The shocking catalogue of abuse at a care home at the centre of a TV investigation was laid bare today in a damning report.
The owners of Winterbourne View, health regulators, local health services and police were all criticised for failing to act on increasing warning signs of institutional abuse by staff at the care home.
The 150-page report by independent expert Margaret Flynn details hundreds of incidents of restraint and dozens of assaults on patients at the private hospital at Hambrook, South Gloucestershire.
Winterbourne View was exposed by BBC1's Panorama last year when an undercover reporter recorded secret footage of patients being abused by carers.
The video appeared to show vulnerable residents being pinned down, slapped, doused in water and taunted.
The footage of the terrible treatment of residents caused a national scandal.
Since the allegations were first broadcast, the home's owner, Castlebeck, has closed Winterbourne View and two other residential homes following concerns raised by the Care Quality Commission (CQC).
Yesterday Michael Ezenagu, 29, became the eleventh member of staff at Winterbourne View to admit offences relating to the ill-treatment of patients. They will all be sentenced at Bristol Crown Court at a later date.
Today's report was published as campaigners warned that another care home scandal like Winterbourne View could happen again unless the Government takes action.
Mencap and the Challenging Behaviour Foundation warned that moving people hundreds of miles away from their families increased the risk of abuse taking place.
The two charities said a report they had compiled, Out of Sight, detailed a series of serious cases of abuse and neglect of people with a learning disability in institutional care.
They said they had received 260 reports from families concerning abuse and neglect in institutional care since the Winterbourne View scandal was exposed.
Peter Murphy, chairman of the South Gloucestershire Safeguarding Adults Board, said: "On behalf of the organisations that make up South Gloucestershire's Safeguarding Adults Board - including the council, the NHS, Avon and Somerset Police and the Care Quality Commission - I would like to take the opportunity today 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."
Mr Murphy said the Safeguarding Adults Board fully accepts the recommendations of the report.
"We are determined that the necessary improvements will be made," he said.
"Many of those improvements are already in hand and our shared objective must be that events such as this never again occur in South Gloucestershire."
Mr Murphy said the report had national ramifications.
"It examines in detail the underlying 'root cause' issues that underpin the existence and purpose of hospitals such as Winterbourne View and the nature and quality of care provided," he said.
"In this respect, 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.
"The board is encouraged by early recognition of this in the June publication of their own interim report by the Department of Health.
"A final report is promised which will incorporate the findings and learning available from today's serious case review report."
David Behan, chief executive of the Care Quality Commission, said: "There is much for all the organisations involved with Winterbourne View to consider in Margaret Flynn's thorough and comprehensive report.
"I will ensure that the Care Quality Commission responds fully to all the recommendations for CQC.
"We will continue to work with other organisations to improve communications and sharing information to ensure we all protect those who are most vulnerable."
Andrew Havers, medical director of NHS Bristol, North Somerset and South Gloucestershire Primary Care Trusts, said: "Many of the systems that could have prevented the shocking abuse of patients at Winterbourne View hospital failed.
"One year on, significant measures have been taken by the organisations represented by the Safeguarding Adults Board to ensure better standards of adult protection and improve commissioning across health and social care services for people with behaviour which challenges to reduce the number of people using inpatient assessment and treatment of services."
It emerged today that Castlebeck charged on average £3,500 per week for each resident's care and the 24-bed home had an annual turnover of £3.7 million.
Dr Flynn's report condemned the firm for putting profitability before care.
"Castlebeck appears to have made decisions about profitability, including shareholder returns, over and above decisions about the effective and humane delivery of assessment, treatment and rehabilitation," Dr Flynn said in the report.
Castlebeck did not disclose to Dr Flynn how the public funding it received from the NHS commissioners was spent.
"The development of Winterbourne View was contingent on Castlebeck Ltd's business opportunism, the encouragement of NHS commissioners and their willingness to buy its services," Dr Flynn said.
From the opening of the hospital in 2006 until last year, there were 38 safeguarding alerts raised about 20 patients from the unit. Only one in five of those was reported to the NHS.
Three alerts the NHS did not appear to have been notified of in any way include an allegation of abuse by staff, concerns about the attitude of some staff, and an allegation of assault by a member of staff.
"Unwittingly, the hospital has become a case study in institutional abuse," Dr Flynn said.
"Although 'person-centred' care, participation and empowerment characterise national policy priorities, these were alien to the experience of Winterbourne View and their families.
"Their silencing was scandalous.
"Regardless of the eloquent first-person accounts and the concerns of their families, the experience of Winterbourne View patients was ignored.
"They did not receive customised support from skilled professionals. Their relatives were rendered invisible or impotent by Winterbourne View's harassed workforce, to whom they appeared to have high nuisance value.
"There was no evidence that families were perceived as partners with a key stake in the health, well-being and safety of their relatives."
