Sydney Local Health District (SLHD) has released the investigation report into the fungal outbreak that occurred in the transplant ward at Royal Prince Alfred (RPA) Hospital between October and December 2025.
SLHD extends its deepest condolences to the families of the patients who died and sincerely apologises to all patients and families affected by the outbreak.
Upon confirming the cluster, SLHD acted as quickly as possible to address the risk posed to patients.
The cluster investigation was promptly undertaken by a team of senior clinicians who specialise in transplant medicine and infectious diseases.
The report has also been considered by an expert advisory panel chaired by Dr Kerry Chant, NSW Health's Chief Health Officer.
The patients impacted or their next of kin have all received a copy of the report and have also been given the opportunity meet with executives and clinicians of RPA to discuss its findings.
While the investigation team was unable to determine a single conclusive cause of the outbreak, the balance of evidence indicates the balcony and nearby construction activities posed the greatest exposure risk, rather than the water ingress in September 2025.
This assessment reflects the ward location of the identified cases relative to the balcony and the proximity of construction works.
Key recommendations have been made in the report:
- Update the RPA Redevelopment Infection Control Management Plan to include a clear governance pathway for monitoring and reporting, including:
- Air sampling reports to be provided to the Facility Infection Prevention and Control Committee
- Decisions relating to the frequency of surveillance programs
- Required actions when concerning mould is detected or mould counts increase, including escalation processes, mitigation strategies, testing timeframes, and retesting to confirm effectiveness.
- Ensure notices of works, which are documents required before any work can commence at the hospital include all known impacted operational and clinical areas (including air intakes, windows and balconies), along with proposed risks and mitigation measures.
- Establish a district‑wide process to better prioritise maintenance and requests for repair within high‑risk clinical areas such as transplant wards.
- Create a formal governance process involving infectious diseases specialists, infection control experts and senior clinicians to monitor and respond to any increase in invasive fungal infections for the duration of construction works.
SLHD is fully committed to implementing every recommendation from the report and strengthening our procedures to prevent future patients and families being impacted.
The report's findings and recommendations are also being reviewed by NSW Health so the learnings can be applied throughout the public health system.
SLHD has already established a fungal surveillance committee and a clinical reference group to strengthen oversight and improve responsiveness.
The fungal surveillance committee, comprising of infectious diseases and infection control specialists, hospital executive and engineering staff, is designed to enhance coordination of cleaning and maintenance activities and ensure issues are reviewed and escalated promptly.
The RPA redevelopment clinical reference group brings together clinicians, engineering teams, Health Infrastructure and redevelopment contractors to review all planned future works and to provide advice on what, if any, additional measures need to be put in place to ensure the safety of our patients.
SLHD would like to acknowledge the contribution of the expert advisory panel and our clinical staff who assisted with this investigation.
The report is available online: Cluster Investigation Report
