A balcony exposed to spores from a construction site was the most probable source of a deadly fungus cluster that claimed the lives of two transplant patients and left four others seriously ill at one of Sydney’s most prestigious hospitals.
The final report into the outbreak, published on Friday, revealed one of the patients remains in the hospital’s intensive care unit – four months after they were diagnosed with a fungal infection caused by the common Aspergillus mould.
The report found environmental testing and cleaning audits failed to meet care delivery standards.
The review team revealed three of the six cases had stayed in rooms which were later found to have mould growth and water damage, but ruled that a balcony exposed to the nearby construction site was a more likely source of exposure to Aspergillus due to the timing of the construction works, and “well-recognised links between construction activity and outbreaks of IFIs [invasive fungal infections].”
The cause of the infections, Aspergillus, is a common mould found in soil, plants and damp environments. Digging and construction works can disturb deposits of the mould, causing airborne spores.
Most Aspergillus strains are harmless, but a few can cause serious illness when their spores are inhaled. This is most dangerous for people with lung disease, asthma, and compromised immune systems.
The balcony was accessible to patients on RPA’s transplant ward while construction occurred next door on the hospital’s $940 million redevelopment. At least one of the cases in the cluster used the balcony before it was shut off from patients in late November, when it was handed over to contractors CPB to continue construction work.
The report found CPB managed and monitored emissions on the boundaries of the construction site, but did not assess the risk of patients’ access balconies near or above construction works. It recommended hospital construction risk assessments and mitigation measures include all known clinical areas including air intakes, windows, and balconies.
Two patient deaths were linked to the cluster, and subject to Serious Adverse Event Reviews (SAERs). Another patient died in November, but their death was attribute to sepsis associated with a skin condition, rather than the fungal infection.
Two cases were discharged home, and one remains in ICU.
NSW Health Minister Ryan Park said the families deserved answers, and he hoped the report provided some.
“There is always room for improvement in our health system, and I’ve made it clear I want these recommendations implemented across all of our hospitals,” he said.
In a media statement, Sydney Local Health District said it had given affected patients and their families the opportunity to meet doctors and management at RPA to discuss the report’s findings.
The health district and Park have faced criticism for keeping the deaths secret for almost three months.
The saga has shined a spotlight on maintenance issues across NSW’s public hospitals including mould outbreaks, bird lice from pigeons, collapsed ceilings, and maggot infestations.
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