The report into abuse at the Winterbourne View care home, first exposed by an undercover investigation by the BBC TV show Panorama last year, has heavily criticised not only the owners but also health regulators, the local health service and police.
The 150 page serious case review by Margaret Flynn, the chair of Lancashire's Safeguarding Adults Board, damned authorities for failing to act on increasing warning signs of institutional abuse by staff at the care home. It detailed hundreds of incidents of restraint and dozens of assaults on patients at the private hospital at in Hambrook, south Gloucestershire.
Between 2008 and 2011 Avon and Somerset police were aware of 29 incidents at the home whilst South Gloucestershire council had received 40 "safeguarding alerts". A whistleblower had also contacted the council about abuse at Winterbourne View, but nothing had been done.
The report says most of the staff were "unregulated support workers" and that Castelbeck, the company that owned the care home, "took the financial rewards without any apparent accountability".
Peter Murphy, chairman of south Gloucestershire's Safeguarding Adults Board, said that on behalf of the organisations that made up the board – including the council, the NHS, Avon and Somerset police and the CQC – he wished to "convey our deep regret for the events that took place at Winterbourne View private hospital".
"In particular, I would like to express our regret to the hospital's patients and to their families, friends and carers.
"Winterbourne View hospital should have been a safe place for them to be treated with care and compassion. But the hospital's owners, Castlebeck Care Ltd, failed to provide that care.
"Instead it left vulnerable adults in the hands of poorly trained and poorly supervised staff, who dealt out torment and abuse to those entrusted to their care.
"Many of those staff have now been subject to criminal proceedings and this should send out a clear and powerful message – that where employees engage in this kind of criminal behaviour they will be held to account."
Murphy said the board accepted the recommendations of the report and that it had national ramifications.
"The findings of the report and its recommendations point towards a national policy debate with far wider implications for the health and social care system.”
11 former members of staff have already admitted to offences against patients.