The chief executives responsible for Fletcher Ward during the care scandal and the period leading up to it are now in senior positions across the NHS.
Andrew Morgan was in charge until July 2007 - four months before police were called to the unit, based in Northwick Park Hospital.
But the Primary Care Trust's (PCT) staff had warned the lack of staff was the most significant risk facing the organisation one year earlier.
He is now chief executive at NHS Bedforshire.
David Slegg took over from him as interim chief executive and was in charge when the abuse of elderly patients took place in October and November.
He was replaced by Dr Sarah Crowther in January this year and is now finance director at Ealing PCT.
When the Observer first reported the story last month the PCT said Dr Crowther had been in charge at the time of the police investigation.
And although she wrote to the paper to apologise to the borough on the trust's behalf, she didn't point out that she wasn't in charge at the time.