A deadly coronavirus outbreak at a rest home spread so rapidly that there were a number of "safe practice issues", including how protective equipment was used.
Rosewood Resthome and Hospital in Christchurch is now linked to six deaths and 33 confirmed or probable Covid-19 cases, of which 18 are staff members.
Many staff had to go into isolation and that led to shortcomings, Canterbury DHB confirmed to the Herald.
"In the demanding context of managing a cluster of frail elderly residents, a significant number of staff needed to be isolated because of exposure to Covid-19 and this contributed to a number of issues regarding safe practice, including the way PPE [personal protective equipment] was used," a DHB spokesman said.
"Canterbury DHB is increasing support to the aged residential care sector in Canterbury with teams of experts in caring for the elderly and in infection prevention and control going out to give further support and guidance as we work together to protect the safety of residents and staff."