Who knew what when Covid-19 reached Waitakere

An internal report into the spread of Covid-19 at Waitakere Hospital does not examine why key specialists were left in the dark when positive patients were sent there. Melanie Reid and Bonnie Sumner report

Key specialists were not involved in the decision to send six Covid-positive residents from St Margaret’s rest home in Te Atatu to Waitakere Hospital.

As a result of that transfer and subsequent mistakes at Waitakere Hospital, seven nurses and four of their household contacts were infected with the Covid-19 virus. One of the nurses, a 26-year-old, has been in a critical condition in a High Dependency Unit in North Shore Hospital. She has since been released. 

Waitematā DHB covers both Waitakere and North Shore Hospitals in Auckland.

Insiders, have told Newsroom a report about the outbreak of Covid-19 among staff at Waitakere Hospital does not address the major issue of the crisis.

They say a number of specialists had no idea a decision had been made to transfer Covid-19 positive residents from St Margaret’s rest home to Waitakere Hospital.

“It doesn’t matter how many managers, geriatricians and specialists … were involved,” says the source. “Critical infectious disease and acute medicine specialists and were never consulted.

“The ESC Cullen Ward at North Shore Hospital had been set up specifically for this purpose. Specialists critical to the planning and moving of any Covid-19 patients had no clue what was going on (with the transfer of the St Margaret’s patients). They certainly should have been consulted first before planning, thinking or moving any Covid-19 patients.”

Newsroom understands some of the specialists excluded were:

· An infectious diseases specialist

· A respiratory consultant specialist

· A consultant specialist in intensive care

· The Incident Management Team clinical lead

· Incident Management Team Infectious Diseases Lead

· Infection, Prevention and Control clinical advisors

After news of the nurses becoming infected at Waitakere became public the DHB commissioned an “investigation to understand the circumstances around how these staff members may have become infected.” The report based on that investigation was released on Wednesday, May 13.

But Waitemata DHB insiders say that critical decision to move the St Margaret’s patients to Waitakere Hospital is not addressed nor was anyone held accountable in the report.

“The top guns knew nothing about it. They weren’t consulted. This was a hasty Friday afternoon decision,” says a source.

Sources have also told Newsroom that some specialists “were horrified to discover on the 6pm television news that night that Covid-positive patients had been moved to Waitakere Hospital.”

What the report says – and doesn’t say

The report describes the decision to transfer the St Margaret’s rest home patients on Friday April 17:

“At 13:00 hours a decision was made to move up to 20 residents out of the facility. Waitematā DHB’s IMT (Incident Management Team) with senior managers and senior geriatricians working with the IMT, considered the options of transferring the patients to Waitakere Hospital or North Shore Hospital.”

The report does not make clear who from the Incident Management Team (IMT) and which senior managers and senior geriatricians “considered the options.”

Newsroom put this to the Waitematā DHB. A spokesperson replied: “Many of the (IMT) function leads and members of their teams were involved in discussions in multiple forums.”

The DHB also provided a list of the roles that make up the IMT.*

However further into the report it says this:

“Mid/late afternoon of 17 April, the IMT Clinical Lead, IMT ID Lead, and IPC clinical advisors were informed of the decision to transfer the residents to the cohort ward at Waitakere Hospital; prior to this they were not involved in discussions about where the St Margaret’s residents should be placed.”

So, according to the DHB’s own report, those “not involved in the discussion” and who were “informed of the decision” were the following hospital Covid-19 specialist heavyweights:

The Incident Management Team clinical lead

Incident Management Team Infectious Diseases Lead

Infection, Prevention and Control clinical advisors

The report does not address why these clinical leads were not involved in this decision. 

Added to that, the heavyweight specialists in infectious disease and acute medicine remained uninformed too.

Newsroom asked the WDHB why some of these medical experts were not included in the discussions. We were told on Friday they would tell us as soon as they found out. We are still waiting.

By the time these individuals and teams were informed of the decision in “mid/late afternoon” the patients were already in transit.

