Annunziate "Nancy" Santoro was discharged from hospital back to a Melbourne aged-care centre in July 2018. Three months later she was dead.

Key points: Ms Santoro's foot wound was left untreated for so long it became infested with maggots and contributed to her death

Ms Santoro's foot wound was left untreated for so long it became infested with maggots and contributed to her death A surgical staple was left in her hip for weeks longer than advised, and her antipsychotic medication dosage was increased tenfold in one month without her family being advised

A surgical staple was left in her hip for weeks longer than advised, and her antipsychotic medication dosage was increased tenfold in one month without her family being advised Melbourne's Assisi aged-care centre has admitted to systemic failures

The elderly Italian migrant had a festering, blackened wound on her heel that had been left without treatment for so long it had become infested with maggots, and eventually contributed to her death, the Royal Commission into Aged Care Quality and Safety has heard.

WARNING: Graphic images below

Her painful last months of life were central to Wednesday's hearings in Darwin, at which damning evidence was given about the "systemic failures" of the facility where she was a resident.

Once a hard-working, religious seamstress from southern Italy, Ms Santoro entered the Italian-language Assisi aged-care centre in Melbourne's north one year before she died.

It was alleged during the hearings that the doctor responsible for Ms Santoro's care, Eric Tay, did not assess her foot wound for nearly two months after she was discharged from Austin Hospital in July 2018.

"Often she had footwear on … I wasn't aware that something had developed," Dr Tay said.

During the doctor's evidence, it was alleged that after the maggots were discovered in Ms Santoro's wound, ward manager Jumuna Jacob was "tense" and "anxious" and "said words to the effect that she could get in trouble if this was disclosed" to Ms Santoro's family.

"There was a breakdown in the relationship between Ms Santoro's family and the facility," Dr Tay said.

Ms Santoro's wounds were infected with maggots while in a Melbourne aged-care home. ( Supplied )

Ms Santoro's infected foot. ( Supplied )

'Maggots used in modern medicine': centre

Ms Santoro's daughter, Anamaria Ng, also gave evidence.

She said after she found out that "a fly had entered [her mother's] wound and laid eggs" she had been "appalled" and sought answers from Assisi.

These had not been easily forthcoming.

In an emotional testimony, Ms Ng alleged that upon raising the issue with Ms Jacob, the ward manager told her "maggots are used in modern medicine" and was "essentially trying to downplay the significance of the whole thing".

The commission heard that Ms Jacob left the centre in June this year, one month after Assisi's former CEO — whose name is supressed for legal reasons — was removed by the centre's board.

Staple left in skin, drug dosage increased tenfold

In the commission hearing, Dr Tay agreed that "in a clinical sense … the bone infection associated with her foot wounds was one of the factors contributing to her death".

Dr Tay also acknowledged that his record-keeping had not been up-to-date, and that he had failed to seek out Ms Santoro's hospital discharge details after they were not sent to him.

"I was too reactive as opposed to proactive," Dr Tay said.

Annunziate Santoro died two days after leaving the Assisi aged-care centre. ( Supplied )

Ms Santoro's health had started to rapidly decline during her residence at the aged-care centre.

While there, she was medicated with sedating antipsychotics about which her family hadn't been properly informed, alleged Ms Ng.

Ms Santoro also suffered from an infected hip after a surgical staple was left in her skin for weeks longer than medically advised.

She had been placed on a course of quetiapine, an antipsychotic medication, which Dr Tay agreed had been at one stage increased tenfold during a month.

He said it was "hard to know" if Ms Ng had been aware her mother was being placed on such dosages of quetiapine, despite the fact he had been corresponding with her via email regarding Ms Santoro's treatment.

Not long after having been alerted to the condition of her mother's foot wound, and when it became clear that Ms Santoro did not have long to live, Ms Ng made efforts to transfer her from the centre.

"My mother's management had been so poor, her pain management, and her care … I had just completely lost faith. I just wanted her out of there," Ms Ng said.

"I essentially begged — I did not want her to die at Assisi."

Ms Santoro was moved to a different palliative care centre in October 2018, where she died two days later.

Assisi 'unwilling to accept responsibility'

In evidence, Assisi's interim CEO Paul Cohen said he had been installed to the role to look "systematically [at] how we improve".

"The board have investigated as much as they are able to with the former CEO; they've acted at a level to remove the CEO," Mr Cohen said.

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He agreed with senior counsel assisting Peter Rozen QC's assessment that there had been "systematic problems" in relation to wound management in the organisation, and that the treatment of Ms Santoro had been a cause of "systemic failure".

"What's striking about this case … it's not just a problem with the hip wound and it's not just a problem with the heel wound, but we see a pattern here, don't we, of poor care, and at some levels an unwillingness to accept responsibility," Mr Rozen said.

Mr Cohen agreed that there had been a lack of transparency in not telling Ms Santoro's family that Ms Santoro's wound had become infested with maggots, an issue that "went to the heart of a very serious cultural problem at Assisi".

The commission heard there were 15 "significant deficiencies" surrounding Assisi's duty of care with Ms Santoro.

The hearings in Darwin continue until Friday.