A culture of "avoidance and denial" allowed a breast surgeon to perform botched and unnecessary operations on hundreds of women, a report has found.
An independent inquiry into Ian Paterson's malpractice has recommended the recall of his 11,000 patients for their surgery to be assessed.
Paterson is serving a 20-year jail term for 17 counts of wounding with intent.
One of Paterson's colleagues has been referred to police and five more to health watchdogs by the inquiry.
Debbie Douglas, who underwent "needless" surgery while in Paterson's care, said all of the report's 15 recommendations must be implemented.
The disgraced breast surgeon worked with cancer patients at NHS and private hospitals in the West Midlands over 14 years.
His unregulated "cleavage-sparing" mastectomies, in which breast tissue was left behind, meant the disease returned in many of his patients.
Others had surgery they did not need – some even finding out years later they did not have cancer.
Patients were let down by the healthcare system "at every level" said the inquiry chair, retired Bishop of Norwich the Rt Revd Graham James, who identified "multiple individual and organisational failures".
Another of Paterson's victims, Tracey Smith, welcomed the recommendations for the health service made by the inquiry.
"Paterson was claiming that there was some sort of cancer hotspot in Solihull. The only problem in Solihull was Ian Paterson," she said.
"Now we will continue to fight so that the recommendations are put in place to stop this from ever happening in the NHS or the Spire or any private hospital in the country."
Among the report's recommendations were:
- It should be made standard practice for consultants to write directly to patients to explain proposed surgical treatment
- A public register should be created detailing which types of operations surgeons are able to perform
- Patients should be allowed time to reflect on their diagnosis and treatment options before they are asked to consent to surgery
- Information must be communicated more effectively to patients on how to escalate a complaint
- Private hospitals, as well as NHS ones, must be made to follow the recommendations
In his report, Bishop James said: "The suffering described; the callousness; the wickedness; the failures on the part of individuals and institutions as well as Paterson himself – these are vividly described in what patients told us.
"The scale of what happened, the length of time this malpractice went on; the terrible legacy for so many families; it is difficult to exaggerate the damage done, including to trust in medical organisations."
The coroner and West Midlands Police are looking into the deaths of 23 of Paterson's patients.
Relatives of some of Paterson's patients who died have called for him to face manslaughter charges.
Hugh Pym, health editor, BBC News
The opening words of the Paterson inquiry are striking. The chair, Rt Revd Graham James, says this was "far worse" than simply a story about a rogue surgeon though that itself was tragic.
He says the healthcare system was dysfunctional at every level when it came to keeping patients safe. And this was less than a decade ago.
He suggests there are currently more than enough regulators with sufficient budgets, but they still aren't doing enough collectively to keep patients safe.
Chillingly he says that based on evidence from clinicians as opposed to regulators something similar could happen now.
Paterson began working at Spire private hospital in Solihull in 1997 and was appointed at Solihull Hospital, part of the Heart of England NHS Trust, a year later.
Between then and 2011, he had 11,000 patients across the two sites. He was suspended by the General Medical Council (GMC) in 2012 while his practices were being investigated.
An independent report by lawyer Sir Ian Kennedy found concerns about Paterson had been raised as early as 2003, but hospital management missed several opportunities to stop him.
Following a trial at Nottingham Crown Court, Paterson, of Altrincham in Greater Manchester, who grew up in County Down, Northern Ireland, was jailed for 15 years in May 2017 after being found guilty of wounding with intent nine women and one man.
His sentence was later increased to 20 years.
Later that year, minister of state for health Philip Dunne established the independent inquiry.
"There was a culture of avoidance and denial, an alarming loss of corporate memory and an offloading of responRead More – Source