LONDON (AP) — The chair of an independent inquiry into how a prominent British breast surgeon was able to perform unnecessary operations for years concluded Tuesday that more than 1,000 patients might have been affecte d by a “dysfunctional” system tha t did not keep patients safe.

In 2017, a jury found rogue surgeon Ian Paterson guilty of 17 counts of wounding with intent to cause grievous bodily harm and three counts of unlawful wounding. Prosecutors say the doctor lied to patients or exaggerated their risk of cancer to persuade them to have surgery.

But Paterson’s patients demanded a more thorough reckoning to prevent such situations from ever happening again. The examination of Paterson’s actions concluded that patients were let down for many years both by Britain’s National Health Service and by private medical insurance and workers. The Rev. Graham James, the inquiry’s chair, said opportunities to stop the doctor’s behavior were repeatedly missed by a system characterized by “willful blindness.”

“Eight years passed between medical professionals raising concerns about Ian Paterson’s medical practice and his suspension,” James said. “He was given the benefit of the doubt time and time again, undeservedly. And the consequences for the patients have been terrible.”

Asked how many patients might have been affected by Paterson’s malpractice, James confirmed it could “certainly” be more than 1,000.

Hundreds of Paterson’s patients were recalled in 2012 after concerns about unnecessary or incomplete operations. Nine women and one man testified about the procedures during his trial, which dealt with surgeries between 1997 and 2011.

Initially sentenced to 15 years in prison, Court of Appeal judges later increased his sentence to 20 years.

Paterson owned a luxury home in Birmingham, in central England, as well as properties in Cardiff, Manchester and the United States, West Midlands police said.

Victims who accused him of playing God with their lives included Deborah Douglas, a mother-of-three who underwent an entirely unnecessary mastectomy that left her in “horrendous” pain. At her home in Birmingham, she keeps memorial cards from the funerals of some other Paterson patients.

“We want recommendations that change the system that allowed Paterson to get away with it, because basically, people have died,” she said. “He left breast tissue behind, and that led to patients’ deaths.”

Among his recommendations, James urged the creation of an “accessible and intelligible” single repository of performance data — a one-stop shop for patients.

Paterson did not accept the inquiry’s offer to comment.