The convicted breast surgeon Ian Paterson pitched one of his patients an unauthorised cleavage-sparing mastectomy “almost like a sales job”, an inquest has heard. Chloe Nikitas, an environmental consultant from Tamworth, died in 2008 at the age of 43 from breast cancer that returned three years after having a mastectomy she believed had removed all of her breast tissue. She is the first of 62 patients operated on by Paterson whose deaths are being investigated as part of one of the largest inquests in British history, to find out whether the surgeon’s actions caused their deaths. Paterson, who is serving a 20-year prison sentence after being convicted of multiple counts of wounding in 2017, refused to attend Nikitas’s inquest on Tuesday. A prison supervisor told the hearing he had a 20-minute conversation with Paterson on Tuesday morning, in which the 66-year-old former surgeon said the “coroner isn’t investigating fairly”, he felt he wasn’t being “listened to” and the proceedings were “biased”. Judge Foster, who is leading the inquests, can impose a fine of up to £1,000, refer Paterson for possible prosecution or refer him to the attorney general for contempt of court. He said he would reserve his judgment in the hope Paterson would change his mind and attend future inquests. “It is a disappointment to me, but more importantly to the bereaved families who have questions that need answering,” he said. Nikitas’s partner of 18 years, Klaus Ströhle, told the inquest how the couple had trusted Paterson, who told them he had “pioneered” a new type of surgery that would preserve the appearance of her cleavage after the breast tissue removal. “It was almost like a sales job – this is the latest new thing he has developed, and there’s nothing to worry about, it’s going to be great,” said Ströhle. “We just assumed this was the new state of the art methodology. We were not aware this was something that had not been sanctioned. “Chloe was highly analytical. We weren’t made aware there would be an increased risk of [cancer] recurrence if breast tissue was left behind, absolutely not – if we had been aware of that, I can assure you we would not have gone for this option. We assumed this was the best course of action.” Nikitas was offered no alternative type of operation, he said. Cleavage-sparing mastectomies, as they were later named by Paterson, were not a recognised or authorised type of operation. They involved leaving some breast tissue behind, instead of completely removing it as was standard procedure in a mastectomy. Nikitas was first diagnosed with breast cancer in 2002 after noticing discomfort in her left breast while breastfeeding her young son. She underwent a mastectomy the same year and then further treatment. In April 2005 she discovered a lump in the same breast, later found to be grade 2 ductal breast cancer – the same cancer as before – that had spread to other parts of her body. “We were told we were exceptionally unlucky, it was a one in a million chance, that it was just bad luck,” said Ströhle. “We were under no illusion that this was a death sentence. It was metastatic, and it was terminal.” After her surgery, Nikitas was referred to a consultant oncologist, Dr Tal Latief, for chemotherapy. He told the inquest he had no idea Paterson had been performing cleavage-sparing mastectomies on his patients as the surgeon never used that terminology, and he had been shocked to read about it in the media. “I was really shocked, because I had never heard the term cleavage-sparing mastectomy. Other surgeons never mentioned it to me or did it,” he said. “[Paterson] only referred to mastectomy, so I treated patients as having had mastectomies. I had no reason to doubt it.” In a statement read at the start of the inquest hearing, Nikitas was described as an “incredibly smart woman” who was “compassionate, passionate [and] never afraid to speak her mind”. The inquest continues.