The final appalling moments of Miriam Merten's life remained in the dark for almost three years.
Until recently her daughter, Corina, believed the 46-year-old died in the adult mental health unit of Lismore Base Hospital after slipping in a shower and hitting her head. Once.
But CCTV footage of Ms Merten's final days aired by News Corp Australia on Friday, tells a different story.
She spent almost six hours in a seclusion cell at the hospital on the night of June 1, 2014.
Stark naked and with no access to water or a bathroom, she was then left for more than 30 minutes covered in her own faeces.
The video shows a nurse unlocking the room the following morning.
Ms Merten is left to stumble around the hallway, eventually collapsing in a corner before an emergency crash cart is rushed in by staff.
She died on June 3 due to a "traumatic and hypoxic brain injury caused by numerous falls and the self-beating of her head on various surfaces, the latter not done with the intention of taking her own life", a coronial inquest found.
"The death occurred as a result of her admission to the mental health unit of the Lismore Base Hospital."
The findings, released in September 2016, state the mentally ill woman fell at least 25 times in seven hours.
A senior nurse at the facility was aware Ms Merten - who was at times difficult to handle - had been sedated with psychotropic drugs and fallen at least once but failed to take appropriate action, the inquest found.
A second nurse was also involved.
One of the two died last month "unexpectedly", her funeral notice states.
"The lack of care and compassion showed to the deceased was monumentally disgraceful and appeared to emanate from an 'Oh it's just Miriam' mentality," coroner Jeff Linden found.
"While this appears not to be a system failure it is clearly a serious human failure."
NSW Health Minister Brad Hazzard on Friday announced a parliamentary inquiry into "all aspects" of the state's mental health system.
There'll also be a six-month independent review by Chief Psychiatrist Dr Murray Wright assisted by international experts.
"We want to know absolutely that whatever can be done, in a very human system, has been done," the health minister said.
The department became aware of the incident following media inquiries last week, Mr Hazzard said.
Dr Wright said his "extensive" review will include the potential for the complete elimination of seclusion rooms.
"I see seclusion as a treatment of last resort, where all other treatment has failed.
"It's a very complex practice because we're changing treatment cultures, we're improving the skill sets and teamwork of our nursing staff and other clinicians."
Dr Wright said in the case of Ms Merten the nurses failed "at almost every level".
But, he said, he hasn't been shown any evidence to suggest "this kind of abhorrent behaviour is systemic".
Premier Gladys Berejiklian has vowed to do everything possible to ensure "this never happens again".
