A woman has questioned why no inquest was ever held into the death of her mother, who was sent home from Homerton Hospital without being told her back was broken.

Carol Solomon’s body has been rotting in a morgue for months because her daughter Elisabeth refuses to bury her until a post mortem is completed to shed light on why she died.

Despite paying £650 to the Whittington Hospital for one herself, the money was bizarrely refunded back to her bank account because she had “been rude to staff on the phone”.

According to Carol’s GP Dr Theresa Murphy De-Souza, the various agencies involved in her care had “all agreed” a month before her death they had “made mistakes from the beginning at the Homerton, at UCLH, in your house, everywhere”.

The admission came at a meeting between various agencies and Elisabeth in February. On March 10, Carol, of Queensdown Road, died.

She had been admitted to the Homerton six times in 2017 after she kept falling over. On September 18 two nurses at Moorfields Eye Hospital made safeguarding referrals for suspected neglect after she was left there alone for a routine appointment covered in bruises, with her buttocks on show and without incontinence pads. Despite her protests, Carol was sent back to the Homerton without an investigation being carried out.

It only came to light in November 2017 that a CT scan at Homerton five weeks earlier had diagnosed her with a suspected broken back but she hadn’t been told. The revelation came at UCLH, which she attended because of excruciating pain, explosive bowel movements and trouble breathing. After her discharge from the Homerton, Carol had been ordered by physiotherapists to try to walk, and an ambulance had to be called when she was unable to get out of a chair she had been hoisted into. By the time she died, she was unable to sit up and in constant pain.

In August, Elisabeth raised concerns the agency Care Outlook entrusted to look after her mother at home had missed seven doses of medication in a over three days – something the manager told Elisabeth “happened all the time”. Action was taken against the agency after three months.

By February, Elizabeth persuaded the council’s head of safeguarding John Binding to arrange the meeting attended by multiple agencies. At the meeting Dr De-Souza said everyone agreed they must work together on a better care package for Ms Solomon.

She added: “We 100pc accept all the terrible things that have happened. No one thinks you’re making things up.

“We all agree we want your mum to have the proper carers coming at the right time with the right medication with the right chair and the right hoist and the right training – all of that. And your job is to be a daughter, and to not be her solicitor, her carer, et cetera. I want you to be really chuffed that we agree.”

Elisabeth, 37, believes the council’s safeguarding board should have referred her mother for a post mortem following her death, because the open safeguarding concerns would make that a legal requirement.

But a spokesman for the council said this would only be done if it was considered a multi-agency problem, and each incident had been treated in isolation.

They said: “Every concern raised by Ms Solomon in relation to her mother has been fully investigated and where appropriate we have taken immediate action to address those concerns.

“Several members of staff have also met with and written to Ms Solomon over a number of months to address all of her concerns and answer any questions she may have.”

Homerton refutes the fracture had any “substantial bearing” on Carol’s subsequent support plan because it was “old” and “didn’t present any symptoms” – despite her “reluctance to mobilise” and complaints of back pain, which were put down to “soft tissue injury”.

Homerton told the Gazette the accusations had been investigated and it was felt she had been “appropriately cared for” during her stays there. “We have advised Ms Solomon regarding her options as she remains dissatisfied with our investigations,” they added.

Just last month Adi Cooper, from the independent City and Hackney Safeguarding Adults Board, decided it was not a matter for her team.

Elisabeth, who used to work as an advocate at DWP tribunals and as a council housing benefit officer, disagrees. But she is now suffering from post-traumatic stress disorder and is “on the verge of a breakdown” having been trying to push for a post mortem and still not having buried her mum.

A MRI scan was never carried out following the CT scan, and she wants to know whether the fracture was stable or not, becuase by the time she died Carol was unable to even sit up unaided. A letter from Homerton states that staff had been told she had “tissue damage”, which could have accounted for the back pain she was experiencing.

Carol’s body is being stored at T Cribbs funeral directors in Beckton, and is deterioriating rapidly as it is not being kept on ice.

“I don’t want her to sit in a morgue,” said Elisabeth. “If I had a brother or sister they would make sure that she was buried.

“I want a safeguarding review. It’s not for my mum as she won’t come back to life but it’s for other people. No one cares about adults here.”

Elisabeth has been banned from Homerton Hospital, all council premises, the Citizens Advice Bureau, Hackney CVS, and the HQ of the patient watchdog Healthwatch Hackney. In her quest for answers she has repeatedly phoned staff and been allegedly “rude”.

Elisabeth believes she is a victim of institutional abuse, however.

She said: “I’m abused, and if I am rude, people who are abused change their character. I’m being honest. I’m being driven to a place I can’t cope. They are robbing me of a once in a lifetime opportunity to grieve for my mum with the stress they are putting me under. They changed the narrative. My narrative is my mum was abused, but they are saying I’m abusive. I’m the scapegoat.”

Coroner Mary Hassell and Adi Cooper were approached for comment.