When Lois Madden's mother went into Radius Lester Heights Hospital she was unwell.
But her family are adamant she was not already dying as the rest home has suggested.
Gladys McKinnon, 84, had gone into the home because the level of care she needed had increased, and Lester Heights could provide that care.
Except they didn't - something the Health and Disability Commissioner and the rest home acknowledge.
Mrs McKinnon became dehydrated at the home, and died days later from organ failure directly linked to dehydration (the death certificate states this).
Bizarrely, the HDC have not recommended prosecution as the breach of care was considered to be "moderate".
This is despite a finding that there was no evidence that registered nurses [at Lester Hospital] cared for Mrs McKinnon (she was not assessed on her arrival), and no evidence of nurses responding to family and caregiver concerns about Mrs McKinnon's health.
Those concerns were around symptoms of dehydration - a relatively common ailment and easily fixed if diagnosed early ... you give the sick person water.
Radius general manager Brien Cree is in an awkward situation - regardless of what he thinks privately, publicly he cannot admit that the rest home caused Mrs McKinnon's death.
The latter is fair comment based on a), admission that the rest home dehydrated Mrs McKinnon and b), the death certificate states dehydration was a causative factor in her death.
In general, any organisation that admits guilt publicly, immediately opens the door to being sued. And sued successfully.
Radius Lester Heights Hospital has admitted poor provision of care, but have made no admission or comment on whether the dehydration at Lester and the dehydration mentioned on Mrs McKinnon's death certificate are linked. A reasonable view could be formed that they are. Why then, is everyone talking around this salient point.
It appears that we have a health system that has flaws not only in its provision of care, but in the review of that provision of care.
Surely this is a matter that would interest our chief coroner, given it falls within the two key coronial considerations - cause of death and are there lessons that can be learned to prevent a similar scenario arising again?
Or, given that we have potentially dangerous prisoners released to live in portable cabins on remote rural roads, are we simply living in a world that has gone mad?