Thirroul woman Tracy Mitchell is still haunted by her mother's death just six weeks after she moved into a residential aged care home.
Ms Mitchell gave harrowing details of her "beautiful mother's" final weeks in an emotional address to the Royal Commission Into Aged Care in Wollongong on Wednesday.
"She was denied pain medication when it was prescribed by a GP; she was left in her own faeces for hours," she said.
"She was left in bed for hours which then caused bed sores on her bottom, and this nursing home was not equipped or stocked with proper wound care dressings for bed sores.
"Mum was left in a lift chair, naked in a bathroom for over an hour on another occasion because the battery went flat.
"She was fed sandwiches, hot dogs, party pies and sausage rolls when she was meant to be on a diabetic diet. ... If her blood sugar was low, she was just given a jam sandwich.
"… And her call bell was put out of reach or hidden under a pillow because staff became annoyed that was was buzzing too much."
Ms Mitchell said her mother suffered large skin tears in those two weeks due to rough handling by staff, and was hospitalised twice, before succumbing to complications from a chest infection, aged 79.
"The nursing home where my dear mum was placed was supposed to be a caring, comfortable, safe home to live out her last years," she said.
"I say years but in fact mum died within six weeks of being in this home. A home where our expectations were she would be safe, supported and cared for, but instead she was neglected, abused and forgotten."
After her death three years ago, Ms Mitchell made two complaints about the nursing home - which was not situated in the IIllawarra - to the Aged Care Complaints Scheme.
"They investigated, and found my mother had received sub-standard care, and there'd been a failure in the duty of care in areas such as medication dispensing, manual handling, personal hygiene and respect," she said. "They did not respect mum's right to be treated with dignity."
Ms Mitchell's calls for more staff, with better training, was mirrored by many of the family members, carers and workers who spoke at the forum. She also called for cameras to be installed at nursing homes 24/7 to not only monitor staff behaviour, but also identify where residents were distressed or in need of help.
"We are making a bed that most of us will have to lie in," she said. "I'm angry, upset, haunted at a system, a government, that allows human beings to be treated so terribly."
Royal Commission hears of aged care failures
The need for ratios in aged care was highlighted at the Wollongong forum, held as part of the Royal Commission into Aged Care Quality and Safety.
Around 20 speakers shared their stories with Commissioner Lynelle Briggs at the forum held at WIN Stadium, with many citing the need for additional staff and further training to ease the pressure.
Family members and carers got emotional as they recounted failures in care with their loved ones - with medication mix-ups, pressure wounds and continence care among the issues.
Workers too talked of their frustrations at heavy workloads, lack of funding and insufficient staffing, with ratios at times of one nurse to 14 residents.
Prime Minister Scott Morrison established the royal commission in September in response to a litany of disturbing incidents or abuse and neglect in aged care facilities.
Ms Briggs and fellow commissioner Richard Tracey will investigate all Commonwealth-funded aged care services, including aged care facilities, in-home care services, and care for young Australians in residential aged care.
Around 300 people attended the Wollongong event, the third community forum held around the country.
Ms Briggs said the aim was to find out how best to provide people with "high quality, safe, person-centred care" within a "culture of dignity and respect".
"The commission understands that when care doesn't meet the needs of people receiving it, it leads to considerable stress and distress for them and their loved ones,' she said.
She said she wanted to hear about people's experience of aged care: "the problems, the strengths and the opportunities for improvement".
"It's very easy for a royal commission to just hear from providers but we are wanting to hear from all Australians, especially older people, their families and carers, the volunteers and workers in the sector," she said.
"We also want to hear from the next generation who will require aged care … about what their expectations are of the aged care system, as the recommendations we make may stand for 50 to 100 years."
More formal hearings will also be held across the country as well as roundtable meetings with experts and site visits. People can also make submissions at agedcare.royalcommission.gov.au
The commissioners are expected to provide an interim report by October 31, 2019, and a final report by April 30, 2020.