A "vicious cycle" of staff and protective equipment shortages, as well as sub-optimal infection control practices, contributed to the COVID-19 outbreak at Sydney's Newmarch House, a review has found.
The outbreak at the Anglicare-run nursing home started on April 11 and was declared over on June 15. In that time 19 residents died, with 17 of the deaths directly attributed to coronavirus.
There were 71 cases of COVID-19 diagnosed in residents and staff during the outbreak.
The independent review found at the time, no other residential aged care home in Australia had experienced an outbreak of such magnitude.
Professor Lyn Gilbert and Adjunct Professor Alan Lilly were in June asked to undertake the review by the federal government.
They released their final report on Monday, highlighting a lack of consistent expert guidance on infection prevention and control at the nursing home.
The report found the lack of this advice at the start of the outbreak led to inconsistent use of personal protective equipment.
"Throughout April 2020,COVID-19 cases among residents and staff continued to increase, fuelling a vicious cycle of staff and PPE shortages, sub-optimal infection prevention and control practice, infection source-control and the resulting increase in workload and COVID-19 transmission," the report said.
A lack of physical distancing between staff during meal breaks, at meetings, and when sharing transport to and from work also led to the rapid depletion in staff numbers.
"These breaches of physical distancing were undoubtedly responsible for some staff being infected with COVID-19 but a much greater number were quarantined but did not become infected," the report said.
Ten different agencies were called to help boost staff numbers, but their skills and experience were found to be variable and their availability unpredictable.
The professors also found some employees were not aware COVID-19 was present at Newmarch House and left soon after arriving for duty.
There was a lack of clarity between the different agencies, which the review found created confusion for the Anglicare board and managers.
Medical care at the nursing home was delivered as a hospital-in-the-home program, which the review found has advantages for elderly residents but its implementation was compromised by inadequate staffing and support.
But Anglicare "spared no effort or expense" in responding to one of the "most significant crises" to occur in residential aged care in Australia.
However, the peak body for non-profit aged care providers Aged and Community Services Australia (ACSA) says the hospital-in-the-home system was always going to fail.
"Aged care homes are not hospitals. They aren't staffed like hospitals. They are not funded like hospitals. They are homes," chief executive Pat Sparrow said in a statement.
"Once a single case gets into a facility it can be impossible to contain."
Ms Sparrow wants all states to guarantee automatic hospitalisation of coronavirus cases in nursing homes.
She says it will save lives by buying facilities time to get their response right.
NSW Health responded to the review saying its outbreak response was "prompt" and delivered in the absence of firm action from Newmarch House or Anglicare.
The department says the lack of preparedness at residential aged care facilities - seen in Newmarch House and in Victoria - prompted NSW Health to step in and ensure facilities can demonstrate they have comprehensive outbreak plans.
Health Minister Brad Hazzard said the department had since developed a protocol to make sure there was clarity around leadership at aged care facilities if an outbreak was to happen again.
"Clearly there were some major concerns at the time that the structure at Newmarch House and Anglicare was not sufficient to be able to respond in a way that was necessary," he told reporters on Monday.
Premier Gladys Berejiklian said authorities had to learn from what had happened to help stop it re-occurring.
"All of us still feel for the relatives and obviously the patients of Newmarch who experienced such trauma and, of course, our hearts continue to go out to them," she told reporters.
Federal Aged Care Minister Richard Colbeck said the Commonwealth would "continue to integrate the learnings from Newmarch and infections in Victoria into the national response as outbreaks occur."
Australian Associated Press