Two months ago the government set its response for Covid-19 outbreaks in aged care – controversially, it was ‘about keeping the hospitals for the young’. By Rick Morton.
Exclusive: The phone call that denied elderly patients access to hospital
In a June 10 phone hook-up, senior clinicians, nurses and leaders from the nation’s aged-care providers begged the federal government’s regulator and New South Wales Health’s deputy secretary to listen to them.
Older Australians had already died, they warned, and they would again if authorities refused to transfer Covid-19-positive residents to hospital for their safety and the wellbeing of those left behind.
There were more than 120 people on the call, which was set up to discuss a draft protocol between the Commonwealth and the NSW government about what should be done in the event of the virus getting into a nursing home.
The Saturday Paper has spoken with five people who were on the call, all of whom corroborated the following retelling.
“It was the worst phone call I’ve ever been on,” one says.
“People spoke up – many of them with extensive clinical experience in public health and aged care – about the urgent need for anyone infected to be moved to hospital to help keep the virus from spreading in facilities. It was rebuffed over and over again.”
According to those on the call, the conversation became increasingly heated. The key contribution from the Aged Care Quality and Safety Commissioner, Janet Anderson, was apparently to remind providers “that they are responsible for infection control under the Aged Care Act”.
It had been just three weeks since the 19th resident at Newmarch House in Sydney died following infection with Covid-19. According to notes from crisis meetings at the Anglicare facility, which were tendered as evidence to the aged-care royal commission, Anderson’s own chief clinical adviser, Dr Melanie Wroth, and executive director Ann Wunsch had argued forcefully that residents be removed from the facility. In the bleak parlance of the bureaucracy, this is called “decanting”.
Notes from a Commonwealth official read: “Need to avoid what happening overseas – high number of deaths.
“Could private hospital agreement be utilised for decanting? Concern about reconditioning of the negative clients.”
Even at the time, the situation at Newmarch House was curious. Just weeks before, in late March and early April, Opal Bankstown had three positive coronavirus cases among its residents. All three were taken to hospital. That facility never had another Covid-19 infection. Newmarch would go on to record 37 cases in residents and 34 in staff.
The deputy secretary of health system strategy and planning at NSW Health, Dr Nigel Lyons, was one of the key officials on the June 10 teleconference. Multiple people have confirmed that when a representative from Anglicare implored him to pay attention to the international evidence – specifically a presentation to the British House of Lords by Hong Kong’s head of infection control, which revealed the island city recorded no aged-care deaths because of a priority to move any infected residents out of a facility to stop the spread – Dr Lyons said there was no peer-reviewed data. He then said something to the effect of: “People keep forgetting there were a lot of good outcomes at Newmarch.”
Lots of people survived the outbreak, he said. There were audible gasps. Commissioner Anderson, the most senior Commonwealth official in charge of quality and safety for aged-care residents, said nothing.
One member on the call said it was obvious they “didn’t want any feedback that would go against a decision they had already made”.
Another said: “There was an underlying view that they just didn’t want older people to go to hospital. I don’t recall Janet speaking out at all.”
That in itself was a departure from Anderson’s previous position. In a flurry of emails between Commonwealth officials, including the Department of Health’s acting first assistant secretary, Amy Laffan, it was noted that the state government’s preference was “not to decant residents into hospitals given the precedent this would set”.
Anderson was powerful in her rebuke, although it was only seen by her peers in the Commonwealth.
“To be clearer,” Anderson wrote in an email on April 16, “if there is a view sitting behind New South Wales Health’s 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.”
In a statement to The Saturday Paper, she said she has been “consistent” in her stance. “I have also consistently said that admission of one or a group of residents from an outbreak facility to hospital must always be on the table among the options for consideration. It should not be ruled out prior to, or even from the beginning of, an outbreak.”
But many hoped the government would recommend positive cases be transferred immediately to hospital, as happens elsewhere. Instead, the protocol left it to local health districts to “determine the processes for clinical deterioration” before considering the possibility of transfer.
Under the legislation, aged-care providers have responsibility for infection control in their homes. But those on the call knew what such a policy meant: if Covid-19 cases were not immediately removed from nursing homes, the virus would spread through residents like a flame through straw.
What chance did they have to stop it when they couldn’t even secure masks, gowns or gloves from the national stockpile?
On April 21, a senior project officer at NSW Health wrote an email to the head of procurement at Anglicare: “As discussed, please make sure the facility know not to use full PPE for anyone but positive and suspected cases.”
At this stage, the low-paid staff at Newmarch House – as a matter of history and chronic underfunding, aged-care staff are among the lowest-paid workers in the nation – were going through 300 protective gowns a day.
The same NSW Health officer wrote back a few days later with an ultimatum: they would release more stock to Newmarch, but only if they promised not to use it for every resident. At this stage, three people had already died at the facility.
“Prior to me seeking approval to supply additional gowns for Newmarch can you … provide me reassurance that if we provide additional gowns they will only be used for positive and symptomatic cases?” the bureaucrat wrote, before adding “i.e. usage rate will equal no more than 300 gowns per day”.
