Women went untreated as county missed warning signs over cancer tests, emails reveal

Mecklenburg County's health director, Dr. Marcus Plescia apologized last month for the oversight that led to the agency's failure to notify 200 women of abnormal pap smears.
Mecklenburg County's health director, Dr. Marcus Plescia apologized last month for the oversight that led to the agency's failure to notify 200 women of abnormal pap smears. dhinshaw@charlotteobserver.com

When top officials announced in February that Mecklenburg County’s public health clinics failed to tell nearly 200 women about abnormal Pap smears, they blamed the lapse on one nurse.

But newly released emails suggest that problems notifying patients about their risks for cervical cancer started before the nurse was assigned the job last May.

In the days before the nurse started, a physician at the clinic emailed nursing supervisors about two patients who had highly abnormal Pap smears. The physician said they were not told about the results even after they visited a health clinic for contraceptive treatment.

“These were missed opportunities to speak to these women face to face about these serious pap results,” said Dr. Lena White, the Health Department’s supervising physician, in an email dated May 9.

Later, in the months that followed, county officials also failed to fully investigate signs of trouble raised by the nurse and another county employee about the lapses, according to emails obtained by the Observer through an open records request.

One message came not long after the nurse, Natalie Nicholson, started in her new duty. On May 31, she sent an email to a supervisor complaining about letters to patients that had been returned to the county dating back as far as three months. She wrote that when she started her new role she was assigned pending cases that went back as far as 2015.

“It was my understanding that all of these outstanding cases should have been addressed prior to 9May16 – when I was to have started the Follow-Up process,” Nicholson wrote in the email.

Another email sent by a clinic nurse in November to Nicholson’s supervisors complained that a patient had not been informed about important test results. In a follow-up email, the nurse said that Nicholson told her she had fallen behind in her work.

County Health Director Marcus Plescia and other top county officials didn’t learn about the problem until January. In an interview, Plescia said he had not previously seen the emails obtained by the Observer.

Plescia said he still believes the issue was mainly caused by one nurse who did not perform her duty. He also said her supervisors practiced poor oversight. Four people, whom the county refuses to identify, left the Health Department earlier this year. Records indicate they were not fired.

Since the issue became public last month, the county has hired consultants and asked the state to conduct a review. In a memo sent to employees on Friday, Plescia said the state had completed several reviews.

“Preliminary communications indicate these reviews went well,” Plescia wrote. “This should help confirm that our agency as a whole is strong and well run.”

‘Massively poor management’

Early detection and treatment is considered key to preventing cervical cancer. That’s why patients who went to county clinics on Beatties Ford Road in west Charlotte and Billingsley Road in southeast Charlotte were supposed to be notified within days or weeks about abnormalities.

In December, however, staffers discovered that the in-box for the nurse responsible for notifying patients contained information about hundreds of cases for women with abnormal Pap smears. County emails show the nurse was Nicholson.

The agency is required to make three phone calls and send a letter to notify patients about abnormal Pap smear results, Plescia says.

But employees initially reported in January there were as many as 740 cases where it appeared those steps were not taken, according to emails. One official speculated that the cases likely reached back to other nurses who previously were assigned to notify patients.

County officials say a subsequent review determined that the total number of patients who county had not properly notified was 185.

The county has since contacted all of the affected patients and is now awaiting results from follow-up procedures of women whose Pap smears revealed the possible signs for cervical cancer.

County officials have said follow-up tests so far show at least two women have abnormalities which are commonly considered pre-cancer and sometimes require surgery to prevent invasive cancer.

Commissioner Jim Puckett told the Observer that he finds the emails alarming. Puckett said they make clear that multiple workers were aware of the issue, but failed to take appropriate steps to fix it.

“I’m no lawyer but I would think that if I saw that these tests were not being handled correctly in May, and that it took an additional 7 months and an outside department to finally get someone to take action I would have a whale of a case,” Puckett said. “I do know that this is a clear indication of massively poor management.”

After reviewing the emails, Commissioner Bill James told County Manager Dena Diorio and others that they raised questions about when the notification delays started and how many women were affected.

“If the problem went back to 2015 as the writer of the e-mail specifies, then how did the problem only come to light in December of 2016?” James wrote to officials on Thursday.

Reached by phone, Nicholson would not answer questions. Her supervisors listed in emails also refused interview requests.

A warning sign

The November email sent by a nurse to Nicholson’s supervisor came about a month before Health Department officials realized they had a serious problem.

Nurse Alisa Weber sent an email Nov. 10 about a patient who had an abnormal Pap smear and a positive test for the Human Papilloma Virus, or HPV. She needed a follow-up procedure, so Weber had referred the case to Nicholson.

“When I looked her up, I saw that nothing had been initiated regarding the referral,” Weber wrote. “We need to see what is happening. I am not sure if there is a back-up system to insure it does not get missed.”

In an email written five days later, Weber said she talked to the nurse about the situation.

“Did not get much info,” Weber said. “She said she had been behind.”

Plescia: No obvious signs

Plescia said there were no obvious signs about problems at the department. Recent audits and other reports did not identify Pap smear test notifications as a cause for concern, he said.

There were no indications the nurse who handled patient follow up was overworked or didn’t have enough time to complete the task, Plescia said.

On the day that a supervisor informed Nicholson she would no longer handle Pap smear notifications, she suggested she could not understand why.

Nicholson wrote in a Jan. 3 email: “I am not sure what information you used to base your decision.”

Clasen-Kelly: 704 358-5027; @FrederickClasen