A report into the deaths of two people at home with Covid-19 highlighted deficiencies in the home isolation system - set to become the norm as the virus spreads across the country. Adam Pearse looks at what went wrong
Hitting home
Isolating at home while recovering from Covid-19 was initially reserved for those with medical conditions that precluded them from spending 14 days in a quarantine facility.
Almost two months into Delta, this was manageable. Public health officials were supporting no more than 50 people in home isolation.
The situation changed dramatically in the final days of October and into November when cases in Auckland spiked.
The isolation model, formerly relying solely on MIQ, quickly moved to self-isolation in the community, in recognition of the limitations of MIQ capacity, expected growth in case numbers and some Kiwis' preference for home isolation.
However, with hundreds of infected people now needing assistance, Counties Manukau DHB chief executive and spokeswoman for Auckland's home isolation programme, Fepulea'l Margie Apa, acknowledges the health system buckled under the pressure of servicing such demand.
"The scale of growth just overwhelmed us for that period.
"This experience has probably exposed our system when it was at its most weak."
It was always the plan to rely on local health and welfare providers to help patients find a home isolation solution but this was let down by inadequate preparation.
Papakura Marae Health Clinic GP Dr Matire Harwood was among those in primary care to notice whānau with the virus starting to slip through the cracks by late October.
It began with a Covid-positive whānau member who had called the clinic, saying they were at home because there was no room in MIQ and had been told to contact their doctor to access vital medication.
The following week, another whānau called - the husband was in intensive care with the virus, while the wife and grandchild were at home with symptoms without any support from public health.
Days later on November 3, a man died while in home isolation - followed by a second man two days later.
"We started to get a little bit panicky because we could see that it was becoming more common in our community," she says.
Even as top health officials assured the nation appropriate home isolation protocols were being followed, Harwood says the kōrero on the ground was very different.
Many whānau were reporting little to no contact with public health, some were without food and others were without pulse oximeters, which record blood oxygen levels.
Over four weeks, Harwood and her team had supported about 140 people through home isolation with little direction from public health.
"It didn't feel like it had been set up very well," she said.
"I thought [a plan] would have come out a bit earlier so we could be more prepared."
'They just don't know what they're doing'
Amelia* tested positive for Covid-19 in October.
As a fierce observer of lockdown rules, the Auckland woman doesn't know where she caught the virus.
It mattered little, the end result meant she was isolating at home while her partner was forced to stay in a caravan on the property.
Her daughter, who had been in her mother's bubble, spent two weeks alone at her own home with three young children.
It took seven days before Amelia received a pulse oximeter just as symptoms were becoming more evident.
"I felt like my head was being squashed in a vice and it felt like someone was sitting on my throat, I could barely breathe."
However, it was the time-wasting calls from public health staff that made the experience even more painful.
Almost daily, Amelia would receive multiple calls from staff asking to speak to her daughter and her children, two of whom were under 2 years old.
Perplexed, Amelia claims she was told it was her "legal obligation" to put them on the phone.
Despite multiple attempts to explain her daughter lived in a different house, Amelia repeatedly took calls on behalf of her daughter and grandchildren.
"It was really frustrating," Amelia says.
Tensions rose after two weeks in isolation. Amelia was forced to report her husband, who had left the caravan and gone into town, frustrated at having waited three days after the two-week period for a phone call to give them the all-clear.
Three weeks later, Amelia received multiple phone calls and texts from public health staff who understood the family to be still in isolation.
While she doesn't blame the staff, Amelia believes the system should have been better equipped to support people already dealing with a taxing virus.
"They just don't know what they're doing."
*Names changed to protect identity
'Potentially preventable'
Earlier this week, a report was released following an investigation into the deaths of the two men - both Māori - who were isolating at home in early November.
Here are summaries of the failings in care prior to each man's passing:
Case A
• His risk of deterioration was raised by living alone and being unvaccinated
• His clinical background was not available to the first public health official to make contact because they couldn't access that information
• The template for the public health interview is not structured to give emphasis to
clinical risk and safety
• It took five days before Healthline could attempt to call him because the system was overloaded with patients
• When Healthline calls went unanswered, the appropriate escalation of priority was not enacted
• The man's whānau were not contacted after he was unable to be reached by Healthline, and his GP first received written contact eight days after the man tested positive.
Case B
• Information about his ill-health upon self-discharge from hospital was not shared with Healthline or the public health team, despite it being recorded by hospital staff
• The administration of medication that created an artificial sense of patient wellbeing was not considered in the initial or follow-up clinical and non-clinical assessments
• Data from his pulse oximeter was not adequately collected because he had difficulty using it
• A backlogged system, caused by software design issues, meant the appropriate action was not taken when he was determined to be in need of urgent medical review.
Among the raft of findings, the review determined essential health information was not readily available, tools to assess safety, acuity and clinical risk were not well developed, escalation pathways were unclear and dysfunctional, there was poor connectivity between agencies and a lack of co-ordination with Māori health providers.
"We unreservedly accept the findings of the review and apologise to the whānau for the shortfalls in the response provided," Apa said.
"Nobody could be more devastated than the whānau and we want to acknowledge how generous they've been in giving us feedback, but for the hundreds of people who work on this response, we're incredibly gutted."
