The shocking report into abuse of residents at a care home by staff has led to those blamed for failure vowing to ensure it does not happen again.
The watchdog responsible for inspecting homes like Winterbourne View said the scandal was a “watershed” while the government said its own review would be published in the autumn.
Other organisations in the care sector said the government needed to show “clear leadership” but warned that a “toxic mix of public sector cuts and ill-considered changes in the way that services are provided” could lead to another scandal.
Calls have now been made for a national policy debate with “far wider implications for the health and social care system”.
The publication of the serious case review by Dr Margaret Flynn came as two charities warned that moving people hundreds of miles away from their families risked another care home scandal.
Mencap and the Challenging Behaviour Foundation said a report they had compiled, Out of Sight, detailed a series of serious cases of abuse and neglect of people with a learning disability in institutional care.
They said they had received 260 reports from families concerning abuse and neglect in institutional care since the BBC Panorama programme uncovering the Winterbourne View scandal aired in June last year.
Care services minister Paul Burstow said the serious case review painted a “horrifying picture of abuse” and highlighted “serious systemic failings”.
“This serious case review paints a horrifying picture of abuse,” Mr Burstow said.
“I will publish the department’s final report of the Winterbourne View review in the autumn.
“This will include the government’s response to the findings of the serious case review and an action plan to drive improvement and change.”
The Care Quality Commission said it had had already made changes to its structure and systems.
The healthcare regulator said it published an internal management review that sets out the results of its own investigation into its role.
The CQC has already made “significant changes” to its systems and processes to ensure that it is “better placed” to respond to concerns of whistleblowers.
Peter Murphy, chairman of the South Gloucestershire Safeguarding Adults Board, expressed “deep regret” for what happened at Winterbourne View.
“In particular, I would like to express our regret to the hospital’s patients and to their families, friends and carers,” he said.
“Winterbourne View hospital should have been a safe place for them to be treated with care and compassion.
“But the hospital’s owners, Castlebeck Care Ltd, failed to provide that care.
“Instead it left vulnerable adults in the hands of poorly trained and poorly supervised staff, who dealt out torment and abuse to those entrusted to their care.
“Many of those staff have now been subject to criminal proceedings and this should send out a clear and powerful message - that where employees engage in this kind of criminal behaviour they will be held to account.”