Covid-19

Inside NZ’s deadliest cluster

District health board emails reveal the inside story of the country’s deadliest Covid-19 cluster. David Williams reports in the first of two parts exploring the tragedy of Rosewood

Clinical nurse specialist Suzy Rogers puts down the phone at her office, near Christchurch Hospital.

It’s Friday evening, April 3, and details are emerging of a Covid-19 outbreak at the three-wing, 64-resident Rosewood rest home in Linwood, just east of the city centre.

That afternoon, one Rosewood resident, a dementia patient, tests positive. Four others are swabbed, with test results yet to be reported.

Rogers, who works in infection prevention and control for the Canterbury District Health Board (DHB), has just been told by Rosewood’s management that, beyond the single confirmed case, 11 other residents in the dementia unit have symptoms, including cough, runny noses and fever. In a separate unit, one resident has “sudden onset chesty cough”.

Three unwell staff are at home. Only one has been tested.

At that point there’s a steep trajectory of new Covid cases across the country.

Earlier in the day, the Health Ministry announces 71 confirmed and probable cases, taking the total to 868. Canterbury has almost a tenth, at 83.

Rosewood is the second Christchurch rest home to have a confirmed case, after Spreydon’s George Manning Lifecare and Village. But given 12 other Rosewood residents have symptoms, and almost all are in the “D6” dementia unit, requiring the highest level of care, the news soon reverberates around the city’s top public health officials.

It’s the nightmare the country was terrified of; the reason rest homes shut their doors before the Prime Minister ordered a national lockdown, eight days earlier: Covid-19 is loose in an aged residential care facility.

In her office, not far from the Avon River, Rogers starts writing instructions to Rosewood’s management.

“Staff to wear full PPE at all times within the [dementia] unit,” she writes in her email, sent about 7pm that Friday. “They must have a break at least 2-3 hourly to rest and hydrate.” The symptomatic resident in the other unit is to be isolated and only dealt with by staff in full PPE gear – “gloves, gown, mask, eye protection”.

Rogers says contact and droplet precautions are to be put in place at Rosewood. Staff must have separate spaces to don and doff PPE, cleaning and disinfecting rooms and communal areas is to happen twice daily, and residents monitored.

The rest home comprises three wings – an advantage when it comes to separating residents, and staff.

Rosewood’s situation isn’t a complete surprise. One staffer has been off sick since March 26 – the day the national lockdown started. Four residents developed symptoms in late March. On that fateful Friday, two residents are still on antibiotics, while another finished their course only two days earlier.

A bed-by-bed occupancy report from Rosewood. Source: Canterbury DHB

Contrary to conventional wisdom, perhaps, and a sign of how dementia patients from the same unit are treated differently, Rogers says five testing swabs will be sent – despite only five of 13 unwell residents having been tested.

“Suggest you screen the most easily amenable residents,” Rogers writes.

(A week later, Director of Public Health Dr Caroline McElnay says: “For some elderly patients in that situation, the distress, the extra distress of having a test which they may not completely understand why they're being tested, that is not something that we need to do and therefore in this situation we don't need to do it.” She adds: “They've been managed as a group who have all been exposed, so we would not expect people to be tested in that situation.”)

Rogers promises to send, that night, “Covid-19 outbreak packs”, with enough PPE to cover 32 staff for a week. The rest home will also get staff and welfare support, she writes.

Five minutes after sending that email, Rogers dashes off another to dozens of people. They include chief medical officer Sue Nightingale, who doubles as one of the emergency coordination centre incident controllers, another ECC controller Dan Coward, the general manager of older persons, as well as key staff at St John, homecare service Nurse Maude, and primary care network Pegasus Health.

Tagged “high” importance, the email is a reply to an earlier one about confirmed Covid-19 outbreaks.

NEW”, Rogers writes in bold. “Rosewood Dementia Care Unit”.

In little more than a month, 12 Rosewood residents would be dead after contracting Covid-19, making the rest home the country’s deadliest cluster.

Burwood Hospital became the emergency home for 20 Rosewood residents. Photo: David Williams

Rest homes are private businesses, of varying sizes and capabilities, providing a service to the DHB, which also regulates them. The homes have to adhere to contracts, standards and pandemic plans (which overlap but don’t always align). But, by and large, they’re left to their own devices.