Last week, several Government ministers gathered in South Auckland to announce $1.5 billion in funding - some of which would go towards improving the home isolation system as the country transitioned to the Covid-19 Protection Framework, or traffic light system.
Alongside more than $200 million in welfare support for isolating whānau, a new "Care in the Community" model was revealed, which included:
• An initial contact from a healthcare provider within 24 hours of a positive result notification, to discuss any health, accommodation and wellbeing requirements.
• A designated point of contact, most likely from a local healthcare provider, who will be responsible for looking out for the person's health and wellbeing needs
• A health pack tailored to the individual's health needs delivered within 48 hours
• Ongoing clinical monitoring over the duration of the isolation period to make sure the person is coping, before a health assessment on day 10 to determine whether the person can end their isolation (this is for vaccinated cases, unvaccinated cases require 14 days).
Actions speak louder than words
For Ester*, the Government's revamped home isolation strategy gives her little comfort.
As featured in the NZ Herald last month, Ester - not her real name - lost her 68-year-old father who was isolating at home with Covid-19 in November.
The man spent the last five days of his life in agony, coughing up blood and was too weak to move.
He was allegedly never given the directive to go to hospital, but was instead offered throat lozenges and paracetamol as treatment.
Ester, who expected to receive the results of a separate investigation into her father's death next week, welcomes the report into the two previous deaths, but is concerned key lessons would not be learned.
"[The report's recommendations] weren't happening in my father's case and obviously in the previous cases and our worry is it's not going to happen in the future and there's going to be the bottleneck effect again," she says.
"In writing, it's amazing and that's definitely what we need, but I don't think it's going to work logistically."
While she lauds the emphasis on engaging local healthcare providers, the fact her father had to wait five days to see his GP indicates how unsustainable the Government's expectation of the primary sector could be.
It's a sentiment reinforced by Harwood, who freely admits she and her colleagues are risking burnout as they add their home isolation duties to their vaccination and testing services, as well as everyday GP work.
In addition to her father, four of Ester's family also caught Covid-19. Two of them required hospital attention but fortunately all made full recoveries.
Her advice to people in home isolation - don't wait until it's too late.
"If you feel you're deteriorating or you feel you need to go to hospital, just go there.
"Don't even wait for Healthline, don't wait for your GP, just go to hospital because you know what you need."
Will the new system work?
Primary care providers say they were urging public officials to plan for home isolation months ago without luck.
It's a claim the Ministry of Health rejects, a spokesperson saying the ministry "continues to engage through multiple forums with general practice and primary care as we have done throughout the Covid response".
Pasifika Futures chief executive Debbie Sorensen is among the providers who have been warning of the issues home isolation would cause.
She says what has been designed will suit many people with the resources to isolate at home - those with spare bedrooms and plenty of kai.
But that isn't the case for some whānau. Just this week, Sorensen, says a family bubble of 36 was referred to them, including 16 children - 24 of whom had tested positive.
"That's a pretty extreme example but most of our families are large families, most live in homes who do not have separate bedrooms and bathrooms to be able to self-isolate," she says.
Of the 868 MIQ rooms, 421 people (227 rooms) are in quarantine - 376 of which are community cases (200 rooms).
There are a further 51 rooms set aside for close contacts. An MIQ spokesperson says these are subject to change as required as a further 470 rooms were currently available.
Roughly 3600 people are in home isolation in Auckland, including 910 cases.
Sorensen says without appropriate investment in alternative accommodation, the system will continue to fail whānau.
"I think what we're seeing is policy on the run."
The other significant change to the approach is welfare, recognising whānau require much more than just health assistance, and this would see regional teams erected to deliver tailored support.
At last week's funding announcement, Social Development Minister Carmel Sepuloni rebuffed the suggestion public officials would interfere with established support networks.
Sorensen thinks differently.
"This is not querying the incredible work that the Ministry of Social Development does and the valuable role that it does [play] ... but I would respectfully say that the ministry is not the answer to everyone's problems.
"It's taken them this long to realise there's an issue, there are already agencies in place to be able to do work, these agencies actually need to be commissioned to do this work and carry on, not to have an alternate system built up around them."
Sorensen's kōrero is reinforced by Apa, who believes Covid-19 taught many sectors that sustainably funding well-connected providers was the key to delivering for Māori and Pasifika.
Ministry of Social Development client service delivery general manager Kay Read denied the approach replaced existing welfare systems and said it was instead focused on enabling locally-led solutions to aid whānau's bespoke needs.
How you can prepare for home isolation
There will be more deaths from Covid-19 and some will be while isolating at home, Apa acknowledges.
While she can't guarantee there won't be more deaths that are later deemed "potentially preventable", Apa believes a system can be created to ensure seamless isolation with support readily available for those who need it.
She advises whānau who are yet to feel Covid's bite to plan ahead. Think of what you might need in that first 24-48 hours while services are being wrapped around you.
However, like Ester, she implores people to seek help when they need it.
"If you are feeling unwell and particularly if you're feeling short of breath, don't hesitate, ring 111 or call Healthline.
"Just don't hesitate, don't wait."
*Names changed to protect privacy