Waitakere: A cluster waiting to happen
Newsroom Investigations editor Melanie Reid, with reporter Bonnie Sumner, outline the growing Covid-19 infections arising from practices at Waitakere Hospital and how authorities repeatedly tried to downplay concerns and fall back on standard procedures.
In the two weeks since the first confirmed case of Covid-19 at Waitakere Hospital in relation to St Margaret’s rest home patients, seven nurses and at least three close contacts have tested positive.
One of those nurses is in North Shore Hospital in a serious condition in the high dependency unit.
Newsroom is aware of at least three of the nurses' household contacts who have contracted Covid-19. We asked the Waitemata DHB, which oversees Waitakere Hospital, to confirm those numbers and it declined.
“We are unable to provide details of contacts of staff due to the risk of identifying individuals and in order to protect their right-to-privacy.”
Initially 57 staff from Waitakere Hospital were stood down, later reduced to 37 being sent home to isolate.
All hospital staff were due to return to work by this Wednesday, May 14, following their stand down which began late last month.
A Major Incident Review is expected this week, which will focus around PPE and staffing protocol - or lack of it - at Waitakere Hospital.
Beyond the supply and appropriate use of PPE gear, hand washing and distancing, each DHB makes its own decisions around whether it is appropriate for staff to work between Covid-positive and general wards.
The body responsible for providing guidelines on protocol for the region’s hospitals, the Northern Region Clinical Technical Advisory Group, still insists staff working between wards is appropriate, despite the outbreak at Waitakere Hospital.
Nurses raised objections
From the beginning of the St Margaret’s outbreak, the NZ Nurses’ Organisation and health and safety representatives have advised that to ensure staff safety and eliminate the risk of infection to other patients, hospital management should not be moving staff between wings.
NZ Nurses Organisation Kaiwhakahaere Kerri Nuku says management did not agree, and staff were required to work between A and B wings: “The Health and Safety at Work Act requires the elimination of risk where possible (so in that case, ensuring that staff aren’t moved between wings), and if that’s not possible, then you seek to minimise the risk. It’s our view that had the employer taken the concerns seriously, then the risk would have been eliminated in accordance with the requirements of the Act.”
She adds that: “Failure to minimise contact has been an issue repeatedly across the country as clusters have developed with staff and patients being exposed despite PPE use. Unions have called for pod rostering and limited bubbles.”
How it came to this
Around the middle of April, an unwanted visitor of unknown origin turned up at St Margaret’s Hospital. Covid-19 has ravaged rest homes overseas resulting in thousands of deaths - some even abandoned and left to die in their beds. The visitor infected a cluster of patients inside the leafy grounds of the rest home and dementia care provider in West Auckland’s Te Atatu Peninsula, bringing the virus to its elderly and vulnerable patients.
Waitakere Hospital, part of the Waitemata District Health Board, sits on Lincoln Road, a short drive from St Margaret’s. The rest home realised it was too short-staffed to handle the infection, and six residents were urgently transferred to Waitakere Hospital, with a second group of nine subsequently transferred to North Shore Hospital, making a total of 15.
Three have since died - all at Waitakere Hospital.
Now a further seven nurses, and a number of their contacts, have been infected. While press releases have been sent out by DHB communications specialists, other staff have been privately sending Newsroom clinical notes, emails and personal accounts which paint a different picture. These sources say a high level of secrecy and disagreements around the use of PPE and staffing practices have put people at risk.
Below is a chronological analysis of what occurred at the hospital.
Monday April 27:
Following the arrival of six Covid-19 patients into Waitakere Hospital’s Muriwai Wing A ward in mid-April, a nurse who had been working in the ward tests positive for Covid-19.
That evening, on a closed social media site for nurses, this is posted:
"Staff had been moving between the Muriwai Wing A ward, which looked after the St Margaret’s patients, and the Older Adults Rehabilitation Ward Wing B ward - and were also rostered in other wards in the hospital."
Testing of staff for Covid-19 begins.
Tuesday April 28:
Staff at WDHB are sent a message saying staff who hadn’t already done so should complete the Covid-19 information training through their mandatory e-learning, an online portal for staff training.
Wednesday April 29:
Newsroom is contacted about Covid-19 in Waitakere Hospital, with the source revealing nurses had been working between Covid-positive wards and wards without Covid present. The source, who did not want to be identified, says they have serious concerns about the protocol at Waitakere Hospital.
“What’s really alarming is that they can be assigned to Covid-19 positive patients one day, then the next day they are roaming around in a different department with other patients. We know we can walk around asymptomatic for a couple of days spreading the virus without even knowing we have it.”
Thursday April 30:
Newsroom sends an email to Waitemata DHB CEO Dale Bramley requesting information about a “flexi” nurse at Waitakere hospital testing positive for Covid-19 who had been working in other hospital wards before the positive test, and asking what the DHB had done as a result of the nurse testing positive.
