In a laboratory at the back of Alder Hey Children's Hospital in Liverpool, a pathologist failed his patients and his profession. Stockpiled in thousands of containers, organs and pieces of tissue from more than 800 children were collected over seven years by a Dutch pathologist, Prof Dick van Velzen.
When an independent inquiry into organ retention at Alder Hey, led by Mr Michael Redfern QC, reported to the government on Tuesday, the full scale of the scandal was revealed.
Prof van Velzen - condemned in the report as a liar who had tried to deceive parents and his colleagues about his collection of body parts - had ordered the systematic stripping of every organ from every child who underwent a post-mortem examination at Alder Hey between 1988 and 1995.
In gruesome detail, the Redfern report discovered that parents had not been asked if they wanted the eyes of their dead children removed - 188 had been retained. And Prof van Velzen did not ask parents if he could store the 445 complete foetuses found in his laboratory at Alder Hey.
His research into intra-uterine growth retardation led him to falsify post-mortem examinations and illegally stockpile organs, but it was a failure of the management system that allowed him to work without restriction.
By the spring of 1991 the executive board at Alder Hey knew that Prof van Velzen was not studying the organic tissue retained from post-mortems, but nothing was done.
Three years later in 1994, the pathologist was carrying out little clinical work for the hospital and when he left his post the following year the hospital trust had a deficit of £68,000. He now faces the prospect of criminal charges and undoubtedly will not be allowed to practise again in Britain.
Sadly, although the circumstances of Prof van Velzen's conduct were deeply distressing for parents and relatives, the situation was not unique.
In language rarely used before in respect of the medical profession, the regional director of public health for the north-west of England, Prof John Ashton, said: "Van Velzen behaved in an extremely criminal way, but what this report also reveals is that within medicine there is a culture of arrogance."
Using similar language, the chief medical officer for England, Prof Liam Donaldson, spoke this week of a "paternalistic" attitude within the medical profession which had retained more than 100,000 organs and body parts, many without consent.
In his census of organ retention in hospitals and medical schools in England, Prof Donaldson highlighted the lack of information provided for parents and relatives, who often thought they were agreeing to the removal of slivers of flesh from their loved ones rather than whole organs.
The medical profession was warned again that the "doctor knows best" attitude must end and the gulf of understanding between pathologists and the bereaved must be bridged.
"There has been no adequate recognition or acknowledgment on the part of the majority of the NHS staff or many doctors of the feelings many people have on the recent loss of a family member, particularly a child, and the extent to which they feel the need to protect a child even after that child's death," Prof Donaldson said in his report.
After the organ retention scandal at Bristol Royal Infirmary and Alder Hey emerged two years ago and with the conviction of the mass murderer and former GP, Harold Shipman, the National Health Service has now taken another battering.
Individual doctors are still being charged with adopting an arrogant attitude toward their patients. It has also been accepted, and proved by the Redfern report and Prof Donaldson's audit, that the NHS in England has failed to keep up with changing social attitudes about patient and family rights.
And some commentators said this week that the number of people choosing to donate organs and carrying organ donor cards could fall unless public confidence in the medical profession was quickly restored.
The Prime Minister, Mr Blair, yesterday condemned "without reservation" the stripping of organs from children's bodies at Alder Hey. At Commons question time he said the "appalling" practice had "simply added to the grief and pain of parents and relatives".
The Health Secretary, Mr Alan Milburn, has promised legislation banning the removal of organs and tissue without informed consent. And as thousands of anxious families call hospital helplines in the wake of the scandal, the NHS will be hoping that important medical research into devastating diseases is not compromised because of the shortcomings of an antiquated system.