Newsroom has confirmed a number of staff were sent an email at 3.30pm to say the patients were already on their way to Waitakere Hospital. By that point, some acute medical specialists had finished their shifts already. 

This meant they only found through the media about a critical decision they should have been involved in.

So who did make the decision?

Newsroom has been told by insiders the critical decision to move patients from St Margaret's to Waitakere Hospital was primarily driven by two geriatricians – doctors trained in the conditions that commonly affect older people – and a Waitemata DHB middle manager “with experience in specialty medicine and the health of older people” (one of the more than 25-strong Incident Management Team).

Both geriatricians worked across St Margaret’s rest home and Waitakere Hospital. They were known to the residents.

But Newsroom sources say: “[They had] no acute medical or infectious diseases experience, no insight into how quickly the patients would deteriorate."

Sources point to an earlier part of the report that says under the model of care Waitakere Hospital set up before the St Margaret’s cluster, it was agreed that Covid-19 patients were “to be admitted under the care of the acute medical team.”

Yet later in the report it says the six positive Covid-19 St Margaret’s residents “would be transferred to Waitakere Hospital that afternoon to be admitted directly to the overflow ward under the care of the geriatric team.”

An underprepared hospital

In the report and in the media, much has been about the consistency of the PPE gear available at Waitakere Hospital and how stressful the situation was for staff when the patients arrived. What’s missing is why everything fell apart so quickly when the ward had already been prepared to accept Covid patients.

According to the report, the decision to move patients to Waitakere Hospital to help with staffing shortages at St Margaret’s rest home was made at 1pm on the Friday.

At 5pm, six Covid-positive elderly residents were moved to Waitakere Hospital, who were not at the time considered “acutely unwell”. They were placed in a ward that had been specially prepared for Covid patients.

However, despite the report saying the hospital had two wards prepared and ready for Covid-positive patients, insiders say it was “chaos”.

“The staff didn’t have the protocols. Nurses did not have the intensive training to safely use PPE gear without cross-contamination. Suddenly people are coming in but the staff hadn’t had proper training, so they were taking PPE off and infecting old gear with the new. These were general trained nurses with limited preparatory training to deal with these conditions.”

It is not made clear in the report, but the ward the patients were sent to is Muriwai A, which sits next door to a ward housing vulnerable elderly non-Covid patients. Both wards were managed by geriatricians. Newsroom has already reported that staff were working between these two wards.

The condition of the patients deteriorated rapidly. By Monday one had became so ill they died and had to be transferred into a waterproof body bag – a different bag than the standard body bag staff were used to using.

“This was a particularly stressful time for the staff as some patients were unwell, confused, incontinent and requiring full care,” says the report.

It was also on this Monday shift that the first three nurses who later tested positive all worked together on the same shift in the Muriwai ward. Two more elderly St Margaret’s patients subsequently died at the hospital.

In a press release response to the report, WDHB’s Deputy CEO Dr Andrew Brant says the report shows “preparations at Waitakere Hospital were well-advanced to receive and look after Covid patients. However, there are clearly some things we could have done better and which we need to learn from.”

He writes that these include better communication between clinical staff “to help them understand the basis for those decisions, particularly where they needed to be made rapidly in response to an emergency situation,” and, “Finding a way of ensuring better consistency of the national PPE supply, reducing the need to change products in the middle of responding to a pandemic, which caused significant concerns to staff.”

He does not mention whether following the Covid-19 model of care set up before the St Margaret’s outbreak would be part of these lessons.

* The Waitematā DHB IMT is aligned with the NZ Co-ordinated Incident Management structure. We have added additional functions where we have identified a need. Roles include IMT Exec, Incident Controller, IMT Support, Communications, Planning, Intelligence, Operations, Welfare, Clinical Technical Advisory Group (led by the IMT Clinical Lead), Logistics, Safety, Welfare. Technical experts advising the IMT include Microbiology, Infectious Diseases (ID) clinicians, Infection Prevention and Control (IP&C) senior nurses.

* Made with the support of NZ on Air *

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