March 4, 2014
For the full report see:
The Forensic Drug Laboratory at the Hinton State Laboratory Institute (“Drug Lab”) in Jamaica Plain was ordered closed by Governor Deval Patrick on August 30, 2012, after one of the lab’s chemists, Annie Dookhan, admitted to tampering with drug samples, raising serious questions about the integrity of the testing performed at the Drug Lab. In November 2012, at Governor Patrick’s request, the Office of the Inspector General (“OIG”) agreed to conduct an independent, top-to-bottom review of the Drug Lab. The OIG’s mission was to carry out a comprehensive investigation of the operation and management of the Drug Lab from 2002 to 2012, a period in which the Drug Lab was primarily overseen by the Department of Public Health (“DPH”), to determine whether any chemists, supervisors or managers at the Drug Lab committed any misfeasance or malfeasance that may have impacted the reliability of drug testing at the Drug Lab, and to make findings and recommendations following its review.
Over the course of fifteen months, the OIG carefully studied the Drug Lab’s policies and procedures, identifying a number of deficiencies in its practices and protocols. With the support of experts in the field of forensic drug testing, the OIG reviewed more than 200,000 documents including, but not limited to, lab records, testing data and results, emails and internal memoranda. Further, in order to fully understand not only the technical shortcomings of the lab, but also the personal dynamics that led to such a failure, the OIG interviewed more than forty individuals associated with the Drug Lab, most of them under oath.
The OIG’s review found that:
- Dookhan was the sole bad actor at the Drug Lab. Though many of the chemists worked alongside Dookhan for years, the OIG found no evidence that any other chemist at the Drug Lab committed any malfeasance with respect to testing evidence or knowingly aided Dookhan in committing her malfeasance. The OIG found no evidence that Dookhan tampered with any drug samples assigned to another chemist even when she played a role in confirming another chemist’s test results.
- The management failures of DPH lab directors contributed to Dookhan’s ability to commit her acts of malfeasance. The directors were ill-suited to oversee a forensic drug lab, provided almost no supervision, were habitually unresponsive to chemists’ complaints and suspicions, and severely downplayed Dookhan’s major breach in chain-of-custody protocol upon discovering it.
- DPH Commissioner John Auerbach and his staff failed to respond appropriately to the report of Dookhan’s breach of protocol; the investigation DPH conducted was far too narrow and Auerbach and his staff failed to disclose another known act of malfeasance to prosecutors, defendants and other interested parties.
- The Drug Lab lacked formal and uniform protocols with respect to many of its basic operations, including training, chain of custody and testing methods. This lack of direction, caused in part by the Drug Lab’s lack of accreditation, allowed chemists to create their own insufficient, discordant practices.
- The training of chemists at the Drug Lab was wholly inadequate. New chemists’ training was limited and lacked uniformity, and DPH offered virtually no continuing education to experienced chemists.
- The Drug Lab failed to provide potentially exculpatory evidence to the parties in criminal cases by not disclosing information about additional, inconsistent testing results. The OIG is in the process of retesting approximately 2,000 of these drug samples to determine whether the results provided to prosecutors and defendants were accurate.
- The Drug Lab failed to uniformly and consistently use a valid statistical approach to estimate the weight of drugs in certain drug trafficking cases.
- The quality control system in place at the Drug Lab, which focused primarily on the functionality of the lab equipment rather than the quality of the chemists’ work, was ineffective in detecting malfeasance, incompetence and inaccurate results.
- The security at the Drug Lab was insufficient in that management failed to appreciate the vulnerability of the drug safe, and did not do enough to protect its contents.
- There were no mechanisms in place to document discrepancies in chain-of-custody protocols or inconsistent testing results.
In consideration of the above findings, the OIG recommends that the Commonwealth undertake a number of measures designed to ensure that all parties in the criminal justice system, as well as the general public, can once again have the utmost confidence in the integrity of forensic drug testing performed in the state.
Specifically, the OIG recommends:
- All state agencies must employ management practices that hold supervisors accountable for their employees. Managers must conduct comprehensive background checks and complete performance evaluations on an annual basis. In forensic drug labs, there must be a system to report deviations from policy, and all managers of forensic labs should be experts in their respective fields.
- The Massachusetts State Police (“MSP”) is the appropriate agency to handle the forensic drug testing that the Drug Lab conducted before its closure. MSP’s infrastructure and financial resources, including the accreditation of its drug lab, make it the agency best equipped to handle the forensic drug testing formerly conducted at the Drug Lab.
- The Legislature should mandate that all forensic laboratories in Massachusetts be accredited and sufficient funding should be appropriated for that purpose.
- Forensic drug chemists should receive extensive, theory-based training prior to analyzing any drug samples. Additionally, all chemists should take part in expert witness training and a mock trial program prior to testifying in court, and should be provided ethics training to ensure they remain unbiased in their forensic science responsibilities.
- All forensic drug labs in Massachusetts must make it a practice to provide the results from all analytical tests run on each sample when providing discovery information to interested parties.
- Quality controls at all forensic drug labs in Massachusetts should focus on both the functionality of equipment and the integrity and accuracy of the chemists’ work product.
- Every employee of a forensic drug lab with access to controlled substances should submit to periodic random drug testing and annual criminal record checks. Further, forensic drug labs should employ and appropriately manage advanced security measures such as biometric devices and closed-circuit televisions.
- The OIG declines to provide an opinion on how the courts should resolve Drug Lab-related cases; however, based on its thorough review, the OIG can comment as follows:
- all samples in which Dookhan was the primary chemist should be treated as suspect and be subject to careful review;
- the OIG found no evidence to support treating cases in which Dookhan confirmed another chemist’s results with any increased suspicion about Dookhan’s involvement;
- the OIG found no evidence to support treating cases in which Dookhan had no known interaction with the drug sample in question with any increased level of suspicion related to Dookhan;
- for cases in which multiple tests were run, and the corresponding test results were not provided to the prosecutor or defendant in a criminal case, the OIG respectfully defers to the courts to determine whether such test results were exculpatory and material to the defendant’s conviction;
- for trafficking cases in which the estimated weight of samples was determined without using a valid statistical approach and the weight finding is close to the statutory threshold for a trafficking charge, the OIG suggests that the cases be carefully reviewed;
- with respect to cases with samples that the OIG wanted to retest, but which no longer exist, the OIG suggests that the cases be evaluated with increased concern.
Finally, as mentioned above, the OIG, with the assistance of an independent, out-of-state laboratory, is in the process of retesting a number of samples that were found to be potentially problematic. The OIG will detail the results of the samples being retested in a supplemental report.
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