It describes an “institutional moral failing” at the heart of the NHS that allowed two psychiatrists, William Kerr and Michael Haslam, to rape or abuse their patients.

When victims tried to report the abuse, they were ignored by GPs, managers failed to investigate properly, and a nurse who tried to expose the scandal was demoted.

Nigel Pleming QC, the inquiry’s chairman, concludes that there was no deliberate conspiracy but “health officials chose to remain silent when they should have been raising their voices . . . It is also a story of management failure, failed communication, poor record keeping and a culture where the consultant was all-powerful.”

The scandal — the biggest single case of sexual abuse by doctors in the NHS — wrecked the lives of dozens of vulnerable women whom the consultants were treating for depression or mental illness.

The £3.2m inquiry followed an investigation by The Sunday Times, which first revealed the allegations against the two doctors in 1999. Haslam sued this newspaper after he was exposed but his action failed. He was eventually jailed for three years. Kerr was judged unfit to stand trial for health reasons.

Pleming details 75 recommendations to prevent a recurrence of the scandal, including placing a duty on NHS staff to report allegations against their colleagues and rigorous checks on references.

Had proper checks been carried out on Kerr when he took his job at Clifton hospital in York in 1965, managers would have discovered he had been accused of sexual assault in his previous job. According to the inquiry, he then went on rape or molest at least 67 women between 1965 and 1988, twice as many as originally thought.

Thirty-eight of the women complained to nurses and 11 GPs but were dismissed as fantasists or troublemakers. Only one GP took a complaint against Kerr any further but he ended up reporting his concerns to Haslam, who dismissed them. Another patient who complained was referred to Beryl Bromham, another Clifton hospital psychiatrist. She listened but failed to tell the patient she was Kerr’s wife.

The doctors’ 20-year trail of abuse came to an end when one patient finally complained to police. However, Pleming’s report warns of a continued problem of doctors exploiting their position.

Research conducted in half the 600 NHS trusts in England found that between 3% and 6% of doctors were having or had previously had sex with patients.

It concludes: “Substantial risks remain that patients and staff who raise concerns or complaints will not be heard.”

Explore UK News

• Crime News

• Education News

• Health News

• Science News

• Scotland News

Times Recommends

• Third of Muslim students back killings
• Curfew tames feral yobs of Cornwall
• £3,000-a-month drug free abroad