Reliving the horror of what happened at Melbourne’s St Basil’s aged care home during last year’s COVID-19 outbreak has been an incredibly painful experience for Branka Lyons.

Key points:

  • In July 2020, Chief Health Officer Brett Sutton ordered all St Basil’s staff to isolate for 14 days
  • A coronial inquiry into the St Basil’s outbreak has heard the bulk of the replacement staff were inexperienced and unable to cope
  • Fifty residents died at St Basil’s Homes for the Aged during Melbourne’s second COVID-19 wave

Her parents Slavka, 82, and Jakov Pucar, 90, were among 50 elderly residents who died in what became the deadliest aged care outbreak in Australia.

Each weekday for the last month, Ms Lyons has sat listening to a coronial inquest examining the deaths.

“It’s been challenging. Sometimes at the end of the day, I just break down and cry,” Ms Lyons said.

“I feel cheated. I feel my parents were cheated. I feel angry because there were so many missed opportunities.”

The inquest’s public hearings conclude next week, but it’s already heard plenty of evidence about the “missed opportunities” early in the outbreak identified by Ms Lyons.

Each “missed opportunity” compounded the impact of the next so that within a fortnight of COVID-19 being detected at the facility, the wheels had fallen off.

Residents were left without proper care, some ending up malnourished and dehydrated, lying in soiled sheets with painful bedsores.

Within six weeks, 50 residents had died.

So what were those missed opportunities, and who failed to take them?

Mass testing delayed

Two women stand, one has arm around man who is seated in chair with arms folded.

Branka Lyons says her parents Slavka and Jakov Pucar would have been protected had testing been prompt.(Supplied)

It’s hard to believe it took six days after the first St Basil’s staff member tested positive for Commonwealth authorities to arrange mass testing at the facility.

The reasons for the delay read like a script from an episode of the satirical ABC show Utopia.

The St Basil’s manager, Vicky Kos, tried to notify the Commonwealth health department on July 9, 2020 — the day she found out about the positive test — but she rang the National Coronavirus Hotline instead of using an email address provided by the department.

The hotline she rang directed her to a Victorian health department number, so Victorian authorities became aware of the outbreak.

The following day Ms Kos also told the aged care regulator, the Aged Care Quality and Safety Commission, about the positive case.

Inexplicably, neither the Victorian health authorities nor the regulator called the Commonwealth health department to tell them about the outbreak, a move that would have triggered mass testing within 24 hours.

The Commonwealth’s aged care team didn’t find out until a Victorian official mentioned the positive case at a joint meeting on July 14.

They scrambled to organise testing for all staff and residents the following day, and when the results came back on July 17, dozens of staff and residents were positive.

The horse had bolted.

On Friday, when foreshadowing his final submission to the coroner, counsel assisting Peter Rozen QC indicated he believed the testing delay was a crucial part of the St Basil’s story.

Ms Lyons agrees.

“The virus must have been spreading like wildfire,” she said.

“I’m 100 per cent sure not only my parents but also a lot of other residents would have been protected if the testing had occurred straight away.

“What were they thinking?”

The furloughing of St Basil’s staff

Brett Sutton speaking at a COVID presser.

Chief Health Officer Brett Sutton made the decision to classify all St Basil’s workers as close contacts in July 2020.(ABC News)

With COVID-19 now rampant in the facility, Victoria’s Chief Health Officer Brett Sutton ordered all St Basil’s staff to isolate for 14 days, forcing the Commonwealth to find a replacement workforce by July 22.

At that stage, less than half the staff and residents had tested positive, and authorities hoped by removing workers, they could help stop the spread.

But the inquest heard three doctors on the ground at St Basil’s warned state health officials furloughing staff would end in disaster.

They’d seen a similar tactic used at an aged care centre nearby where the loss of experienced staff who knew the residents well led to a dramatic decline in care.

Professor Sutton told the inquest senior health department officials didn’t pass on the doctors’ warnings.

Counsel assisting, Peter Rozen QC: “I understand your evidence to be that essentially you were not told that there was going to be any fundamental problem. Is that right?”

Professor Sutton: “That’s right.”

Peter Rozen QC: “But equally, you didn’t ask, did you?”

Professor Sutton: “No, I didn’t ask.”

Ms Lyons is angry Professor Sutton made the momentous decision to remove St Basil’s staff without getting the full picture on the ground.

“Because people on the ground were telling him, ‘No, don’t do that, the place needs to be shut down, people need to be hospitalised.'”

