The NHS is failing to deal with patients' complaints adequately, according to the Health Service Ombudsman.
Systems need to be focused on patients, experts agree
Ann Abraham said in her report that there was poor leadership, systems that did not focus on patients' needs and a lack of capacity and competence.
She called for the Department of Health and the watchdog Healthcare Commission to address these "key failings".
Ministers said they were determined to put patients' interests first.
Ms Abraham said part of the problem was fragmentation of complaints systems across health and social care and the NHS and private sector.
This has led to a system which makes it difficult for patients and their families to have things put right when they have gone wrong, she said.
She said: "Many fine words have been spoken over the years about the need for a truly patient-focused complaints system but it has still not become a reality.
"The fifth report of the Shipman Inquiry gives us an opportunity to reflect on why the NHS complaints system is still failing patients.
"We must not lose this opportunity to make change happen at last."
She called for commitment and leadership from the Department of Health in setting standards to be met by all providers of NHS care.
She said the Healthcare Commission, in its role of inspector, should assess the performance of Trusts against these standards and share learning from complaints across the health service.
"All NHS bodies need to be responsive to complaints and value the feedback they provide. To do so they need competent, trained and motivated staff using robust local procedures.
"Dealing with complaints should not be a stand alone activity. The lessons from them must feed into improvements in the service delivered to patients," she said.
Health Minister Rosie Winterton welcomed the report.
"The government is determined to put patients' interests at the centre of everything we do.
"The NHS treats one million people every 36 hours but we want services to be personal to individual patient needs.
"This includes making the complaints system more simple and responsive so that when patients have a complaint, they are taken seriously, listened to and something is done about it."
Shadow Health Secretary Andrew Lansley blamed the abolition of Community Health Councils and the fragmentation of the patient advocacy functions in the NHS, under Labour.
He said: "The loss of independence in local resolution has led to a potential trebling of second-stage complaints this year compared to last.
"We have to ensure that patient voice gives health providers, obligations to respond to complaints and incentives to learn from them."