Myles Bradbury was sentenced to 16 years in prison in 2014 after admitting 25 counts of abuse against children during his time as a blood cancer specialist at Addenbrooke's Hospital in Cambridge, including sexual assault and voyeurism.
He was also found to have 16,000 indecent images of children, many of which were collected via a pen with a recording device that he carried with him.
The report, by Veritas, found the hospital chaperone policy - which states if a doctor is conducting an examination outside of hospital with a lone patient, he must be accompanied - was often ignored.
And tell-tale signs of abuse were not acted on by both staff and parents.
For example a parent saw Mr Bradbury put his hand in her daughter's shirt without warning but she didn't want to question what he was doing.
When a doctor confronted Mr Bradbury when she realised he was seeing a boy by himself. Mr Bradbury said this was at the patient's request and no further action was taken.
And he also went on holiday with a child patient's mother. When another consultant confronted him about his, Mr Bradbury agreed he couldn't be the child's doctor anymore, but no further action was taken.
Lucy-Scott Moncrieff, the Veritas report author, said: "One of the things that Bradbury was able to do was to persuade families that it was normal to see their children on their own.
"That's not normal, and families now know that's not normal, so once again that should prevent anyone from being able to take advantage of that in the future."
And David Wherett, acting CE of Cambridge Hospitals Trust said: "This has been a deeply distressing case and the NHS must learn from it.
"My message to other organisations is that as well as enforcing robust policies, we need to raise awareness of much more manipulative behaviour by individuals like Bradbury.
"Greater rigour and checks will make it more difficult for abuse to take place."
But Renu Daly, a lawyer for most Mr Bradbury's victims, said: "Unfortunately it does not appear that the report has investigated as far as we had hoped.
"There are numerous recommendations although their effectiveness is questionable as a very small proportion of victims were actually interviewed."
During his tenure at Addensbrooke Hospital Myles Bradbury was known as a "devout Christian", and for a short time he attended KingsGate Christian Evangelical Church in Peterborough, Cambridgeshire. He attended a trip to Swaziland to help orphan children whose parents had died from AIDs.
KingsGate said at the time Myles Bradbury was arrested: "We are shocked and deeply saddened at the actions of Dr Myles Bradbury and at the devastating impact that these have had on the lives of many.
"As soon as the charges against him were revealed in early July 2014 we promptly contacted Bulembu.
"Bulembu then instituted a detailed investigation to make sure that he had not had any one-to-one contact with children during that time.
"They found no evidence that he had any unsupervised involvement with children and was always accompanied by community development project staff."
Mr Bradbury was interviewed for the Veritas report and said he "knew that what he did was wrong" and that he was "very sorry".