Families condemn care home after coroner says neglect led to five deaths

http://www.theguardian.com/society/2013/oct/18/families-care-home-coroner-neglect-deaths

Version 0 of 1.

Families have condemned standards of care at a Sussex home for elderly people as "beyond comprehension" after a coroner ruled that neglect led to the deaths of five elderly people.

In harrowing evidence during a five-week inquest, it was revealed that residents at Orchid View care home in Copthorne, West Sussex, were given wrong doses of medication, left soiled and unattended because of a lack of staff and suffered because of serious failures in the home's management.

Penelope Schofield, the West Sussex coroner, said those involved in the neglect at the now closed home should be ashamed as it was announced that a serious case review had been set up.

"There was institutionalised abuse throughout the home and it started, in my view, at a very early stage, and nobody did anything about it. This, to me, was from the top down. It was completely mismanaged and understaffed and failed to provide a safe environment for residents."

It was not cheap, with the residents paying £3,000 a month to stay there. But Schofield said it was disgraceful that the home was allowed to be run in the way it was for around two years.

The court heard that call bells were often not answered for long periods or could not be reached by elderly people living at the home, which was deemed "an accident waiting to happen".

Schofield also questioned why the regulator, the Care Quality Commission (CQC), gave Orchid View a "good" rating in 2010 – a year before it shut.

"I question how this could be the case and I question whether the inspection that did take place was fit for purpose," Schofield added.

In a statement Andrea Sutcliffe, the CQC's new chief inspector of adult social care, said: "I am shocked at the descriptions of the care received by residents at Orchid View in 2010 and 2011." Sutcliffe said she would oversee a "root-and-branch review" of the case and the regulator would be changing the way it ran inspections.

The coroner said it was a cause for concern that many people who worked at Orchid View were still working in the industry. This was echoed by Lisa Martin, the whistleblower who first informed police about the care home's failings. Speaking of her former colleagues, she said: "They shouldn't be allowed to work in the industry."

Martin said coming forward had been the right thing to do morally but had cost her personally as she had not been able to work for the last two years. She went to the police after being told by a nurse that they had found 28 drug errors from just one night shift.

The coroner said 19 residents at Orchid View suffered "sub-optimal" care. All of those residents died from natural causes, she ruled. But five of those died from natural causes "which had been contributed to by neglect", Schofield ruled. They were Wilfred Gardner, 85, Margaret Tucker, 77, Enid Trodden, 86, John Holmes, 85, and Jean Halfpenny, 77.

The inquest heard that Halfpenny was given an overdose of the blood-thinning drug warfarin while at Orchid View, which had failed to monitor and administer her medication properly.

Martin, who worked as an administrator at the home, said she was asked to shred forms after Halfpenny had to be admitted to hospital for bleeding.

The coroner heard that Meera Reed, an Orchid View manager, looked at the medication administration record (MAR) brought into the office by a nurse and said: "Shit, we can't send her to hospital with those. They will shut us down."

Blank MAR forms were filled out instead, and Martin said she was asked not to disclose the shredding of the original documents to anyone.

Reed denied asking anyone to dispose of the forms, but the coroner ruled that they had been shredded. Schofield also said she was satisfied Halfpenny was given too much warfarin at Orchid View.

Linzi Collings, Halfpenny's daughter, said the care home had failed to provide her mother with the dignity and compassion she deserved.

She said: "Whilst my sister and I are pleased with the thoroughness of the inquest and we are grateful to the coroner for investigating, the horrific details that have emerged about Orchid View are beyond comprehension.

"How the corporate failings of Southern Cross could create these events and how such terrible standards could go unnoticed by the authorities for so long has left us baffled."

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

In the same year, Sussex police launched an investigation into alleged neglect at the home, in conjunction with the NHS, West Sussex county council, the CQC and Schofield.

Five people were arrested, including some on suspicion of manslaughter by gross negligence in relation to Halfpenny's death, but insufficient evidence existed to support a prosecution and the case was passed to the coroner.

The multimillion-pound home was said to have had a "five-star" feel when it opened in September 2009. Its appearance "seduced" families into believing it was well-run.

A Department of Health spokesperson said: "The lack of care and concern shown towards these care residents was truly appalling. We have made it clear that there must be a sharper focus on taking tougher action when things go wrong and holding those responsible to account.

"Confidence in the regulation regime has been shaken, but we have now turned a corner. We welcome Andrea Sutcliffe's – the new chief inspector for social care – commitment to protecting vulnerable people from abuse and neglect, and to ensuring they receive better care.

"We need to make sure that providers and staff are always meeting the basic requirements for care residents so they are protected from harm, treated with dignity and respect, involved in their care, and given the chance to live a fulfilling life.

"We need to make sure everything possible is done to protect people from poor care wherever it might take place."

Our editors' picks for the day's top news and commentary delivered to your inbox each morning.