Urgent Debates — COVID-19 Response—Report into Deaths in Self-Isolation

Members, earlier this afternoon, the Speaker accepted an urgent debate application on the findings of the independent review panel into two COVID-19 deaths in self-isolation, and the House gave leave for it to be held following the third reading of the Ahuriri Hapū Claims Settlement Bill. I therefore call on Brooke van Velden to move that the House take note of a matter of urgent public importance.

Thank you, Madam Speaker. I move, That the House take note of a matter of urgent public importance.

People put their faith in this Government every single day that the Government will act with the best intentions to keep them safe—keep them safe from harm. We especially expect this to be done in a time of crisis like the COVID response. That’s why New Zealanders have tuned into announcements every day during lockdowns, to make sure they’re hearing the most up-to-date information about what they can do to keep others in their community safe, to keep their family safe, and to make sure that if they are ill or they have COVID, they know how to keep other members of their community safe. We are all collectively working hard to make sure that we get through this COVID response together. People have stayed at home. They’ve done the right thing. People who have had positive COVID tests have turned themselves in for managed isolation and quarantine (MIQ) spots and done the right thing to prevent infections and spread throughout the community. People have been at home for months with their kids, making sure that they’re not putting their own children in harm’s way. And people have, sadly, been missing their cancer appointments and their screenings and diagnosis. A lot of people have put their lives on hold because the Government has asked us to do the right thing.

In exchange, the expectation is that the Government will do the right thing by New Zealanders and that they will take on that duty of care, and work hard to put New Zealanders first and put our safety first. But this hasn’t happened. New Zealanders have the right to expect good government and expect an efficient system that puts them first. The system has failed New Zealanders, and, in this particular case, it has failed two New Zealanders, who have died as a result of home isolation. I want to acknowledge those people who may be watching who are family members or friends of those two people who died while at home isolating and doing the right thing.

But we have to acknowledge how we ended up in this situation. The Government failed in its duty of care to New Zealanders by consistently being slow off the mark throughout the entire COVID response. We have been slow to put systems in place since COVID hit our shores last year. We’ve had vaccines: they took ages to actually get procured and come to New Zealand and be put in arms. We’ve had the vaccine roll-out, still, to this day, not be complete, but the vaccine passport, at the same time, wasn’t done in tandem, and that’s taken extra time too. We’ve seen delays when it came to rapid antigen testing and putting that in place in communities when it could’ve been done months ago. When we had home isolation, we knew, from talking to doctors in the community, that they were asking for this to be put in place months before the Government actually rolled it out. They were slow making sure that we had a plan to keep New Zealanders safe in their homes. And we have been slow with basic things like making sure that we have ICU capacity in the hospitals. We had 18 months, and not a single new ICU bed put in place. And we’ve also had nurse shortages. You know, I talked to a woman who was locked out of New Zealand, and she was a critical care ICU nurse without her family here in New Zealand, struggling to get back through the border because she wasn’t seen as essential to the COVID response, to get back through the border. That’s how slow and badly planned this COVID response has been.

But when it comes to self-isolation, we weren’t prepared for Delta at all. We had, at the beginning of this latest lockdown, MIQ that was being used, and we knew that the cases would increase as people ran out of MIQ spots. And that’s exactly what happened. So the Government rolled out self-isolation, and they weren’t prepared for what that would actually mean in reality. They announced it after we went into a Delta outbreak. That’s why I’ve brought this debate to Parliament—because people have died at home, at home while they have been isolating away from the community.

Last week, we saw findings of a review into home isolation that said that these deaths were potentially preventable deaths. Deaths that are preventable is extremely significant to Parliament. This is one of the largest errors that policy can make—to lead to potential preventable deaths. There is nothing more significant to people than that they would lose their lives from an error of Parliament and an error of the Government.

I have a real concern, and the ACT Party has a real concern, with what this means for New Zealanders now. We have thousands of people who are currently isolating at home, and as we go into summer, as we see the COVID protection framework being rolled out, which is more commonly referred to as “the traffic light system”, this means that more people will be moving around the country, more people will be contracting COVID-19, and we will see more cases in the community self-isolating. We need to know that the system will actually be prepared for an increased number of cases and that people will have care when they’re doing the right thing by isolating and staying out of the community. It is absolutely essential that we are scrutinising what is happening, because people deserve good care; they have a right to it. If we’re asking people to stay home, we need to ensure that they have faith in the system so that they actually do it. This debate, I have to stress, is not about politics; it is about people. It is about people because people have lost their lives. Two people have died and more are potentially at risk currently self-isolating.

The Minister of Health, Andrew Little, stood in Parliament two weeks ago, after I questioned him in the House, and I asked, “Does he have confidence in the home isolation system?” And the Minister assured me that he did have confidence in the system. He also raised that every person who is COVID positive and isolating at home should have a clinical assessment from a GP or another competent clinician if a GP is not available to assess them when they get a positive case. He also said that we do have metrics for clinical assessment.

But if you look at what has been coming out of these report findings, what the Minister and the people in charge and the Government have been saying is completely different to what the doctors and the people working on the front lines of the COVID response have been seeing in their communities. Papakura GP Dr Harwood said that top officials said that protocols were being followed but that the kōrero on the ground was completely different. People weren’t having contact with public health, and pulse oximeters weren’t being issued to people who did have a positive case. The Counties Manukau chief executive and spokeswoman for the Auckland home isolation system said that the system buckled under pressure.

We need to know that the system can continue going forward, and we have so many questions because the findings of this review said that there were problems with assessments and clinical safety, welfare needs, mental wellbeing of COVID-19 patients, issues with connectivity between all parts of the system to ensure clinical oversight. There was a need for stronger clinical governance, for adequate reporting systems, and rapid, informed review of adverse events.

I don’t want to go too in depth into the cases of the two people who died, out of respect for their families, but there are some issues that do need to be addressed. In the case of case A, it took five days before Healthline even attempted to call him, because the system was overloaded with patients. When Healthline calls went unanswered, the case was not escalated as a case for priority. The man’s whānau were not contacted after he was unable to be reached by Healthline. And his GP first received a written contact eight days after he tested positive.

In the case of case B, the information about his ill health when he was discharged from hospital was not shared with Healthline, despite it being recorded by the hospital staff. The administration of medication that created an artificial sense of patient wellbeing was never considered in an initial or follow-up clinical assessment. Data from his pulse oximeter was not adequately collected, because he had difficulty using it. And a backlogged system meant the appropriate action was not taken when he was determined to be in need of urgent medical review.

The Government and the system failed two New Zealanders, and the ACT Party has questions about what went wrong. We know that we’ve seen some of these report findings, but, importantly, we need to know what changes have been made to the system so that this doesn’t happen again for another New Zealander. We need to know that as we go into summer, thousands of New Zealanders will be safe, they will get the adequate care that they deserve, and they won’t be another one—another person who is let down and loses their life because of bad public policy.

We need to know where the pulse oximeters are for every person who’s got them. We know that the Minister says we have nearly 30,000 pulse oximeters in New Zealand, and yet we’re not issuing them in every case. I don’t understand why we are giving different abilities of care to different New Zealanders throughout the country. Every person should be expected to receive the same amount of care when they are at home.

