The deaths of two nursing home residents with dementia have raised serious questions about the regulation of the aged care sector, and despite damning findings from two coroners, the nursing homes remain fully accredited.

Anne Connolly reports.

Date: 21 September 2014

Source: ABC Background Briefing

The government is increasingly encouraging elderly Australians to stay at home for as long as possible, which means that when they do enter a nursing home, they are sicker and more frail than ever before.

Despite nursing home residents needing more specialist care for their complex needs, critics say nursing homes are employing staff with less training and asking them to take on greater responsibility.

‘We have basically seen a decline in the number of registered nurses working in residential aged care across the country and we are seeing a commensurate increase in our personal care workers, which are I guess the lowest skilled workers in a nursing home,’ said Charmaine Crowe, a senior adviser with the Combined Pensioners Superannuants Association.

There are no mandated staff-to-resident ratios for nursing homes, which puts further pressure on aged care workers who sometimes have to supervise and care for large numbers of residents.

Caterina Montalto, a resident at Arcare Hampstead in Melbourne, died in 2011 after falling into a fountain in the nursing home courtyard. Susan Mutami, the nurse’s aide, alerted staff to the accident.

‘I opened the blinds and I saw something pink in the fountain and you could see the hair floating and I was really shocked,’ she said. ‘I rang the receptionist saying, “hurry, hurry there’s someone in the water fountain.’”

A coroner’s court later heard that instead of admitting to the failure to monitor Mrs Montalto—who was a resident in the home’s specialist dementia unit—staff changed her clothes, put her into bed and told her family that she’d suffered a heart attack.


Reporter: Anne Connolly

Researcher: Anna Whitfeld

Supervising Producer: Linda McGinness

Sound Engineer: Simon Branthwaite

Executive Producer: Chris Bullock

This article represents part of a larger Background Briefing investigation. Listen to Anne Connolly's full report or use the podcast links above after broadcast.

Full transcript:

Anne Connolly: Australians are living longer. The 65-plus age group will make up a quarter of the country's population by the middle of this century, that's double what it is now. But the fastest growth is in the 'old, old' age group, 85-plus, that will treble and put enormous pressure on aged care services.

People are encouraged to stay home for as long as possible, so by the time the elderly are entering nursing homes, they have increasingly complex care needs. More than half have dementia.

Nursing homes are currently assessed by a government regulator that needs them to meet 44 criteria. And 95 per cent are accredited with a perfect score, 44 out of 44. Although there are good nursing homes operating in the system, there are huge inconsistencies across the industry.

Maree Bernoth: I have witnessed a great disparity between what they say they do and what they actually do and that's not being picked up by the accreditors. The facilities can put on a face that is different to what is actually happening.

Anne Connolly: Hello, I'm Anne Connolly, and today on Background Briefing the story of two deaths. These deaths raise serious questions about the provision of care in nursing homes owned by two of the country's biggest private aged care operators.

BUPA ad: BUPA already looks after almost 6,000 older Australians in over 60 homes around the country…

Arcare ad: Arcare is committed to improving the quality of life for all our residents. Throughout our facilities and our home care service you will meet dedicated and experienced staff committed to your wellbeing.

Anne Connolly: Both homes had top scores for care; one billing itself as a five-star facility. They also cast doubt over the effectiveness of the government regulator, the Australian Aged Care Quality Agency. Both cases reached the coroners’ courts because of two determined individuals. Clive Watson wanted answers after his wife's death and it took a coronial inquiry to get the information that a NSW nursing home had kept from him for months.

Clive Watson: If you look at the information in the brief of evidence you find that Beryl was agitated and I have a pretty fair idea why she was agitated. She had a back that had a blazing sore on it, she couldn't drink, she couldn't eat, at the later stage she couldn't even breathe.

Anne Connolly: And in Victoria, nurse's aide Susan Mutami tells of what happened when she saw a dementia patient facedown in a nursing home's courtyard fountain.

Susan Mutami: I opened the blinds and I saw something pink in the fountain and you could see the hair floating and I was really shocked, I was like, oh my god. So I then rang the receptionist and I told them, 'Hurry, hurry, there's someone in the water fountain.' You know, when I saw her in water I just felt something in me that said, you know, she didn't deserve to die an undignified death in a five-star nursing home.

