Independent Review: Response to the North-West COVID-19 Outbreak
Executive Summary
The North-West Tasmania COVID-19 outbreak in March and April of 2020 resulted in a number
of significant challenges for the Tasmanian health system. Knowledge of the global pandemic and its
impacts was still emerging at the time of the outbreak. National guidance as to how to manage it was
evolving rapidly. This required keeping abreast of the best available evidence but at the same time resulted
in confusion and uncertainty for all concerned. Unlike major natural disasters, or significant yet
localised traumatic events such as shootings for which our health system is generally well-prepared,
this outbreak event was both unprecedented and took place predominantly within the North-West Regional
Hospital. Transmissions among staff were a major component, rather than the more anticipated patient to-staff route.
In the face of this significant and rapidly emerging challenge, those at the coal face responded with great adaptability and resourcefulness. The Review heard repeatedly about the long and arduous hours worked by many hospital and health system staff.
This Report notes that various controls put in place nationally and in Tasmania in the period leading up to the outbreak reduced the case numbers arising from returned overseas travellers and the associated risk of COVID-19 transmissions within the community. It is likely that they also supported prevention of further spread and containment of the outbreak in the NorthWest of Tasmania after it arose.
As at the time of writing this Report, scientific understanding of how this coronavirus is transmitted, and best practice options for prevention of spread in health care settings, is still emerging. However the additional knowledge that has emerged since the outbreak will help to prevent and better inform the response to any future outbreaks in Tasmania.
This Report sets the scene for the COVID-19 outbreak globally, nationally and at the State level. It sets out the particular characteristics of the resourcing of hospitals in the North-West. North-West Tasmania is a regional area, and in many ways, isolated from the centre of the health system’s organisational centre.
Much has already been learnt from the outbreak, and a number of changes have already taken place in response to it. The Review considers that directions, notices, orders and regulations made under the Emergency Management Act 2006 and the Public Health Act 1997, in respect of the North-West, were effective and appropriate.
The Review is not aware of any requirement for legislative amendments. It is of great credit to the State’s emergency management system, DoH and the many dedicated people who worked long and arduous hours that the outbreak was successfully contained.
In addition to the recommendations set out below the Review considers the following to be of particular significance:
• It is the assessment of this Review that closure of the NWRH and NWPH was a major, difficult and ultimately entirely correct decision – despite the complexities of the transfer of patients to MCH and LGH, and how that impacted on the community.
• The command and control systems within the Department of Health need to be further refined and those in charge of hospitals must have the power and authority, subject to overall accountability to those to whom they are responsible, to direct activities and personnel within their hospital. Clarity of control and responsibilities is critical in times of emergencies.
• There needs to be a complete upgrade of government IT systems and in particular those within the Department of Health to enable the making, storing, access and interrogation of records across Government of the patient and staff records that are essential for responding to a pandemic outbreak.
• The current efforts to improve the culture within the Department of Health must continue and be enhanced to eliminate parochialism and the fear of retribution for those who wish to offer constructive criticism. Despite appropriate assurances from the Premier and DoH Secretary, a significant majority of those who wished to make submissions requested anonymity for fear of retribution. Evidence of the actions of some managers suggest that those fears are not unfounded. Accordingly, much of the evidence in this report is referred to in general terms because specificity would lead to the identification of the source.
• From a Tasmanian population perspective, the outbreak in the North-West was successfully contained. It could have become significantly more widespread, and it is important to not lose sight of this outcome.
Summary of Recommendations
1 That the Public Health resources of the State be upgraded to, and maintained at a level, which enables expanded provision of public health services, across a range of protection and prevention issues, for the community and the health care sector, and which allows the Director of Public Health to lead the health response in future pandemics.
2 That a comprehensive respiratory protection program is implemented to address broader staff safety considerations including ventilation, design, and other aspects involved in a ‘hierarchy of controls’ approach as well as PPE.
3 That substantial stocks of PPE are always kept on hand and regularly rotated.
4 That efforts to promote consistent education and practice in relation to the handling and wearing of PPE continue via mandatory training, including refresher training.
5 That all health care staff who frequently perform or assist with aerosol-generating procedures or undertake other activities assessed as high risk for COVID-19 transmission carry out fit testing of N95 masks as a priority, and a range of solutions should be developed for those who cannot obtain a fit with the available respirators.
6 That when an outbreak occurs within a health facility (which may need to be declared following a single case) all relevant staff and patients, irrespective of presence of symptoms, be tested in addition to those identified through usual contact tracing processes.
7 That the Department of Health (DoH) strengthen and maintain its capability for rapid contact tracing in both community and health care outbreak settings. This should also include training and maintenance of surge capacity, and establishing the capacity and protocols to immediately provide supplementary outbreak management solutions such as a ‘contact tracing Flying Squad’ to attend and work together with health facility staff to support future outbreak responses.
8 That the circumstances and legislative framework supporting the dissemination of medical and associated information to all those involved in the contact tracing process and pandemic issues management generally be widely communicated and included in educational and training materials. This should apply not only within the health system itself, but more broadly across all Government agencies.
9 That major decisions in DoH which affect multiple agencies and the community, and require close coordination with the emergency management structure, be communicated to those agencies before there is an announcement to the media.
10 That DoH streamline the communication process and give greater authority to managers in an affected hospital to communicate directly and quickly with their staff about an outbreak. DoH should also seek opportunities to work in partnership with third parties like unions to improve the speed and relevance of communication, building on its work with organisations like PHTas.
