COVID-19

Inquest into Covid-19 deaths at Newmarch House reveals provider’s failures

Anglicare executives failed to provide sufficient leadership during the deadly 2020 Covid-19 outbreak at Newmarch House aged care facility in western Sydney, an inquest has found.

On Friday, Coroner Derek Lee delivered his findings into the incident in which 19 residents died as Covid-19 tore through Newmarch House at the pandemicā€™s height, concluding that three of the elderly residents who lost their lives may have been saved had they been transferred to hospital instead of receiving care within the aged care facility.

Following an inquest in 2022, Mr Lee found that Anglicare senior executives failed to provide sufficient leadership to frontline staff.

ā€œThe evidence established that frontline management personnel at Newmarch House did not have a clear understanding of the necessary chain of command and what overall management structures were in place at the commencement of, and during, the outbreak,ā€ he said in his findings.

ā€œSimilarly, frontline management personnel did not receive effective and direct support from Anglicare senior executives.

ā€œConsequently, Anglicare did not demonstrate adequate leadership and governance during the course of the outbreak.ā€

The decision to not have Anglicareā€™s most senior executives at the facility was ā€œsensibleā€. However, the ā€œalmost comĀ­plete absence or only ā€˜occasionalā€™ presence of senior management at Newmarch House during the outbreak created confusion for frontline management personnelā€ who were ā€œoverwhelmedā€.

Mr Lee said communication between the home and the loved ones of residents was inadequate, with the information passed on to them ā€œlargely genericā€ and sometimes inaccurate because of the pressures placed on staff.

There also were lapses in basic care, with residents on occasion not administered medication or provided with nutrition.

Flower tributes to the deceased left outside the entrance to Newmarch House, May 2020.
Picture: NCA Newswire/Dean Lewins

The inquest examined the decision to treat the patients in-house after becoming infectious instead of sending them to hospital. The court heard that at the outset of the outbreak a decision was made that all residents were close contacts and could not leave Newmarch House.

Instead they were treated in the facility under the Hospital in the Home program.

Mr Lee said 12 Newmarch residents were transferred to hospital during the outbreak, with six of them being Covid-19 positive.

However, he said they were all transferred to hospital for other conditions or after suffering a fall.

He called the decision to provide in-house care as ā€œvexxedā€.

The court heard the Department of Health and Aged Care Quality and Safety Commission advocated for the patients being moved out of Newmarch House.

Infectious disease expert James Branley, from Nepean Hospital, took over management of all Covid-19 positive residents at Newmarch in mid-April 2020.

Mr Lee said Dr Branley, in his evidence, conceded with hindsight that by April 20, ā€œa decision should have been made to transfer the Covid-19 positive patients to hospital.ā€

ā€œHe also conceded, again in hindsight, that the decision not to do so was wrong,ā€ Mr Lee said in his conclusions.

He found that in large part the 19 deaths could not have been prevented after the residents, many of whom had comorbidities and serious conditions, contracted Covid-19. However, some of their outcomes could have been different had they been transferred to hospital rather than being treated via in-home care.

He found that had three of the residents ā€“ Alice Bacon, Margaret Sullivan and Leone Corrigan ā€“ been transferred to hospital, it might have made a ā€œmaterialā€ difference to their outcome and could have saved their lives.

He also found that several patients could have avoided infection in the first place if they were cared for differently.

Family of the deceased Joyce Parker and Mary Watson speaking to media, Coroners Court, Lidcombe.
Picture: NCA NewsWire/Damian Shaw

Mary Watson, who is the Alice Bacon's daughter, said she and her family were vindicated by the findings.

Anglicare Sydney chief Simon Miller released a statement acknowledging the immense grief that family and friends of the deceased have experienced.

ā€œAnglican Community Services wishes to extend its sincere condolences to the family and friends of the 19 residents of Newmarch House who passed away during the Covid-19 outbreak in 2020,ā€ Mr Miller said.

ā€œAnglicare 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. 

ā€œAnglicare 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.

ā€œAnglicare wishes to acknowledge the personal sacrifice and compassion of all of those people who supported Newmarch House during the outbreak and thank them for their contribution.ā€

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