Understanding failings in patient safety: lessons from the case of surgeon Ian Paterson
Intended for healthcare professionals
Evidence and practice    

Understanding failings in patient safety: lessons from the case of surgeon Ian Paterson

Frank Milligan Senior lecturer in patient safety (retired), University of Bedfordshire, Luton, England

Why you should read this article:
  • To learn about cases of surgical malpractice such as that of Ian Paterson, and the relevant systemic issues that led to failings in patient safety

  • To recognise nurses’ responsibilities in raising concerns about suboptimal practice

  • To identify strategies that could enhance patient safety and which could be implemented in your healthcare organisation

While rare, incidents of inappropriate and/or unnecessary surgery do occur, so effective surveillance of surgical practice is required to ensure patient safety. This article explores the case of Ian Paterson, a consultant surgeon who was sentenced to 20 years in prison in 2017 for wounding with intent and unlawful wounding, primarily by undertaking inappropriate or unnecessary mastectomies. The article details the main points of the Paterson case, with reference to the subsequent government-commissioned inquiry and its recommendations. It also outlines various strategies for enhancing patient safety, including applying human factors theory, improving auditing, and rationalising NHS and private healthcare. The author concludes that nurses have a crucial role in the surveillance of surgical practice and that combined reporting of surgeons’ practice across NHS and private healthcare organisations is required.

Nursing Standard. doi: 10.7748/ns.2021.e11622

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software



Conflict of interest

None declared

Milligan F (2021) Understanding failings in patient safety: lessons from the case of surgeon Ian Paterson. Nursing Standard. doi: 10.7748/ns.2021.e11622

Published online: 01 June 2021

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