Stafford Hospital: Q&A
The public inquiry into the Stafford Hospital failings was published after one of the biggest scandals in the history of the NHS.
The inquiry sat for more than a year between 2010 and 2011, taking evidence from more than 160 witnesses over 139 days.
More than a million pages of evidence were submitted.
What did the report say?
The report argued for "fundamental change" in the culture of the NHS to make sure patients were put first.
It said the trust management ignored patients' complaints and local GPs and MPs also failed to speak up for them.
The local primary care trust and regional health authority were too quick to trust the hospital's management and national regulators were not challenging enough, the report said.
The Royal College of Nursing was accused of not doing enough to support nurses who were trying to raise concerns.
Meanwhile, the Department of Health was criticised for being too "remote" and embarking on "counterproductive" reorganisations.
The report recommended making it a criminal offence to hide information about poor care, introducing laws to oblige doctors to be open with patients about mistakes, a code of conduct for senior managers and an increased focus on compassion in the recruitment, training and education of nurses.
What happened at Stafford Hospital?
Data shows there were between 400 and 1,200 more deaths than would have been expected.
It is impossible to say all of these patients would have survived if they had received better treatment.
But it is clear many were let down by a culture that put cost-cutting and target-chasing ahead of the quality of care.
Examples included patients being so thirsty that they had to drink water from vases and receptionists left to decide which patients to treat in A&E.
Nurses were not trained properly to use vital equipment, while inexperienced doctors were put in charge of critically ill patients.
Some patients needing pain relief either got it late or not at all, leaving them crying out for help, and there were cases where food and drinks were left out of reach.
The failings have led to scores of legal challenges from the families of patients.
What has happened to the individuals involved?
The senior managers in charge during the years in question have now left the trust. When the scale of the failings emerged, the chief executive, Martin Yeates, resigned.
The chairman of the trust, Toni Brisby, left soon afterwards.
The two people who filled the post of director of nursing during the period - Jan Harry and Helen Moss - have also left the trust.
They have both been criticised for their roles. Mrs Harry was eventually suspended by the Nursing and Midwifery Council for her role. She then retired from the profession.
Officials further up the NHS system have also been implicated. Cynthia Bower was head, from 2006 to 2008, of the West Midlands Health Authority, which oversaw the trust. She left to become head of the Care Quality Commission, the regulator which replaced the Healthcare Commission. She left that post last year amid criticism of the regulator's performance.
She told the public inquiry she was sorry for failing to spot the problems. Concerns had been brought to her attention in 2007 but after an investigation it was decided there were no systematic problems.
NHS chief executive Sir David Nicholson has also come in for criticism. Sir David was head of the health authority before Ms Bower. In his evidence to the inquiry he said he did not think Stafford represented a systematic failure as it had been the only case uncovered on such a scale.
Tom Kark QC, the counsel to the inquiry, described that as "naive" and "dangerous".
This was not the first inquiry, is it?
No. There have actually been five major investigations. The scandal first came to national prominence following the publication of a report by the Healthcare Commission in March 2009.
The regulator criticised the hospital for its "appalling" standards.
The investigation was prompted by complaints and statistics showing more people were dying than would be expected.
The publication of the report prompted the government to launch other inquiries, one of which was an independent inquiry chaired by Robert Francis QC.
The findings were published in February 2010 and detailed the "unimaginable" distress and suffering of patients between 2005 and 2008.
But the inquiry, held in private, was criticised by relatives of patients for being too narrow as it did not look at whether the wider NHS system had been culpable.
In opposition, the Tories had promised a full public inquiry. A month after the coalition was formed, David Cameron announced it would take place.
So how was this one different?
In recognition that the harrowing stories of what happened at Stafford Hospital had already been covered, the public inquiry was charged with looking at how the lapses could have been allowed to take place and why they were not picked up earlier.
Mr Francis was once again asked to chair the inquiry.
His remit included the commissioning, supervision and regulation of the hospital.
This means the role of senior management at the hospital, the local and regional NHS bodies responsible for it and the national organisations in charge of overseeing them.
Despite the extensive investigations already carried out several key questions still remained unanswered.
Why wasn't the alarm raised earlier? How did the trust manage to become a foundation trust - an elite status which requires sign-off from ministers and a regulator? Could this happen again?
The inquiry attempted to answer these questions and now the government is responding to its recommendations.