Vulnerable patients with learning disabilities were subjected to years of dangerous restraints, gratuitous violence and torment by ‘care staff’ at a private hospital obsessed with making money, as blindingly obvious signs of systematic abuse were ignored by the authorities.

The police, NHS, social services and the national regulator are all in the dock alongside owners of Winterbourne View hospital after an independent serious case review report revealed dozens of missed opportunities to stop the abuses earlier.

Patients who self-harmed or ran away to escape the abuse were brought back by police, patched up by A&E and sometimes sectioned by obliging psychiatrists. These increasingly common incidents were sometimes reported to the council’s safeguarding board and Care Quality Commission but no-one joined the dots, preferring to accept the flimsy excuses offered by the abusers.

The dangers of institutional care are highlighted in the damning report which warns that the hundreds of people with learning disabilities and autism still living in such outdated places are at high risk of similar abuse and prison-like conditions. These institutions, which should not exist in the 21st century, should be subjected to intense and regular scrutiny by regulators rather than the light-touch regulation which failed, said the independent experts.

The serious case review was published in full by South Gloucestershire council yesterday after a 11th and final former staff member pleaded guilty to criminal charges relating to abuses exposed by an undercover BBC investigation last year.

Repeated failures to adequately respond to serious allegations by patients, relatives and whistleblowers were at least in part down to the hospital owners, Castlebeck Ltd, and the CQC putting their reputations first, the report found.

Last night the government and CQC vowed that such a scandal would never happen again as the regulator’s inspection regime and system to deal with whistleblowers had been strengthened. The local NHS, safeguarding organisations and Castlebeck also said major improvements had been made.

In 2010 Winterbourne View near Bristol had an annual turnover of £3.7million, as Castlebeck charged the NHS on average £3,500 per week per person. But high sickness rates and a high staff turnover rate meant the hospital was largely run by untrained, unregulated support workers with little or no senior supervision or management.

The vulnerable residents, who were miles away from home and their families supposedly for assessment or rehabilitation, suffered broken bones, had their teeth knocked out, faces punched, hair pulled, and fingers bent backwards. Distressed patients were physically and chemically restrained by staff who abused them for kicks and had no understanding about their physical or psychological needs.

Police attended on 29 separate occasions in response to missing patients, fights, and dangerous restraints but only pursued one case of assault. Almost 80 visits to A&E by patients for injuries, accidents and self-harm were not linked but treated as unrelated incidents.

The council’s safeguarding board received 40 alerts of possible abuse or wrongdoing but relied on assurances from the hospital staff that things were okay. Warnings and improvement notices by the safeguarding board and CQC (and its predecessors) were ignored by Castlebeck; no-one bothered to chase them up so the abuses continued to escalate.

Staff abused patients, and patients abused each other and staff during hour after hour of total boredom which was penetrated only by fear and violence. Patients were goaded into fighting each other.

The disturbing report reveals hundreds of incidents of physical restraint, and dozens of assaults against patients over a three year period. Patients and their families who reported the serious problems were dismissed or falsely reassured; relatives were deliberately kept away when the bruises were too hard to cover-up.

One patient who was upset on the day she was admitted to Winterbourne was restrained for 50minutes a few hours later. Another was restrained under a duvet - highly dangerous due to the risk of suffocation.

The painful and distressing t-supine restraint used daily on Winterbourne patients should be banned in such hospitals, the authors recommend.

More than a year after the hospital was closed-down by Castlebeck, some patients are still severely traumatised by the abuse.

The report said it was a classic case of “business opportunism” by Castlebeck which charged NHS trusts the going rate for unacceptable institutional care and got away with it because no-one bothered to check what their money was actually buying for patients. The Department of Health said it was working on new guidance to help NHS trusts.

Last night Castlebeck said it had made changes at board level and overhauled its policies and procedures to ensure that nothing like this could ever happen again. “All our service users now have access to independent advocacy and we are introducing a range of initiatives to ensure we listen to, and act on, their views in regard to the care and support provided.”