Newly-released documents and interviews reveal what happened during New Zealand's deadliest Covid-19 cluster, and the extraordinary bravery shown by those at its centre. Nicholas Jones reports.
After dying on a Covid ward, Camille Vincent was wrapped in a cloak of feathers.
The 84-year-old held to life for 10 days after being taken by ambulance to a Covid-19 ward at Christchurch's Burwood Hospital.
Six other residents from Rosewood Rest Home had died on Ward GG, and Camille's family arranged for a korowai to be sent from Auckland, with feathers representing the fingers of her children, grandchildren and great-grandchildren.
The cloak arrived in the hour after her death on April 16, and was taken by the family to the hospital, and inside by staff.
"It was wrapped around Mum - we saw that, there were photographs taken - and we were so grateful the nurses did that for us," says one of her six children, Mark Vincent.
"She knew then that we were all with her - supporting her - and we knew what she was going through. It was very powerful to see that."
The korowai was the idea of Camille's grandchildren, and will now be with them for life's milestones.
"We will use it when we have special events; graduations, birthdays and births," said Vincent, pausing to regather himself.
"So our mother can be with us."
Inside the outbreak: 'Like holes in a dam'
The Weekend Herald has obtained documents that give new insight into an outbreak that took the life of 12 Rosewood residents (nearly half of New Zealand's entire Covid-19 death toll).
After 20 residents from the rest home's hospital-level dementia facility were taken to Burwood Hospital, including Camille, another 44 residents remained at Rosewood.
Most had complex care needs, and some later tested positive for Covid-19.
Some residents didn't get dressings changed or medication on time because of short staffing, documents show - despite Canterbury DHB having taken over the facility, and amidst no-shows by some workers.
"It is still hard to describe the situation we were faced with," recalled Jo Hathaway, who worked at Rosewood later that month as a palliative care clinical nurse specialist, and emailed DHB leaders to praise the "mountains moved" by frontline staff and those supporting them.
There was no time to read up on the medical needs of the sick and fragile strangers, Hathaway wrote, "and how could you read anything with a fogged-up visor anyway?"
"Meanwhile your brain clouds over until our lungs adjust to breathing through a mask, becoming increasingly breathless with every shouted conversation to an unidentifiable colleague.
"Patients' symptoms would spring up left, right and centre like holes in a dam...diarrhoea, back pain, dry cough, delirium, the occasional temperatures, lungs filling up fast with thick mucus, and plummeting oxygen saturations...for some, positioning became a matter of life and death."
Nurses sweltered in PPE, and double-gloved hands struggled to work touchscreens to record drug schedules and notes for off-site GPs, or answer phone calls and messages from families.
Amid the unrelenting workload were personal touches; finding the right station on the radio for a resident, "singing happy birthday, complete with a little cake and candles".
After the initial onset of illness, most patients seemed "largely untroubled by the roller coaster of symptoms that lingered as days turned into weeks", and on their bad days would go quiet, refuse food and drink and sleep peacefully.
That gave some comfort but was also when staff worried the most.
"And this is when two of them slipped away peacefully," Hathaway wrote.
"We tried, we really did."
Shortfalls in staffing - and care
Rosewood had its first case confirmed on Friday, April 3, and on Sunday most staff were ordered into two weeks' isolation, including the facility manager, nurses, healthcare assistants, kitchen and laundry staff and cleaners.
Canterbury DHB was now in charge and scrambled to find temporary staff, including from agencies.
On Monday, April 6, the DHB transferred 20 dementia residents to Burwood Hospital because of problems identified at Rosewood including nurses having worked across all units despite one meant to be for isolated residents, and PPE not being used properly.
"Rosewood dementia hospital wing unsustainable," a DHB manager emailed colleagues. "No one will work there and practices not safe."
That same day there weren't enough staff at Rosewood and it was all hands on deck; a DHB manager left at 9pm after a "huge day...pureeing meals, putting on pull-ups and piecing together a very light and fragile roster".
Problems recorded over the following three days - April 7-9 - included "major issues with staffing, a number of shifts with inadequate staffing, staff not turning up for shifts, staff not familiar with the facility or with residents".
