CHARLOTTE, NC (Fred Clasen-Kelly, Caroline Metzler and Emmanuel Morgan/Charlotte Observer) - Outgoing Mecklenburg County Health Director Marcus Plescia for months has given the public and other officials this assurance: The agency's failure to notify patients about abnormal Pap smear results did not reflect the overall quality of care at two public clinics.
But newly released emails show that an internal review found widespread problems and concluded that patients have likely suffered harm from substandard care.
In the weeks after the Pap smear failures were discovered, an agency nurse compiled a report, shared concerns with her supervisor and provided information to Plescia and a team of agency employees who were trying to respond to the mistakes. The nurse wrote that she had been assigned to review records because she had 18 years of experience performing follow-up with patients about Pap smears – tests that can reveal signs of cervical cancer.
"The problem is much worse (than) I was told, and it includes poor performing employees, bad supervision, bad data management, bad clinical procedures, bad initial assessment of the problem, bad triage and incomplete corrective actions," Julie Secrest wrote in a Feb. 2 email. "Patient care has been poor at best, and at worst, patients health and safety has been at risk. After reviewing the information that I have seen, I believe bad patient outcomes are inevitable and/or have occurred in some cases."
A few weeks later, Secrest sent Plescia a message that suggests there were more cases that involved incomplete or failed patient follow-up than the county has publicly acknowledged, according to an email obtained by the Observer through an open records request.
The county has said 185 patients were not contacted about abnormal Pap results from May 2016 to December. Most of them are Latina and African-American women with low incomes.
But on Feb. 20, Secrest sent Plescia a chart that shows she believed as many as 300 patients did not get proper notification or follow-up.
Her emails appear to bolster accounts from health department employees who for months have peppered county commissioners with emails and calls. They allege that patients who depend on clinics on Billingsley Road in southeast Charlotte and Beatties Ford in west Charlotte endure unacceptably long waits for appointments and sometimes receive inaccurate test results for pregnancies and sexually transmitted diseases and other poor care.
Three county commissioners told the Observer that the emails confirm their suspicions that problems within the health department reach beyond the Pap tests and reflect poor management. One commissioner said it appears county administrators have tried to keep unflattering information from public view.
'A big problem'
Plescia resigned under pressure earlier this month and will leave the department in August. Through a county spokesman, Plescia refused an interview request.
Plescia has repeatedly blamed the Pap smear failings on a nurse whom he says didn't perform her duty to contact patients about their results. The nurse and three of her immediate supervisors resigned.
Earlier this year, Plescia told commissioners that an ongoing state review of clinic operations to that point had found no problems serious enough to warrant a corrective action plan. Officials had already acted on 15 of 16 recommendations from the state, he said.
"We had a big problem that occurred and we are looking at it as an opportunity to improve," Plescia said, adding moments later, "I'm encouraged."
The county did not make officials available for interviews, but provided written responses from County Manager Dena Diorio.
She did not answer questions about patient care and operations at the health clinics, saying that she will wait for a consultant's report to be released in July. Diorio did acknowledge, however, that Plescia's successor faces a challenging task that will involve implementing reforms while rebuilding trust with employees and the public.
"We will do whatever is necessary to address issues in Public Health and restore trust," she said.
Diorio disputed suggestions that the county attempted to cover up unfavorable information about the health department.
'Tip of the iceberg'
Mecklenburg's health department is the community's first line of defense against threats such as STDs, highly contagious diseases and food-borne illnesses.
The agency, which has roughly 800 employees, has a wide range of duties, including regulating restaurants, child care centers and swimming pools.
Plescia has come under public scrutiny since the Observer first reported in February that the clinics did not notify patients about abnormal Pap smears. Later, some commissioners said they were also concerned that health department employees gave operating permits to public swimming pools this month without reinspecting water quality and equipment to ensure last season's safety violations were fixed.
The county has hired Alma "Gibbie" Harris as interim health director until a permanent successor can be found. Consultants hired by the county are scheduled to deliver reports next month that recommend improvements.
Commissioner Pat Cotham said the emails depict a far different picture of the health department than the information county administrators provided commissioners.
"A lot of us were worried there was more," Cotham said. "We only get the tip of the iceberg."
Commissioner Jim Puckett said the emails show the Pap failures were a symptom of larger management problems within the agency.
"It's an embarrassment," Puckett said. "It doesn't speak well to the overall management of the county. There was an active choice not to be transparent. It looks like anything but transparency."
Commissioner Matthew Ridenhour said board members have repeatedly heard about deeper issues beyond the Pap tests within the health department.
Ridenhour said he believes there were shortcomings in the agency's leadership and that he supported Plescia's decision to resign. He noted that after the Pap smear lapses surfaced, the department was again in the news for lax oversight of swimming pools.
"Given the microscope they were operating under, they didn't dot their i's and cross their t's," Ridenhour said. "That performance was a reflection of leadership."
In response to unflattering media coverage, Plescia sent a memo to agency employees May 9.
"I am deeply disappointed that a few past and current employees have disparaged our clinical work and suggested we have created a culture of fear," Plescia wrote. "The quality of our work is supported by a documented history of regular state and internal audits and reviews, and the successful re-accreditation of our department in 2015, which included specific accolades for our 'culture of quality.'"
But many of the agency's roughly 300 nurses disagreed with that assessment.
Secrest, the nurse who was assigned to conduct the internal review, began reviewing records for 1,750 Pap smear results in January, according to emails.
On Jan. 24, she sent an email to a nursing supervisor listing problems she observed in the clinics. A quality improvement effort had resulted in longer patient wait times and more laboratory errors, among other issues, she wrote.
Three days later, documents show, a group that included Assistant Health Director Connie Mele and Medical Director Dr. Stephen Keener met and discussed Secrest's findings. The group asked Secrest's supervisor to work with her on a summary and a list of recommendations.
"The entire problem is much bigger and broader than anyone would have guessed," Secrest wrote in a Feb. 2 email. "The Health Department has failed to maintain a standard of care for its patients. The Department has already failed to meet any notification standard or requirement and every day the situation gets worse."
Reached by phone Wednesday, Secrest refused comment.
Five current and former employees with direct knowledge of the agency's management, patient care and laboratory operations told the Observer that the health department has under-reported the number of women impacted by lack of notification and follow up.
Each spoke on the condition that their names not be used because they are not authorized to speak publicly about their concerns and they fear reprisals from management.
The employees said the health department is counting only cases where the nurse made no attempt to reach patients. Employees estimated there were as many as 100 other instances where the nurse made some effort to contact the women, but did not complete the follow-up and tracking process.
An email that Secrest sent to Plescia on Feb. 20 appears to support their account. A chart she compiled indicates there were 115 more patients who should have been sent additional letters or had other tracking and follow-up.
According to meeting minutes from a closed-door session in January where commissioners learned about the problem, the board was told there were 258 women affected.
In written responses to questions from the Observer in March, the county said the correct number is 185. Officials denied that there were 100 additional cases where a patient was not properly notified.
An outside consultant is now reviewing the handling of the Pap results.