Middlemore Hospital has been forced to stand down 29 staff for 14 days after failing to isolate a symptomatic patient who later tested positive for COVID-19.
And then - even when staff knew of the positive result - the patient wasn't moved to his own room for another 80 minutes. In total, 120 patients are now being treated as COVID-exposed.
So why didn't Middlemore put the COVID patient into a separate room, where there'd be a lower chance of infecting vulnerable patients?
Even before the latest COVID outbreak, Middlemore was one of many hospitals overflowing with patients.
Counties Manukau DHB chief medical officer Dr Pete Watson says Delta has upped the pressure.
"Delta has really changed the way we deal with this, as we've seen, far more rapid, far more hospital admissions, there's less common symptoms presenting," he says.
The hospital is often at capacity and the COVID case admitted at the weekend was left on a ward for around nine hours while they awaited test results because there was nowhere else to put him.
"Unfortunately our single isolation rooms on that surgical ward were full at the time, if they had been empty, we would have transferred them there but what we did was what we could do at the time," says Dr Watson.
As a result, due to the risk of infection, four wards have been closed and dozens of staff are now in isolation.
"We have stood down 29 staff, not all of them of one profession," says Middlemore's medical services director Dr Vanessa Thornton.
They include 11 doctors and 13 nurses and they're having to redeploy staff, adding even more pressure.
"It does seem to signal to us that the Government's not been well prepared for a pandemic," says Nurses Organisation kaiwhakahaere Kerri Nuku.
"Our nurses are absolutely frightened and scared about how we're going to be protected going forward."
Dr Watson says they're doing all they can to keep staff and patients safe.
"We're now protecting everybody by ensuring that they're getting tested and I'm really pleased to say that nobody so far has returned a positive test."
Also being tested are around 100 patients at potential risk of exposure but Dr Watson says the risk is low.
"Hence why we're being cautious, we always worry, we like it when there's no risk, there is a risk but it's very, very small," he says.
"I want to assure the families that your whanau members who are patients with us are being cared for and looked after, that we're providing the same high-quality care that we always do."
He says anyone needing treatment shouldn't be put off going to Middlemore Hospital, insisting that patients will be safe and get the care that they need.