It's hard to imagine the agony the frail, elderly woman went through as she lay in her nursing home bed with an undiagnosed and untreated necrotic wound eating away at the flesh of her toe; and scabies mites infesting her skin.
The 85-year-old mother, grandmother and great-grandmother had lived at Allity's Redleaf Manor residential aged care facility, in the Sydney suburb of Concord, for less than four months before she was taken to hospital on February 15 at the request of her doctor and the insistence of her daughter.
She was covered in scabies, had sepsis, golden staph, was dehydrated and had bruising on her cheeks. Ambulance officers called to the nursing home remarked on the "offensive smell" coming from her foot.
Mrs Pearce's daughter Karen Orman said that on the night her mother was admitted to hospital she went into septic shock and almost died.
Mrs Pearce died in hospital on March 3, the cause of her death recorded as sepsis from a necrotic ulcer and peripheral vascular disease.
Karen had looked after her mother at home for three-and-a- half years.
When caring for the dementia sufferer who was bed-bound and had other medical conditions including heart disease, osteoarthritis, Parkinson's disease, hypothyroidism and peripheral vascular disease, became too much, Karen moved her mother into the $5000 a month Redleaf Manor. She also paid a $450,000 refundable deposit.
Mrs Pearce's family visited regularly and on occasions expressed concern over bruises which were explained away by carers. They had no idea of the wound festering under the bedclothes or that the red rash they reported to staff on January 1 - with a request to call an after-hours doctor if necessary - would eventually be diagnosed as contagious scabies.
Mrs Pearce did not see a doctor until January 25.
Two years later and after an investigation by the Aged Care Complaints Commissioner, Karen still can't believe how her mother could have been so badly neglected.
The necrosis and scabies is not in question. The aged care provider has acknowledged to the Commissioner that there were gaps in the care provided and said it had "addressed" these.
Karen is still haunted by the memory of her mum's last days.
She didn't choose Redleaf Manor lightly. She had investigated nursing homes, visited and inspected the facility and spoken with staff and the manager; and it was close to where she lived.
"I had no idea that this could happen. Nobody noticed anything or documented anything. It was disgraceful.
"It's made me very aware that no matter how much you feel you are on top of everything you have to check your loved one from top to toe every time you visit.
"Check their feet, question their bruises, check their pad. Don't take anything for granted. You've got to be a detective.
"If we can save just one person from going through what my mum went through it will be worth it."
Karen is an advocate of cameras in nursing homes, including bedrooms, to monitor the care residents receive
She provided The Senior with a number of photographs of her mother taken after she was admitted to hospital. We believe they are too graphic to print.
In a statement to The Senior, Allity acknowledged there were gaps in the care given to Mrs Pearce. "We do not take a position of making excuses, and acknowledge there were gaps in communication, documentation and care delivery at the time in relation to providing specialist wound care for Mrs Pearce," the statement says.
The organisation, it says, has undertaken actions including ongoing training, a review of capabilities and improving processes and procedures to "mitigate recurrences of incidents of this nature".
Redleaf Manor was audited by the Aged Care Quality Agency from March 8-10, 2016, just five days after Mrs Pearce's death.
It passed all 44 of the expected outcomes of the accreditation standards and was accredited for three years. It was previously audited in March 2013 when it also passed all 44 accreditation standards.
The Australian Aged Care Quality Agency is to be shut down following revelations of its failure to protect victims of abuse at a South Australian nursing home.
Its role will be included in a new Aged Care Quality and Safety Commission to begin operations in January.
The Aged Care Complaints Commissioner provides a free service for anyone who has concerns about the quality of aged care services subsidised by the federal government.
Complaints can be raised by those receiving aged care, partners, family members, friends, representatives and carers, advocates, aged care staff and volunteers, health and medical professionals.
The Commissioner received 4713 complaints in 2016-17 with the majority (78 per cent) about residential care. A further 15 per cent concerned home care packages and 7 per cent were about the Commonwealth Home Support Program.
- Aged Care Complaints Commissioner, 1800-550-552, www.agedcarecomplaints.gov.au
The role of the Commissioner will be incorporated into the new Aged Care Quality and Safety Commission.