LAST UPDATE | 23 Nov 2022
THE TREATMENT OF patients affected by the failures of CervicalCheck is still not sufficient five years on from the first inquiry into the screening programme, according to Dr Gabriel Scally.
A new review of how the recommendations from the 2018 inquiry have been implemented identifies that while progress has been made, more still needs to be done to protect current and future patients.
The 221+ patient support and advocacy group said the report shows there are still gaps in the Irish healthcare system in acknowledging and rectifying problems if a mistake is made.
In 2018, Dr Scally conducted a sweeping, four-month inquiry into the CervicalCheck screening programme, finding significant failures in its governance structures and making a series of recommendations for the Department of Health, the HSE, and the Irish government.
He said the biggest failure he identified was the non-disclosure of information from audits to patients – the same devastating error discovered by Vicky Phelan as she studied her own medical files.
Reviewing the progress that has been made since then, Dr Scally identified several problems still impacting the people affected by the screening programme’s failures.
In particular, transparency or ‘open disclosure’ regarding medical errors and the treatment of patient advocates must be addressed, he said.
A Patient Safety Bill meant to address the issue was introduced in 2019 but still has not passed through the Dáil.
Additionally, the review described the “limited scope” of the bill as “problematic”, with a mandatory requirement for open disclosure only required in the case of 13 categories of incidents, 12 of which relate to the death of a patient.
The types of incidents the bill covers would represent “a tiny proportion of harm caused to patients through clinical error”, the review found.
“I’ve been very moved by some of the women involved, some of whom are now dead, who took it into their own hands to achieve resolution,” Dr Scally said.
The women achieved this through “sitting down with the consultants that they’ve had a legitimate grievance about their behaviour in terms of non-disclosure and discussing that with them face-to-face and hearing and exchanging views and hearing how each of them felt”.
“I know that made a difference. We need to engage much more and facilitate that form of resolution.”
Speaking to media upon the publication of the new review, Dr Scally said: “One of the important things I think that has happened as a result of my recommendations is that there have been patient voices and patient advocates placed in various important places, for the first time in many cases, whether it be on the board of the HSE or in other organisations such as the National Screening Committee and that has been a very welcome step.
“There have also been real difficulties, I think, in some of the engagement with 221 and the way organisations haven’t necessarily valued their input and sought their input at the right time.
“The development of the process of resolution as I mentioned in my report was one of these. It is so important that you sit around the table as equal partners. They are not subservient, they are not peripheral. Patients are central here and they need to be treated as such.
“One of the things that upset me enormously is what I’ve been told by a number of women that they are not being treated properly by some of the consultants and some of the doctors that they come across who want to know whether they are a member of 221+ before they will take them on.
“That is completely unacceptable and it’s very remiss at this time that this sort of the attitude is still present.”
Health Minister Stephen Donnelly said the inquiry “will be looked back upon as a seminal moment in the history of Irish healthcare”.
He added: “The work of patient advocates, including 221+, in facilitating that engagement has been crucial and I want to acknowledge their role also.
“Honesty and transparency are vital in healthcare and should be embedded in the culture of the health service. Patients and carers have the right to know when mistakes are made, what the consequences are, or may be, and what action has been taken not only to correct mistakes but to prevent similar occurrences in the future.”
Meanwhile, the HSE said it “accepted in full, without exception, the recommendations from Dr Scally’s Scoping Inquiry into CervicalCheck, and embraced the changes required to improve screening services.”
The 221+ was established in 2018 to offer support and advice to people affected by the screening programme’s failures.
Several members of its steering group attended the publication of the review this afternoon, including Lorraine Walsh, Stephen Teap, Rosie Condra, Liz Yeates and Evelyn Fenton.
In its official statement reacting the report, the group said: “The context for today’s report is very different to that which faced us all four years ago.
“We had barely connected the dots, or the people then. We didn’t know what to expect and despite our individual experiences, we were shocked.
“We now know a lot more. From the stories of hundreds of women we know that our individual lived experiences were not about us, but about a system that has been, and in many case still is, fundamentally flawed and in desperate need of regeneration.”
The group said that the latest report is “not looking at the system through our eyes or in language that we would be comfortable with”.
“We respect that Dr Scally was confined to operating within the frame of reference established by the previously published Scoping Inquiry into the CervicalCheck Screening Programme.
“That notwithstanding, it still highlights a range of continuing shortcomings, and actions that have not been addressed. We thus have mixed feelings about today’s report.”
“It commends fair progress made that is important because protecting and strengthening the future of screening is critically important. It also reflects our long-expressed concerns that there remains an active determination within the Irish healthcare system to avoid dealing upfront with things that go wrong and with respecting those who point out those missteps.”
Lorraine Walsh, a founding member of 221+ whose diagnosis of cervical cancer was delayed by an incorrect reading of a smear test, said that until CervicalCheck programme management “acknowledge and accept” events that occurred, “we, the women involved in this and every woman in this country, can’t have trust in it”.
“We’ve always supported the screening system and we know it does save lives. We deserve a screening programme that is fit for purpose,” she said.
Both Dr Scally and members of the 221+ remembered Vicky Phelan, who died aged 48 last week after years of spearheading the fight to bring attention to the injustices experienced by cervical cancer patients whose audited results were not communicated to them.
“This is the first time that we didn’t have Vicky with us to review a report,” Lorraine Walsh said.
“Vicky was an extremely intelligent woman and very detail-focused. When trawling through this to try to figure out the information of what was in it, there was a huge void because Vicky would always have been totally on top of that.”
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