Giving evidence about her experience during a COVID-19 outbreak in April and May 2020, nurse Lorena Bestrin said she was overwhelmed with work amidst an influx of agency staff unfamiliar with the Anglicare-run home or its residents.

In the evenings, she would walk dimly lit corridors hearing residents calling for help out of their rooms.

"I'd just walk and I was shocked because it felt like a horror movie ... Everyone would say 'help, help, help' and I can still picture them," she said through tears.

Currently a nursing consultant, Ms Bestrin was part of the surge workforce brought into Newmarch after most regular staff either came down with COVID-19 or were self-isolating.

During the April/May outbreak at the Kingswood-based facility, 37 out of 97 residents tested positive with 19 dying. A further 34 staff also caught the disease.

The inquest focuses on Anglicare's Hospital in the Home program where residents with COVID-19 were treated on-site rather than being sent to nearby hospitals.

While working as a care manager at Newmarch from April 15 to May 24, Ms Bestrin said the environment was like a war zone with an army of agency staff coming in but with no systems in place to direct what they should do.

While she did not want to blame anyone, she described her experience as terrible.

"When I was there, I just didn't want to go anymore because I would cry every day on my way to work. But I thought if I quit it, I wasn't going to help the situation," she told Lidcombe Coroners Court.

A three-and-a-half hour training session was provided by Anglicare before the outbreak which covered infection control and PPE. However, Ms Bestrin said she walked away from the session after not having learned very much.

The inquest heard nurses were allowed in for at least the first week of the outbreak without temperature checks or a required COVID-negative result.

Ms Bestrin was also not provided access to the centre's iCare patient management platform for the first few days she worked there and had to organise to get the password on her own.

Things at Newmarch got better once Baptist Care took over the centre's management on April 24, she said.

"As soon as they came, we had a whole army of people and things improved. There was more direction."

An infectious disease physician from Nepean Hospital, Dr James Branley, gave evidence about the difficulties in swabbing and testing at Newmarch.

On one occasion, there was confusion about whether COVID test results coming in were already known or had not yet been counted, he said.

"I think it was multiple lines of reporting creating confusion and fuelling a degree of panic about the numbers," he told the inquest.

Another time, three positive results came back a surprisingly long time after the individuals had been tested. While this initially caused enormous concern, it turned out to be a false alarm, merely being a case of double counting, Dr Branley said.

The doctor described how on one occasion he had to personally drive a batch of 30 to 60 swabs over to Westmead Hospital to ensure they were tested within the 24 to 36-hour turnaround time.

Swabbing patients with dementia also posed problems meaning that the quality of the swabs was not as good as it could have been, he said.

There have been six past reviews conducted into the Newmarch outbreak since June 2020, including a hearing held during the Royal Commission into Aged Care Quality and Safety.

Shine Lawyers is also investigating a class action against Anglicare on behalf of family members of those who died because of alleged mismanagement at Newmarch.

The inquest in front of Deputy State Coroner Derek Lee continues.

Australian Associated Press