The Belfast Health Trust failed to intervene quickly enough in the practice of a doctor which led to Northern Ireland's largest ever patient recall, the Independent Neurology Inquiry has found.
More than 5,000 former patients of neurologist Michael Watt were invited to have their cases examined for possible misdiagnoses.
Among the conditions being treated were stroke, Parkinson's disease and multiple sclerosis (MS).
The inquiry found "numerous failures".
The Independent Neurology Inquiry concluded that the combined effect of the failures ensured that patterns in the consultant's work were missed for a decade.
Key conclusions include:
- The Belfast Trust should have intervened earlier, but failed to do so.
- Systems and processes in place to assure the public about patient safety prior to November 2016 failed.
- The effect of numerous failures ensured problems were missed for many years and opportunities to intervene were lost.
- Failures not confined to Belfast Trust - information was contained in silos with communications between different organisations and management levels poor and inadequate.