A Victorian coroner has said that the recent nursing home toilet death should not be allowed to happen again. "If it’s happening here, it might have happened elsewhere, it might be happening elsewhere," Coroner Olle said.

Of course it is. That is because many staff in aged-care homes regularly take short cuts in order to get the job done. And they will continue to do so until something is done about the appalling staff/resident ratios in many of our aged-care homes.

There is nothing new about leaving frail older people in the toilet for long periods of time. It certainly happened to my mother.

Sadly, it is all too easy to imagine how a harried staff member might forget to return. But, then again, for no-one to even check on the well-being of this resident between 2.45pm and 4.40 pm must send shivers up the spine of anyone contemplating residential care.

After all, the whole purpose of going to a nursing home is to receive caring attention.

Then there is the question of actually being tied to a toilet. Now that is a prospect to consider!

There are strict rules about restraint in aged-care homes. In this instance, these rules were ignored. It leaves one wondering about the whole culture of the home for this to occur.

What other rules were broken? What other short cuts were taken? Was any training and mentoring given to staff?

The Productivity Commission has completed its Report on aged care. One would like to think that a key objective of this Report would have been to deal with the critical staffing problems endemic within the system.

These issues were certainly raised in many of the submissions received by the Commission. But this is not the case. Instead, Commissioners have relied on the vague hope that deregulation and changes to funding arrangements will encourage providers to employ more staff.

Every time one of these distressing tragedies occurs, the public loses even more faith in the system of aged care.

We become even more fearful that we might have to move into residential care.

We all wonder if such a thing might happen to us or to one of our loved ones.

That is why the key to reforming aged care is to ensure that homes are properly staffed with skilled nurses and carers.

And this is what the Productivity Commission failed to do.