CITY OF NEW HAVEN RELEASES FULL INDEPENDENT INVESTIGATION & REPORT ON NEW HAVEN HEALTH DEPARTMENT’S VACCINE TEMPERATURE EXCURSION INCIDENT, FIRST REPORTED IN FEBRUARY 2022
New Haven CT – Today, the City of New Haven released the full independent investigation and report into the New Haven Health Department’s COVID vaccine temperature excursion incident that was first identified in February 2022, where 656 doses of the COVID-19 Pfizer vaccine were improperly stored at a freezing temperature longer than the recommended period and were subsequently administered to 625 different individuals. Because Pfizer, the vaccine manufacture, could not give assurances that the improper storage would not reduce the vaccine’s efficacy, the individuals who received these vaccines were immediately notified and encouraged to get re-vaccinated.
The independent investigation and review were conducted by New Light Investigations, a third-party company, and provides extensive details on the events preceding and immediately following the discovery of the incident. The report supports and corroborates, with extensive evidence, the findings of the New Haven Health Department’s internal review which was conducted in February 2022 immediately upon the discovery of the issue.
“We promised accountability, transparency and a full and thorough investigation into this incident, and the City’s internal investigation and New Light Investigation’s independent investigation deliver on this commitment,” said Mayor Justin Elicker. “It is truly unfortunate this incident occurred, and we apologize for the inconvenience that it caused to patients. 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.”
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.
“I want to thank New Light Investigations for their detailed and comprehensive report,” said Dr. Mehul Dalal, New Haven Community Services Administrator. “I am confident all relevant aspects of the incident have been thoroughly reviewed.”
New Haven Health Director Maritza Bond stated, “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 full investigation and report by New Light Investigations can be found here: https://bit.ly/Vaccine-Temperature-Excursion-NLI-Report
New Light Investigations delivered an unredacted version of the 474-page report and related exhibits to the City of New Haven on June 1st, 2022. The final redacted version of the report was delivered to the City of New Haven on August 1, 2022. Prior to public release, the report was reviewed for confidential information and personal health information, which needed to be redacted prior to its distribution today.
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