A highly critical review of an investigation into alleged abuse at care homes in south Wales says one of the owners should have been prosecuted.
Dr Margaret Flynn said Dr Prana Das, whose trial was ended when he was injured following a burglary, "should have and could have been prosecuted".
Her review found care providers "impervious" to older people's needs.
The Crown Prosecution Service (CPS) said it still believes there is insufficient evidence for a conviction.
First Minister Carwyn Jones said the report was "testament to inaction and inadequate controls".
He told AMs such treatment of vulnerable people "must never happen again".
Operation Jasmine focused on six care homes in south Wales and cost £15m.
Launched by Gwent Police in 2005 after the death of an 84-year-old woman, it involved 75 police officers over seven years.
In 2013 the trial of the owner of two of the care homes, Dr Prana Das, was ended after he suffered a brain injury in an attack by burglars.
Publishing her findings on Tuesday, Dr Flynn was critical of the decision not to pursue the case against Dr Das because he remained as company director and company secretary for 564 days after the attack.
"I would like the CPS to review this again," she said, adding that the "absence 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" - a quote from Dr Flynn's report
The report said the Director of Public Prosecutions should refer the Operation Jasmine investigation to the Special Crime and Counter Terrorism Division of the CPS.
The inquiry identified over 100 potential victims of abuse and neglect. One woman was found to have developed pressure sores that exposed her bones.
Families who raised concerns about the care given to their loved ones faced a "take it or leave it" attitude, Dr Flynn said.
But the CPS said there are no plans for Operation Jasmine to be reviewed, with a spokesman saying: "We explained to the report that there was insufficient evidence to provide a realistic prospect of a conviction."
Dr Flynn responded: "It's a matter of concern that the CPS reason that the case would fail the basis on lack of evidence of causation.
"There is a section within the report, written by lawyers, that challenges that very fact."
In 2008, the prosecution of eight nurses and carers was dropped.
First Minister Carwyn Jones, who ordered the report in 2013, said it was a "compelling and upsetting read" that "does not flinch from laying out the events that occurred".
"Indeed, things have changed and, in many cases, have got better, but Dr Flynn's report is clear, there is more to be done," he told AMs on Tuesday.
Mr Jones said he would set out in the autumn what Welsh ministers had already done and what further action would be taken in response to the recommendations.
He said he expected a response from any organisation highlighted in the report.
Review recommendations include:
- The residential and nursing care home sector becomes a sector of primary national strategic importance for Wales, is shaped by policies to improve the quality of care, and that care home managers are registered and are members of a professional body which has disciplinary powers
- That the Welsh government, in association with Public Health Wales, ensures that the significance of deep pressure ulcers is elevated to that of a notifiable condition, meaning authorities have to monitor the condition
- That "protective outcomes" ensure the wellbeing of individuals when an allegation is made or evidence of harm has occurred
- Inquests should be held into the deaths of Stanley Bradford, Megan Downs, Edith Evans, Ronald Jones and others known to the coroner
- Gwent Police provides the families of older people in the six homes included in Operation Jasmine with the information prepared by members of the expert panel
- The General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) consider the need for continuing reform to ensure that fitness to practise proceedings are conducted as quickly as practicable
- The Director of Public Prosecutions refers the Operation Jasmine investigation to the Special Crime and Counter Terrorism Division of the Crown Prosecution Service
- Source: In Search of Accountability, a review by Margaret Flynn
Dr Flynn has been involved in previous serious case reviews involving the elderly, and is chair of Lancashire's Safeguarding Adults Board.
She said: "No agency had any traction in bringing to an end the appalling practices.
"Mistakes and errors in judgement characterise the agencies involved in this review."
Mario Kreft, chair of Care Forum Wales which represents care homes, said the review had highlighted "abhorrent" cases of neglect that must never be allowed to happen again.
The Care and Social Services Inspectorate Wales (CSSIW) said it had altered its practices as a result of Operation Jasmine.
It said it had made the accountability of providers clear, toughened enforcement processes, and "placed the experiences of people receiving care at the heart of our inspections".
Chief Inspector Imelda Richardson said: "These events should never have happened. We told families when we met them how sorry we were.
"Everything we have done since has been built on the principle of putting people first.
"We do not tolerate failing care. Providers have an opportunity to put things right, but when they don't, we take prompt action."
Healthcare Inspectorate Wales said the report raised challenges about how effectively different bodies worked together to share information and respond to concerns.
It said it echoed issues found in previous inquiries such as the Keogh review prompted by death rates in Mid-Staffordshire NHS Trust hospitals.
- Home Office review launched in 2005 into alleged neglect at care homes in south Wales following the death of 84-year-old Gladys Thomas
- Mrs Thomas had been a patient at Bryngwyn Mountleigh nursing home in Newbridge and was admitted to Newport's Royal Gwent Hospital after being given incorrect doses of medication. She later died.
- A nurse at the home admitted neglect on the basis of not administering the correct medication
- Eight carers and nurses were charged with wilful neglect relating to injuries on her body but the prosecution dropped the case three weeks into the trial in 2008
- Following the inquiry, Dr Prana Das faced charges relating to neglect and fraud at two care homes he owned - Brithdir Care Home in New Tredegar, near Bargoed, and The Beeches in Blaenavon
- After he suffered a violent assault by burglars, the trial against him was shelved in 2013 but the charges against him remain on file
- More than 4,000 statements were taken during Operation Jasmine; 100 potential victims were identified