Video report by ITV News Correspondent Paul Davies
The victims of the Hillsborough tragedy and their bereaved relatives were "dehumanised" and treated in a "cruel" manner by public authorities, a report on the families' experiences has found.
The review by Bishop James Jones aimed to provide an insight into what the families have been through over the past 25 years.
It was commissioned by the now-Prime Minister Theresa May following the conclusions of the fresh Hillsborough inquests in April 2016, which found that the 96 Liverpool FC fans were unlawfully killed at the 1989 FA Cup semi-final and errors by the police and ambulance service caused or contributed to their deaths.
Gerard Baron Jnr, whose father Gerard Baron was the oldest person to die at Hillsborough, told the review that after Lord Justice Taylor's inquiry, which was published in 1990, there was "a complete systematic degradation and humiliation of the 96, families, survivors and all the good I was raised to believe in".
Bishop Jones, the former Bishop of Liverpool, set out 25 "essential" learning points in his report, titled "The Patronising Disposition of Unaccountable Power". Three points which he described as "crucial" were:
The creation of a Charter for Families Bereaved through Public Tragedy, which public bodies would sign up to and commit to ensuring that the perspective of bereaved families is not lost
Ensure there is "proper participation" by bereaved families at inquests, placing them at the centre of the process and making sure there is publicly funded legal representation for families at inquests where public bodies are legally represented
The establishment of a "duty of candour" for police officers to address the "unacceptable behaviour of police officers" who fail to cooperate fully with investigations into alleged criminal offences or misconduct
In the report, published on Wednesday by the Home Office, Bishop Jones wrote: "What is needed is a change in attitude, culture, heart and mind.
"To bring this about, I first ask that those in positions of leadership listen seriously to the experiences of the Hillsborough families described in this report."
He added: "I suggest that the way in which families bereaved through public tragedy are treated by those in authority is in itself a burning injustice which must be addressed."
Bishop Jones also said that some of the issues faced by the Hillsborough families in the aftermath of the tragedy on April 15, 1989, still persist today.
The Bishop, who chaired the Hillsborough Independent Panel, said the response of South Yorkshire Police to criticism over Hillsborough had included examples of "institutional defensiveness" and recommended College of Policing training for senior police officers to ensure an "open and transparent approach" to inquiries and independent investigations.
What the families told the review
Families have shown 'exceptional' bravery and tenacity
The report found that the first inquests into the deaths, which had a cut-off time for evidence of 3.15pm on the day, failed to accurately establish how the 96 came about their deaths, and families were unable to successfully challenge the "flawed basis" on which the inquests took place because their legal representation was unfunded and inadequate.
In the report, Bishop Jones said: "The bravery and tenacity of the Hillsborough families has been exceptional; it is clear that without their determination and endurance there would never have been any redress for their 96 loved ones.
"But the fact that this level of resolve and persistence was necessary demonstrates a systemic failure of the processes that should work to bring about accountability and justice."
The Bishop supported the introduction of a "Hillsborough Law", which has been called for by families and would make it a criminal offence for public officials to cover up wrongdoing within an organisation.
Responding to the review, Home Secretary Amber Rudd said: "I am grateful to Bishop James Jones for undertaking this important piece of work. His thoughtful and considered report raises important points.
"The Government will now carefully study the 25 points of learning and we will provide a full response in due course."