The outbreaks at St Basil’s and Epping Gardens, where 38 people died, were among the largest during Victoria’s second wave.

“These stark numbers do not begin to convey the trauma and grief suffered by all residents, whether or not they developed COVID-19, and the enormous impact on families,” the review authors found.

A body is removed in July from Epping Gardens, where 38 died and 220 residents, staff and others contracted coronavirus.

A body is removed in July from Epping Gardens, where 38 died and 220 residents, staff and others contracted coronavirus.Credit: Eddie Jim

Sue Cashman’s 96-year-old mother Peggy contracted coronavirus in Epping Gardens and survived. “But she’s not in a good way,” Ms Cashman said, adding that the events at Epping Gardens had accelerated her dementia.

“If used to own a childcare centre. If I was licensed to have 148 children, which is what Epping Gardens had, and 38 children died, people would be after my blood. Because they are old people … people think because they are old they were going to die anyway.”

Christine Golding, whose 84-year-old mother Efraxia died after contracting coronavirus at St Basil’s, said the report showed “what a horror show it was inside St Basil’s.

But she said it was a “whitewash” for the Commonwealth government. “It doesn’t really refer to them or their role in stopping this happening.”

Sue Cashman's mother, Peggy Shallcross. Ms Cashman blames her worsening dementia on the coronavirus outbreak at Epping Gardens.

Sue Cashman’s mother, Peggy Shallcross. Ms Cashman blames her worsening dementia on the coronavirus outbreak at Epping Gardens.

“What’s missing from the review is accountability – they talk about systemic failures, but who was ultimately responsible for the neglect?”

The report found both facilities had poor emergency planning, or plans which relied on external resources, although it found that, such was the scale and number of outbreaks in Victoria, that any amount of planning may not have been sufficient.

Both facilities had inadequate staff training and controls in key aspects of infection prevention and control, despite “multiple reminders to providers to prepare for a potential COVID-19 outbreak”.

The review found that leadership faltered at both Epping Gardens and St Basil’s, with COVID-19 outbreaks becoming established before effective responses were put in place.

The chief executive of Epping Gardens, Greg Reeve, said the report was “a pretty honest account” of what had occurred, but said that much of the blame for what had occurred should be sheeted home to the federal government, not the operators, who were dealing with extraordinary circumstances.

He said throughout the outbreak at his centre, the Commonwealth tried to tell him that, since Epping Gardens was the approved provider, it had to deal with the problem.

“I totally accept that, but our problem was that we did not have any staff – there was no-one here. So I kept telling them ‘You can make it my problem as much as you like, but without any staff, I can’t get the residents looked after’.”

The report found surge workforce planning was inadequate and exacerbated by a growing scarcity of staff across the sector at the time, and highlighted ongoing challenges in communications between the facilities and health department.

Former Aged Care Minister, now Minister for Aged Care Services Richard Colbeck, said it was important to understand what occurred to help “make sure we can prevent similar outbreaks now and into the future”.

But opposition health spokeswoman Julie Collins said the report showed the federal government did not have a COVID-19 plan for aged care, and it had failed to learn from earlier aged care outbreaks in NSW.

“The Morrison Government’s failings are heartbreaking and completely unforgivable,” she said. “This could have been avoided if the Morrison Government had a proper plan for COVID-19 in aged care and learnt from previous mistakes.”

If you or anyone you know needs support call Lifeline on 131 114, or Beyond Blue’s coronavirus mental wellbeing support service on 1800 512 348.

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