Why isn’t the Ministry of Health as available as it should be to New Zealanders? Why are some people spending days waiting for a phone call while others will receive them within 24 hours? Why is there not more consistency with the calls? And why is it that some people when we’re being promised that they’ll be contacted by a GP, or somebody who’s clinically trained, are not being contacted by these people? They are being contacted by people who have already gone to the media and said, “We are not adequately trained to deal with this.” I think that is very disappointing.

The actions going forward are that every person should be issued a pulse oximeter. There are thousands of them. We should give them to everybody, not just the ones that the Minister believes are clinically assessed for it. We should be ensuring that GPs and clinically trained people are contacting people who are COVID positive within 24 hours of them having their positive test and then being at home. We need to ensure that the Minister is being transparent. It’s not good enough that the Government can stand up and say that they have confidence in the system and say things are working well, when people who are on the front line are painting a very different picture. We need to know what’s going wrong so it can be rectified. The Government needs scrutiny because people have a right to know what is actually going on. New Zealanders need to know that if they get sick and if they stay at home, they have certainty that they will get good care. There are thousands of people who are currently sitting at home wondering, “Will I be next? Will that happen to me? How am I supposed to know how to keep care of myself if people are not contacting me, to know how I’m supposed to do that?”

I want to just end on acknowledging the two people that did die. I think it is a real shame that this Government and its systems led to that, and I think we can do better and we have to do better for all of those other New Zealanders who are currently self-isolating and who will be self-isolating over summer. We need to provide certainty that they will get the care that they need. Thank you, Madam Speaker.

Thank you, Madam Speaker, and can I begin by firstly acknowledging the tragedy of this situation and of these two deaths, and express my condolences to the families and whānau of these two men who lost their lives when they were isolating at home with COVID.

It’s important, as indeed the member who has just resumed her seat, Brooke van Velden, says, that there is transparency and openness, and it was because of those deaths—it was straight after the first death that the investigation, which is the subject of this report, was commenced. It was a day later that the second death happened and the report was amended to include that second death as well. The report was conducted by a group of people, a number of clinicians, as well as those working in the welfare front line as well. They have concluded their report. They’ve made their findings and they’ve made some recommendations, and they have done that in a matter of weeks, and we now have the benefit of their report. The report writers of course acknowledge that their review and their focus was on the processes from the time at which these men entered the care in the community system to the time of their deaths, but it is for the coroner to rule on cause of death. So I think we do need to pay heed to the content of the report in terms of the processes that they examined for two patients who came under the care of the care in the community system.

I should acknowledge also that the DHBs who are responsible for the organisation that provides the care in community service, the Northern Region Health Coordination Centre—those DHBs have apologised for the failings of that system. Indeed, the DHBs said—and I quote—“We unreservedly accept the findings of the review and apologise to the whānau for the shortfalls in the response provided.” The DHBs go on to acknowledge the input that whānau had into the completion of the report.

It was interesting to note that writers of the report made a comment about the speed with which things were happening, and indeed, at the time they were writing their report, they made the comment, and I quote, “The panel acknowledges that changes to the care and community systems are being introduced daily, informed by the issues that are arising. We are acutely aware that even in the few days of the review period, some of the recommendations we will make are becoming a reality.” So the review panel was aware that as a consequence of these events, changes were already being made.

The review panel also acknowledged the speed of change that was happening around this time, and they acknowledged that the speed with which the number of daily cases was rising in Auckland had overwhelmed the system. They pointed out, for example, that at the time that they were writing the report, the system was supporting 1,255 patients with COVID and their whānau and close contacts: a total of 2,835 people in 885 households. And just a matter of weeks before, there was one organisation being required to support just 50 families at the commencement of the programme. That is how quickly things changed. For the record, there are now over 6,500 people being supported in the system, and that is requiring a daily programme of a size that has never had to be geared up before. None of that is comfort to the whānau and families of these men who have died.

The Government has been acutely aware, since the beginning of the pandemic last year and since the beginning of the August outbreak in Auckland, that the measures that the Government supports and the measures that the health system has to put in place have to prioritise preserving life, and that is what we have done and that is why the track record of this country when it comes to the management of COVID has been to see one of the lowest levels of mortality and one of the lowest case numbers of any country in the world.

As Delta arrived and we managed our response to that, we knew that we had to adapt our system to allow for more people to recover from COVID in the community. That planning started in September. On 14 October, myself and some colleagues confirmed the model that we were adopting, the care in the community model, which was very much based on models that had already been put in place in Canada and in New South Wales. That was the model that was being put in place as Auckland, in particular, was adapting to the rapid rise in case numbers that were experienced at that time. The reality is the system as it was, and during its adaptation, was being overwhelmed and, tragically, the steps that ought to have been taken in relation to these two men were not taken.

The Government had made clear its expectation that the priority is a clinical assessment of those who are being required to isolate at home or to remain at home while they are being cared for. Because the first question is, is that the right place for them to be, and have all the relevant factors been taken into account—both them, their health and their health profile, the rest of the household, and indeed other personal circumstances that might be applicable? So the first question that the system needs to answer is should the person even be at home? The system was used to referring anybody with COVID immediately to a managed isolation facility, but that wasn’t going to continue and it never was going to be a permanent feature, because at some point, as the population became vaccinated and as we became used to COVID and as more therapeutics came on that could help us manage COVID, we knew that we had to prepare for more people being able to recover at home. Those are all the steps that this Government has backed and supported and financed in preparation of a change of mode in response to this virus.

So in addition to prioritising the clinical assessment, we also had to prioritise a welfare assessment. There are some who can look after themselves at home, but not everybody is in that circumstance. There are some people who have a number of other issues, including whānau members, it might be pets, it might be their personal circumstances and their employment relationships and what-have-you that have to also be taken care of. If they are living on their own and they can’t go out and get food, then that has to be supplied and they have to be supported for that as well. So all of that was part of the model that was being put in place and is in place now.

I think what became clear is that the transition from the public health assessment, which was what the system was geared up to do primarily because they knew that once a person had returned a positive test they’d be whistled off to managed isolation or to hospital—but the shift from public health assessment to personal, clinical, and welfare assessment was too slow. The system did not keep up and so the right assessments were not carried out by the right people at the right time. But the reviewers, as they recorded in this report, have noted that changes that they have recommended should be made were already being changed at the very time that they were examining the processes. And I can say with confidence that those processes have changed, and when I see the way the system has responded in other places where the outbreak has just emerged—so, for example, in Nelson last week where an outbreak emerged, I’m confident that the DHB, which like all DHBs had engaged in the preparation planning, was prepared, was ready, was waiting, and was able to respond effectively and quickly and properly to the needs of that community and those who returned positive tests. And that has happened.

There are a number of things that the report has highlighted where there were inadequacies in the system. The reality is some of these have been historical problems, the relics of an extended period of time where the investment in health infrastructure was at an appallingly and embarrassingly low level—so little or no investment in our IT platforms and our health system. So we’re meant to have a national health system, but we allowed 120 different systems to set up because the previous Government just didn’t have its eye on the ball, just ignored the problems. So we now have—we’ve started the investment in an IT platform that means that all the systems talk to each other and are accessible wherever you are in the country. But it wasn’t ready. It hasn’t been ready. We had to build a system especially for our border management when COVID arrived—the border case management system. We had to build that especially for COVID in New Zealand, a system that is accessible nationwide and can track cases coming in. But that was to map people crossing the border who had COVID. That was all it was set up to do, and it had to be adapted, and it has taken time to adapt it to do a much more complex and comprehensive function.

