The Local Government and Care Service Ombudsman found that the elderly woman, identified as ‘Mrs Y’ in the report, was repeatedly failed by her care home and Portsmouth council
An elderly woman who was fed microwaved dog food had been subject to a “catalogue of errors” in the months before she died, an ombudsman review has found.
The woman, referred to as Mrs Y in a report from the Local Government and Care Service Ombudsman, received “inadequate, negligent and inhumane” at-home care from GP Homecare Ltd, known as Radis, in Portsmouth before her death. Mrs Y’s family said they had been left devastated and felt unable to move on and grieve properly for the woman, who was left with reduced mobility and confined to her bed following a fall in April 2024.
On top of being fed dog food, additional reports found she had “eaten almost nothing” some days, was given “stale or inedible” food, and was left unattended “for prolonged periods”, including overnight and while wet.
According to the report, Mrs Y, described as an “older adult” who met the criteria for care and support under the Care Act, was receiving in-house care with Radis that was commissioned by Portsmouth City Council. She was receiving most of her care from her bed, and reliant on workers repsonsible for administering food and fluids, personal care, and medication.
Her family started raising concerns about her care not long after she started receiving it, with her son initially submitting formal safeguarding concerns that his mother was not being cared for in line with her care plan. An enquiry was then opened under Section 42 of the Care Act 2014, and an investigation carried out by a social worker later discovered that care workers were unaware that she required a soft diet following a mini-stroke to reduce her risk of choking.
On some days before the dog food incident, the report found, Mrs Y “had eaten almost nothing”. In mid-June 2024, the report stated that care workers supporting Mrs Y had fed her what was recorded in daily logs as a “lamb dinner”, which they only realised wasn’t lamb after seeing the packaging in the kitchen.
In early July, not long after Mrs Y’s family started looking for a new facility to take care of Mrs Y, the report found that the process was postponed after her health markedly declined. Radis then started providing end of life care, but a further alleged failing was found during this time when Mrs Z claimed footage from her home camera “showed evidence of a care worker force feeding Mrs Y”.
Mrs Y died in July 2024 of what a coroner confirmed was frailty from old age, with a report uncovering a laundry list of failings from her time at Radis. Among them, it was discovered that the Section 42 enquiry into Mrs Y’s care had not started seven weeks after it was allocated by the council. The report stated that the Radis manager had reported “not knowing how to progress the enquiry and did not seek support”.
The full list of failings put together in the report includes:
- Poor repositioning and lack of support with mobility
- Inadequate food provision, including stale or inedible food
- Failure to monitor and accurately record food and fluid intake
- Medication provided in a way Mrs Y could not independently access
- Mrs Y left unattended for prolonged periods and on occasions left wet or in darkness overnight
- Inconsistent staffing and concerns about staff attitude, compassion and respectful communication
- Staff unintentionally prepared and fed dog food to Mrs Y
- CCTV footage alleged to show a care worker feeding Mrs Y in a manner the family considered forceful
- Concerns that staff did not follow the Speech and Language Therapy plan for a soft diet
- Care plans significantly out of date and did not reflect Mrs Y’s increased needs
- Staff did not know how to access care plans, and key documents such as the DNAR were not properly stored
- Families could not access electronic care records
- Allegations that staff falsified records and that some visits had not taken place despite being recorded
- Lack of clarity about management cover during absence, including uncertainty about who to contact in an emergency
- High staff turnover and concerns the registered manager did not receive sufficient oversight or support
The ombudsman concluded in a damning statement that Mrs Y was subject to a “catalogue of errors” in relation to her care and support. It said: “As a result of the enquiry, it has been identified that there was a catalogue of errors in relation to the care and support [Mrs Y] received from Radis in the last few months of her life.
“The enquiry identified concerns such as inaccuracies recorded in [Mrs Y’s] care plan, inconsistencies in care visit recordings and documentation, unclear escalation protocols and procedures for staff, poor handover communication tools, care staff not adhering to [Mrs Y’s] care plan, a carer unintentionally feeding [Mrs Y] a meal made from dog food, a lack of compassion during interventions with [Mrs Y] on two occasions, a significant delay in commencing an allocated Section 42 enquiry from the Local Authority and an overall reduced quality of care.”
The ombudsman proposed following the report conclusion that the council could apologise, refund the care fees, and offer a symbolic £1,000 payment to the family to “recognise significant distress” and “delays” in the safeguarding investigation. Councillor Matthew Winnington, cabinet member for community wellbeing, health and care, said in a statement: “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. The care described in this report is not the standard anyone should expect, particularly at such a vulnerable time in someone’s life. We have apologised to the family and are very sorry for the distress they have experienced; we know this has been deeply upsetting for the family.”
He added: “These events happened two years ago, and since then we have taken action to strengthen how we oversee care providers… Our adult social care services recently received a ‘good’ rating from the Care Quality Commission, reflecting the wider positive experiences of residents, the strength of partnership working across the city, and the support available to help people remain independent.”
Radis Community Care said it “voluntarily withdrew” from providing services in Portsmouth at the end of 2025, and that it has since improve both its services and procedures, and was not employing the care worker involved in the dog food incident. A Radis spokesperson said: “The fact that dog food was mistakenly provided was wholly unacceptable.”