Imagine what it’s like for those facilities when the DHB steps in.

The DHB appoints three people to oversee Christchurch’s two Covid-positive rest homes – clinical nurse specialist Rogers, nursing director of older people Richard Scrase, and geriatrician Val Fletcher. (George Manning’s first case was confirmed on Thursday, April 2, and it was declared a significant cluster by the Health Ministry nine days later.)

On Saturday, April 4, no health board staff actually visit Rosewood, but contact tracing phone calls start. It’s split between Rogers’ infection prevention and control team, and community and public health officials.

A record of Rosewood’s 64 residents, sent to the DHB by the rest home’s management, shows the D6 dementia unit has 20 beds, all of which are occupied, the D3 rest home, for less severe dementia patients, has 24 of 26 beds occupied, while 20-bed “unit one”, known as the hospital, is full.

The rest home is sent various educational posters. One urges staff “Don’t bring it home”. Another shows the correct sequence for putting on PPE. (Gown, mask or respirator, goggles or face shield, followed by hand hygiene, and, lastly, gloves.)

A Covid-19 poster sent to Rosewood. Source: Canterbury DHB

Matthew Reid, a Christchurch public health medicine specialist, concludes by Saturday evening that transmission from residents’ relatives at Rosewood is “less likely”.

“They effectively went into lockdown on 18/3/20, apart from a couple of exceptions,” he writes to Rogers and others. “Therefore, more likely to have come from staff.”

(That concurs with a Health Ministry-commissioned review of rest homes with Covid-19 outbreaks, which found the most common vector was staff members.)

The number of symptomatic Rosewood staff increases to four. Reid says via email a Rosewood staffer was swabbed on March 28 – “not detected, but we will be pursuing” – one was swabbed during the day, and at least two others are yet to be tested.

There’s a tension between prudent practice and operating the rest home safely. More workers are expected to test positive, and there is a mind to how, and who, will run the rest home. Reid speaks to Nightingale, the incident controller, just before emailing Rogers, mentioning staffing issues at Rosewood.

Some staff will be close contacts of Covid cases – “but not (yet) symptomatic” – Reid tells Rogers. “We would normally stand them down and have them self-isolate for 14 days. Clearly this would create staffing issues for Rosewood.”

Reid doesn’t think the outbreak will stop with Rosewood and George Manning. He says he’s asking questions “for clarity”, “and so we have a shared understanding with these and the next ARC [aged residential care] clusters”.

Despite the risks, nurses and other DHB staff are quick to help. Eight nurses from Christchurch private hospital Fortè Health are sent to cover shifts at the two Covid-affected rest homes. More are sent by St George’s private hospital, just north of the city centre.

A St George’s manager asks advice about staff moving between facilities. They’re sent the latest guidelines for aged residential care facilities and draft Covid-19 guidelines.

In a rundown of the two facilities, incident controller Nightingale warns: “Rosewood is slightly more problematic. They have 20 roaming patients.” Staff there are all wearing full PPE, she says.

The St George’s manager says the hospital is happy to help. “Thank you to you and your teams for the great job you are doing to lead this response – much appreciated.”

However, the illusion of authorities being on top of things at Rosewood is about to be dispelled.

“No one will work there and practices not safe.” – Sue Nightingale

Rest homes are difficult to run at the best of times. Staff aren’t well-paid for what is stressful and physical work.

That makes it hard to retain staff, so the ones that remain are generally worked too hard – unsafely, unions argue. When you’re close to breaking point at business-as-usual, a virus sent surging through your facility seems a certain way to reach it.

The DHB is not just keeping an eye on Rosewood.

Extra staff are sent to Greymouth while frontline hospital workers isolate after the country’s first death on March 30, a Sunday. Like many other health boards, Canterbury cancels or postpones elective surgery as it prepares for a potential surge in Covid cases. Staff are on edge, but many want to help.

On Sunday, April 5, two days after Rosewood’s first confirmed case, there are fears the pandemic has reached the doors of Christchurch Hospital.

Alan Pithie, of the DHB’s infectious diseases group, tells colleagues four inpatients with respiratory symptoms are “scattered round” the hospital, in isolation. Test results are pending.

