Health Secretary Jeremy Hunt calls for new era of openness and safety after Stafford Hospital scandal

The public inquiry into the Mid Staffs scandal was not just a significant moment for the local community.

It was a watershed for the NHS, and for me personally. The report of the Mid Staffs inquiry was one of the first things that came across my desk when I was appointed as Health Secretary in 2012.

What immediately struck me was how could an organisation so important, so close to all of our hearts, have been responsible for so many terrible lapses in care?

One of the key NHS pledges to patients is fairness. That means high quality healthcare for all, regardless of income. But we can only back up that pledge with a relentless determination to deal with poor care whenever and wherever it happens.

Following the emergence of the Mid Staffs scandal, my first instinct was to ask why we knew so little about the variations in quality of care across the NHS, whether that be in clinical specialities or between regions.

Parents know about how good schools are, thanks to Ofsted, but there was nothing equivalent for health. So I introduced Ofsted style inspections for every NHS organisation, with new Chief Inspectors responsible for different areas.

From June we will have Ofsted-style ratings on the quality of mental health provision, dementia care, diabetes care, cancer care and care for people with learning disabilities - another global first for transparency in a healthcare system.

A huge amount of progress has been made in improving our safety culture following Sir Robert Francis' report. But to deliver a safer NHS for patients, seven days a week, we need to unshackle ourselves from a quick-fix blame culture and acknowledge that sometimes bad mistakes can be made by good people.

I've met too many patients and families who have faced a closed and defensive culture when they've tried to find out the truth when things have gone wrong.

That's why I want us to be the first healthcare system in the world that truly learns how to make care as safe as possible by adopting a culture where we really are better at learning from mistakes.

Organisational leadership is vital if we are to change this approach. We can see world class organisations inside and outside healthcare have a very different approach. They have the boldness to probe more deeply and learn precious lessons. They see a medication error as an opportunity to make labelling clearer, a mistake in an operating theatre as a chance to improve teamwork and communication, just as airlines did after the crash of United 173.

Justice must never be denied if a professional is malevolent or grossly negligent, but the driving force must be the desire to improve care and reduce harm, fired by an insatiable determination to improve. That is why I am committed to making the NHS the world's largest learning organisation.

We want to give clinicians the reassurance they need that it will be safe to speak out when there is a safety investigation. We want to improve safety and transparency within the NHS – to help build a safer service for patients seven days a week.

Expert medical examiners will independently review and confirm the cause of all deaths, as originally recommended by the Shipman Inquiry, and subsequently by Sir Robert Francis. If any death needs to be investigated and if there is cause for concern, appropriate action will be taken.

Taken together, these measures will signify the start of more openness in the NHS' response to mistakes. Families will get the full truth faster; doctors will get support and protection to speak out; and the NHS as a whole will become much better at learning when things go wrong.

As Health Secretary, it is my duty to be able promise families who have suffered avoidably 'never again.' Today we take a step forward to building a new era of openness and the safest healthcare system in the world.