Three elderly rest home residents are dead, and seven nurses who looked after them at Waitakere Hospital have been infected with Covid-19. Kirsty Johnston reports on what went wrong.

Nurses on the hospital ward that took in six elderly Covid-19 patients were given just three hours to prepare, after it was discovered the patients' rest home had no backup plan and the situation had become increasingly "unsafe".

The decision to transfer unwell residents from St Margaret's rest home in West Auckland to Waitakere Hospital was made in the middle of a "difficult, evolving and intense" time, exacerbated by staffing shortages, PPE issues, poor communication, an investigation into how nurses came to catch the virus has revealed.

It comes as seven nurses from the hospital are confirmed to have Covid-19. Three of the patients have died.

The report, by independent panel members including the chief nurse and midwifery officer at Waikato DHB and a NZ Nurses' Organisation representative, sets out the chain of events that led to three nurses becoming infected.

It describes how the worsening situation at St Margaret's evolved so rapidly that senior staff were not told of the decision to move the residents until they were already on their way.

It said despite daily meetings between the rest home and the health board's incident management team, there had been no discussion of what would happen if it became unsafe to manage the residents at the facility.

As staffing concerns grew, it became obvious the residents couldn't stay at the home for the weekend. "As a result, the decision to transfer the residents had to be made quickly on a Friday, which is not ideal," the report said. Admissions pathways weren't followed, adding to the confusion.

Concerns about staffing and PPE dismissed

The report said a nursing roster for the new ward was developed quickly, pulling together staff from across units who hadn't necessarily worked together before. However, because the hospital was so short-staffed, some nurses worked across wards.

Despite multiple staff raising concerns this would spread the virus, it continued until after the nurses got sick, despite an earlier review.

When the patients arrived on Friday April 17, they were placed into an overflow ward, the report said, instead of a ward with negative pressure, because they were not thought to be critically ill.

However, this proved to be a poor choice, as the patients rapidly deteriorated to the point they needed a high level of full nursing care.

One required oxygen, all were confined to their beds. They were incontinent, all were coughing and were unable to follow instructions. There were all fully dependent on staff for their personal care.

The nurses had access to full personal protective equipment (PPE), the report found. But there was issue upon issue. For example, because the medical staff did not go on to the ward, the staff had to leave patients' rooms several times per shift to telephone the geriatrician. They also had to leave to get equipment and medicine.

This was time consuming for the nurses and not standard practice. It also meant the nurses had to take their PPE on and off up to eight times a shift.

"It is well recognised that donning and doffing PPE, particularly doffing, is high risk for viral transmission, and it is therefore important to try and minimise the number of times this occurs," the report said. "This needs to be balanced with the need to ensure staff are not exposed for prolonged periods unnecessarily in enclosed rooms with confirmed Covid-19 patients."

Additionally, some of the PPE didn't fit, or was uncomfortable. The velcro tabs at the back of the gowns loosened easily, creating gaps at the back.

The initial eyewear provided was a frame with a removable lens. The lens was a hard plastic that could flick when removed. Initially the lens needed to be cleaned. Alternative eyewear provided some days later had a disposable lens. Later, the eyewear was changed to goggles that didn't fit some staff, who had to use a tie to hold them in place.

Original N95 masks - the gold standard - ran out, and were replaced with a different type of N95, which didn't fit. Despite asking for more of the original type, the charge nurse manager was told they were not necessary, and that "N95 were being reserved for high risk areas" and the ward was deemed "low risk".

The changes of supply, combined with overwhelming, ever-changing information about PPE, made it stressful for the staff, the report found.

The panel commended the manager and the geriatrician for advocating for the nursing staff to have a consistent supply of high quality PPE, and said the DHB needs to listen to the concerns of staff.

"With the high viral load of unwell Covid patients coupled with their incontinence and full-care needs, this area should have been considered a high-risk area, automatically receiving N95 masks," it said.

'We are deeply saddened that these nurses became infected'

The report described one day, April 20, detailing it as "particularly busy and challenging".

One patient deteriorated rapidly over the day with progressively increasing oxygen needs, it said.

"One of the patients died and had to be placed in a waterproof body bag, which was different than the standard body bag."

"This was a particularly stressful time for the staff as some patients were unwell, confused, incontinent and requiring full care. This was the only time that the three nurses who tested positive for Covid-19 all worked on the ward on the same day."

In an appendix from the Auckland Regional Public Health service, it said it was likely those three nurses - and the four colleagues who would later be infected - got the virus from that ward; or from person-to-person spread.

The report said nursing staff provided exemplary care to the six patients on the ward; they were compassionate, professional and worked to ensure the patients were provided with the best care possible, the report said.

Waitemata District Health Board Deputy CEO Dr Andrew Brant said the report would be used to improve how similar situations were managed in future, and apologised to staff.

"We are deeply saddened that these nurses became infected with Covid. They were being selfless in caring for others in the middle of a difficult, evolving and intense situation at St Margaret's," he said.

"We recognise their professionalism in caring for patients from St Margaret's and we regret that they became ill in the course of their work."

The report said earlier back-up planning could have helped manage the situation.

For example, the ward team could have been configured, become familiar with processes on the ward and practised scenarios.

Brant said: "Although we prepared as best we could, admitting Covid-positive St Margaret's residents has caused stress to our DHB and our staff.

"The report released today shows our staff were well-trained and personal protective equipment (PPE) was used at all times. We have also had confirmation that 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."