THE report lays bare a list of 290 recommendations to be implemented on a number of themes.
It starts by suggesting that 'every single person serving patients' is accountable for contributing to 'a safer, committed and compassionate and caring service.'
This, the report says, will require a common set of core values and standards, leadership at all levels and a system which recognises values of transparency, honesty and candour.
Casting doubt on the ongoing future of both the Care Quality Commission and Monitor, the report says: "There should be a single regulator dealing both with corporate governance, financial competence, viability and compliance with patient safety and quality standards for all trusts."
Reporting of incidents of concern relevant to patient safety should "not only be encouraged, but be insisted upon.
"Where patient safety is believed, on reasonable grounds to to be at risk, Monitor and and other regulator should be obliged to take whatever action within their powers is necessary to protect patient safety.
"In the end the trust was uncovered in part by attention being paid to the true implications of [the trusts] mortality rates, but mainly because of the persistent complaints made by a very determined group of patients and those close to them.
"This group wanted to know why they and their loved ones had been failed so badly."
The report says the NHS is a service of which the country can be "justly proud" but that those responsible for the oversight of the service were 'bewildered' how the scandal at the trust could have happened and not been discovered sooner.
Mr Francis says the Inquiry heard numerous times the responsibility for allowing standards at an acute trust to fail must lie at the feet of the executive board but adds it is because not all boards are capable of maintaining acceptable standards that healthcare regulators exist.
"As a result, it is clear that not just the trust's board, but the system as a whole failed in its most essential duty - to protect patients from unacceptable risks of harm and from unacceptable, and in some cases inhumane, treatment that should never be tolerated in any hospital."
Mr Francis makes the point that previous inquiries have often been slowly implemented.
"The suffering of patients and those close to them described in the first inquiry report requires a fully effective response and not merely expressions of regret, apology and promises of remedial action.
"They have already been at the receiving end of too many unfulfilled assurances for that to be acceptable."
He says that while implementation could benefit from Department of Health coordination, many of the recommendations of the report can be implemented by other bodies.
"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 recurrence was so low that major preventative measures would be dispproportionate.
"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.
"No findings of fact or criticism made in this report are determinative of any form of civil or criminal liability.
"There is a tendency when a disaster strikes to try to seek out someone who can be blamed for what occurred and a public expectation that those held responsible will be held to account.
"All too frequently there are insufficient mechanisms for this to be done effectively.
"A public inquiry is not a vehicle which is capable of fulfilling this purpose except in the limited sense of being able to require individuals and organisations to give an explanation for their actions or inaction.
"The understandable human need to identify one or more people to be held to account means that whenever something goes wrong a hunt starts and the larger the disaster the more pressure there is.
"On the whole the purpose of identifying where individuals have fallen below relevant standards should be to show examples of conduct or judgements to be avoided in future.
"In a systems failure as widespread as that identified in this Inquiry, it becomes a futile exercise to undertake; so many are in one sense accountable, it is far more effective to learn rather than to punish.
"To place too much emphasis on individual blame is to risk perpetuating the illusion that removal of particular individuals is all that is necessary. That is certainly not the case here. To focus, therefore on blame will perpetuate the cycle of defensiveness, concealment, lessons not being identified and further harm."
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