A review has found the deaths were ‘potentially preventable’, and pointed to holes in the system including inadequate clinical assessment, crossed wires, logjams and a lack of equity focus.
In the middle of Labour weekend, on Sunday October 24, the test result came back – it was positive. The 40-year-old man, who lived alone in a Manukau apartment, was one of more than 100 people whose swab had returned positive, joining the 2,500 or so people who had been infected as part of the delta outbreak. Within four hours, the regional public health team was on the phone. The assessor on the line, however, was lacking a crucial piece of information. They could not access the regional online “clinical portal”. That initial risk assessment, therefore, was made without access to notes on the man’s complex medical background.
These initial conversations are not designed as clinical assessments, so the people who undertake them do not have clinical analysis skills. The script the interviewer followed did not include looking for many risk factors that might lead to increased concern, such as obesity. There were no red flags raised out of the interview, even when the man was unable to continue a short phone call as a result of severe pain.
Five days passed before Covid Healthline made the first attempt to call the man, named “Case A” in an independent review published today. That delay was caused by the sheer number of people who were now isolating at home with Covid-19 – as the volume of community delta cases had grown, the existing managed isolation and quarantine systems, where nurses conduct regular checks, had become insufficient. The days of a positive test prompting in most cases health authorities picking you up and taking you to a designated hotel were over. Most people were being asked to stay at home, a shift in approach acknowledged by the Covid response minister Chris Hipkins on November 3. “We are moving much more now to the default of people isolating at home unless there’s a good reason for them to go into MIQ,” he said.
That five-day lag, the reviewers found, was the result of a logjam of people testing positive and beginning home isolation, officially called the Community Supported Isolation and Quarantine system. The multiple parties involved in the process made it convoluted enough already. The surge in numbers meant it had, simply put, “become overloaded”.
That was immediately obvious to people on the ground. At the time, South Auckland GPs were sounding the alarm over snowballing delays in oversight from health authorities of people isolating at home, saying they were having to step into the breach to support positive cases in the community.
When the man failed to answer calls – as he did at least three times on each day – his case should have been escalated. That “escalation pathway” failed for the first time, on October 30, because of a spelling error. When the man did not respond to calls the next day, October 31, on November 1, on November 2 and November 3, it failed again. Why? “The reasons,” found the review team, “remain unclear.” There was an attempt at escalation to Manaaki Services, but it was by email, “without any prioritisation or urgency, and the number of emails was overwhelming”.
When Case A, who was unvaccinated, did not respond to attempts to contact him, there was no attempt to alert his whānau. His GP was not contacted until November 1, eight days after the positive test was returned.
On November 3, he was found dead at his home by a family member.
These events are laid out in a report from an independent review panel chaired by Dr Jonathan Christiansen, commissioned by the Northern Region Health Coordination Centre in consultation with the Ministry of Health. A couple of days after the review was initiated, another person died in home isolation, and the review team was asked to add this fresh tragedy to its scope.
Case B was a man in his 50s, who died in his Mt Eden apartment after discharging himself against medical advice from hospital. The review found that the public health team was unaware of the circumstances of his self-discharge and his condition at the time, despite this being noted by hospital staff on the written referral term. The referral system did not offer an option for a clinical handover from the inpatient team to the public health group.
A follow-up call to the man to assess his condition after his return home was made by a non-clinical Healthline staffer. It was escalated for urgent medical review. The account concludes: “Due to software design issues at the time the system was backlogged and allocation for escalation did not occur prior to Case B’s death.”
The reviewers concluded that both deaths were “potentially preventable”. Of the overall system they acknowledged that “given the speed of change and the complexity of the system, it is remarkable that so much has gone well”. However: “There were missed opportunities that contributed to a tragic outcome for two Māori men.”
Four key themes run through the panel’s recommendations. Initial assessments needed to be substantially improved, and to include urgent clinical questions. The overall “connectivity” of the system fell short – the IT itself was lacking, information sharing was woeful, and the left hand appeared oblivious to the right hand’s activity. There is a call for clinical governance to oversee the reporting and review systems.
