Alex Reid said conditions in his mother's nursing home were so bad that he was asked, as a scuba diving instructor, to train the staff on how to use oxygen tanks.
Flicking through photos of his late mother Nancy, Alex Reid chuckles at the good memories and rues some bitter ironies.
Photos show a beaming, idealistic young nurse - who after World War II, worked with the legendary surgeon Sir Edward "Weary" Dunlop to care for returned soldiers.
But Ms Reid spent her last year in a Canberra facility that struggled with serious shortages of staff, training and other resources.
“I had to supply my own incontinence pads because there was a limit on the number made available,” Alex Reid said.
“That’s just unacceptable”.
One day Mr Reid found his mother looking exhausted, her oxygen bottle disconnected.
“They'd put the regulator on backwards and hadn't taken out the cap. I'm actually an oxygen administrator for scuba diving," he told SBS News.
"They said 'oh our staff are not trained', and the result was they asked me to train the staff on how to use oxygen.”
Many such tales of neglect – and other stories of abuse - are beginning to emerge at the Federal Government’s Royal Commission into Aged Care Quality and Safety, which holds its third round of public hearings next month.
Researcher Maree Bernoth interviewed dozens of relatives of aged care residents across NSW, Victoria and the ACT for post-doctoral work between 2011 and 2013.
She catalogued cases of extremely poor care and neglect, including malnutrition, dehydration, and people being left for hours on toilets.
"If we’re going to envisage our older people as sources of income and profits, we’re not going to be concerned about their humanity," she said.
"We’re not going to be concerned about making a change that’s going to impact on the profits of our for-profit aged care organisations. ”
Ms Reid had been placed in a not-for-profit facility. Visiting his mother three times a day, before her death in 2010 from cancer and emphysema, Mr Reid saw much.
"I heard people calling out from the room the podiatrist used, I looked in and found a lady screaming and I said, 'what's going on ?'," he said.
"'Oh, I'm cutting her toenails,' and I could see that they were slightly bleeding and I said 'mate, you're obviously hurting her, why are you doing it that low ?' and he said, 'because there's not enough funding to get me in here as regularly as I need to just trim them lightly'."
'I would like to shoot you with rubber bullets'
There’s evidence of warnings given – and ignored – within facilities, and beyond.
Mr Reid, a secondary-school teacher, still has the typed notes he stuck to his mother's door for the benefit of staff.
Among them “Hourly check please – I keep falling out of bed”.
Once he discovered that her emergency button – plus her food and drinks trolley – had been inadvertently pushed out of reach by carers.
“How long had she been like this and what would have happened if I was not so attentive," he wrote in an email. "Could this have led to another fatality in care?"
Former nurse Maree Bernoth, now an Associate Professor of Nursing at Charles Sturt University in Wagga Wagga, said she presented findings of malnutrition and dehydration to an Elder Abuse conference in Adelaide five years ago.
“Afterwards a South Australian aged care CEO approached me and said, 'Maree, what a shame we can’t say something positive about aged care'."
But her realisation that “people didn’t want to know about the bad things happening in aged care” hit home in 2006.
"At a meeting of 14 managers across the organisation, when I told them of my concerns of what I'd been hearing from staff, one of the senior managers said, 'Maree, I would like to shoot you, I would like to shoot you with rubber bullets'. And to make it worse, no-one said anything about that, it was just silence after she had said that," she said.
She said she was so unnerved that she moved her family to another town.
What chance of change?
Both Dr Bernoth and Mr Reid say that under-resourcing of aged care facilities has only worsened since their experiences.
Dr Bernoth is just the latest advocate to trace the crisis back to the Howard Government’s 1997 Aged Care Act which provided for much greater private sector involvement.
The privatisation of staff education, she said, meant that in most states facilities were no longer required to employ registered nurses, but only care workers with a wide range of skills and training.
"And the accreditation system, that’s based on paperwork, has proved to be ineffective and easily subverted by aged care operators," she said.
Neither Aged Care Minister Ken Wyatt, nor the two Royal Commissioners, would be interviewed for this story.
For now, both Dr Bernoth and Mr Reid are telling their stories via submissions to the Commission, adding to some 1700 already lodged.
For Mr Reid, it’s taken some time to reach this point.
“It brought back a lot of emotions for me. And that's why, I guess, I was a bit reluctant to be involved in it," he said.
"However, it was clear that if things haven't changed I needed to put something in. So that's what I did.”