Outbreaks of COVID-19 in residential aged care settings have produced Australia's poorest COVID-19 outcomes to date. As at 9 October 2020, cases in aged care facilities represented only 7.5 per cent of all cases in Australia yet accounted for 74.6 per cent of COVID-19 deaths.
In the Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19) the Department of Health (DoH) provides, in relation to responsibility for the safety and security of people within aged care facilities:
The Australian Government will also be responsible for residential aged care facilities; working with other healthcare providers to set standards to promote the safety and security of people in aged care and other institutional settings; and establishing and maintaining infection control guidelines, healthcare safety and quality standards.
The Australian Government (government) failed to adequately prepare the aged care sector for COVID-19, was too slow to respond to issues with outbreaks in residential aged care facilities, and failed to accept full responsibility for the sector despite being the government responsible for funding and regulating aged care in Australia.
The government's mismanagement of the sector resulted in the Senate taking the rare step of censuring the Minister for Aged Care and Senior Australians, Senator the Hon Richard Colbeck, for failing to recall basic and tragic facts about aged care residents, dismissing deaths as a 'function' of aged care, and 'failing to take responsibility for the devastating crisis in the aged care sector'.
This chapter discusses:
the government's refusal to accept responsibility for the aged care crisis during COVID-19;
issues relating to preparation in light of the known vulnerabilities within the aged care sector;
lessons from early outbreaks in New South Wales (NSW) aged care services;
the government's response to increased community transmission in Victoria; and
concerns relating to the actions of the Aged Care Quality and Safety Commission (ACQSC).
Responsibility for the aged care crisis
Box 4.1: Interim finding
The aged care sector experienced a COVID-19 crisis which resulted in unacceptably poor outcomes, including hundreds of tragic and preventable deaths.
The Australian Government failed to accept full responsibility for the aged care crisis, despite being the primary source of funding and the principal regulator of the sector. The crisis had catastrophic consequences for many elderly Australians and their families.
How the crisis unfolded
The first COVID-19 outbreak in a residential aged care facility occurred on 3 March 2020 at Dorothy Henderson Lodge when a personal care worker was diagnosed with a confirmed case. The outbreak was not declared to be over until 7 May, by which time 16 of the 80 residents had tested positive along with five of the staff. Six of the residents diagnosed with COVID-19 lost their lives—a mortality rate of 37.5 per cent.
Outbreaks occurred at two other residential aged care facilities in NSW. One—at Opal Aged Care's Bankstown facility on 23 March—was brought under control quickly. The other—which occurred at Anglicare's Newmarch House between 11 April and 15 June—was a significant outbreak with tragic consequences. 37 of the 97 residents, along with 34 staff contracted COVID-19 and 17 residents died, putting the facility's mortality rate at 46 per cent.
Following these outbreaks in NSW, the government displayed what Counsel Assisting the Royal Commission into Aged Care Quality and Safety (Aged Care Royal Commission) described as 'a degree of self-congratulation and even hubris', and there was a sense that 'Australia may have weathered the COVID-19 storm in a way that avoided the large-scale deaths in other countries'.
On 18 June, the government became concerned about the level of community transmission in Victoria. However—as this chapter highlights—the government did not take the threat to aged care residents seriously until much later.
On 9 July, the Minister for Aged Care and Senior Australians, Senator the Hon Richard Colbeck, wrote to aged care providers telling them they had 'responded incredibly well to the unprecedented challenges of COVID-19'.
On the same day, St Basil's Home for the Aged (St Basil's) in Melbourne confirmed its first case of COVID-19 in a resident. The virus spread rapidly and by 21 July, the entire staff and management had to be isolated, leaving 115 residents in the care of a small number of surge staff contracted by the government, with reports of residents going hungry and being left in soiled sheets.
In the period between 9 July and 11 September, COVID-19 outbreaks occurred at over 200 Victorian residential aged care facilities, with 1917 confirmed cases and 557 deaths from COVID-19.
Horrific stories emerged about inhumane conditions during this period. As a recent article in the Lancet detailed:
A 95-year-old woman in a Melbourne care home was left with ants crawling over a wound on her leg. Other residents had not had food or water for 18 [hours]. There were faeces on the floor. Hundreds of residents were locked in their rooms for weeks as relatives were shut out from visiting their loved ones.
