Clinicians, regulators and NHS culture have been criticised by the much-awaited Francis report into the failings at Mid Staffordshire hospital, released today.
The 1,781 page report claimed government targets on "financial issues" had created a "ingrained culture with no thought for patient safety".
Robert Francis QC, who led the inquiry said there was an "appalling lack of care, compassion and leadership".
He said the evidence was "truly shocking" and many would find it "difficult to believe it all occurred in an NHS hospital".
"We must provide the standards of care to which patients are entitled," he said.
"We can't just blame one person for the failings or suggest reorganisation, we need a change in culture, a patient centred culture."
Francis called for a "structure of fundamental standards, openness, transparency and candour" throughout the healthcare system, improved compassion in nursing and stronger leadership.
The report calls upon GPs to recognise a "duty of care" that extends beyond referral to hospitals, adding "they have a responsibility to all patients to keep themselves informed of the standards of care available...at various providers in order to make patients' choice a reality."
It said "there was a clearly ample opportunity for GPs to raise issues," but that it was likely they did not, as the issues of which they had experience were not sufficiently significant and GPs were not required to act in this way.
While the report stopped short of singling any one out for criticism, it did say it was "unfortunate" that it did not occur to GPs to report concerns.
The report accused Monitor, the hospital regulator of "failing to achieve what should have been its primary objective".
It recommends that the Care Quality Commission (CQC) and Monitor should merge, but that it "should not be used as a justification for the reduction of resources".
It said nurses should be tested by a "minimum period of work experience" which should eventually be "reinforced by a system of revalidation".
There should also be specialist registered status for those nursing older people, according to the report.
Communication failures between Monitor and the Health Care Commission (HCC) may have come about because Monitor was "fiercely guarding its independence" at the expense of creating "good relationships."
The report was critical of the management of primary care trusts (PCTs) reorganisation, which it said let to them missing "one of the worst examples of bad quality service delivery imaginable."
PCTs "failed to put into place systems and processes to manage risks," the report said.
Clinical commissioning groups (CCGs) must work differently from PCTs to improve healthcare and should be allowed to carry out their own inspections, according to the report.
There is an urgent "need" to rebalance and refocus commissioning so that it will "enhance standards" for patients, the report said.
This will only work if commissioners are "recognisable public bodies" with an "infrastructure of technical support", it said.
Francis said that all organisations should report back on whether they have implemented his 290 recommendations.