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Women 'put at risk by secrecy'
Lawyer Sir Ian Kennedy has accused managers at the Heart of England NHS Trust of "preferring good news to true news".
Hundreds of women were kept in the dark that their breast cancer might come back after "weak and indecisive" hospital managers failed to take action against a surgeon, according to a damning report.
Those who underwent mastectomies at Solihull Hospital - part of the Heart of England NHS Trust - were put at unnecessary risk due to "secrecy" following years of complaints about breast surgeon Ian Paterson.
Lawyer Sir Ian Kennedy, who led a review into the "tragic story", accused managers at the trust of "preferring good news to true news" between 2003 and 2011.
Mr Paterson, who has been suspended by the General Medical Council (GMC) and is being investigated by police, was allowed to carry on operating on women for several years despite serious concerns raised about him by other staff.
He carried out inadequate partial mastectomies on many women. When quizzed by doctors and nurses, he said he had left behind "fatty tissue" to give the women a more "satisfying aesthetic appearance" with a cleavage.
The technique he invented - "cleavage-sparing mastectomy" - left tissue behind that put women at risk the disease would come back.
Figures released by the trust today show that women given these mastectomies have double the risk of cancer coming back within five years compared to those given full mastectomies by Mr Paterson.
Sir Ian's review was heavily critical of senior figures at the trust, saying they chose to ignore Mr Paterson's failings or took inadequate action.
Even when the trust did decide to take decisive action years later, it recalled only 12 women for further investigation - an approach that was "hopelessly flawed".
A full recall of all patients was announced only when new managers took up posts at the trust in 2010.
Sir Ian's report said: "This is a tragic story. It is a story of women faced with a life-threatening disease who have been harmed. It is a story of clinicians at their wits' ends trying for years to get the trust to address what was going on.
"It is a story of clinicians going along with what they knew to be poor performance. It is a story of weak and indecisive leadership from senior managers.
"It is a story of secrecy and containment. It is a story of a board which did not carry out its responsibilities. It is a story of a surgeon who chose on occasions to operate on women in a way unrecognised by his peers and thereby exposed them to harm."
Mr Paterson was employed by the trust in March 1998, having previously been subject to an investigation and suspended by another trust, the Good Hope Hospital in Sutton Coldfield.
He left Good Hope without serving his notice on request from the chief executive at the time.
The "charismatic and charming" doctor was "much-liked by his patients" but was not regarded as a "team-player" when it came to the care of patients, Sir Ian said.
Fellow doctors became concerned that Mr Paterson was not removing enough tissue during mastectomies. At the end of 2003, an audit was carried out followed by another investigation the following year.
It made a number of recommendations about Mr Paterson's surgery which were not acted upon.
"Surprisingly, it only referred in passing to one of the central concerns - that, on occasions, Mr Paterson was leaving behind tissue after carrying out what was supposed to be a mastectomy - and made no recommendation on the matter," Sir Ian said.
The report also overlooked the "crucial issue" of consent among patients - something managers continued to overlook between 2003 and 2011.
The review said concerns were raised by a yet another surgeon in 2007 but were not properly acted upon although Mr Paterson agreed to stop cleavage-sparing mastectomies after that time.
A further review said Mr Paterson's surgery needed to be "less rushed" and raised other concerns about his care.
But Mr Paterson carried on working, today's report said. He was suspended by the trust in May 2011 but his pay was not stopped until November 2012.
Sir Ian said the trust's failure to issue a full recall of patients came partly out of a desire to keep a lid on the story.
One of the reasons seemed to be "a desire to contain and control the fallout from the concerns and thereby protect the reputation of the trust," he said in his report.
But even as 12 patients were being recalled, others "began to present themselves at clinics who had not been selected for recall, but needed further examination".
The delays in recall "meant that some patients may have been put to even greater risk by having to wait before being recalled or seen. It also greatly added to the anxiety of women."
Data from the trusts shows that, of one group of 768 patients who underwent a mastectomy by Mr Paterson, there were 237 cases where evidence clearly showed the surgery was "suboptimal".
The women's chance of cancer coming back was 4.6% in the five years after surgery.
This was more than double the rate among patients who had a full mastectomy by Mr Paterson - not leaving any tissue behind - where the recurrence rate was 2%.
In cases where it was unclear what type of mastectomy patients had had, recurrence at five years was 3.4%.
Sir Ian told a press conference many of the themes he had identified during his review were familiar in reports of things "going wrong in the NHS".
He said: " Ultimately they boil down to the culture of the organisation. Ideally NHS trusts should encourage a culture in which the needs of patients and the safe and proper care of them are the highest priority.
"When things go wrong, it is the culture that has gone wrong."
Trust chairman Lord Philip Hunt said: "We give a full and unreserved apology to all of the patients and their families, for the way they were both mistreated by Mr Paterson whilst he was a surgeon at the hospital, and subsequently let down by the trust's management team at the time, over the way the concerns about Mr Paterson were handled.
"We also apologise to staff and other professionals who raised concerns about Mr Paterson's practices - but were not listened to by the former leadership team."
Chief executive Dr Mark Newbold, who ordered the full patient recall and the review, said: "We need to work with patients, staff and external experts to drive a real change in the way we deliver care.
"We must continue to act quickly to ensure that failings such as those highlighted in the Kennedy Review can never re-occur. We have the capability to deliver the highest levels of care quality. Nothing less will do."
Up to 400 women are thought to be suing the trust and private health firm Spire, where Mr Paterson also worked, for failing to take action over the claims.