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A coroner has slammed the care given to six residents who died at a scandal-hit nursing home as he gave a withering summary of a catalogue of failings, accusing managers of "dehumanising" the elderly.
Assistant Gwent Coroner Geraint Williams relayed his findings after hearing six weeks of evidence into the deaths of the residents at the Brithdir nursing home in New Tredegar, Caerphilly.
He accused the owners and staff at the home of a "gross betrayal of the trust" placed in them by the relatives of the residents by keeping them in the dark over the poor standards of care.
Six residents - Stanley James, 89, June Hamer, 71, Stanley Bradford, 76, Edith Evans, 85, Evelyn Jones, 87, and William Hickman, 71 - died between 2003 and 2005.
They suffered dehydration, malnourishment, and pressure sores on their bodies with rotting flesh described as smelling like a "dead cat".
In a lengthy summing up of the evidence, Mr Williams said: "The view of Margaret Moody, the nursing expert, and Professor Malcolm Hodkinson, the consultant geriatrician, was that the attitude of the staff at Brithdir was that residents were being 'warehoused'.
"They explained this as a situation where the residents were simply kept and were being fed and watered with the bare minimum being done and then the staff going home.
"I accept without hesitation that description of the philosophy.
"What is worse, in my judgment, is that even the feeding and watering - to use Prof Hodkinson's phrase - was inadequate, given that some of the residents were admitted into hospital suffering from dehydration and malnutrition and that the bare minimum was resolutely below any acceptable standard.
"Such philosophy I find led inextricably to a neglectful and abuseful attitude on the part of many of the staff at Brithdir."
The coroner said one manager had authorised the practice of changing residents' incontinence pads in the lounge in the presence of other staff.
"He justified that practice on the basis that as the residents were suffering from dementia, they would not know what was happening to them," the coroner said.
"That practice I consider was one by which the residents were dehumanised and is perhaps the lowest point in the story of the Brithdir nursing home.
"I have no hesitation in confirming as an unequivocal fact all these matters contributed significantly to the deaths."
Mr Williams recorded narrative conclusions for all but Stanley James, whom he ruled had died from natural causes.
A hearing into the death of a seventh resident, Matthew Higgins, 86, will be held in due course.
Resident Stanley Bradford's daughter had previously described him as looking like an inmate from a prisoner of war camp because he was 'skin and bone'.
Gaynor Evans said her father had begged not to return to Brithdir while in hospital.
Residents were often unkempt and dirty, care plans would be ignored, documents falsified, and residents would be humiliated by staff.
One former staff member said she saw a care worker draw a moustache with a permanent marker on the face of a female resident.
During the inquest several Brithdir staff apologised for the "shocking lack of care", which was "bordering on being negligent".
Others said there was a "systematic failure of the system" at Brithdir with staffing levels "dire", and carers having to provide their own PPE.
Relatives who raised concerns about the care their loved one was receiving were fobbed off after receiving a "good explanation".
Brithdir was part of a group of 24 care homes owned by local GP Dr Prana Das and his Puretruce Health Care company.
Temporary embargoes on new residents were placed on Brithdir, regular inspections were carried out and improvements notices issued but it was not until 2006 the home finally closed.
Dr Das was known to be "very rude and offensive" with social care inspectors and would often launch legal challenges to decisions of regulators.
Social workers also failed to carry out regular assessment of the residents being funded by Caerphilly County Borough Council, with senior managers admitting there were "systemic failings" and it was "quite possible" they should have taken tougher action much earlier against Dr Das.
Police launched the Operation Jasmine inquiry in 2005 following the death of an elderly resident at another home.
The inquiry lasted nearly a decade and cost more than £11 million, with detectives looking at 63 deaths.
Charges were brought against Dr Das and the Puretruce chief executive but the trial collapsed in 2013 after Dr Das suffered severe head injuries in an aggravated burglary at his home. He died last year aged 73.
Dr Das had been the subject of complaints about his homes dating back to the mid-1990s and there had been a long history of involvement with the authorities.
In 2015, several staff were struck of the nursing register and others received suspensions.
In a statement, the Older People’s Commissioner for Wales Heléna Herklots CBE, said: “I know that the pain and grief amongst families who lost loved ones following the shocking failures of care highlighted by this inquest are still very real, and I would like to pay tribute to the dignity with which they have made their voices heard and spoken up on behalf of their relatives.
“Their hard work and tenacity over many, many years has provided much needed, although often very painful, answers about the catalogue of failures, at both an individual and system level, which resulted in dehumanising and degrading treatment that ultimately contributed significantly to the deaths of their loved ones, vulnerable older people whose trust was betrayed in such an appalling way.
“Today’s findings underline why the changes we have seen across our social care system in the years since these failures occurred have been so important, and why learning and work to deliver improvements must continue to ensure that older people never again experience the kind of shameful care that the residents of Brithdir sadly endured.”