Inadequate PPE for staff, poor infection control and confusion over clinical management contributed to the Newmarch House COVID-19 outbreak that killed 17 elderly residents, a report has found.

Overall some 37 residents and 34 staff tested positive for the virus at the Sydney nursing home during the largest outbreak then seen in Australia.

An independent review published on Monday said it was “often unclear who was in charge” as the virus began sweeping through the facility in April — growing from one case to more than 50 within two weeks.

State health officials pushed for a ‘hospital in the home’ approach, where most of the infected residents were treated in the home itself, rather than being transferred to hospital.