As a result, residents got only basic care. "Skin integrity issues developing," stated one document summarising problems. "Medication adherence issues."
Incontinence nappies and dirty washing were left on floors, and food left out. It could take hours to find medication.
At times there was "unclear and confusing messaging" from both the infection prevention and control team and Community and Public Health, a division of the DHB that serves as the region's public health unit and which had ordered the Rosewood staff into isolation.
Some Rosewood staff were now indicating they wouldn't return to work once their isolation was over.
On Wednesday, April 8, then Canterbury DHB chief executive David Meates and other leaders deemed the situation "unsustainable staffing-wise and significant risk to both residents and staff".
Twenty more residents would be moved. Burwood Hospital was again considered, but worries about the mortality rate of moving such frail residents meant it was decided to send them to other aged-care homes, where they could permanently stay.
The next day DHB manager Carolyn Gullery sent a letter to Rosewood's owners, finding the facility in breach of its obligations including cleanliness, food and laundry services (there was no hot water in the laundry at one point), and officially appointing a temporary manager.
"I am concerned that we had not heard from you or your general manager following confirmation of the outbreak," Gullery wrote in the letter. "This is a challenging time for everyone, however, our expectation is that you, as the owner, would have urgently contacted your CDHB contract manager as this exceptional situation developed so we could work together to manage this."
Six residents were moved out from April 10-12 - but other transfers were abandoned after a Rosewood worker tested positive and other rest homes refused to take more residents.
An unrelenting workload
Canterbury DHB declined to release correspondence or feedback from staff, saying this could stop forthrightness in future.
Instead, a summary of "themes" was given, including that staff struggled with unfamiliar systems and policies, and "rapid changes in messaging and advice both locally and nationally was problematic making it difficult to identify a single source of truth".
Rosewood workers could be hard to contact, and fear and stigma made it hard to recruit outsiders to work at the facility "and impacted on their relationship with 'business as usual' colleagues and consequently acceptance back within their normal workplace".
More insight into working conditions is provided by Hathaway, the programme facilitator for palliative care for the South Island Alliance, formed by the region's five DHBs to share health services.
She volunteered to work shifts in the latter half of April, in an area of Rosewood reserved for confirmed or possible Covid cases. Over that time her 4-year-old son lived with his grandparents in Ashburton, to protect him from any transmission.
Many of the 14 patients in the ward were bed-bound, incontinent and non-verbal. Workers wore "double PPE"; an N95 air filtration mask and full-face visor, operating theatre scrubs, a couple of polythene aprons, and two layers of gloves.
In pre-Covid times, the hospital wing of Rosewood had 20 residents cared for by a nurse and two healthcare assistants, per shift. During the outbreak, it took at least nine staff to cover 14.
If a person needed changing, for example, three people needed to change into new lots of double PPE and then, together, hoist the patient into bed and clean them very carefully - to manage the infection risk, and not appear rushed and distress the patient.
There were days when half a dozen patients needed changing, hourly - Hathaway could change PPE 50 times on those shifts.
The DHB employed invaluable "PPE champions", who'd act like ever-present referees; bringing attention to infractions like a mask overdue for changing or a loosely tied apron.
It was an unsettling time for residents.
"We would sing to them and be with them, and make a lot of effort to mitigate what we assumed would be quite a scary experience," she told the Weekend Herald.
"And because we were talking to families as well, they'd say, 'Can you tell him such and such,' or, 'Make sure he listens to Radio New Zealand Concert.' We tried to keep things as normal as possible."
That was helped by notes left around the facility by Rosewood staff; "Bob likes fruit with his Weet-Bix" or "Nancy hates mushy carrots."
However, some routines changed. Hathaway worked when some Rosewood staff returned from isolation, including when the rest home's nurse discovered one patient was being spoon-fed.
"She's like, 'Oi, so and so, get up in the chair and feed yourself.' And she pops out of bed, sits in the chair and starts feeding herself toast, with a big smile on her face, like, 'I got away with it for that long.'"
