The Ministry of Health allowed a family to remain in the community for more than two days after escaping managed isolation during last year's first level 3 lockdown.
The case was never reported publicly and was deemed low risk because they had come from a country without Covid-19.
But it had some officials in Auckland scrambling, with one person writing to the Ministry of Health to denounce their lack of direction over the incident.
Auckland Regional Isolation and Quarantine (RIQ) response manager at the time Lee Hazlewood wrote a critical email, obtained under the Official Information Act, that the ministry needed to step up.
The blunt email was sent to all agencies involved "respectfully for the record" with some of the issues he had identified.
He said the email was sent in case the breach became a public health issue and said his team contacted the Ministry of Health (MOH) first thing the morning after the breach seeking direction.
"We discussed several options with MOH during the day, [including] sending a clinical nurse to relay MOH guidance and supervise visit, [and] sending the staff member from the RIQ to relay any guidance from the MOH [National Health Coordination Centre]," the email read.
"The RIQ received no direction to act at this time or at any other time during the period that [the family] was outside of [managed isolation]."
His staff were also told conflicting stories around whether the family would return to quarantine or not.
Initially, they were told the family would remain in the community, before being advised less than an hour later that they would indeed return to managed isolation.
Hazlewood said there were plans to stand the isolation teams down because of the lack of communication.
He said the ministry, and more specifically the National Health Coordination Centre, need to take control of the situation if this happened in future.
"The RIQ, police, regional mho representative nor the overall response manager at no point since the initial incident occurred received any direction to take an action.
"Therefore, from the time that the incident was reported until such time that the individuals involved formerly arrive back at a MIQ facility, the individuals (in normal circumstances under the protection and care of the RIQ) are and were under the direct purview of the NHCC and their agents.
"For the protection of all those involved at the RIQ, I ask that it be formally acknowledged when the NHCC is assuming direct responsibility for an action at the operational level. Going forward, I will be asking for this acknowledgement to be noted on the formal record."
How they fled
The family arrived in New Zealand on 10 May, on an afternoon flight into Auckland from a country free of Covid-19, via Brisbane.
They were in Auckland to visit a relative on their death bed.
Less than eight hours after arriving at the Rydges Hotel managed isolation facility, the family had absconded in two vehicles, doing so in the face of a health official who was trying to talk them out of taking drastic action.
According to a statement written by the official involved and obtained under the Official Information Act, there was never any indication the family were planning to leave quarantine.
The official had been called out of bed at about 11pm to talk to the family who were eager to get an exemption to see their dying relative, and at one point during their conversation the family brought up a video call with a family member who was at the bedside of their dying relative, showing the official live footage to try and plead their case.
When the family realised an exemption would not be granted they decided to leave the hotel immediately and fled into two waiting cars.
Police were then called and found them the next day with their dying relative.
Because of the lack of direction from health officials, police did not act and simply monitored the situation throughout the next day, as about two dozen people came into contact with the family.
They told officials they would not act without direction from the ministry.
In hindsight, the case worked out well, but not due to good planning on the behalf of the ministry.
The sick relative died later that day, giving the family one full day with them before they died.
They did not leave the house, and according to emails from public health doctor and University of Auckland associate professor Collin Tukuitonga, the family took a detailed contacts register at the house as people came and went.
Return to MIQ
The family did eventually return to managed isolation and were later granted an exemption to attend the funeral of their family member.
But that was not without some advocating on their behalf from Tukuitonga, who questioned the need for them to return quarantine.
"He followed the rules and applied for quarantine exemption but there was no response from the ministry," Tukuitonga said in his email to officials.
"I am uncertain of the benefits of insisting on their return to quarantine - I think we have intruded enough into their grief."'
What the Ministry of Health says
In a statement, a Ministry of Health spokesperson said "The MIQ system was in its infancy when this situation arose, and systems were continuing to evolve.
"Since then standard operating procedures to respond to incidences such as this have been created to guide these types of situations. We were also trying to do the best for this family who were going through what was likely to be one of the worst times in their lives.
"We continue to work closely with our counterparts and take a whole of systems approach to the pandemic."