Senior managers of the Buckinghamshire Hospitals NHS Trust came in for the harshest criticism in a shocking report by the Healthcare Commission after the c diff bacteria was a factor in the deaths of 65 elderly patients.

Nearly 500 patients caught the bug between April 2003 and March 2006, but news of this was kept quiet until after a second major outbreak in 2004 when Health Secretary Patricia Hewitt called in the commission to investigate.

The report says managers did not take sufficient action to prevent infections, did not listen to their own infection control team when they said there was a problem, and could not cope when things did go wrong. It calls for the leadership to be replaced but then points out the chairman and chief executive had already decided to go.

It also says management put Government targets ahead of patients' safety and did not take action to help the c diff problem, because it would affect them reaching their targets.

Anna Walker, chief executive of the commission, said there were serious management failures. She said: "Management centred on its priorities and forgot that patients' safety must always come first."

She refused to criticise Government targets which hospitals have to achieve, saying they were valuable for patients because they cut waiting times for operations and in A and E.

"We don't seek to damn targets," she said.

But the trust should be able to manage hitting targets and protect patients, she added, and if it could not it should have approached the commission.

She said: "At Stoke Mandeville there were competing priorities and they took their eye off the ball."

Members of the commission team paid at least five visits to the hospital, talked to 200 people including staff, patients and families, looked at case notes and examined documents.

Their report gives a horrific list of dirty conditions in which germs could proliferate, including faeces on bed rails; dirty lavatories, wards and commodes; pubic hair in baths; mould in the showers; bedding and equipment on floors; no lockers for patients' belongings; bags of rubbish piled in sluice rooms and a lack of hand- washing facilities. Some of these conditions were still prevalent at a commission inspection in April this year.

The report states: "The fact that there was a further outbreak in December 2005 indicated that there are continuing problems with cleanliness, infection control and levels of staffing.

"We were pleased, during our visit in April 2006, to note improvements to the environment in which patients were cared for, particularly in the new part of the hospital, and improvements in the control of infection. However, we were not convinced that other aspects of the safety of patients were being given sufficient priority, even while our investigation was in progress.

"Because of the severity of the situation, and our judgment that there were significant failings on the part of the leadership team, we recommend that the leadership must change."

Other issues highlighted in the report included the condition of the hospital, the facilities for isolating infected patients, staff shortages and the staff's knowledge of, and ability to carry out, infection control measures.

It also refers to the inability to isolate infected patients, which the hospital's small infection control team raised repeatedly with senior management from October 2003, but with little effect.

They warned without success that infection could spread because of management's 's determination to hit Government targets, such as getting patients through A and E in less than four hours.

To speed things up some patients were admitted from A and E to beds in side wards, which could have been used for isolating patients with the bug.

In November 2004 when two medical wards were infected and the team asked for an isolation ward they did not get one, the report states.

There were also dozens of incidents of patients being moved round the hospital and infected patients being put into open wards.

The infection control team reported that patient equipment was not being properly cleaned but the commission could find no evidence that their reports were discussed by the trust board, despite the seriousness of the subject.

The report calls for better hygiene and better training. Staff had 25 minutes in their induction programme, but in September 2005 only 35 per cent of staff had sufficient training in hygiene.

Another factor was a lack of staff. Wards were three or four short and there was a low ratio of qualified nurses to beds because the trust was not filling staff vacancies with agency staff because of the high costs.

But the staff shortages meant those who were there had no time to do routine hygiene work, such as cleaning mattresses and staff were so busy that basic precautions like hand washing did not always take place.