Singapore - To err is human, to confess remarkable

It came as a shock that the much vaunted Health Sciences Authority (HSA), whose laboratories are recognised internationally, had perpetuated an error for 10 months without realising it.

The authority called a press conference on the matter on Tuesday.

The mistake was caused by a laboratory manager who misread the concentration of the reagent used for DNA tests. As a result, he made up a solution 10 times as strong as it should have been.

The solution was for use throughout the year. This reagent was used to test the DNA samples in more than 400 criminal cases. Such scientific proof could be used to link a person to a crime or scene of crime.

At the time the error was discovered, in August last year, even the scientists were not sure how far-reaching the consequences could have been.

As a result, more than 30 prosecutors at the Attorney-General's Chambers spent weeks re-tracing more than 400 cases that might have been affected. Of these, samples from 87 cases were deemed necessary for retesting.

This amounts to about 2,000 samples - equal to about three months of work at the laboratory.

When the error first surfaced on Aug3, there was fear that the consequences would be far graver than they turned out to be.

Could an innocent person have been punished for a crime he did not commit? Or could a guilty person have been let off - just because the DNA test was wrong?

Fortunately, as it turned out, the error merely resulted in a lower sensitivity of the test - which meant the test could not pick up DNA profiles from poorer quality samples, such as hair and skin.

This, however, should not excuse the HSA from taking the lapse very seriously. Correcting the error will be costly in time and money.

More importantly, HSA has to use this as a wake-up call to put in even more stringent gate-keeping to prevent a similar occurrence in the future.

HSA audits its DNA tests to make sure that they are correctly done. What it did not do was to double-check the solution used.

This is not required in laboratories anywhere else in the world either, since the solution is just a basic tool used.

Now, of course, this has changed in Singapore. Every batch is now tested by an independent laboratory.

To be fair, there is every indication the HSA has taken the error very much to heart and is now looking at where else its processes can be further strengthened.

When asked why no test was done on the solution in the first place, Mr Roy Quek, deputy secretary at the Ministry of Health (MOH), which oversees the HSA, said: "That's a question we're all asking ourselves now."

But putting in more stringent checks is just one of two lessons to be learnt from this incident. The other big lesson from this regrettable episode is that human errors can and do happen.

This is why systems and processes must be robust - to prevent such lapses.

When the consequences can be dire, when human lives and freedom hang in the balance, it is better to have more than fewer systemic safety nets.

It could have been a real tragedy had someone been sent to the gallows on the strength of a wrong DNA sequence. But since human error happens, it is equally important that an organisation and the people in it have the right attitude on what to do when an error surfaces.

In this case, the mistake was made by the laboratory manager, said to be a very senior person with 30 years of experience.

He discovered the mistake when mixing the solution for a next batch for the following year. Instead of covering up, he had the courage to report it, in spite of the possibly severe consequences both to him personally and to the HSA. This is highly commendable.

In fact, I would go so far as to say that this person's integrity - in the face of possible professional ruin and personal embarrassment - has done HSA and Singapore proud.

The error was an honest mistake, and if deemed necessary, he should be punished for it. But it should not overshadow the significance of his act in reporting the error.

Such behaviour should be lauded and encouraged.

As noted at the press conference on Tuesday where representatives of various government bodies, including the Attorney-General's Chambers and the police, were present, if he had kept quiet, the error would likely have gone undiscovered.

It took moral courage for the lab manager to own up to the error, and integrity for HSA to call in all relevant government agencies to review the import of the mistake and take steps to rectify the wrong.

This kind of personal and institutional integrity to admit wrongdoing and take steps to fix a wrong goes a long way to help the public maintain confidence in the HSA.

Salma Khalik

The Straits Times

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