Inquest into the deaths at Newmarch House

Contributing factors

• Inadequate infection control measures
• Staffing shortages and surge workforce inadequately trained
• Delayed PCR testing allowing viral propagation
• Hospital-in-the-Home model not appropriate for acute COVID-19 outbreak
• Inadequate pain management
• Suboptimal fluid management
• Delayed or absent hospital transfers despite clinical deterioration
• Inadequate Advance Care Plan discussions with families and residents
• Poor documentation and communication between services
• Cognitive impairment affecting consent in residents with dementia
• Delayed administration of anticipatory medications

Coroner's recommendations

1. Early, aggressive testing protocols should be implemented immediately upon identification of any infectious disease outbreak in aged care
2. Advance Care Plans must be reviewed and discussed individually with residents and families when circumstances change
3. Pain and symptom management must be optimised in acute illness with regular assessment and timely provision of medications
4. Fluid and nutritional support must be actively managed with clear documentation
5. Hospital transfer decisions must be individualised based on clinical need and residents' expressed wishes
6. A different model of care should have been implemented involving early transfer of COVID-19 positive residents to hospital
7. Clear clinical leadership and responsibility must be designated with defined escalation pathways
8. Adequate staffing levels must be maintained with appropriately trained personnel during outbreaks
9. Communication with families must be regular, clear, timely and individualised
10. Telehealth should not be used as sole assessment method for complex acute illness; face-to-face review by senior clinicians required
11. Staff training in infection control, PPE use, and outbreak response must be mandatory prior to implementation
12. Capacity assessments must be conducted for residents with cognitive impairment before treatment decisions