Mass failures in unheard-of, deadly aged-care outbreak

The lives of some vulnerable aged-care residents could have been saved during a devastating COVID-19 outbreak that ripped through an aged-care home if not for missteps and leadership failures.

Major service provider Anglicare on Friday offered a wide-reaching apology as a coroner handed down his damning findings after an inquest into the "unprecedented and devastating" deaths of 19 people at Sydney's Newmarch House.

Some of those deaths could have been avoided had proper testing for the virus been implemented during the 2020 outbreak, NSW deputy state coroner Derek Lee found in his 344-page judgment.

Residents were also left without medication, food and water during the breakdown in services, while senior executives were notable in their "almost complete absence" from the under-siege facility.

Less than two months after the aged-care centre in Sydney's west entered lockdown in late March 2020, 37 residents and 34 staff members had contracted the virus.

Transferring five residents could have saved their lives or improved the level of care they received, Mr Lee said.

Instead, management from the 102-bed facility opted to treat sick residents on-site under Hospital in The Home (HITH), a clinical care service run by NSW Health.

But that program was incompatible with managing an outbreak of an infectious disease such as COVID-19, the coroner said.

There was no attempt to conduct site-wide PCR tests at the facility in the early days of the outbreak, a measure that would have identified positive cases faster and reduced the extent and severity of the spread.

Information given to concerned families was generic rather than specific to their relatives and in some cases was "inaccurate or understated the seriousness of what was occurring", Mr Lee found.

Frontline personnel also did not receive effective or direct support from senior executives at Anglicare during the outbreak.

"The almost complete absence, or only 'occasional' presence, of any senior executives at Newmarch House during the outbreak created confusion for frontline management personnel who became overwhelmed," Mr Lee said.

While Anglicare took appropriate steps to ensure sufficient employees were available, changes to the definition of close contacts requiring self-isolation meant fewer staff were available than were anticipated.

This resulted in a dire staff shortage that severely jeopardised infection control and resident care, the coroner found.

"The evidence established that on occasion some residents were not administered regular medication, showered, or provided with nutrition and hydration," Mr Lee said.

But the coroner did not make any recommendations, noting Anglicare and NSW Health had already made improvements to their policies and procedures.

Joyce Parker, whose mother Alice Bacon died during the outbreak, said she and other relatives of Newmarch residents stood outside the facility during the outbreak hoping to find out more.

"We had mum ringing - no water, no food, no medication - 'I'm hungry'," she said outside court.

Staff did their best but they weren't trained to do what needed to be done and her mother could still be alive had she been given the proper care, Ms Parker added.

"We knew that things weren't right in there and we tried to speak up and now it's out there for everyone to see," she said.

Anglicare chief executive Simon Miller apologised on behalf of the faith-based provider.

"We are sorry for the stress experienced, for the loss of life during the COVID-19 outbreak in Newmarch House for the residents, their families and their loved ones," he said.

"There have been many improvements since that time - much has changed in the way COVID is managed, not just at Anglicare but right across the aged-care sector."

A class action brought by some of the dead residents' relatives reached a confidential settlement in November.

NSW Health has been contacted for comment.