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Two other patients deaths had also occurred while they were under Waitematā DHB’s care.
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Tamaki Heke was one of the inpatients who died in May, 2019. Through interviews with patients’ families and DHB staff, the report, prepared by Alison Masters, Malcolm Steward, Sarah Gordon, Stu Bigwood and Jason Cabral-Tarry, found a number of issues with the unit. These included problems with leadership and culture, the model of care given and issues with nursing care and staff deployment. The design of the building was also found to be problematic. The report writers found leadership was lacking and inadequate” at the time of the deaths.