A SERIOUS case review into what went wrong at Winterbourne View has condemned owners Castlebeck Ltd as ‘business opportunists’ who profited from the systematic abuse of its patients.

But report author Margaret Flynn also blamed the failures of South Gloucestershire’s Safeguarding Adults Board, which is made up of the NHS, Care Quality Commission, the police and South Gloucestershire Council, for the scandal which was exposed by the BBC’s Panorama programme.

Ms Flynn told a press briefing at the publication of the review on Tuesday: "The development of Winterbourne View Hospital was contingent on Castlebeck Ltd’s business opportunism, the encouragement of NHS commissioners and their willingness to buy its services.

"If it had not been for an undercover reporter working as a care worker for five weeks in early 2011, it would have taken a very long time for events at this hospital to come to light. "Principally this report is about learning lessons and Winterbourne hospital has taught us many. It is not about individuals, it has always been a matter for organisations."

Ms Flynn retold the harrowing accounts of patients’ torment at the hands of their care workers and nurses and spoke of the ongoing trauma it had caused them and their families.

She said Castlebeck, which earned £3,500 a week per patient and had an annual turnover of £3.7million at Winterbourne View – the most financially successfully home in its group, had abused the commissions it received from the NHS.

"They did not deliver what NHS commissioners believed they were purchasing for their patients," she said. "In short, Castlebeck took financial rewards without any accountability."

A review by NHS South of England, also published on Tuesday, said ‘commissioners were attempting to do a difficult job in a complex context’ but accepted it could and should have done more.

Andrew Havers, medical director of NHS Bristol, North Somerset and South Gloucestershire, 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 services."

Peter Murphy, director of community care and housing at South Gloucestershire Council, said the board fully accepted the report. When questioned if he should resign following the scandal, he said a wide range of organisations had visited Winterbourne View and one central information ‘hub’ should be created to monitor similar facilities in future.

Avon and Somerset Constabulary, whose officers were called to the hospital on 29 occasions over a three-year period, also admitted failing to link incidents of physical injuries and patients trying to escape. DCI Louise Rolfe said: "Officers attending were overly reliant on people they believed to be experts and professionals in their field," she said. "We very much recognise there were failings there and we did not make the links we should have done.

"We have reorganised our structure and are carrying out extra work and training."

The serious case review called for an end to long-stay hospitals and more community-based care. It said NHS commissions of people with learning difficulties and autism to private facilities need to be followed up with outcome reports.