Two hospitals missed opportunities to take action against a consultant breast surgeon who was performing unnecessary or incomplete operations, a review has found.
Spire Healthcare began investigating the work of Dr Ian Paterson at two private West Midlands hospitals in 2007.
Mr Paterson was suspended by the GMC in 2012.
A number of key events and missed opportunities occurred at Spire Parkway in Solihull and Spire Little Aston in Sutton Coldfield leading to a failure to take action against Mr Paterson, the independent review concluded.
The private healthcare organisation was alerted by Heart of England NHS Foundation Trust (HEFT) to issues surrounding his work in 2007.
But the review said there was poor communication between the trust and Spire about HEFT’s investigation into Mr Paterson.
A total of 15 recommendations for improving procedures were made in the report and all will be implemented, Spire said.