The other recommendation echoes a concern that has been voiced repeatedly across the Covid health response: equity. The community isolation “system design”, finds the review, “has not developed with equity at its heart. The combination of lower vaccination rates in Māori and Pasifika, and the spread of Covid-19 in low socio-demographic and marginalised communities has meant that the burden of Covid-19 has fallen disproportionately on Māori and Pasifika communities. There is a risk that the current [home isolation] system could further magnify this inequity.”
In a statement summarising the review’s conclusions, the head of the Northern Region Health Coordination Centre, Fepulea’i Margie Apa, said, “It is a very sad time for both the whānau and friends of these two people and our hearts and thoughts are with them as they come to terms with their loss. We are fully committed to providing any support we can.”
Margie Apa, who is also CEO of Counties Manukau Health, accepted that “it is clear that more could have been done and needs to be done … We unreservedly accept the findings of the review and apologise to the whānau for the shortfalls in the response provided. We are grateful to whānau for providing input at such a difficult time.”
She noted that many steps had already been taken to address the concerns. “These two deaths resulted from a combination of situations and events, and we needed to analyse them quickly so we can improve our care in the future. The model for CIQ we have in place now is not the end point, it is an interim back up while we support primary and community based teams to build their capability to look after their enrolled patients.”
The minister of health, Andrew Little, told The Spinoff: “The government acknowledges the report released today into the deaths of two people with Covid-19 who were being cared for at home, and expresses its condolences to their families.”
The government accepted the recommendations, he said.
“The report says that at the time of the deaths, health authorities in Auckland were dealing with an extraordinary situation caused by the rapid spread of the delta variant, and acknowledges that most of the actions it is recommending have already been put in place,” he added.
“I have made it clear that I expect all Covid patients being cared for at home will be clinically assessed within 24 hours and that clinical considerations are at the heart of all decisions. That is the principle at the heart of the Covid Care in the Community system I outlined last week.”
As well as the 24-hour expectation, the new model, announced last Thursday, sets out requirements for close contacts to isolate and be tested, a designated point of contact, such as a GP, to check in with the case and discuss a response plan, and a “health pack tailored to the individual’s health needs delivered within 48 hours to help the person manage recovery”.
The National spokesperson for the Covid response, Chris Bishop, said the opposition had been “warning for months that the government had not been adequately preparing for delta, and sadly that appears to have been borne out”. It showed, he said, that the government had not appropriately expended a $57 billion fund created “with the express purpose of improving our Covid response”.
The health and disability commissioner, Morag McDowell, told The Spinoff on November 15 that she had written to the Ministry of Health requesting “urgent attention” be paid to concerns around care for those self-isolating, adding: “While I recognise the pressure the health system is currently under with the rise in Covid-19 cases, this issue needs immediate attention.”
In the letter, provided to The Spinoff, McDowell wrote: “I am concerned that the fragmented nature of the current system of community isolation potentially risks the immediate health and wellbeing of those Covid-positive patients.”
A couple of days later McDowell told The Spinoff she had met with the ministry, “and I understand they are working with urgency to improve the clinical pathways and systems to support people with Covid-19 isolating at home. I’ll be keeping a close eye on how this work progresses, particularly in relation to concerns raised about the safety of consumers. Ensuring consumers receive an appropriate standard of care remains my priority.”
Asked about the report at the post-cabinet press conference on Monday afternoon, Bloomfield said: “In this case it was identified that there were slipups in the system and things that could have been done better and that the deaths were potentially preventable.” He added: The point of doing the review is to find out exactly where are the areas that need to be strengthened and improved, and those improvements have been put in place.”
The panel did not look into the cause of death in either case, which are currently the subject of inquiry by the coroner. They did not look, either, at a third case of a Covid-19-related death at home, a man in his 60s who died after coughing up blood, prompting his daughter to raise public concerns about the effectiveness of the home isolation system.