In June 2014, Karen Sorensen staggered out of the aged care home where she had long worked as a registered nurse and collapsed on the footpath.
She had just left the job she loved, and the clients she cared about, because she wasn't sure it was safe anymore. And no one was listening.
Earlier, Ms Sorensen had discovered that her manager had again dressed a highly infectious wound without gloves. When she took them aside to reiterate the importance of never repeating that breach of protocol, she was admonished. "I can do it this way," came the answer.
This wasn't the first time Ms Sorensen had had serious fears about how the clinical care policies she set were being followed since the facility expanded and this particular manager arrived. Months before they had left early for a break on the coast during a blackout, leaving Ms Sorensen and three other staff alone to juggle 50 residents, including at least one who was running out of oxygen without power to their breathing machine.
Staff had also been instructed to bill for pain relief massages never performed, she claims, while other nurses had been left in "in tears" because medical orders from the manager conflicted with advice from doctors and Ms Sorensen.
But this time, she repeated her concerns in writing. When nothing changed, she notified the homes' chief executive who promised to take care of it. Instead, what followed she believes was a "concerted campaign of bullying and retaliation", designed to silence and discredit her.
It didn't end that day on the footpath but she was eventually awarded hundreds of thousands of dollars in compensation for permanent psychological injury sustained on the job.
Ms Sorensen's story is one of many shocking experiences which will be shared with the Royal Commissioned into Aged Care when it holds hearings in Canberra this week. But the most shocking part for the former nurse is that she worked at one of the better facilities in the region.
"We were doing really innovative things, we were really well regarded," she says. "But when I spoke up, when I blew the whistle, I was punished.
"The worst part, walking out, was thinking how I'd abandoned all those people. By the end, I was even forbidden from speaking to their doctors. And I was in charge of clinical care. It was out of control."
Ms Sorensen also alleges her own medical notes were tampered with by the same manager after she had signed them - to claim "no infection" was present in a wound that later required the patient be rushed to hospital.
Will there be a whistleblower willing to risk their health and their job next time?Former aged care registered nurse Karen Sorensen
In June, Ms Sorensen filed a grievance and demanded an investigation into a litany of unsafe practices she had witnessed or heard staff concerns about. In response, the facility tasked another manager, also named throughout the complaint, with reviewing it. It's understood an external investigator was eventually brought in when Ms Sorensen complained, but only to collect statements from some people involved - no finding was ever made.
"To this day, they have not investigated my concerns properly," Ms Sorensen said.
When the facility came up for accreditation three months after she left, it passed.
"A lot of my procedures were still in place then, but not all of them were actually being followed," Ms Sorensen said.
Then in late 2018, a snap audit believed to have been triggered by a tip off from another concerned staff member uncovered the same failures in safety and clinical care Ms Sorensen had warned about four years earlier. The home failed on nine measures, including clinical care, pain relief, medication management and wound care.
It is understood the manager involved in many of Ms Sorensen's complaints has since left the facility, and in 2019, after cleaning up its procedures and beefing up staff numbers, the home passed a second audit, meeting all 44 expected outcomes.
The facility cannot be named due to the terms of Ms Sorensen's settlement and could not comment on her allegations, but said it was aware of three formal complaints made to the royal commission.
"A lot of people got away with covering it up, and some of them are still working in the sector," Ms Sorensen said.
"That's the sting in the end of the tail. That's what still worries me. Will there be a whistleblower willing to risk their health and their job next time?"
The federal government is now developing a "serious incident response scheme" for aged care to broaden the scope of incidents which must be reported, alongside a $537 million cash injection to address early recommendations from the royal commission's damning interim report.
That same report also pointed to critical gaps in reporting and accountability in the sector and noted its unwillingness to "listen to feedback" from those on the ground, "particularly when the regulatory system appears so distant and ineffectual".
In her own submission to the commission, Ms Sorensen has called for more in-depth audits and a confidential complaints portal for staff, and says the mandatory reporting schemes now in place to protect children should be extended to other vulnerable people including those in aged care.