By Michael Norton, Matt Murphy and Colleen Quinn
State House News
BOSTON -- Calling it "one of the greatest health-care tragedies in my memory," the Patrick administration's top health official told lawmakers Wednesday that she is committed to finding out how fungal meningitis tied to tainted steroids from a Framingham company killed 32 people and infected 438 more to date.
"I know you are questioning what happened, and I am too," Health and Human Services Secretary JudyAnn Bigby told members of three legislative committees that convened to discuss industry regulation and the problems associated with the New England Compounding Center.
"These past few months have weighed heavily on me, both as the Secretary of HHS and as a doctor," Bigby said. She said the events "have uncovered unacceptable breaches on the part of individuals, gaps in regulatory processes and above all, the need for immediate and lasting solutions."
While acknowledging that state regulators "should have done better," Bigby said state employees "who failed to act and displayed serious lapses in judgment" have been removed and assigned blame on NECC.
While noting "poor judgment, missed opportunities and a lack of appropriate action" by the state Board of Registration in Pharmacy enabled NECC to "continue on their troubling course," Bigby said that NECC bears "primary responsibility" for the harm caused to patients.
She said the company "knowingly disregarded sterility tests, prepared medicine in unsanitary conditions and violated their pharmacy license, endangering thousands of lives as a result," according to her written testimony.
Looking forward, Bigby said she's working to identify a Department of Public Health official to address quality assurance and safety issues department-wide and suggested a retooling of professional oversight boards to include members who are free of conflicts of interest.
Gov. Deval Patrick told reporters Wednesday that the "whole story hasn't been told" and said he is trying to show "the patience of developing the whole story and getting to the bottom of it" before making any additional changes in how the state pharmacy board operates.
The Patrick administration on Nov. 1 announced a commission to examine compounding pharmacies.
"I'm trying to get some help -- that is what this commission is about -- in thinking through comprehensively, so when we are ready to make a fix, and there is going to be a fix, it is comprehensive. It is one-time," Patrick said.
Patrick said "there is no doubt there are some failings here," adding they occurred at the state level, staff level, board level, and some are systematic and will require changes to state law. "But I don't want to do it bit by bit. I want to do it comprehensively."
State Rep. Hank Naughton, a Clinton Democrat and co-chairman of the Legislature's Public Safety Committee, said at the outset of the hearing, "We're not here to call anyone on the carpet but if that's where it leads, that where it leads."