The worst hospital scandal in more than a decade has triggered the biggest review of safety in the NHS since the Labour government came to power.
Andy Burnham, the Health Secretary, announced an unprecedented five separate reviews of measures to protect patients yesterday, in response to an independent inquiry into failings at the Mid-Staffordshire Foundation Trust which concluded that it "routinely neglected" patients.
It is the biggest shake-up in the monitoring of the NHS since the Bristol children's heart surgery scandal of the mid-1990s, in which babies lost their lives because doctors were not being properly checked. That scandal led to the establishment of regulatory mechanisms to protect patients which the catastrophe at Mid-Staffordshire has now shown to have comprehensively failed.
Gordon Brown said the failings were "completely unacceptable." He told the Commons: "We understand both the sadness and the sorrow of all the relatives who lost loved ones in the Mid Staffordshire hospital trust."
The report of the inquiry, chaired by Robert Francis, QC, has convulsed the Department of Health which has scrambled to produce a response that would reassure patients barely two months ahead of an election. The reviews announced by Mr Burnham yesterday will examine how the regulatory bodies failed to spot what was going wrong at Stafford hospital (to be chaired by Mr Francis), the use of death rates to highlight problems in the NHS, alleged misconduct by doctors and nurses, a new system to regulate managers (who may be "struck off" like failing doctors), and protection for whistleblowers.
In addition, more than 300 cases where patients or relatives have concerns about the treatment they received at the trust are being reviewed by independent medical panels, a number of which are expected to lead to malpractice claims.
But the measures were not enough for the Tories who demanded a full public inquiry. Andrew Lansley, the shadow Health Secretary, said patients would be worried that the Government was "still not doing all it can" to prevent a repeat of "these awful events".
Patients admitted to Stafford Hospital received care that was so lacking in the basic essentials that lives were sacrificed as a result. Mr Francis refused to put a figure on the number who had died but said it was "undeniably higher" than in other hospitals. Last March, an investigation by the NHS watchdog, the Healthcare Commission estimated there were between 400 and 1,200 excess deaths among emergency patients treated at the hospital between 2005 and 2008.
The inquiry re-iterated the earlier findings by the Healthcare Commission that patients were left lying in soiled sheets or on commodes, sometimes for hours, frightened and ashamed, as calls for help to use the bathroom were ignored. Some were left unwashed for up to a month, and others were left in pain, without drugs, and with food and drink out of reach. Staff failed to make basic observations and patients were often discharged before it was appropriate, with in at least one case alleged fatal results.
The report, which runs to 900 pages and is based on evidence from more than 900 patients and 80 current and former staff, is the most devastating indictment of an NHS organisation in memory.
There was a culture of low morale and a tolerance for poor standards fostered by a management board focused on financial targets rather than patient welfare. It persisted even after the Healthcare Commission exposed the hospital's failings last March, with some staff and managers dismissing the findings and alleging the commission had blown matters out of proportion.
In answer to one of the biggest puzzles – how staff allowed the appalling care to persist for so long – the report found those who spoke out were ignored and there was "strong evidence" that many were deterred from doing so through fear and bullying.
Accepting all the recommendations, Mr Burnham said: "This was an appalling failure at every level of the hospital to ensure patients received the care and compassion they deserved. There can be no excuses for this."
The former chairwoman of the trust, Toni Brisby, resigned last March. The former chief executive, Martin Yeates, stepped down from his post in March and resigned in May.
Case History 1: The cyclist
Twenty-year-old John Robinson was close to his siblings and parents and was popular among his peers. His motto was "Life is for living".
In April 2006, he was cycling with a couple of friends down a steep hill. He went over the handlebars of his bike and the handlebar hit his ribcage. He complained of pain in the ribs and difficulty breathing. He was taken to Stafford Hospital by paramedics, given morphine and taken for X-rays.
His friends recalled that after an hour they were allowed in to be with him, and saw vomit all over the floor; their friend was sweating profusely and holding his stomach in "horrendous pain".
He told them he had been taken for X-rays but he had not yet been informed of the findings. He continued to vomit, at which point his friend told him that he would go to find a nurse.
When he found the nurse, his friend said she appeared irritated that he was asking questions that she was too busy to answer. Mr Robinson continued to vomit, and after a considerable time a nurse checked on the patient, shortly followed by a junior doctor, who said that he had just suffered bruised ribs and would be fine. Although he continued to vomit, the nurse provided him with a wheelchair and said he was ready to leave.
His friend then helped him into their van and took him home, where he tried to make him comfortable on the sofa before leaving. A short time later, his condition deteriorated and he called 999.
On opening the door to the paramedics, Mr Robinson collapsed and died. His spleen had ruptured. This had gone undiagnosed at Stafford Hospital's accident and emergency department.
At the inquest, a consultant in A&E concluded that the death of Mr Robinson was "an avoidable situation" and that "there is a high probability that the level of care delivered to... [the patient] was negligent."
Case History 2: Injured 90-year-old
Graham Bunn's 90-year-old mother, Ivy, lived on her own and was an extremely active and independent woman. She was a keen gardener who, despite her diabetes, led a "completely normal life". The whole family loved her very much.
In October 2008 she had a fall and was taken by paramedics to Stafford Hospital. After nearly six hours of waiting in A&E, she was found a bed in the emergency assessment unit. Despite the wait, she was quite cheerful and was able to sit up in bed.
When her son left her that night he remembered that she looked bright and well.
The following day she seemed unable to use her arms. The next day she became extremely confused. There was gauze on the back of her head, and a bandage. After the family demanded an explanation, the ward sister said that their mother had fallen during the night. They had found her nightdress in the bedside cabinet and when they got home discovered it was "saturated in blood".
The following night Mr Bunn received another call to tell him his mother had suffered a further fall, and he was asked to come to the hospital. "My mother was lying... full stretch out on the tiled floor," he said. "Some effort had been made to remove the blood. It was smeared all over the floor. You could not see a hair on her head. It was completely swathed in bandages. There was a lady doctor holding my mother's head in her hands."
Mr Bunn recalled saying, "Oh Mum, what have they done to you..." to which the doctor replied coldly: "I have got a mother too." The son later remarked: "There was no compassion in that woman whatsoever."
His mother was sent for a scan. She had a huge bleed on one side of her brain and her brain was swollen. The doctors told the family it was impossible to operate, and that if she regained consciousness then she would not be the same.
Mr Bunn then learnt that his mother had suffered a further previous fall that he had not been made aware of, and a doctor said to him: "We have let you down."
The following day the ward sister was very anxious to explain to the family what had happened to their mother. She told them that their mother had experienced "two insignificant falls". On being challenged, she said: "Do you want to know what I said after the third fall... oh, bloody shit." His mother died shortly afterwards.
"I will never forgive them for that," Mr Bunn said.
Under the microscope: Staffordshire inquiries
March 2009 Healthcare Commission finds "appalling" standards of care and up to 1,200 excess deaths over three years.
May 2009 Death rates for every hospital in England published.
May 2009 Investigation into treatment at Mid-Staffordshire trust between 2005 and 2008 found patient complaints had been ignored.
May 2009 Investigation into emergency care found "significant" improvements had been made.
February 2010 Independent inquiry finds patients were "routinely neglected".
February 2010 Five more reviews announced by the Health Secretary.