Anne Connolly: Instead of admitting the truth about the death, staff at the nursing home covered it up and the whistle-blower—Susan—was sacked.

On his rural property on the NSW north coast, Clive Watson is still getting used to being alone, almost three years after his wife's death.

Clive Watson: She was shorter than me about two inches, five foot and half inch, the half-inch was an extremely important thing. Slim, so much so that I could put my hands around her waist and they'd touch all the way around.

Anne Connolly: They were just teenagers when they met.

Clive Watson: Beryl's debut. She needed a partner for her debut and that's how I got conned [laughs].

Anne Connolly: Conned or not, Clive and Beryl were soon married. They weren't able to have children so they adopted -- a boy and a girl. The adoption turned out to be a blessing in more ways than one. Beryl had two serious genetic conditions. At 53 she was diagnosed with dementia. Later, another devastating illness; Huntington's disease, an illness which attacks the muscles. To improve their quality of life, they moved back to a family holiday spot.

Clive Watson: That mountain, Mt Yarrahapinni has been our rock ever since because I used to come here in the '50s, so when she got sick and I retired, this became the obvious place and I tried to find somewhere where we'd enjoy looking around and looking at our mountain and there it was.

Anne Connolly: As Beryl lost the ability to walk, talk and feed herself, Clive did it all.

Clive Watson: It was never hard. It was time consuming, and the more the disease developed the more work I had to do. We made a decision years ago that we'd look after one another, and maybe it's our age or whatever it is but it's something we took seriously, and the fact that it was Beryl and not me was totally irrelevant.

Anne Connolly: Then in November 2011 Clive had a medical condition of his own which needed surgery.

Clive Watson: And I had to have an operation in North Sydney and the only way I could do that was to put Beryl in care during that period of time.

Anne Connolly: Clive took Beryl for respite care at the nearby Kempsey nursing home owned by BUPA, the biggest private operator of aged care homes in the country, and gave them details of her care needs and her medication.

Clive Watson: I gave them a full care plan, it was about four pages long, of everything that I did. It was based on all the information I'd collected from doctors, dieticians et cetera.

Anne Connolly: After Clive had recovered from surgery in Sydney, he drove to the nursing home in Kempsey to collect his wife.

Clive Watson: I must admit I was excited to pick her up because it had been three weeks. I hadn't been away from Beryl for that long for ages. And when I got to the door I looked inside and Beryl was in a day chair, she was canted back and a nurse was sucking stuff out of her throat. I didn't know what it was, all I could hear was the pump going. And she turned and looked at me and said, 'Oh you're here, you'll have to see your GP to get one of these.' I was totally shocked.

Anne Connolly: Beryl had weighed just 44 kilos on admission. Chronically ill as she was, Clive could still see a definite decline.

Clive Watson: She looked thin, gaunt and when I actually got her out and put her into the car I nearly threw her in the air she was that light.

Anne Connolly: That night Beryl hardly ate or drank anything and when Clive was getting her ready for bed he discovered the condition of her back.

Clive Watson: When I took her clothes off I looked at her back and I could see why she was in pain. Her back had skin hanging off it, it was red raw, there was also, as I found out later, scabs in it. It was horrific and if I was angry when I was at the nursing home, I was absolutely livid when I saw this because they had told me nothing about it. My camera bag was in the bedroom and I just grabbed it and took three photos.

Anne Connolly: These photos would become crucial.

Clive took Beryl to their GP who ordered her straight to hospital. She was diagnosed with pneumonia, malnutrition and dehydration. Septicaemia had set in. After 10 days at the hospital at Macksville, it was clear she wasn't going to recover.

Clive Watson: Then I knew that was it as far as Beryl and I were concerned. The following day was one of the best days that we'd had for quite some period of time because they'd put us in a private room and we just sat and talked, and that was a good day but that night I had a phone call from the hospital or early the following morning and that's where she passed away.

I remember walking on the beach a lot and just trying to think things through. It was anger, yes, but not anger necessarily at the fact that Beryl had died but anger at the fact that it had been allowed to happen. And I'm one of those sort of individuals that if I find something of that nature I do something about it.

Anne Connolly: Clive Watson wrote to BUPA looking for an explanation for the poor care his wife had received at their Kempsey home.

Clive Watson: In the letter my objective was not to denigrate anyone, not to blame anyone but to fix the thing up. I wasn't even looking for an apology at that period of time. My basic reasoning was the fact that I didn't want another husband to have to go through what I'd been through.

