A woman has told how maggots were found in a wound in her mother's heel shortly before her death which had been left untreated for months in a Melbourne aged care home.
Anamaria Ng wept while telling the Royal Commission into Aged Care about how horrified she was about had happened to her mother Annunziata Santoro.
The Assisi Centre nursing unit manager Jamuna Jacob had tried to stop her GP Eric Tay telling Ms Ng and other family members about the maggots, she said.
Dr Tay confirmed that on Wednesday.
Mrs Santoro, who had dementia, died only days later at the age of 94 in October 2018 with a bone infection in her heel contributing to her death, according to Dr Tay.
The wound was allowed to deteriorate for at least two months before the family or Dr Tay were told about it, the commission heard.
Assisi staff told Ms Ng and Dr Tay that Mrs Santoro's increasing agitation was a behavioural problem, that she was "not in much pain at all" and did not give her painkillers over three months as the wound became a bone infection.
That mistake led to Dr Tay prescribing anti-psychotic medicine she did not need.
It also led to Ms Ng and her two brothers paying extra for physiotherapy for their mother that included weight bearing exercises that would have added to her excruciating pain.
Her last days were spent in pain and heavily sedated, which also resulted in rapid weight loss that Assisi did not address, an emotional Ms Ng said.
Ms Jacob had made light of the maggots and blamed it on family members who had taken her on a day trip, she said.
"I was appalled that she was essentially not prepared to take responsibility for what happened," Ms Ng told the Royal Commission.
She relocated her mother to palliative care elsewhere but Mrs Santoro died within a couple of days.
"At this point my mother's management had been so poor, her pain management and her care and I had just completely lost faith," said Ms Ng.
"I just wanted her out of there.
"I believe would still be alive today if her pain and care had been properly managed."
She contacted the Aged Care Complaints Commissioner, also angry about repeated falls and another infection when staples were not removed after hip surgery.
The aged care commissioner made scathing findings of "significant gaps" in Mrs Santoro's care, including them not telling the family or doctor about the heel wound "until it was too late".
"It's really hard to imagine a more serious finding being made about an organisation that exists solely to provide care for elderly people isn't it?" Counsel assisting the commissioner Peter Rozen asked Assisi's chairman Don Smarrelli.
"Correct, it is," Mr Smarrelli replied.
The not for profit organisation was doing a "root cause analysis" to "ensure that this type of incident or any incident for that matter never occurs again", he said.
Assisi's CEO at the time - who cannot be named - was recently sacked, having been accused by Mr Smarrelli of withholding information and possibly misleading the royal commission.
The Australian Health Practitioner Regulation Agency are investigating Ms Jacob and another unit manager, Anna Yow.
Australian Associated Press