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| Orchid View inquest: Home riddled by 'institutional abuse' | Orchid View inquest: Home riddled by 'institutional abuse' |
| (35 minutes later) | |
| A care home where 19 residents died was riddled with "institutionalised abuse", a coroner has said. | A care home where 19 residents died was riddled with "institutionalised abuse", a coroner has said. |
| Penelope Schofield has ruled neglect contributed to five of the deaths, at Orchid View in Copthorne, near Crawley. | Penelope Schofield has ruled neglect contributed to five of the deaths, at Orchid View in Copthorne, near Crawley. |
| The West Sussex coroner said the home, then run by Southern Cross, was "mismanaged and understaffed". | |
| Ms Schofield has also criticised the Care Quality Commission (CQC), which gave the home a "good" rating in 2010, a year before it closed down. | |
| 'Heart-breaking case' | |
| A serious case review has now begun into the elderly residents' deaths, which are all "unexplained". | |
| At the final day of a five-week inquest into the deaths, Mrs Schofield said the problems at the home were from the top down and started at an early stage, but nobody did anything to address them. | At the final day of a five-week inquest into the deaths, Mrs Schofield said the problems at the home were from the top down and started at an early stage, but nobody did anything to address them. |
| Orchid View has since reopened under a new name and new management. | Orchid View has since reopened under a new name and new management. |
| Ms Schofield said it was "disgraceful" Southern Cross was allowed to run the home in the way it was, for about two years. | |
| Referring to the CQC's rating of the home, she said: "I question how this could be the case and I question whether the inspection that did take place was fit for purpose. | |
| "It's a heartbreaking case. We all have parents who will probably need care in the latter part of their lives." | |
| While summing up, Ms Schofield said she had found that medical documents for resident Jean Halfpenny, 77, were falsified and that she was given too much of the blood-thinning drug warfarin. | |
| Home manager Meera Reed had earlier denied ordering staff to shred documents and filling in new forms to cover up the overdose. | |
| Continuing, the coroner said that another resident was found naked and in pain with his catheter twisted, while a family member found staff eating toast and drinking tea with their feet up. | |
| 'Staff still working' | |
| Whistleblower Lisa Martin, who first informed police of problems at Orchid View, said she felt she had no choice but to come forward. | |
| Speaking outside the inquest, she said: "I had witnessed too much poor management and care to vulnerable adults. | |
| "I couldn't live with the knowledge any longer and felt I had no choice but to tell the police." | |
| She said she knew she had done the right thing morally, but said she had not worked for two years and the case had had a huge impact on her life. | |
| Speaking of her former colleagues, she said: "They shouldn't be allowed to work in the industry." | |
| During the inquest, the coroner also said it was a cause for concern that many people who worked at Orchid View were still working in the industry. |