But, see, that’s what happens when you run down a health system, and even with the best effort that has been made in the last four years to massively increase investment and do the massive catch-up job, sometimes you just don’t catch up fast enough. But I acknowledge the work that the health system has done: the Ministry of Health, DHBs, and an amazing health workforce that has, frankly, been under the pump month after month after month, since this virus arrived, to provide the best care possible. But it hasn’t been perfect—but it hasn’t been perfect—and I again acknowledge the tragic loss of these two men.

If there is a lesson in this anywhere at all—and there is a lesson, actually—this virus has highlighted a number of things about our health system. One is that you cannot, year after year, short change our health system and expect a world-class health system 10 years later. Also, we know there is inequity in our health system—huge inequity in our health system—and the light has been truly shone on it in recent months and indicated by these two cases as well, where it is pretty clear, according to the report, that the proper cultural responses were not made; that two Māori men who needed care were not communicated with in an appropriate way. Community organisations who could have provided appropriate intervention were not plugged into the system sufficiently to enable that to happen.

So those things have been acknowledged and those things are known, and the system has adapted and continues to improve and will always continue to improve. When we have events like this—tragic events such as this—we need to know and the system needs to have confidence that it can examine itself, that it can find its shortcomings, and that it can be given the opportunity to overcome its shortcomings and, at the very least, honour the loss of these two men in the improvements that will be made that will be for the benefit of everybody else in Aotearoa New Zealand.

I’m confident that those who have led the system at the DHB level, at the regional health coordination centre level, and at the ministry level have understood what the gaps were and were rapidly trying to deal with them as case numbers were rising, and have taken the steps and made the measures, with the support of Government, with the support of additional investment, to ensure that everything that can possibly be done to prevent this sort of thing happening again has been, and is being, and will continue to be done. That is what we owe people—that is what we owe people.

The member who opened the debate was right when she said that people put their faith in Government to act with best intentions, especially in a crisis like this, and that in exchange for the sacrifices that people have made and are making, every effort is made to ensure the system is as effective as possible. I can assure the member, and I assure this House, that is what has happened. Every person, every public servant, every clinician, every person on the end of a phone, every person involved in the community, the community organisations, the NGOs who have been involved, and everybody in this precinct who gets to be involved and gets to make decisions, that is the value that has underpinned everything we have done. But tragically, it will never be perfect and we have discovered imperfections, and the clinicians and others who put this report together have revealed those imperfections, and steps were being taken at the time, have been taken since, and are being taken now to make sure we have the best system possible to respond to COVID, not just in Tāmaki-makau-rau any more, and Waikato, but right around the motu, right around Aotearoa New Zealand, and I’m confident the system is a good one.

Thank you very much, Madam Assistant Speaker. If I could give you the “too long; didn’t read” version of that Minister’s lamentable 15-minute contribution to this very important debate, it would be: “Two people have died in preventable ways in a Government-run home isolation system. That’s terrible and we weren’t ready.” That’s basically the short summary of a very lamentable 15-minute contribution in this debate, which is: we accept that two people have died in preventable ways—and that’s to quote the northern health organisations’ review of those deaths—we don’t like that, that’s regrettable, and the system wasn’t ready.

Well, my question to the Government is: why was the system not ready? What we had was a stunning admission just then from the Government, and in their response to media reports of these deaths, that the system was not schooled up, the system was not geared up to cope with the number of daily cases that presented in this most recent outbreak. And I quote the Minister: “The system wasn’t ready for the rapid escalation in the number of daily cases. … [We expected] 100 to 120 cases a day. … [We were not ready for] 150 to 200.”

Here’s a question. Why was the system not ready? When is Andrew Little as the Minister of Health going to stop blaming everyone other than the Government and his own ministry for the failings that he presides over? Because the thing that has come through with this Government, whether it’s vaccination passes or business or the health system readiness or rapid antigen testing, or anything at all—when it comes to COVID, the clear theme that comes through is it’s everybody else’s fault but the Government’s. Everything that happens is everyone else’s fault. It’s never the responsibility of the Ministers. They’re always able to disclaim responsibility. It’s always somebody else’s fault.

Well, the question for Andrew Little and the Government Ministers that will follow in this very important debate moved by Brooke van Velden is: why was the system not ready? Why has Sir Brian Roche written a report to Government in September this year, 23 September, saying that there are urgent issues with respect to New Zealand’s preparedness for reconnecting—in other words, opening up. And the current outbreak—and remember, this is in September and the outbreak started in August—has revealed the very poor level of preparedness of the hospital systems for Delta. Why is that the case?

I put it to you that, unfortunately, the Government spent the first few months of this year assuming that elimination would work. They assumed that they’d run the same playbook as 2020, which was very successful, which was that we would erect the border barriers, not let anybody in, and we would use the hard measures of lockdowns to eliminate COVID from New Zealand again. The reason I say that I think the Government thought that is because that’s pretty much what the Prime Minister said. When Delta turned up on 17 August and it had been in the community for a few days, but the first case came through the system on 17 August—everyone remembers; here we go again. Delta has arrived; 20 percent vaccination. The numbers were so low. The Prime Minister turned up on national television and she said “short and sharp”. Remember that? Remember a “short and sharp lockdown”?

Poor old David Seymour got a $3,000 parking bill because he believed her. I would have thought a guy who’s been in Parliament for four years would know better than to believe the Prime Minister, when it comes to exhortations from the podium of truth or the podium of mistruth, as is now being called—the podium of platitudes, as we now call it on this side, because that’s all we get these days. We don’t get the truth from the podium; we get platitudes. But I would have thought David Seymour as an experienced member of Parliament would know better than to believe what he listens to from that podium. He got a $3,000 parking fine, poor guy, because he thought it was going to be short and sharp. What’s that?

💬 David Seymour: You can’t even trust the PM with your parking now.

You can’t even trust the Prime Minister with your parking. He thought it would be short and sharp. And as it turned out, because there was no prep work whatsoever for Delta, it was not short and sharp, and because our vaccination rates were so low—20 percent in mid-August—we had to do the lockdown and it went on and on because there was no prep work for Delta.

And as it turned out, as the outbreak persisted, the Government had no idea what to do. Now, a sensible Government would have listened to people like Rako Science, who said, “Let’s scale up the testing—let’s scale up the saliva testing that we can provide. Let’s carpet-bomb South Auckland with rapid antigen tests to try and find as many people with COVID as possible.” But no, no, no. This smart Government that eliminated COVID last year, they knew better. They’d just run the 2020 playbook and all would be well. Well, actually, what happened was all was not well, and we have now spent four months, the better part of the last four months of this year, in Auckland in a lockdown which is only now lessening. There was no back-up plan from the Government. I don’t like using the word “Plan B”, because of the connotations that that has come to be associated with. So I talk about back-up plan. There was no back-up plan. It was assumed that elimination would work.

