Rockhampton nurse cleared of wrongdoing in COVID-19 scare
A nurse who worked at a Central Queensland aged care facility while infected with coronavirus has been cleared of wrongdoing, with an investigation finding her calls for guidance were ignored.
QLD News
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The Rockhampton aged care nurse whose coronavirus diagnosis sparked a major health scare in Central Queensland had called her bosses to ask if she should attend work while awaiting her COVID-19 test results in May and never received a response.
Investigators have today cleared the nurse, who worked at the North Rockhampton Nursing Centre while infected with COVID-19 of any wrongdoing in relation to the health bungle, but have called for more than a dozen changes to health protocols and procedures after finding management had not adequately communicated staff expectations during the pandemic.
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The investigation, ordered by Queensland Health Director-General Dr John Wakefield, also found the treatment of the nurse by her leaders could have been “more respectful and caring” and that had there been a more “collaborative and caring culture” at the facility, the incident may never have happened.
“The investigation found the nurse did not breach Aged Care Direction Number Three,” Dr Wakefield said.
“The investigation also found the public health response to the case was appropriate, with health officials working extremely well and conscientiously to prevent an outbreak at the centre.”
However the investigation report has revealed there was a lack of appropriate checks for staff upon arrival at work and the nurse was never even asked why she took two days off work in the days before she was diagnosed with the virus.
The nurse, who had isolated for two weeks after returning from overseas, worked at the Rockhampton aged care centre in May while she was awaiting coronavirus test results when she had a mild sore throat and swollen neck glands.
“For various reasons including the fact that the subject officer had not received relevant education and memoranda, the subject officer did not appreciate that (she) was required to exclude (herself) from NRNC in these two circumstances,” the report said.
“Further, the subject officer did not contemplate that the subject officer would have COVID-19 because the subject officer had self isolated for 14 days after returning from an overseas trip…”
“While the above matters may be difficult to believe in the abstract the investigators find the subject officer’s view were genuinely held.”
The investigators found “improvements” could be made to the process for nurse education, the sharing of information with nurses, workplace culture at NRNC, sick leave and COVID-19 screening for NRNC employees that could have resulted in the nurse being better educated about the exclusion requirements.
More than 25 people were interviewed as part of the extensive investigation into the incident that sent the facility into lockdown and more than 300 staff and residents were tested for the virus.
Investigators said they had “no concerns” about the quality of the NRNC coronavirus outbreak response, noting that the CQHHS “worked extremely well and conscientiously” to manage the outbreak.
However they made a number of suggestions to avoid a similar occurrence relating to clinical education, workplace culture, the management of the subject officer and information dissemination and compliance.
Other concerns related to nurse education, aged care ratios, media management, adequacy of IT systems relating to patients and staff and clinical leadership and governance.
According to the report, on May 13, the nurse phoned the CQHHS Roster Centre before attending work and asked if she should attend work given she was waiting for a test result for COVID-19.
“The subject officer did not receive a response to the subject officer’s question from the roster centre,” investigators wrote.
On arrival at work on May 13 and 14 her temperature was taken but she was not asked any questions as part of the facilities’ screening process and she was never questioned about her reasons for being off work on May 11 and 12.
“While it is not clear that if the subject officer had been asked screening questions the subject officer’s responses would have resulted in the subject officer’s exclusion from the workplace, this may have occurred however, the questions should have been asked,” investigators wrote.
The investigators also took into account evidence that if there was “a more collaborative and caring culture between leaders and managers with their staff at NRNC” the nurse may have been stopped from working on May 13 and 14.
The investigators said the nurse was not aware she was required to self-exclude from the NRNC if she had a mild sore throat with no fever or if she had been tested.
“The subject officer’s understandings … may be surprising given the subject officer is … working in aged care who was aware of COVID-19 and had previously taken precautions to prevent contracting and spreading of COVID-19.
“However, the investigators accept the subject officer’s evidence.”
Dr Wakefield said it was found the nurse did not breach the relevant Aged Care Direction and she had been notified of the findings.
“As we have seen in other states, a COVID-19 outbreak in an aged care facility can be catastrophic, which is why we immediately took strong, decisive action,” he said.
“Queensland Health has left no stone unturned in taking steps to keep Queenslanders safe since the very beginning of this pandemic.
“We have taken every opportunity to apply what we have learned, including from this event, for the benefit of Queenslanders.”
He said steps to improve included changes to staffing and pandemic leave, pre-shift screening, training, infection control procedures and swift action in the event of a positive case of the deadly virus.
“It is these actions, along with our culture of continuous learning and improvement, that has kept COVID out of our residential aged care facilities,” Dr Wakefield said.
“I do want to remind everyone – particularly health and aged care staff – to stay home and get tested if you have any COVID-19 symptoms.
“I would like to thank those people involved in the investigation and in the incident response.”
Monday, May 4: The nurse went to work.
Tuesday, May 5: The nurse went to work where she had contact with residents and staff. She experienced a mild sore throat.
Wednesday, May 6: The nurse again went to work where she interacted with others while she had a sore throat.
Thursday, May 7: The nurse worked again with a mild sore throat, coming into contact with staff and residents.
Friday, May 8: Aged Care Direction 3 came into operation and dictated that aged care employees must not be at work with a temperature of 38 degrees or higher or have symptoms of acute respiratory infection. The nurse again went to work where she interacted with others while she had a sore throat.
Monday, May 11: The nurse did not attend work. The reason for her nonattendance is redacted in the report.
Tuesday, May 12: The nurse is tested for COVID-19 and again does not attend work. Screening for NRNC employees begins.
Wednesday, May 13: The nurse phones the CQHHS Roster Centre to ask if she should go to work while awaiting a test. No one responds to her question so she goes to work. On arrival, her temperature is taken but she is not asked any questions as part of the process. She works and has contact with residents and staff.
Thursday, May 14: The nurse again works and while her temperature is taken upon arrival, no more questions are asked. At about 8pm her coronavirus test is returned with a positive result and she is directed to self-isolate.
Friday, May 15: Contact tracing and widespread testing continue. The nurse is immediately suspended from work and a new director of nursing and medical commander are appointed for the NRNC. Queensland Health issue a media release about the case.
Saturday, May 16: The nurse is tested a second time. Meanwhile some NRNC residents are moved to other facilities.
Sunday, May 17: The second test returns a positive result. More residents are moved.
Monday, May 18: The nurse returns a positive blood test for COVID-19. More residents are moved and lockdown and quarantine efforts continue.
Originally published as Rockhampton nurse cleared of wrongdoing in COVID-19 scare