“One staff member [redacted] currently in ED with new onset resp symptoms,” Pithie writes from his phone. “CoVid team aware.” (An internal update on Tuesday afternoon notes no one with confirmed Covid-19 is being treated in Christchurch Hospital.)

Scenarios for helping rest homes without enough workers might include sending DHB nurses there to cover shifts or transferring high-risk residents to hospital. (Later in the month, both of those happened at Auckland’s CHT St Margaret’s Hospital and Rest Home in Te Atatū, Auckland.)

Clinical nurse specialist Rogers takes a call from Rosewood’s management just before midday on Sunday. It’s not going smoothly.

Soon after, Rogers writes, reassuringly: “I think it is reasonable and understandable that in last 24 hours there has been a few teething problems, whilst staff are implementing this new process.”

Her tone seems unconcerned – upbeat, even. She arranges to visit at 2.30pm the next day with some of the infection prevention and control (IPC) team. They’ll check the new measures, offer ongoing advice and support. “Hopefully we have the results of the four residents screened yesterday then too.”

Contact tracing is being followed up with unwell staff, she writes, and the close contacts of infected cases. “We are in close communication with them, the older person mental health and the ECC [emergency coordination centre] teams, to ensure this outbreak is contained and all residents and staff are followed up and managed safely.”

Sunday marks the first visit to Rosewood by DHB staff – Scrase and representatives of the IPC team – since Friday’s positive result. The tone of internal emails changes – and quickly.

Forty-five minutes after Rogers’ email is sent, Mardi Postill, the team leader of older persons’ health, writes a “vulnerable person and ARC report” to the ECC manager.

The residents at Rosewood and George Manning are stable, Postill writes, but staffing continues to be an issue.

There’s some sympathetic context. Rosewood’s a small independent rest home, she writes, without a wider organisational or governance structure. The DHB has offered the manager support with communications and accommodation options for affected staff. (Six Rosewood staff are effectively kicked out by their flatmates, so a hotel stay is arranged for their isolation period.)

Postill cuts to the chase: “Rosewood: PPE use major issue, all staff need to be replaced, working on solution at time of writing.”

About 4.15pm on Sunday, Karalyn van Deursen, the DHB’s executive director of communications, updates Rosewood’s Covid numbers. There are now four confirmed cases, all residents, with 11 more listed as probable. Four staff are also probable cases, taking the total to 19.

“These will be reported on the Ministry website tomorrow afternoon,” van Deursen writes.

As the minutes tick towards the earlier sunset of 6.12pm (the clocks have just gone back), the reality at Rosewood kicks in.

At 5.30pm, Rogers alleges some Fortè Health and St George’s staff haven’t followed PPE protocols. One staffer didn’t wear goggles during the Sunday morning shift, while two others didn’t wear goggles over their glasses.

Rogers adds: “On discussion with Rosewood staff today – many of the close contacts from unit 2 (isolation unit) have been in contact with other staff, and the registered nurses have worked across all units 1, 2 and 3.” She asks Rosewood to send a list of all their staff.

Josh Freeman, the acting clinical director of the IPC team, writes back: “Oh dear… surely the external staff were aware of NZ/CDHB PPE recommendations? Apparently not.”

He calls a meeting for Monday morning “to take stock of events at Rosewood” and decide what needs to be done. Additional support might be required, Freeman says, “particularly if time has to be invested in navigating media interest”.

Incident controller Nightingale, who received Rogers’ email, responds to Freeman at about 7pm. The situation at Rosewood’s dementia unit is “unsustainable”, she says. “No one will work there and practices not safe – 20 patients being moved to Burwood tomorrow.”

The situation is escalated to the top of the health service: that night DHB chief executive David Meates calls director-general of health Ashley Bloomfield.

PPE use was a key issue for stand-in staff at Rosewood. Photo: David Williams

Crisis responses are often hampered by unclear lines of responsibility and accountability – just look at the recent hotel quarantine situation.

The complex nature of rest home contracts and service agreements with DHBs means, in a crisis, the expectations of public health units and DHBs about what rest homes are capable of might be artificially high.

Important policies can be set to protect residents and staff, but they’re next-to-useless unless a facility is able to respond. Effective leadership, and, in some cases, direct oversight, are key.