Through the home's glass doors Hathaway saw a stream of deliveries; scrubs, boxes of PPE, food for patients and staff, and gifts from neighbours and other aged-care homes. The other way went empty meal trays, used linen and "sadly, those that died who were now on their way to a funeral home".
Families asked for their loved ones to be kept alive long enough so they could see them in person again. Some called 10 times a day.
"Dying and death are so steeped in our social rituals and traditions. Not being able to be there as they lay dying, and not being able to accompany other family members during funerals and the grieving process will, I'm sure, leave many scars," she wrote in her May 6 email.
"I will be forever grateful to, and proud of, all those who honoured these people by going above and beyond the call of duty to do everything possible to care for them."
'Amazing people, with such beautiful hearts'
The Vincent whānau's wound is raw, but one salve is the care given by Burwood Hospital staff.
One particular nurse "filled the role the family normally would have", Mark Vincent said - holding his mother's hand and arranging video calls on her phone.
"She was with my mother right through the last stages of her passing, and that was very powerful for us - somebody could take over the mantle of being us, and guiding us through what was happening with Mum."
More than 100 people attended a memorial on August 2 at the Shirley Golf Course, which is almost within sight of the family home where Vincent and his siblings grew up.
Burwood nurses were there and were given a greenstone toki as a mark of gratitude.
"They are very much part of our whānau now, in terms of what they did. They are just amazing people, with such beautiful hearts...anyone in that type of industry needs more than a pay packet - they need blessings right across their whole lives."
Vincent expresses the same praise for Rosewood staff, who he'd see during regular visits before the pandemic. Mother and son would sit and talk; despite her dementia, she was still full of spirit and life, "and very bossy as normal".
However, the family is frustrated by a lack of answers. They wrote to Rosewood owner Malcolm Tucker with questions including how the virus got into the facility, and what health and safety guidelines were in place.
The family is also preparing a complaint to the country's top health watchdog, the Health and Disability Commissioner.
A proper, independent inquiry into how exactly the virus got into and spread within Rosewood is needed to provide some closure, they say - which will also help protect the 35,000 people living in aged-care facilities if any future outbreak happens.
Mike Kyne, a spokesman for Rosewood owner Malcolm Tucker, declined to comment.
However, Tucker recently opened the facility's doors to the Sunday programme, and said, "I believe everything was done correctly at the time and under the conditions."
"We were not in authority, and we were not in control. When you stand down 71 staff, of course you cannot supply food, laundry services," Tucker said.
"The facility manager was in constant talks with the CDHB."
Rosewood's first case was confirmed on April 4, but that person's onset of illness was March 26. By April 4, another 22 people in the cluster had fallen ill.
Dr Cheryl Brunton, Canterbury DHB's medical officer of health, said how and when the virus was introduced into Rosewood hasn't been established, "including the possibility that the infection was introduced by a staff member who may have been asymptomatic at the time".
The rest home had its last Covid-linked death announced on May 6 - a woman in her 60s, who died while being comforted by a staff member.
The facility returned to normal management and staffing from the week commencing April 20.
Dr Sue Nightingale, Canterbury DHB's chief medical officer, said staffing was an issue up until the return of Rosewood workers, not only in terms of numbers but because of the experience needed in aged care.
Treating skin problems can be a matter of life and death in aged care - pressure injuries, also called bedsores or pressure ulcers, can be fatal if infection takes hold.
However, Nightingale said problems were quickly fixed.
"In the first few hours, some residents were not mobilised or moved as frequently as would have been desired because of low staffing numbers, with some residents late to receive their medications and to have dressings changed.
"This was rectified quickly and although there was a risk of skin integrity issues, no residents developed pressure injuries during this period because staff were able to identify those at risk and act accordingly."
A pandemic hits
An ongoing Herald investigation has uncovered problems at other rest homes.
The Health and Disability Commissioner launched an urgent and ongoing investigation after a complaint about the care provided to residents at Ellerslie Gardens Lifecare in Auckland.
After Covid cases, 67 of 75 regular staff were stood down and temporary nurses and healthcare assistants were hastily rushed in by Auckland DHB.
