The coroner concluded that universal testing of staff and timelier reporting of results could have decreased the outbreak's severity.

The inquest explored the decision to treat patients in-house rather than transferring them to hospitals, concluding that while some deaths were unavoidable, better outcomes could have been achieved with hospital transfers.

Coroner Lee suggested that transferring some residents to hospitals could have improved their treatment, including better access to oxygen and fluids.

Instead of transferring patients, Anglicare opted for on-site treatment under the Hospital in the Home program, which was deemed inadequate for COVID-19.

A significant staff shortage during the outbreak jeopardized infection control and the care provided to residents.

Coroner Lee noted that frontline staff lacked a clear understanding of the command structure at the start of the outbreak, which hindered effective response and care.

Families of residents did not receive adequate or accurate information about their loved ones during the outbreak, with communication often being generic and sometimes inaccurate.

Nicole Fahey, a family member of a deceased resident, expressed hope that the findings would prevent future occurrences, emphasizing that families did not blame individual staff members for the outbreak mishaps.

An inquest held on January 24, 2025, scrutinized the actions of Anglicare's senior management during a COVID-19 outbreak at Newmarch House in 2020, which resulted in the deaths of 19 residents.

Coroner Derek Lee's review highlighted poor leadership, insufficient communication, and significant staff shortages as major issues that contributed to the outbreak.

Anglicare Sydney's CEO Simon Miller reiterated the organization's apology for the distress and loss of life during the outbreak, acknowledging improvements made in care since then.

The coronial inquest found that some of the 19 deaths could have been avoided with proper testing and better management.