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.
Inquiry chairman Robert Francis QC said hospitals which failed to comply with a "fundamental standard" should be forced to close, and healthcare providers should be liable for prosecution if they fail to comply with standards.
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".
There was a failure to communicate between the plethora of regulatory agencies and "too great a degree of tolerance of poor standards", he said.
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 today 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."
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.
It's culture was one of "self-promotion rather than critical analysis and openness", the report states, while 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.