A CORONER has criticised a lack of communication between agencies which led to a vulnerable woman not being seen for two weeks before she was rushed to hospital.

Janet Borrino, who had mental health problems, died from multiple organ failure as a result of pneumonia four days after police had to force their way into her Stratton Grove, Horwich, home and found her unconscious on her living room floor.

Assistant coroner Timothy Brennand said it was clear there had been a communication breakdown between the agencies involved in delivering Miss Borrino’s care.

He added: “The home care support team took the view that they simply had to get the shopping in and had not taken the view of noting anything that might touch on her eating disorder.”

Her sister, Pamela Currie, told the inquest that when she visited the flat after Ms Borrino was taken to the Royal Bolton Hospital on November 18 last year it ‘smelled like a toilet’ and it seemed she had been surviving mainly on a diet of crisps.

A diary intended to be a daily record of Ms Borrino’s condition only contained one entry, dating back to August – although it was not established if this was the only diary in use.

Ms Borrino, aged 55, was treated for an eating disorder at Clatterbridge hospital in Liverpool towards the end of December 2015 and then transferred to a psychiatric ward at Royal Bolton Hospital.

Following her discharge in January 2016 a care package was put in place by the community mental health team, social services and home care support workers.

At this time she would not see her family and also had a history of refusing to engage with mental health services. In November she cancelled care, claiming she was going away on a caravan holiday for a week.

But, no holiday was booked and she did not leave her home.

The inquest heard that the last time a home care support worker had contact with Ms Borrino was the last week of October.

Mr Brennand, who described the case as ‘sad and troubling’ said while he did not find there had been negligence, there had been communication breakdown.

He recorded a narrative conclusion that Ms Borrino had died of natural causes, but added: “Natural causes is not enough to reflect the complexity of this case.”

Following the inquest Ms Borrino’s mother, Rita Wildish and sisters Pamela Currie, Lorraine Wildish and Gillian Peacock said that they accepted the coroner’s findings, but had expected harsher criticism of the agencies responsible for her care.

Mrs Currie said that before Ms Borrino’s mental health difficulties they had a good relationship with her.

She said: “Unfortunately when she needed help the system let her down.”