The nation's chief nursing and midwifery officer initially advised against a mass evacuation of a coronavirus-hit Victorian aged care home, just over a week before it was shut down.
Ordered by Health Minister Greg Hunt and then-chief medical officer Brendan Murphy, Alison McMillan attended St Basil's Home for the Aged on July 22 last year as regular workers were sent home and replaced by inexperienced agency staff.
There were at least 50 positive COVID-19 cases connected to the home when St Basil's staff were declared close contacts.
Forty-five residents at the Fawkner facility eventually died from COVID-19, while a further five died of neglect, during the state's second wave last year.
Professor McMillan was asked to observe the staff transition and report back.
"There was concerns that the replacement staff would not arrive in the morning," Prof McMillan told the Victorian Coroners Court on Tuesday.
Counsel assisting Peter Rozen said an email exchange between Mr Hunt and Dr Murphy as well as other officials, which Prof McMillan was not privy to, showed they were "actively considering" moving infected residents out of the facility.
Prof McMillan sent an email later that night to Dr Murphy and his deputy Paul Kelly after spending about four-and-a-half hours on site overseeing the handover process.
In the joint report, based on consolidated notes with Victorian health department official Terry Symonds, she said all 117 existing staff had been informed of the need to isolate and there was a "good ratio" of registered nurses to personal care assistants.
But there were also several issues, including the need for interpreters as few of the replacement staff spoke Greek, additional cleaning staff and extra personal protective equipment for "reassurance".
She concluded: "My assessment is a fit for purpose facility has the systems and processes to manage the current situation, no need for a significant evacuation of positive residents to hospital but will need close ongoing management of residents who are unwell and in reach."
Prof McMillan declared the facility "fit for purpose" despite not touring it, something she would have done in retrospect.
The handover was "orderly", in her view, but both existing and surge staff suggest otherwise.
Although Victoria's Chief Health Officer Brett Sutton ordered the handover be completed by "close of business", existing staff were only given until 11am before being told to go home and self-isolate.
Registered nurse Lubo Zhang, who had worked at St Basil's since 2015, was tasked with providing a handover to replacement staff and felt it was rushed.
Jacinta MacCormack, one of the new staff members from Aspen Medical, said existing staff became "hostile" when informed they would be stood down.
On her second day on the job, she noticed residents were "malnourished" and "dehydrated".
"There was a couple that actually looked quite emaciated. Their hip was sticking out," Ms MacCormack said.
An email from Dr Sandra Brown of Northern Health's Residential In-Reach team, dated November 24, highlighted "major issues" including residents not being fed, a lack of personal care for incontinent patients, and poor understanding of infection controls.
She wrote basic care had been "delivered well" until Aspen took over.
"Yesterday we felt that we were enabling neglect."
That same day, the evacuation of residents to hospital began.
Prof McMillan was copied into the email but said she did not feel the need to return to St Basil's immediately.
When she did at the behest of Dr Murphy on July 26, she found it to be "chaotic" and unclear who was in charge.
Barwon Health's Alison Patrick was seconded to lead the response the next day before she and Prof McMillan agreed to evacuate the remaining 30-odd residents, which was completed on July 31.
The inquest will resume before Victorian State Coroner John Cain on Wednesday.
Australian Associated Press