Patients were let down by the healthcare system "at every level" said inquiry chair Rt Revd Graham James, who identified "multiple individual and organisational failures".
"There was a culture of avoidance and denial, an alarming loss of corporate memory and an offloading of responsibility at every level," he said.
This didn't happen because of one egotistical surgeon, it was a failure by lots of different people in lots of roles.
My heart goes out to the people affected.