By now, two more staff are confirmed to have Covid-19, and Newsroom receives information that many more staff are hurried through testing late that afternoon:
“The nurses and Health Care Assistants got into a panic frenzy and started lining up.The sadness was only those staff who worked from the 26th to the 28th were made priority and are priority at the present time,” she said. “And only 65 people were allowed to be tested on that day, because that’s all the tests they had.”
Despite three days passing since the first staff member tested positive, no public statement is made.
Friday 1 May
Around midday on Friday, Newsroom publishes the story that three nurses have tested positive.
About the same time, the DHB puts out a press release saying Waitematā DHB is “taking immediate steps to manage any potential risk to patients and staff after three staff members tested positive for Covid-19”.
The hospital had closed affected areas to further admissions and say they are “considering any other precautionary measures that need to be taken for the patients in those wards who may have come into contact with the Covid-positive staff members.
“As soon as we became aware of these cases, we moved quickly to respond and we will take all appropriate actions to minimise any risks,” says Waitematā DHB Deputy CEO Dr Andrew Brant. “It is unclear at this stage whether contact with those patients was the source of the staff contracting Covid-19 or whether any of the cases are linked.”
However, in the days to come, other parts of the press release would soon be disputed by staff and even the Prime Minister, including its statement that: “Full personal protective equipment was made available and worn by staff at all times in this area.”
The press release goes on: “The DHB has an auditing programme in place on the appropriate use of PPE for all Covid patients. An urgent review is in progress to understand how and where the infection may have occurred. Contact-tracing of staff and patients is under way to identify close and casual contacts for follow-up. A number of staff are being stood down from work as a precaution and are going into self-isolation pending test results.”
Saturday May 2:
By Saturday, 57 Waitakere Hospital staff have been temporarily stood down as a precaution.
Sunday May 3:
On Sunday, Newsroom reports again on the story, revealing nurses had in fact been working between wards, despite the advice of NZ Nurses’ Organisation.
Then, at 8.30pm we receive an email from the DHB citing the Northern Region Clinical Technical Advisory Group lead Dr Vanessa Thornton, which continues to back the movement of staff between wards.
“The Northern Region Clinical Technical Advisory Group supports that staff are able to move from Covid-19 areas to non-Covid-19 areas for work as long as the following usual principles are followed for infection protection control when working with patients who have infectious disease.”
By now though, chief medical officer of the WDHB, Dr Jonathan Christiansen, tells media the standard policy of allowing staff to move between wards has been changed, and they would no longer allow those working on Covid-positive wards to work in other wards.
Monday May 4:
On Monday morning, Newsroom sends an email to the DHB and the Northern Region Clinical Technical Advisory Group asking exactly what the protocol for staff crossing wards is. The DHB responds, saying: “It is acceptable practice for nurses who have cared for Covid patients to work on other wards on subsequent shifts, providing appropriate precautions such as use of PPE are observed.”
It goes on to say it will be instituting ward bubbles after all, “in response to concerns raised by our staff”. They say this “goes further” than the guidance to protect health and safety.
By now, six patients at a different ward to those housing the St Margaret’s positive patients are being considered as close contacts and treated in isolation, with the DHB admitting it was apologising to the families of these patients and changing their staff rostering.
A third source contacts Newsroom - in confidence for fear of losing their employment – to say that, contrary to Dr Brant’s statement to Newsroom, WDHB had failed to provide nurses with adequate personal PPE when they cared for positive and probable Covid 19 patients.
“… the nurses working within the unit with probable St Margaret’s Covid-19 patients were told to wear ordinary surgical masks, which are known to be inadequate protection against Covid-19 in close nursing situations. Apparently the nurses were told that they did not need N95 masks because they were not in direct contact with patients who had tested positive, despite the closed nature of the unit, and all patients in the unit being considered probable cases. In addition, nurses in close direct contact with the ‘Covid-19 tested positive patients’ within the unit were not either advised (or permitted) to change their PPE when it became wet, making it ineffective.”
The Prime Minister, in answering questions on RNZ the following morning, says: “They [Waitakere Hospital] have had access to PPE. I leave the decisions around which PPE are used, where, to the clinicians. They of course state that N95 masks, the masks that are a bit gruntier than the usual surgicals used where there’s aerosol type therapeutics in use – and they weren’t at Waitakere, but those are clinical decisions that I leave to the director-general and the DHB, but they are taking a second look at the PPE.”
When asked about staff moving between wards, she refers to the advice sent out in the press release from the Northern Region Clinical Technical Advisory Group the day before. “They gave permission for nurses to work between wards, but never on the same shift, so no one on the same shift should have been working on a Covid ward and then a general ward, but in separate shifts.”
