The lack of a “mature culture of emergency management” at the University of Maryland College Park could have delayed earlier and more robust responses to a mold infestation and viral outbreak in fall 2018 that led to the death of a student, according to an independent investigation released this week.
A deeper culture of emergency management across all levels of campus leadership “would have provided early opportunities for escalation and more effective emergency management for both incidents,” a panel of six experts and two attorneys concluded in a 141-page report.
The panelists also unanimously agreed that the university followed local and federal protocols in handling the crises last fall.
The panel – which includes experts in university management, health care and building industries, all with no prior ties to the university – began work in September after a vote of the Board of Regents, which was urged by Gov. Lawrence J. Hogan Jr. (R) to undertake an independent investigation of the death of freshman Olivia Paregol in November 2018 from adenovirus.
Paregol died last Nov. 18 after a weeks-long battle with adenovirus, which has symptoms similar to the flu, but can be dangerous in certain strains or for immunocompromised people, like Paregol. She was initially treated for a bacterial infection after living in Elkton Hall, a dormitory infested with mold, and her family has argued that earlier knowledge of the adenovirus outbreak and earlier treatment by antiviral medications could have saved her life.
The panel’s 141-page report concludes that university employees involved with the adenovirus and mold outbreaks on campus “worked tirelessly to address the issues they confronted,” that no employee intentionally withheld or delayed releasing pertinent information, and that student health and safety was a chief concern and cost was not a limiting factor in responses to either issue.
“That is not to say that the University’s response to these events was perfect. No response ever is,” the panel wrote.
In particular, both the mold issues in student residential housing and the adenovirus outbreak should have been viewed and handled as campus-wide emergencies to make more campus personnel and resources available for responses, the report states.
The campus also did not appear to hold any formal campus-wide or Office of Emergency Management after-action meetings after the mold infestation and adenovirus outbreaks.
In the future, the university should err on the side of activating emergency response plans and then scale them back if necessary, the panel recommended.
About 13 pages of the report are dedicated to recommendations for how to better handle emergencies in the future.
Those recommendations include streamlining campus-wide communications, a process that is currently “cumbersome and unclear.”
At one point in mid-November, after three cases of adenovirus hospitalization had been confirmed and while Paregol was in the intensive care unit at Johns Hopkins Hospital, the Campus Infectious Disease Management Committee met and decided to send a campus-wide email about the adenovirus outbreak. But the process of drafting and approving the text of the message stretched into the evening on Friday, Nov. 16 and the message was not sent until Monday, Nov. 19, the day after Paregol died.
The panel concluded that the timing of the email was not related to Paregol’s death, but highlighted the university’s inability to send messages in a more immediate fashion.
Portions of the report about the medical conditions of Paregol and other students are redacted for public release.
Some of the panel’s recommendations have already been implemented by the campus. For example, starting this fall, the University Health Center began more closely monitoring health trends on campus and asking students ― particularly those with compromised immune systems ― to voluntarily turn over health information history that could guide targeted notifications about health conditions during flu season or during infectious outbreaks.
The university has also upgraded HVAC systems to control moisture in Elkton Hall, though further upgrades could be made, the panel concluded.
The panel’s investigation included a review of more than 25,000 documents turned over by the university and interviews with 11 campus employees, a company hired to help with mold remediation and with Ian Paregol, Olivia’s father.
College Park President Wallace D. Loh responded to the release of the investigation in a campus-wide email on Wednesday.
“Our campus works tirelessly on behalf of the health and safety of our students, faculty and staff, and we will carefully consider the report’s recommendations,” Loh said. “The panel unanimously found that university employees prioritized student health and safety above all else.”
“We do not want another child and family to suffer through this unimaginable pain, and if pushing for an investigation to evaluate the university’s responses can prevent that from happening and avoids another unnecessary death, then at least we have made some progress in accountability within the UMD system,” Paregol told the Post.
The family filed notice earlier this year that it may seek legal action against the university.
The full report is available online.