And we know from the Government’s own documents that from August the officials were writing to Ministers Peeni Henare and David Clark. They were writing to the Ministers saying: we are now starting some work on Delta. In August! Why were the officials writing to Ministers in August, saying things like: “We’re setting up a work programme to consider the effect of Delta on New Zealand.”? Hmm. What a sensible idea that would be! I’ll tell you when it would have been a sensible idea to do: maybe back in March and April, because Delta was in managed isolation and quarantine (MIQ) from the first week of April. The Prime Minister says, “Oh, well, Delta. It’s a very tricky virus, you know. Look, there’s no playbook for it.” Actually, there was a playbook. We knew what was coming because we were the last to get it. That’s the other thing. We were the last to get Delta because we’re at the bottom of the world and we had these high barriers, and we looked at the UK and we looked at the United States and we looked at Australia and we knew that it was going to come. But the Government only got on top of doing some work on it in August—in August! It’s just unfathomable when it was in MIQ since April. That is the context for this report.

The Government should have been ready. It was as clear as day to anybody that at some point COVID was going to turn up here again and we had to be ready for it, and the Government had no plan. That’s the context with which this report comes, because if you read the report, it makes it very clear that the Government had to very quickly stand up a home isolation system. Just read it. Page five: “The speed of change mandated by the rapid rise in cases cannot be over-emphasised, with consequences including confusion and delayed response. … the rapid increase in the number of patients requiring the service far exceeded planning and expectations. Capacity … was initially overwhelmed.” That’s in the report and the Minister accepts it. The Minister accepts the findings of the report and he says, “Well, we’ll put it right.”

Well, that’s all very well and good now, but we need to know, and the House needs to know, why that was not done earlier. Why did the Government spend April, May, June, July, August, September in denial about what Delta would bring?

💬 Barbara Kuriger: Because they’re hopeless.

Because they’re hopeless, says Barbara Kuriger. Why did the Government spend all that time assuming that elimination would work? It’s possible to walk and chew gum at the same time, or it should be, for a competent Government. Clearly, we had to try and make elimination work. No one doubts that as a strategy. We adopted an elimination strategy that enjoyed bipartisan support across the Parliament, particularly in the first six months of this year. Clearly, we had to make elimination work, but you don’t put all your eggs in one basket. You do not. You have to plan for the future.

What the Government should have been doing was saying, “In the event that Delta turns up, it will spread. What will we do when it does? Well, we’re going to end up with a lot of cases in ICU and a lot of cases in hospital, and we’re going to end up with some cases in the community; we need a plan for that.” What is so clear from these documents, from reading the Sir Brian Roche advice of September and reading the Northern Region Health Coordination Centre’s own report is that no one bothered to do that. No one bothered to say: go away and do some work on home isolation. I got an Official Information Act (OIA) response from the Whanganui DHB the other day. Three weeks ago, I OIA’d them and I said, “What’s your home isolation plan? I want to see a copy of it.” They hadn’t even produced one. This was three weeks ago, in mid-November. You know, you ask yourself why that is the case, and the reality is there’s probably no central direction. So I find this incredibly depressing, because it was so clear that we needed to be planning for the future.

Good government is not just about responding to what’s in front of you on a day-to-day basis; it’s not. It’s not just about reacting week by week and turning up in question time and saying things are OK when they’re not. That’s not good government. Good government is thinking ahead. Good government is actually directing the officials to think ahead and to think about what’s coming. And the tragedy of these reports and the tragedy of these two poor men who have died is they died in preventable ways. That’s what the report says. If this Government had been on the job and competent from the outset, they would not have died. Thank you very much.

E te Māngai o te Whare, tēnā koe. Nā, te mea tuatahi he mihi aroha ki te whānau pani o ērā tāne. Mauria mai ngā tini aituā hei tangihia hei maumaharatia. Haere ki te puna wairua, ki te puna roimata, ki te puna tangata. Haere, haere, haere atu rā.

[Madam Speaker, greetings. Firstly, I would like send my condolences to the bereaved families of those men. Carry with you the many deaths that need to be mourned and remembered. Go to the spring of the spirit, to the well of tears, to the source of life. May they rest in peace.]

I begin today by acknowledging the whānau and friends of these men—people who loved them, who are mourning, and who are rightfully angry at these tragic and seemingly completely preventable deaths. We’ll take part in this debate because we want to honour their lives and all the people who have so far passed away from this pandemic. We hope that it will continue to be the wake-up call that the Government needs, but we acknowledge the hard work of the Government. We acknowledge how hard our health workers, our community people, how everybody has rallied, and Māori communities and Pasifika, all our migrant people—everybody is working as hard as they can. They are tired. They are really tired.

However, some of this, and the impact on Māori, is because of some key strategic decisions that were made that from the beginning have impacted on us. So, from day one, the Government decided against an equity approach. An age-based vaccination roll-out inherently and completely disadvantaged Māori from the beginning because of our underlying health conditions that see us die on average 20 years younger, because of overcrowded housing, but mostly because of the institutional racism that the health system is set up on. That’s just not me and the Greens saying that. In this report, and I quote, “Most importantly the system design 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”—this is the community supported isolation and quarantine—“system could further magnify this inequity.” So that is the place we start from.

Every single Māori and even non-Māori expert that we have spoken to and that I have questioned in the Health Committee that has gone on record has agreed that even if the rest of the country has 100 percent vaccinations, if Māori do not, it doesn’t matter. They will be fine generally; we will not. So we make up about half of the cases, despite being less than 20 percent of the population. Nearly 85 percent of Māori have had one dose; that is great, that is awesome—72 percent have had two. While nearly all DHBs have reached that magic 90 percent first dose, and Tai Rāwhiti is so close, only two DHBs in the country have got 90 percent of Māori that have had their first dose.

And when we look at this report that has been done, I was so, so sad reading this, because I know how hard people in our health workforce are working. No one there wants to make mistakes. No one wanted to be the person who realised that the call wasn’t made because of the technology. Those are horrible, horrible reasons and horrible things to deal with in your work. What struck me, though, in both these cases is it was not just one thing that happened; it was a succession of things that went wrong. Things escalated, and in some cases the escalation that should have happened never did.

So we acknowledge things are moving very, very fast. We acknowledge we’re trying to work things out with old systems. We acknowledge that the health system has multiple systems that do not speak to each other, and that holds us back not just for this, but in probably most aspects of health. And the new health system—we’re looking and waiting for the magical IT unified system that will have no glitches, that will speak to everybody and everybody’s information will be updated, their correct name and gender will be in the system, their iwi, perhaps, will be connected to their name.

So supporting our workforce. People need everything in place to do their job well. We understand the key times, the key places where our most qualified people need to make the decision. People on the end of a phone who are not qualified cannot make those assessments. They can triage things, they can tell you who to call, but we need those systems in place. We need enough of those people with those qualifications. I absolutely agree with my colleagues who are saying, “What are we doing about all those people who are waiting to come here but do not have an MIQ spot? Qualified health workers that we need right now in our system.” We need to unify the families of people who have come here for that purpose, because that’s a health and wellbeing thing for our staff.

We absolutely need the technology that allows people to do their job properly, but we also need those strong local connections. My first thing when I hear somebody’s self-isolating, it’s like, “Where are they?” Lots of us are living in overcrowded spaces. Where have they gone to be by themselves? And it may be, because we don’t know all the details, that these were people who lived alone, but where were their families? Why were their families not told? So those local connections—who’s stepping in to check on them? Who’s coming to just see if they’re all right, even if they’re standing outside the door to have a chat? Who’s bringing them food? Who’s making sure their cat’s all right?

