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18 October 2013, 15:19 | Updated: 18 October 2013, 15:24
A coroner has ruled that neglect contributed to the deaths of five elderly people who died after staying at a care home which has come under fierce criticism.
Penelope Schofield, the West Sussex coroner, said there was "institutionalised abuse'' at Orchid View care home in Copthorne.
She said those involved in the neglect of pensioners at the now defunct home should be "ashamed'' as it was announced a serious case review has been set up.
A five-week inquest heard how some residents were given wrong doses of medication, left soiled and unattended due to staff shortages and there was a lack of management.
Call bells were also 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''.
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 understaffed and failed to provide a safe environment for residents.''
Ms Schofield 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 - 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'', Ms Schofield added.
She went on: "It's a heart-breaking case. We all have parents who will probably need care in the latter part of their lives.''
And she said a cause for concern was that many people who worked at Orchid View are still working in the industry.
Speaking outside the inquest, Lisa Martin, who first informed police of the problems at the care home, said she felt she had no choice but to come forward.
"I came forward because I had witnessed too much poor management and care to vulnerable adults and I couldn't live with the with knowledge any longer and felt I had no choice but to tell the police,'' she said.
"Morally I know I did the right thing but personally I have not worked for two years and the case has had a huge impact on my life.
"However, I wouldn't want to dissuade people from doing the right thing if they see vulnerable elderly people being abused and neglected.''
Speaking of her former colleagues, she added: "They shouldn't be allowed to work in the industry.''