Taking over a rest home, however, is a huge challenge. As the week starts in Christchurch, the scale of that challenge is becoming painfully clear.

A handover email by the emergency coordination centre controller says the incorrect use of PPE at Rosewood on Sunday “created crisis” and Fortè staff are “being pulled”.

(Fortè Health’s general manager Rachel Hillyer confirms two of its registered nurses who cared for a Covid-19 positive patient at Rosewood on Sunday raised concerns about the appropriateness of PPE use. “Fortè Health immediately raised these concerns with Canterbury DHB, who made the necessary adjustments to PPE usage by the end of the shift. Our two nurses acted incredibly professionally, following all PPE guidelines for the entire duration of their shift. It is pleasing that the issues they identified were responded to so quickly.”)

An urgent meeting of DHB staff on the morning of Monday, April 6, notes media are aware Rosewood residents are being moved – “two security staff en route”. The bullet points in the meeting’s minutes corroborate the chaos:

  • All staff and patients are now considered close contacts.
  • Questions over the ongoing viability of staffing. Safety of the site to be reviewed. “Clinical teams will meet with current staff to determine if able to manage over next 24 hours to enable planning to occur for potential transfer to other facilities.”
  • No hot water for laundry, no kitchen staff present, new acting facility manager raising significant concerns “and may have issues continuing in the role”.
  • Food and bottled water, for staff and patients, needs to be provided. Food needs to be puréed.
  • Infection protection and control, community and public health and a microbiologist are required to meet staff on-site.

News of Rosewood’s difficulties breaks before Bloomfield’s 1pm briefing.

Stuff’s Christchurch daily newspaper The Press takes photos of ambulance staff in PPE helping residents from the dementia unit into two ambulances and a shuttle.

A media outlet asks questions of the DHB’s communications team at 10.33am – roughly the time the ambulances arrive at Rosewood – prompting van Deursen, the comms executive director, to warn Burwood Hospital’s security team: “The media are likely to be snooping”.

She replies to the outlet: “We are unable to provide any information on this at the moment. An update will be provided by Ashley Bloomfield at his 1pm media briefing today.”

As the clock edges closer to 1pm, the DHB is playing catch-up.

A draft email, in the name of Rosewood’s temporary manager, which will be sent to the families of Rosewood’s hospital-wing residents, is circulated. It says the “temporary isolation relocation” to Burwood would be for at least 14 days while they “see out their infectious period”.

“Please be assured that this infection is limited to the dementia wing only and due to the physical barriers between the areas and different staff we do not believe there is any increased risk to your loved one.”

However, this contradicts Rogers, who, the night before, said close contacts from unit two were in contact with other staff, and registered nurses had worked across all units. It’s also unclear if, by then, the isolated resident from unit one has been cleared of coronavirus.

Just after midday on Monday, “draft 31” of the DHB’s media release about the Rosewood residents’ move is circulated. The number of confirmed and probable cases has dropped to 16.

The release glosses over the array of problems. It says a temporary manager has been appointed because of self-isolation requirements for a large number of staff, including the facility manager. More experienced staff are being sought, and further relocations might be necessary – “although this is not the current plan”.

(The release incorrectly calls Rosewood’s dementia unit the Hennessy wing, which is actually a wing at George Manning.)

Coward, the incident controller, approves an email about the arrival of the dementia unit residents.

“I want to reassure all staff working at Burwood Hospital that this transfer will be managed with complete oversight from infection prevention and control, and staff who will be caring for these patients have been fully briefed on following the IP&C protocols required when caring for COVID-19 cases.”

People are still nervous, however – and for good reason.

After nurses in ward GG talk to Stuff about their fears of infection, and community transmission, they’re given new masks and face shields. A DHB staff member who helps transfer the residents, and works at Rosewood, will become infected with Covid-19, as will three Burwood Hospital staffers.

Behind the scenes scurrying continues. Permission is sought from Nightingale to lock Burwood’s GG ward “for the safety of patients and staff”. And options are prepared for a possible “second decant” of Rosewood residents to Burwood.

Just after 1pm on Monday, April 6, Rosewood becomes national news.

* This narrative has been compiled from a 303-page Official Information Act response released to Newsroom, and publicly available sources.

Keep reading: part two of ‘Inside NZ’s deadliest cluster’.

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