11 That there be a clear separation of Public Health advice for the general community from advice for the clinical community.
12 That DoH investigate use of an App-based tool for providing the latest information to staff, so that staff do not have to read through large numbers of emails to find key information, but instead open the App to find the latest advice on issues such as PPE. This might also require investment in smart devices to ensure information can be ‘pushed’ to all relevant staff at the same time, irrespective of where they are located.
Media release – Peter Gutwein, Premier, 9 December 2020
North West Outbreak Independent Review Report
Today we have released the Report from the Independent Review into the North West COVID outbreak.
The purpose of the Independent Review has been to ensure we fully understand what worked well, and also what improvements can be made, so that we have the best possible systems and practices in place in the event of future outbreaks.
The Report outlines that the situation in the North West could have been considerably worse, were it not for the hard work, skills and sense of responsibility of staff, the Department of Health and State Emergency management personnel.
The Review was also told of the suppliers and businesses who went out of their way to provide additional assistance and support during this time.
To each and every person involved I say thank you.
The Independent Review has provided 37 recommendations, and whilst we’ve already undertaken action against a range of recommendations, the implementation plan will look at what we need to do over coming months.
This work is being supported through our record $9.8 billion investment into hospitals and health system announced in the 2020-21 State Budget, as well as $150 million for our Health preparedness and response provided through the Government’s Social and Economic Support package.
We have committed $3.5 million to strengthen the Emergency Services Operations Centre and $23 million into a Health technology package including modernising the human resources system, as well as $121 million over four years for delivery of a unified, digital Tasmanian Government Radio Network (TasGRN), that will ensure fast and secure communications during emergencies.
We have also provided specific funding to establish rapid response contact tracing capabilities of $3.3 million as well as further allocations to keep Tasmanians safe during COVID-19 including to strengthen our border response and emergency accommodation for health care and frontline workers.
I want to again reiterate my sincere condolences to those who lost loved ones, and to those who have been affected by the North West outbreak.
Tasmania has a proud history of learning from emergencies and this report has provided further learnings that will strengthen our response framework in the future.
Given this, the Government has accepted all recommendations, either fully or in-principle*.
I would like to thank the Independent Reviewer, Greg Melick AO SC, and the Working Group for undertaking the report and providing recommendations, which will now be thoroughly reviewed and an implementation plan developed by the end of January 2021.
A copy of the full report can be found here:
http://www.dpac.tas.gov.au/independent_review_of_the_response_to_the_north-west_tasmania_covid-19_outbreak
*Where the Government states in-principle this means we support the intent of the recommendation but it may not be possible to implement it exactly as written.
Media release – Australian Medical Association Tasmania, 9 December 2020
INDEPENDENT REVIEW OF THE RESPONSE TO THE NORTH-WEST TASMANIA COVID-19 OUTBREAK REPORT
AMA Tasmania welcomes the release of the Independent Review of the Response to the North-West Tasmania COVID-19 Outbreak report. We will take a close look at the recommendations and work with the government and our doctors to implement those recommendations where appropriate.
AMA Tasmania called for this independent review, and we have always maintained it was never about the blame game but rather an opportunity to look at what failed in the system and what went well so that we can try to reduce the risk of such an outbreak happening again.
The report findings have never been more significant considering this morning’s announcement of three returned travellers from overseas returning positive COVID-19 tests.
Taking into account that the government has had the report for the past week or more, we would hope that the conclusions of the report would have helped inform decisions taken around the processes set up to support the quarantine of overseas passengers arriving in Tasmania as well as the care and treatment of any COVID positive patients.
It is critical that all appropriate precautions are put in place to protect health workers from contracting the virus and to minimise the risk of COVID-19 escaping once more into the Tasmanian community.
AMA Tasmania is keen to review any recommendations made by the report and to work with the government closely on implementation strategies.
Sarah Lovell MLC, Shadow Health Minister, 9 December 2020
North West COVID outbreak review contains serious lessons for government and must not be ignored
The Gutwein Government needs to immediately commit to each of the recommendations contained in the independent review of the North West COVID outbreak and genuinely ensure each is adopted.
Shadow Health Minister Sarah Lovell said there were several concerning findings in the report which cannot be swept under the carpet and the Premier needs to guarantee his commitment to taking action urgently.
“From the outset all Tasmanians owe their sincere thanks to everyone who spoke and made submissions to the inquiry and the health staff who helped prevent a wider outbreak through their dedication,” Ms Lovell said.
“But the report shows a lot of work remains to be done and the government needs to commit to getting on with the job of doing that work. It’s critically important that they properly fund and resource so these recommendations can be genuinely adopted.
“The review shows a number of issues – about access to PPE, about resourcing, about staffing, about consistency of infection control, about COVID testing for staff – were raised by Labor and health staff prior to the outbreak but the government continued to provide reassurances that everything was OK.
“The government made repeated assurances those important issues were under control – the report finds they clearly were not.
“The review has also found public health has remained underfunded and under-resourced for many years under this government, describing it as a ‘poor cousin’. That lack of resourcing and underfunding is of the greatest concern across our hospitals and that can no longer be ignored by the Liberals.
“It’s disturbing that the review has found an unacceptable culture throughout the health system where staff actively feared punishment for speaking out. That’s a big red flag.
“It’s extremely concerning that 26 out of 39 submissions requested confidentiality because they feared retribution – and that fear was found to be real. Fear should not guide our health staff’s willingness to speak out and the government has to work now to remove these barriers and change the culture.”
