LONDON -- Shockingly bad care and inhumane treatment at a hospital in the Midlands led to hundreds of unnecessary deaths and stripped countless patients of their dignity and self-respect, according to a scathing report published on Wednesday.
The report, which examined conditions at Stafford Hospital in Staffordshire over a 50-month period between 2005 and 2009, cites example after example of horrific treatment: patients left unbathed and lying in their own urine and excrement; patients left so thirsty that they drank water from vases; patients denied medication, pain relief and food by callous and overworked staff members; patients who contracted infections due to filthy conditions; and patients sent home to die after being given the wrong diagnoses.
"This is the story of the appalling and unnecessary suffering of hundreds of people," Robert Francis, the lawyer appointed by the government to lead the inquiry, said at a news conference.
"They were failed by a system which ignored the warning signs and put corporate interests and cost control ahead of patients and their safety," he added. "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."
The report into what has been called the biggest scandal in the modern history of the health service found that many of the problems were due to the efforts of the hospital to meet health-service targets, like providing care within four hours to patients arriving at the emergency room. It also said that in its efforts to balance its books and save $16 million in 2006 and 2007 in order to achieve so-called foundation-trust status, which made it semi-independent of control by the central government, the hospital laid off too many people and focused relentlessly on external objectives rather than patient care.
Speaking in the House of Commons, Prime Minister David Cameron apologized for the way the system had allowed "horrific abuse to go unchecked and unchallenged" for so long. So deeply rooted was the trouble, he said, that "we cannot say with confidence that failings of care are limited to one hospital."
Mr. Cameron said that he planned to create a new post, chief inspector of hospitals, beginning in the fall. And he said that he would ask the regulatory bodies in charge of doctors and nurses to explain why no one had had their medical licenses revoked as a result of the scandal.
Since the failings at the hospital first came to light, many of the executives in charge of the hospital and the regional health care body that ran it have left their jobs. But the top official in the region at the time, Sir David Nicholson, is now chief executive of the National Health Service in England, and patients' rights campaigners have called for him to resign.
"We are not scapegoating anybody, but the man at the top of the N.H.S. has not got the leadership skills to take this report forward," said Julie Bailey, who founded the advocacy group Cure the N.H.S. when her mother, Bella, died at Stafford Hospital.
The scandal came to light in 2007, when the Healthcare Commission, the body then charged with overseeing care at the National Health Service, became concerned about unusually high mortality rates at Stafford Hospital. The report on Wednesday is one of several into what went wrong there, and the first to result from a public inquiry.
The report made nearly 300 recommendations, designed, Mr. Francis said, to change the culture at the health service to put patients' needs first. These include prosecuting hospital executives who mislead or withhold information from the public or regulators about events that have harmed patients; prosecuting health care providers for "noncompliance with a fundamental standard leading to death or serious harm of a patient"; ensuring better regulation of health care workers; and relentlessly focusing on fundamental standards of care.
Families of patients who were mistreated at the hospital said that they hoped the report would prevent a repeat of what happened to them.
"We don't want other people suffering like our family did," Christine Dalziel, whose 64-year-old husband, George, died after a bowel cancer operation at Stafford in 2007, told reporters.
Though the operation was successful, Mr. Dalziel went for days without pain medication after his epidural was dislodged, she said, and was left in bed in soiled sheets and lost nearly 60 pounds before dying in the hospital. "His bones were sticking out of his back," she said.
This article originally appeared in The New York Times.