There should be a "zero tolerance" approach to poor standards of care in the NHS, the head of the inquiry into "appalling" failings at Mid Staffordshire NHS Foundation Trust has said.
Robert Francis QC said hospitals which failed to comply with a "fundamental standard" should be forced to close. Healthcare providers should also be liable for prosecution if they fail to comply with standards.
Inquiry chairman Mr Francis made a total of 290 sweeping recommendations for healthcare regulators, providers and the Government in his 1,782-page report. He said the NHS has a series of checks and balances which should have prevented "serious systematic failure of this sort".
The system failed in its primary duty of protecting patients, he added. There were "numerous" warning signs which should have alerted authorities to problems at the trust. There was also a failure to communicate between the plethora of regulatory agencies and "too great a degree of tolerance of poor standards", he said.
Fundamental standards should be policed by a single regulator - the Care Quality Commission (CQC), he said. He added that the regulator Monitor should be stripped of its powers to award trusts foundation trust status - a supposed marker of excellence in the NHS. The regulator awarded the trust the status in 2008 - at the height of its troubles.
Mr Francis said "appalling" conditions suffered by patients at the trust, which runs the hospital, were primarily caused by "serious failure" on the part of the trust board. The trust failed to tackle an "insidious negative culture" including a tolerance of poor care standards. They also failed to appreciate the enormity of the situation, he said.
Managers had "no culture" for listening to patients. As a result of poor leadership and staffing policies, a "completely inadequate" standard of nursing was offered on some wards at Stafford Hospital. Patients and their families were excluded from their care.
In the scathing report, he attacked local health authorities and the trust board but he refused to blame any individual for failures at the trust - even though many have previously called for NHS Commissioning Board chief executive Sir David Nicholson to resign over the scandal.
Speaking as the report was published, Mr Francis said: "This is a story of appalling and unnecessary suffering of hundreds of people. They were failed by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety.
"I have made 290 recommendations designed to change this culture and make sure that patients come first. We need a patient-centred culture, no tolerance of non-compliance with fundamental standards, openness and transparency, candour to patients, strong cultural leadership, caring compassionate nursing, and useful and accurate information about services."