Video report by ITV News Correspondent Stacey Foster
An independent inquiry into how rogue breast surgeon Ian Paterson was able to go on performing unnecessary operations for years uncovered a healthcare system "dysfunctional at almost every level".
The inquiry found "patients were let down over many years" by the NHS and private hospitals and opportunities to stop Paterson were "missed, time after time."
Inquiry chairman the Rt Rev Graham James, Bishop of Norwich, said there was a culture of "avoidance and denial", which allowed the breast surgeon to carry out unnecessary and botched operations on hundreds of women.
The inquiry has recommended the NHS Trust which employed Paterson and private health firm Spire Healthcare recall all of Paterson's patients.
ITV News Health Correspondent Emily Morgan explains what impact the inquiry might have
It heard 181 first-hand accounts from the surgeon's former patients.
The Government is also being asked to introduce reforms, including regulation of insurance protection for patients as a "nationwide safety net".
But Rt Rev James said there has "not been a single change to regulations which would prevent another Paterson."
Paterson carried out unnecessary operations in NHS and private hospitals, exaggerating or inventing cancer risks and claiming payments for more expensive procedures.
In 2017 he was jailed after being found guilty of 17 counts of wounding patients with intent, against 10 of his victims.
Initially handed a 15-year prison term, Court of Appeal judges later increased his tariff to 20 years.
However Paterson has insisted he is innocent of all the offences he was jailed for.
A statement issued by lawyers said: "Ian Paterson maintains his innocence of all of the criminal charges of which he was convicted and is actively working on an appeal against those convictions.
"Mr Paterson submitted a number of written representations to the Inquiry, headed by the Bishop of Norwich, and answered all questions put to him, as far as his current circumstances permitted him to do."
Lawyers said sent they sent submissions to the inquiry "raising concerns about possible bias."
Ian Paterson was asked about his motivations before he was jailed in 2017
Responding to the report, one of Paterson's victims, Deborah Douglas, who was instrumental in getting the public inquiry established, said the report's recommendations "must be implemented".
The inquiry report urges the creation of an "accessible and intelligible" single repository of consultants' key performance data, as a one-stop shop for patients.
Mrs Douglas, a mother-of-three who underwent an entirely unnecessary operation which left her in "horrendous" pain, said: "What was really really shocking were the numbers of patients affected.
"Instead of talking hundreds, you're talking over 6,000 Ian Paterson patients - so huge numbers that I wasn't really expecting."
Mrs Douglas, who runs the Breast Friends Solihull support group, continued: "What you're going to see in this inquiry report are over 200 statements.
"It's going to be horrific because it tells how they were failed in both the NHS and the private sector - these recommendations must be implemented."
Victim Tracey Smith said of the 6,617 patients Paterson treated at Spire, he operated on 4,077 of them.
"That's the highest rate than any other surgeon, did that not tell them that there was something not right, people were going in there, having unnecessary surgery," she said.
"Ian Paterson was claiming there was a cancer hotspot in Solihull. The only problem in Solihull was Ian Paterson.
"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 other recommendations, the inquiry says it should be made standard practice for consultants writing to patients about procedures to copy the letter to the patient's GP.
The inquiry also states that when hospitals investigate a health professional's behaviour, if there is a perceived risk to patient safety, that individual should be suspended and other employers informed.
As part of the inquiry's terms of reference, it was allowed to refer individuals considered to have committed a "disciplinary or criminal offence" to the relevant authorities.
Following the investigation, five health professionals have been referred to either the General Medical Council (GMC) or Nursing and Midwifery Council (NMC).
Another case has been referred to West Midlands Police.
The consultant breast surgeon was employed by the Heart of England NHS Foundation Trust (HEFT) but had practising privileges in the independent sector at both Spire Parkway and Spire Little Aston in Birmingham.
In September 2017, more than 750 patients treated by Paterson received compensation payouts from a £37 million fund.
Health minister Nadine Dorries said: "I deeply regret the failures of the NHS and the independent sector to protect patients from the devastating impact of Paterson's malpractice.
"We will give thorough and detailed consideration to this report and its findings and will provide a full response in due course."
Ms Smith was told by Paterson she needed to have surgery for breast cancer, which she did not have.
She told ITV News she has been left with severe epilepsy after the botched surgery, and said "she will be left medicated for the rest of her life."
"He's never apologised, he's never given us an answer why he did what he did," Ms Smith said.
15 recommendations of the report:
Complete recall of all patients of Ian Paterson from NHS trust and Spire Healthcare
A national framework or protocol is developed about how recall of patients should be managed and communicated
"Accessible and intelligible" single repository of consultants' key performance data
Standard practice for consultants in NHS and private hospitals to send a letter to patients outlining condition and treatment and copy letter to patient's GP
The difference between how NHS and private care is organised, is explained clearly to patients receiving private healthcare
Introduction of short period of time for patients to reflect on diagnosis and treatment before consenting to surgical procedures
CQC should assure all hospital providers are complying with national guidance on multi-disciplinary team meetings
Information on how to complain to an independent body is communicated more effectively in NHS and private sector
The Government should, as a matter of urgency, reform the current regulation of indemnity products for healthcare professionals
Current system of regulation and the collaboration of the regulators serves patient safety as the top priority
When a hospital investigates a healthcare professional’s behaviour, any perceived risk to patient safety should result in the suspension of the healthcare professional
When NHS or private hospitals do not take responsibility for what has happened, the Government addresses, as a matter of urgency, this gap in irresponsibility and liability
When things go wrong, boards should apologise at the earliest stage of investigation
If the Government accepts any of the recommendations concerned, it should make arrangements to ensure that these are to be applicable across the whole of the independent sector’s workload (i.e. private, insured and NHS-funded) if independent sector providers are to be able to qualify for NHS contracted work.
Watch the inquiry findings into the disgraced breast surgeon: