Testimonies of relatives of elderly Greeks who died neglected, malnourished and dehydrated during Australia’s largest COVID-19 aged care outbreak will be heard publicly for the next five weeks.

The coronial inquest into the 2020 deaths at Melbourne’s St Basil’s residential aged care facility started its hearings on Monday.

With the July and August events under scrutiny, the inquest aims to shed light into the deaths of 50 residents during Victoria’s second wave of the pandemic, most of whom – over 40 – were of Greek background.

The death of forty – five of those was directly attributed to COVID-19, making the virus spread at St Basil’s “the largest outbreak in Australia since the start of the pandemic” as noted by the Counsel team assisting the State Coroner Judge John Cain., Peter Rozen QC, Naomi Hodgson και Kathleen Crennan.

The first day of the inquest hearings opened with a tribute in the memory of those deceased, with His Honour Judge Cain directing all present at proceedings to stand while the names of the 50 victims were being read with each person’s photograph displayed on a screen.

List of St Basil’s residents who lost their lives during July and August 2020:
AKRITIDIS George (83), ANDREOU Theodoula (85), ANDRIKOPOULOS Gina (84), ATZARAKIS Fotini (77), BARBOUSSAS Paul (79), BARBOUSSAS Anna (81), BOURNOXTFIS Orea (86), CARDINI Fortunata (98), CHRISTOFILOS Ethalia (85), COUTLAKIS Con (88), DAKOURIS Konstantinos (86), DIMITRIADIS Michael (94), DIMITRIOU John (73), DIMOTAKIS Pavlos (72), FOTIADIS Dimitrios (79), GINIS Basile (83), IOANNOU Lemonia (75), KARAHALIOS Margarita (85), KARASAVIDIS Barbara (77), KARAVIAS Maria (93), KAZAKO Afroditi (94), LA ROCCA Alexandra (88), MAKRIDIS Theodoros (91), MANOLAS Chryssi (82), MIHELAKOS Christos (88), MITSINIKOS Georgia (87), NUNZIATO Renato (96), PATSAKOS Vasiliki (85), PATSALIS Maria (87), PETKOVIC Boro (82), PIERIDOU Androula (72), PINGIARO Nicolina (90), POULAKOS Con (86), PUCAR Jakov (90), PUCAR Slavka (82), ROUSSAS Dimitrios (93), RUKAVINA Marija (86), SAMARAS Athanasios (91), SAVVA Archondia (98), SKENDERIS Zisis (83), TAKIS Illias (81), TRIMBOS Illias (76), TRIMBOS Hrisoula (78), TSALANIDIS Efraxia (84), TSINTZIROPOULOS Dimitrios (92), TZOULIS Vasilios (80), VALKANIDIS Malama (83), VARVARIS Christos (93),VASILAKIS Maria (81), XYNIDAKIS Filia (77)

Family members of ten of the Greek Australians who died then will be amongst those called to give evidence, with daughter Efraxia Tsalanidis, Christine Golding, appearing first on Monday.

“I’m here to bring my mother’s story to life but also to show the court that […] This is about real people, real people that lived, that had hopes and dreams, that suffered because of systemic failures that I’m sure the court will explore. I know the court will explore.”

“They didn’t deserve what happened to them,” said Ms Golding in her opening statements.

  • ST BASIL’S INQUEST: KEY INFO
    The purpose of the Court is to investigate and identify the causes of the deaths and the circumstances in which they occurred, enabling also the State Coroner to make appropriate recommendations to inform the response on any future disease outbreaks in aged care settings.
  • A total of witnesses will be called to provide evidence, amongst them relatives of the deceased, staff members, management representatives, including former St Basil’s Chairman Kon Kontis and then Manager Vicky Kos, as well as commonwealth and state government officials like Victoria’s CHO, Brett Sutton.
  • Hearings are scheduled to conclude the week ending 10 December.
  • The scope of the inquiry includes evidence and assessments across five timeframes, starting from the adequacy of the preparation for an outbreak at St Basil’s in the months preceding the index case, covering the response of the authorities to the initial spread and the decision to replace the facility’s workforce by Commonwealth deployed staff, and the evacuation of residents to private hospitals.

EARLY FAILURES ON THE SPOTLIGHT
The outbreak at St Basil’s in Melbourne was not the fist large scale of its kind in an Australian aged care facility, as pointed out by the teams of Counsel Assisting the State Coroner.

Sydney’s Newmarch House outbreak in April 2020 had already cost the lives of 19 elderly residents.

“Sadly for the residents at St Basil’s and their families, the evidence in these inquests suggests that these lessons [deriving from the Newmarch House outbreak] had not been learned,” they note.

St Basil’s infection control preparation processes were the focus of the inquest at the start of the week, with the investigation focusing on both the facility’s state of preparedness, as well as the guidelines provided to staff in cases of suspected infections.

Early omissions identified in the hearing on Tuesday include a ‘preparedness visit asssessment’ at the home conducted the week before the outbreak by a Victorian Department of Health outreach team, resulting in a rather positive audit that “seems to have been heavily reliant on what the assessors were told by the management” instead of actual assessments.

The facility’s “false sense of security” was tested just days later when the first positive case to the virus was identified.

An independent expert report about the response to the outbreak, conducted by Dr Ian Norton describes a delay of 8 days between the identification of the case and testing of residents and staff as “the root cause of a serious outbreak not being contained”.

In fact, the Commonwealth government protocols at the time required testing to be conducted with 4-6 hours of a case made known.

But, as evidenced, the policy on Pandemic & Outbreak Management that had been prepared by an aged care consultant engaged by St Basil’s was submitted in April 2020 and had not been updated as per latest guidelines.

Among key resources missing at the time of the outbreak was a Commonwealth government guidance note titled ‘First 24 hours – Managing COVID-19 in a Residential Aged Care Facility’.

Importantly, the omission led the Commonwealth Department of Health not being immediately notified of the COVID-19 case as was required.
St Basil’s officials reported the case to the Victorian Department of Health as per guidelines they had available, with DHHS officials also failing to notify Commonwealth authorities.

The lack of coordination between the Commonwealth and state authorities was also highlighted by Dr Norton as “another root cause of the tragedy at St Basil’s […] an outcome that was preventable.”