Healthcare staff who fail to provide a safe standard of care should face criminal charges, the Francis Report recommends.
The landmark inquiry into the Stafford Hospital scandal has called for medical staff to be made personally responsible for the level of care their patients receive and insists a "zero tolerance" policy must be taken to poor care.
A statutory obligation of "candour" could also be implemented, whereby doctors, nurses and hospital managers would be required to be honest with patients, families and healthcare regulators.
The inquiry was chaired by Robert Francis QC and he has made 290 recommendations, which are contained within a 1,782-page report.
He said the healthcare system requires a "fundamental culture change", but not complete reorganisation.
"It requires changes which can largely be implemented within the system that has now been created by the new reforms," Mr Francis explained.
This enquiry was set up to assess the lessons that need to be learned from the scandal, where the failings of the Mid-Staffordshire NHS trust and the wider NHS are said to have been responsible for around 1,200 deaths.
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