Among the findings:

• Errors and neglect by King/Drew's staff have repeatedly injured or killed patients over more than a decade, a pattern that remains largely unscrutinized and unchecked. Some lapses were never reported to authorities — or even to the victims or their families. And some people learned of the severity of the failings only by suing or, in several instances, from Times reporters who sought them out to learn about their care.

• Although King/Drew opened in 1972 with the promise that it would be "the very best hospital in America," it is now, by various measures, one of the very worst. It pays out more per patient for medical malpractice than any of the state's 17 other public hospitals or the six University of California medical centers.

• Entire departments are riddled with incompetence, internal strife and, in some cases, criminality. Employees have pilfered and sometimes sold the hospital's drugs; chronic absenteeism is rampant; assaults between hospital workers are not uncommon. Despite King/Drew's repeated promises to regulators, the problems have gone unfixed for years.

• The hospital's failings do not stem from a lack of money, as its supporters long have contended. King/Drew spends more per patient than any of the three other general hospitals run by Los Angeles County. Millions of dollars go to unusual workers' compensation claims and abnormally high salaries for ranking doctors.

• The hospital's governing body, the county Board of Supervisors, has been told repeatedly — often in writing — of needless deaths and injuries at King/Drew. Recently the supervisors have made some aggressive moves aimed at fixing the hospital. But for years, the board shied away from decisive action in the face of community anger and accusations of racism.