Anne Connolly: In response to his letter, BUPA management invited Clive in for a meeting.

Clive Watson: We had morning tea in at BUPA where they stated that they had an investigation and they'd made a report and it would be available soon but it had to be typed up.

Anne Connolly: When BUPA's internal report arrived, Clive Watson was shocked.

Clive Watson: The investigative report was an absolute sham. Basically it said that any problems that Beryl had, like her back, she came in to the home with, they did not change during the period of time in the home, therefore it's my fault. The second thing, that Beryl had no problem drinking her fluid at any time during her stay. They also said she had no problem with eating, except for one night.

Anne Connolly: BUPA did admit some errors in handing over Clive's care plan to the nursing home staff but insisted Beryl had received good care. Feeling like they hadn't dealt with his concerns, Clive Watson sought advice from his GP.

Clive Watson: Anyway, he said, 'We've gone far enough with this, you've been to them, it's time we went further.' I couldn't think of where further would be apart from the Aged Care Complaints and he said, 'We'll go to the coroner.'

Anne Connolly: The photographs Clive Watson had taken of Beryl's back were central to the coroner calling for an inquest.

BUPA's documents were subpoenaed and finally he began to learn the truth about his wife's care while at the nursing home.

Clive Watson: Their documentation was…I've used the term 'poor', in reality it's even worse than poor. The documentation shows culpability as far as I'm concerned. If we talk about food, there was absolutely no monitoring of her food intake at all and yet at the finish she was malnourished. Secondly, her fluid intake, it was noted that it should be monitored, it was recorded but it wasn't monitored.

Anne Connolly: The care plan Clive had given the nursing home specified that Beryl needed at least a litre and a half of fluids every day. But on one day it was recorded that she received just 190 mls. While the amount of water was critical for Beryl, so was the way she was given fluids. Huntington's disease attacks muscles, including those in the throat, making swallowing difficult. Clive gave strict instructions about how to carefully give food and fluid to Beryl, which the home didn't completely follow.

Clive Watson: It was the fact that they fed Beryl her fluid with a cup, with a mug. Now, any speech pathologist will tell you a person with a swallowing difficulty requires to be fed with a spoon, small amounts at a time. They virtually flooded Beryl's lungs.

Anne Connolly: On top of everything else, a crucial daily medication which Clive had provided to the home hadn't been given to Beryl due to an administrative error. For almost two weeks Beryl went without the drug until her GP was finally contacted but by then she was in serious withdrawal. Nursing home records show Beryl was unsettled, 'writhing in bed and making noises'. One nurse noted that she was 'biting at her draw-sheet' and she was given paracetamol.

After a three-day hearing, the coroner concluded that Beryl was already very ill, nearing the end of her life when she entered the BUPA nursing home. But he found that 'a series of cascading mistakes or oversights led to her demise'.

Clive Watson: Quite simply, by neglect they had allowed the situation to get to such a stage that Beryl was unrecoverable, because in the hospital they did everything they could.

Anne Connolly: The coroner described how the nursing home had a small number of nurses looking after a large number of patients. Despite Beryl's worsening condition, no one made urgent calls to a doctor or sent her to hospital. And when Clive took his wife home, no one warned him of how ill she really was. Clive was left with his own conclusion.

Clive Watson: A total lack of confidence in the home and probably the system.

Anne Connolly: When Clive Watson had written to BUPA after Beryl's death, he was told that they had introduced new policies, training and systems for respite patients.

Two years later, BUPA's lawyers gave the same assurances to the coroner who questioned whether anything had really changed.

This is a reading from the coroner's report:

Reading: When the northern regional manager of BUPA wrote to Mr Watson in April 2012, he assured him his concerns were either without foundation in fact or those which were valid had been addressed by remedial changes made since the death. However, evidence given to this inquest calls into question the reliability of both assertions.

Anne Connolly: The coroner went on to say:

Reading: Two of the nursing staff who have worked at the centre for many years and continue to do so said in evidence they were not aware of any changes in these areas. In those circumstances, relying on the bare assertion of BUPA's lawyers that the problems have now been fixed could be characterised as unduly credulous.

Anne Connolly: The coroner recommended that these promised changes around admitting respite residents be put in place and that the regulator—the Aged Care Quality Agency—ensure this occurred.

