Ian Paterson was sentenced to 15 years in prison in 2017 for carrying out unnecessary operations on 10 patients for personal gain. His sentence was increased to 20 years due to the seriousness of his crimes.

An independent inquiry has recommended that thousands of public and private sector patients be recalled to assess his surgery, and that there was an institutional failure to respond to "well-evidenced" complaints about his work.

"Our report finds that patients were let down over many years by multiple individual and organisational failures," said Graham James, a retired Anglican bishop, who chaired the inquiry.

"There was a culture of avoidance and denial, an alarming loss of corporate memory and an offloading of responsibility at every level," he added.

Paterson worked between 1997 and 2011 at Spire Healthcare in the private sector, and in public National Health Service (NHS) hospitals between 1998 and 2011. Across the sectors, he saw 11,000 patients and performed operations on over 5,000 of them.

Paterson lied to exaggerate the risks of patients developing breast cancer, performing needless surgery in his private practice and in some cases mastectomies for which patients paid.

"We accept that there were a number of missed opportunities to challenge Ian Paterson’s criminal behaviour when these incidents happened prior to his suspension in 2011," said Justin Ash, Chief Executive of Spire Healthcare.

The report took testimony from 211 of Paterson's former patients or their relatives. Some made complaints which were not taken seriously, while others did not suspect anything was wrong until they heard about him on the news.

The report said that Paterson offered some patients a "cleavage-sparing mastectomy", a procedure which is not recognised in medical practice and leaves tissue behind, meaning some of those who did have cancer were not properly treated.

"There was a catalogue of failings, that resulted in harm to thousands of patients, causing devastatation to countless lives," Nadine Dorries, a junior health minister, told parliament, apologising for failings by the government and NHS.

"We are absolutely committed to ensuring lessons are learned and acted upon from the findings of this shocking inquiry, in the interest of enhancing patient protection and safety both in the NHS and the independent sector."

(Editing by Stephen Addison)

By Alistair Smout