A further 13 inquests have been opened into the deaths of former patients of the disgraced breast surgeon Ian Paterson.
Consultant Paterson was convicted of 17 counts of wounding with intent and three counts of unlawful wounding in 2017.
An inquiry later found the 62-year-old had carried out unnecessary operations in NHS and private hospitals on more than 1,000 patients over 14 years.
He exaggerated and invented cancer risks and claimed payments for more expensive procedures.
The 2017 Nottingham Crown Court trial heard how he carried out unapproved "cleavage-sparing" mastectomies on patients which left behind breast tissue, risking a return of cancer.
He was initially jailed for 15 years, before the Court of Appeal increased his sentence to a 20-year term.
Paterson lost a 2021 bid to the same court to challenge his conviction, where three senior judges heard Paterson "denied, and indeed continues to deny, the misconduct of which he was accused at his trial".
In January 2020, West Midlands Police asked Birmingham and Solihull senior coroner Louise Hunt to look at a "random selection" of 23 former patients of Paterson's, to decide whether any died of unnatural causes due to "potentially substandard treatment".
In July 2020, inquests into the deaths of seven of those patients were then opened and adjourned.
But the coronial investigation has been continuing, beyond that original selection of cases.
Further inquests opened and adjourned at Birmingham Coroner’s Court on Friday 28 October including:
Catherine Coyne, 51, who was a married retired data protection officer from Solihull, West Midlands. She died of cancer at her home in Hampton Coppice, Solihull, on February 2008.
Eunice Jones – known as Pam – was a 47-year-old wife from Knowle, Solihull, who died of breast cancer at Solihull Hospital in 2004.
Rosemarie Blake, a married care assistant from Erdington, in Birmingham – but who was born in Northern Ireland – was 56 when she died of cancer in 1997 at Good Hope Hospital.
Elaine Turbill, of Castle Bromwich, in Birmingham, was 63 when the married retired legal secretary died of breast cancer at her home in 2017.
Pauline Clarke, of Silhill Hall Road, Solihull – but who was born in County Durham – died in June 1998 at home. She was a married retired midwifery nurse and also died of breast cancer.
Virginia Holder, of Colonial Road, Birmingham – but who was born in Barbados – was a widowed retired assembly worker. She died, aged 72, at a hospice in Solihull from breast cancer in 2001.
Phyllis Colfer, of Vera Road, Birmingham – but who was born in Ireland – was a retired traffic warden. The 67-year-old died at a nursing home as a result of cancer in 2002.
Christine Skelcher, of Shard End, in Birmingham, and a married office clerk was 59 when she died at home in 2004 from breast cancer.
Olive Bayliss, of Lea Hall Road, Birmingham, was a married retired cleaner. She was 75 when she died at the Marie Curie Hospice in Warwick Road, Birmingham, in 2001, from breast cancer.
Isobel Chandler, from Solihull, was a married secretary and 51-years-old when she died at Heartlands Hospital, Birmingham, in 2001. Cause of death was given as metastatic breast cancer.
Christine Hill, of Stratford Road, Solihull – but who was born in Sheffield, South Yorkshire – was an 81-year-old wife. She died at home in 2010, also of metastatic breast cancer.
Jean Bonehill, of Sutton Coldfield, near Birmingham, was a retired office clerk who died of breast cancer, aged 72, at her home in August 1998. Mrs Hunt made a public appeal for Ms Bonehill’s family to make contact with her office, after exhaustive efforts to trace her next of kin had failed.
Deborah Preston, of Foxhollies Road, Acocks Green, Birmingham, was a married 42-year-old who died of breast cancer at Heartlands Hospital in 2004.
Ms Hunt repeated the same remark about all 13 people: “I do have reason to believe the deceased’s death was caused or contributed to by substandard treatment provided by Mr Paterson and other clinicians involved in the care of the deceased.”
Future inquests would consider “any failings in supervision” of Paterson, including by “clinical colleagues” and whether they “should have informed the appropriate authorities”.
The evidence would also examine whether there were “systemic failings by hospital management… in addressing and responding to concerns raised about Mr Paterson”.
“Any inaction or failure of supervision by the regulatory agencies… any failings in the culture at the hospitals where Mr Paterson worked (and)… any failings in the recall system of patients,” would also be examined.
She stressed to loved ones of those attending the openings that the adjournments were “pending the review of all the other cases”, after which there would be a pre-inquest review.
The final inquests would “likely” be held under Article 2 human rights provisions “given the apparent serious defaults by a number of state organisations” said Ms Hunt, meaning the coroner would be looking at the wider circumstances of the deaths.
Ms Hunt added: “It is my duty to ensure the relevant facts will be fully, fairly and fearlessly investigated and its likely a report to prevent futures deaths will be considered.
An independent inquiry published in February 2020 said Paterson, who operated at NHS and Spire Healthcare hospitals in the West Midlands, performed unnecessary operations amid “dysfunctional” healthcare system that failed patients, and recommending more than 11,000 of his patients be recalled.