"How could this be allowed to happen?" That was the understandable question asked by the Prime Minister David Cameron when presented with details of Jimmy Savile's abuse.
The answers are many and various, today's investigation into his activities at Stoke Mandeville concludes, before adding that "one of the most compelling is quite simply that the basic building blocks of legislation, policy and procedure designed to maintain both public safety and probity were bypassed".
The report suggests that essential safety nets were waived by ministers and senior civil servants in Whitehall because the Thatcher government wanted to use Savile as the poster-boy for charitable funding of the NHS.
"Successive politicians and NHS and DHSS senior officers feted Savile and placed him in a position of authority and trust," the report says, singling out Health Minister Dr Gerard Vaughan for particular criticism.
"It is evident to the investigation that in his desire to promote a public /private partnership an unorthodox arrangement was put into place (that) bypassed statutory frameworks and resulted in the disempowerment of NHS commissioners and managers."
The report explains how Dr Vaughan assigned James Collier, a senior civil servant at the DHSS, to remove obstacles. "Savile was understood to be likely to walk away from the project if bureaucratic processes hindered his autonomy."
The investigations says that Collier "did not just sweep aside bureaucracy to enable the project, he was instrumental, once he had been placed in charge of the scheme, in sweeping aside some legitimate concerns raised by statutory bodies".
In 1979, the new Thatcher government was determined to reduce public spending. At the election Labour had suggested the NHS was not safe in their hands and ministers were encouraged to find new and innovative ways to fund the NHS.
In September of that year, Jimmy Savile "invited himself to tea" with the Health Secretary Patrick Jenkin to discuss funding of a new spinal injuries centre at the much-loved but down-at-heel Stoke Mandeville hospital.
This strange celebrity was seen as an opportunity by the new Conservative government. "Margaret Thatcher sponsored Savile in his role as fundraiser," Dr Androulla Johnstone told today's news conference. Her report details how the DJ was invited to Downing Street and to the prime minister's residence at Chequers.
He enjoyed private conversations with her and civil servants found themselves running around afterwards trying to find out what had been agreed. An internal memo in 1981 "wanted to know if she had offered Savile money for the Stoke Mandeville appeal, and also whether she had agreed to appear on 'Jim'll Fix It'", the report reveals.
Investigators tracked down the civil servant James Collier, now 91 and unable to remember much of the detail of the time. Gerard Vaughan is dead but Patrick Jenkin did speak to the inquiry and suggested that it appeared Whitehall had failed in its duty to speak truth unto power.
The report says: "Savile was regarded as unconventional and people feared he would disengage if the bureaucratic process was put in place."
Today's independent inquiry report for the government on "lessons learned" from the Savile scandal, also picks up on the role of government in creating an environment in which he was able to abuse so many victims.
His criminal behaviour at both Broadmoor and Stoke Mandeville "was supported and facilitated by ministers or senior civil servants," Kate Lampard's report to Health Secretary Jeremy Hunt concludes.
Savile was appointed to the task force that ran Broadmoor in the late 80s and oversaw the fundraising at Stoke Mandeville. "In appointing Savile to these roles and in allowing him the licence and free rein he had in exercising those roles, minister and/or civil servants either overrode or failed to observe accepted governance processes."
In addition to the report's recommendations on hospital governance, it points out that ministers and officials "should not undermine the processes of good governance and local management."
None of today's reports suggest that anyone within government knew that Savile was a predatory sex abuser. But they are clear that in "putting aside" the policy and frameworks that existed, they helped create a situation where he could abuse.