Stafford Hospital report: At a glance
More than a year after it finishing sitting, the final report of the public inquiry into the Stafford Hospital scandal has been published.
It is long. It runs to three volumes and contains nearly 1,800 pages. The executive summary alone is more than 100 pages long.
And there are a total of 290 recommendations. But what does it actually have to say?
The hospital's board should take ultimate responsibility
The report is clear - fault lies with the board at the time.
It was the board which took the decision to pursue a cost-cutting drive to achieve foundation trust status and it was the board which refused to listen to the complaints of patients and - at times - staff.
The report said it "failed to appreciate the enormity of what was happening and reacted too slowly, if at all".
But it does not stop there
Responsibility, the inquiry said, goes right through the health service.
GPs and local MPs did not do enough to help patients who came to them.
The local primary care trust, which oversaw the hospital at the time, failed to put in place a system which would pick up problems.
Meanwhile, there was a lack of clarity about the role of the regional health authority in monitoring quality and when concerns were brought to its attention the authority was too ready to put its faith in the hospital's management.
The government has a lot to learn too
The Department of Health was criticised for being too remote and not always putting patients first, prioritising policies over patient considerations.
It also warned that while there was not a culture within the department that could be properly described as bullying, there was evidence that "well-intentioned decisions and directives have either been interpreted further down the hierarchy as bullying, or resulted in them being applied locally in an oppressive manner".
The regulator is not in the clear either
The Healthcare Commission, which was the NHS care regulator at the time, may have brought the problems to national attention in its 2009 report, but it did not escape censure.
The report said it should be given credit for exposing what happened, but the fact it did not prevent it or detect it earlier was worrying.
So do heads need to roll?
Not according to the report.
There are still senior officials in the health service and politics who were involved with Stafford Hospital at the time (NHS chief executive Sir David Nicholson was head of the regional health authority, while shadow health secretary Andy Burnham signed papers to allow the hospital to pursue foundation trust status when Labour was in power).
But the report said to place too much emphasis on individual blame was to risk perpetuating the illusion that removal of particular individuals is all that is necessary.
That - its says - is certainly not the case here.
But fundamental change is needed
The report was clear: the scandal should not be seen as a one-off.
It said Stafford was "not an event of such rarity or improbability that it would be safe to assume that it has not been and will not be repeated".
To move forward, the report called for a "fundamental change" in culture whereby patients were put first.
This would require a commitment from all those working and connected to the health service to make sure they put this at the heart of everything they do.
That does not mean more reorganisation though
In fact, inquiry chairman Robert Francis was clear that one of the factors behind the problems at Stafford Hospital was the constant upheaval the NHS is under.
This had to stop, he said, as change could be achieved within the existing structures.
Nonetheless, he did recommend some regulatory and system changes to help engineer this cultural shift needed.
It should become a criminal offence to withhold information about poor care or to provide care that results in serious harm.
Better regulation of managers and healthcare assistants was needed, while the regulation of all care functions should be brought under the umbrella of one organisation.
At the moment it is spread across two - Monitor and the Care Quality Commission.