LONDON (AP) — A scathing review into three scandals that have rocked Britain's National Health Service concluded Wednesday that patients suffered avoidable harm because their concerns were ignored by a system that moved at a glacial pace.

The review chaired by Julia Cumberlege, a former health minister, offered a withering look into the health system's response to complaints about three medical interventions.

It studied pelvic mesh, which has been linked to crippling, life-changing complications including chronic pain; the anti-epilepsy drug sodium valproate, which has been linked to physical malformations; and hormone pregnancy tests such as Primodos, which is thought to be associated with birth defects and miscarriages.

The review, called “First Do No Harm” outlined “heart-wrenching'' stories of how the treatments led to “acute suffering, families fractured, children harmed and much else.’’ Patients then fought for decades to have their concerns heard.

“We met with hundreds of affected patients and their families ... it became all too clear that those who have been affected have been dismissed, overlooked, and ignored for far too long,'' the review said. “The issue here is not one of a single or a few rogue medical practitioners, or differences in regional practice. It is system-wide.”

The two-year study heard mainly from women whose lives were catastrophically affected. It also took evidence from the NHS, private healthcare providers, regulators and professional bodies, manufacturers, and policymakers.

Cumberlege acknowledged that at a time when the NHS' response to the COVID-19 outbreak had led to praise, her report would offer uncomfortable reading. But she said the system just wasn't good enough at spotting trends that gave rise to safety concerns.

“It does not adequately recognize that patients are its raison d’etre,'' the report said. “It has failed to listen to their concerns and when, belatedly, it has decided to act, it has too often moved glacially. ”

The report offered nine recommendations, including a fulsome government apology and the need for separate plans to meet the cost of providing additional care and support to those who have experienced avoidable harm.