These were not isolated cases. Union bosses who gave evidence at the Royal Commission into Aged Care Quality and Safety on Wednesday described scenarios where personal care workers were limited to just two pairs of gloves for an entire shift. Others, according to Australian Nursing and Midwifery Federation federal secretary Annie Butler, were told to just use one glove on one hand at a time. Or to re-use them by putting them in bags at the end of a shift, which would then be “cleaned” and returned to staff.
“A whole range of incredible breaches in infection control,” Butler told commissioners.
The issue was also raised with officials on the June 10 phone meeting. The chief executive of the community aged-care peak body, Patricia Sparrow, said home care providers – domestic assistants, care workers and nurses – did not have adequate supplies of personal protective equipment.
Janet Anderson was crisp in her response: “Well, Patricia, they would be in breach of the standards.”
There is little in the federal government’s account of what actually happened in aged care before and during the Covid-19 pandemic that makes sense.
In his opening address at the special royal commission hearing on Monday, counsel assisting Peter Rozen, QC, launched a plainly worded broadside against a woefully disorganised Commonwealth.
“While there was a great deal done to prepare the Australian health sector more generally for the pandemic, 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,” he said.
This scathing assessment prompted a last-minute bid by federal government solicitors to have former chief medical officer Brendan Murphy, now secretary of the federal Health Department, to join the witness list for the commission hearings.
What followed was a comedy of errors so astounding in its proportions, so impoverished in its delivery and inept in its schoolyard-like execution, as to raise the ire of Commissioner Tony Pagone.
On Wednesday, and without warning, Murphy first sought to “crave the indulgence” of the commission to make a statement correcting what he said were inaccuracies in Rozen’s opening statement.
After a brief adjournment, this was denied. He then attempted to make reference to a “foundational plan” for aged care in his response to questions that were unrelated to this subject. Rozen chided him and asked him to stay on topic. The hearing paused again.
“Mr Rozen, a note has been given to me. I understand that counsel for the Commonwealth wants to make a submission of some kind,” Commissioner Pagone said.
That submission was the missing, signed summary of Murphy’s evidence, which Commonwealth lawyers said he had “managed in the limited time available to put together”.
Pagone was not impressed. “I think that is probably something that you really could have taken offline rather than occupy space of the commission time,” he said.
The commission ultimately heard from Health deputy secretary Michael Lye, Professor Murphy and Janet Anderson. Here, in the witness box, were the three most senior Commonwealth officials responsible for aged care – the funding and regulation of which comes fully under the umbrella of the federal government – and they could not agree on a story to counter evidence put to them.
At times, what they provided was in direct contradiction to their own signed witness statements, tendered to the commission.
Take, for example, the Communicable Diseases Network Australia (CDNA) document first published on March 13, which Aged Care Minister Richard Colbeck and his public servants have repeatedly pointed to as evidence of a plan.
The “National Guidelines for the Prevention, Control and Public Health Management of Covid-19 Outbreaks in Residential Care Facilities in Australia” had three versions. Although all versions went to great effort to establish the roles and responsibilities of state and territory governments, and aged-care providers themselves, the first two versions of the document from March and April did not include any reference to the federal government and the role it would or should play in an outbreak.
“Just in relation to the title of this, it’s not actually entitled a plan, is it? It’s entitled ‘guidelines’,” Rozen said to Lye.
“It’s the case, isn’t it, Mr Lye, that in the first two versions of this document, of this key Commonwealth government document, the Australian government Department of Health was not identified as having a role in relation to responding to Covid-19 in residential aged-care facilities? Do you agree with that?”
Lye struggled to answer the line of questioning and, after a few attempts, Professor Murphy covered his mouth as he attempted to give an answer to the deputy secretary. Rozen was clearly surprised.
“Did Professor Murphy just whisper to you the answer he suggest you give, Mr Lye?”
Murphy attempted to explain: “I just… I just said it was an Australian government document, which… which it is. I was just...” he said, before stopping himself and staring blankly at a wall.
Two things stand out about this document. First, it says it does “not warrant or represent that the information contained in the guideline is accurate, current or complete”. Then, it offers guidance that aged-care providers should plan to cover an expected staff absentee rate of 20 to 30 per cent during an outbreak.
This was patently not true. Newmarch House reported losing 84 per cent of its workforce within a matter of days. Other aged-care homes had to furlough their entire workforce within days of an outbreak. This was known to authorities when the document was updated in April, although the guidance remained unchanged.
Both Murphy and Lye said this was the figure they anticipated providers would have to meet, and anything beyond that would be met by the Commonwealth’s surge workforce.
“Absolutely, Counsel … there had been a number of instances where very large no-show rates and quarantining in isolation have led to significant workforce loss in excess of that,” Murphy said.
“Whether it’s reasonable for the facility to meet that rather than the extra surge we put in place is another question.”
Lye said “it is not reasonable to suggest that they should have a plan that could account for, say, 60 or 70 per cent of their workforce; even the biggest and most proficient providers would struggle at that level”.