Some reported being brought to tears by floors dirtied with "stinking" urine and faeces, overflowing bins and residents suffering falls and waiting too long for feeding and toileting.
Across town, DHB nurses sent to CHT St Margaret's residential aged-care home in Auckland's Te Atatu - where there were four Covid-linked deaths - reported "poor or non-existent" orientations and a lack of basic equipment including gowns and eye protection. There was also a need for bins for PPE disposal.
Like at Rosewood, a rushed decision was made to move a group of Covid-positive residents to hospital because enough staff couldn't be found, and three died soon after that disruption.
In April director-general of health Dr Ashley Bloomfield announced an independent review of how the aged-care sector coped with Covid-19 (six rest homes have had cases, with deaths from the Rosewood and St Margaret's clusters).
It was released in June but didn't name facilities or DHBs. The review found PPE wasn't readily available in some homes, and advice from health authorities was sometimes confusing and inconsistent. Delays in realising Covid-19 was spreading within some facilities meant more people were infected.
"Clear continuity planning for staff backfilling was limited to reduction in 20 per cent, 40 per cent or 50 per cent of staff, but did not require continuity planning for up to 100 per cent staff reduction and was not stress-tested," the report noted.
Some DHB staff sent to Covid-hit homes weren't properly briefed, with one telling of arriving to chaos.
"Everyone was new," they recalled. "We had no idea of the work routine, nothing got documented, we couldn't work the hoist, and all we could do was feed, keep people clean, toilet, and ready at bedtime."
The review made 19 recommendations, including a national outbreak management policy, due for completion by next month.
Simon Wallace, chief executive of the NZ Aged Care Association, which represents most aged-care facilities, said the replacement workers sent into Rosewood weren't from a dementia or aged-care background, nor familiar with electronic medication management systems, "increasing the risk of errors".
Because of this, two nurses worked together to administer medications, which took longer.
"In dementia-level care, residents may not be able to respond accurately to nurses' questions. This also adds the risk of mistakes being made where the nurses don't know the residents, as was the case during this outbreak."
The sector should lead the response to any future outbreaks, Wallace said. His association's nursing leadership group was now working with various DHBs, and a clinical review group set up with an exclusive aged-care focus.
There are signs of lessons learned: when it was found a person who later tested positive for Covid-19 visited a Morrinsville rest home, all staff and residents were rapidly swabbed (and subsequently tested negative).
By comparison, St Margaret's residents were only all swabbed 11 days after a staffer returned the first positive test - turning up three undetected cases.
Burwood Hospital
Camille Vincent entered Burwood Hospital singing and humming to herself, and quickly won over her new carers.
"She talked of her home up north, her children, her garden," a nurse who led the team looking after her recalled in a speech at her memorial service.
"She frequently sang waiata under her breath, sometimes breaking into loud vocals with great gusto. And she welcomed anyone to join in - 'Come on, darling, sing!'...she was gentle, she was sweet, and she radiated love."
Camille obliged staff requests for Pokarekare Ana, The Bridge and E pari ra, and fussed over friends on the ward, "rearranging their cuffs or clearing away their cups - a hangover from her long-time caregiving roles".
Nurses heard about her love for her whānau, her garden - particularly dahlias - "her smokes, coffee and the pokies".
Some video calls featured four generations, spread around the world.
Camille delighted in her grandchildren's banter about who was her favourite, the nurse told the gathering, and lay in the sun with a coffee, smiling and "listening to you stir up the memories of her childhood in the Far North".
She had only a mild cough when she arrived, but on the morning of April 16, she stopped singing.
Her children, grandchildren and great-grandchildren spoke to her in te reo on a last video call, laughing at a lifetime's memories.
"And sometimes she laughed too. But now she had laid down and she had closed her eyes," the nurse remembered.
"'Come here, darling,' she said, pulling me close, while I balanced the phone with dozens of your faces, all focussed on her one face. And she held me and I held her back because she was giving all her love to me, as a vessel to pass on to you.
"'Hold on,' I told her, 'there is something very special coming from your whānau.' The dahlias arrived. And Camille quietly left us."