By Nick Triggle
BBC News health reporter
Inspectors employ a light touch to NHS regulation
Back in the summer of 2007 analysts working deep in the bowels of the leading London university Imperial College noticed something appeared amiss at a hospital many miles away.
The researchers, working for the private group Dr Foster, had spotted death rates at Mid Staffordshire NHS Trust were too high.
They raised the issue with the Healthcare Commission in July, and then the following month more anomalies were noted by the Imperial team.
The Healthcare Commission's own assessment system also started noticing potential problems, and within months a full investigation was launched.
It resulted in the watchdog publishing one of its most damning reports on an individual NHS trust.
The Healthcare Commission said standards of emergency care were "appalling" and would have led to unnecessary deaths.
Lessons to be learned
But what are the implications for the rest of the NHS?
Healthcare Commission chairman Sir Ian Kennedy said it was a story of one badly run hospital.
The watchdog looks into 12 alerts a month on average - the majority of which do not even result in a formal investigation.
None of these have thrown up the combination of concerns raised in the Mid Staffordshire report - namely low staffing levels, inadequate nursing, lack of equipment, poor training, and bad management.
Things were so bad, the inspectors said, that receptionists were carrying out initial checks on patients arriving at A&E.
However, the watchdog still felt compelled to issue a number of warnings to the rest of the health service.
It said managers should not become obsessed with targets to such an extent that patient care is no longer the priority - as happened with Mid Staffordshire.
The report highlighted the use of a ward near to A&E which acted a "dumping ground" for patients so the hospital could meet the four-hour waiting time target.
It also said monitoring performance and comparing it to other NHS trusts was essential.
This is something the central command of the NHS at the Department of Health is expected to focus on in the coming weeks.
Ten regional medical chiefs are currently being recruited to monitor the quality of care in hospitals across their patch, and report to the NHS medical director Sir Bruce Keogh.
There is also likely to be more pressure on hospitals to publish comprehensive death rates - something doctors have been particularly resistant to.
However, many of the issues raised in the report will also have wider resonance for the rest of the NHS.
During the period of excess deaths the trust was under severe pressure to save money, amid the furore over NHS deficits, and because of its desire to become a foundation trust - given to the elite performing hospitals in the health service.
In total 150 posts were cut in the end.
And while this was going on the local and regional bodies responsible for overseeing the hospital - primary care trusts and health authorities - were coping with structural reorganisation ministers had enforced, the watchdog said.
And concerns are being voiced about how the NHS trust was granted foundation trust status in February 2008.
This was after the alerts were raised, and just two months before the investigation was formally launched.
The Healthcare Commission said Monitor, the body which is in charge of giving trusts foundation status, had not even asked if the watchdog had any concerns.
However, the report also makes uncomfortable reading for the Healthcare Commission.
The watchdog was not even the first to notice something could be wrong, despite the availability of evidence of higher death rates dating back to 2003.
In recent years the trust has also climbed the ratings ladder, becoming "good" in 2007.
At the time the Healthcare Commission assessed the core standards at the trust and judged them to have been met.
The Healthcare Commission since its launch has pioneered a light touch to regulation.
Gone are the days when inspectors would patrol the corridors of hospitals, and in their place is a system largely based on self-assessment and feedback.
But Sir Ian rejected any suggestion that the watchdog was culpable.
He said the very fact the report had now been published was proof the watchdog's approach to inspection was working.
He said: "Everyone else was fobbed off. We alone stayed the course."
But whatever the truth, it seems the fall out from Mid Staffordshire has only just begun.