The owner of a care agency, dropped by a council after a serious case review into an elderly woman's death, has spoken about the case.
The Coventry woman, 91, died after being admitted to hospital with bed sores.
Martin Carey, owner of the dropped care agency My Care UK, said others were also at fault over her care.
A council spokesman said the important outcome was to reduce the likelihood of a similar event.
The case review concluded better communication between health and social care workers would have improved her care and her deterioration would have been noticed and addressed more quickly.
But the council stopped using My Care UK, and the firm has since collapsed.
The woman, who is not being identified and who has been known as Mrs A, had been cared for at home after leaving hospital where she had been treated after having a fall.
She had been getting four visits per day from health and social care staff.
She died the day after being admitted back into hospital, in January 2009. The cause of death was given as sepsis, also known as blood poisoning.
Mr Carey, of My Care UK, said a senior carer for his firm had contacted a social worker who had looked after the woman in hospital and advised her that there needed to be an urgent review of the woman's care package.
He added a referral was made by the social worker for an occupational health visitor to visit, but the urgent review which he expected did not take place.
"I think its abhorrent that it actually took Mrs A's death, a police investigation, the demise, if you like, of my company, just for a serious case review for example to identify one of its summary findings that maybe we should communicate better with each other.
"I think that's a travesty," he said.
Police and the Crown Prosecution Service have said they investigated the case but decided not to prosecute.
In a statement, Brian Walsh, chairman of Coventry's Safeguarding Adults Board, said reviews were not about apportioning blame.
"This review carefully considered the circumstances involved in this case in order to gain an understanding of the lessons that can be learnt," he said.
- 27 July 2010