On 27 July, the Australian Defence Force deployed three nurses into the Eppington Gardens residential aged care facility in response to a critical staff shortage. When they arrived, 'no staff on the night shift were familiar with the facility or the residents', and 'it was apparent that infection control procedures were problematic'.
Communication with the families of aged care residents was a problem throughout the COVID-19 pandemic. As Counsel Assisting told the Aged Care Royal Commission:
We all saw the images on the news of relatives camped outside
Newmarch House in April, seeking the most basic information about their loved ones. Tragically, we have seen similar scenes outside homes during the recent outbreaks in Melbourne. Once again, some families have been unable to ascertain even whether their loved ones are alive or dead.
The issues experienced by the sector were heard in some detail by the Aged Care Royal Commission in special COVID-19 hearings between
10 and 13 August. The Aged Care Royal Commission was so concerned by what it heard that it published Aged care and COVID-19: a special report on
1 October, concluding that immediate action was required by the government across a number of areas including a national aged care plan for COVID-19 and the deployment of accredited infection prevention and control experts into residential aged care homes.
The Australian Government's refusal to accept responsibility
In his appearance before the Senate Select Committee on COVID-19 (committee) on 21 August, Minister Colbeck was reluctant to accept that the government was accountable for the tragic outcomes experienced in the aged care sector during the COVID-19 outbreak.
When asked if it was the government's responsibility to keep aged care residents safe during a pandemic, Minister Colbeck declined to provide a yes or no answer and instead offered that the government was responsible for 'the setting of the standards and, through the ACQSC, the application of the standards'.
When the Chair put it to Minister Colbeck that 'you're saying it's not your job to keep people in residential aged care safe from the pandemic', he replied that:
Well, in combination with the states, it's everybody's responsibility to prevent the spread of the virus.
These attempts to obfuscate the government's primary responsibility for aged care are not supported by fact. In response to questioning from the Chair on whether it is the government's responsibility 'to establish and maintain infection control guidelines, healthcare standards and quality standards for residential aged-care facilities' Minister Colbeck responded in the affirmative.
Further, the Aged Care Royal Commission states in its report on COVID-19:
The Australian Government is responsible for 'aged care services', as defined in our Letters Patent. The development and implementation of aged care policy, including advising the Australian Government, funding and administration are the domain of the Australian Department of Health. The Aged Care Quality and Safety Commission is responsible for aged care regulation.
Of additional concern to the committee was that Minister Colbeck was not able to answer whether he had briefed the Federal Cabinet or the National Cabinet on the outbreaks in aged care prior to 5 August. By 5 August, there were
959 confirmed cases of COVID-19 in residential aged care facilities in Victoria across nearly 100 facilities and 130 Australians living in aged care had died.
The government's failure to accept responsibility for aged care had catastrophic consequences for the hundreds of Australians who died in aged care, their families and for the staff in the aged care facilities.
Preparation and planning for COVID-19
Box 4.2: Interim finding
Australia's aged care system was in crisis before the pandemic arrived.
Lack of access to health care staff, inadequate staffing levels, and lack of access to personal protective equipment and infection control training were all problems that predated COVID-19 and that had been outlined to the government in various reports over several years including in the 2019 Aged Care Royal Commission's report titled Neglect.
The Australian Government failed to develop a COVID-19 plan for the sector, which was unprepared and ill-equipped to protect the safety of residents when the pandemic hit.
The committee does not accept the argument put to it by the Minister and senior officials that once community transmission of COVID-19 occurs, outbreaks and deaths in aged care are inevitable.
In his appearances before the committee, Minister Colbeck suggested that the devastating number of infections and deaths in the sector from COVID-19 had not been anticipated, but were consistent with international experience, and were a 'reality' during periods of elevated community transmission. The Chief Medical Officer (CMO) also gave evidence before the Aged Care Royal Commission of the inevitability of outbreaks in aged care in areas where there was community transmission of the virus.
The committee is concerned by this evidence and how it may have impacted on decisions about how to respond to the COVID-19 crisis in aged care in Victoria in June, July and August 2020.
The committee does not agree that the outbreaks and deaths that occurred in residential aged care facilities were an inevitable function of community transmission, nor does it agree that they could not have been anticipated.
