When a blind and deaf woman developed a bone-deep leg wound three months after moving into a Victorian aged-care home, her daughter flew into a rage.
Heartbreaking details of the final and pain-filled days of Bertha Aalberts' life have been revealed during hearings held by the aged care royal commission.
Known to her family as Beth, the Dutch post-war immigrant died in hospital in August last year after multiple falls.
The 87-year-old also developed chronic pressure sores and the hematoma on her leg in her short stay at the Avondrust Lodge in suburban Melbourne.
Her daughter Johanna Aalberts-Henderson says her mum was cognisant and continent when she moved into Room 17, and could still get around with a walker despite being deaf, legally blind and struggling with heart problems.
But her decision to live at the lodge was the start of a rapid decline.
Three months later she was dead.
Conflicting evidence was given to the commission about why Mrs Aalberts was treated the way she was.
Mrs Aalberts was taken to hospital after falling and breaking her wrist.
That same fall was the cause of large hematoma on a her leg.
Senior Counsel Assisting Peter Rozen QC read from records where a doctor treating Mrs Aalberts at the hospital said he didn't want her to be discharged, and told her daughter he wanted her to get surgery for the wound.
But the family didn't want her to go through with it because they feared she would become further distressed and confused by anaesthetic.
Staff at the home were made aware Mrs Aalberts would be returning from hospital with a leg wound that needed attention.
It would later became the most significant aspect of her care needs.
Robert Van Duuren, general manager of residential services for MiCare Ltd, which runs the home, said documentation he had seen showed Mrs Aalberts-Henderson did not want surgical intervention.
"We need to respect whatever the decision is that was made by the family, or the resident themselves if they made that decision," he said.
Ms Aalberts-Henderson says she made an immediate decision never to return her mother to the home after seeing the wound for herself at a later point.
She accused the home of failing to tell her about the increasing severity of her mother's various sores, and says she'll never forget the audible reaction of hospital staff as a gauze dressing was removed from the leg wound.
"It was unbelievable to see," she said of the wound.
"I was in an icy cold rage."
The daughter said her mother deserved a more dignified death.
"I can't unhear her cries, and I can't unsee what I saw," she said.
A week after Mrs Aalberts died, the Aged Care Quality Agency audited the home and was unable to say it had enough skilled staff to provide appropriate care for dozens of high-care residents.
In January this year, after the agency audit and after the royal commission was called, the home dramatically increased nurse numbers and nursing hours.
Australian Associated Press