The report by lawyer Sir Ian Kennedy found concerns about surgeon Ian Paterson dated back to 2003 but were not dealt with for four years.
He carried out "cleavage sparing" mastectomies while at the Heart of England NHS Foundation Trust and the review found some women were exposed to a risk of cancer returning.
The trust said it was "very sorry".
Solihull Hospital previously found the surgeon breached guidelines over a procedure that involved leaving behind breast tissue to provide an improved cleavage.
Sir Ian's report made a number of recommendations relating to better transparency, improved recording of information, the role of regulators, encouraging staff to raise concerns and increased scrutiny.
It found senior managers at the trust did not respond effectively until 2007 and said their response was neither sufficiently robust nor rigorous.
Following Mr Paterson's suspension by the General Medical Council [GMC] last year, it referred the case to officers at West Midlands Police.
A spokeswoman for the force confirmed its investigations are continuing.
Sir Ian's report said the case had lessons for the whole NHS.
"It is a story of clinicians at their wits' end trying for years to get the trust to address what was going on.
"It is a story of clinicians going along with what they knew to be poor performance.
"It is a story of weak and indecisive leadership from senior managers. It is a story of secrecy and containment."
Mr Paterson was appointed by the trust as a surgeon in 1998.
Sir Ian said the breast surgeon, who has since been placed under an interim suspension order, was allowed to carry on operating on women for several years despite a series of concerns raised about him by other medical staff.
He added: "I was shocked by how long it took for effective action to be taken. Why was there not in place a system that could properly address the needs of women?"
Sir Ian said senior managers resorted to "a sort of auto pilot" and "excluded everyone but a small number in the know".
However, the report went on to say that it was "mistaken and naive" to believe that any one person was truly responsible.
The report said the trust had "a huge task on its hands to win back some measure of confidence".
It added: "[Staff] have lost confidence in the management of the trust, they...feel betrayed that no one listened to them, that things were allowed to go unchallenged for so long, that they cannot trust those charged with leading the trust."
The review found the trust board was excluded from access to much of the information by senior managers and made no formal effort to assert itself and become involved.
Sir Ian said: "The board is responsible for everything that happens in the trust and if they are going to sleep on the job and don't hold their chief executive to account then they have failed."
Up to 400 women are believed to be suing the trust for failing to take action over the claims.
NHS England said it "fully supports the recommendations that Sir Ian details in his report".
Trust chairman Lord Philip Hunt said: "I wish to give a full unreserved apology to all patients and their relatives. This was completely unacceptable and I am very sorry indeed."
He said a taskforce would be set up in January to oversee the implementation of Sir Ian's recommendations.
Lynne Rolinson, 53, from Solihull, underwent a mastectomy and breast reconstruction surgery performed by Mr Paterson in January 2007.
She said: "I feel it's quite a tragedy. Had the trust listened to people who raised concerns in 2003 and 2004 I would not be standing here.
"It's very difficult to deal with on a day-to-day basis, because I don't really know if I'm clear or I'm not."
Kashmir Uppal from Thompsons Solicitors, which is handling almost 400 of the compensation cases, said she welcomed the conclusions of the report.
She said she was "concerned about the failings of the trust and the failings of senior management" to act against Mr Paterson.
"The fact that clinicians tried to raise their concerns and weren't listened to... it's just not acceptable."
Bosses at an NHS trust failed hundreds of breast cancer patients, an independent report has found.