These are external links and will open in a new window Close share panel Image caption Orchid View, which has since reopened under new management, was run by Southern Cross A care home where 19 residents died was riddled with "institutionalised abuse", a coroner has said.
These are external links and will open in a new window Close share panel Image copyright other Image caption An inquest found all 19 people who died received Orchid view care and five cases involved neglect A man whose mother died at a scandal-hit care home has said a serious case review has not gone far enough and the private care home sector has failed.
Russell Tucker, 54, whose mother Margaret Tucker died at Orchid View, has called for government action to prevent other similar cases. The West Sussex home saw 19 unexplained deaths - five cases involved neglect. The review has made 34 recommendations.
Orchid View, which was run by Southern Cross in Copthorne, closed in The care home has since reopened under a new name and new management.
After the serious case review findings were published on Monday, Mr Tucker, from Oswestry, Shropshire, said: Useful information has come out on a local basis, but equally issues have come out that impact nationally that is outside the remit.
The private sector is not the place for the care of the most vulnerable in society, and it has failed. Residents were left soiled and unattended, and one night shift saw staff make 28 drug errors.
Media playback is unsupported on your device Media captionJudith Charatan, daughter of resident Doris Fielding: Solicitor Laura Barlow also said questions remained over who was ultimately accountable and added: Independent chairman and author of the report, Nick Georgiou, wrote: Image copyright BBC news grab Image caption West Sussex councillor Peter Catchpole said the report would help prevent similar cases in the future Following publication of the serious case review findings, the CQC issued its own report.
Andrea Sutcliffe, chief inspector of adult social care, said Southern Cross and Orchid View staff were primarily responsible for failings, but the CQC had looked at its own role and knew it did not fulfil its purpose.
Ms Sutcliffe said action had been taken to make the CQC more responsive to risks, and to improve inspections and further improvements would be made. Some of the recommendations were local to West Sussex, and others were applicable more widely.
West Sussex councillor Peter Catchpole said:Fulfillment by Amazon (FBA) is a service we offer sellers that lets them store their products in Amazon's fulfillment centers, and we directly pack, ship, and provide customer service for these products.
Orchid View has since reopened under a new name and new management. Ms Schofield said it was "disgraceful" Southern Cross was allowed to run the home in the way it was, for about two years.
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