Staff shortages in the social care team at Redbridge Council were so extreme earlier this year that it was effectively “not functioning”.
An inquest earlier this month heard an Ilford woman died in her home in April, after the adult social care team failed to contact her for months after a referral.
Vulnerable Ilford cleaner Helena Opoku, 67, was flagged as being at risk to the council by hospital staff and her own family on January 7.
However, despite this referral, she was not assigned a social worker until April 1 and died at home three days later.
Her inquest revealed she suffered carbon monoxide poisoning from charcoal fires she used for heat and cooking after her gas and electricity were cut off.
Coroner Graeme Irvine said he had “huge sympathy” with the social care team but fear “future deaths could occur unless action is taken”.
He said: “The service was not functioning, that put people at risk and the information in front of me has not satisfied me that those risks will go away.”
The court heard that, at the time Helena was flagged as at risk, three staff in an 11-person team were off sick and one was on annual leave.
Two sets of agency staff also chose not to stay beyond their inductions in January.
Social care team manager for the area, Renata Wojciechowska, told the inquest Helena was discharged from hospital to a short-term care home called Fernways.
She said a COVID-related staff shortage and a “miscommunication” with Fernways had led the team to “assume” Helena was “not an immediate risk”.
Despite claims in her signed statement that her team had contacted Fernways and tried to speak to Helena, Renata admitted she did not know how or when this was done.
When warned it is a criminal offence to mislead a coroner, she admitted: “I was helped with the writing of this statement.”
She added: “Safeguardings are always treated as a higher priority, we colour coded them and put them as red.
“But when we have such a shortage of staff that we are unable to even immediately allocate the safeguardings, we had to look at the safeguardings again.”
Renata said her whole department was “acutely aware” of the staff shortage, but was not sure if there was a “paper trail” showing it had been raised with her directors.
On hearing the coroner apologise for their loss, Helena’s daughter Sarah emotionally said: “That’s the first time that anybody in authority has said that and sounded like they meant it.
She added: “That’s the point of this, that nobody else has to die and that nobody else has to go through this.”