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A home carer fed a woman microwaved dog food in the last few months of her life in the course of giving care described as a 'significant personal injustice'.
The Radis Community Care worker cooked and fed the woman the pet food in June 2024 despite the fact it was kept in packaging labelled 'for adult dogs and puppies'. The care worker logged it as a 'lamb dinner'.
It was one of a litany of errors that occurred over a number of months ranging from giving her stale food to leaving her in her own mess and in darkness overnight, falsifying care visit records and force-feeding as her health deteriorated.
Portsmouth City Council, which had commissioned Radis to provide care services for people in the area, has apologised and dropped the care firm's services.
The Local Government and Social Care Ombudsman investigation was told that the woman, named as Mrs Y, began receiving care from Radis after a fall in April 2024.
Shortly after, her son raised a safeguarding complaint about how his mother was being positioned, food hygiene and medication.
A 'do not resuscitate' note was found scrunched up in a cupboard and there were days where she appeared to have eaten nothing at all.
It led to Radis being given an action plan by Mrs Y's social worker and, following a mini-stroke, an agreement to feed the elderly woman soft food.
A woman was fed microwaved dog food from a packet labelled 'for adult dogs and puppies', an investigation found (stock photo)
Local Government and Social Care Ombudsman Amerdeep Clarke (pictured) called it 'a truly shocking case'
Around this time, the woman was fed the dog food, which was also labelled as a 'fresh take on dog food'. The vacuum packed food had been microwaved, and the woman had been given three mouthfuls.
Another care worker who had been present noticed the packaging in the kitchen - but it took her a week to get hold of a senior colleague in order to raise the alarm. The food was then removed from Mrs Y's kitchen.
Efforts were being made to remove Radis from the picture when her health deteriorated, and around this time a home camera caught a care worker appearing to force-feed the elderly woman.
A new supplier was not found before she died in July 2024, a coroner ruling she died of 'frailty of old age'. Radis, while accepting its workers had failed to look after Mrs Y, refused to agree to remedies demanded by the woman's daughter.
Portsmouth City Council investigated and found Radis had delivered 'poor' care amidst 'unsafe practices, weak management oversight and failures in record keeping'.
The Ombudsman went on to recommend that Radis refund Mrs Y's care fees to her family - a rare intervention but justified because 'the service provided was so poor that the provider effectively failed to deliver the service paid for,' it said.
'We find the care was so poor that Mrs Y’s estate should receive a full refund of any client contributions she paid to the Council between April and July 2024,' it said.
It has told Portsmouth City Council to apologise to Mrs Y's family, to refund care fees, and to pay an additional £1,000 in recognition of the distress caused by both the failings in care and subsequent delays into a safeguarding investigation.
The council says it has met those requests.
Councillor Matthew Winnington, the authority's cabinet member for community wellbeing, health and care, said: 'We accept the Ombudsman's findings in full and recognise the seriousness of what happened in this case.
'We ended our contract with Radis early and we no longer work with, or commission services from them.'
Local Government and Social Care Ombudsman Amerdeep Clarke said: 'This is a truly shocking case.
'A vulnerable woman's care deteriorated over many months while a statutory inquiry drifted without proper oversight.'
Radis claimed in a statement to the BBC that it 'voluntarily withdrew' from its contract in Portsmouth.
It said: 'The fact that dog food was mistakenly provided was wholly unacceptable.'