Prior to being admitted to Calvary Hospital, Robyn said her 85-year-old mother Gwen was full of life and energy.
"She was able to drive herself around and she was living independently in Canberra. She was very lively," Robyn said, who did not want her surname published.
However, that all changed when Gwen was taken to Calvary in late April last year, suffering from an infected leg ulcer.
During a weekend visit to see her mother in hospital in May 2017, Robyn said Gwen's condition deteriorated rapidly after contracting sepsis in one of the wards.
"Mum had gone a very strange colour and she was struggling to breathe and she couldn't be roused," Robyn said.
Despite the constant pleas from Gwen's family, staff were unable to check her condition over the weekend, as regular doctors and specialists were only available on weekdays.
Robyn said staff told her doctors were not able to be called in for a fear of backlash and intimidation from senior staff.
It was these factors, Robyn alleged, that led to her mother's death just weeks later. Following her diagnosis of septic shock, Gwen was transferred to Calvary's intensive care unit and eventually discharged into a high-care nursing facility, before she died on July 6 last year.
Her daughter said negligence from staff as well as staff being intimidated as a result of a culture of bullying at the hospital contributed to her mother's death.
An investigation into the circumstances that led to Gwen's death, undertaken by the ACT Health Services Commission, found that staff failed to call emergency medical teams to treat her, despite Gwen's Modified Emergency Warning Score (MEWS) being high enough to warrant an emergency response.
In a statement to the commission at the time, the ward's clinical nurse consultant said emergency medical staff were not called due to previous encounters of intimidation by senior staff over similar incidents.
"The nurse did not feel confident to call the [emergency team] as she had been made to feel foolish by the team in similar circumstances when she did," the nurse consultant said.
Calvary's after hours medical officer also said the behaviours had previously taken place.
"The registrar should certainly have been notified," the officer said.
"I can certainly emphasise with the nurses' comments, however [as] registrars are often extremely overworked and can get quite crabby if [they are] called inappropriately. Some anxiety around making these calls is to be expected.
"This applies to junior doctors too, and I have experienced this first hand and it can be very intimidating."
Calvary's patient safety and quality manager said "there was a culture in some areas of Calvary Public Hospital of not making after-hours calls to medical staff due to retribution", according to transcripts of a meeting between Robyn's family and Calvary representatives.
Following the commission's review, a summary of its findings found after-hours staff "lacked the requisite variety of experience" to identify sepsis.
"Calvary acknowledges that treatment team attending Gwen did not conclusively identify the severity of [Gwen]'s sepsis. A more experienced clinician may have done so," Calvary chief executive Karen Edwards wrote in a letter on September 6 last year, seen by the Times.
Robyn said: "It just added trauma on top of all of the grief.
"We were just appalled at the way the hospital acted at the time."
In a statement to the Sunday Canberra Times, Calvary Bruce chief executive Barbara Reid said processes were in place to treat patients at times, such as weekends, where there were fewer staff members.
"Calvary Public Hospital Bruce has protocols that support quality practice and safe care of our patients," she said.
"Protocols include those that support the management a patient may deteriorate or require patient care; whether that occurs during general weekdays or a weekend."
Following a complaint made by Robyn on June 22 last year about the treatment of her mother before her death, Robyn said she was told by a senior staff member at Calvary Hospital that there was a "culture" of not calling staff on the weekend in the event a patient's health had rapidly deteriorated, due to a backlash of bullying and intimidation.
"No staff members on the ward conducted observations on my mother or even entered the room while we were there on that Sunday afternoon," Robyn said.
The health commission review also heard from clinical nurse consultants on the ward Gwen was on at the time, and said a medical emergency team (MET) should have been called.
"Escalation pathways for patients who are not responding to treatment is a MET call," the staff member said.
"Staff do acknowledge that they should have considered a MET, but also feel that the backlash of "inappropriate" calls often influences this.
'The education around communication and patient/family engagement is ongoing."
A three-hour conciliation took place in February this year between Calvary Hospital and Robyn's family, but no agreement between the two parties was reached.
"The mediation process and associated legislation ensures confidentiality for the mediation for all parties," Ms Reid said.
"As such, Calvary cannot provide any further comment to The Canberra Times regarding specific questions asked about [Gwen]."
In her last correspondence with the hospital, Robyn wrote to Calvary suggesting staff training in respectful behaviour between doctors to prevent circumstances that happened to her mother happening to other patients. She has not received a response.
"Three separate times I've been told there's intimidation and bullying going on," she said.
"Obviously there's a bullying culture going on, and there should be a mandatory course for all staff members in respectful behaviour towards each other."
Almost one year from her mother's death Robyn said she was still searching for answers.
"It was a collective failure and a series of dreadful errors of judgment that led to mum passing earlier than she should have," she said.
"We got a lot of apologies and condolences from Calvary, but nothing else."