A privately-run hospital caring for severely disabled people put its own profits before basic humanity, a scathing report has revealed.
Health regulators, police, social services and the NHS were are all heavily criticised in an independent report for failing to spot the warning signs about the treatment of patients at the Winterbourne View care home.
The serious case review was published the day after the final member of staff accused of abusing patients at the home in Hambrook, South Gloucestershire, pleaded guilty. A total of 11 former staff have admitted between them 38 charges of either neglect or ill treatment of people with severe learning difficulties.
The shocking catalogue of abuse at the hospital only came to light when whistleblower Terry Bryan, a senior nurse at the home, contacted BBC1's Panorama. Its undercover five-week investigation, broadcast in June last year, recorded secret footage of patients being abused by carers.
The video showed frail and confused residents being forcibly pinned down, slapped, soaked in water, trapped under chairs, taunted and having their hair pulled and eyes poked.
Dr Margaret Flynn, who wrote the 150-page serious case review, said her findings could be the "tip of the iceberg" and said that care at Winterbourne View had become "institutional abuse".
Her report detailed hundreds of incidents of restraint and dozens of assaults on patients and said that had it not been for Panorama the scandal may never have come to light. Dr Flynn said there were enough warning signs over the preceding three years for the authorities to have investigated further.
Senior managers at Castlebeck, which ran the care home, ignored internal reports of excessive use of restraints and injuries to patients and concerns of its own staff. The 24-bed home was exclusively funded through contracts with local authorities and the NHS and charged on average £3,500 a week per patient.
After the broadcasting of the Panorama programme, Castlebeck closed Winterbourne View and two other residential homes following concerns raised by the CQC. The publication of the serious case review has led to those blamed for failure vowing that it would never be repeated.
The CQC said the scandal was a "watershed" while the Government said its own review would be published in the autumn.