Background Briefing sought a response from BUPA who said that the coroner had found Beryl died of natural causes and they had since improved policies and procedures. (HYPERLINK TO BUPA’S RESPONSE HERE)

The Australian Aged Care Quality Agency is the regulatory body which assesses nursing homes, their standards and systems. Nick Ryan, the CEO:

Nick Ryan: What occurred here was a series of very, very bad outcomes and a series of breakdowns of communication and a lack of clinical care by the home in Kempsey. So what occurred there has been examined by the coroner and that's now a matter on the public record.

Anne Connolly: The BUPA Kempsey home was fully accredited at the time of Beryl's death and had met all 44 criteria demanded by the regulator. These accreditations happen once every three years.

Nick Ryan: Can a home that is fully compliant still have a bad instance of care? It could. However, a home that's fully compliant has the systems in place and the quality assurance that significantly reduces the likelihood of it happening and, if it does occur, that these matters are picked up by the provider, and where they're not picked up by the provider, the Complaints Scheme and ourselves are there to attend to these matters very quickly.

Anne Connolly: Background Briefing has since discovered that the Aged Care Quality Agency conducted another of its scheduled assessments in April 2012 - just four months after Beryl Watson's death. At that time Clive Watson had an official complaint on the records at BUPA and management had conducted an official investigation into his concerns about malnutrition, dehydration and bed sores. Still, BUPA Kempsey again received a perfect score, meeting all 44 criteria.

We asked the Aged Care Quality Agency if the complaint had been taken into account as part of its assessment. The agency responded, saying it was 'unaware of a specific complaint or matters around Mrs Watson's death', and suggested the 'Aged Care Complaint Scheme is the appropriate place to investigate and resolve complaints about individual care'.

Maree Bernoth: The Aged Care Complaints system is ineffective.

Anne Connolly: Dr Maree Bernoth is an academic who's done extensive research with aged care facilities, their staff and residents' families.

Maree Bernoth: There's this bureaucratic speak where families who complain to them get this letter back that's full of bureaucratic language that doesn't show any appreciation for the stress and distress that the families have gone through. It pays token recognition to the complaint and it talks about things like; they've looked into the complaint and the facility has changed their policies or changed their procedures.

Anne Connolly: The problem is, says Dr Bernoth, those policy and procedural changes often don't make it off the paper and into practice.

Maree Bernoth: What can often happen is yes, they've changed their procedures, but no one knows about it, there's no education being provided, there's nothing to inform the care staff that there has been a change, and there's no one to follow up that the care staff are implementing the change.

Anne Connolly: The CEO of key consumer group, Alzheimer's Australia, is Glenn Rees. He's also critical of the agency's emphasis on systems while ignoring a record of bad care outcomes.

Glenn Rees: So we don't have an outcomes based system. We do have a systems checking system. There's no really substantive evidence that the accreditation agency, over a long period, has improved outcomes. There remains a lack of transparency. It's very difficult for a family carer or an older person to know what the quality of care is that's being offered by a residential aged care facility.

Anne Connolly: As Clive Watson waded through Beryl's documentation from the nursing home, he was getting an education not just on how BUPA worked but also the requirements of how the nursing home system was regulated.

Clive Watson: The first thing is there is no level of staffing requirement at any nursing home. According to the information I've received, the only statement in the regulations is it must be ‘sufficient’. I don't know what 'sufficient' means. Quite obviously the auditors that audit nursing homes don't know what 'sufficient' means, because there's no indication anywhere as to whether they do have sufficient staff or whether they don't.

Anne Connolly: Clive Watson's right. Nursing homes aren't judged on staff-to-resident ratios. They only have to show they have 'sufficient' or ' adequate' numbers of staff.

How do you assess staff ratios at the nursing home?

Nick Ryan: We're fundamentally focused on the resident and then we're focused on that the home can guarantee and can assure us and can assure the resident and their families about the outcomes for them. Depending on the care needs of the individual resident and the care needs of the home, providers then match that with appropriate staff. We don't focus on a particular ratio because the reality of nursing homes across Australia is quite diverse.

Anne Connolly: Nick Ryan, CEO of the Aged Care Quality Agency.

The Combined Superannuants and Pensioners’ Association says it receives hundreds of calls from members concerned that their relatives aren't receiving appropriate care because of a lack of staff in nursing homes.

