The Calvary Mater hospital was plagued for years by "multiple, interrelated infrastructure failures" that caused the mould and maintenance scandal, internal health documents show.
The documents, which emerged through the parliamentary inquiry into the scandal, reveal the hospital's problems began 17 years ago.
A Calvary Health Care document tabled with the inquiry said the infrastructure failures included "mould in clinical areas, significant water ingress, electrical non-compliance, ageing and dysfunctional heating, ventilation and air-conditioning (HVAC) systems and persistent maintenance delays".
"Building issues related to non-compliant cladding ... allowed water to enter the building and create an environment conducive to mould growth," the document said.
"This is attributable to original design and construction defects and has therefore been a known issue since 2009."
An internal Hunter New England Health (HNEH) document confirmed there had been "numerous reports of visible mould in clinical areas dating back to at least 2018".
The Newcastle Herald has revealed that at least 16 invasive fungal infections occurred at the Mater from 2019 to 2024. These infections have a high mortality rate.
Additionally, 120 families have registered for a class action into alleged mould-related deaths at the Mater, most of whom lost loved ones to pneumonia.
The Aspergillus fumigatus mould detected at the Mater - the Hunter's main cancer hospital - can seriously harm and kill immunocompromised people.
Inquiry chair Amanda Cohn said "there have been many years of short-term patches, secrecy and blame-shifting, while the underlying issues have not been addressed".
"That the mould has been a known issue for over a decade without being adequately addressed speaks to this being a systemic problem," Dr Cohn said.
"The hospital must be managed by NSW Health in the public interest, not in the interest of shareholders of the private partners."
Dr Cohn said the Mater scandal was ultimately "a failure of the previous NSW government".
Dr Cohn and Shadow Health Minister Sarah Mitchell grilled NSW Treasurer Daniel Mookhey in NSW Parliament last week over the issue.
"How long will the people of Newcastle have to wait before you act to return this hospital to public ownership?," Ms Mitchell said.
Mr Mookhey responded that "the government is monitoring developments very closely".
Dr Cohn urged the government to "be honest" and say publicly that it will end the Mater public-private partnership (PPP).
"Treat the Newcastle community with the same respect you treated the Northern Beaches," she said.
The PPP was approved in December 2005 and the hospital's redevelopment was completed in 2009, with further work done by 2012.
The PPP involves the Sydney-based company Novacare Health and NSW Health's Health Administration Corporation (HAC).
Novacare subcontracts the hospital's maintenance to US corporate giant Honeywell.
NSW Health commissioned Covaris to do an engineering review for Hunter New England Health in 2023-24 for "maintenance improvement" at the Mater.
The engineering report, dated June 2024, highlighted "a concerning rise in mould growth across hospital areas, posing significant risks, especially for immunocompromised individuals".
"Prevalence of mould detection between March and May suggests ideal conditions for growth during high humidity and heat at the end of summer and into the autumn months," the report said.
The Calvary document said it was "most concerning that even after receiving an independent report on the engineering issues in 2024 ... no meaningful remediation has been undertaken by HAC".
"HAC is responsible for ensuring the maintenance ... under the PPP."
Asked for comment on this, HNEH reissued a statement from November last year saying it had been "working with Novacare on the appropriate management of the mould issue".
"Mould has been detected at the Calvary Mater Newcastle since 2018. In April 2025, testing of the HVAC system identified Aspergillus," it said.
However, the Covaris report said Aspergillus - which causes infections in the lungs and other organs - was detected at the hospital in 2023.
"The information from... inspection for mould conducted in 2023 supports ongoing investigations that suggest mould growth in the hospital's HVAC systems," the report said.
Calvary, which operates the Mater's clinical services, said the hospital had "experienced progressive and increased incidents of visible mould colonies throughout the building".
This included acute clinical areas within haematology (ward 5C), medical oncology (ward 5B), general medicine (ward 4C), the emergency department and intensive care unit (ICU).
"In August 2018, the hospital first became aware of potential mould issues in ward 5C," the document said.
"Throughout 2022 to mid-2023, a total of 123 mould incidents were logged by Calvary to HAC."
A NSW Food Authority audit found "too many spores to count" in a kitchen cool room.
In 2022, mould was found in the airflow for the emergency department and intensive care unit.
Honeywell did a "trial of biocide treatment, although the contamination continued".
"Each time remedial cleaning occurred, however the root causes were not identified nor rectified," the Calvary document said.
In November 2022, Honeywell developed a mould management plan that was "reviewed and reissued in 2023".
Calvary said the plan had omissions and "Honeywell failed to implement it consistently".
In April 2025, Honeywell engaged consultant Hazmat Services, which found mould "at very high levels, particularly inside air-conditioning ducting and on air-conditioning vents".
Despite this, "neither Novacare nor Honeywell developed a satisfactory remediation plan", the Calvary document said.
Calvary and HNEH introduced "duct cleaning, HEPA filtration and installation of air purifiers", but by May 2025 "the situation reached a critical point" with "airborne levels of Aspergillus above accepted thresholds in areas occupied by at-risk patients".
By December 2025, the mould levels were five to 54 times higher than "acceptable thresholds for at-risk patients".
The Herald then revealed that the deadly mould caused cancer wards and the ICU to be shut in January. A ward was also closed due to maggots falling from the air-conditioning vents.
The hospital transferred vulnerable patients out of the ICU, but it was reopened once cleaning and additional HEPA filters were installed.
The hospital was concerned that leaving the ICU closed would risk patient harm if it had "no life-sustaining treatment options".
The Calvary document said the "mould issue is an ongoing concern".
In February 2026, four elevated mould levels were recorded in the ICU, two in wards 4A and 4B and one in ward 4C.
Whistleblowers Luke Carroll and Tim Paton told the inquiry that Honeywell and Novacare caused the hospital's mould and maintenance problems through neglect, amid allegations of "falsified records".
The two companies have denied this. They attribute the problems to structural building issues and a lack of humidity control in the HVAC system.
Novacare said it was headed for voluntary administration, amid a dispute over who would pay for a new or upgraded HVAC system at the Mater.
NSW Minister for Health Ryan Park said in March that "cladding on the hospital's external facade", which caused water leaks, was being replaced and work was "expected to be completed by mid-2027".
Mr Park said an independent assessment of the Mater's building infrastructure, including the HVAC system, was being done. The building audit is expected to be completed soon.
