The Auckland Regional Dental Service still does not know who incorrectly connected a pipe at a South Auckland dental clinic, potentially exposing thousands of children to unsterilised water containing blood and saliva.
In January RNZ revealed that about 2500 children might have been exposed to unsterilised water at the Pukekohe Intermediate dental clinic, and the Counties Manukau District Health Board was notifying parents of those treated between 13 September and 23 January.
At the time the health board said the suction hose was connected to the hose that provides air to remove debris from a patient's mouth.
Children who had a procedure involving compressed air, a drill, extraction or suction were offered testing for blood-borne viral infections, in particular Hepatitis B, Hepatitis C and HIV.
Affected parents were outraged they had to find out about the issue through the media.
Findings from an independent investigation into the incident were released to RNZ today.
The report described the communication with parents as "well-managed", but one parent, Stuart Johnstone, disputed that.
"Finding out about it through the media first of all is not handling it well. Our daughter was tested before we were actually phoned by anyone in regards to this," he said.
"And I think my wife had received three or four phone calls where the people didn't seem to realise we'd already been phoned. So that aspect of it was not handled well."
Mr Johnstone said the lack of communication continued today when he was contacted by RNZ about the report, rather than health officials.
"We haven't heard back from anyone since those first few phone calls that we had regarding the situation.
"I had begun to wonder what had happened, if there was a report, where things were up to. So it was very good to find out that there is, but still disturbing that we're finding out about that through the media, not through official channels."
A communications person for the Auckland Regional Dental Service said letters were sent out last week to all the caregivers and parents of the affected children.
Despite several attempts, no one from the DHB was available to be interviewed regarding the report.
Report unable to determine who caused hose mix-up
In the report the independent technical investigator was unable to pinpoint who caused the hose mix-up.
It said in July last year the dental clinic's suction pump had to be fixed so a loan pump was installed while that took place.
When the loan pump arrived the hose connections did not match up so a second discharge hose was connected with one of its ends going into a used-water container.
The report said some weeks later, when the original pump was reinstalled, the discharge hose was left behind but with one end submerged in the used water.
It was found that someone went into the room in January where the pump was and saw that the hose wasn't connected so they attached it to the compressor air intake nozzle under the presumption they were correcting a fault.
The report said the person was likely to be someone without technical knowledge of the plant, but it wasn't unusual for staff to fix equipment.
The report summary said because the clinic was in a rural area there would also be an additional call-out service cost, which led staff to fix equipment - something Mr Johnstone said was "terribly concerning".
"You're dealing with people's children at this dental clinic. Getting the equipment fixed and checked should just be automatic," he said.
About 400 of the 2139 children contacted for screening were not seen. The DHB said this was because an overwhelming majority of the cases only ever had a visual inspection, which was usual for pre-schoolers. One family was yet to be contacted.
The clinic has now restricted access to the pump room and started logging entries. Further clarity over the ownership and responsibilities of the clinic's equipment, facility, and operations, implementing risk management measures and reviewing and developing training for staff were still to come.
The clinic reopened to the public on Tuesday this week.