Newmarch House: Coronavirus review condemns Anglicare leadership
Elderly residents were given the wrong medication, suffered pressure sores and skin conditions due to mass confusion during the deadly Newmarch House coronavirus outbreak, a damning report has found.
NSW
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Elderly residents were given the wrong medication, suffered pressure sores and skin conditions due to mass confusion and failures during the deadly Newmarch House coronavirus outbreak, a damning report has found.
An independent review of the COVID-19 outbreak at Newmarch House in Caddens, where 19 elderly residents died from the disease, has identified serious communication, leadership, staffing, infection control and leadership issues throughout the emergency.
Among the litany of failures detailed in the report, incorrect use of and shortages of PPE, and staff ignoring social distancing in the lunch room or when socialising “after hours” contributed to the rapid spread of coronavirus through the facility.
The review, led by Professor Lun Gilbert and Adjunct Professor Alan Lilly found the “hospital in the home” strategy of treating elderly residents in the nursing home rather than moving them to a hospital was “compromised” by “inadequate staffing and support”.
“Many residents and their families felt that it often failed to fulfil its promise to provide care
equivalent to that of inpatient hospital care,” the report authors said.
Staff shortages led to poorer medical care for patients — including those without COVID-19.
A temporary shift to paper record keeping because a large number of staff did not know how to use the online system meant GPs attempting to help remotely were unable to access critical information to pass on to families.
The review found GPs were “frustrated” as they were unable to tell families if a loved one had contracted the virus or if they had died.
Prof Gilbert and Prof Lilly also found communication was “consistently highlighted” as an issue for families who felt “disconnected from their loved ones” during the crisis.
“Not only did this have an adverse impact on them, it also increased the isolation of their loved ones,” the report said.
“Challenges with communication also extended to advocacy and other support agencies trying to ease the situation at Newmarch House.”
Operator Anglicare had factored in staff losses of up to 40 per cent — above the federal government guidelines of 20 to 30 per cent — but was not equipped for the 84 per cent loss it suffered.
In another incident a large quantity of end of life drugs were delivered to Newmarch House late on a Friday, creating an “acute problem” of a lack of available storage to keep the medicines locked safely.
The review was critical of infection prevention and control measures at Newmarch House, noting it was “identified as a significant concern with shortcomings identified in the early, crucial phases”.
“Routine (infection) practices needed to be significantly updated to meet the challenge of containing the spread of COVID-19,” the report said.
Unfamiliar personal protective equipment (PPE) practices also led to “shortfalls” in care and “neglect of” or “delays” in routine care of the elderly.
One infection control issue identified in the review was the “unnecessary” use of full PPE including masks, gowns and gloves in non-clinical parts of the facility, such as the foyer, followed by a “failure” to change into fresh PPE on entry to the rooms of residents without coronavirus.
“Apart from inconsistent use of PPE, other reasons for the rapid depletion of staff numbers, were frequent instances of staff-to-staff contact due to a lack of physical distancing during meal breaks, at meetings, when sharing transport to and from the workplace or when socialising in groups after hours,” the report said.
“In these situations, PPE was not indicated so long as physical distancing was maintained. “Although staff were instructed to stay at least 1.5 metres away from others when not using PPE, some apparently disregarded, misunderstood or found it difficult to follow this instruction.”
The review also highlighted leadership at Newmarch House and in the “broader Anglicare organisation” was so insufficient it led to the Aged Care Quality and Safety Commission appointing an independent advisor to stabilise the situation.
“Leadership and management at Newmarch House and in the broader Anglicare organisation, was generally invisible to external parties interacting with them,” the report said.