Today Sydney Local Health District (SLHD) has released the cluster investigation report into the fungal outbreak that occurred in the transplant ward at Royal Prince Alfred Hospital between October and December 2025. You can read the report here.

We extend our heartfelt condolences to the families of the patients who passed away, and we sincerely apologise to all patients and families affected by the outbreak.

The investigation was undertaken promptly by senior clinicians with expertise in transplant medicine and infectious diseases. The findings were then reviewed by an expert advisory panel chaired by Dr Kerry Chant, NSW Health Chief Health Officer.

Summary of recommendations:

• 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 welcomes the report and is committed to implementing the recommendations in full. 

We have already established a fungal surveillance committee and a clinical reference group to strengthen oversight and improve responsiveness.

All patients impacted, or their next of kin, have received a copy of the report and have been offered the opportunity to meet with RPA executives and clinicians to discuss the findings.

SLHD would like to acknowledge the contribution of the expert advisory panel and our clinical staff who assisted with this investigation. 

And we again acknowledge our patients and their families and reassure our community that their care and safety is our priority.