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HomeNewsArchivesHUMAN ERROR CITED IN MISSING HIV TEST SAMPLES

HUMAN ERROR CITED IN MISSING HIV TEST SAMPLES

Dec. 15, 2003 – The case of missing HIV test samples from a June health fair on St. John recently passed under the microscope of the V.I. Inspector General's Office. That investigation resulted in a finding that the disappearance of the human tissue samples and confidential information gathered from 22 people was the result of human error.
Inspector General Steven van Beverhoudt had harsh words for the Health Department administration as he laid out two scenarios for how the test samples might have disappeared. One possibility revolved around what he described as a reckless and undisciplined environment at the St. Thomas HIV-STD clinic, where, he said, hostilities among the staff members were evident.
Among the recommendations listed at the end of the Dec. 10 audit report: a call for Acting Health Commissioner Dionne Carty to "provide for, and insist upon, proper and effective management at the clinic."
In a written response to the audit, Carty wrote that a number of "persons deemed not best suited for the mission of the agency have been released." Neither Carty nor the agency's legal counsel, Devin Carrington, could be reached for further comment.
The inspector general acknowledged the commissioner's response in his report but said there was no evidence in the way of supporting documents to show what corrective actions had been taken. Van Beverhoudt promised to review the situation at the HIV clinic again "at a later date" to determine whether steps had been taken to rectify the situation.
Health officials began an inquiry into the whereabouts of the missing HIV test samples after their disappearance was reported to police in mid-July. (See "Meeting set for those tested for HIV at June fair".) At some undisclosed time afterward, the inspector general was asked to intervene.
Investigators traced the transport of the tissue samples from the June 28 test site in Coral Bay to the Westin Resort, where a nurse practitioner in charge of the samples stayed before returning to the HIV clinic on St. Thomas. The last time anyone reported seeing the samples was on July 2, the day before the clinic closed for the Emancipation Day/Independence Day holidays. According to the inspector general, the fact that the test samples were missing became apparent on July 11 during a public confrontation between members of the clinic staff.
Following is an excerpt from the inspector general's audit regarding the loss of the tests: "The clinic was closed since the employees were attending a training session. The coordinator had come from St. Croix to St. Thomas and needed to get into the clinic to look for the missing tests. She went to the training session and asked the senior case manager to use her keys to get into the clinic; however she refused. According to the outreach worker, an argument ensued, and it was alleged that the senior case manager stated that the press was going to hear about the missing tests."
Van Beverhoudt said the investigation revealed "bad blood" between members of the clinic staff. "For whatever reason, left to their own devices, the relationship of the employees at the clinic deteriorated to the point that no one respected anyone else or the clinic's mission," van Beverhoudt said.
But equally to blame, he said, was the Health Department administration, which provided almost no supervision at the clinic and never provided the clinic's doctor, described as the "titular head" of the operation, with a job description or the authority to direct the conduct of the clinic staff.
Carty, in a letter to the inspector general dated Nov. 4, said protocol problems had already been addressed and job descriptions were under review. Specifically to keep what happened in June from happening again, Carty said, a detailed chain of custody protocol for the handling of test specimens had been sent to the federal Centers for Disease Control and Prevention for review and comment.
Carty expressed the hope that the mystery of the missing HIV tests could be put to rest once the matter was made public by the release of the inspector general's audit.
Van Beverhoudt said how the matter is finally resolved remains to be seen.

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Dec. 15, 2003 - The case of missing HIV test samples from a June health fair on St. John recently passed under the microscope of the V.I. Inspector General's Office. That investigation resulted in a finding that the disappearance of the human tissue samples and confidential information gathered from 22 people was the result of human error.
Inspector General Steven van Beverhoudt had harsh words for the Health Department administration as he laid out two scenarios for how the test samples might have disappeared. One possibility revolved around what he described as a reckless and undisciplined environment at the St. Thomas HIV-STD clinic, where, he said, hostilities among the staff members were evident.
Among the recommendations listed at the end of the Dec. 10 audit report: a call for Acting Health Commissioner Dionne Carty to "provide for, and insist upon, proper and effective management at the clinic."
In a written response to the audit, Carty wrote that a number of "persons deemed not best suited for the mission of the agency have been released." Neither Carty nor the agency's legal counsel, Devin Carrington, could be reached for further comment.
The inspector general acknowledged the commissioner's response in his report but said there was no evidence in the way of supporting documents to show what corrective actions had been taken. Van Beverhoudt promised to review the situation at the HIV clinic again "at a later date" to determine whether steps had been taken to rectify the situation.
Health officials began an inquiry into the whereabouts of the missing HIV test samples after their disappearance was reported to police in mid-July. (See "Meeting set for those tested for HIV at June fair".) At some undisclosed time afterward, the inspector general was asked to intervene.
Investigators traced the transport of the tissue samples from the June 28 test site in Coral Bay to the Westin Resort, where a nurse practitioner in charge of the samples stayed before returning to the HIV clinic on St. Thomas. The last time anyone reported seeing the samples was on July 2, the day before the clinic closed for the Emancipation Day/Independence Day holidays. According to the inspector general, the fact that the test samples were missing became apparent on July 11 during a public confrontation between members of the clinic staff.
Following is an excerpt from the inspector general's audit regarding the loss of the tests: "The clinic was closed since the employees were attending a training session. The coordinator had come from St. Croix to St. Thomas and needed to get into the clinic to look for the missing tests. She went to the training session and asked the senior case manager to use her keys to get into the clinic; however she refused. According to the outreach worker, an argument ensued, and it was alleged that the senior case manager stated that the press was going to hear about the missing tests."
Van Beverhoudt said the investigation revealed "bad blood" between members of the clinic staff. "For whatever reason, left to their own devices, the relationship of the employees at the clinic deteriorated to the point that no one respected anyone else or the clinic's mission," van Beverhoudt said.
But equally to blame, he said, was the Health Department administration, which provided almost no supervision at the clinic and never provided the clinic's doctor, described as the "titular head" of the operation, with a job description or the authority to direct the conduct of the clinic staff.
Carty, in a letter to the inspector general dated Nov. 4, said protocol problems had already been addressed and job descriptions were under review. Specifically to keep what happened in June from happening again, Carty said, a detailed chain of custody protocol for the handling of test specimens had been sent to the federal Centers for Disease Control and Prevention for review and comment.
Carty expressed the hope that the mystery of the missing HIV tests could be put to rest once the matter was made public by the release of the inspector general's audit.
Van Beverhoudt said how the matter is finally resolved remains to be seen.

Back Talk



Share your reaction to this news with other Source readers. Please include headline, your name, and the city and state/country or island where you reside.

Publisher's note : Like the St. John Source now? Find out how you can love us twice as much -- and show your support for the islands' free and independent news voice.. click here.