Vax Mess Report Pins Blame On Employee

A third-party investigator found that poor communication by the city’s fired former public health nursing director was largely what led to hundreds of Covid-19 vaccine doses being mishandled by the city Health Department in late 2021 and early 2022.

That finding is found in a 474-page report that city spokesperson Lenny Speiller sent out in an email press release Thursday afternoon.

The fired director, meanwhile, argued he has been made a scapegoat for deeper problems in the city’s health department.

The report was written by New Light Investigations, a third-party company that the city hired to look into a ​“temperature excursion” incident at the city Health Department that led to 656 doses of the Pfizer vaccine being rendered potentially less effective at warding off Covid-19 because they were stored in a freezer for longer than they should have been. Those potentially less effective vaccine doses were then administered to 625 different individuals between Dec. 23 and Feb. 7 at the city’s 54 Meadow St. clinic.

The report concludes that much of the blame for what went wrong lies at the feet of former city Public Health Nursing Director Stacey Hutcherson, who was fired from his role on Jan. 21 of this year. Read further down in the story to hear his version of the episode, as depicted in the report, about structural problems in the Health Department that in his view led to the vax mess. (And click here to read a Jan. 30 article by the New Haven Register’s Mark Zaretsky that features an in-depth interview with Hutcherson about how he felt he did a good job during his tenure as public health nursing director, and how he argued the position had so many job responsibilities that it should be split into two.)

“Our investigation verified the majority of facts reported within the New Haven Health Department’s Internal Review,” the New Light Investigations report reads in its conclusion. “[City Deputy Health Director Brooke] Logan and [City Health Director Maritza] Bond were forthcoming and cooperative with our investigation. Hutcherson was also cooperative and participated in a lengthy interview.

“Our investigation found that Hutcherson did not effectively communicate with Bond, Logan or with clinic staff with regard to vaccine management duties, storage and handling. Hutcherson’s communication deficits present as significant factors that caused the temperature excursions. It is also evident that Hutcherson failed to execute a clear transition plan to reassign vaccine management duties and ensure that training and updated standard operating procedures were in place following [former Clinic Charge Nurse Robert] Blocker’s resignation. 

“Hutcherson presented many mitigating factors regarding his performance, including the overall workload of the DPHN, overworked staff, staff shortages, and rapidly changing information and protocols during the pandemic. These arguments may have merit relating to his performance issues but do not mitigate his communication issues.

“Our investigation also found that the New Haven Health Department identified the operational deficits and errors in an expedient manner following Hutcherson’s termination. We also determined that the NHHD and Mayor’s Office immediately notified the public upon identifying all of [the] affected patients and receiving revaccination guidance from Pfizer Medical on February 11, 2022.”

Click here to read the full investigatory report.

Update: After this story was originally published, Hutcherson sent the Independent the following statement: ​“Apparently there has to be a fall guy in this instance. I took on a position during the height of the Covid-19 pandemic. I was sought for the position, I did not seek the position. Further, I put protocols in place to ensure proper documentation of all vaccinations administered by the NHHD. Bond was never present, too busy campaigning. Logan is non clinical and was never available because she was too busy running the department in Bond’s absence.”

The email press release sent out by the Elicker Administration, meanwhile, includes an apology for what went wrong — and celebrates the administration’s act of sending out the report. 

Mayor Justin Elicker is quoted in the press release as saying that the investigation bears out his administration’s commitment to ​“accountability” and ​“transparency.”

“It is truly unfortunate this incident occurred, and we apologize for the inconvenience that it caused to patients,” the mayor is quoted as saying in the press release. ​“We owed it to them to get to the bottom of this issue, to identify what went wrong, and to take corrective action to help ensure it doesn’t happen again — and, as this report outlines, that’s exactly what we’ve done.”

And city Health Director Bond is quoted as saying: ​“The report is a testament to the active efforts being put forth by the New Haven Health Department team. We will continue to strive towards equitable and timely access to clinical services.”

The press release summarizes the report’s findings as follows:

“Specifically, the report finds the former Public Health Nursing Director failed to communicate challenges and problems with vaccine management in a timely manner to Health Department leadership and failed to plan for the transition of responsibility for vaccine management following the resignation of the employee previously charged with this function.

“The report also found that The New Haven Health Department acted in an expedient manner to review all relevant aspects of clinical operations once the Public Health Nursing Director was terminated. In addition, the Health Department acted in an expedient manner once the temperature excursion was identified and notified the public and impacted patients.

