Despite finding no direct breaches, the investigation into Brisbane's Hotel Grand Chancellor COVID cluster points to gaps in infection prevention and control.
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A joint police and health department investigation of the cluster, which triggered a snap three-day lockdown of Greater Brisbane, handed down its report on Friday.
There were no CCTV cameras on level seven at the time of the outbreak, but police concluded from interviews that no one breached quarantine.
WHAT HAPPENED?
* Six cases were of specific interest; four guests at the hotel, the cleaner and her partner.
* The investigation began on January 13 at the direction of the premier.
* The report states case one acquired an infection from overseas and likely passed it to the person they were travelling with (case two) in the hotel. Both arrived on December 30 and stayed in a hotel room on floor seven.
* Case three (the cleaner) likely got infected on January 2 in the hotel through indirect contact with a surface exposed to the virus. She tested positive on January 6 and did not enter the rooms of the guests of interest at any time.
* Case four (her partner) was likely infected in their home.
* It's likely two other guests were infected at the hotel from contact with a surface contaminated by virus shedding from case one or two. They also stayed on floor seven but in a different room.
THE FINDINGS:
* The review team was unable to find the root cause of transmission and there were no direct breaches of quarantine or security identified.
* The report states the cluster is most likely a result of multiple gaps in infection prevention and control.
* The air conditioning system has been ruled out as a cause of transmission.
RECOMMENDATIONS INCLUDE:
* Install CCTV in all government-run quarantine hotels to capture all movements in and out of guest rooms.
* Review the deep clean process that follows a quarantined person testing positive and adopt a whole-of-government procedure consistent across all hotels.
* Implement a supervision, monitoring and auditing process for deep cleans.
* Minimise the number of time guests open their doors by synchronising food delivery, linen collection, etc.
* Ask guests to wear a mask when opening their doors for any reason, which the government has agreed to enforce
* Minimise traffic in hotel corridors connected to guest rooms.
Australian Associated Press