Charmaine Crowe: You know, we have staff-to-resident ratios in our child care system, and yet our nursing home system, which has responsibility for looking after some of the most vulnerable people in our community, there are still no staff-to-resident ratio.

Anne Connolly: Charmaine Crowe is the senior policy adviser for CPSA.

Staffing levels affect every aspect of life at a nursing home, from complex needs like medication and clinical care to the basics of washing, toileting and feeding residents.

Charmaine Crowe: Many residents need assistance to eat and to drink, and what can happen is that the staff just simply don't have the time to spend with the resident to ensure that they eat their meal and finish their meal or get adequate hydration, and that's one of the biggest complaints that we hear. Residents are sitting with a plate of cold food in front of them, unable to eat it themselves because they may have mobility problems or they may have dementia, and, you know, half an hour later the meal is taken away because the staff just simply do not have the time to feed that resident. So it's no surprise to me that studies have found up to 50 per cent of nursing home residents have some level of malnutrition, and there are also significant problems with dehydration.

Anne Connolly: As with staffing, Nick Ryan says the Aged Care Quality Agency assesses nourishment and hydration on a basis of whether it's 'adequate'.

How do you explain a number of residents…a fairly common occurrence of malnutrition and dehydration in nursing homes that get a perfect score of 44 out of 44?

Nick Ryan: Again, what we look at is do they have the adequate systems in place. Even where a home with the best policies and the best procedures and systems in place, there may be individual instances of bad care. They're never acceptable when they occur, and when they do occur we will certainly look where that's brought to our attention.

Anne Connolly: As well as concerns about overall staff numbers, a decline in the number of the most skilled workers in nursing homes is also proving to be an issue.

Charmaine Crowe: We have basically seen a decline in the number of registered nurses working in residential aged care across the country, and we have seen a commensurate increase in personal care workers who I guess are perhaps the lowest skilled care workers in a nursing home.

Anne Connolly: The aged care workforce is also undergoing a massive change. A recent report shows a third of workers are new migrants to Australia, arriving in the past five years from places like India, the Philippines and Africa. Susan Mutami came from Zimbabwe in 2007 and undertook training to become a nurse's aide in Melbourne.

Susan Mutami: It's very hard to get into nursing, in some countries it's really hard, and I was so happy. I have a soft spot for old people because at a younger age I was taught to respect the elderly. When I'm at work in an aged care facility I don't see them as the elderly or oldies, I see them as my grandfathers and grandmothers.

Anne Connolly: At 22 she took up her first job with Arcare, one of the biggest private nursing home operators in the country. She was working at Arcare Hampstead in suburban Melbourne.

Arcare ad: Arcare is committed to improving the quality of life for all our residents. Throughout our facilities and our homecare service you will meet dedicated and experienced staff committed to your wellbeing.

Susan Mutami: I was so excited to work for them because they're a big company, as you know, and they are a five-star company, so I was really excited to work for them, that I'm working for the best people in the industry.

Arcare ad: It is this positive attitude that gives Arcare the reputation of being one of the best in the aged care industry. We look forward to welcoming you soon.

Anne Connolly: But Susan soon discovered the care at the home was not what she had expected. At one point she made an official complaint about the food, but nothing changed. She became concerned that the culture at the nursing home was to turn a blind eye to bad care, and this attitude was being handed down from older workers to new.

Susan Mutami: I felt like it was a place where you couldn't air your views or contribute, especially the quality of nursing care, and some of my co-workers said it's been going on for a long time, it's more like you come, you do your job, you go home, and you mind your own business.

Anne Connolly: Minding her own business is exactly what Susan Mutami was doing on May 31, 2011. She was on the first floor of the nursing home, serving afternoon tea to residents.

Susan Mutami: After afternoon tea I went around checking on the residents because when you come on a shift you introduce yourself to the patients. And I introduced myself to my clients. And I open the blinds and I saw something pink in the fountain and you could see the hair floating and you could see legs outside. And I was really shocked, I was, like, oh my god. I couldn't remember the phone number for the nurses downstairs, the only number I could remember was the receptionist number, so I then rang the receptionist and I told them, 'Hurry, hurry, there's someone in the water fountain.'

Anne Connolly: This is the first time Susan Mutami has spoken publicly and in detail about the events of that day. Susan watched as five staff came running to drag the woman from the fountain. As she later told a coronial inquiry, amongst the staff were nursing home manager Cathy Condon and registered nurse Lea Sanchez.

