The patients, all frail and suffering from dementia, were transferred by Barnet Health Authority from Napsbury Hospital, Hertfordshire, to the privately-run Elmstead House nursing home in April this year. Out of the 24 transferred, seven were dead in less than two weeks from natural causes.
The first death was on 5 April - only four days after the patient had been transferred there. Another patient died on 15 April, four more on 19 April and one a day later. Six weeks after that another patient died.
The report found that planing, implementing and monitoring of the move was not carried out in sufficient detail. As a result, many of the patients, whose average age was 80, were transferred without any recent update in the medical records, and little was known about their individual needs.
One social worker visiting the homes noticed than an elderly patient who was allergic to fish was being given a fish meal and in another case a special mattress needed by a patient was not available.
Three patients developed bed sores, one within 24 hours of arriving at Elmstead. Following the deaths, the health authority stopped the transfer of patients to the home.
The review panel, made up of five local organisations and the charity Age Concern England, concluded that "Insufficient weight" was given to the risk of mortality.
Barnet's director of public health, Dr Stephen Farrow, said that there had been a lack of continuity of care which meant that patients' needs had not been met. While the panel could not be certain that individual deaths themselves were precipitated solely by the move, it concluded that the plan for familiarising the new staff was not sufficiently specific or detailed. And with the original staff only staying for a few hours on the day the patients were moved, there was "insufficient time to completely hand over the care of very ill and confused patients".
As many as 15 people were transferred in a 24-hour period - the recommendations now suggest no more than two should be moved at any one time and no more than three within a seven-day period.
"These eight people were among the most vulnerable of the patients in the Health Service ... I failed and we failed to provide them with the care they needed," said Dr Farrow.
He added that regrets were not enough and he had personally apologised to all the relatives of the patients.
Evelyn McEwen, director of information for Age Concern, said that national guidelines should be drawn up to stop such an occurrence happening again.
"The Government has got to take action ... we need guidance in transferring patients for use in every authority ... rather than as happens so often, [each one] re-inventing the wheel," she said.
Andrew Dismore, Labour MP for Hendon, said that he was seeking a meeting with Paul Boateng, the minister responsible for care of the elderly.
"There is no doubt that the eight elderly patients faced increased and avoidable risks due the transfer... the best interests of the patients should be paramount, not schedules and timetables. I will be seeking assurances that the Department of Health accepts the recommendations that national guidelines should be produced for the transfer of elderly patients in the future," he said.