Two council workers have been suspended and face further disciplinary action following a report which found that officials had failed to care for an 81-year-old woman who died after being left without food or medication for nine days.
The serious case review into the death of Gloria Foster, published on Monday by Surrey Safeguarding Adults, says council officials neglected to call her to make alternative care arrangements when the care company looking after her was raided and closed down by immigration officials.
An official subsequently attempted to cover up the oversight, noting in the official log that a phone call had been made to Foster's home. Police records show that there were no calls made to her by the council over the relevant period, according to the serious case review.
Surrey county council apologised for its failures and said disciplinary action would be taken against two members of staff who had already been suspended.
Carefirst24, the care company responsible for visiting Foster four times a day to feed and care for her, was raided by the UK Border Agency on 15 January this year after allegations that the firm was employing illegal immigrants.
The UKBA liaised with officials from both Surrey county council and Sutton council before the raid in order to pass on details of all the clients on the care company's lists and give them time to arrange alternative care.
Care was put in place for everyone except for Foster, a frail widow with dementia, who was entirely dependent on the visits from carers. A note placed in the log book after the discovery of Foster's body stated that a call was made to her home, noting that there was no response, but police records showed that no calls were made.
The review states: "Further inquiries have since established that Surrey county council's telephone systems (landline and mobile) do not contain a record of a call being made to Mrs Foster across a three-week period including 14-16 January 2013. Yet on 25 January it was recorded in the Surrey ASC adults integrated solution (AISS) that there was no reply to a telephone call made to Mrs Foster on 16 January 2013. Mrs Foster's phone did not have an answerphone facility but the police have confirmed there were no incoming calls from any relevant party."
The serious case review panel has concluded that this discrepancy about phone calls "should be the subject of further Surrey county council investigations".
The formal note of the disputed phone call was made in the log books the day after details of Foster's abandonment by social services became headline news.
The senior Surrey council official responsible for setting up alternative care noted on the records on 25 January: "T/C [telephone call] was made to Mrs Foster on 16.1.13, no reply. Unfortunately I did not put this note … at the time I rang as I was busy setting up emergency care for other service users who had the same care agency.
"I did ring this lady but there was no reply. I assumed, which I probably should not have done, that as a self-funder she was able to arrange her own care, in hindsight this lady should have been visited, this was an error on my part."
The report does not name the individual, nor does it call for disciplinary action. However, Andrew Povey, a former leader of Surrey county council who has been campaigning to get more detail about the circumstances leading up to Foster's death, said: "I think that someone must be held responsible; ultimately it is the leader who is responsible."
Foster was discovered by a district nurse, who was making a routine visit to her home, on 24 January. The review states that the nurse found Foster in a "very poor physical state".
"She was cold, lying partially off her bed, which was sodden with urine and faeces, and she appeared dehydrated with cracked lips. The ambulance crew were unable to record a blood pressure or find a radial [wrist] pulse, indicating that her blood pressure was extremely low," it reads.
Surrey county council's strategic director for adult social care, Sarah Mitchell, apologised for what had happened to Foster and promised changes were being made.
"We are very sorry for our failure to help Gloria Foster to get the support she needed. This report points out we should have done more and we completely accept that," she said.
"While we have already made changes following this dreadful case, we'll now act on these findings to do all we can to prevent anything like this happening again. Two members of staff have been suspended and we'll be taking disciplinary action in light of these findings."
Foster died in Epsom hospital 11 days after being admitted.
Friends paid tribute to her in the report. Ann Penston, her closest friend, described Foster as a "gregarious person who would sit down and chat with anybody". She was also described as fiercely independent.
