Coroner Rules Neglect in A Care Home Caused Five Deaths


A coroner has ruled neglect in a care home has  contributed to the deaths of five elderly people .

They died after the Care Home  Orchid View in Copthorne came in for severe criticism

West Sussexcoroner, said there was described the neglect in the care home as  “institutionalised abuse”.

Orchid View, which was run by Southern Cross Group of Care Homes , was closed down in late 2011 after an investigation by the Care Quality Commission (CQC) found it had failed to meet eight of its essential standards of quality and safety.

Simultaneously that year Sussex Police launched an investigation into alleged care home  neglect at the home. This was carried out  in conjunction with the NHS, West Sussex County Council, the CQC and Ms Schofield the Local Coroner

The investigations led to five people being arrested. Some of the neglect led to suspects being held  on suspicion of manslaughter by gross negligence.

This allegation was in respect of one of the residents who died, but insufficient evidence existed to support a prosecution and the case was passed to the coroner.

The care home does not now exist but the Coroner Ms Schofield said those involved in the neglect in the care home  of the  pensioners should be “ashamed” . A serious case review was set up to look into what caused the neglect in this particular care.

The Inquest lasted five weeks and heard how some residents were given wrong doses of medication and some were left soiled and unattended. In addition  there was lack of management of the staff and also there was insufficient staff to run the care home properly.

Other problems identified were alarm calls often not answered for long periods or the warning bell could not be reached by elderly people living at the home. This was deemed by the Coroner “an accident waiting to happen”.

The Coroner also said it was “disgraceful” that the Care home was allowed to be mismanaged and understaffed. The management had failed to provide a safe environment for residents for around two years in total

The Coroner also had criticism of the Care Quality Commission (CQC) which gave Orchid View a “good” rating in 2010. This was only a year it was forced to close.

A final cause for concern was that astonishly many people who worked at Orchid View are  still apparently working in the  care provision sector. 

The coroner ruled that in all 19 residents at Orchid View suffered “sub-optimal” care.

However all of  those residents died from natural causes she concluded after the evidence was heard into the causes of their death.

But five of those died from natural causes “which had been attributed to by neglect”, Ms Schofield ruled. They were Wilfred Gardner, 85, Margaret Tucker, 77, Enid Trodden, 86, John Holmes, 85, and Jean Halfpenny, 77.

The Home opened in 2009 and was said to have had an appearance of a five star hotel. Thie belied the fact that the staffing and the management was so ppor but the appearances nevertheless convinced a number of families that it was well run and appropriate to rust with their loved ones.

The inquest concluded that the reality was that residents were treated with a lack of respect and dignity and that staffing levels and mismanagement had led to an entirely avoidable neglect in a care home.

Lawyers  acting for some of the families  have called for a public inquiry to be set up, but the coroner decided that she would await the outcome of the independently-run Serious Case Review first.