SEVEN residents died at the Brithdir Nursing Home in New Tredegar between 2003 and 2005.

Here is a timeline of events:

  • 1995: A television programme raises concerns about standards of care and staffing levels at three homes, including Holly House, owned by Dr Prana Das and his wife Nishebita and their company Puretruce Health Care.
  • 2001: The couple are fined £3,000 because one of their homes had no one in charge of it.
  • 2001 to 2005: Six care homes are deregistered by the authorities, three of them owned by Dr Das and his wife.
  • May 2002: Puretruce Health Care takes over management of Brithdir.
  • June 2003: Care Inspectorate Wales inspectors walk out of a meeting with Dr Das having felt threatened by him.
  • September: Paul Black is appointed deputy chief executive of Puretruce Health Care. He has a background in medical sales and marketing. Within weeks he has made savings of more than £100,000.
  • October: Puretruce Health Care is placed in receivership after running into financial difficulties. Care Inspectorate Wales inspectors issue Dr Das with a notice for “urgent remedial action” over care standards in his homes, including problems with pressure sores.
  • November: Care Inspectorate Wales inspectors meet Mr Black about poor standards of care and staff levels at night.
  • January 2004: Dr Das writes to Care Inspectorate Wales to complain about an inspector and blaming them for the death of a patient.
  • February: Dr Das accuses a Care Inspectorate Wales inspector of racism.
  • July: At a Protection of Vulnerable Adults meeting Mr Black acknowledges staffing problems.
  • October: Caerphilly County Borough Council places an embargo on further placements at Brithdir. There are concerns residents had poor nutrition and pressure sores.
  • December: The embargo is lifted but with conditions.
  • May 2005: Dr Das appeals to the Care Standards Tribunal over the cancellation of the registration of Holly House. He later wins the appeal.
  • June: A BBC documentary exposes poor standards of care in homes owned by Dr Das.
  • September: Care Inspectorate Wales issues a new notice to cancel Holly House’s registration.
  • September 29: Stanley Bradford dies at Brithdir.
  • September 30: Edith Evans dies in hospital.
  • October: Gwent Police launch Operation Jasmine following the death of a resident at another nursing home in Newbridge. The following month the police inquiry is widened to include Brithdir.
  • November: Caerphilly County Borough Council gives six months’ notice of cancellation of its contract with Puretruce Health Care.
  • November 30: Evelyn Jones dies.
  • April 2006: The last resident is moved from Brithdir and the home is later sold.
  • July: A Care Standards Tribunal upholds the decision to cancel the registration of Holly House. It is deregistered in September.
  • October 2011: The Health and Safety Executive and the Crown Prosecution Service seek to bring charges against Puretruce Health Care, Dr Das and Mr Black.
  • September 2012: Dr Das is attacked at his home by burglars and sustains severe head injuries.
  • March 2013: Legal proceedings are halted as Dr Das is unfit to stand trial.
  • December: First minister Carwyn Jones announces he is setting up a review of Operation Jasmine.
  • May 2015: The review by Margaret Flynn is published.
  • January 2021: Inquests into the deaths of six residents begin at Gwent Coroner’s Court.
  • March: Assistant Gwent Coroner Geraint Williams records conclusions that neglect contributed to the deaths of five residents. He records a conclusion of natural causes for the sixth resident.

More on the conclusion of the inquest: