The number of coronavirus infections and deaths at two Victorian aged care homes during the state's second wave are only the beginning of the trauma for staff and families, a report has found.
St Basil's Home for the Aged recorded 188 infections among staff and residents, and 45 residents died. At Epping Gardens there were 38 resident deaths among 189 infections.
A report into the effects of the outbreak at the two Melbourne aged care facilities was released on Monday.
"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," the report's authors, Professor Lyn Gilbert and Adjunct Professor Alan Lilly, said.
They found leadership and management had faltered in different ways in both facilities, and preparations for major outbreaks had been "significantly underestimated".
Communication with residents and their families were often delayed or inaccurate, and there was disjointed communication between state and commonwealth agencies that also affected families.
There was also a lack of infection prevention and control arrangements, and limited staff training and competency despite meeting accreditation requirements, exacerbated when replacement staff with little experience were brought in.
The professors called for handover and business continuity plans to be developed so replacement staff could be adequately informed and supported when necessary.
More than 7000 staff across Victoria's aged care system were furloughed during the second wave because they either contracted COVID-19 or were a close contact.
That led to more than 36,000 shifts being filled by replacements staff, which the professors said were generally young and inexperienced, with many speaking only basic English.
"With little preparation or supervision, it is not surprising that many did not stay and those who did, were quite likely traumatised," the authors found.
They said relatives, interviewed as part of the inquiry, had described the resilience and kindness of those who stepped in to fill the void - helping residents stay in touch over the phone, via iPads or to shout greetings through open windows.
"We must not forget them or the dedicated teams of frontline staff, who were sometimes brought to tears by what they saw but simply got on with the task of making it better," the report said.
Federal Health Minister Greg Hunt acknowledged the role families and residents played in the release of the report, at a difficult time.
"In extending our sincere condolences to the families of those who died, this investigation serves as a platform for understanding and action," he said.
However, Shadow Minister for Ageing and Seniors Julie Collins said the federal government had "learnt nothing" from prior COVID-19 outbreaks in NSW aged care homes.
"Neglect. That's the legacy of this government when it comes to aged care," she said.
"Australians deserve better."