The first two investigations by the Commission for Health Improvement have identified failures in clinical governance systems which allowed 'cruel practices' to go unchecked.

CHI delivers its heaviest criticisms in the report on the disgraced North Lakeland Healthcare trust - where elderly people with mental health problems were refused food and tied to their commodes while eating breakfast.

It warns that 'lack of awareness' of clinical governance responsibilities could allow a repeat performance of such abuse.

At Carmarthenshire trust, in Wales, where a patient died after the wrong kidney was removed, problems were rooted in the 'management of nursing staff ' and 'arrangements which could allow people to absolve themselves of responsibility for decision-making'.

Technically, CHI kept its promise that it would not name and shame individuals. Instead its investigations identify by job title - and provide an index.

At Lakeland, CHI was 'deeply disturbed' by the failure of Dr Chris Hallewell, associate medical director and consultant responsible for the abused patients, to accept his accountability. His defence - that he was 'made to feel like a visitor on the ward and had not known of the abuse' and was unaware of the recurrence of the abuse despite earlier investigations - showed 'an inadequate sense of responsibility in so senior a figure'.

The fact that Dr Hallewell - who is still in post - holds joint responsibility for clinical governance across the trust, 'compounds CHI's concern'. Disturbingly, from the evidence gathered at the time of its visit in May of this year, 'CHI could not be confident, even at that time, that abuse or malpractice would be reported, or that the trust would respond effectively to such reports'.

The report points out that if the trust had acted on reports from student nurse whistleblowers back in 1996 it could have prevented further abuse, reported by two bank nurses in 1998.

Director of nursing and quality David Moorat headed an investigation, but 'wider issues. . . and previous instances of abuse were not investigated'. Some staff were given warnings, a healthcare assistant was dismissed and a ward manager resigned.

Mr Moorat has now retired.

Chair Mary Styth was dismissed in March. Chief executive Alan Place was dismissed in October.

CHI's investigation into Carmarthenshire trust was sparked by events leading to the death of pensioner Graham Reeves after the wrong kidney was removed.

The investigation found that by June the trust's 'paper' action plan had 'not been implemented at clinical level' and a director of nursing 'does not appear to have a responsibility for quality in nursing'.

It calls for the appointment of a human resource director at executive board level, and a review of trust-wide strategy for clinical governance.

The investigation flagged up 'several concerns' about the management of nursing staff, with a structure that 'operates separately from the general and clinical management of the trust' and a centrally held nursing budget.

See news focus, pages 13-15; comment, page 21.