‘Not crossing work stations on the same day’ now becomes a catch cry from health authorities, or as those in the PR business call it: “re-directing the message” - despite this message being irrelevant if a nurse is infected and asymptomatic.
The “narrative” from authorities at this stage is that they have no problem with staff working between wards, but only if meticulous use of all appropriate PPE is carried out, along with maintaining good hand hygiene and physical distancing within the workplace.
But according to staff, none of this was happening. The DHB then decides to implement ward ‘bubbles’, even though they don’t consider it necessary. So here we are, in a pandemic the likes of which we have never seen before in our lifetime, and there is no Ministry of Health national protocol, but instead each DHB can pick and choose, relying solely on PPE gear that is found not to be foolproof.
Later that day, an email to staff from Brant reiterates the advice from the technical advisory group that use of appropriate PPE gear, hand-washing, physical distancing and daily self-monitoring for symptoms was still an appropriate response, but they would be changing protocol anyway.
“We have been consistent with this advice from the outset and it was good to hear our Prime Minister acknowledging this view in an interview with Radio New Zealand this morning. That said, we have listened to your feedback and introduced a temporary “bubble” system as a further precautionary measure to ensure that any Waitemata DHB ward with Covid-19 patients, or confirmed close contacts, is staffed exclusively by a dedicated pool of nurses who will not work subsequent shifts elsewhere.”
However, according to a medical staff source who contacted Newsroom on the condition of anonymity, North Shore Hospital (also under the Waitemata DHB umbrella) already employs strict isolation protocol when dealing with Covid-19 patients, including keeping their Covid staff in the Covid ward. “They eat, toilet and do everything within that ward – never going into any other part of the hospital. Strictly isolated. So North Shore Hospital haven’t had these issues.”
Another press release is also put out by the WDHB on Monday, announcing the launch of a Major Incident Review, to have its draft report completed by Friday, May 8. It says: “Waitematā District Health Board had an investigation under way after the first case was identified but is now extending the panel membership and updating the terms of reference. Changes have been put in place as a result of the positive cases, and further changes will be made as new information becomes available in the investigation rather than wait for the completion of the report.”
On Monday evening, Newsroom is leaked an internal shift handover document that says three more people - close contacts - have been infected with Covid-19, which we publish at 6pm.
It is also revealed 37 staff are still on stand-down from working at the hospital.
Tuesday May 5
At the afternoon public briefing, Director-General of Health Ashley Bloomfield announces five existing cases would now be linked to the St Margaret’s cluster: “These are not new cases, what has happened is following further investigation, cases from what was previously considered a separate smaller cluster have been linked to the St Margaret’s cluster and merged. Three nurses nursed six Covid-positive patients from St Margaret’s. There has been wide testing of their close contacts, both family and work. There is an audit under way to find out what the source of infection is.”
When asked whether this was a wake-up call for the practice of allowing staff to work between Covid and non-Covid wards, he says: “This is a learning experience” and points to a review under way due to be released Friday. He adds: “All DHBs will be interested in this, what can we learn, how can we strengthen our protocols and make sure we’re reducing the risk to our frontline health workers.”
After which Ardern again states: “Just to reiterate, they weren’t working between wards on a single shift.”
It is announced that all staff at the four northern DHBs can now be routinely tested for Covid-19, and that Waitakere Hospital is offering free psychology sessions for staff concerned at the internal outbreak.
Waitakere Hospital also no longer has any Covid-19 patients, having moved the remaining three St Margaret’s patients to North Shore Hospital.
The numbers of Covid-affected people, as written in the leaked internal handover document, are three nurses and three close contacts.
Wednesday May 6
The six cases in the outbreak are reassessed to three nurses, and two close contacts.
Friday May 8
An insider tells us a 26-year-old nurse from Waitakere Hospital has tested positive – and is critically ill in North Shore Hospital. She is the fourth nurse to be infected.
Saturday May 9
Two new cases of Covid-19 are announced, both linked to the St Margaret’s cluster, one confirmed and the other probable. The confirmed case is a household contact, and the probable is another nurse – the fifth.
This means that linked to the St Margaret’s patients who arrived at Waitakere Hospital in mid-April there have been six patients (three of whom have died), five nurses and at least three household contacts.
Sunday May 10
A household contact of a nurse from Waitakere Hospital tests positive.
Monday May 11
Two more nurses test positive, taking the total number of nurses infected to seven. This is especially concerning because they had tested negative earlier and were asymptomatic while self-isolating in their homes and were only tested as a precaution before starting back at work.
Newsroom can also confirm the WDHB Covid-19 status report says there are currently 41 WDHB inpatients “under investigation”.
This means people who present to the Emergency Departments from the community with respiratory symptoms, who have been tested, and are admitted while they await results.
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