By Clare Murphy
BBC News health reporter
Come next April, the healthcare regulator will have the power in principle to march into failing hospitals and close them down.
The trust is failing on a number of key standards
The Care Quality Commission admits this is the "nuclear option": it also says that in the case of the Royal Cornwall Hospitals NHS Foundation Trust it is simply not practical.
The trust is the only one to have been rated weak every year since the ratings system was started four years ago. This means it has failed every year to meet a significant number of basic standards.
The trust, which comprises the Royal Cornwall Hospital in Truro, West Cornwall Hospital in Penzance and St Michael's Hospital in Hayle, serves a large area surrounded by water on three sides.
It is also a location which is sparsely inhabited with an ageing population.
Local health campaigner Graham Webster said: "This is the problem. Patients say the clinical services you receive once you are actually in the system are very good. But actually physically getting to services which can be miles away from where you live, waiting times, capacity, they all let us down.
"I am the trust's biggest critic but also it's biggest fan - I want it to succeed. It operates in a unique geographic and demographic context. It needs the resources to do that."
Ongoing movement at the top in recent years has failed to bring about improvement and are held up as evidence that management change does not guarantee change for the better.
The last permanent chief executive, John Watkinson, was hired to turn around the trust's fortunes after its debts hit £36m. But he was suspended in late 2008 after a report revealed financial failings at Bromley, the trust he had left to take up the Cornwall post.
THE CQC says refusing to give the trust a licence - a power which the regulator will wield from April next year - is not an option because of the lack of local competition. There is no other trust in the county which could step in.
It wants to work closely with the trust to iron out problems ahead of the April deadline, but says there will always come a point with a failing organisation where a fundamental review of the way it is set up becomes necessary.
Campaigners say they are worried that ultimately all treatment outside of emergency care will be moved beyond the county borders. They highlight the transfer of upper gastrointestinal services to Plymouth as a case in point, noting that millions of pounds have followed the patients.
But Cornish health authorities have argued that the clinical evidence suggests better outcomes for patients when they are treated in large numbers at specialist centres, and that all non-surgical care would continue to be carried out in Cornwall.
The trust itself says the rating does not reflect the progress made since the latter part of 2008, and highlights its success in reducing hospital infections.
"Standards of clinical care at all three of the trust's hospitals are good; our survival rates are among the top 10% in the country, we achieved unconditional registration with the care quality commission in respect of the hygiene code, and 93% of patients rate their care as excellent," said Peter Colclough, the trust's acting chief executive, the second this year.
"I am sure I can speak for all our staff when I say that the quality of and safety of our services is paramount and this is our focus in attaining continued improvement."