Poor leadership central to deadly aged care COVID-19 outbreak

An inquest into the COVID-19 outbreak that resulted in the death of 19 aged care residents in Western Sydney has reached its official conclusion with the Coroner’s Court of New South Wales finding that at least three deaths were preventable under another model of care. 

The 65-day outbreak at Anglicare’s Newmarch House in Kingswood was one of the earliest examples of COVID-19’s devastating cruelty. In total, 37 of the home’s 97 residents contracted the virus during that outbreak, with 19 dying as a result of the infection and complications from comorbidities. 

Key points

• The NSW Coroner found that at least three resident lives could have been saved if a different level of care or response to their COVID-19 infection was provided by Newmarch House staff
• Additional lives could have been saved if a different model of care had been implemented to limit the spread of COVID-19
• Instances of suboptimal and/or delayed care were recorded, including the delayed provision of pain relief and fluids; some residents could have also benefited from a hospital transfer

After three long years, Deputy State Coroner Derek Lee handed down the findings on January 24, declaring that Anglicare Sydney did not demonstrate proper leadership or provide individualised care to residents who tested positive for COVID-19. 

Residents were told to isolate in their rooms when the first case was reported at Newmarch House, with families informed that no resident could leave the home because of the risk of cross-infection.

Expert analysis said most infections were acquired within the outbreak’s first seven days, meaning all cases after April 18 or 19 were potentially preventable. 

Despite daily testing, Magistrate Lee said more frequent testing and prompt reporting would have identified positive cases in a timelier manner. The steadfast decision not to transfer residents to the hospital could have also saved several lives. 

“The decision as to whether to transfer residents out of Newmarch House obviously became an important consideration. It is accepted that the transfer process and a hospital environment created potential further infection risks, and the cohorting of residents of potentially mixed infection status created an additional risk of increasing the secondary infection rate,” Magistrate Lee said. 

“However, the issue of infection control should not have been the only issue relevant to the question of transfer. Consideration also ought to have been given to the needs of those residents who tested positive for COVID-19 and whether their care needs could be adequately met in a residential facility rather than a hospital. 

“Further, if only COVID-19 positive residents, once promptly identified, had been transferred out of Newmarch House this likely would have slowed the rate of new infections.”

Mixed messaging from government departments did not help the situation, however, while internal management failed to reach a genuine consensus when debating whether to move residents. 

Magistrate Lee said Anglicare should have realised a blanket decision was not suitable.

“Quite apart from the merits of each approach in favour of, or against, the transfer of a cohort of residents out of Newmarch House, it appears that neither approach centred on the needs and wishes of individual residents, and their families… the individual needs of each resident ought to have informed the issue of transfer,” he added.

This was compounded by Newmarch House’s attempt to adopt a model of care that combined virtual care and Hospital in the Home (HITH) which ‘spectacularly failed’ as integration and implementation fell short. 

“Anglicare did not have a clear understanding of the model of care that was being implemented, and instead its expectation of the level of care that would be provided was higher than what was actually delivered,” Magistrate Lee concluded. 

Anglicare’s response to the findings

Anglicare Sydney Chief Executive Officer Simon Miller released a brief statement responding to the NSW Coroner’s findings. It included a reference to an apology from 2022. 

“Anglicare acknowledges that the circumstances in which family members of Newmarch lost their mothers, fathers, grandparents, partners or friends made the loss much greater. For the residents and their families, the physical separation from their loved ones and intense distress and worry about them was traumatic,” the apology read.

“Anglicare is sorry for the distress experienced during the outbreak by the residents of Newmarch House and their families and friends. Anglicare acknowledges that this was a time of intense anxiety and uncertainty for all of those involved in the outbreak.

Mr Miller also acknowledged ‘that time does not diminish the grief and loss that many feel’. He said Anglicare remains committed to living its vision, mission and values through continuous reflection, learning and improvement.

“We continue to remember the residents who lost their lives, their families and loved ones, and recognise the staff at Newmarch House who showed great compassion and care during the outbreak,” Mr Miller said. 

“The release of the Coroner’s findings marks the end of the Inquest. Much has changed since the start of the pandemic and many lessons have been learned and practices improved by Anglicare and the aged care sector more broadly about how to better manage COVID-19.

“Anglicare acknowledges the findings that are critical of some aspects of our approach to the 2020 outbreak, and we will now take the time to thoroughly review and carefully consider the Coroner’s findings.”

Leadership lessons result in growth

The Newmarch House outbreak stands out as a costly lesson for the aged care sector and leadership faults were a contributing factor.

The inquest included comparisons between Newmarch House’s outbreak and another at BaptistCare’s Dorothy Henderson Lodge. 

In this case, 17 out of 76 residents became infected with COVID-19. Those who tested positive were initially transferred to hospital. Just six of them died.

Tracy Burling, the Acting Residential Manager at Dorothy Henderson Lodge, was asked to take on the Newmarch House’s facility manager role during the outbreak. She described Anglicare Residential Manager Melinda Burns as ‘overwhelmed’ and the facility as ‘chaotic’. Others said there was a lack of reporting structure, clinical management and leadership. 

“It was a traumatic situation. You had really no idea what was going to happen next. You were just trying desperately to make sure that the basic needs of the people that you really wanted to provide care for were there, and you wanted to be able to communicate some sort of reassurance to the families, but it was extremely hard to do,” Ms Burns said in a previous statement. 

The exact opposite was reported at Dorothy Henderson Lodge with its clear management structure praised.

Magistrate Lee concluded there was no clear understanding of the chain of command and overall management structures during the outbreak. Additionally, there was no effective and direct support from senior executives, and daily management would have benefited from more frequent executive management guidance on the ground.

Mr Miller acknowledges that senior executives should have been on-site during the crisis. 

Since then, the organisation has made meaningful changes to its structure, showcasing that it learnt from mistakes made during the unprecedented crisis.

This includes introducing more board members with clinical and public health expertise while introducing a Head of Infection Prevention Control and Outbreak Management and the General Manager – Quality, Safety and Risk. Every home has had an infection control lead since December 2020.

Anglicare is also more responsive to outbreaks with daily COVID-19 management meetings, increased workforce capacity and improved communication with residents and primary contacts during an outbreak via their communications manager.