A rogue breast surgeon was able to perform botched surgery on hundreds of patients because of multiple blunders by a "dysfunctional" NHS system, a report has found.
Disgraced Ian Paterson, 61, was jailed for 20 years for carrying out needless operations on his patients between 1997 and 2011.
He left male and female patients significantly deformed, with one looking like a "car crash victim" after telling them they were at risk from cancer when they were healthy.
A court heard the butcher surgeon “exaggerated or invented” risks of tumours so he could earn extra money and maintain his “successful reputation”.
The damning report found Paterson was able to perform the damaging surgery due to a "culture of avoidance and denial" and a “wilful blindness” from staff.
It was found he may have harmed more than 750 women during his time working with cancer patients at NHS and private hospitals in the West Midlands over a 14 year period.
Retired Bishop of Norwich Graham James, who chaired the inquiry, said patients were let down "on every level" due to "multiple individual and organisational failures".
He said: “Our report finds that patients were let down over many years by multiple individual and organisational failures.
“There was a culture of avoidance and denial, an alarming loss of corporate memory and an offloading of responsibility at every level.
“Patients were initially let down by Paterson when he performed inappropriate or unnecessary procedures and operations and they were let down both by the NHS and independent providers who failed to supervise him appropriately and did not respond correctly to well-evidenced complaints about his practice.
“Once action was finally taken, patients were again let down by wholly inadequate recall procedures in both the NHS and the private sector.
“When patients complained to regulators they were frequently treated with disdain.
“Finally, they were let down by a discretionary indemnity system that avoided giving compensation to Paterson patients once it was clear his malpractice was criminal."
Asked how many patients might have been affected by his malpractice, the bishop confirmed it could "certainly" be more than 1,000.
He said: "All I can do is give you the overall figure of those whom he treated.
"Of course, in many cases they have not been recalled and individuals investigated, so that figure is not available with any degree of accuracy."
Giving her views on the report, one of Paterson's victims, Tracey Smith, said: "Paterson was claiming that there was some sort of cancer hotspot in Solihull.
"The only problem in Solihull was Ian Paterson.
"I've always been angry, from 2012 when I was told my breast cancer surgery was unnecessary - hence why myself and Deb went to Whitehall and fought for this inquiry.
"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."
Asked if the fight goes on after the inquiry, Debbie Douglas - who received an unnecessary mastectomy at the hands of Paterson - said: "The fight goes on until the legislation has changed.
"We don't want somebody from the Government giving us lip service and saying that lessons will be learned.
"It sickens me. Lessons aren't learned unless legislations change.
"You look at the GMC - why, when people have reported the same consultant over and over again, is that consultant still working?"
In September 2017, more than 750 patients treated by Paterson received compensation payouts from a £37 million fund.
The findings come after West Midlands Police asked Birmingham and Solihull Senior Coroner Louise Hunt to investigate 23 deaths where individuals had been former cancer patients of Paterson.
The report criticises the Heart of England NHS Foundation Trust as well as Spire Parkway and Little Aston, the independent hospitals where Paterson practiced, for “failings” in checks and balances.
It includes accounts of more than 211 people about their own or their family members' treatment, many of whom feel the breast surgery was unnecessary.
The report made 15 recommendations to improve the regulation of healthcare and reduce the risk of a similar scandal.
It included the creation of a public register of what types of operations surgeons are able to perform and multidisciplinary meetings to ensure patients know the full risks.
They also recommend making it standard practice for consultants to write to patients outlining their condition and treatment in "simple language".