A review into a £15m police investigation into alleged abuse in care homes in South Wales, concluded that Dr Prana Das who owned two of the six care homes being investigated should have been prosecuted.
Operation Jasmine was a major Gwent Police investigation which started in November 2005 into 63 deaths in care homes in South Wales.
Some of the victims were residents of Brithdir Care Home in New Tredegar, near Bargoed, and The Beeches in Blaenavon run by Puretruce Health Care Ltd and owned by two GPs, Dr Prana Das and Dr Nishebita Das.
However in January 2010, the Crown Prosecution Service (CPS) formally advised Gwent Police that there was insufficient evidence to support a reasonable prospect of prosecution for either gross negligence manslaughter or wilful neglect.
In her report 'In Search of Accountability', Dr Margaret Flynn criticised the CPS for this decision saying it ‘should have been tested before a jury’.
She added that the lack of a judgement or legal resolution ‘compounds the families' grief and sense of grievance’.
‘Older people's injuries, pain and life-threatening deep pressure wounds were unobserved, unreported, reported inaccurately and/or reported belatedly - and yet, in this case, no crimes were identified by the Crown Prosecution Service,’ she added.
During 2011, responsibility for leading the investigation was transferred to the Health and Safety Executive (HSE). Charges were then laid against Puretruce Health Care Ltd, Dr Prana Das, and the chief executive, Paul Black, under the Health and Safety at Work Act 1974.
However this trial had to be stopped after Dr Prana Das was assaulted during a burglary in which he suffered head injuries.
The review, which was commissioned by the Welsh Governmnent, called on the Director of Public Prosecutions to refer the Operation Jasmine investigation to the Special Crime and Counter Terrorism Division of the Crown Prosecution Service.
The report said the people operating the homes investigated by the inquiry "appeared impervious to the needs of older people and the growing concerns of their families".
Mario Kreft, chair of Care Forum Wales, which represents care homes in Wales, called for a “fundamental change of culture” in the wake of the review. He said: “We very much welcome this important review and we have to make sure that these abhorrent events never happen again.
“We must collaborate to work in a very different way in the future - not just in identifying poor services but improving all the services we provide.
“A great deal of what is being recommended in the report chimes with what Care Forum Wales has been saying for 25 years, that social care providers need to work collaboratively on a local, regional and national level.
“We need to create a climate where people take responsibility, promote transparency and not become even more risk averse than they already are.”
Action on Elder Abuse Cymru (AEA Cymru) welcomed the report saying it has exposed the failings in the handling of cases of neglect of older people in care homes in South Wales.
AEA Cymru director, Rachael Nicholson, said: “We know that older people are let down time and time again by the Criminal Justice System, and this is highlighted in In Search of Accountability.
“We are pleased to see Dr Flynn’s recommendation for the Operation Jasmine investigation to be reviewed by the CPS. Dr Flynn reported that care home staff ‘had neither the skills nor the knowledge to care competently.
“AEA Cymru exists to protect and prevent the abuse of older people in Wales and will campaign to ensure that all care home staff receive adequate training, support and supervision, and that Criminal Justice agencies consider all allegations of abuse as crimes.”