Oct. 8, 2004 – New details are emerging from a follow-up audit report issued by the V.I.
Inspector General's Office over the disappearance and re-appearance of HIV test samples collected at a St. John health fair at Skinny Legs bar in Coral Bay on June 27 of last year. (See "Missing St. John HIV Test Specimens Found").
No criminal charges are being recommended by Inspector General Steven van Beverhoudt against anyone believed to have been involved in the incident. Investigators believe, however, they have a motive – resentment and jealousy.
"We saw the whole motive of this was to embarrass the organization," van Beverhoudt said Thursday. He also said in the course of interviewing the people considered the most likely responsible parties, one person complained about being mistreated by Health officials and being disciplined for questioning management decisions.
On Thursday Health Commissioner Darlene Carty said if the inspector general is correct in his assessment, the person or people involved "did a good job" of embarrassing the Department of Health.
The Sept. 27 audit report says investigators were not able to produce evidence showing any one person was responsible for the disappearance of the box containing 22 human tissue samples collected as part of a territorywide campaign held in conjunction with the 2003 National AIDS Awareness Day.
However the report strongly suggests one individual had the "motive, ability and opportunity," to place a box with HIV test samples on top of a file cabinet in a storage area behind the Administrator's Office at the HIV Clinic in Hospital Ground, St. Thomas. Van Beverhoudt said criminal charges were not brought and no one was named in connection with the incident specifically because no one could be singled out as a suspect.
An analysis of the box that was found and its contents showed the samples were tampered with. Between two and six samples were declared missing when an inventory of the contents was taken after the re-appearance of the box on Jan. 28, 2004. The inspector general also noted that the box itself had been changed and that documents with confidential patient information were missing. (See "Human Error Cited in Missing HIV Test Samples").
Investigators were, according to the second audit report, able to narrow down the transit of the box from the health fair in Coral Bay to the St. Thomas Clinic at the old Knud Hansen Hospital. As of the second report it was determined that the test samples made it off-island before they disappeared.
Although she was not in charge at the time of the two incidents, Carty called the findings a matter of "grave concern." On Thursday she acknowledged there were problems with the way the HIV program was being carried out. Steps have been taken to address those problems, the commissioner said, including some personnel and procedural changes.
"We have addressed chain of custody issues," Carty said Thursday.
She also said outreach workers have spent the past few months visiting St. John in an effort to contact people who took advantage of the free HIV testing that day. Tissue samples contained in the missing box were rendered unusable because of the way they were handled. Documents were separated altogether from at least three samples and the commissioner said case managers are encouraging everyone involved to take the tests again.
The Centers for Disease Control and Prevention has also assigned a field worker to provide technical assistance to officials in the HIV program.
The disappearance was first reported to police on July 15, 2003. The Inspector General's office led an investigation into the first event and produced an audit report, "Disappearance of HIV Test Specimens – St. John, Virgin Islands," on Dec.10 of last year.
Upon its re-appearance the box was turned over to the then Commissioner Mavis Matthew. Five persons in all were interviewed as officials tried to find out how the vanishing box of tests had re-appeared, including three people who were present when the box was turned over to the office of the Health commissioner.
In the course of the investigation three people were subpoenaed and asked to complete a questionnaire concerning their knowledge of the discovery. The inspector general identified those three as the people who had keys and access to the storage room when the box re-appeared. Two agreed to cooperate, but the third person refused and under questioning became hostile, the report said.
"This same individual, during questioning, was openly defiant and refused to cooperate with the interview process. After some time, the belligerence became less open but was nonetheless near the surface throughout the interview. Often, the individual would respond to questions with incomplete answers, half-truths and untruthful answers. The belligerence initially in evidence would erupt from time to time when faced with conflicting statements or improbable scenarios suggested by the answers to questions," the audit said.
Further confusion occurred when the discussion turned to the box, with the subject at one point accusing investigators and Health officials of tampering with it after it returned to official custody.
Carty expressed disappointment when hearing van Beverhoudt's assessment of why things went so wrong after the St. John HIV health fair. She said, however, she was confident that setting up a written protocol and paying more attention to chain-of-custody issues would keep this kind of human error from happening again.
In a letter dated Sept. 8, 2004, the commissioner wrote the inspector general, sending a list of 18 new steps to be taken at the Health Department towards improvement. Among those proposals is separating the duties of the HIV program administrator from the medical director. Officials are also in the process of buying fireproof file cabinets with locks and talking to security guards who work in and around the St. Thomas clinic.
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