Inquest findings, delivered on Friday, declared some of the 19 deaths during the 2020 outbreak at Sydney's Newmarch House could have been avoided had proper testing for the virus been implemented.
A decision not to transfer some residents to hospital could have improved the level of care they received, including their access to enough oxygen and fluids, Magistrate Derek Lee found.
Instead, the Anglicare-run facility opted to treat sick residents on-site under the Hospital in the Home program.
Nicole Fahey said family members like her did not want to see what occurred swept under the rug. (Steven Saphore/AAP PHOTOS)
This program was not viable and was inconsistent with infectious diseases such as COVID-19, Mr Lee said.
More personalised assessments should have been made with individual residents to determine where they were treated, he found.
Staff shortages compounded problems including a confused leadership structure and insufficient communications with family members who wanted to know what was happening in the facility, he said.
However, the coroner did not make any recommendations, noting Anglicare had already made improvements to its policies and procedures after the outbreak.
Less than two months after Newmarch entered lockdown in late March 2020, 37 residents had contracted the virus.
Speaking to AAP before the findings were delivered, Nicole Fahey - whose grandmother Ann died in the outbreak - said family members like her did not want to see what occurred simply swept under the rug.Â
"I'm hoping the findings that are handed down are of substance enough for the families to feel like, moving forward, what occurred won't happen again," she said.
At the outset of the inquest, which began in 2022, counsel assisting Simon Buchen SC said one question to be answered was whether residents and their relatives had consented to be part of the Hospital in the Home program.
Mr Buchen also described preparations by the Anglicare-run home before the outbreak as insufficient for what ultimately occurred.
But he also noted that family members mostly approved of the home before the COVID-19 outbreak, describing staff as dedicated, conscientious, caring and kind.
Families mostly approved of the home before the COVID-19 outbreak, describing staff as caring. (Joel Carrett/AAP PHOTOS)
Numerous issues emerged once the virus took hold, including medications being missed, doctors not wearing PPE and failures to deliver meals to residents or ensure oxygen cylinders were full, the inquest was told.
"What had hitherto been a well-run and well-managed home assumed a level of chaos and dysfunctionality," Mr Buchen said.
Despite what she saw as missteps, Ms Fahey said she did not hold individual staff members, many of whom also contracted the virus, personally responsible.
"Some of the rules and regulations that were put in place at the time definitely shouldn't have been put in place," she said.
"(But) the people in there did the best they could with what they knew at the time.
"A lot of the families don't have any angst for the staff, they did the best that they could."
A class action brought against Newmarch by some of the dead residents' relatives reached a confidential settlement in November.
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