Overview
- NSW Health released the final investigation, which points to a level‑9 patient balcony beside redevelopment works as the most probable source of Aspergillus exposure for six transplant patients.
- Reviewers found environmental testing fell short and cleaning audits were poor, with some rooms later showing mould growth and water damage.
- Outcomes from the cluster include two deaths now under Serious Adverse Event Reviews, two patients discharged, one unrelated death from sepsis, and one patient still in intensive care.
- The report said contractors tracked dust at site boundaries yet missed risks from patient-accessible balconies, and it called for risk checks to cover air intakes, windows and balconies.
- Health officials accepted every recommendation, including more air sampling and a new fungal surveillance committee, which could tighten controls where building works can send mould spores into the air.