A large body of evidence concerning the inadequacies of Australia's aged care system existed prior to the pandemic. In an interim report tabled in
October 2019, titled Neglect, the Aged Care Royal Commission described the aged care system to be 'fragmented, unsupported… underfunded' and 'poorly managed', and reported a high number of complaints in relation to hygiene at facilities.
The inadequacies of the aged care sector were also well known to key stakeholder groups in the sector. The COVID Safe Elders Group, a group of concerned family members of residents in aged care, expressed grave concern 'that the already under-resourced, rigid and barely functioning aged care sector has been unable to cope'.
As noted in Chapter 2, health experts had provided warnings well before the emergence of the pandemic that the National Medical Stockpile of personal protective equipment (PPE) had insufficient numbers of masks and respirators for health workers.
The Aged Care Royal Commission also highlighted that training on the use of PPE across the aged care sector 'is a matter that requires urgent attention by the government' and key stakeholders.
Once the pandemic hit, the government failed to properly prepare the sector. Counsel Assisting the Aged Care Royal Commission argued that 'neither the Commonwealth Department of Health nor the aged care regulator developed a COVID-19 plan specifically for the aged care sector'.
In its special report into aged care and COVID-19, the Aged Care Royal Commission found there was 'a clear need for a defined, consolidated, national aged care COVID-19 plan'. Furthermore, the Aged Care Royal Commission found that:
While the AHPPC [the Australian Health Protection Principal Committee] acknowledged this significant issue, it is now clear that the measures implemented by the Australian Government on advice from the AHPPC were in some respects insufficient to ensure preparedness of the aged care sector.
Confused and inconsistent messaging from providers, the Australian Government, and State and Territory Governments emerged as themes in the submissions we have received on COVID-19… At a time of crisis, such as this pandemic, clear leadership, direction and lines of communication are essential.
Key stakeholders in the sector continue to raise the same concerns that were raised prior to the pandemic, such as the very low staffing levels and the lack of training and skilled workers within the aged care sector. The Queensland Nurses and Midwives Union observed that '[t]he aged care workforce is depleted under usual circumstances and the chronic understaffing and widespread lack of skills in the sector is worrisome in the face of a global pandemic'.
The COVID Safe Elders Group noted similar concerns and provided an example of a residential aged care facility where the staff to resident ratio is 'one to 30 or 60 in the day, and as high as one to 170 on night shift'. The group also submitted that:
…staff have poor/no training in infection control, poor hygiene practices, lack appropriate supervision, and may work across multiple facilities. There is no paid sick leave for casual aged care staff which means they need to work even if sick in order to have an income.
It is clear that the government, knowing the risk that COVID-19 presented to residents in aged care facilities, failed to adequately prepare the sector for COVID-19 and, when outbreaks occurred, failed to respond in a timely way to the seriousness of the problem. This approach cost lives.
Failure to anticipate shortages of staff and PPE
Box 4.3: Interim finding
The committee does not accept claims by the Australian Government that it was unable to anticipate the situation which occurred at St Basil's Home for the Aged and other Victorian aged care facilities.
The Australian Government failed to learn from earlier outbreaks at aged care facilities in New South Wales, particularly in relation to surge staffing capacity, personal protective equipment and infection control
In April 2020, the government received an independent review into the first major outbreak of COVID-19 in an Australian aged care facility, at
Dorothy Henderson Lodge. The review identified major challenges with staff numbers and compliance with infection prevention and control procedures, and recommended new guidelines including the need for ongoing regular training in infection and prevention control and the use of PPE for staff.
A second independent review commissioned into the COVID-19 outbreak in Newmarch House that occurred on 11 April found that 'staff and PPE shortages and the presence of COVID-19 positive residents in different zones of the home, undoubtedly contributed to [infection prevention and control] breaches and ongoing transmission of COVID-19'.
Following these earlier outbreaks in NSW aged care facilities, the government failed to ensure aged care facilities had sufficient PPE prior to further outbreaks occurring. DoH, in answer to a question on notice from this committee, advised that less than half of the 2865 requests for PPE made by residential and in-home aged care service providers between March and
mid-August were approved.
In its special report on COVID-19, the Aged Care Royal Commission commented that:
Insufficient supplies of PPE and infection control training for the aged care workforce were the subject of evidence in the form of union surveys and accounts. We heard of workers being told they could only use one glove rather than two, and a guideline at a residential aged care facility that only permitted two masks per shift.
