Four months after losing her mother to COVID-19, Kathy Bourinaris received a call from her mother's Melbourne nursing home offering her a tour.
Staff at St Basil's Home for the Aged wanted to know if Fotini Atzarakis was still interested in respite care and the family was invited to look around the Fawkner facility.
It was during a two-week respite period that Mrs Atzarakis contracted COVID-19 at the home. She died in hospital days later.
Ms Bourinaris told an inquest into 45 deaths at the home during the July 2020 coronavirus outbreak that the call made her feel sick and she had to pull over.
"This shouldn't happen, somebody needs to be held accountable," Ms Bourinaris said.
"This should never ever happy again to anybody."
Maine Tsihlakis told State Coroner John Cain on Friday that she believed what happened to her mother Georgia Mitsinikos was medical manslaughter.
She was already unhappy with the care her mother was receiving, saying staff seemed run off their feet even before the outbreak, and noted she had been put on a lot of new medication including sedatives.
When staff began testing positive Ms Tsihlakis said there was no communication to families that they or close contacts had been sent home to isolate.
She said families of residents were communicating with each other in Facebook groups about what was happening, including fears their loved ones were "sitting ducks".
Mrs Mitsinikos died in hospital on July 23, three days after her family was told she had tested negative.
Public health registrar Naveen Tenneti, who is the director of Victoria's human services public health policy, said he first learned of the St Basil's outbreak on July 14, two days after his department was notified.
He blamed the stress of the department's workload, juggling multiple major outbreaks, for it not being escalated to him earlier.
The inquest heard multiple doctors working with St Basil's had warned in meetings with Dr Tenneti against the department's decision to stand down the entire workforce and bring in fresh workers.
One doctor described the decision as a "shocking idea", especially after a takeover at Estia Heidelberg occurred it resulted in medications being lost, missed meals and diets not being modified, and analgesia not being provided.
A senior geriatrician had told a meeting with the health department that there needed to be continuity of regular staff, noting it "turns out to be a disaster if (there's) no regular staff".
Dr Tenneti said the decision to replace all the staff was made by balancing the risks of potential impacts to continuity of resident care with the real risk of a further spread of COVID-19.
Earlier he said decisions he made during that period had weighed heavily on him since, while acknowledging that weight was nothing compared to what residents families had felt.
The inquest will resume on Monday and is scheduled to run until December 17.