The daughter of a woman who lay dead on the ground of a supported residential service for more than two hours has called for changes to the system that "failed" her mother.
Warning: The following story contains details and images some readers may find distressing.
Evidence about the "neglect" of 65-year-old Kaye Wilson came on the last day of the disability royal commission hearing into homelessness and insecure housing.
The woman's daughter, Georgia Wilson, gave emotional testimony about the two months her mother lived at one of Victoria's supported residential services (SRS).
Kaye Wilson, who had mental health issues and schizophrenia, moved into the SRS in February 2020.
She paid $490 a week, the total amount of her disability support pension (DSP), for a room with a toilet and shower.
SRS are privately-owned and operated facilities that provide accommodation and support for people who require assistance with everyday living, including people with disability.
After two days of evidence, commissioner John Ryan said they had heard from residents of different SRS who were "routinely hungry, cold and living in unhygienic conditions".
There are 114 registered SRS in Victoria that currently house about 3,100 residents. An estimated 1,600 NDIS participants live in these facilities, the inquiry heard.
The Victorian government provides $13.6 million of funding to SRS each year.
Mother's death treated with 'lack of dignity'
Kaye Wilson's daughter had become increasingly concerned about her mother's safety in the SRS and felt that her mother was seen as "a number and a pay cheque".
Ms Wilson told the inquiry the manager asked for detailed information about her mother's National Disability Insurance Scheme (NDIS) plan and said "it's all about money, money, money".
Soon after Kaye Wilson moved into the SRS, Victoria went into lockdown.
Ms Wilson had to rely on phone calls to the SRS to check on her mother's welfare.
When she was notified of her mother's death in April, Ms Wilson went to the SRS to identify the body.
She found her mother lying on the ground in an open courtyard and covered with a tarpaulin.
Police said her mother was found dead on a couch in the courtyard at 10:30am and paramedics moved her to the ground, when they performed CPR at 10:45am.
Ms Wilson said: "The whole environment just seemed odd."
Police told her that paramedics said her mother died of "natural causes" and it did not need to be reported to the coroner.
In a "state of shock", she was asked by police if she thought her mother's death was suspicious and advised that if she did, there would be a "tonne of paperwork".
The funeral home later emailed Ms Wilson to say her mother was "very dirty," with "matted" hair and dirt under her nails and all over her hands, legs, neck and face.
After making a formal complaint to the Department of Health and Human Services, Ms Wilson learned from a paramedic's report that her mother had been sitting on the ground for "two-and-a-half hours" before they arrived and "was never on the couch".
The report said her cause of death could "not be determined" and she "needed to go to the coroner", but the inquiry heard that never happened.
A GP informed Ms Wilson that her mother had not been taking her medication, contradicting the information provided by the SRS manager.
"I put all of my trust in that manager and all of my trust in the Victorian government to do what's right," Ms Wilson said.
"The manager lied, plain and simple."
Ms Wilson said she'd had no contact with the SRS and no apology for the "lack of dignity" around her mother's death.
Resident would rather 'live on the streets'
A current resident of an SRS told the royal commission she would sometimes go "weeks at a time" sleeping on a bare mattress with no bed sheets.
The 34-year-old woman, known to the inquiry as Bel, is an NDIS participant.
She lives with depression, anxiety and borderline personality disorder.
Bel pays $920 a fortnight for a room, bathroom and support services.
The inquiry heard all SRS charged fees based on the resident's pension, plus their entire Commonwealth rent assistance.
They "usually" took between 85 and 95 per cent of a resident's pension, which equated to between $900 and $1,000 a fortnight.
Bel said she had no money left after she paid the SRS and was "angry" that she did not get enough support with her cleaning and washing.
"I often think I would rather live on the streets than continue to live in an SRS," Bel said in her statement.
SRS which closed during COVID an 'awful' place
The inquiry also saw evidence of "putrid conditions" inside a former SRS, which shut down after its poor conditions were discovered during a COVID-19 outbreak.
Denise, a former resident of an SRS called Hambleton House in inner-Melbourne suburb Albert Park, gave evidence that she was "terrified" sleeping in her room as the lock was broken on the back door.
"I thought that someone was going to come in and kill me in bed," Denise, whose surname cannot be published, said.
Denise, who is in her 70s, said her bed was infested with bed bugs that bit her all over.
Another witness, who provided photos of the rooms at Hambleton House, talked about the "pungent smell" of the facility.
Denise said she was "sick all the time," and the bathroom she shared with other residents was "cold as ice".
She said Hambleton House was the most "awful" place she ever went to in her life and the other residents were "nasty people".
Hambleton House was closed in August 2020 and Denise and the other residents were relocated.
Regulator admits it 'could have done better'
SRS are regulated by a unit within the Victorian Department of Families, Fairness and Housing, that has about 20 "authorised officers".
Director of the Human Services Regulator, Anthony Kolmus, told the inquiry the proprietors of Hambleton House were no longer working in the sector.
Mr Kolmus said the regulator had the power to issue both infringement notices and compliance notices to SRS.
In his almost three years in the role, Mr Kolmus said no infringement notices had been issued.
Asked about the death of Kaye Wilson, Mr Kolmus said it was an "unpleasant situation all round" and admitted his department "could have done better".
He told the inquiry that the SRS had not breached the law in its treatment of Kaye Wilson as the regulator formed the view that, because she "was deceased, technically meant they were no longer a resident".
After detailing the circumstances of her mother's death, Ms Wilson asked the royal commission to make recommendations for changes, including an increase in staff ratios.
"I feel the Australian disability system treats people with disability without dignity, respect and humanity," Ms Wilson said.
"The government departments which are supposed to be there to investigate and prevent such mistreatment cannot be trusted to do their jobs correctly."