This was a process failure, and the degree of any human error is being established.
Snee, to his credit, says as chairman he takes responsibility. In a way, that in itself is a breath of a fresh air - ownership of a problem.
Funny, by he way, that public never gets to hear about the lives saved each day by DHB employees, the brilliant work of staff, the amazing surgery, the clean wards, the hospital food people enjoy, the kind words from nurses that help change lives.
Somehow the negative steals the spotlight.
Right now, it is all anyone can do now, but to wait for the 55 patients to be cleared over the next 24 weeks - this is the time frame needed to get an accurate "all clear" on the tests.
The mistake is a serious one by a DHB under all sorts of pressure. And by all sorts, we mean a variety. On any given day there are decisions made by DHB employed health professionals in pressurised situations.
Like other DHBs in New Zealand, Hawke's Bay has had strikes by health professionals.
Each time there are assurances that everything is being done to ensure public safety is not compromised.
There are no guarantees. There can't be.
At any time - fully staffed or not - no workplace can guarantee human or systemic error will not intervene in the otherwise smooth running of their respective business or service.
But we make big efforts to ensure we avoid factors that can lead to error.
Whether the DHB likes it or not, the public will draw conclusions that strike action is linked to poor performance. The DHB's investigation over the next few weeks will clarify for all of us what has happened.
The other example that points to a regional health sector pressure are the current delays to see a GP.
It is not unusual for a registered patient to be told they cannot see their doctor for two weeks.
However, if they think they are acute they can come to the practice and wait.
In effect, patients are being asked to self diagnose the severity of their illness or ailment and make a crucial health decision.
The obvious danger is that people will not front at a GP to wait, will get worse and die.
Blunt, and a worst case scenario. But a scenario none-the-less.
These days there is consistent messaging for people to see their GP if they think they are depressed. To be told you can't see one for two weeks might be too late for some people.
There is also the potential for people to front at A&E at Hastings Hospital rather than their GP.
Hospitals frequently tell the public to not come to the A&E unless it is urgent, and to see their GPs.
But if you can't see a GP for two weeks, what do you do?
Here is where we spare another thought here for the 55 patients awaiting news of whether they have contracted HIV or hepatitis.
They would probably swap a 24-week wait for a two-week delay in a heartbeat.
