putting financial or professional gain ahead of patients’ needs. The following decade saw the introduction of a Safer Surgery Checklist (carried out before every operation to ensure that the correct procedure is performed as safely as possible).

National and regional audits of clinical performance were brought in for every hospital, as well as strict evidence-based guidelines on how surgery is performed. Patients are now the responsibility of not just a single specialist but a multi-disciplinary team, which is required to meet regularly to review every aspect of clinical care. There are also initiatives to support staff who reveal bad practice.

STAFF TOO SCARED TO SPEAK OUT

Fear: Staff are unwilling to speak out against fellow medics

So why didn’t these measures stop Mr Paterson? The fundamental flaw in this system is that it depends crucially on other health professionals speaking out about their colleagues. ‘Safe surgery relies on a culture where members of the multi-disciplinary team accept their professional obligation to voice concerns,’ says Professor Charles Vincent, co-director of the Centre for Patient Safety and Service Quality. ‘Unfortunately, such a culture can be strongly resisted — especially in an environment where there is a rigid professional hierarchy, or where senior professionals, such as surgeons, are motivated above all by professional pride.’

Basically, staffs are unwilling to speak out against fellow medics.  Indeed, a recent survey by the Royal College of Nursing found that more than eight in ten nurses said they would fear personal reprisals or an effect on their career if they blew the whistle on colleagues. ‘For patients to be protected, whistle blowers have to be fully supported, and feel confident that if they raise concerns then something will be done about them,’ says Dr Peter Carter, general secretary of the Royal College.  ‘The survey suggests that clearly isn’t happening.’

Even when health professionals do speak out, hospital trusts are often unwilling to listen, according to GP and Private Eye columnist Dr Phil Hammond, who first reported the Bristol babies scandal in 1992, long before it was finally investigated. ‘I’ve seen so many cases over the years where professional colleagues have raised concerns repeatedly over a long period, but the hospital or trust has not investigated the concerns or taken action to protect patients from avoidable harm.’ He believes the same culture of denial that bedeviled Bristol has led to numerous similar incidents, including the deaths of up to 1,200 patients due to substandard care at two hospitals in Mid-Staffordshire between 2005 and 2009. My guess,’ he says, ‘is that this is what has happened with Mr Paterson.’

Indeed, it appears that in 2003 and 2007 medical colleagues did raise concerns about the cleavage-sparing mastectomies carried out by Mr Paterson at Birmingham Heartlands Hospital, Solihull Hospital and Good Hope Hospital in the Midlands. However, the Trust appears to have been shamefully reluctant to act — as Ann Butler, 71, a former teacher from Shirley in the West Midlands has discovered. She was given the breast-conserving surgery in 2001, even though she said she wanted to have a full mastectomy. In February 2011, she was asked to attend the outpatients department and told about the problems with Mr Paterson. ‘A breast cancer nurse told me then that a cancer specialist had raised concerns about the procedure back in 2003, and an investigation into Mr Paterson’s clinical performance was carried out in 2004.’

HE IGNORED ORDERS TO STOP

So why was nothing done about the problem then? According to the official minutes of a meeting Miss Butler had with the Trust earlier this year, this was simply because ‘staff became quite used to seeing patients after this procedure’ — in other words, they just didn’t think to question it as being out of the ordinary. Yet three years later, in 2007, ‘colleagues of Mr Paterson including oncologists and other surgeons’ warned the Trust that ‘patients may be at increased risk of recurrence of breast cancer’ as a result of his cleavage-sparing mastectomy.

When at least two cases of breast cancer were confirmed in patients given the procedure, hospital executives instructed Mr Paterson to stop performing it — an instruction which he flagrantly ignored. At this point, you might think the Trust would contact Mr Paterson’s patients to see if they’d been affected. In fact, as those official minutes reveal, ‘it was thought that this would cause a  lot of distress to the many patients who hadn’t actually had a cleavage-sparing mastectomy’. Instead, the management decided to ‘find the patients by reviewing the notes of all Mr Paterson’s patients and look for clues’. Two years later, the Trust began screening patients as they went for their follow-up appointments.

In December 2009, the medical director of the NHS Trust, Dr Ian Cunliffe — Mr Paterson’s lead clinician — consulted a medical ethics academic to find out if there were circumstances in which it would be ethical to fail to inform patients that they had been given an unconventional therapy. In her response, the academic, Dr Anne Slowther, acknowledges that there are circumstances where it may be ethical to withhold such information, provided ‘the prognosis is exactly the same now as it would be ... with the conventional therapy. ‘That’s clearly not the case for patients like me,’ says Miss Butler. It wasn’t until 2011 — four years after their review — that the Trust initiated the process of recalling the many hundreds of Mr Paterson’s other breast-conserving patients.

OFFICIAL SILENCE BETRAYED PATIENTS

A disastrous ripple effect of the Trust’s silence was to delay measures to stop Mr Paterson carrying out unnecessary cancer surgery, including mastectomies, on the 450 healthy women such as Carole Johnson. These operations, almost exclusively carried out at local private hospitals, including the Spire Parkway and Little Aston Hospitals, have only come to light in the past few weeks when a team of independent consultant breast surgeons checked Mr Paterson’s patients’ records.

Mrs Johnson was called in to see one of these independent surgeons.  ‘I could hardly believe it when the surgeon told me there was nothing wrong with me,’ she says. ‘He had to show me the front of my notes, on which a colleague had scribbled: “It’s a joke. This lady did not need any surgery for cancer, never mind seven operations.” ‘The surgeon was very kind and said he could barely believe what his team had discovered. “I can’t sleep at night knowing what one of my colleagues has been doing,” he told me. Mrs Johnson says she is still in a state of shock.  ‘I can’t get my head round the fact that this man who seemed to be so caring had betrayed me. At least I can be grateful that I didn’t have a mastectomy.’ When the Mail contacted  the Trust for its comments, the medical director, Dr Aresh Anwar said: ‘An external independent inquiry is being commissioned to look at the exact timeline and nature of concerns surrounding the care of patients under Mr Paterson.  'These will be shared and published.’

Source: Daily Mail UK 

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