It really disturbed me, that thing about the oximeter, because some of our people who are given these pieces of technology to use—and it said in the review that even though they were struggling with it and didn’t know how to use it, they were still sent away with them. Now, that was critical to monitoring that person that it was used and updated, because they didn’t know how to use it, the information wasn’t updated, so one of the ways the alert could have been raised never happened. A simple, simple thing of someone going to the house and checking they know how to use it.

I’ve spoken in this House before about whare tapa whā; that our health system mainly focuses on the tinana, the bodily integrity, what happens to our physical self. But I think one of those other aspects is around whānau. We have to stop treating each case as an individual and look at where they fit in their whānau, who is their community of support around them, and then helping resource those whānau, those community people who will be the ones that will go in and check on them—their hinengaro; their mental wellbeing. These are unprecedented times, but actually we’ve had things like this before, because, for Māori, even though COVID impacts on Māori disproportionately, it’s just the latest thing. There’ll be something after this. We’re not designed for these Pākehā diseases. We are pinning all of our hope on the Māori Health Authority. There’s a lot of burden going on this one little statutory authority to fix—centuries of problems with Māori health, but this one is happening right now. So for the same reason that the Government knew they had to set up an independent Māori authority if they wanted to make an impact on Māori health for COVID, for whether it’s home isolation, whether it’s MIQ, however things are rolling out, if you want Māori to live, you ask the Māori experts what to do and then you do it. Nō reira, tēnā koutou, tēnā koutou, kia ora huihui mai tātou katoa.

E aku apa whatukura e te ika huirua kua riro atu ki te pō, kia tāpai ake ki tini kua riro atu i tēnei tāima o te urutā, kia tangihia wā tātou mate ki te tāhuhu kōrero o tō tātou Whare e tū nei. Ki a koutou katoa kua riro atu ki te pō, haere mai, haere.

Ka whakahokia mai ngā rārangi kōrero ki a tātou, e te Māngai o te Whare, tēnā koe, kia ora tātou katoa.

[To my many spiritual ancestors and to the two victims who have recently passed away, adding to the many who have passed during the time of this epidemic, let us lament our dead as they pass into the history of this House. To all those who have passed away, may you rest in peace.

Bringing the discussions back to ourselves, Madam Speaker, greetings to you and greetings to all.]

As I have done on many occasions, I stand first to lament the loss of these two gentlemen. Of course we send them and farewell them, with all of those whom we’ve farewelled during this tricky time and challenging time of COVID-19, whether they’ve passed because of the disease of COVID-19 or whether they’ve passed during the time of lockdown. We know that these particular challenges on our whānau have been heightened in the Māori community, heightened in the Pacific community, but I will say this: heightened across all communities of Aotearoa. And I want to take the opportunity to farewell them and farewell them appropriately here in the House.

The Minister of Health has already explained that we accept the recommendations from this report. We know that, as COVID-19 has been in our community, in particular over the last four months, we have required a system that must be agile and nimble during what is a particularly tricky time, and if I can echo the sentiments of our colleague Dr Kerekere in thanking a hard-working health sector—and I mean hard-working. I’ve travelled the country to meet with Māori health providers, primary health organisations (PHOs), pharmacies, health leadership, and I acknowledge the role that they’ve played in adapting to these tricky COVID times and making sure they can continue to serve their community and not in a one-size-fits-all approach. And I’ll come to that a little bit later in my contribution, as we look towards what the report recommends and how we might continue to make sure that we’ve got a better system that will continue to serve our people, as we look towards the new protection framework and, of course, the 15 December date that has been offered to allow the people in Tāmaki-makau-rau more freedoms across the country and the ability to travel. What we know, in the conversations in the community, is that, while we count down to 15 December, communities right across the country are looking towards the right model that suits them for care in the community. And I can say that if we get the framework right, the leadership right, the most important part will be how we connect it to the execution on the ground—the way that we implement it amongst our people—and that’s going to be key.

If we look towards these two gentlemen and acknowledge their Māori whakapapa—and Dr Kerekere is right in saying that we can’t simply look towards a clinical assessment. While we acknowledge, in the report, that that was lacking, we acknowledge too that that must be one of the first priorities as we find whānau members and community members who contract COVID, to have a clear clinical assessment early. From there, we must look towards the entire system to cater for them and their whānau. And I want to give an example: what we know, in recent times, is a particular person in a whānau has contracted COVID-19, and what’s happened is that the health response was strong—actually, a strong clinical assessment, a strong connection with the whānau—and then, sadly, what happened was the social connection wasn’t there. In a remote area, how was that whānau supposed to be able to go and get the needs of their tamariki, their mokopuna who all live in the same house? And who stepped into the breach? Māori health providers—Māori health providers. And we’ve heard it right across the country. I suspect members right across the country have heard the same line: trusted members of the community—not just anybody but a trusted member, and a skilled member, and the right person in that community to continue to work with that family.

So we accept these recommendations, and as the report already outlines, we’ve already gone some way to making sure that we can fulfil those recommendations, to make sure we can adjust the system to be able to respond. And I want to come back to a previous point I’ve made: it is important that we have a good structure and good leadership here, but the system must be able to respond according to its environment, and we know that these particular cases are in Tāmaki-makau-rau, where, despite the challenges on the health sector, there is a health infrastructure there that you will not find in either Kaitāia, Te Tai Rāwhiti, and more remote, rural area across Aotearoa. So we need to make sure the settings are right to allow the ability for our providers in our community to lead the isolation at home. And I want to come to that very shortly.

I want to address a couple of the points that have already been made by members from the other side of the House. One of them is: “OK, what has the Government done to be able to prepare ourselves for COVID-19?”—and in particular the Delta strain. I have been travelling the length of this country since March to promote the most effective tool to protect our whānau during these times, whether it was before Delta or even after Delta, and that is the vaccine. I can tell you that certain members on the other side of the House have proven a roadblock or challenged the push for equity in this space as we’ve looked to support Māori communities to vaccinate, to make sure that our people have the number one tool that will help them in the onset of COVID-19 in their community. Those efforts continue today, and I want to be clear to the Māori community in particular, but also to our Pacific community, our ethnic communities, and our tangata whaikaha communities: we will not give up on you. We will continue to push the vaccine to make sure it’s readily available to you, to help give you the best protection as we move forward.

The other part I want to touch on is, of course—right, we accept the recommendations of the review, of the report—where to from here? And I’m actually quite proud to stand here and say that, about a month and a half ago, we announced a significant investment of funds to be able to make sure that, amongst iwi and in particular in Māori communities, we can support them now to do the planning for care in community. And I’ll tell you what makes that special: not only do we have the health expertise to be able to do that, led by Māori health providers, PHOs, and regions, but we also have the more fulsome tapa whā model that Dr Kerekere refers to that are led by iwi, led by hapū, led by Māori communities.

And I want to really emphasise that point, because I’ll tell you why: in recent days, a member from the ACT Party has likened the actions of iwi to protect their community to thuggery, calling them thugs. Now, what we know is that for this model to be successful, we need iwi on board. In fact, I’ve seen multiple iwi plans for care in community which are fantastic—iwi-led, community-led. For example, Ngāti Tūwharetoa showed me their plan, which would look toward isolating the case of COVID. They’d wrap around support in the whānau, and instead of putting the positive case into the marae, what they’ll do is take in the whānau, those who test negative, and put them on to the marae, where we would normally care for and cater for our whānau while wrapping the health services around the positive case isolating at home. Now, that’s how you do Māori care in community, and the support that we are giving iwi to plan this, to lead this amongst our own people, in our own communities is really important. Now, that planning isn’t just done in Tāmaki-makau-rau, where a large percentage of our Māori population are. In fact, 74 percent of Ngāpuhi live in Tāmaki-makau-rau. What it also does is support our more rural, isolated communities, and that’s going to be the key so that we don’t repeat the mistakes that have been identified in this report.