What is interesting about these statements is that, on June 29, the Commonwealth issued a separate document to guide providers “in the first 24 hours” of a coronavirus outbreak.
It said: “Keep in mind up to 80 to 100 per cent of the workforce may need to isolate in a major outbreak.”
Exactly a month later, Scott Morrison stood next to Professor Murphy at a press conference in Canberra and responded to reports about St Basil’s Homes for the Aged in Fawkner, Victoria, which had to furlough all of its aged-care staff amid the devastating second wave.
Morrison said the idea that a single facility could lose all of its staff in this way was something “that had not been anticipated or foreshadowed at a state level, or considered at a federal level”.
Murphy agreed and said it was a situation they had “not experienced before”.
The protocol developed between the Commonwealth and NSW on that June 10 teleconference is significant because, according to Michael Lye, it was “more or less endorsed by all jurisdictions as the basis for operating with us during the pandemic”.
In his signed, sworn statement to the same inquiry, however, Lye says “the protocol only applies to crises arising in NSW”.
Nevertheless, aged-care representatives on the phone call understood the damage such a precedent would set. When the meeting ended, all three of the aged-care sector peak bodies, as well as key staff from non-profit providers, decided separately to write to every state and territory Health minister in the country. The Saturday Paper understands they were in a state of shock and fury. They believed that what happened in NSW could never be allowed to happen again.
Just weeks later, it did. In Victoria.
As case numbers began to climb in the state, the precarious aged-care workforce became one of the key drivers in the spread of the virus across metropolitan Melbourne. By the middle of July, outbreaks were being recorded in nursing homes across the state. Menarock Life in Essendon had 29 cases and on July 17 the aged-care watchdog announced that it “supported the decision to transfer residents from Menarock Essendon to Latrobe Private Hospital to ensure their ongoing safety and wellbeing”.
This process for transfer was not always followed and sometimes it was blocked. Within weeks, there were more than 1000 cases linked to aged-care homes.
On Thursday, Premier Daniel Andrews reiterated his government’s position on hospital transfers, which is a carbon copy of the response codified in the NSW protocol.
“Doctors and nurses have sat down on a case-by-case basis and made assessments based on clinical need about what is the best way to handle the Covid outbreak,” he said.
“Anybody who needs, in the view of their treating doctor, to go to hospital will go to hospital.”
In late July, The Saturday Paper reported a non-profit nursing home in Melbourne attempted to have one of its Covid-19 patients moved to a hospital. The hospital refused. This was not an isolated problem and subsequent reporting in The Australian has confirmed the systemic nature of these refusals.
On Thursday, the premier said there were limits to what was possible. Early on in the pandemic, he said, one provider ordered 100 ambulances to transfer its residents, “as if that would be something that would be in any way feasible”.
Andrews said more than 400 aged-care residents had been transferred to hospital. Many nursing homes, including an additional three announced at the Thursday update, have been completely taken over by state health services.
In South Australia, however, a completely different approach has been taken. On Monday, the state’s chief health officer, Professor Nicola Spurrier, told the royal commission that South Australia had followed Hong Kong’s example and implemented a policy of immediately transferring positive aged-care residents to hospital. So far, there have been no deaths connected to aged care in the state.
After the Newmarch House outbreak in NSW, the number of aged-care residents as a proportion of total Covid-19 deaths in Australia was about 20 per cent. The second wave in Victoria took that proportion to 70 per cent.
Geriatric medicine specialist Professor Joseph Ibrahim, from Monash University, told the royal commission on Wednesday that the situation in aged care is the worst he has seen in his career.
“In my opinion, hundreds of residents are [dying] and will die prematurely because people have failed to act.”
Professor Ibrahim said the number of deaths made Australia the “second or worst” performing nation in the world on aged care, behind Canada, where 80 per cent of those who died from coronavirus were in long-term elderly care.
Peter Rozen asked Department of Health deputy secretary Michael Lye for his opinion on “why Australia is faring so badly”.
“Counsel, if it is acceptable, I would like to defer that question to Professor Murphy, who actually is an expert in this area,” Lye said.
“No, I don’t want Professor Murphy to answer the question, Mr Lye. I’m asking you,” he said. “You told us you were the senior-most official with aged-care responsibility within the Commonwealth Department of Health, and I would like you to answer the question, please.”
Lye prefaced his response by saying every aged-care death “is an absolute tragedy”. He continued: “But nonetheless, given the nature of the Covid and its preponderance to affect the frail, aged population … where it takes hold, then we necessarily see that result.”
The sector was in shock. Far from necessary, those on the June 10 phone call felt a conscious decision was being made about the sector. “I left those conversations with the distinct impression that this was about keeping the hospitals for the young,” one senior sector member said. “It was infuriating and they wouldn’t be argued with.”
This article was first published in the print edition of The Saturday Paper on August 15, 2020 as "Exclusive: The government phone call that denied elderly coronavirus patients access to hospital".
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