Among the aggravating features of the case identified was the fact that the errors occurred amid a "general malaise" in standards and priorities at Stafford Hospital between 2004-2007, a judge has said.
"The underlying causes of the breaches and the malaise were fundamental organisational and managerial failures, which can be traced to the very top of the organisation." Mr Justice Haddon-Cave said.
A judge sitting at Stafford Crown Court said the death of Gillian Astbury, who was not given insulin despite being diabetic, had been caused by an "effectively broken" system for hand-overs between staff and poor record-keeping.
Passing sentence on the Mid Staffordshire NHS Foundation Trust, High Court judge Mr Justice Haddon-Cave described the 66-year-old's death as tragic and wholly avoidable.