The Coroner presiding over an eight-week inquest into deaths in a care home in South Wales in the early 2000s has found that there was serious abuse by the nursing staff and managers. Anna Midgley represented the contracting local authority. There were concerns that steps should have been taken earlier by that authority, the local health board, and the regulator CSIW as it then was, to terminate the contract for care with the provider and/or take enforcement action. Whilst the Learned Coroner held that there had been too much focus on processes, the outcome of the inquest was that it was acknowledged that the employees of the state agencies had acted to the best of their ability, were working in extremely difficult circumstances, and were hamstrung by the legislation in place at the time. The inquests had been significantly delayed as a result of a massive police investigation and criminal trials, one of which was unsuccessful due to an attack on the defendant Dr Das, who was the owner of the home in question. Following an inquiry (the Flynn Review) and extensive review of procedures within the state agencies involved, the conclusion of the inquests marks the end of a long road of learning lessons for the agencies, and, it is hoped, provided some answers for the families.
