Three nurses at Waitākere hospital likely contracted Covid-19 on a stressful day when a patient died and others were sick and confused, Waitematā DHB says.
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A report has been released after an urgent review of three nurses who caught the disease while caring for St Margarets Rest Home patients at Waitākere Hospital.
Four more nurses later contracted the virus.
The review has described ill-fitting personal protection equipment (PPE), nurses needing to remove it several times a day, and very stressful nursing situations.
The report gave no definitive answer to how the three nurses initially caught Covid-19, but Waitematā DHB's deputy chief executive Andrew Brant told Checkpoint it had a strong hint of what happened.
"The patients had clinically deteriorated, and as result of that there was a lot of in-and-out of the rooms and that's where I think probably is the most likely, but that's not for us to determine, that's for public health to determine," he said.
Dr Brant apologised to the nurses, saying better systems were needed.
He commended the nurses for providing exceptional care to the six residents from the St Margaret's Rest Home, but the report paints a grim picture of the realities on the Waitākere Hospital ward, which was not prepared to deal with high-care needs patients with Covid-19.
One entry in the report said: "Monday, 20 April, was a particularly busy and challenging day for the staff, with one patient deteriorating rapidly over the day with oxygen needs progressively increasing.
"One of the patients died and had to be placed in a waterproof body bag, which was a different bag 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."
Dr Brant told Checkpoint a lack of staff was not a contributing problem.
"There was consistency of everyone interviewed, they thought there was enough staff and a good case mix of staff at the time. One thing ... that is a lesson to be learnt out of that is making sure we fully implement a buddy system.
"What that means is every time someone actually puts on their PPE is that they are observed and checked before going in and out, and caring for patients."
Another entry in the report said: "There were problems with the usability of the PPE equipment that was regionally supplied: the gowns’ velcro tabs loosened easily creating gaps at the back.
"The initial eyewear provided was a frame with removable lens. The lens was a hard plastic that could flick when removed. Initially the eyewear lens needed to be cleaned, with alternate eyewear provided some days later that contained a disposable lens. The eyewear was changed to goggles that didn’t fit some staff with staff using a tie to hold the goggles in place."
Dr Brant however maintained there was no problem with the quality of PPE, but the buddy system was necessary to ensure correct wearing of the gear.