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“All the agencies involved have worked hard to prevent this happening again.

Since this situation first came to light almost two years ago, we have continued to examine and improve our own practice.

"This will have been tremendously upsetting for the victims and their families and the board very much thanks them for the support they gave the investigation.

"I know that the agencies involved have learned lessons and I hope that they can be learned nationally too." Mark Lever, chief executive of the National Austistic Society, which runs Mendip House, has issued a statement.

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“We want to take this opportunity to repeat our previous apologies to the residents at Mendip House and to their families for the distress they experienced.

"That is why some of our key recommendations are addressed to the Department of Health and Social Care and national bodies.

"This board exists to protect vulnerable people and reduce the risk of incidents like those at Mendip House happening again.

The review has sparked calls for nationwide changes to the way care placements are managed.

Richard Crompton, independent chairman of the SSAB, said: "These reviews are not about apportioning blame.

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