Nurses at Waitakere Hospital dealing with Covid-19 patients were forced to change their protective wear up to eight times a shift, one of a suite of issues that may have led to staff catching the virus.
An report released this afternoon also found "usability" issues with the personal protective wear (PPE), and that was stressful for staff.
The Waitematā District Health Board has apologised to the staff - seven now have the virus - who were caring for patients from St Margaret's rest home.
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The report said the patients transferred to Waitakere Hospital in the middle of a "difficult, evolving and intense" situation.