The deaths of two people isolating at home with COVID-19 in Auckland last month were "potentially preventable", a review has found.
A man in his 50s in Mt Eden and another person in Manukau were found dead in their homes days apart in early November.
In a statement on Monday, the Northern Region Health Coordination Centre (NRHCC) said an independent panel has since released its findings into the deaths.
Whānau of the deceased were consulted before the report was made public, the statement said.
"The NRHCC has already made important changes," the public health authority said.
NHRCC said the report highlighted significant opportunities to bolster the patient focus, capability, safety and equity of the home isolation system.
"The panel also considered both deaths were potentially preventable and there were missed opportunities contributing to the outcome."
NHRCC lead Fepulea'l Margie Apa admitted more could have been done.
"The main lesson is the need for improvement, which is what we are all committed to achieve."
Apa said the report highlighted shorfalls in the responses provided.
"It is a very sad time for both the whānau and friends of these two people and our hearts and thoughts are with them as they come to terms with their loss. We are fully committed to providing any support we can.
"We unreservedly accept the findings of the review and apologise to the whānau for the shortfalls in the response provided. We are grateful to whānau for providing input at such a difficult time."
The report's recommendations, summarised by review panel chair and and Waitematā District Health Board chief medical officer Jonathan Christiansen:
- The need for earlier assessment of clinical safety, welfare needs and mental wellbeing of COVID-19 patients in community upported isolation and quarantine
- better connectivity between all parts of the system to ensure clinical oversight
- heightened focus on equity and cultural safety, specifically Māori and Pasifika
- the need for stronger clinical governance for adequate reporting systems and rapid informed review of adverse events.
According to the NRHCC, it's already made changes - including the reduction of time taken between a positive COVID-19 test and the first clincal assessment.
It's also started door knocking COVID-19 patients not able to be contacted, particularly those isolating alone.
"The report highlights a number of areas where improvements to the whole system were needed. As with the rest of the world, we're moving in a fast-paced environment where we have to change our response as things evolve," Apa said.
"Importantly, one of the key areas of improvement relates to the assessment of individual welfare needs and wellbeing and there is extensive work happening across the health and social sectors, and with our Māori and Pacific communities, to support a strengthened response.
"What is clear is the serious nature of Delta and how it can affect people very quickly, especially those who are unvaccinated with pre-existing conditions. When it strikes, it can be swiftly devastating.
"This report provides valuable lessons for all New Zealanders who need to take this illness very seriously."
