The deaths of hundreds of hospital patients, left without food or water in filthy conditions, exposed an urgent need to change the culture of Britain's National Health Service (NHS), a report said on Wednesday.
Between 400 and 1,200 patients are estimated to have died needlessly at Stafford Hospital in central England between January 2005 and March 2009 in one of the worst scandals to hit the NHS since it was founded in 1948.
"There were patients so desperate for water that they were drinking from dirty flower vases," Prime Minister David Cameron told parliament in a statement on the report.
Describing events at Stafford Hospital as "a despicable catalogue of clinical and managerial failures", Cameron apologised to all the families affected on behalf of the government and the country.
The author of the 3,000-page report, lawyer Robert 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," Francis said in a televised statement as his report was published.
The NHS, which provides medical care for free at the point of delivery, is an institution so dear to British hearts that it was proudly showcased to the world in the opening ceremony of the Olympic Games in London last summer. The harrowing details of what happened at Stafford have shocked the nation.
"Elderly and vulnerable patients were left unwashed, unfed and without fluids. They were deprived of dignity and respect. Some patients had to relieve themselves in their beds when they were offered no help to get to the bathroom," said Francis.
He said some patients were left in excrement-stained sheets and some who could not eat or drink without help did not receive it. Medicines were prescribed but not given.
"Many will find it difficult to believe that all this could occur in an NHS hospital," he said.
"DUTY OF CANDOUR"
Francis described a culture of secrecy and defensiveness in which whistleblowers were silenced and bereaved relatives who asked questions were ignored.
He said hospital managers were focused on a narrow set of bureaucratic targets and on balancing the accounts so that they could obtain the coveted status of "NHS Foundation Trust", instead of paying attention to the quality of care.
Francis said the NHS had undergone one root and branch re-organisation after another over the decades and he did not want to recommend yet another upheaval. He stressed that what was needed was cultural, not organisational change.
"My recommendations are intended above all to support all in the service to make patient-centred values and standards real, but also to bring teeth to the task of changing behaviour when required," he said.
His 290 recommendations included that there should be a legal "duty of candour" on doctors, nurses and all others in the health system to be open with patients about any mistakes and that breaches of this duty should be a criminal offence.
The report also said contractual gagging clauses silencing whistleblowers should be banned.
Cameron said the report's findings of systemic failure in the NHS meant that "we can't say with confidence that failings of care are limited to one hospital."
He said he would create a new post of chief inspector of hospitals and enforce a new regime of hospital inspections by the autumn.
Underlining the special place the NHS holds in British life, Cameron prefaced his statement by declaring: "I love our NHS".
"What makes our National Health Service special is this very simple principle ... that whoever you are, wherever you're from, whatever's wrong, however much you've got in the bank, there's a place you can go where people will look after you," he said.
"The shocking truth is this precious principle of British life was broken."
(Reporting By Estelle Shirbon; Editing by Robin Pomeroy)