Breast surgery review: 'Numerous opportunities missed'
19 December 2013 Last updated at 12:55 GMT
A review into how NHS surgeon Ian Paterson was able to continue carrying out unnecessary surgery, and using a controversial technique that left hundreds of women at risk from breast cancer, has found concerns dated back to 2003.
The independent report also said the managers did not treat concerns with sufficient seriousness, or investigate claims with sufficient rigour or care.
They failed to adequately respond partly because they were focused on "man management" when they should have been examining "Mr Paterson's surgical practice and competence", report author Sir Ian Kennedy said.
"Opportunities were missed on a number of occasions", he added.