Some of the 19 deaths during a 2020 Covid-19 outbreak at a NSW aged-care home could have been avoided had proper testing for the virus been implemented, a coronial inquest has found.
Poor leadership, insufficient communication and staff shortages were highlighted in coroner Derek Lee’s review of the deaths from a wave of the virus that swept through Sydney’s Newmarch House.
Less than two months after Newmarch entered lockdown in late March 2020, 37 residents had contracted the virus.
The coroner concluded, among other findings, that:
If universal testing of staff had been performed once the outbreak had begun, and timelier reporting of results had allowed for cases of Covid-19 to be identified more readily, it would likely have reduced the extent and severity of the outbreak;
Frontline management at Newmarch House did not clearly understand the chain of command and did not get effective support from Anglicare senior executives. “Consequently, Anglicare did not demonstrate adequate leadership and governance during the course of the outbreak”, Lee said;
There was a lack of clarity at Newmarch House as to who, if anyone, bore ultimate responsibility for clinical decision-making;
Anglicare did not give residents’ families enough specific information about their loved one, and in some cases it was inaccurate or understated the seriousness of what was occurring;
During the initial stages of the outbreak there was a “significant deficiency” in the number of staff available which “meant that infection control and the care provided to residents was gravely jeopardised”.
Transferring some residents to hospital could have improved the level of care they received, including their access to enough oxygen and fluids, Lee said.
Instead, the Anglicare-run facility opted to treat sick residents on-site under the Hospital in the Home program. This program was not viable and was inconsistent with infectious diseases such as Covid-19, Lee said.
More personalised assessments should have been made with individual residents to determine where they were treated, he found.
However, the coroner did not make any recommendations, noting Anglicare had already made improvements to its policies and procedures after the outbreak.
Speaking before the findings were delivered, Nicole Fahey – whose grandmother Ann died in the outbreak – said family members like her did not want to see what occurred simply swept under the rug.
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“I’m hoping the findings that are handed down are of substance enough for the families to feel like, moving forward, what occurred won’t happen again,” she said.
Despite what she saw as missteps, Fahey said she did not hold individual staff members – many of whom also contracted the virus – personally responsible.
“Some of the rules and regulations that were put in place at the time definitely shouldn’t have been put in place,” she said. “(But) the people in there did the best they could with what they knew at the time.
“A lot of the families don’t have any angst for the staff, they did the best that they could.”
A class action brought against Newmarch by some of the dead residents’ relatives reached a confidential settlement in November.
