Doctors, nurses, politicians, bureaucrats, patients and the public, in short, everyone in the UK, have been stunned by the results of two inquiries into dreadful conditions at a hospital in the Midlands.
A report in 2010 into Stafford Hospital found that hundreds of patients had died unnecessarily and that conditions were sometimes unspeakably bad. Some patients were left in excrement-soaked sheets and some had to drink from dirty flower vases because nurses failed to bring them water.
A second report by a leading barrister, Robert Francis, into the causes of this disaster makes depressing reading. He found that there had been a total collapse of the system at the Mid Staffordshire NHS [National Health Service] Foundation Trust, which is responsible for running the hospital. In the report, which was released earlier this month, Mr Francis writes:
"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. Patients were let down by the Mid Staffordshire NHS Foundation Trust. There was a lack of care, compassion, humanity and leadership. The most basic standards of care were not observed, and fundamental rights to dignity were not respected."
Mr Francis's brief was to identity the reasons for the breakdown in care. He made 290 recommendations to change the toxic culture at the hospital and to make sure that patient care comes first, ahead of financial targets.
Some of the more important recommendations are that failure to comply with standards should be a criminal offence if death or serious injury results; misleading patients, the public or regulators should be a criminal offence; nursing staff should be trained to give compassionate care; and a NHS leadership college should be established to ensure high standards.
The reaction of the UK government was entirely predictable. Prime Minister David Cameron denounced the enormity of the failure, apologised to patients and their families and promised root and branch reform. However, the scepticism of Mr Francis about whether this will actually happen is frightening.
"The experience of many previous inquiries is that, following the initial courtesy of a welcome and an indication that its recommendations will be accepted or viewed favourably, progress in implementation becomes slow or non-existent...
"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 or that the risk of a recurrence was so low that major preventative measures would be disproportionate. The consequences for patients are such that it would be quite wrong to use a belief that it was unique or very rare to justify inaction."
The reports can be downloaded at the Inquiry's website.