Neglect played a part in the death of a disabled pensioner who was strangled by the safety belt of her wheelchair at a Birmingham nursing home, an inquest jury ruled.
The eight-strong jury also identified six "gross failures" in the care given to Brigid O'Callaghan, who was found dead in 2005 after being left unchecked overnight at the Bupa-run Amberley Court Nursing Home in Edgbaston.
Returning a verdict of accidental death to which neglect contributed, the jury found that Mrs O'Callaghan, 74, died of asphyxia after slipping down in her wheelchair.
A four-day inquest at Birmingham Coroner's Court was told Mrs O'Callaghan, who had suffered brain damage in a road accident in 2003, was found with the chair's "posture belt" wrapped around her neck in her bedroom on October 28 2005.
Returning the jury's verdict after two hours of deliberation, its foreman told the court: "Following a Halloween party on the evening of October 27, Mrs O'Callaghan was wheeled to her room by a carer and left there, still strapped into her wheelchair and unable to reach the buzzer.
"Mrs O'Callaghan was then left unchecked for the night."
West Midlands Police arrested a nurse and launched an investigation following the death, but no charges were brought.
Mrs O'Callaghan's son Dennis, said: "The witnesses who gave evidence from Bupa all seemed more inclined to try and blame individual care staff than to acknowledge their own management failures at the home."
Oliver Thomas, operations director for Bupa Care Homes, said: "Immediately after the incident occurred two years ago we investigated and dismissed the staff members who failed to meet the high professional standards we demand."