Federal government had no Covid-19 aged care plan, royal commission hears

The Morrison government has said it did have a strategy for Australia’s vulnerable aged care sector, despite the senior counsel assisting the royal commission into aged care arguing the health department and regulator both failed to develop a Covid-19 plan, rendering the industry “underprepared”.

After Monday’s blistering opening statement at the royal commission by Peter Rozen QC, the federal minister for aged care, Richard Colbeck, issued a statement saying the government had been “continuously building on our response to Covid-19 in residential aged care since January 2020”.

Colbeck said the measures undertaken included issuing specific infection control guidance for residential aged care “combined with freely available training for the aged care workforce”.

He said the government had imposed restrictions on visits to homes, had overseen the rapid provision of personal protective equipment, had provided additional skilled workers to support the provision of care and contain transmission in the event of an outbreak, as well as “in–reach pathology testing for Covid-19 and access to telehealth to ensure residents continue to safely receive needed healthcare”.

Aged care is a commonwealth responsibility. The sustained outbreak in residential nursing homes during the second wave of infections in Victoria has prompted serious questions about whether the Morrison government was adequately prepared for the crisis, and whether reporting between the tiers of government and the regulator has been adequate.

Last Friday’s national cabinet meeting resolved to roll out rapid response units aimed at preventing Victorian-style outbreaks across Australia – but it will take another fortnight to resolve the protocols.

A parliamentary inquiry was told last week that 97 Victorian aged care facilities had been affected in the second wave, with 657 residents and 594 staff infected with Covid-19. A further 25 home care services for the elderly were also affected. Seventeen recipients of these services were infected, as were 24 staff working in-home care. There had been 108 fatalities.

The royal commission will later this week examine evidence of a “stand-off” between commonwealth and state health authorities over how to best handle an outbreak at Sydney’s Newmarch House, where the medical recommendation to send infected residents to hospital was discouraged out of an “intolerable” fear of setting a precedent.

Health professionals on Monday gave evidence that attempts to replicate a “hospital in the home” were futile, due to issues including poor building airflow and staff undertrained in infection control. The commission heard that when outbreaks occurred, a facility’s workforce could be almost entirely replaced with surge staffing, who needed to be “oriented” to that particular aged care home.

The royal commission on Monday heard from Merle Mitchell - an 85-year-old resident of a locked-down aged care home in Melbourne. Despite no Covid-19 infections being reported at her facility, she described her restricted life under the pandemic. “Every morning when I wake up I think damn I’ve woken up. If you asked most people here they would all say they would rather be dead rather than living here, if they’re honest”.

The resumption of the royal commission, and its focus on the aged care sector’s response to Covid-19, comes after the aged care quality and safety commissioner, Janet Anderson, revealed on Monday morning her organisation had taken four days to alert the health department about what would become a deadly outbreak at Melbourne’s St Basil’s aged care home. The commonwealth later intervened at the facility.

Related: Families at Melbourne nursing home say staff testing was delayed after coronavirus case

Related: Victoria's Covid-19 aged care disaster: 'This virus is like a fire out of control'

During damning opening remarks on Monday, Rozen revealed the Aged Care Quality and Safety Commission and the federal health department had no Covid-19 response plan for the aged care sector.

Rozen noted the federal health minister, Greg Hunt, said in late July that “aged care around the country has been immensely prepared” and the royal commission “will be scrutinising” that claim.

“Regulating the aged care sector as it confronts Covid-19 has been and continues to be this regulator’s biggest test. What did the commissioner do to prepare the sector? What has she done by way of regulating the sector?” Rozen said.

“The regulator did not have an appropriate aged care sector Covid-19 response plan. Given that it was widely understood that recipients of aged care services were a high-risk group, this seems surprising.

“The evidence will reveal that neither the commonwealth department of health nor the aged care regulator developed a Covid-19 plan specifically for the aged care sector.”

Highlighting a range of the concerns set to be examined by the royal commission, Rozen said the Australian Health Protection Principal Committee did not update its advice for aged care for “a crucial period of six weeks”, until 3 August, as the Victorian outbreak escalated.

