Inspector General of the Peace Corps’ Report on the death of PCV Bernice Heiderman

PCV Bernice Heiderman (Comoros 2018) died of undiagnosed malaria in 2018.

Please read the article Peace Corps faces questions over another Volunteer death (Comoros) posted here in Peace Corps Worldwide. The New York Times published this article, October 2, 2020. The article quotes from the Inspector General of the Peace Corps’ report.  Her parents are preparing to sue the agency over the death of their daughter.  As the Peace Corps evidently plans to send a new contingent of Volunteers overseas, when countries are safe and are willing to welcome new PCVS, the problems identified by the OIG become even more important to resolve.   Click here to read the entire OIG report.

Here is the Executive summary:

EXECUTIVE SUMMARY

“This report provides the results of our review of the circumstances surrounding the death of Peace Corps Volunteer Bernice Heiderman (PCV Heiderman) on January 9, 2018, in Comoros. PCV Heiderman died from undiagnosed malaria, specifically cerebral malaria caused by the species Plasmodium falciparum (P. falciparum). This is the deadliest species of malaria when left untreated, and the dominant species in Comoros. Because of the risk of infection from malaria in Comoros, the Peace Corps requires all Volunteers to take antimalaria medication. The Peace Corps’ medical technical guidelines for malaria diagnosis and treatment directs its medical officers to assume that all Volunteers serving in malaria endemic areas could become infected with malaria, and to always consider a diagnosis of malaria in any Volunteer with a fever. Rapid malaria tests and malaria treatment medication (Coartem) are provided to Peace Corps Volunteers and maintained in medical units in order to initiate treatment for malaria when necessary.

Our review found the Peace Corps medical officer (PCMO) in Comoros, PCMO Nizar Ahamada Said, did not consider a diagnosis of malaria at any point from January 2, 2018, until PCV Heiderman’s death on the morning of January 9, 2018. Malaria test kits and treatment medication were available in Comoros to assist in diagnosing and treating PCV Heiderman throughout her illness, but were not used. Our review found that if PCV Heiderman had been diagnosed with malaria when her initial symptoms indicated a possible malaria infection (headache, nausea, diarrhea, lower abdominal pain, vomiting, dizziness, sweats, chills and a temperature of 37.9°C, or 100.2°F) and had she received timely treatment, she could have made a rapid, full recovery.

Our review also found that PCV Heiderman had not been adhering to her required malaria suppression medication regime for several months prior to her death from malaria. The Peace Corps medical unit in Comoros was unaware of this fact and assumed that PCV Heiderman was taking her antimalarial pills.

Our review identified several vulnerabilities associated with the Peace Corps’ failure to provide an early diagnosis and prompt treatment for PCV Heiderman’s malaria. The agency had staffed the medical unit in Comoros with one medical officer who had limited training in infectious diseases and limited clinical experience caring for non-immune travelers to Comoros, who are at greater risk of dying from untreated P. falciparum malaria. Unlike most Peace Corps overseas medical units which are staffed by at least two qualified medical officers, no other PCMO was available in Comoros to observe PCV Heiderman and discuss with PCMO Nizar possible diagnoses and causes of her illness.

In addition, PCMO Nizar had a clinical proclivity to associate a diagnosis of malaria with the presence of a high fever, based on his two years of experience treating patients at the local public hospital in Comoros. However, since PCMO Nizar detected only a mild fever in PCV.

PEACE CORPS OFFICE OF INSPECTOR GENERAL —  I

Heiderman, he never suspected malaria as a possible diagnosis. PCMO Nizar remained ‘anchored’ to his original diagnosis of a suspected headache disorder and a gastrointestinal disorder, and believed that his treatment for PCV Heiderman was effective, including up until the evening before her death. After reviewing PCMO Nizar’s consult note about PCV Heiderman on January 8, 2018, the Director of the Office of Medical Services, Dr. Colantino, called PCMO Nizar to discuss PCV Heiderman’s case and advised him to keep PCV Heiderman on IV fluid, monitor her vital signs and urine output, and to do lab work first thing in the morning of
January 9. The recommended lab work included conducting a basic metabolic panel, including creatinine and electroylytes, and a complete blood count. Dr. Colantino did not ask Dr. Nizar if he had considered a diagnosis of malaria.