In addition to the issues with access to PPE, the government also failed to learn crucial lessons from the earlier outbreaks in relation to impacts on staff, particularly where almost an entire workforce had to be removed and isolated as had been the case in Newmarch House.
The outbreak at St Basil's was significant. On 8 July, St Basil's confirmed its first positive case of COVID-19 and 10 weeks later there had been 183 confirmed cases of COVID-19 from St Basil's, of which, 91 staff members
(49.7 per cent) had been infected with COVID-19 and 44 residents had died.
At the peak of the outbreak, the entire workforce at St Basil's had to be stood down due to either contracting COVID-19 or being a close contact of someone who had.
Appearing before the committee on 21 August, Minister Colbeck testified that the government had not anticipated what occurred at St Basil's, despite advising aged care providers on 29 June that 'up to 80 to 100 per cent of the workforce may need to isolate in a major outbreak'.
The minister also confirmed that at no point did the government develop a surge workforce strategy for future outbreaks in aged care facilities, despite the 'key learning' from the Newmarch House review that 'the Department of Health should consider expanding its surge workforce capacity providers'.
The circumstances at St Basil's and other aged care facilities in Victoria were clearly foreseeable given the government's own advice to the sector and the independent reviews of previous outbreaks.
The government's failure to anticipate what occurred is impossible to understand. It cost the lives of 44 Australians who lived at St Basil's and over 600 more across other aged care facilities in Victoria as the outbreak raged through aged care facilities between July and September 2020.
Response to heightened community transmission in Victoria
Box 4.4: Interim finding
The Australian Government failed to respond quickly enough to protect elderly Australians living in aged care facilities.
The Victorian Aged Care Response Centre should have been stood up before
25 July when there was already 294 infections and 26 deaths.
A more urgent response from the Australian Government could have prevented the significant loss of the lives of elderly Australians.
According to the Acting CMO, Professor Paul Kelly, the government first became concerned about community transmission in Victoria on 18 June. However, no formal governance arrangements were put in place by the government until 25 July when the Victorian Aged Care Response Centre was established. By this point, Victoria had recorded 294 confirmed cases in residential aged care facilities and 26 residents had died.
On the question of whether any of the deaths in Victorian aged care facilities were avoidable, Dr Brendan Murphy, Secretary of the DoH and former CMO, conceded that:
…if we had stood up the Victorian Aged Care Response Centre earlier on—if we had been aware and had prior warning that the public health response may have been compromised—that's something that might have prevented some of the spread amongst facilities by responding more quickly.
Dr Murphy also acknowledged that if the Victorian Aged Care Response Centre had been established one week earlier, 'we may have been able to respond better' to the two major outbreaks that resulted in the entire workforce of two aged care facilities being stood down.
When pressed by the committee on the measures put in place by the government during the month of June, Minister Colbeck pointed to the fact that some advice was provided to the sector around infection control.
Beyond sending this advice to aged care facilities, the committee is concerned that no evidence could be provided to demonstrate that the government took any further action to protect Australians living in Victorian aged care facilities during the month of June.
Evidence from the Aged Care Royal Commission also suggests that the government was too slow to act in mandating the use of masks for aged care workers in Victoria, which did not occur until 13 July. Dr Murphy conceded that, '[i]n hindsight, you could have implemented that earlier, absolutely'. The Aged Care Royal Commission questioned whether this was a matter of hindsight:
Masks are a very cheap and effective method of slowing the spread of COVID-19… one or two cases, as they started to increase in June, should have been an alert that this is potentially a problem…
There was no guidance provided by the AHPPC to aged care providers in this crucial period between 19 June 2020 and 3 August 2020.
On 7 August, the Australian Medical Association (AMA) demanded the mandated use of filter respirator masks for the care of any COVID-19 patient, and suggested that , '[i]t may be that supply constraints of P2 or N95 masks is behind the reason to not mandate their use in COVID-19 patient care'.
The committee considers that had certain measures been introduced sooner—such as the establishment of the Victorian Aged Care Response Centre, the introduction of paid pandemic leave for aged care workers and the mandatory use of masks by aged care workers and COVID-19 patients—the widespread infection of COVID-19 within aged care facilities and the consequential loss of lives could have been reduced.
