Disregard for human life.
Those four words stand out above all in the thousands that make up the 370-page report into deaths of more than 650 patients at Gosport War Memorial Hospital.
Applied to a mass murderer they would chill the blood, but applied to a hospital they defy all belief and understanding.
How could a hospital, meant to care for the sick and the old, allow hundreds of people to die unnecessarily though prescription of drugs they did not need?
Nurses at the hospital voiced their fears as long ago as 1991 but their words went seemingly unheard by their superiors. Official enquiries began in 1998 — 20 years ago — when Gillian Mackenzie, whose mother Gladys Richards died aged 91 in 1998 at the hospital, went to the police with her suspicions.
Over the years many others added to the growing chorus of fear about practices at the hospital.
It has taken 20 years of dogged campaigning by those families to be heard and to be vindicated.
What they need now is justice.
Criminal proceedings could be brought in the wake of yesterday’s shocking revelations.
Hospital management, Hampshire police, the Crown Prosecution Service, General Medical Council, and Nursing and Midwifery Council all have questions to answer.
The families have some answers but no justice.
Wrongdoing on this scale cannot go unpunished.