A report into failures at the Vale of Leven Hospital in Dunbartonshire has been passed to the procurator fiscal to see if charges should be brought.
The review examined how an outbreak of Clostridium difficile led to the deaths of nine people, and contributed to the deaths of nine more.
The hospital has been criticised over hygiene and infection control.
It was also criticised over poor hand washing facilities and the use of antibiotics.
The review found that facilities at the hospital were inadequate for effective patient isolation.
It also criticised poor hand washing facilities and the use of antibiotics.
Nine patients died as a direct result of the infection, with C.diff cited as a "contributory factor" in nine others.
C.diff is linked to poor hygiene and the over-use of antibiotics.
The report said: "The facilities at the Vale of Leven Hospital were inadequate for effective patient isolation and infection control, and there were frequent patient transfers between wards and other hospitals during this period.
"The facilities were inadequate in terms of hand washing facilities, single room accommodation with sufficient toilets, appropriate spacing between beds, clinical and storage space to facilitate effective infection control practices.
"There was no active monitoring of the implementation of antibiotic policies or feedback on usage to clinical staff."
The report has recommended that NHS Greater Glasgow and Clyde (NHS GGC) takes "specific actions" to avoid a repeat of the outbreak.
It also recommended the development of policies on "the governance of infection control, the development of clinical leadership to board level, improvements to patient communication, maintenance of a safe environment and death certification practices".
The reports also calls for another independent review visit at the end of the year with representatives of the patients and their families to ensure that all the recommendations have been implemented.
The board said infection control teams and senior managers were taking action on these "valid complaints".
Apology move
Scotland's Health Minister, Nicola Sturgeon, said the recommendations would be implemented in full and delivered a strong rebuke to NHS GGC.
"The picture painted by the independent report of the facilities and procedures at the Vale of Leven is appalling and unacceptable and there should be no doubt NHS GGC owe the patients and the families concerned an unconditional apology," the minister said.
"Their messages stand out clearly, and I can assure them we are listening and acting."
Relatives of those who died at the Vale of Leven welcomed the report but said the case remained for a public inquiry.
Founding member of the C.diff Justice Group, Michelle Stewart, said: "We have maintained from the start that the report should have been independent of government and NHS Scotland. It was not. "This was, in the main, a case of the NHS investigating the NHS.
"We also believe that the remit did not fully cover the relationships and contact between Health Protection Scotland, NHS Scotland, the Scottish Government and the health minister."
Ms Stewart's sentiments were echoed by group chair, David Logan.
"Let's not forget that 55 people were infected and 18 people died of C.diff," he said.
"There are clearly lessons that have been learned and a clear need for me now, on behalf of NHS Greater Glasgow and Clyde, to apologise to the families affected"
"If it had not been for the persistence of the families we are clear that the matter would have been covered up and swept under the carpet.
"There has been a massive systems failure and we need an open, transparent and independent public inquiry to get answers."
NHS Greater Glasgow and Clyde said additional cleaning and strict infection control measures had been implemented at the Vale of Leven Hospital since the scale of the infection had become known.
Chief executive Tom Divers recognised the report's criticisms of poor hand washing facilities and spacing between beds at the hospital and said he had ordered immediate improvements.
He also said a new system for "surveillance of infections" had been introduced across all of the authority's hospitals.
"There are clearly lessons that have been learned and a clear need for me now, on behalf of NHS Greater Glasgow and Clyde, to apologise to the families affected," he added.
"I have instructed infection control teams and senior managers to take action on these valid complaints."
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