Dr Ian Cunliffe and Dr Mark Goldman were accused of ignoring warnings about Dr Paterson and failing take action to stop his malpractice, which left victims scarred, disfigured, and with long-term psychological effects

Dr Paterson, who worked at NHS and private Spire hospitals in the West Midlands, is currently serving 20 years in prison after he was convicted of 17 counts of wounding with intent and three counts of unlawful wounding against 10 patients.

More than 1000 Patients Subjected to Unnecessary Operations
An inquiry later concluded that more than 1000 patients were subjected to damaging and unnecessary operations over 14 years before he was finally stopped. In many cases, Paterson exaggerated patients' cancer symptoms and performed needless mastectomies when less-invasive treatment was more appropriate.
He also carried out unregulated "cleavage-sparing mastectomies" (CSMs), in which some breast tissue is retained for cosmetic reasons, which increased the risk of cancer returning.

Dr Cunliffe, a former medical director, and Dr Goldman, a former chief executive, at the Heart of England NHS Foundation Trust, were accused of failing to protect patients from "the risk of harm" posed by Paterson. But a Medical Practitioners Tribunal Service (MPTS) misconduct hearing found various charges relating to their alleged managerial failings not proved.

Both Cleared of Charges
Both were cleared of failing to act sooner to stop Dr Paterson, who wasn’t suspended until 2011, and not reporting him to the General Medical Council (GMC) despite several investigations and complaints from patients, GPs, and other surgeons dating back to 2003. They were also cleared of failing to recognise the significance of an absence of patient consent to the CSM or subtotal mastectomies he performed, and of allowing Paterson to review and refer patients himself.

The tribunal noted that Dr Cunliffe did not receive any advice from his management team or externally that Paterson should be reported to the GMC and he had not "reached the clear judgment" that the surgeon was "a serious potential danger to patients or staff".

He was not challenged by GMC on receipt of an external report, it found, so there was no failure on his part to protect patients from the risk of harm from Dr Paterson.

A charge that Dr Cunliffe failed to put systems in place to ensure monitoring and enforcement of a verbal agreement by Paterson to stop performing procedures was not proved because there was no evidence that the "the confidence" in which he and Dr Goldman retained in the surgeon to abide by the agreement was "misplaced".

Dr Goldman was cleared of failing to 'promptly' inform the Trust’s board of clinical concerns about Dr Paterson, to report their full history, and to pass on colleagues' concerns that the breast cancer surgeon had not obtained patient consent for procedures. He was also cleared of failing to investigate concerns using an appropriate process and opting to use a "confidential" HR process instead, and not passing investigators a "full history" of concerns.

Dr Goldman had faced a charge of failing to stop Dr Paterson after concerns were raised in 2007. But the tribunal found that no-one had advised him to do so and due to an ongoing investigation, he "was not under any duty to protect patients from risk of harm by imposing a general restriction on Dr Paterson's breast surgery". Similarly, allegations that he failed to put restrictions on the cancer surgeon's practise and failed to implement a full recall or structured monitoring of all of his surgery patients in light of concerns raised at an MDT meeting in 2007 were also not proved.

'Willful Blindness' to Dr Paterson's Behaviour: Inquiry
Dr Paterson was jailed for 15 years in 2017 following a 7-week trial at Nottingham Crown Court. Jurors heard how he carried out many life-changing operations for "no medical justifiable reason", while many victims were forced to live under the shadow of cancer for many years. He was accused of carrying out surgery for financial motives and regularly "miscoded" procedures and charged for more expensive treatment.

Dr Paterson's sentence was later increased to 20 years by the Court of Appeal, which deemed the original jail term imposed in May was "unduly lenient".

In 2020, an independent inquiry investigated how he was able to carry out unnecessary surgeries undetected for so many years. It found 1000 women were subjected to needless surgery between 1997 and 2011. It found that Dr Paterson was allowed to carry oil performing harmful surgery due to "a culture of avoidance and denial" in a "dysfunctional" healthcare system where there was "wilful blindness" to his behaviour.

Victims were "lied to, deceived and exploited" and "let down time and time again", the report sais, first by him, then by the hospitals where he worked, and then – once the harm they had suffered was known – by healthcare regulators who treated them with disdain.
The inquiry, chaired by the Rt Rev Graham James, a former bishop of Norwich, called on ministers, NHS bosses and the private healthcare industry to introduce measures to reduce the risk of another health professional inflicting such life-changing harm on patients.

It also led to a further 5500 of Paterson's patients being recalled and last year, Spire Healthcare set aside £22 million to cover the costs of the new compensation claims. A £37 million compensation package for more than 750 patients was approved by a High Court judge in 2017. This included £27.2 million paid out by Spire Healthcare and £10 million paid by Paterson's insurers and former employers at the Heart of the England NHS Trust.