The level of responsibility burdening management, the state and federal government and private actors involved in the St Basil’s tragedy remains to be determined.

But one thing has become clear after a week of hearings at the coronial inquest into Australia’s deadliest coronavirus outbreak.

Errors were back-to-back and created a crisis where deaths of our elderly were not just caused by COVID-19 but importantly a lack of basic care.

READ MORE: St Basil’s Coronial Inquest: Timeline of events which have unfolded so far

The latter was at the centre of concerns raised by doctors of the outreach team assisting the aged care home, before the Victorian government decision to stand down its entire workforce amid the outbreak.

Decision made without “setting foot in St Basil’s”

“I felt they were following a textbook approach and not taking into account the context,” Dr Sandra Brown, a senior Northern Health doctor told the court on Tuesday.

Questioned repeatedly by Mary Anne Harley QC, the barrister representing DHHS, about her team’s opposition to the decision to furlough staff, Dr Brown responded:

“The public health unit would have benefitted by setting foot in St Basil’s and then they may have been able to make a more nuanced decision.”

The doctors’ position, she said, was informed by their “experience on the ground” and stemmed from concerns about “insufficient surge workforce”.

At the time, Dr Brown said, “knowing how many people had already tested positive” and how many were suspected to be infected due to exhibiting symptoms, their focus turned into “the only thing we can do for the residents is to ensure adequate care”.

Northern Health’s geriatrician Zi Yi Low had also warned officials that removing all staff was “a shocking idea”, quoting fears of a scaled up disaster similar to an earlier COVID-19 outbreak, at Estia aged care home in Heidelberg where 10 people died.

“Medications were lost, meals were not provided, no modified diet or fluids and no analgesia,” reads an excerpt of Dr Low’s statement prepared for the Coroner.

A general view of the Coroner’s Court of Victoria at the inquest into the COVID-19 deaths of residents at St Basil’s Home for the Aged at the Coroner’s Court of Victoria in Melbourne, Thursday, November 18, 2021. Photo: AAP/Con Chronis

But a senior medical adviser to the state government denied warnings of an imminent disaster were ignored.

Dr Naveen Tenneti told the court on Monday that he believed the replacement staff sent by the Commonwealth would be sufficient despite missing an email from a Commonwealth public servant informing Victorian authorities that surge workforce had “dwindled quickly”.

Reacting to the evidence heard, Judge John Cain described the interaction between the state and federal government as “quite passive” and asked why a direct phone call was missing to clarify with the Commonwealth “have you got it covered, assure me you’ve got it covered?”

“No time for proper handover”

The care of residents was compromised quickly after the replacement workforce came in, according to evidence presented on Monday by St Basil’s staff employee, Connie Apidopoulos, who worked at the kitchen.

“There was no time to give them a proper hand over because we were being rushed[…]The whole day was so stressful. I could see so many mistakes that were going to happen,”

“The residents were getting upset and sad while the hand over was going on. They would come out and ask for food and their medications as they knew what times they were meant to eat and take medications,” reads an excerpt of Ms Apidopoulos statement.

Fingers were also pointed at St Basil’s management over the replacement of staff process, with Ms Harley, the barrister representing the Victorian Health department raising allegations about an inadequate handover.

READ MORE: Scenes of ‘chaos’ described as St Basil’s tragedy unfolded

Ms Harley told the court that based on witness statements from agency workers that are yet to be made public, St Basil’s manager Vicky Kos failed to make available clinical notes, keys, and computer passwords to the new staff.

The decision to designate the entire St Basil’s workforce as close contacts and replace them with external agency staff was implemented on 22 July.

But according to Spiro Vasilakis, son of one of the residents who passed amid the outbreak, “a fire was burning at St Basil’s” way earlier.

“Total disorganisation”, “chaos” and a “lame excuse”
In their joint testimony on Tuesday, Spiro and Theodora, son and daughter of Maria Vasilakis, detailed the timeline of events preceding their mother’s death from COVID-19 and their experience with the aged care home.

Late Maria Vasilakis with her son Spiros and daughter Theodora. Photo: Supplied

Ms Vasilakis was taken into hospital on 17 July after testing positive but returned back to the aged care home on the same day due to having minor symptoms.

Daughter Theodora had then asked the doctor if she could take her mother home instead, but was advised she would be looked after “just as well” at the nursing home as she would in hospital.

In the days that followed, the siblings told the court they witnessed “a total disorganisation” and “chaos” during their visits, describing instances of “a lack of adherence to protocols” and incorrect use and storage of PPE equipment.

Ms Vasilakis passed away on 23 July, a day after she was readmitted to hospital.

“Sadly enough at the same time hospital was trying to contact my sister and myself to tell us that mum had passed away, seconds before we received a call from St Basil’s from a lady trying to tell us that our mum was in her room and well,” Spiro Vasilakis said.

READ MORE: Spiros Vasilakis who lost his mother to COVID-19 speaks to Neos Kosmos

At the conclusion of their joint testimony, Mr Vasilakis told the court this coronial inquest was “the opportunity this family had been waiting for”, before reading some notes about a letter sent on 24 July last year to families of residents by then St Basil’s chairman Konstantin Kontis.

“He said he didn’t mandate the use of PPE before July 23 because the Commonwealth had not advised. That’s really a lame excuse. Is Mr Kontis saying he’s incapable of being proactive to save his staff and the residents? If there was smoke coming out of the building, would he call the Commonwealth government if he should attempt to put it down? This is exactly what was happening. A fire was burning at St Basil’s”.

Throughout the pandemic, Mr Vasilakis said, it became clear that the elderly were the most vulnerable.

“Those in aged care homes should have been the most protected. And look where we are today.”