So we’ve got a job to do to continue to support those efforts, and I acknowledge that as we look towards care in the community, as we look towards making sure that Māori actually can play a lead role in this space, we need to continue to drive home some very key messages to our community: (1) vaccination. Our rates are climbing for Māori, and I’m proud of that. In fact, if we look towards all the vaccination programmes ever run in this country, we have now well exceeded the best that Māori communities have ever done in the past on a vaccination programme. Long may that continue. The next one is to allow the space and to resource Māori communities to do this. And I’m proud to say that on this side of the House, we are doing that now, and we will continue to do that. Ultimately, though, as we look towards the way that we care in community and the 15 December date that I’ve already mentioned, who’s going to lead this? It is going to be our community. It’ll get there with strong health leadership from the centre, from this Government, from health infrastructure across the country, and I’m confident that, as we move forward into the coming weeks and months, we will manage this well during summer.

Thank you, Madam Speaker. I te tuatahi, ki ēnei mate, haere ki te kāinga tūturu o tō tātou Matua i te Rangi, moe mai, moe mai rā.

[Firstly, to those who have passed, go to the permanent dwelling place of our Father in Heaven; may you rest in peace.]

First of all, I want to acknowledge these two people who have succumbed to this terrible disease and extend thoughts to them, and particularly to their family. I want to, in this offering, address several parts around these very sad reports. First of all, why did this happen? Secondly, what actually happened? And third, most importantly, where to from here?

The question of why this happened—well, this is a sad tragedy of being underprepared through this report. The Government was underprepared for increasing community cases, and while it’s alluded to in the report, I actually find the answers in written question No. 52015, which asks questions around home isolation. The answer to this question was this: “A rapid increase in COVID-19 cases during the August 2021 community outbreak put pressure on managed isolation and quarantine (MIQ) places and it was necessary to quickly implement a community isolation and quarantine option.”—it was necessary to quickly implement a community isolation and quarantine option.

This Government was unprepared. They had 18 months from the first COVID outbreak in 2020, and yet when COVID cases went up this year in August 2021, 18 months later, they had to quickly look at implementing a community isolation programme—hospital at home. When did we start doing ICU-lite? Surely that’s an oxymoron in itself. When did we start pushing cases out into the community and saying, “Oh, by the way, our health system’s unprepared, so you just help yourself.”? “Oh, by the way, we’ll give you one of these things.”, which is the pulse oximeter that I keep in Parliament for who knows when. When we say, “Here’s your hospital at home. Good luck to you. God bless you. Figure it out.”, when did that happen? When did we start saying to the community, “You’re responsible, because we don’t prepare the health system properly, and you just figure it out.” Because that’s what it looks like through these cases here.

If we look at what actually happened—reading through the cases themselves is quite revealing, and there’s a number of points, but I’ve broken it down to two: first of all, the risk factors, and secondly, communication. In case A, the risk factors were very clear. The person was living alone and they were unvaccinated. So the risks start going up just by virtue of that, quite aside from any of their personal demographics, how old they were, what other pre-existing conditions they may have. That was risk enough, as is being pointed out in the case review.

Then, secondly, for me, it’s the communication aspect. What didn’t we learn from the KFC worker in South Auckland who could not be contacted? They didn’t bother to turn and knock at the door. Three or four days later, as I recall, was when they were first contacted, and we’ve revisited that same mistake. We have not been a learning enterprise during coronavirus.

Here’s what the findings from the case reviews are for case A around communication: there was a five-day delay in the COVID Healthline making the first attempt at phone contact. How can that be? Discharged home, sent home, and five days before Healthline makes contact. Then when that failed, case A’s whānau were not contacted. How can that be? Written contact—and I’ll come back to primary care—with case A’s last known GP was not made until many days later. Secondly, the information that was seeking to be collected was poor quality, it wasn’t clear, it was inconsistent. We should have learnt from the outbreak last year many, many things that would have helped this time. Again, communication. If I look at case A, I pull out two things: risk factors and communication.

If I look at case B, there’s two slightly different things here—a little bit different. I need to acknowledge it’s always hard when a person self-discharges against advice. That’s challenging. They’re making a call of their own autonomy, and it’s against medical advice. That just raises the risks. It is what it is. That was the call. That raises the risks. It should have raised the response as well. But, in fact, what happened was the public health team weren’t aware of the self-discharge status, and when they were sent home, they were sent home with a pulse oximeter, by all accounts, looking at the findings, with really not much health literacy around what that means.

I think we need to be careful we don’t overreach with pulse oximeters. They’re just one measure, one tool to assess a person’s status. For example, you’ve got to think of it like a thermometer. If I take someone’s temperature and they’re a normal temperature, if they look sick, they’re sick. I don’t care what their thermometer is saying. So you’ve got to weigh up a whole lot of other things, not just the oxygen sats or the pulse that the pulse oximeter is telling you.

If I wanted to make it something more ubiquitous in the environment, I think of it like a peak flow meter. People will have more of a sense of that. Those people with asthma who blow get a peak respiratory flow rate through their peak flow meter. A pulse oximeter is just like that. It’s just a measure. If the person’s short of breath and they’ve got other things going on with them, actually, that’s the whole picture we need to be talking about. So I don’t want to be distracted. This is not a hospital in the home. It’s not ICU-lite. It’s just one tool that needs to have a lot of health literacy around it to do a good job. I accept some of the overseas studies that have shown that it’s important, and I think it probably is, but we’ve got to wrap around the other education parts to make it really effective.

So then what also happened was it failed to have primary care involved. So on 18 October, Allan Moffitt from ProCare goes to a meeting with the Northern Region Health Coordination Centre (NHRCC) and he’s angry. He’s angry because primary care haven’t been involved, because what the system tried to do initially was say, “Nah, we’re not going to involve primary care. What we’ll actually do is we’ll use the doctors in MIQ. The few that we’ve got who are managing MIQ, they’re going to be our response. They’ll do the hospital at home.”, and that failed miserably. GPs were telling them, “This will fail. If you don’t involve us, what’s going to happen is when you get overwhelmed, it will drop back on us. We will again be the safety net.” Sure enough, that’s what played out.

So Allan Moffitt goes to a meeting with NHRCC on 18 October, and he’s ready to do “battle” with the system to say, “We have to be involved.” Thankfully, when he got there, by all accounts, they’d also figured it out—“Oh, we’re going to have to have primary care involved. Yes, Allan, you’re right. Let’s sweep in behind ProCare. Let’s bring others on board.” Late again—just as late as primary care has been to give the vaccine, like pharmacies have been late to give the vaccine.

Big shout-out to pharmacies printing out the COVID passports, by the way. My goodness, we’d be struggling if they weren’t doing that for older people and laminating it. Shout-out to pharmacy. Thanks for doing that. That’s really helpful. But, again, they’ve been late to other parts of this response.

