The shocking catalogue of abuse at a care home at the centre of a BBC Panorama 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.
'Systematic mistreatment of patients by staff'
An undercover journalist for Panorama spent five weeks working at Winterbourne View recording shocking abuse.
He had been tipped off by former employee Terry Bryan who went to the programme with his concerns after they were ignored by Castlebeck and the CQC.
In a four-page email to the hospital's acting manager on October 11 2010 entitled "I've had enough", Mr Bryan, a senior nurse, set out his grave concerns.
He listed 18 concerns and said on one occasion he overheard a support worker referring to him as a "f****** c***" to other staff members.
Mr Bryan's email was known to Castlebeck's regional operations director, the senior manager and the human resources officer, the serious case review stated.
The hospital's acting manager forwarded the email to South Gloucestershire Council, which sent it on to the CQC adding a series of "thoughtful questions" to Mr Bryan's original complaint.
When Castlebeck failed to take any action, Mr Bryan forwarded his original email to the CQC.
"A meeting with Winterbourne View's acting manager to discuss the disparate forms of harm detailed in the email was postponed by the acting manager," Dr Flynn said.
"This precluded a consideration of the email against the accumulation of individual alerts known to South Gloucestershire Council Adult Safeguarding.
"This meeting did not take place until February 1 2011.
"There had been unchecked assumptions by Adult Safeguarding and the Care Quality Commission about who was taking action.
"Accordingly, there was no inter-organisational acknowledgement that the email provided confirmation about the fact and extent of institutional abuse.
"As a result, Winterbourne View was not held to account."
Following the damning expose, South Gloucestershire Council sacked two staff who were responsible for protecting patients at the hospital.
Kevin Haigh, an experienced team manager who had worked in the area for 16 years, was dismissed in March and Brian Clarke, the council's safeguarding adults manager with 10 years' experience, was dismissed in April.
Both were employed by the council and worked on its Safeguarding Adults Board.
In her report Dr Flynn said that '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."
'Unwittingly, the hospital has become a case study in institutional abuse'
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."
'The wretched history of Winterbourne View'
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.