Orchid View: Residents remembered
A coroner has said that a care home in West Sussex where 19 residents died was riddled with "institutionalised abuse".
The hearing, in Horsham, heard concerns about staffing, training and use of medicine at Orchid View in Copthorne, near Crawley.
The inquest looked into the deaths of Jean Halfpenny, Wilfred Gardner, Percy Bates, Ellen Bates, Graham Miller, Maisie Martin, Maureen Donaghey, Margaret Tucker, John Holmes, Enid Trodden, Bertram Jerome, Doris Fielding, Jean Leatherbarrow, Ethel Mehemet, Brenda Anderson, Winifred Redhead, Vera Redmond, Barbara Wilkinson and Ronald Kenward.
Coroner Penelope Schofield said the 19 residents suffered "sub-optimal" care. She ruled that all had died from natural causes, but five of those died from natural causes "which had been attributed to by neglect".
Below are profiles of the five.
Wilfred Gardner died aged 85 in May 2011. His daughter Lindsey Ball said she never saw a care plan and on several occasions her father was in pain but not given medication.
Mrs Ball said she was told he had to ask for medication, but she said to them: "He's got dementia, how would he know what to say?"
Mr Gardner was diabetic and had to inject insulin up to three times a day but sometimes there were no strips to check his blood sugar levels, the inquest heard.
"He was also not always given his insulin but I only found that out after reading paperwork I was sent," his daughter said.
Enid Trodden, 86, who had dementia and Parkinson's disease, died in October 2011.
Her daughter, Lesley Lincoln, said she raised several concerns about her mother's care, including bruising probably caused by inappropriate handling.
She told the inquest that she felt manager Meera Reed was "too young, inexperienced and out of her depth".
She said that Mrs Trodden's medication was given at the wrong time and sometimes at wrong levels, and added that she found her mother cold and wet in bed with her curtains drawn, trying to get up, with her breakfast and lunch on the bedside table.
Seventy-seven year-old stroke victim Jean Halfpenny's health deteriorated after she started living at Orchid View.
She was admitted to the home in November 2009 and died in May the following year.
Her daughter Louise Halfpenny said her mother was given three times more warfarin than her prescribed dose on regular occasions.
The inquest heard Mrs Halfpenny was left unattended and found by a social worker naked and crying in bed.
Margaret Tucker's daughter Patricia Newman said she believed staff deliberately withheld information about how her mother fractured her ankle.
Mrs Tucker, 77, suffered bruises for which she never received any explanation, was left partially-dressed more than once, and on one occasion was left hanging out of bed for about two hours, she said.
Mrs Newman said she twice found her mother's medication in her handbag or on the chest of drawers next to the bed.
She told the inquest that her mother's fracture was discovered days after it happened.
Brenda Mulvaney said she found her 85-year-old father John Holmes, who had dementia, soaking wet in bed even though she had provided incontinence pads for him.
She said staff would make him wear pads during the day when he did not need them, and that she thought this had been done for convenience.
Jeffrey Holmes, Mr Holmes's son, said his father lost a stone in the seven weeks he spent at Orchid View before his death.
"In hindsight I regret putting dad into Orchid View," Ms Mulvaney said.
She said she felt staff were running staff levels "on a budget" and "getting away with the minimum they could".