What happened at Orchid View care home was unforgivable.

That much is evident.

Neglect at the home contributed to the deaths of five people who should have been spending their last few years in comfort.

That 14 more who died received “sub-optimal” care increased the scale of the scandal.

Let’s forget the jargon for a minute. For sub-optimal read shoddy and unacceptable, adding misery to twilight years.

Four years later we are told that West Sussex County Council is introducing new measures to help prevent another Orchid View.

On first viewing these measures hardly seem to address the issue. There are also serious questions about why it has taken the authority so long to respond to this scandal.

Even something as sensible as a list of homes on the council’s website linked to their Care Quality Commission report will not be in place until September. Why not now?

Indeed why not four years ago.

Did the authority really need to wait for a review to report on Orchid View to bring in some common sense changes?

To hear the county council leader say that some recommendations will take even more time to implement beggars belief.

Although measures such as special teams to advise on care home standards are fine, what the elderly and their relatives really want to know is how rigorous is the monitoring of these homes to identify problems in the first place?

It is hard not to come to the conclusion that the authority’s response remains inadequate.

It is even harder not to agree with the coroner that a full public enquiry needs to take place that examines the role of every participant included West Sussex County Council.