Review findings released following two deaths in home isolation

The Northern Region Health Coordination Centre (NRHCC) has committed to learn from an independent review into the deaths of two people who had tested positive for COVID-19 and were self-isolating at home.

The independent review panel released its findings today on two separate cases, the first is a person who was living in Manukau. and another in Mount Eden. Both were living alone at the time of their passing.

The review findings have been released following consultation with the whānau of the deceased, who have provided feedback that has been included in the report. This considers each case as well as the Community Supported Isolation and Quarantine (CIQ) system. The NRHCC has already made important changes.

The Chair of the Review Panel, Dr Jonathan Christiansen, Chief Medical Officer, Waitematā DHB, has summarised key findings of the report and its recommendations including:
• The need for earlier assessment of clinical safety, welfare needs and mental wellbeing of COVID-19 patients in Community Supported Isolation and Quarantine (CIQ)
• Better connectivity between all parts of the system to ensure clinical oversight
• Heightened focus on equity and cultural safety, specifically Māori and Pasifika
• The need for stronger clinical governance for adequate reporting systems and rapid informed review of adverse events

It also identified significant opportunities to rapidly strengthen the capability, safety, equity and patient focus of the CIQ system.

The panel also considered both deaths were potentially preventable and there were missed opportunities contributing to the outcome.

The report was initiated by the Northern Region Health Coordination Centre (NRHCC) in consultation with the Ministry of Health following the first death on 3 November 2021. The second death followed two days after.

Northern Region Health Coordination Centre Lead (and Counties Manukau Health CEO) Fepulea’l Margie Apa, responded to the report saying:

“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.

“People in healthcare work tirelessly to provide the best care possible, however, it is clear that more could have been done and needs to be done. The main lesson is the need for improvement, which is what we are all committed to achieve.

“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. I want to acknowledge the steps that have already been taken to strengthen the approach and address the recommendations made.

“This has been a thorough but swift process, undertaken by independent experts. This was absolutely essential to ensure transparency and for people to understand what happened.

“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 review report points out the CIQ system was established to meet the needs of a rapidly growing number of patients with COVID-19 and their whānau in a short space of time. It says that, given the speed of change and the complexity of the system, it is remarkable that much has gone well.

It also says there are significant opportunities now to rapidly strengthen the capability, safety, equity and patient focus on the CIQ system and the care pathway overall.

Changes have been made to CIQ in the last three weeks with clinicians, administrators, public health teams and community organisations working to stabilise and improve the system. Improvements made to date include:

o The piloting of new models with Māori and Pacific providers who are able to provide holistic clinical, social, welfare and mental wellbeing support
o Immediate clinical assessment using information already available to quickly identify those who are high risk and needing special clinical, social or mental health support
o Reduction of the time taken between a positive test and the first clinical assessment
o The launch of a Hospital in the Home initiative across all three DHBs for cases needing a lot of health support
o Door knocking for those not able to be contacted, particularly those isolating alone
o The establishment of a CIQ Clinical Governance Group with the purpose of identifying emerging risks and trends, so that issues can be addressed. The Group has already met.

Margie Apa continues:
“The report highlights a number of areas where improvements to the whole system were needed. As with the rest of the world, we’re moving in a fast-paced environment where we have to change our response as things evolve.

“Importantly, one of the key areas of improvement relates to the assessment of individual welfare needs and wellbeing, and there is extensive work happening across the health and social sectors, and with our Māori and Pacific communities, to support a strengthened response.

“We are managing an increasing number of positive COVID-19 cases in the community. What is clear is the serious nature of Delta and how it can affect people very quickly, especially those who are unvaccinated with pre-existing conditions. When it strikes, it can be swiftly devastating.

“This report provides valuable lessons for all New Zealanders who need to take this illness very seriously. Everyone should get vaccinated to give them maximum protection when they are exposed to the virus, and no one should dismiss symptoms or wait and see how it develops.

“Act immediately, get tested and stay at home until you get your result. If you become unwell call healthcare services or your GP, and if you have difficulty breathing or are very unwell call 111. All these services are free when COVID-19 is involved.

“Treat COVID-19 seriously and get help. Listen to the advice you are given. Be aware of your whānau and friends, and help them if needed. Most importantly, get vaccinated to reduce the risk of serious consequences from COVID-19.

“The CIQ system has been analysed in detail in this report. As a health system, a community and a nation, we all have a responsibility to look after each other as we continue to battle this pandemic.”

Notes
The Northland and metro Auckland DHBs (Counties Manukau, Waitematā and Auckland DHBs) are operating a regional response to the COVID-19 pandemic through the Northern Region Health Coordination Centre (NRHCC).

The information contained in this media release is specific to the metro-Auckland region.

Timeframe:
The review was initiated by the NRHCC in consultation with the Ministry of Health on 4. November 2021. Discussions were held with key people involved in the delivery of care and with the whanau. The Review Panel have now finalised their report which was sent to the Ministry of Health before public release.

Panel members:
• Dr Jonathan Christiansen, Chief Medical Officer, Waitemata DHB, (Chair of Panel)
• Dr Penny Andrew, Clinical Lead of Quality, and Director of the Institute for Innovation and Improvement, Waitematā DHB
• Dr Ramon Pink, Medical Officer of Health/Public Health Physician, Community and Public Health, Division of the Canterbury District Health Board
• Selah Hart, CEO Hapai Te Hauora
• Anne Stevenson, Ministry of Social Development
• Norma Lane, Telehealth and Community expertise