A hospital trust exposed women with breast cancer to the risk their disease would come back despite repeated concerns about a surgeon's abilities, a damning report has found.
Women who underwent mastectomies at Solihull Hospital - part of the Heart of England NHS Trust - were largely left in the dark despite years of complaints about breast surgeon Ian Paterson.
Lawyer Sir Ian Kennedy, who led a review into what happened, accused managers at the trust of "preferring good news to true news".
He said what happened between 2003 and 2011 was a "tragic story" that was also a story of "secrecy and containment".
Mr Paterson, who has been suspended by the General Medical Council (GMC), was allowed to carry on operating on women for several years despite serious concerns raised about him by other medical staff.
Sir Ian said that even when the trust did decide to take decisive action, it recalled only a handful of women for further investigation - an approach that was "hopelessly flawed".
Mr Paterson carried out partial mastectomies on many women, leaving tissue behind, which left them at risk the disease would come back.
A full recall of all patients was announced only when new managers took up posts at the trust.
Up to 400 women are thought to be suing the trust and a private firm for failing to take action over the claims.
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."
Mr Paterson was employed by the trust in March 1998, having previously been subject to an investigation and suspended by another trust, the Good Hope Hospital in Sutton Coldfield.
He left Good Hope without serving his notice on request from the chief executive at the time.
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.
Fellow doctors became concerned that Mr Paterson was not removing enough tissue during mastectomies. At the end of 2003, an audit was carried out followed by another investigation the following year.
It made a number of recommendations about Mr Paterson's surgery which were not acted upon.
"Surprisingly, it only referred in passing to one of the central concerns - that, on occasions, Mr Paterson was leaving behind tissue after carrying out what was supposed to be a mastectomy - and made no recommendation on the matter," Sir Ian said.
The report also overlooked the "crucial issue" of consent - something managers continued to overlook between 2003 and 2011.
"Women were giving their consent to a mastectomy. But, on occasions, a variation of a mastectomy was being carried out; what became known later as a "cleavage-sparing mastectomy".
"This was not a recognised procedure. Women did not consent to it in any properly informed way."
The review said concerns were raised by a yet another surgeon in 2007 but were not properly acted upon although Mr Paterson agreed to stop partial mastectomies after that time.
A further review by a more experienced surgeon said Mr Paterson's surgery needed to be "less rushed" and raised other concerns about his care.
But Mr Paterson carried on working, today's report said. He was suspended by the trust in May 2011 but his pay was not stopped until November 2012.