A coroner ruled that neglect contributed to five of the 19 deaths that occurred at Orchid View care home in Copthorne, West Sussex.
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The daughter of a woman who died due to neglect at Orchid View care home said her mother was denied the "dignity and compassion" she deserved and called for "dramatic changes" to the care system to ensure that there are consequences for care home owners for "substandard services."
Speaking outside the court, Linzi Collins, whose mother Jean Halfpenny overdosed on a blood thinning drug whilst in the care home, said:
"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.
"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.
"Our mum deserved to be treated with dignity and compassion but Orchid View failed to provide her with even a basic level of care, despite being paid a significant amount of money to do so
"We believe dramatic changes are needed to the current care system, starting firstly with greater accountability for care home owners if they are found to be making unnecessary mistakes and offering substandard services."
Lisa Martin, a former care home worker who alerted police to failing at the Orchid View care home in Copthorne, said she the "final straw" for her came when she was told by a nurse that 28 drug errors had been made on just one night shift.
She called police who arrived the next day.
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 attributed to by neglect", Ms Schofield ruled.
They were Wilfred Gardner, 85, Margaret Tucker, 77, Enid Trodden, 86, John Holmes, 85, and Jean Halfpenny, 77.
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 knowledge any longer and felt I had no choice but to tell the police.
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."
Penelope Schofield, the West Sussex coroner, 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.
It's a heart-breaking case. We all have parents who will probably need care in the latter part of their lives.
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.
Neglect contributed to the deaths of five elderly residents at the Orchid View Care Home in West Sussex, a coroner ruled today.
Relatives of the 19 elderly people who died inside Orchard View care home in Copthorne, West Sussex, told an inquest into their deaths they were concerned about the levels of care inside the home.
Call bells were often not answered for long periods of time, and in some cases were in places that the residents could not reach.
Relatives said their loved ones were not tended to properly, were often left unattended and physically inactive for long periods of time, and were not given any mental stimulation or attention by staff.
The inquest hearing into the deaths of 19 elderly residents who died in Orchid View care home in Copthorne, West Sussex, heard that some residents were given the wrong doses of medication, and were left unattended for long periods of time due to shortages of staff.
The relatives of 19 elderly residents of Orchard View care home on Copthorne, West Sussex, will hear the results of an inquest into their deaths today.
A five-week inquest has scrutinised the levels of care received by the residents before they died.
The care home closed down two years ago, and has since reopened under a new name and management.