A fatality inquiry has found there was no neglect in the case of an Edmonton woman who became emaciated and developed a gangrenous toe at her nursing home in 2005.

In a two-page report released Monday, Provincial Judge Paul Sully said 83-year-old Jean Warden died from pneumonia due to a heart condition.

Sully said Warden's other health conditions – namely arthritis, high blood pressure and a wasting condition known as cachexia – also served as contributing factors.

After being treated in hospital due to a fall in March 2005, Warden was admitted to the Devonshire Care Centre at 1808 - 142 Street.

Her son, Rob Warden, claimed his mother started to lose weight rapidly. Because of her arthritis, she required help with eating and drinking – but Rob said she did not get that help.

About six months after being admitted to Devonshire, Rob and his wife discovered Jean's toe was bandaged. On a website that has since been taken down, Rob claimed that staff were unable to say what was wrong with the toe.

Jean Warden gangrenous toe

Jean Warden's family said they found her gangrenous toe bandaged and uncared for at the care home. (Warden family)

The next day, Rob and his sister removed the bandage and found that Jean's toe was gangrenous, and decided that day to admit her to the University of Alberta Hospital.

According to a report posted on Rob's website and accessed by CBC News through a web-archiving tool, a hospital social worker spoke to the family about allegations that Jean had been left in bed for long periods of time at the care home, was left in wet diapers and that facility staff were unwilling to listen to their concerns.

The social worker's report says an investigation was commenced by the province under the Protection for Persons in Care Act.

However, according to Ruth Adria, director of the Elder Advocates of Alberta Society and someone who was closely involved in the case, allegations of abuse were not proven.

System failed: advocate

"We feel the whole system has failed her," Adria told CBC News.

"If this had been an animal in that condition, there would have been outrage. This would have been front-page, charges would have been laid."

'If this had been an animal in that condition, there would have been outrage.' - Ruth Adria, Elder Advocates of Alberta

However, Judge Sully wrote that Warden "appeared to have been provided with adequate medical care" from the onset of health problems in 2002 until her death.

Adria, who attended the four-day fatality inquiry in December 2012, insisted evidence was presented that the condition of Jean Warden's toe was not passed on to a special "wound team" at the nursing home that deals with infections.

Adria said Warden's story is one of dozens she has documented, and underlines that everyone is responsible when it comes to elder care.

"Families believe when they entrust their loved one into care, that literally they will be cared for. Unfortunately, in far too many facilities, seniors … are being warehoused. They're not receiving care. And when there is a very difficult situation, there's no accountability in the system."

Rob Warden spoke to CBC News Monday from his new home in South Dakota, but he did not want to talk about the specifics of the case. He only wanted to give a warning to other families with elderly parents.

"With our experience, we urge other families to keep and eye on their parents in care," he said.

Since Warden's death, Devonshire Care Centre was purchased by Vancouver-based provide Park Place Seniors Living, which also owns Hardisty Care Home. A call by CBC News to Park Place was not returned Monday.