Found Eastern Health pathology lab in disarray, expert testifies
No textbooks, no standard procedures, insufficient training cited in 2005 review
A pathology department in St. John's was so ill equipped to handle cancer tests that one operating room did not even have a refrigerator to hold tissue samples taken there, an expert has told a public inquiry.
Trish Wegrynowski provided the Cameron inquiry Tuesday with long-awaited key evidence into the state of Eastern Health's pathology lab in September 2005, when the authority recruited her to find out why it had been producing inaccurate hormone receptor tests.
Wegrynowski, a senior medical laboratory technologist at Mount Sinai Hospital in Toronto, wrote reports that were at the heart of a court battle this winter to keep them secret.
Wegrynowski told Justice Margaret Cameron she witnessed one serious problem after another during her five-day visit, including inconsistent methods, a heavy turnover among technologists and poor documentation of lab work.
"I was surprised," Wegrynowski testified.
"Why were you surprised?" asked co-counsel Sandra Chaytor.
"That there were not standard operating procedures," replied Wegrynowski.
As well, staff at two Eastern Health hospitals, the Health Sciences Centre and St. Clare's Mercy Hospital, were using different methods for the same functions.
She found that fixation — the process by which a tissue sample is treated in order to stop the breakdown of cells — was hampered at St. Clare's Mercy Hospital because a fridge was not available to hold the samples taken in an operating room. She said stringent regulation of temperature is critically important to this line of pathology work.
Technologists lacked training, experience, textbooks
Her review found that technologists did not have a strong understanding of the complicated nature of immunohistochemical staining. Indeed, instead of reviewing their work, she proceeded with a training exercise to boost their knowledge and skills.
The technologists were hindered, she testified, by a lack of textbooks, and did not even have internet access for research and reference.
"They had nothing," she said.
Wegrynowski told the inquiry that the technologists reported a myriad of frustrations, from not having enough training to being responsible for too many duties.
"They were being pulled in far too many directions," she said.
Eastern Health had wanted to keep reports private
Wegrynowski was one of two outside reviewers that Eastern Health recruited to help solve problems in its lab. After the Cameron inquiry was called, though, Eastern Health fought — but lost — in Newfoundland Supreme Court to have those reports blocked from public release.
The reports found that, contrary to what Eastern Health had advised government officials as recently as this year, the equipment in the lab was not at fault. Instead, the problems related to how the labs were being operated.
In a memo that proved important at the Newfoundland Supreme Court case involving the release of the reports, the reviews were described by a breast cancer pathologist as being "fairly damning" of how the labs were managed.
The other reviewer, British Columbia pathologist Diponkar Banerjee, has not yet testified at the inquiry, which was called to examine how Eastern Health produced hundreds of inaccurate hormone receptor test results for hundreds of breast cancer patients between 1997 and 2005.
Wegrynowski said the lack of resources and training in the lab were all too apparent, as was a prevailing attitude of what was expected of technologists on the lab floor.
"It was your sense that they were to come and do, not to think. Is that a fair statement?" Chaytor asked Wegrynowski.
"I think that is a rather fair statement," she replied. "It's not meant to be critical, but if you don't have the tools, you can't think to troubleshoot."