An 81-year-old widow died after being left alone in her home for nine days after she slipped through the net when the agency caring for her was shut down, an inquest has heard.
Gloria Foster, who suffered from dementia, diabetes and a number of other health problems, depended on carers from agency Care1st 24, based in Sutton, to visit her four times a day.
They provided her with medication and helped to dress and feed her.
But the agency was shut down as the result of an immigration raid last year, leaving her without a carer for nine days.
Somehow she slipped through the net as Sutton Council and Surrey County Council, which both used the agency's services and had been told about the raid in advance, made alternative arrangements for its clients.
An inquest into Mrs Foster's death, which is being held at Woking Borough Council's Civic Offices, heard today that she was found semi-conscious with a faint pulse, low blood pressure, bed sores, dehydrated and in her own urine and faeces by a nurse who visited her at her home in Priory Court, Chipstead Road, Banstead, last January 24.
She died in Epsom Hospital on February 4.
Her cause of death was given as pulmonary thromboembolism and deep venus thrombosis.
Mrs Foster's GP, Dr Imran Rafi, based at the Longcroft Clinic, in Banstead, said he had tried to visit Mrs Foster on January 22 for a check-up, but no one had answered.
He told coroner Richard Travers that he had not been informed that Mrs Foster's care agency had been shut down.
Mrs Foster was only found when a district nurse Rosemary Greig visited her at her home to conduct a routine blood test two days after Dr Rafi's attempted visit.
She said: "I stepped over a small pile of mail and a newspaper at the front door which alerted me that something was probably not quite right.
"There was also a very strong smell of concentrated urine and the flat was extremely warm."
The nurse said she found Mrs Foster fully clothed, lying across her bed, with her legs "dangling over the side" and that her eyes were "very, very stuck together".
She said she called Dr Rafi at his surgery, whose receptionist called for an ambulance.
"I thought she must have been there at least seven days.
"There was extensive tide marks of urine," Ms Greig said.
"I went through her care manual and could see she had no care, food or medication for a nine or 10 day period.
"There was food in the fridge, most of it was out of date. There was rotten fruit in a bowl in the living room."
Ms Greig said she telephoned Care1st 24 six times but the number was "unavailable".
The nurse said she then called social services who informed her that the agency had ceased trading on January 15.
She said: "They said they tried to contact Mrs Foster. They tried to phone her but got no reply."
Dr Geoffrey Rob, a consultant at Epsom Hospital, said Mrs Foster was "very seriously ill" when she was admitted.
Mrs Foster had been diagnosed with pulmonary embolism, a clot in her lung, in 2011.
Dr Rob said that the hospital was aware of the risk to Mrs Foster of developing clots and that she had been given an anticoagulant, to stop her blood clotting.
He said that her condition initially improved, but she died shortly after deteriorating and that her immobolisation and dehydration were relevant in her having developed deep venus thrombosis.
Giving evidence to the court, Ann Penston, Mrs Foster's guardian and friend, said she too only found out that the Care1st 24 agency had been shut down when she visited its base in Sutton on January 25.
She said she was told by someone outside "Oh, they have been closed down, didn't you see it in the Sutton Guardian?"
Ms Penston said she had known Mrs Foster, who was brought up in India, since the 1980s after meeting her at a ladies' bowls club.
She said that Mrs Foster, whose husband died in the 1970s, had always been a sociable and active woman but became very confused and depressed in 2006-7.
By 2012, Ms Penston said her friend would no longer leave her house.
The inquest is expected to last for five days and deal with how Mrs Foster died.
But inquests do not aim to attribute blame.
In May, the Crown Prosecution Service and Surrey Police said they conducted an extensive investigation into Mrs Foster’s death and concluded that there was no criminal case for anyone to answer.
A report into her death by the the Surrey Safeguarding Adults board cleared Sutton Council of blame.
However, it revealed a Surrey County Council worker charged with making sure Mrs Foster was looked after made a record claiming to have called the vulnerable pensioner the day after the raid only to get no answer.
The subsequent police investigation revealed no such call was made.
The inquest continues.