“The New Haven Health Department launched a corrective action plan immediately after the temperature excursion was discovered and are actively monitoring clinical operations. The report supports the continuation of this corrective action plan.”

Elicker was later asked what lessons the administration drew from the incident.

“The main thing is putting notification and redundancy systems in place so that we’re not reliant on one employee to identify problems and ensure vaccines are handled correctly,” the mayor responded. ​“The health department has put in a digital system to monitor vaccines. It flags when they’re pending expiration. Multiple people have access, and it’s a better way to track.”

Blamed Employee: Vax Mess Stemmed From Dept. Mess

Following is the New Light report’s summary of Hutcherson’s version of why the vax mess occurred:

Hutcherson made many mitigating arguments in response to this investigation. He said that the structure of the health department and DPHN duties are not conducive to delivering effective and safe health services. Specifically, he stated the DPHN position is split between overseeing City Health Services and School Nurses. He said he had two phones and two email accounts. He believed there should be two DPHN positions, one for the City of New Haven and one for the Board of Education (BOE).

Hutcherson also stated in his interview that when he was first hired as the temporary DPHN in March 2021, there were multiple positions that were empty: the clinic charge nurse, administrative assistant, PHNC (Public Health Nurse Coordinator), and a vaccine manager, who should be an APRN. The responsibilities of these positions, which included physically managing the vaccines, were reportedly delegated to himself and other clinic nurses. He stated that this placed massive amounts of stress on all of them. He stated that in addition to the pre-existing staffing shortage, nurses were working mandatory overtime and were calling out sick due to outbreaks of new COVID variants. He also stated that the processes and procedures that were in place were poor, if they existed at all, and that both the City of New Haven and the BOE were transitioning from paper immunization records to electronic databases. Additionally, with new COVID vaccines coming out, every dose needed to be tracked in the VAMS system (Vaccine Administration Management System). He said there were many challenges in transitioning to electronic record management systems for both the City of New Haven and the BOE. There was also a shortage of portable tablets to log the vaccines electronically. Nurses faced connectivity issues and at times had to document the vaccines on paper then transfer them into the database after the clinics ended, which created additional administrative duties for them. Many of the nurses struggled to use the databases because they did not have proper training.

Hutcherson stated that when he was hired as the temporary DPHN in March 2021, the former Director of Nursing, Jennifer Vasquez, did not provide him with much information regarding the nursing duties at the New Haven schools. The schools had not been fully opened for a year and his focus was to get schools fully staffed with nurses and health services. He believed that his priorities were consistent with the major responsibilities of the DPHN. He stated that approximately 75 – 80% of the responsibilities for the DPHN are related to the Board of Education. Thus, Hutcherson’s focus was on training and staffing the New Haven schools with enough nurses. There are 44 schools within the city’s school district and, though most schools needed one nurse, there were about four or five schools that required two. He alleged that he was in negotiations with the Nurse’s Union for increasing salaries to attract more applicants.

Hutcherson stated that he and Lopez were constantly working, that the environment was chaotic, and that information rapidly changed. Hutcherson stated that there were a lot of homebound residents who needed to be vaccinated. Homebound residents are individuals who cannot travel to locations to obtain health services and need to be cared for in-home. Hutcherson stated that he created a partnership with AMR and strategically coordinated response teams to ensure that Homebound residents were vaccinated. These residents were particularly at risk because of their comorbidities and required medical staff to remain on-site to observe them following their vaccinations.

Hutcherson stated that while the Omicron variant was exploding, non-vaccinated city employees were mandated to be tested weekly. The testing site was set up at the fire academy. He had to figure out how to set that up and implement testing procedures. He said there were a lot of logistical challenges in terms of the days of the week for the testing due to conflicts with the fire academy’s training schedule. Because PCR testing results took so long to come back, Hutcherson implemented rapid tests to be self-administered and overseen by staff. He said the delay in the PCR test results caused 40 fire academy employees to be exposed by a non-vaccinated employee.

Additionally, Hutcherson stated that COVID testing procedures and protocols needed to be implemented in the schools and city-wide.

Hutcherson stated that he struggled to communicate with Logan and Bond. He stated that he was accused of both over-communicating and under-communicating, and that Logan and Bond simply did not have a realistic outlook on the situation and on the challenges he faced. He said that staff was spread too thin, and he told the administration that they needed to shrink their efforts rather than expand them.