Spiros and Dora Vasilakis had already said a last goodbye to their dying mother Maria in hospital when a nursing home called them saying she was "alive and well".
The 81-year-old woman was diagnosed with renal failure after becoming sick with COVID-19 at St Basil's Home for the Aged during Victoria's second wave of the virus in July 2020.
Ms Vasilakis' children knew she was about to die.
But as they waited for the dreaded call from the hospital, a staff member from St Basil's rang them to say she was "alive and well" at the Fawkner nursing home.
"This is how chaotic it was," Spiros Vasilakis told an inquest into a deadly COVID-19 outbreak at St Basil's on Tuesday.
Maria Vasilakis died on July 23 last year.
She was one of 45 St Basil's residents who died from the virus that month after regular workers at the home were declared close contacts and replaced by inexperienced agency staff.
Her son told the inquest he and his sister had to physically prevent another resident wandering into their mother's room from a contaminated area.
"There was no one around to stop this lady," Spiros Vasilakis said.
Dora Vasilakis said when she visited her mother in mid-July, after she briefly returned to St Basil's from hospital, the 81-year-old was slumped to one side and having difficulty swallowing water.
Ms Vasilakis had been reassured that Maria would receive the same standard of care at the nursing home as at the hospital.
But she had to ask someone to prop her mother up before questioning why her mother had not been provided an intravenous drip.
"I felt the inside of my brain exploding," Ms Vasilakis told the inquest.
"I cannot stomach the suggestion residents would have got the same care at the home as at the hospital - they clearly didn't."
Northern Health sub acute services divisional director Dr Sandra Brown said St Basil's was in a "dire" situation when she visited on July 23 - a day after staff were replaced.
Dr Brown described night staff not turning up for their shift as well as residents not being provided meals and lying in soiled beds.
She then broke down in tears when asked to read out parts of her summary of that visit to the inquest.
"I find this really hard to relive," Dr Brown said.
"This was the most distressing day of my career."
Dr Brown added that she believes the decision to furlough staff without appropriate staffing contingencies led to the neglect of residents at the aged care home.
The hearing continues before Victorian State Coroner John Cain.