18 Oct 2013

‘Institutionalised abuse’ at care home – coroner

A coroner rules that neglect contributed to the deaths of five elderly residents at a care home and says that those responsible should be “ashamed”.

West Suffolk coroner Penelope Schofield said there was “institutionalised abuse” at Orchid View care home in Copthorne. A serious care review has now been set up to examine what went wrong.

Ms Schofield said 19 residents, all of whom died from natural causes, suffered “sub-optimal” care. But five of them died from natural causes “which had been attributed to by neglect”.

They were Wilfred Gardner, 85, Margaret Tucker, 77, Enid Trodden, 86, John Holmes, 85, and Jean Halfpenny, 77, pictured above.

The five-week inquest looked at the regime, staffing levels and treatment of pensioners at Orchid View before it closed two years ago. The hearing was told that some residents were given wrong doses of medication and left soiled and unattended due to shortages of staff.

There was institutionalised abuse throughout the home and it started, in my view, at a very early stage, and nobody did anything about it. Penelope Schofield, coroner

Call bells were often not answered for long periods or could not be reached by elderly people living at the now-defunct care home, which has reopened under a new name and management.

‘Mismanaged and under-staffed’

Ms Schofield said: “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 under-staffed and failed to provide a safe environment for residents.”

She said it was “disgraceful” that the home was allowed to be run in the way it was for around two years. She criticised the Care Quality Commission (CQC), which gave Orchid View a “good” rating in 2010, the 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”, Ms Schofield said. “It’s a heart-breaking case. We all have parents who will probably need care in the latter part of their lives.”

She also said a cause for concern was that many people who worked at Orchid View were still employed in the care industry.

Relatives of some of the residents spoke of family members not being tended to properly, of a lack of physical and mental stimulation and not being shown care plans they had asked to see.

One resident, Jean Halfpenny, had been administered three times her regular dose of the blood-thinning drug Warfarin at the home. Whistleblower Lisa Martin, who worked as an administrator at the home, said she had been asked to shred forrms after Mrs Halfpenny had to be admitted to hospital for bleeding.

Her daughter, Linzi Collings, said the home had failed to provide her mother with the “dignity and compassion” she deserved. She added: “In this day and age, you expect measures to be in place to protect vulnerable members of society from being subjected to such horrendously poor care … Orchid View failed to provide her with even a basic level of care, despite being paid a significant amount of money to do do.”

Ms Collings said no-one had been prosecuted for what had happened “and providers across the UK have nothing to fear by not meeting targets and Care Quality Commission standards”.

Orchid View, which was run by Southern Cross, closed in late 2011 after an investigation by the CQC found it had failed to meet 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 the West Sussex coroner.

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

Other pensioners who died were Wilfred Gardner, 85, Percy Bates, 95, Graham Miller, 88, Ellen Bates, 88, Maisie Martin, 89, Maureen Donaghey, 87, Margaret Tucker, 77, John Holmes, 85, Enid Trodden, 86, Bertram Jerome, 93, Doris Fielding, 90, and Jean Leatherbarrow, 88.

The cases of six other residents are also being dealt with by West Sussex coroner Penelope Schofield. Those residents were Ethel Menhennett, Ronald Kenward, Brenda Anderson, Vera Redmond, Winnifred Redhead and Barbara Wilkinson.

Until 2011, Southern Cross was Britain’s biggest care homes provider and was running 750 properties. Financial problems, due to falling income and higher rents, resulted in the company’s collapse and its homes being taken over by the landlords of the premises.