The Aged Care Quality and Safety Commission
Box 4.5: Interim finding
The Aged Care Quality and Safety Commission (ACQSC) failed to use all available regulatory powers to ensure the safety of aged care residents.
The ACQSC placed too much reliance on self-assessment surveys by aged care service providers to gauge the sector's preparedness for keeping elderly Australians safe.
ACQSC assessors perform essential work and should not have suspended all unannounced visits during the pandemic.
As the national regulator of Commonwealth-funded aged care services, the ACQSC's role is to 'protect and enhance the safety, health, wellbeing and quality of life of older Australians receiving aged-care services'.
Ms Janet Anderson PSM, Aged Care Quality and Safety Commissioner, explained that the ACQSC has a number of 'administrative paths' to ensure that age care service providers are meeting necessary standards; from requesting further information, to issuing a notice to remedy, to its most powerful tool of issuing a sanction.
The power to issue sanctions is relatively new, with its introduction in
January 2020 following the recommendations of a 2019 review of the mismanagement of a particular aged care service. The review, Inquiry into events at Earle Haven, found that the ACQSC missed a number of warning signs and that there 'were also occasions when regulators failed to engage critically with information received or follow through with necessary action'.
However, the ACQSC appears reluctant to use these new powers.
From 1 January to 12 August 2020, it received 5934 complaints, predominately in relation to residential care. From 1 January to 4 August, the ACQSC made 229 decisions of noncompliance with relevant standards. As of 29 September, the ACQSC had issued 21 Notices to Agree during COVID-19.
The ACQSC issued five sanctions in the January to March quarter across Australia. However, no sanctions were issued between April and June 2020, and no sanctions were issued in Victoria between 1 June and 21 August 2020.
While the committee recognises sanctions are not the only enforcement tool available to the ACQSC, it questions why the Commission issued so few sanctions when there were so many complaints and non-compliance decisions.
The committee also does not agree with the ACQSC's decision to suspend unannounced visits and replace them with 'short notice visits' from 16 March until 1 June, after which it conducted both unannounced and short-notice visits.
In April, the ACQSC only conducted 12 short-notice visits. The committee acknowledges the need to minimise the risk of bringing infections into aged care services. However, given the ACQSC oversees nearly 2700 aged care services this figure is inexplicably low when measured against the risks faced by the vulnerable elderly population residing in these facilities and the ACQSC's responsibility to ensure they are cared for safely.
The small number of visits is concerning because the ACQSC was otherwise reliant on a self-assessment tool completed by aged care providers 'to help guide a service's own assessment of readiness against best practice and undertake a critical check of their outbreak management plan'. The ACQSC assessed risks based on these survey responses and followed up any concerning survey responses by contacting or visiting the service.
On 4 August, there were 117 residential and home care service providers with one or more confirmed case(s) of COVID-19. Of those, 112 provided a self-assessment survey response. Of the 112 aged care services, on the question about service readiness in the event of a COVID-19 outbreak:
33 reported 'best practice';
78 reported 'satisfactory'; and
one reported they were in need of improvement.
The ACQSC told the committee that, based on regulatory intelligence including self-assessment survey responses, it undertook site visits at 13 of the above 117 services between 1 March and 4 August 2020.
The committee questions whether self-assessment is the best or most accurate way to determine if an aged care service provider is prepared for a COVID-19 outbreak.
The committee is concerned that from 1 March to 4 August, the ACQSC undertook site visits of only 11 per cent of aged care providers with one or more confirmed case(s) of COVID-19.
The committee is also concerned that more than one-quarter of ACQSC employees are employed under temporary contracting arrangements. As at 31 August, the ACQSC employed 657.33 full time-equivalent staff members, of which approximately 27 per cent were contractors. In answers to questions from the Chair about the ACQSC's high reliance on contractors, Ms Anderson explained there was '…an expectation by government that overall numbers of public servants will be kept at a particular level' and that this impacted on how staff were employed.
The disastrous outcomes within the aged care sector during COVID-19, in combination with the high number of complaints and the lack of regulatory action taken by the ACQSC suggests it has failed to avoid repeating past mistakes. It was only last year that the Earle Haven Inquiry found the ACQSC had missed early warning signs and failed to engage critically with information received. This appears to have played out once again during COVID-19 with terrible consequences for aged care residents and their families.