Coroner Julian Morris said it was “obvious that something had gone wrong” when Seleoane’s repeated failure to co-operate with her landlord, gas engineers or the police failed to raise suspicions. The body of Seleoane, 61, a medical secretary who appeared to have no friends or close family, was found in February after a member of the public alerted police to damage to the patio door of her flat in Peckham, south London. and officers forced entry. “Any death is sad. Going unnoticed is hard to understand,” Morris said as he concluded the investigation. The case attracted publicity because of the unusual length of time Seleoane’s body remained undisturbed in the block, Lord’s Court. This was despite neighbors repeatedly complaining about the smell to their landlord, the Peabody Trust, and asking her to do a welfare check. An independent report into the case commissioned by Peabody published on Friday was scathing of the housing association’s failure to recognize that its tenant had died or live up to its corporate aspiration to be a “humane and kind” landlord. The report, by consultants Altair, found there were numerous missed opportunities to discover her body, as well as 89 attempts to contact Seleoane between August 2019 and February 2022 that were not followed through. These included reports of maggots and flies from her apartment within weeks of her rent payments stopping in August 2019. A report to the Peabody Customer Center from a neighbor in October 2020 said the smell was like a “corpse.” “What might have been designed as a customer-centric service failed. Instead, the focus has become the proceedings themselves and Peabody appears not to have seen the triggers, listened to Ms Seleoane’s neighbors or connected the dots,” it said. Peabody officials failed to secure any “meaningful contact” with Seleoane, the report said, preferring instead a “transactional” approach that treated sending emails, texts, letters or phone messages as proof that work had been done. Peabody’s neighborhood managers had unusually large “patches” by industry standards, responsible for up to 1,200 units each, meaning they could not easily track individual cases. The culture of the organization had to change, he added. “There is no doubt that Peabody’s reputation has been damaged, with stakeholders, the industry and, most importantly, with its tenants. Work needs to be done to restore their reputation,” the report concludes. Peabody Trust directors who gave evidence to the inquiry admitted they had “failed to connect the dots”. Ashling Fox, deputy chief executive of the trust, said: “We could have raised the alarm earlier.” Asked about the impact of the case on Peabody staff, a visibly upset Fox said: “You could tell everyone was devastated. I don’t think anyone comes into work to do a bad job.” In a statement, Peabody chief executive Ian McDermott said: “We are devastated by what has happened. We are very sorry for our part in this and apologize to Sheila, her family and everyone who lives at Lord’s Court. When we took action on this case, we didn’t ask the most fundamental question: Is Sheila OK?’ Police who found Seleoane’s body told the inquest that the dates on shopping receipts and food boxes found in her flat suggested her likely date of death was August 2019. The inquest heard that a Peabody local manager had asked police to carry out a welfare check in October 2021. However, a police error meant they mistakenly reported to the manager that officers had ‘spoken to the resident [Seleoane]who was safe and well” and the case was closed. Morris said medical records showed Seleoane had suffered from inflammatory bowel disease in the past and had contacted her doctor about a chest complaint in August 2019. However, there was no evidence of a cause of death and she issued an open conclusion . Even if her owner had responded more quickly, it would not have saved Seleoane’s life, the coroner said. “She was already dead,” he said.