Dr Flynn's report records the failure of the health care watchdogs - the Healthcare Commission and the Mental Health Act Commission, until April 2009, and their successor the Care Quality Commission - as well as local council, NHS and police to act on concerns raised at Winterbourne View.
South Gloucestershire Council received 27 allegations of abuse by staff to patients at the hospital, 10 allegations of patient-on-patient assaults and three family-related alerts.
Avon and Somerset Police recorded nine carer-on-patient incidents, five patient-on-patient incidents, three patient-on-staff incidents, and 12 other incidents.
The report detailed that Castlebeck recorded a total of 379 physical interventions during 2010 and 129 for the first three months of 2011.
"It is recognised that these figures underestimate the true extent of restraint at Winterbourne View Hospital," Dr Flynn said.
"It is shocking that the practice of restraint on a daily, routine basis was not identified as constituting abuse by any professional.
"The review has demonstrated that the apparatus of oversight was unequal to the task of uncovering the fact and extent of institutional abuse at Winterbourne View," the report said.
"Taken section by section, this serious case review builds a bleak collage of the phenomenon of institutional abuse.
"That the whole is greater than the individual sections is no cliche.
"The insights arising from the efforts of the individual agencies, sharing a common geographical and political context, confirm the difficulties of responding to the highly situational needs of patients when information about concerns, alerts, complaints, allegations and notifications are either unknown or scattered across agencies.
"It is concerning that Winterbourne View strayed far from its purpose of providing assessment and treatment and rehabilitation.
"A service's reputation is no substitute for interventions with a credible conceptual basis which result in successful outcomes.
"The restricted and isolated model exemplified by Winterbourne View has nothing to offer adults with learning disabilities and autism.
"It is clear that at critical points in the wretched history of Winterbourne View, key decisions about priorities were taken by Castlebeck Ltd which impaired the ability of this hospital to improve the mental health and physical health and well-being of its patients."
The report revealed that, between January 2008 and May 2011, residents at Winterbourne View attended accident and emergency departments 76 times - yet no medics alerted the authorities with any concerns.
Of those, 27 were for epileptic seizures; 18 for injury or accident; 14 for self-harm; 14 for lacerations; 14 for studies/treatment; nine for dressing change or wound review; eight for removal of a foreign body; eight for other; seven for head injury; four for illness; two for cardiac/respiratory arrest; and one for a fall.
"Putting to one side emotional, verbal and psychological harm, although there is no comparative data on which to draw, there was considerable visible, physical and quantifiable violence at Winterbourne View for which patients required hospital treatment and yet there were no safeguarding alerts from accident and emergency," Dr Flynn said.
The report also said the GP contracted to attend Winterbourne View, the psychiatrists employed by Castlebeck and the professionals attending the Care Programme Approach (CPA) reviews were unaware of what was going on inside the hospital and there was no evidence of "clinical leadership".
Yet, the warning signs were there.
The Mental Health Act Commission 2008 annual report noted the hospital's approach to patient restraint and physical intervention - but Castlebeck did nothing.
Staffing levels were low and the hospital often relied on agency workers to fill the gaps.
Staff retention was low and two migrant workers were even arrested by the UK Border Agency, the report revealed.
"Castlebeck Ltd did not act on the actions required by the Healthcare Commission and records attested to the continued and harmful use of restraints," Dr Flynn said.
"There is no evidence that the written complaints of patients were addressed.
"Castlebeck Ltd's human resources officers were aware of the breaches of patients' supervision requirements, concerns about under-staffing and the misgivings of some staff concerning the use of restraint.
"During 2010, 'on the job' training and inadequate staffing levels persisted with poor recruitment practices and further instances of unprofessional behaviour in an increasingly non-therapeutic hospital.
"Patients lived in circumstances which raised the continuous possibility of harm and degradation.
"Castlebeck Ltd's managers did not deal with unprofessional practices at Winterbourne View.
"Absconding patients, the concerns of their relatives, requests to be removed and escalating self-injurious behaviour were not perceived as evidence of a failing service.
"The documented concerns of a whistleblower made no difference in an unnoticing environment.
"There was nothing fair, compassionate or harmonious during Winterbourne View's final months of operation.
"Neither the hospital's discontinuous management, nor their sporadic approach to recruiting sufficient numbers of skilled professional and experienced staff, were prompts to Castlebeck Ltd to assume responsibility.
"These 'input' matters were not given the weight they merited in the historical and 'outcome'-oriented reports produced by the Healthcare Commission and latterly the Care Quality Commission.
"Before Castlebeck Ltd received a letter from the BBC alerting them to the 'systematic mistreatment of patients by staff', it was business as usual at Winterbourne View.
"Patients' distress, anger, violence and efforts to get out may be perceived as eloquent replies to the violence of others - including that of staff - rather than solely as behaviour which challenged others and confirmed the necessity of their detention."