Susan Mutami: I stood by the window watching what was happening and I saw them all come though and I could hear everything, I saw everything. I heard Lea Sanchez the nurse, she cried when she pulled her by her hair, she said, 'Mamma, Mamma, please stay with me,' and she started crying, calling out her name; Caterina. When I saw the jacket I knew it was Caterina because she loved that jacket, she wore it a lot.

Anne Connolly: It was Caterina Montalto, a 76-year-old resident from the specialist dementia unit.

Susan Mutami: She was so nice, I remember she used to call me bella, I think it's Italian, it means beautiful, she called everyone bella. She was such a lovely lady. When I saw her in the water I just felt something in me that said, you know, she didn't deserve to die an undignified death in a five-star nursing home. Nobody knew how long she had been in the water for.

Anne Connolly: In fact it was later discovered that Caterina had been in the water for almost an hour. It emerged in the coronial inquiry that staff had lifted Caterina Montalto from the fountain, dried her off and changed her clothes. They put her into bed and rang her two sons, Frank and Joe. They were told their mother had passed away and it was too late for any medical intervention.

When the GP arrived at 7pm she was told the same thing and—in good faith—she signed the death certificate saying Mrs Montalto had died of a heart attack. The GP later told how she was furious at being misled.

Frank and Joe noticed a graze on their mother's forehead but did not mention it. Frank later remarked on the staff's demeanour at the time, 'like rabbits caught in the spotlight'.

Later that day, knowing what she had witnessed, a senior staff member approached Susan Mutami and asked if she was okay.

Susan Mutami: She started being friendly towards me and she said that if I needed anything I should contact her, and if I'm having any problems at work I should let her know and that I'm not supposed to discuss what I saw with any other staff member, to keep everything that I saw to myself.

Anne Connolly: She was taken aback. Other staff were talking about Caterina's death and what they understood had happened.

Susan Mutami: Just as I was about to walk out of the facility, another downstairs carer then came to me and said oh…because I used to look after Caterina downstairs…and she said, 'Oh, did you hear, Caterina Montalto died this afternoon, she died of a heart attack in the corridor.' So I just knew that a cover-up was underway.

Anne Connolly: The next day, Susan sought advice from her union, the Australian Nurse's Federation, who suggested she call police. She says a union rep warned her.

Susan Mutami: She said you better be telling the truth because they won't let somebody like you ruin their reputation. I thought to myself I'd done the right thing. Little did I know that the truth doesn't set you free sometimes.

Anne Connolly: The inquest heard that about the same time that Susan was calling the police, Arcare management was making calls to a public relations firm. It provided the nursing home with potential responses to media inquiries. Nursing home manager Cathy Condon was given suggested responses such as: 'Say it appears the lady suffered a heart attack. She was found near a pond in our dementia care unit's sensory garden, where she frequently liked to walk.'

When Susan arrived for her shift two days after Mrs Montalto's death, she was called into Cathy Condon's office.

Susan Mutami: She then opened the file cabinet, took my file out, she handed me the letter. You know you have that jaw-dropping moment when you think, oh my god, and it's termination of employment. It was very distressing.

Anne Connolly: Susan was sacked for 'breaching confidentiality'.

Later that day, local police visited Arcare Hampstead and spoke to Cathy Condon about the death of Mrs Montalto. The police officer told the coroner she was 'quite vague'. As he was leaving he noticed a closed circuit camera pointing into the courtyard. He says when he played the footage on the computer desktop in the Arcare office, Cathy Condon became 'quite concerned' and couldn't watch. The footage showed how Caterina Montalto died.

Susan saw that footage for the first time as it was played in the Victorian Coroner's Court.

Susan Mutami: I saw her, she walked, like paced back and forth, and there was another male resident who passed there. And the next minute she came and she looked inside the fountain and she tripped inside, face down, and she never moved.

Anne Connolly: The coroner found some staff undertook a cover-up. Lea Sanchez, the registered nurse on duty that day, testified that nursing home manager Cathy Condon had encouraged her to falsify the account of events in official documents. Lea Sanchez said she had wanted to write that 'Mrs Montalto was found lying on her left side in the fountain' but that Cathy Condon had said 'not to write that'.