 A ‘completely inadequate’ replacement workforce

A sign for the St Basil's Greek Orthodox aged care home in Fawkner attached to a wire fence.

Emails produced for the inquest show Commonwealth officials struggled to find a replacement workforce.(ABC News)

As a result of Professor Sutton’s close-contacts order, Commonwealth health department officials had about 72 hours to find a replacement workforce for St Basil’s to start at 7am on July 22.

Emails produced for the inquest show they struggled from the beginning.

At 8pm on July 21 — just 11 hours before the handover — the Commonwealth official in charge of sourcing staff sent an email describing the replacement workforce as “completely inadequate”.

Not only were there not enough staff, many were inexperienced and unable to cope with a crisis situation.

Sadly, the warnings from the St Basil’s doctors were spot on.

The replacement staff were overwhelmed within hours of starting, and basic care standards fell away, leaving vulnerable elderly residents without food and water.

The inquest heard some of those who worked on the first day were so horrified by what they saw they refused to return for their next shift.

Branka Lyons can’t understand why senior Commonwealth officials, who clearly had misgivings about the size and quality of the replacement workforce, continued with the handover.

“They should have immediately contacted the state government and said we can’t go ahead with this,” Ms Lyons said.

Australia’s Chief Nurse declares St Basil’s ‘fit for purpose’

A woman with long blonde hair cleans the eye of an elderly seated man.

Branka Lyons says she feels angry at the missed opportunities that led to the death of her parents.(Supplied)

On the morning of July 22, as the replacement workforce took over at St Basil’s, Australia’s Chief Nurse Alison McMillan arrived to assess the facility.

She was there on behalf of the Commonwealth Health Department Secretary Brendan Murphy and the Health Minister Greg Hunt, who were considering at least a partial evacuation of St Basil’s.

Within hours, Professor McMillan emailed Dr Murphy, declaring the facility was “fit for purpose” and there was no need to evacuate.

Her view differed markedly from two experienced nurses who were part of the replacement workforce.

They told the inquest they found residents emaciated, malnourished, and dehydrated on the first day of the handover.

The nurses also said the bulk of the replacement staff were inexperienced and unable to cope.

In one of the more stunning moments of the inquest, it emerged Professor McMillan had made her “fit for purpose” assessment without checking on any residents.

It led to an awkward exchange with the coroner, John Cain.

Coroner John Cain: “Would you think it appropriate, knowing what you know now, to at least walk around the facility and have a look and see some of the residents in the various units?”

Professor Alison McMillan: “With the benefit of hindsight, absolutely, Your Honour, I would.”

The “fit for purpose” assessment infuriates the families who lost loved ones at St Basil’s.

Branka Lyons believes Professor McMillan’s visit should have triggered a full evacuation or at least the removal of the COVID positive residents to hospital.

“That just made me sick. It’s outrageous.”

The handover

What happened at the handover meeting on the morning of July 22 has been the subject of intense scrutiny at the inquest.

The St Basil’s manager, Vicky Kos, met with two senior members of the replacement workforce for about an hour.

One of them, Heleni Bagiartakis, told the inquest she was surprised when Ms Kos told them she wouldn’t accept phone calls regarding the clinical care of residents.

The other replacement worker, Angela Cox, said Ms Kos’s refusal to take calls about clinical care concerned her.

“Because we didn’t know the residents, we didn’t know what they had previously done with the residents,” Ms Cox told the inquest.

“If we can’t contact her or an RN (registered nurse) who knows the resident, it’s very difficult to manage.”

Ms Kos is yet to respond to this evidence at the inquest.

Man in suit with arm around woman in black blazer.

Branka Lyons says she hopes the inquest delivers some answers for the sake of her parents, Slavka and Jakov Pucar.(Supplied)

In a dramatic moment this week, a barrister representing Ms Kos and the former chair of St Basil’s, Kon Kontis, told the coroner they were seeking to be excused from giving evidence on the grounds they might incriminate themselves.

The coroner, John Cain, will rule on their application on Tuesday.

Ms Lyons and several other families contacted by the ABC are furious Ms Kos and Mr Kontis don’t want to front the inquest.

“We’ve been waiting for them for so long,’ Ms Lyons said. “We want answers. We want to know straight from the source.”

Ms Lyons misses her parents terribly and hopes for their sake something comes of the inquest.

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Family mourns ‘missed opportunities’ at St Basil’s aged care as inquest reveals horrors
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