A nurses union wants an external investigation into how seven Waitākere Hospital nurses caught Covid-19 while caring for elderly patients.
A Waitematā District Health Board review has been released into the circumstances in which the first three nurses contracted Covid-19 while caring for St Margaret's Rest Home patients with the disease.
It found the hospital was ill prepared for the arrival of the rest home patients, that personal protective equipment was ill fitting, and nurses had to take it on and off up to eight times a day.
Nurses Organisation kaiwhakahaere Kerri Nuku welcomed the report, which she said highlighted the chaotic situation the nurses were working in.
But WorkSafe should step in, she said.
WorkSafe had said the investigation did not fall into its scope but it should be because the nurses had all been unsafe at work, Nuku said.
"If these health workers have been exposed to a hazard like this then surely that should trigger a WorkSafe external investigation," she said.
On the day the nurses most likely became infected one patient died, another deteriorated rapidly and others were unwell, confused and incontinent - requiring constant care, the report said.
It was not in its remit to determine how exactly the nurses caught Covid-19.
But the DHB's deputy chief executive told Checkpoint it was likely that day.
Nuku said it had been a very stressful time.
"We've had vulnerable patients at the centre of this and families that have been incredibly concerned about their family members - and not just the patients' families but also staff families," she said.
All district health boards should look at the findings to improve their systems, she said.
Director-General of Health Dr Ashley Bloomfield told Morning Report there was no need for an independent review.
"The report is transparent about what happened," he said adding that an independent review wouldn't provide any information further than that.
WorkSafe said it was still deciding whether to investigate and would give it careful consideration.
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