Four months after losing her mother to Covid-19, Kathy Bourinaris received a call from her mother's 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 Atzarakis contracted Covid-19 at the home. She died in hospital days later.
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.
She's only thankful her father wasn't in the car when the call came in.
"That would have destroyed him," she said.
She still hasn't been able to share that call with him knowing it would hurt him to think management didn't remember what happened to his wife, but she gave AAP permission to publish details of the call.
"This shouldn't happen, somebody needs to be held accountable," Bourinaris said.
"This should never ever happy again to anybody."
Bourinaris is far from the only family member to believe that.
In a hearing before state coroner John Cain on Friday, Maxine Tsihlakis said she believed what happened to her mother, Georgia Mitsinikos, was medical manslaughter.
She was already disappointed with the care her mother was getting at St Basil's, where she moved after suffering a head injury when she was struck by a car.
Tsihlakis said even before the outbreak staff had seemed run off their feet.
She said her mother was put on a lot of new medication, and when she asked for a GP to review it learned some of those medications were sedatives.
When staff began testing positive she said there was no communication to families that they or close contacts had been sent home to isolate.
Tsihlakis said families of residents were communicating with each other in Facebook groups about what was happening, including fears their loved ones were "sitting ducks".
Mitsinikos died in hospital on 23 July, 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, began his evidence offering condolences to the families of Covid-19 victims.
"I was involved in nearly every significant case or outbreak that occurred in Victoria - all those decisions weigh on me, just as every patient I treated in a clinical setting weighs on me," he said, his voice breaking.
"That weight obviously can't match the experience of a loved one and I express my deep sympathies to them."
