Hospital bosses ignored complaints about butcher surgeon with 'God complex' for years, report finds
Complaints about convicted surgeon Ian Paterson had been made for years but managers at the NHS trust which employed him "preferred good news to true news", a 2013 report said.
Bosses at Heart of England NHS Trust failed hundreds of breast cancer patients, the report by lawyer Sir Ian Kennedy found.
Paterson, who has been suspended by the General Medical Council, was allowed to carry on operating on women for several years despite serious concerns raised about him by other staff, the report said.
Sir Ian Kennedy published his findings in December 2013 - more than three years before Paterson stood trial at Nottingham Crown Court, alleged to have wounded ten patients treated privately at the Spire Little Aston and Parkway hospitals, West Midlands, between 1997 and 2011.
The jury in the trial were not told of this report, and Paterson was convicted.
Paterson carried out "cleavage sparing mastectomies" with the review into his work at the Heart of England NHS Trust finding a number of women were exposed to the risk of the cancer returning.
The report said Paterson carried out inadequate partial mastectomies on many women, which he defended by saying he had left behind "fatty tissue" to give the women a more "satisfying aesthetic appearance".
The hospital trust offered an unreserved apology to all patients and their relatives following the report's publication.
Sir Ian's review was heavily critical of senior figures at the trust, saying they chose to ignore Paterson's failings or took inadequate action.
Even when the trust did decide to take decisive action years later, it recalled only 12 women for further investigation - an approach that was "hopelessly flawed".
A full recall of all patients was announced only when new managers took up posts at the trust in 2010.
Sir Ian's report said: "This is a tragic story. It is a story of women faced with a life-threatening disease who have been harmed. It is a story of clinicians at their wits' ends trying for years to get the trust to address what was going on.
"It is a story of clinicians going along with what they knew to be poor performance. It is a story of weak and indecisive leadership from senior managers.
"It is a story of secrecy and containment. It is a story of a board which did not carry out its responsibilities. It is a story of a surgeon who chose on occasions to operate on women in a way unrecognised by his peers and thereby exposed them to harm."
Paterson had been suspended from another trust, the Good Hope Hospital in Sutton Coldfield, when he started working for Heart of England in March 1998.
The "charismatic and charming" doctor was "much-liked by his patients" but was not regarded as a "team-player" when it came to the care of patients, Sir Ian said.
The review said concerns were raised by a surgeon in 2007 but were not properly acted upon although Paterson agreed to stop cleavage-sparing mastectomies after that time.
A further review said Mr Paterson's surgery needed to be "less rushed" and raised other concerns about his care.
But he carried on working, the report said. He was suspended by the trust in May 2011 but his pay was not stopped until November 2012.
Sir Ian said the trust's failure to issue a full recall of patients came partly out of a desire to keep a lid on the story.
One of the reasons seemed to be "a desire to contain and control the fallout from the concerns and thereby protect the reputation of the trust," he said in his report.
But even as 12 patients were being recalled, others "began to present themselves at clinics who had not been selected for recall, but needed further examination".
The delays in recall "meant that some patients may have been put to even greater risk by having to wait before being recalled or seen. It also greatly added to the anxiety of women."
The then trust chairman Lord Philip Hunt said: "We give a full and unreserved apology to all of the patients and their families, for the way they were both mistreated by Mr Paterson whilst he was a surgeon at the hospital, and subsequently let down by the trust's management team at the time, over the way the concerns about Mr Paterson were handled."