Neglect by a care home contributed to the death of a severely autistic man who ate cigarette butts, a coroner's court has concluded.
Anthony Dawson, 64, died at Ashmount care home in Epsom, Surrey, from an undetected gastric ulcer in May 2015.
The jury at Woking Coroner's Court said the fact that a GP was not called when he appeared ill was a "gross failure".
Surrey and Borders Partnership NHS Trust said it accepted there were areas where its care was not up to standard.
Mr Dawson's sister Julia said her family had never liked the home, and they had wanted him moved to a more suitable unit.
"It was not a home; it was somewhere to contain people," she told the BBC.
"Anthony was a very gentle person... he was treated less than a full human being."
In a statement, the trust's chief medical officer, Dr Justin Wilson, said: "We fully accept there are areas where our care for Anthony fell short of the standards we expect within our residential services and are truly sorry for this.
"We will now carefully consider the findings from the jury and coroner today to see what actions we need to put in place in the coming weeks to improve the quality of the care we provide, in addition to the quality improvements we have already made since Anthony's death."
The trust said it offered its heartfelt condolences to the family.
The coroner, Darren Stewart, said he would be writing to the trust seeking a review of their procedures to seek appropriate medical advice for residents.
Mr Dawson suffered from the eating disorder Pica, where a person craves non-food items.
He had spent more than 50 years in care and had been a resident of Ashmount for 16 years.
His autism meant that he could not talk but he could understand most conversations.
Ashmount provides residential care for up to seven men with learning disabilities.
A Care Quality Commission inspection a few days after Mr Dawson's death found the home was inadequate, with numerous failings.
It was placed in special measures, but has since been re-inspected and rated as good.
The inquest jury heard that the home was chaotic, with staff failing to properly care for residents, who were left to wander the grounds.
'Death was preventable'
Ms Dawson said it had been known "years ago" that her brother would eat cigarette butts, and she had constantly asked the trust to ensure the site - which had no-smoking signs - was free of them, but her concerns were ignored.
"I did take it high up. I was told by a manager that they couldn't eliminate all risk. It just continued," she said.
Ms Dawson said she believed her brother's death could have been prevented.
"All they had to do was clean their environment. He should have been protected," she said.
The inquest heard that in the days leading up to Mr Dawson's death he was lethargic and had stopped eating.
His sister asked staff to call a GP but this was not done.
A charge nurse called the trust doctor, a psychiatrist, who said Mr Dawson was constipated.
He collapsed on 16 May 2015 in the dining room of the care home.
The cause of death was a gastric haemorrhage as a result of bleeding from a gastric ulcer.
It later emerged that Mr Dawson had not had any blood tests since 2002.
NHS England has ordered an independent investigation.
Charities Mencap and the Challenging Behaviour Foundation said Mr Dawson had "spent his life in the same place shut away from the world, despite the efforts of his family to change this".
In a statement, they added: "It is taking too long for the government, the NHS, the Care Quality Commission and local authorities to deliver on their promises to ensure people with a learning disability get the right support, within their communities and with access to proper healthcare."
The BBC has approached the Department of Health for a comment.
Correction 19 October 2017: This story originally said several staff had been referred to the Nursing and Midwifery Council which was not the case. We have amended the report.