We found that the agency’s medical technical guidelines for the diagnosis and treatment of malaria were outdated and out of alignment in key respects with prevailing malaria diagnosis guidelines from the World Health Organization (WHO, 2015), which instructs doctors to suspect malaria in any sick patient with a mild fever of 37.5°C (99.5° F) and recommends using a rapid diagnostic test to confirm the presence of malaria parasites. The Peace Corps’ medical technical guidelines for malaria from 2006 were less clear than 2015 WHO Guidelines about the definition of “febrile” in terms of a temperature, and did not instruct medical officers to suspect and test for malaria using a rapid diagnostic test, although the agency does provide the tests to Volunteers and medical officers. PCMO Nizar in fact had rapid diagnostic test kits in the sick bay where PCV Heiderman died from undiagnosed, untreated P. falciparum malaria, but did not use any of them because he did not recognize PCV Heiderman’s symptoms as being consistent with a malaria infection.

PCMO Nizar, as well as other agency officials, expressed the viewpoint that it was more challenging to arrive at a diagnosis of malaria in PCV Heiderman because she did not have a high fever. We found that this viewpoint was inconsistent with clinical diagnosis guidelines that stress that patients with malaria typically present initially with non-specific symptoms, and that early diagnosis and prompt treatment for malaria, especially P.falciparum malaria in a non- immune patient, is key to patient survival.

While treating PCV Heiderman from January 2 through January 9, PCMO Nizar also did not follow the agency’s medical technical guidelines for clinical documentation. Specifically, PCMO Nizar did not record PCV Heiderman’s vital signs or document his clinical assessments of her condition for each of his encounters with her from January 2 through January 9. By not taking her vital signs, completing patient encounter forms, or documenting the basis for his assessment that PCV Heiderman’s condition was improving, Dr. Nizar made diagnostic and treatment decisions for PCV Heiderman based on insufficient clinical evidence. The lack of clinical data also made it challenging to review the provision of care for PCV Heiderman and difficult to create an accurate timeline of the circumstances surrounding her death.

PEACE CORPS OFFICE OF INSPECTOR GENERAL — II

PCMO Nizar did not follow the agency’s clinical escalation policy related to medical emergencies or follow instructions he received from the Director of the Office of Medical Services on January 8, 2018. Specifically, on January 8, PCMO Nizar did not recognize that PCV Heiderman’s vital signs had met the threshold for a medical emergency, and so did not initiate a clinical escalation properly. Had he recognized this, PCMO Nizar should have escalated the matter by placing a phone call to the Office of Health Services. Instead, PCMO Nizar submitted a written consult note through the agency’s electronic medical records system with no specific request for guidance. When he was contacted late in the evening on January 8 by the Director of the Office of Medical Services about this consult note, PCMO Nizar maintained that PCV Heiderman was getting better and was not in crisis. PCMO Nizar then failed to follow the instructions he received on that call from the Director of OMS to call her back should PCV Heiderman’s condition change in any way in the night of January 8. PCV Heiderman died in the early morning on January 9 before PCMO Nizar could perform the diagnostic tests that he had been instructed to do that morning.

Finally, we found that the agency’s patient safety event review focused on the clinical decision- making of PCMO Nizar and that the agency had not yet assessed its systems or processes to identify ways to decrease the likelihood of another Volunteer death from undiagnosed malaria. OIG has four outstanding recommendations to the Peace Corps to improve its sentinel event review process in order to identify and address systemic or institutional vulnerabilities that contribute to serious adverse events.

This report also summarizes the investigative steps OIG took to respond to allegations that PCV Heiderman’s death may have been a homicide.

This report makes 7 recommendations to the Peace Corps to address the vulnerabilities we identified and make it more likely that medical officers will provide timely diagnosis and prompt, effective treatment for malaria so that future Volunteer deaths from the disease can be prevented.”