An inquest into the deaths of 19 people during a COVID-19 outbreak at a Western Sydney aged care home has found several cases were preventable, and at least three could have had a different outcome under another model of care.
During the 65-day outbreak at Newmarch House in Kingswood, 37 of the 97 residents contracted COVID-19 from April to June 2020.
Deputy State Coroner Derek Lee handed down the findings on Friday, uncovering that Anglicare — which owns and runs the facility — failed to demonstrate proper leadership and maintain sufficient communication with residents and their families.
It also found a lack of support and clarity from senior Anglicare executives, staff shortages and inexperience, as well as poor infection control practices.
During the outbreak, the facility chose to treat sick residents onsite under a program the inquest found was not viable and was inconsistent with infectious diseases.
While the inquest acknowledged that uncertainty and underlying anxiety in the early days of the virus contributed to that decision, Magistrate Lee said transferring them could have improved their level of care, including access to enough oxygen and fluids.
"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," the final report said.
The CEO of Anglicare, Simon Miller, apologised to the loved ones of the 19 residents who died and to staff members at the facility after the findings were handed down.
"We are sorry for the stress experienced and the loss of life during the COVID-19 outbreak at Newmarch House, for the residents, families and their loved ones," Mr Miller told reporters.
Families hope to move on
The three-week inquest into the circumstances surrounding the deaths concluded in 2022, and the findings were meant to be handed down in early 2023.
The daughters of resident Alice Bacon, who died at Newmarch House in May 2020, said it had been an anxious wait but the findings only proved what they had known all along.
At age 93, Ms Bacon became the 100th death in Australia from COVID-19 and was one of the residents named in the findings as someone who could have had a different outcome under hospital care.
Mary Watson is still coming to terms with her mother's death.
"Mum's outcome could have been very different had she been cared for and she wasn't cared for," she said.
"Being locked away in your room and starved of attention, food, water, washing your clothes in the bathroom sink … It was hard then.
"Now we hope we can sort of move on."
The inquest acknowledged there were instances where the basic care needs of some residents were not attended to, or only attended to after significant delay and repeated prompting by family members.
"The evidence established that on occasion some residents were not administered regular medication, showered or provided with nutrition and hydration," the report said.
'They tried to have inquest shut down'
Anthony Bowe's mother, Patricia Shea, contracted the virus while living at Newmarch House during the outbreak, where he said Anglicare blocked family members from being near the facility or being able to see into the rooms of their loved ones.
After waiting years to hear an outcome, Mr Bowe said Anglicare's response had been "grubby".
"They tried to have the inquest shut down … they wanted no accountability at all which is disgusting. They're supposed to be a Christian organisation," he said.
Mr Bowe said the main focus should be on the role of NSW Health, with residents unable to raise the alarm about their own health.
"There was no monitor attached to the patient, so they went hours without anyone knowing if the person behind the door was struggling to breathe or not.
"So, it was set up to suffocate people and people were found dead."
In November 2024, Shine Lawyers settled a class action on behalf of 18 people whose loved ones died during the outbreak, who are awaiting settlement approval from the court.
