A 93-year-old woman died after a blunder left her without any care for three days. Elsie Melling was found collapsed at home by her daughter and died just days later in hospital.
An inquest heard how she had a fall at home and a chiropodist treating her feet called an ambulance.
When her daily carers came they were told by the foot specialist she was going to the hospital and they did not need to come in.
But after paramedics arrived it was decided Mrs Melling would not be taken to hospital.
The carers who were meant to come four times a day never came back.
It meant Mrs Melling, from Barnsley, West Yorkshire, never got her vital daily heart failure and high blood pressure medications.
At the inquest Ian Jukes, director of Creative Care and Support which was providing the care to Mrs Melling, apologised to her family.
He said the error occurred after Mrs Melling had suffered a fall at home.
When a carer arrived at lunchtime, Mrs Melling was with a podiatrist who said the emergency services were on their way.
He said: "The podiatrist said 'you can go, the ambulance is on its way,' that's the message that was relayed to our office. We took that as she was going to hospital. We should have checked that thoroughly. That was our mistake and I want to apologise to Mrs Melling's family for that.
"We shouldn't have accepted that, and the person knew she had made a mistake. We now have a more robust policy in place."
Mrs Melling's daughter Julie Loveland described how she had found her mother on January 28 2018. She had not taken her medication.
Coroner David Urpeth did not find there had been neglect, but said the failures had been 'gross'.
He recorded a narrative verdict, which stated: "There was a breakdown in communication which led to Mrs Melling not receiving care for a three day period.
After the inquest, Mr Jukes said: "It was the case that we made a significant error in the care of Mrs Melling and we have met with her family on several occasions to offer our sincere apologies.
"To this end, every possible step has been taken to ensure the error is not repeated."
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