The Local Government and Social Care Ombudsman is urging councils and care providers to learn urgent lessons about accountability and safeguarding, after an investigation found an elderly Portsmouth woman received months of substandard care - including being fed dog food - while a statutory safeguarding inquiry sat unresolved for six months.

The Ombudsman's report into Portsmouth City Council, who commissioned the homecare from Radis Community Care, found the woman was subjected to what the council itself described as "a catalogue of errors".

Care workers visited the woman, who was cared for in bed following a fall, several times a day to provide food, fluids, personal care and to administer medication. But the council’s own safeguarding enquiry found concerns about staff:

• allegedly falsifying records and not carrying out some visits despite them being recorded as having been undertaken
• ignoring or not being aware of the woman’s care plan
• not positioning her properly and not supporting her with her mobility
• feeding the woman inappropriate food, including stale and inedible food. This also included CCTV footage allegedly showing a care worker feeding the woman in a way the family considered forceful, and staff not following the Speech and Language Therapy plan for a soft diet
• providing medication in a way the woman could not independently access it
• not monitoring her or accurately recording her food and fluid intake
• leaving her for prolonged periods, and on occasions leaving her wet or in darkness overnight
• unintentionally feeding the woman microwaved dog food - recorded in the daily log as a "lamb dinner".

The family also discovered the woman's Do Not Attempt Resuscitation (DNAR) document scrunched up in a cupboard, its details unknown to the care workers responsible for her.

The Ombudsman’s report also highlights failures of oversight by Portsmouth City Council. When safeguarding concerns were first raised in April 2024, the council opened an enquiry. Its own local policy sets a 28-day completion target, but this was not completed till October 2024 - six months later.

The Ombudsman found the council had treated Radis' internal investigation as if it discharged its own statutory duty, without putting in place independent scrutiny - despite Radis already being subject to a separate Large Scale Safeguarding Enquiry at the time. The Ombudsman found the failings engaged the woman’s Human Rights under Articles 3 and 8, relating to degrading treatment, dignity and private life.

Local Government and Social Care Ombudsman, Amerdeep Clarke said:

"This is a truly shocking case, with abysmal failures. In this case, a vulnerable woman's care deteriorated over many months while a statutory inquiry drifted without proper oversight. It is a stark reminder that a council's safeguarding duty does not end when a contract is signed. Councils must actively scrutinise the care they commission - especially where concerns already exist about a provider.

“For care providers, the message is equally clear: robust care planning, clear escalation, and accurate record keeping are not administrative niceties, they are the foundations of safe care. I urge every organisation working in adult social care to look carefully at the lessons from this case."

The Local Government and Social Care Ombudsman remedies injustice and shares learning from investigations to help improve public, and adult social care, services. In this case Portsmouth City Council has accepted the Ombudsman's findings and has agreed to apologise to the family, refund the woman's care fees for the period April to July 2024, and make symbolic payments totalling £1,000 to recognise the distress caused.

The council no longer commissions services from Radis.

Article date: 05 August 2026