The UK Healthcare Commission, the NHS standards watchdog, has slammed a trust hospital, at Mid Staffordshire, for "shocking and appalling" care. Evidence suggested that as many as 400 deaths at Mid Staffordshire NHS Foundation Trust could have been prevented, the report held.
The Commission's investigation, based on more than 300 interviews and an examination of over 1,000 documents, found inadequately trained staff who were too few in number, junior doctors left alone in charge at night and patients left without food, drink or medication as their operations were repeatedly cancelled.
Some patients were left in pain or needing the toilet, sat in soiled bedding for several hours at a time and were not given their regular medication, the Commission heard.
Receptionists with no medical training were expected to assess patients coming in to A&E.
Describing the episodes as a "gross and terrible breach of trust of the patients the NHS seeks to serve", Sir Bruce Keogh, medical director of the NHS, said the report showed there had been a "complete failure of leadership" at the Trust.
He added: "I'm proud of the NHS but actually I'm really saddened by this report."
Earlier this month the Trust's chief executive, Martin Yeates, and chairman, Toni Brisby, resigned.
The Healthcare Commission's chairman, Sir Ian Kennedy, said the investigation followed concerns about a higher than normal death rate at the Trust.
Although it is not clear how many deaths could have been avoided, the Healthcare Commission said patients undoubtedly suffered as a result of lapses in the standard of care.
Those in charge of the Trust, which runs Stafford Hospital and Cannock Chase Hospital, failed to give an adequate explanation of these figures, prompting the Commission to launch a full investigation.
"The resulting report is a shocking story," Sir Ian said. "Our report tells a story of appalling standards of care and chaotic systems for looking after patients.
"These are words I have not previously used in any report.
"There were inadequacies in almost every stage of caring for patients.
"There was no doubt that patients will have suffered and some of them will have died as a result."
Alan Johnson, the Health Secretary, said he had requested a further full independent review of the Stafford Hospital by Sir George Alberti, National Clinical Director for Emergency Care, to ensure all lessons had been learnt.
"On behalf of the Government and the NHS I would like to apologise to the patients and families of patients who have suffered because of the poor standards of care at Stafford Hospital.
"There was a complete failure of management to address serious problems and monitor performance. This led to a totally unacceptable failure to treat emergency patients safely and with dignity."
The local MP, Bill Cash, said the hospital at the centre of the scandal, Stafford Hospital, needed a "radical shake-up".
Mr Cash said he had received a "significant number" of complaints from relatives and friends of patients who had died in the hospital, including 47-year-old Julie Bailey, who has spent the last 14 months campaigning for an inquiry into Stafford Hospital following the death of her mother in November 2007.
Ms Bailey was so concerned about the care being given to her 86-year-old mother Bella that she and her relatives slept in a chair at her hospital bedside for eight weeks.
"What we saw in those eight weeks will haunt us for the rest of our lives," she said. "We saw patients drinking out of flower vases, they were so thirsty.
"There were patients wandering around the hospital and patients fighting. It was continuous through the night.
"Patients were screaming out in pain because you just could not get pain relief.
"Patients would fall out of bed and we would have to go hunting for staff. There was such a lack of staff.
"It was like a Third World country hospital. It was an absolute disgrace."
Ms Bailey, from Stafford, launched a campaign group, called Cure the NHS, following her mother's death to encourage a full inquiry into the Mid Staffordshire NHS Foundation Trust.
"We had to stand outside the hospital for 14 months to get to this point," she said. "We have campaigned tirelessly.
"The neglect is still happening. We are still taking calls from patients on wards."