The rise in temperature of the Health Board's cold store, which destroyed €3 million worth of medicines around Midsummer, was likely caused by faults with the design and construction of the building, an investigation has found.
The report of the committee headed by the state secretary says the failure of the Health Board's cold stores was most likely caused by faults in the design and construction of the building, which manifested themselves during a prolonged period of hot weather. The cold stores in the building were designed and built in such a way that, according to the Estonian Consumer Protection and Technical Regulatory Authority, they would have ceased to function as cold stores at some point.
The design and construction errors had not been identified before the completion of the building by the state real estate management company RKAS. Nor was the identification of design and construction defects supported by the Health Board's quality system and rules of procedure.
The increase in temperature in the cold rooms was detected by duplicated monitoring and information systems meant for that. However, the rules of procedure were incomplete, and due to the combined effect of the faultily performed name server change by RKAS and the inadequate quality system of the Health Board, the alert did not reach those it was meant to reach.
The construction design of the building of the Health Board did not comply with the requirements of the Building Code and the outline design in the portion concerning cold storage rooms, and at different design stages, neither the main designer nor the contractor ensured the rationality and compatibility of the different parts of the design and solutions, as a result of which the building is not compliant with valid requirements, the report finds.
After the incident, the Health Board does not store cold medicines on these premises. The Health Board quarantined the medicines that were affected by the temperature deviation, which means that they were not dispensed to health care workers, the Estonian people did not receive them.
The committee recommends that the Health Board immediately review, complement and expedite the implementation of relevant processes governing the handling and storage of vaccine and medicinal products and ensure sustainable quality control at the Health Board.
The committee recommends that the Ministry of Finance, in cooperation with RKAS, assess whether and to what extent and to which parties a claim for damages can be submitted for design and construction errors in the cold rooms of the Health Board. In addition, the committee recommends that the Ministry of Finance assess the ability of RKAS to ensure the proper development and management of special projects.
The committee's recommendation for the Ministry of Social Affairs is to assess whether the regulations for the supervision of persons handling medicinal products are sufficient or whether they need to be supplemented.
It also has to be assessed whether the storage of the stockpile of vaccine and pharmaceutical medicinal products should be handled by the state alone or done in cooperation with the private sector. The committee will forward the report to the Office of the Prosecutor General for an assessment of whether there are grounds for opening criminal proceedings on the basis of the facts identified in the report.
As the company that installed the Health Board's monitoring and reporting system, Guard Systems Estonia OU, and its Norwegian parent company, GSGroup AS, have not to date provided the Health Board with any information on the account that made the change to the system configuration on September 30, 2019, or the person associated with it, it is necessary to assess whether the system has been unlawfully interfered with, the committee said.
The committee, convened by the state secretary in July, was tasked with finding out the circumstances that led to the failure of the health board's cold store in the second half of June 2021. The committee was made up State Secretary Taimar Peterkop, Marika Priske from the Ministry of Social Affairs, Meelis Peerna from the National Audit Office, Kaur Kajak from the Consumer Protection and Technical Regulatory Authority, Katrin Kiisk from the State Agency of Medicines and Merike Saks from the Ministry of Finance.
The committee's task was to provide a comprehensive picture of the results of the proceedings initiated by the Consumer Protection and Technical Regulatory Authority, the Health Board, the State Agency of Medicines and RKAS. The committee's report and the conclusions it contains are not an administrative act. The purpose of the report was to establish the circumstances of what had happened for the government.
Peterkop: Pile up or errors led to failure of Estonian Health Board's cold store
Mistakes were made at every stage in the construction and management of the Health Board's cold store, and the accumulation of errors led to the breakdown of the cold store during the heat wave in the second half of June, Taimar Peterkop, Estonia's state secretary and chair of a committee that looked into the causes of the failure, said.
Peterkop told reporters on Wednesday that the findings are preliminary, but mature enough to be made public. He emphasized that the committee did not interfere in the oversight conducted by the various agencies.
"They were completely independent and the committee used the results of the oversight proceedings to put together a comprehensive picture," he said.
"Mistakes have been made at almost every stage, and the accumulation of these errors led to the failure."
Finding those responsible won't be easy
Peterkop, also said that all parties have their own fault and it will not be easy to pinpoint those responsible.
He said the people who oversaw contracting for the Health Board's cold storage building and those who carried out the procurement are no longer in employment at the state real estate management company RKAS or the Health Board.
"It is difficult to show personal guilt," he said. "Everybody has done their part below par, everyone has their fault to bear."
"Whether someone is criminally liable is a matter for the prosecutor's office. Whether there is civil liability -- that is a matter for the Ministry of Finance and RKAS. It won't be simple," said the state secretary.
According to Peterkop, it was not the inquiry committee's job to identify the culprits, but to establish the circumstances of what happened.
He admitted that the case was complex and that "mistakes were made throughout the many-year process."
Peterkop said that he has worked in public service jobs for more than 20 years, but the circumstances of the case were so baffling to him too that his "mouth dropped open."
Peterkop pointed out that, in his view, this situation is due to the fact that in Estonia's "thin state" there is very little in the way of relevant competence, while, simultaneously, some areas continue to suffer from low sense of ownership.
Builder: Health Board's storage building consistent with design documentation
The CEO of construction company AS Oma Ehitaja, which built the building of the Estonian Health Board in Tallinn, said on Wednesday that the construction work was carried out according to construction design documents.
"Oma Ehitaja built the building of the Health Board in 2016 according to a contract for services concluded with Riigi Kinnisvara AS. The completed building was handed over to the contracting authority in early 2017. The construction work was carried out in accordance with the design documentation provided by the contracting authority," the CEO, Kaido Fridolin, told BNS.
He said Oma Ehitaja has fulfilled its contractual obligations on time and in accordance with the wishes of the client.
"As far as we know, the building and the systems installed in it have functioned smoothly until the unfortunate incident this summer," he said.
"Drawing a link between the accident of this summer and Oma Ehitaja comes as a surprise for us at the moment. We will examine the report of the Consumer Protection and Technical Regulatory Authority and then decide on further action," the CEO added.
Editor: Helen Wright