The NHS must be transformed into a patient centred culture with “zero tolerance” for patient harm and criminal sanctions for failure to provide safe care, a landmark report into one of the health service’s biggest scandals has recommended.1

The public inquiry into Mid Staffordshire NHS Foundation Trust found failures at every level up to and including the Department of Health, which together allowed “terrible and unnecessary suffering” by patients to go undetected for years.

The trust, which ran Stafford and Cannock Chase hospitals, was intent on meeting targets set by the NHS and qualifying for the status of foundation trust, focusing on corporate governance and financial control. But patient safety and care were ignored, and there were nearly 500 excess deaths between 2005 and 2008, although signs that should have raised concerns were present years before.

Patients “were failed by a system which ignored the warning signs of poor care and put corporate self interest and cost control ahead of patients and their safety,” said inquiry chairman Robert Francis QC.

“There was an institutional culture in which the business of the system was put ahead of the priority that should have been given to the protection of patients and the maintenance of public trust in the service.”

Patients’ voices were not heard, local GPs failed to raise concerns, primary care trusts did not have the tools to ensure the quality of the services they were buying, the strategic health authority defended trusts rather than …