So we need to get to the “What next?” What learnings are we going to take from this? What do we understand could be a better response than what has been? So we already said it was hopeless, it was late, it was underprepared—yeah, yeah, yeah. So what are we going to do tomorrow? I must admit, some of the recommendations in the investigation are useful: the piloting of new models with Māori and Pasifika providers to provide holistic clinical social welfare and mental wellbeing support—that’s a good idea. I’m a big fan of treating people in a culturally competent context. You get a better outcome.

Immediate clinical assessment using information already available—so this is going to be integration with primary care databases. What we’re struggling on one level with Whānau Ora and John Tamihere—struggling with that. But one of the cases, it was very clear that the information was held in the primary care database. The discharge summary hadn’t got out to the public health people, and that would have been extremely useful if it had.

Reduction of the time taken between a positive test and the first clinical assessment—that must be another key performance indicator (KPI). As we’re assessing the system, as we’re assessing contact tracing—that should be a KPI. Give it a number, something that people can be accountable for. From your positive test to the time you’re first called for a clinical assessment it should be this, and then report it. Put it out in the public domain. Be transparent with it, so we can all hold ourselves accountable.

The launch of a hospital in the home initiative across all three DHBs for cases needing a lot of health support—that’s what we’re talking about. Door knocking for those who are not able to be contacted, particularly those isolating alone. We should have learnt this from the KFC worker in South Auckland a year ago. This was exactly that situation. We did not learn. When they cannot be contacted a certain number of times, hop in the car and knock on the door, surely. The establishment of a Community Supported Isolation and Quarantine System clinical governance group with the purpose of identifying emerging risks and trends—that’s just appropriate self-monitoring.

Here’s one of my concerns: so this whole philosophy of hospital at home. On one level, it does have a place. But here’s my concern—because this is fundamentally what the business case for the whole health sector reforms are predicated on: keep people at home, don’t send them to hospital, kick them out early, so you’ve got an early discharge, and push them back into the community. Look at the business case. Look at the business case and the risks for the health sector reforms, and it is exactly this. My concern is this is what we’re going to see, because this is how capable they are at managing health at home, this is how capable they are at managing hospitals at home, and this is what the business case—have a look at the risks. It’s really clear for both the Māori Health Authority and for Health New Zealand. This is where the money’s going to be made. This is the big saving. Oh, and by the way, there’s no mention of primary care or how exactly this is supposed to roll out. But that’s where the cost-benefits lie in this keeping people at home. I’d have to say, the track record from this Government in these two cases of doing that successfully gives me a sense of foreboding for the whole health sector reforms.

This has been a fail. Pick up the learnings. Do a better job. We’re happy to help with that, but we need to do a better job. Thank you, Madam Speaker.

Members, the time has come for me to leave the chair for the dinner break. I will resume the chair at 7 p.m.

Sitting suspended from 6 p.m. to 7 p.m.

Members, the House is resumed. Before the dinner break, we were in an urgent debate, and we’re up to a Labour Party call—five minutes.

I want to share my condolences with the families of the two men whose deaths were investigated as part of the report that we are currently debating tonight. If I reflect upon the families of patients who have passed away, who I have worked with, I think about the universal sense that I picked up from those families: that they want to see lessons learnt to understand what went wrong, if anything, for their family members, so that systems can improve. For that reason, I thank those families for being forthcoming with the investigations that were undertaken in relation to those two deaths so that we can find out how to better improve our systems, and in case these deaths could have been prevented.

It’s important to note that the review that we have seen published relates to a moment in time—a specific moment in time—when the community self-isolation and quarantine model was being rapidly scaled. As the results of the review say, many of the findings of it have already been implemented.

I want to talk about a few areas—those relating to process, equity, and information technology. It is clear that there were areas where either the processes were not followed or those processes were not suitable, and there are areas of gaps in communication—communication that should have occurred and didn’t. These certainly contributed to the care of both men and may have contributed to their outcomes.

It’s worth noting that there are a variety of systems improvements under way. Notably, all patients being cared for in the model will be clinically assessed within 24 hours of their being diagnosed. There are scheduled health and welfare checks and clear information to be provided to patients. Underpinning all of this are clinical protocols including assessments and escalation pathways.

I was surprised by the comments of Dr Reti, the last speaker in this debate. He described this system as “ICU-lite”. That’s surprising to me, having cared for people with infections in this country for a long time, because we know that the vast majority of influenza is treated in the community. The vast majority of pneumonias are treated in the community. Of course the COVID response involves standing up appropriate clinical care in the community. That is the only feasible way to really care for COVID at any scale. So I am surprised that Mr Reti seems to have a different view on this and that the idea that high quality care should be provided in the community isn’t a goal he shares.

We need to think carefully about equity in the roll-out of these plans. The reason why equity matters is that most of our patients that we are caring for will be people who are unvaccinated. Increasingly, by definition, people who are unvaccinated have some type of barrier in accessing care—whether that is their socio-economic status, cultural or language barriers, prior bad experiences in the health system, or lack of trust in the Government, even. Our challenge for our health services is that those who need us most now will be those that we have traditionally struggled to serve. That’s why there are important improvements under way, including the involvement of Māori and Pacific providers to provide that manaaki—that early wraparound support—in the patient journey.

Finally, the reports document the decades of under-investment that have led to information technology problems that are widespread. I think anyone who works in our health system will not be surprised that things like primary care data are not available to specialist or other services. I’m proud that this Government has worked to remediate those things through historic investments in our health information technology systems.

We honour those who have died from COVID-19 by learning from their deaths. I am pleased for the opportunity to debate this report. I thank the member from ACT for initiating this debate so that we can have the opportunity to cast light on these findings. The lessons are at the heart of the community-care model that Minister Little has now implemented. It is with these lessons in mind that we go forward and make sure that New Zealanders can have confidence that we can care for them, should they have COVID in the future.

I rise to speak on the independent review into the deaths of two people who tested positive with COVID-19 who were self-isolating, and I wish to acknowledge the ACT member for bringing this urgent debate to this House. I also want to acknowledge the two gentlemen, one 60 years old and one 50 years old, from Glen Eden and Mount Eden, who died on 3 November and 5 November. I want to acknowledge their family, their whānau, and their friends. These were tragic deaths, and that is acknowledged in this House.

I also want to acknowledge the independent committee that has prepared this report, in particular Dr Jonathan Christiansen, the chief medical officer from Waitematā District Health Board, and Dr Penny Andrew—both individuals that I have worked with closely when I was at that district health board, both individuals who I hold in very high regard and are respected within their sector. I also want to acknowledge Selah Hart, who has contributed as part of that committee as well—her contribution in terms of Māori health and progress within that sector is to be acknowledged—and Norma Lane, who previously was a member of the executive with St John Ambulance.

The report indicated four recommendations, and I think we’ve heard in the House today what they are, but the need for earlier assessment of clinical safety, welfare, and mental health was one of the significant findings. The finding in regards to better connectivity between the parts of the system and particularly around the clinical oversight was also a factor that played into the sad outcome that we were dealing with here, and the heightened focus around equity and cultural safety, particularly for Māori and Pasifika. Lastly, I think the important recommendation was around the need for strong clinical governance and adequate reporting systems and the need for that to be very agile in terms of the pace at which it operates. These deaths, as the committee and the panel have found—both deaths—were potentially preventable and there were missed opportunities contributing to that outcome.