He also said it was “surprising” the commission had not itself investigated the circumstances of the Dorothy Henderson Lodge and Newmarch House outbreaks in Sydney, despite incident investigations being “normally one of the key tasks of any regulator”.

Outlining evidence that the royal commission will hear about the Covid-19 outbreak at Newmarch House – where 37 residents tested positive and 17 died – Rozen said there was a “stand-off” between health authorities about hospitalising Covid-19-positive residents.

When Grant Millard, the chief executive of Anglicare, the operator of Newmarch, gives evidence on Tuesday, he is set to describe the “vigorous disagreement between the commonwealth and NSW officials” about providing “hospital in the home” care for infected residents.

While the chief clinical adviser to the Australian aged care quality and safety commission, Melanie Wroth, “strongly” recommended infected residents be removed from sites, health department correspondence showed that NSW Health’s preference was “not to decant residents into hospitals given the precedent” it would set for future aged care outbreaks.

Related: Victoria's aged care Covid toll is devastating. Forget the blame game, we need answers | Gay Alcorn

This allegedly prompted Anderson to write to the department.

“We must be vigilant in calling out the elephant in the room if ever we sense it might be present. To be clearer: if there is a view sitting behind the NSW Health position that aged care residents with Covid-19 should always be cared for in situ and should not be transferred to a hospital in any circumstances, then WE MUST CALL THIS OUT as an intolerable and unsupportable assumption,” she wrote in an email on 16 April, while Newmarch’s outbreak was still active.

Millard said he was ultimately told by Colbeck to follow the advice of NSW Health. This meant only two Covid-19-positive Newmarch residents were transferred to hospital, one of whom died there. Of the 35 other infected residents who were kept at the aged care home, 16 died there.

Millard said that Anglicare had conservatively estimated it would lose between 30% and 40% of its staff during an outbreak, but that the operator acknowledged this was a “massive underestimate” and that it “effectively had to stand down its entire workforce”.

Rozen said the royal commission had already examined “the consequences of a shortage of clinical skills in aged care homes” in a system where “providers have the ultimate say concerning the numbers and skill mix of their workforce and can choose between paying the hourly rate of a university-educated nurse and that of a care worker with or without a certificate 3”.

These issues with staffing were echoed by Melanie Dicks, a BaptistCare manager involved in the Covid-19 response at Dorothy Henderson lodge, which is understood to be a relative success story given the virus spread to only 16 residents (13 of who were sent to hospital) and there were six deaths. Dicks was then sent to provide advice to Newmarch House.

She told the royal commission Newmarch’s “hospital in the home” strategy struggled particularly due to staff skills shortages.

“We had a new [surge] staff that didn’t fully understand what hospital in the home model was and we needed to continually orient those staff as well,” she said.

A further issue with the hospital in the home model was identified by Marylouise McLaws, a professor of epidemiology at the University of New South Wales and an adviser to the World Health Organisation.

“In hospitals, the airflow change needs to be at least 40 to 80 litres per second per patient, and in most homes it’s nowhere near that,” she said. “Sometimes it’s even less than three litres per second per person in a home … They won’t be opening up windows to get good air flow and decontamination.”

Rozen noted health department data that said between 8 July and 9 August, more than 1,000 residents had been diagnosed with Covid-19, and 168 had died.Monday’s hearing is the first after the program was suspended in March as a result of the Covid-19 outbreak. This week’s program will not examine the current outbreaks in Victoria.

“During the recent outbreaks in Melbourne, once again, some families have been unable to ascertain even whether their loved ones are alive or dead,” he said. “That this can happen in Australia in 2020 is unacceptable; that it is happening again so soon after Newmarch House is unforgivable.”

Colbeck said: “Unfortunately where there are high rates of community transmission, as has been the experience globally, it is very hard to keep Covid-19 out of aged care facilities and other environments where there are people residing in close proximity including hospitals.”

“When it gets in, the results can be devastating, even with the required infection control and screening preparedness in place,” the minister said.

“This is what has happened in Victoria after quarantine breaches, the numbers in aged care sadly reflect the high level of community transmission within the surrounding areas.”