March 25, 2016
The City of Houston’s Office of Inspector General (OIG) has completed an investigation
into three incidents at the Houston Forensic Science Center (HFSC) and made
recommendations to avoid similar situations in the future. HFSC requested the OIG
investigation in February 2016 immediately after an anonymous complaint was filed
with the Texas Forensic Science Commission (TFSC.)
The OIG investigated three separate incidents in HFSC’s Toxicology Section, focusing
on the mistakes, but more narrowly on how the errors were reported to the Center’s
Quality Division.
The three separate incidents involved analysts accidentally pushing the wrong button
on a new piece of lab equipment, contaminating evidence. In all three instances, the
analysts had a second, uncontaminated vial of blood to test and the end result was
unaffected. However, because the incident reoccurred, HFSC opened its own internal
review in October when the Quality Division was informed and has since updated its
procedures to ensure the same mistake does not happen.
“HFSC appreciates the careful and considered investigation by the OIG and looks
forward to cooperating with TFSC to further look into the incidents and ensure the
mistakes do not reoccur,” said Dr. Peter Stout, the Center’s COO and vice president.
“HFSC is aware the incidents investigated by the OIG and TFSC could have and should
have been avoided. HFSC has conducted its own internal review to determine what
went wrong and has changed policies and procedures to avoid similar incidents going
forward,” Stout said.
The incidents investigated by the OIG and TFSC involved the incorrect use of a new
instrument, a Hamilton 600 pipette, that allows analysts to remove and inject substances
from one container into another. The instrument has two buttons, one on top of the
other. One button draws a liquid into the pipette tip, while the second ejects the
substance. HFSC began using the instrument in April 2015. About a month later, on
May 28, 2015, the first error occurred in the use of the instrument. In October the
mistake was made two more times.
The October incidents were immediately reported to the Center’s Quality Division, and
an internal investigation began. At that point, the Quality Division was also informed of
the May incident, and it too was included in the investigation. By November 18, the
Quality Division’s investigation was completed and changes were implemented to
avoid this error from being repeated.
Analysts are now required to remove blood from the evidence vial and place it into a
separate labeled container. This is then used for further testing, preserving the original
evidence. The Hamilton 600 never touches the original evidence container.
The anonymous complaint to the TFSC stated the first incident in May should have
been investigated internally. But the Quality Division had not been informed until
October when the two additional errors occurred. As a result, the OIG has
recommended HFSC update its reporting procedures to ensure staff understand
everyone is responsible for guaranteeing the integrity of HFSC’s science and
immediately reporting nonconformities to the Quality Division. HFSC is currently
updating its manual.
“HFSC is constantly working to improve the quality and efficiency of its scientific
analysis,” said Dr. Daniel Garner, the Center’s CEO and president. “That said, we do
rely on people in our laboratories, and on occasions mistakes will be made. It is our job
to immediately address such incidents and put processes and procedures in place to
avoid them going forward.”
HFSC is a local government corporation that provides forensic services to the City of
Houston and other local agencies. HFSC is overseen by a Board of Directors appointed
by the Mayor of Houston and confirmed by the Houston City Council. Its management
structure is designed to be responsive to a 2009 recommendation by the National
Academy of Sciences that called for crime laboratories to be independent of law
enforcement and prosecutorial branches of government.
HFSC currently operates in nine forensic disciplines.
Ramit Plushnick‐Masti
Public Information Officer
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