The accountability for the system failures falls squarely with the Minister and this Government. The lack of preparedness in regards to COVID-19 has been highlighted by the findings recently in the last couple of weeks by Sir Brian Roche. The lack of planning in the response has been indicated—the Government had adequate time to prepare for this eventuality—and the lack of engagement with primary care, which I think has been raised, and particularly by Dr Shane Reti. Primary care, which sits at the heart of delivery of healthcare services within our communities; primary care, who were left outside for too long before being engaged.

I also want to acknowledge the St John Ambulance crews who responded to at least one of the victims, according to media reports, and just acknowledge the challenges and difficulties which those individuals face day to day as first responders, in responding to what are difficult clinical challenges, and the role which they do, and for all the officers that are out there right now protecting and keeping our community safe.

The Deputy Prime Minister noted after the sad passing of these two individuals that at the time he remained confident in the self-isolation system. The Director-General of Health, Dr Ashley Bloomfield, was quoted just after, saying that the home isolation system was working well overall. It is clear—crystal clear—from this independent review that the findings of the review show that the reality of the situation of systematic failures is very different from what has been quoted.

I also want to just acknowledge some of the comments that the Minister of Health made this evening—acknowledgment that, actually, part of this failure is due to the poor delivery of prior Governments. In a quote: “sometimes you … don’t catch up fast enough.” was the type of feedback that we’ve had from a Minister. What this shows very clearly is a Minister who is not willing to take responsibility, a Minister who is not willing to accept the accountability of his office, and, as a result, the system has failed two Kiwis.

The lesson here from these findings is that we need to and must do better. We must protect those most vulnerable within our communities, and this Government, this House, must take every action necessary in order to protect those individuals and take accountability for those actions, as and when they are required. Mr Speaker, thank you.

Thank you, Mr Speaker, for this opportunity. I want to acknowledge the contributions made by people across the House on this particular matter.

I acknowledge the ACT Party for raising this debate on a matter that’s quite painful, particularly when we acknowledge that two people have died, which has been part of this report. I want to convey, on behalf of this side of the House, our sincere condolences to the men who are tabled in this report who died in the month of November. No amount of rhetoric in this House will bring back the lives of the loved ones belonging to those extended families in Auckland. I think perhaps what we can look at is that by acknowledging the mistakes that the system has made—and all of us have a part to play in that—and looking at how we can improve the health system, that’s the kind of legacy that I’m hopeful will remove the pain that the whānau of the two men referred to in this report feel. Condolences to them for their loss.

It’s also important to acknowledge the staff of our health system, both the Northern Regional Health Coordination Centre across the Auckland region and everybody that has been working at the grassroots level. Most of us in this House have no idea of the kind of effort that has gone in from last year, which was a very different scene, to this year, which, again, is very different from last year.

As painful as it is for everybody concerned, I want to acknowledge and thank the members of the independent panels who have been part of this report and those who volunteered to give feedback to the independent members. It would not have been easy, but here’s the thing, ladies and gentlemen: our health system is one where we do not blame our people, because we need to adopt this no-blame system so that people working in the health system are able to feel confident in coming forward and in acknowledging the faults and the flaws of a system, and it is our task as politicians to make sure that we pick up on the recommendations—every single one of those recommendations—and improve on it.

So to those who are part of the health system in Auckland, but I know also those throughout the whole country in the health system stand in solidarity, I am one of many of our Ministers who sit in, day in, day out, and hear the day-to-day reports from our health workers. There are times when I’m upset with the way things are flowing, but, by and large, in the health system we’ve got people who are dedicated to giving their all for the sake of our community. Why? Because this Government laid down a strong foundation when we became the Government that we’d prioritise lives and we’d prioritise livelihoods, and I think, as challenging as it has been for our health system, that has been their mandate and that has been what everybody has been working towards.

In trying to draw a line and in looking forward in an attempt to acknowledge that there were faults and mistakes that have been made but acknowledging how we do better than this going forward, I want to acknowledge those who have spoken in support and acknowledgment of the inequities that our communities face, particularly the challenges of Māori, Pasifika, and people with disabilities, because when somebody who gets infected with COVID—as we’ve seen with both case A and case B—it’s not just COVID that we’re dealing with; it’s other long-term conditions that that side of the House knew about and that we on this side of the House have always known about. That’s why we’re talking equity. Never before in the nine years of the previous Government has there been a discussion about equity. For the first time ever, we’re talking about equity.

So it’s not just COVID. COVID has highlighted long-term conditions which make Māori, which make Pasifika, and which make people with other physical disabilities more vulnerable than other members of our society. Diabetes, rheumatic fever, heart diseases, high blood pressure—these are the things that are being highlighted as a consequence of COVID.

So, in many ways, let’s learn from this. You know, if you look at case A, I acknowledge, as painful as it is, that the initial phone call was prompt, as the report says, but the clinical background wasn’t made available to the caller. The risks weren’t fully assessed. The template itself wasn’t fit for purpose. There was a delay in the clinical assessment by a registered health person. There was no follow-up when the patient didn’t answer the phone.

What that highlighted also was the fact that last year, what we saw when people were infected was that it was a totally different group of people. This year, since August, over 9,000 people have been infected, largely Māori and Pasifika. At the moment, our numbers stand at 45 percent for Māori, about 30 percent for Pasifika, 20 percent or so for Pākehā, and for Asian communities, the highest vaccinated group, they’ve been relatively safeguarded because of the vaccination.

In case B, the person discharged himself against medical advice. The COVID Healthline weren’t aware of his clinical condition. The public health team were unaware of the circumstances of the self-discharge. The oximeter machine was provided with training, but the patient still had difficulty using it. That’s normal, and I suppose what that also highlighted was that within our health system, you have a number of factors and a number of streams of work that are separated. The left hand often doesn’t know what the right is doing. What we are trying to do as a Government is to get more collaboration and more line of sight across.

I want to acknowledge our health providers—Māori, Pasifika, and our general health providers—right across the motu. It’s been relentless, this year. If we thought last year was unrelenting, this year has been relentless for them. It’s gone on two years now that our health workers have been on the ground having to face all of this, and I just want to acknowledge and thank them.

The pūtea that this Government has provided to our health system and, more particularly, to our Māori and Pasifika health and disability providers—they have said that never before has there been an investment of this kind. In the pilot that is taking place with the Fono Trust and South Seas Healthcare in Auckland, they are providing this holistic, whole of care, end-to-end support.

Face to face is important. What we’re recognising since August is that the cohort that has now been infected, largely—Māori, Pasifika, and others—are the ones that we do need to pay attention to, and we need to understand that they speak different languages. We need to understand that the holistic approach means that we’ve got to involve their whānau into this, and, more importantly, you see that the report also says that there has been year in, year out of under-investment into the system.

We need to get our system in place so that we’re sharing that information across the motu so that people on the ground are able to save lives, and that’s what this Government is about. It is about trying to do the best under the circumstances. The whole world is grappling with this, but, suffice to say, despite the high number of infections and despite the relative number of deaths, if you compare that to what’s happening in Fiji, in Papua New Guinea, in Australia, in the US, and in Europe, our system has helped keep us safe thus far.

In the new environment that we’re now in with the COVID-19 Protection Framework, there is a lot more work that we have to do to get confidence to our communities to be prepared for home isolation. We need to engage and provide education and workshops, and that’s a whole new year coming up.

Next year is going to be different from this year. I say to all our providers: take a well-earned break.

The time for this debate has expired.

The debate having concluded, the motion lapsed.