Charlotte women’s clinic failed to notify 200 about abnormal cancer screen results

Nearly 200 low-income patients who participated in Mecklenburg County’s cervical cancer screening program last year were not told of their abnormal test results for as long as eight months – even though those women should have been contacted immediately, county officials said Tuesday.

County Manager Dena Diorio told members of the Board of Commissioners that the Health Department has tried to contact the women and set up appointments since officials discovered the error. Early detection is credited with reducing rates of cervical cancer.

But 20 patients who were seen at clinics on Beatties Ford Road in west Charlotte or Billingsley Road in southeast Charlotte have not been found, leaving them unaware that they may face potential health risks.

Tuesday was the first public notification of a lapse in the program, and many questions remained unanswered.

Diorio said four people who were working on the program no longer work for the county, but she did not identify who they are or reasons for their departure. It was unclear when the mistake occurred, or exactly how.

The disclosure came after the Observer began inquiring about potential failures on Monday.

Health Director Marcus Plescia said of 185 women with abnormal Pap smear results, 110 who needed repeat tests have been contacted. Seventy-five more showed potentially more serious problems that needed additional attention, and 55 of them are scheduled for new visits. The remaining 20 have not been located.

Plescia said none of the 185 women had pre-cancerous results.

“I don’t want people to be anxious that they have some cancer, and that isn’t the case,” Plescia said.

Commissioner Bill James said officials discovered the mistake when they “stumbled” across the fact that the “in-box” for a nurse responsible for the results “was just huge” from unanswered notifications. The county took eight months to discover what went wrong, James said.

Health department clinics serve predominately low-income residents and are supposed to notify patients quickly about abnormal results from Pap tests. Plescia said the department considers even a one or two week delay unacceptable.

Commissioner Vilma Leake was outraged by the report.

“We’re talking about the health and well-being of our people and for anything to go wrong on our part, meaning the Health Department, is unacceptable,” she said. “I can’t believe this number of women were not notified and not given any information coming from a body that we hold accountable.”

Diorio responded: “The person you need to hold responsible is me.”

“We take full responsibility for the mistakes that were made and we’re trying to do all we can to set it right. We have investigated thoroughly, taken action and made steps to see that it never happens again.”

But Vice Chair Jim Puckett and at-large commissioner Pat Cotham pushed for more. Puckett called for the state to review the county’s actions. “The people who made the mistake are telling us its not a problem,” he said.

“These are vulnerable women who put their trust in the Health Department,” Cotham added. “There could be someone with bad news coming who need our help. We have to do better.”

Most board members sided with Commissioner Dumont Clarke, who urged the board to allow Diorio to seek a third-party reviewer and report back to the board. That motion passed unanimously.

State involvement “is like trying to kill a gnat with a sledge hammer,” Commissioner George Dunlap said. “Everything we were told would be done has been done.”

During sometimes heated exchanges, commissioners debated whether county administrators had given them sufficient information about what happened.

Plescia, in an interview, said the problem came to light when a Health Department practitioner noticed potential problems with notification to women of test results. Other supervisors heard a triage nurse in charge of contacting patients complain of being behind in her work.

Commissioners were notified of the problem in closed session in January, when the department began to take personnel actions, he said.

The department will bring in consultants in the aftermath, Plescia said. Electronic health records that track patient status are “not being used to their full potential,” he said. There is also a concern about staffing levels, Plescia said.

“We have looked at multiple levels and we have taken action at multiple levels,” he said.

Commissioner Trevor Fuller said it is imperative the county put in place procedures to prevent the problem from happening again.

“This time we hope, we pray, it didn’t result in anyone being in danger,” Fuller said. “It may not be the case next time.”

This story was originally published February 21, 2017 at 9:44 PM with the headline "Charlotte women’s clinic failed to notify 200 about abnormal cancer screen results."