The prosecutor questioned Lea Sanchez about that day. This is a re-enactment from part of the Coroner's Court proceedings:

Prosecutor: You said she dictated the words that you were to write?

Lea Sanchez: She dictated, yes.

Prosecutor: Did you express any concern that that wasn't what you saw?

Lea Sanchez: Yes.

Prosecutor: So what did you say?

Lea Sanchez: Well, that's when she said that, 'Tell your staff, don't mention about this issue, and otherwise you will be sacked.'

Prosecutor: Are they the words she used to you?

Lea Sanchez: Sacked.

Prosecutor: Were you shocked by that?

Lea Sanchez: I was.

Anne Connolly: Cathy Condon was stood down by Arcare and then resigned, six days after Caterina Montalto died.

Because Caterina had been embalmed, it wasn't possible to determine the true cause of death. Drowning or a blow to the head were considered the most likely causes.

Handing down her findings, Coroner Spooner was extremely critical of 'an underlying failure in the culture of Arcare, a culture that was reactive rather than proactive regarding the safety of residents'. She also made a point of saying that staff newly arrived from other countries, of which there were many at the Arcare home, were more susceptible to manipulation and exploitation.

Susan Mutami: They intimidate nurses because at the end of the day you're employing somebody who has come from…especially me, I've come from Africa, a Third World country with absolutely nothing.

Anne Connolly: Susan Mutami was praised by the coroner for having the courage to speak up and uncovering the true cause of Caterina Montalto's death.

Susan Mutami: To have somebody believe in you and to see that you were motivated by the desire to do the right thing is a big thing because I thought…I had this mentality that the union didn't believe me and Arcare didn't believe me.

Anne Connolly: Arcare had already implemented changes before the hearing, but the coroner recommended that the fountain be removed and that the Aged Care Complaints Scheme investigate the actions of some staff in covering up the death.

In response, Arcare removed the fountain, posting a 'before' and 'after' shot in its report to the coroner. It also produced a 'Values Roadshow Movie' for staff in order to 'assist the moulding of the culture at Arcare'.

As for the Aged Care Complaints Scheme's investigation, Arcare said it had responded to a letter of request for information from the scheme but was unwilling to provide Background Briefing with its response to that letter. The Complaints Scheme said it would be a breach of privacy laws to make it publicly available.

Despite the damning findings in the Victorian and NSW Coroners' Courts against both Arcare Hampstead and the BUPA home in Kempsey, both remain fully accredited, with 100% scores. You can read both coroners' reports, as well as responses from BUPA, the Aged Care Quality Agency and the Complaints Scheme on the Background Briefing website.

For Susan Mutami and Clive Watson, the two cases represent a systemic problem within nursing homes and a lack of accountability.

Susan Mutami: Honestly I don't think they paid any price, they need to be punished, they need to be an example in the industry that something like this shouldn't happen and bullying of nurses especially, it's unacceptable.

Anne Connolly: For his part, Clive Watson says carers have to look to the regulator for information when they need to place loved ones into a nursing home.

Clive Watson: The agency that's supposed to be doing that is the Aged Care Quality Agency, and the only thing we as carers can actually abide by is their assessment. All we can do is hope that the agency has done its job. In Beryl's case it didn't.

Anne Connolly: Two key advocacy groups in aged care believe a Royal Commission may be necessary. Charmaine Crowe is a senior adviser for the Combined Pensioners and Superannuants’ Association.

Charmaine Crowe: If this kind of poor care, neglect, abuse was occurring in our child care system, there would be a Royal Commission straight away, and I think that it is well overdue that we have a Royal Commission into the aged care industry or nursing homes in particular so that we can lay everything out on the table and really look at what needs to be reformed in the system.

Anne Connolly: The CEO of Alzheimer's Australia, Glenn Rees, has a similar view.

Glenn Rees: I think it's quite possible that people will conclude that action should've been taken by successive governments to do more about the quality of care in the residential care sector. From a consumer perspective I think that if government and the industry and consumers cannot bring themselves to act on issues around medical and physical restraint and some of the unacceptable stories that we've heard about in the last two years, then the case for a Royal Commission will become increasingly strong.

Anne Connolly: Background Briefing's coordinating producer is Linda McGinness, research by Anna Whitfeld, technical production by Simon Branthwaite, the executive producer is Chris Bullock, and I'm Anne Connolly.