Dec 23, 2020

Report into COVID-19 outbreaks at St Basil’s and Epping Gardens highlights what went wrong

In July and August 2020, Victoria experienced a second wave of COVID-19 infections, at a scale which had never been seen in Australia.

It directly affected more than 2,000 aged care residents and 2,200 aged care workers.

The Australian Government commissioned an independent review into the COVID-19 outbreaks at St Basil’s Home for the Aged and Heritage Care’s Epping Gardens residential aged care facilities.

The review was conducted by Professor Lyn Gilbert and Adjunct Professor Alan Lilly.

At St Basil’s, 94 residents and 94 staff members were infected, and 45 residents died with COVID-19.

At Epping Gardens, 103 residents and 86 staff were infected, with 38 resident deaths.

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 their families.

They do not account for the distress of staff members, who knew and had cared for residents for long periods but were quarantined and obliged to leave them in the care of “strangers”.

Many of the agency workers who replaced quarantined staff, came with little, if any, preparation or experience in aged care and were also deeply traumatised by the experience.

Minister for Health, Greg Hunt said the report underlined the critical elements that led to the tragic outbreaks at the height of the second wave of community transmission across Melbourne following the Victorian Hotel Quarantine failures as outlined in today’s Inquiry.

It highlights the vital role the Commonwealth played to support the residents, staff and management affected by the outbreaks and underlines the lessons from both incidents.

Forty-five residents at St Basil’s Home for the Aged and 38 residents at Heritage Care’s Epping Gardens passed away.

“In extending our sincere condolences to the families of those who died, this investigation serves as a platform for understanding and action,” Minister Hunt said.

“I would like to acknowledge the role of residents and families in the preparation of the report during what clearly has been a very difficult time.”

As part of the Government’s considerations, a briefing for families with the authors of the report has been arranged ahead of its release.

“The health and wellbeing of senior Australians – and the workers who care for them – is of the utmost importance to the Australian Government,” Minister Hunt said.

“We continue to work day and night to safeguard the most vulnerable in our community.”

Minister Colbeck said the Australian Government has been adapting the National Response Plan for COVID-19 in aged care since early 2020 and, with the aged care sector, state and territory governments and health authorities, incorporating lessons learned from Australia and other countries.

The review into the two Victorian outbreaks was commissioned to give a voice to those who were directly affected by the tragic events.

Its authors are members of the AHPPC’s Aged Care Advisory Group (ACAG) and have been informing the Australian Government since the pandemic started on an ongoing basis.

“It’s important we understand what occurred and what can be learned to make sure we can prevent similar outbreaks now and into the future,” he said.

Both St Basil’s Home for the Aged and Heritage Care’s Epping Gardens remain subject to a Notice to Agree (NTA) issued by the Aged Care Quality and Safety Commission.

A Notice to Agree is a serious enforcement measure which, if ignored, can lead to the approval to provide Australian Government subsidies being revoked, and comes at a cost to the provider.

Minister Colbeck said establishing the Victorian Aged Care Response Centre (VACRC) and significant actions by the Commonwealth Government to support providers to respond to emergency event in aged care is acknowledged in this report.

At the height of the second wave in Victoria, advice from the VACRC, is that there were more than 7,000 aged care staff furloughed who had either contracted COVID-19 or were close contacts.

To find replacements for this many staff was a mammoth task.

During the outbreak, according to VACRC data, more than 36,000 shifts were filled by replacement staff.

“The coordinating role of the VACRC was found to be a major driver in facilitating effective interagency communications,” Minister Colbeck said.

On 21 August 2020, National Cabinet endorsed the Commonwealth, State and Territory Plan to Boost Aged Care Preparedness for a Rapid Emergency Response to COVID-19.

A key component of the plan is the establishment of Aged Care Emergency Response Operations Centres. Within each jurisdictions’ public health response structure, a dedicated aged care emergency response team has been established and key personnel identified at the state and Commonwealth level.

“All jurisdictions have provided assurances that their Aged Care Emergency Response Centres can be stood up within 48 hours,” Minister Colbeck said.

The Australian Government will continue to work collaboratively with the states, the aged care sector, and public health authorities, to adapt and refine the approach to outbreaks in six key areas:

  • Leadership and management
  • Communication
  • Emergency planning and preparation
  • Infection prevention and control capacity and capability
  • Pathology testing
  • Surge workforce.

The Australian Government has now invested $1.8 billion to support older Australians in aged care since the start of the pandemic. This includes $132.2 million in response to the Aged Care Royal Commission’s recommendations on COVID-19.

Minister Colbeck acknowledges the work of report authors Professor Lyn Gilbert and Adjunct Professor Alan Lilly and all of the people who have taken part or supported these independent reviews.

As members of ACAG, the desire of the authors was to ensure the key findings from their research could be incorporated directly into advice to the sector.

Having been closely considered by the AHPPC and ACAG, where it has not already occurred, key learnings of the review will be implemented.

Every age care provider and facility leader in Australia should read this report – it is a powerful additional source of advice and information.

The report on the independent reviews of COVID-19 outbreaks at Heritage Care’s Epping Gardens and St Basil’s Home for the Aged can be found here.

Support for care recipients, families and aged care workers

The COVID-19 pandemic has had a significant impact on the lives of so many Australians.

The release of the report may be confronting for anyone affected by the impact of the pandemic on Australia’s aged care sector.

The following free support is available:

  • The Older Persons Advocacy Network can be reached on 1800 700 600
  • The Australian Centre for Grief and Bereavement offers free grief counselling to aged care recipients, their families, loved ones and aged care staff: Phone 1800 22 22 00; upload “My Grief” app available at or via the Google Play and Apple Store
  • Dementia Australia provides advice to people caring for someone with Dementia where behaviours are impacting their care: Phone 1800 699 799
  • Phoenix Australia provides information and tools to support those who have had traumatic experiences: visit
  • The Essential Network for health professionals – a website and mobile app by the Black Dog Institute: visit or upload via the Google Play and Apple Store
  • Beyond Blue Coronavirus Mental Wellbeing Support Service: Phone 1800 512 348 or visit
  • Lifeline can be reached on 13 11 14
  • Head to Health provides access to free and low cost digital and phone mental health services and supports: visit

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  1. Aged care has always been managed “on the edge” that is spend as little as possible because we do not have the money or we want to extract as much as we can for profit. There was no slack in the system for emergencies on this scale. Now aged care policies must manage for all possibilities not profit Therefore the profit motive needs to be removed. The system should be managed so that all care is at the highest standard.

    The current standards need to be written to cover not clinical but social and safety matters which can only be achieved by more mandatory requirements that specify what social, clinical, safety and hotel services. If these can be met it will be a start of improvement. The culture of owners and management of these establishment must be improved to improve thee


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