206 WOMEN WRONGLY GIVEN THE ALL-CLEAR FOR CANCER
HSE admits shocking level of errors in reading smear test results after case brought by dying mother Vicky Phelan
MORE than 200 women were wrongly given the allclear for cervical cancer and should have been sent for further checks, the HSE admitted last night.
Figures released to the Irish Daily Mail show that 206 cases that were reviewed should have gone on for further investigation.
‘In 442 cases, review was warranted.
Of those 442 cases, 206 cytology reviews suggested a different result which would have recommended an investigation to occur at an earlier stage,’ it said.
The admission came as the HSE was last night accused of covering up the smear test scandal.
And as it faced unrelenting criticism over how the vulnerable women involved were treated, Tánaiste Simon Coveney described what happened to them as a ‘shameful series of events’.
He revealed that the HSE waited for two years after becoming aware of Vicky Phelan’s misread cervical
cancer screening before her doctor was told. Even then, the 43-yearold Limerick mother-of-two wasn’t told by her doctor about the false ‘all-clear’ reading for another year.
Her solicitor Cian O’Caroll said yesterday that there is ‘a great deal of anger about the cover-up’, and as politicians from all sides demanded clarity, the HSE last night admitted that as many as 206 women, whose cases were reviewed after smear tests, should have been sent for further checks.
Health Minister Simon Harris said that ‘in some years, you could be talking about ten to 15’ women whose smear test results were wrongly read and who were eventually diagnosed with cervical cancer. He has now ordered that the smear test screening programme CervicalCheck – which has completed over 3 million screenings since it started in 2008 – write to all doctors involved to ensure they have passed on information to their patients.
Mr Coveney said what happened could not be defended.
He apologised to Mrs Phelan and told the Dáil that at the time when a review found that Mrs Phelan’s original smear test result was incorrect, in 2014, it was normal practice not to pass that on to patients or their doctors.
Instead, it was used to improve the screening system.
He said: ‘This changed in late 2016, and subsequently current and historical outcomes of the audit process were made available to clinicians for communication to
‘There’s a great deal of anger’
their patients on request.’
He added: ‘I think anybody who has listened to this story or read about it will come to the conclusion that this was a shameful series of events, particularly where information flow is concerned.
‘The tragedy and challenges that Ms Vicky Phelan and her family are facing now have been made all the more difficult because of the failings in passing information on.’
Mr O’Carroll said: ‘I think it’s fair to say there’s a great deal of anger about the cover-up. Whether you can say there’s a vast conspiracy of cover-up, perhaps you would need more evidence but clearly this information was deliberately kept from my client and it was information of the greatest relevance to her personally, her health bills and to her planning for the rest of her life.’
He added that keeping that information served CervicalCheck, and it was CervicalCheck who kept it.
‘The most benign interpretation you could put on it was that it was a bungling sequence of unfortunate events, because the correspondence shows that they told doctors “Don’t tell everyone”.
‘Maybe they did this for the good purpose of not scaring everyone, and whether or not CervicalCheck was as effective as people wanted it to be, but now they have a full on scandal on their hands.’
The HSE said: ‘Since 2008 a total 1,482 cases of cervical cancer have been notified to the CervicalCheck programme. In the majority of these cases there has been no requirement for further review.
‘In 442 cases, review was warranted. Of those 442 cases, 206 cytology reviews suggested a different result which would have recommended an investigation to occur at an earlier stage.’
It said that 173 cytology reviews suggested that a referral to colposcopy might have been recommended earlier and for 33 cases a repeat smear might have been recommended to occur earlier.
It also emerged yesterday that CervicalCheck had told doctors, whose patients had an incorrect test result, to exercise their judgment on whether to tell them.
It also advised doctors to simply record the error on the files of patients who had died.
Fianna Fáil’s health spokesman Stephen Donnelly called for clarity over whether or not there was an attempt to ‘cover up’ the smear test scandal.
He told RTÉ’s News At One: ‘How did this happen? Why was Mrs Phelan’s doctor not comfortable telling her right away? Clearly, there was discomfort there, why was it there?
‘Do they believe that any of this has the suggestions of cover-up?
‘You might believe that there was no hint of any cover-up. What I’m saying is, it is incumbent on the Government to look at this very closely. For example, we know that the circular said that in the case where a patient had passed away, that it simply needed to be noted in their records.’
In response to questions from the Irish Daily Mail yesterday, the HSE said: ‘Since 2010, as part of our quality assurance, we review
‘We should have open disclosure’
the screening history of every woman with a diagnosis of cervical cancer who has participated in the programme.
This process is in line with international best practice and offers an important opportunity to learn from individual cases about how cancers develop and are diagnosed and to assess if any areas of the screening pathway could be improved for women. Up to recently, the outcomes of this review have been sent to a woman’s treating doctor, with advice to use their clinical judgment to communicate this to the woman.’ It said CervicalCheck would be contacting every affected woman.
‘While the HSE is confident that the majority of women involved in this process have already been contacted by their doctor, CervicalCheck is today writing to those doctors who were originally requested to contact patients to confirm that this has occurred.’
However, it said that it would not be carrying out a review of every smear test.
‘The identification of a small number of cases with a false negative screening result is not unusual for a population-based screening programme. There was no negligence associated with this case and all laboratories contracted by CervicalCheck report performance levels that are acceptable and within set targets and standards.
‘There is no clinical indication that would warrant a review of smear tests of women who have not been diagnosed with cervical cancer.’
The Taoiseach extended his ‘sympathies to Ms Phelan and to all of the people who have been affected by these issues in relation to cervical check’.
Leo Varadkar said he wanted to ‘encourage women to continue to participate in the programme and to continue to go for a smear if they are called for one’.
He added: ‘It is very definitely Government policy, and now protected by the law, that we should have open disclosure in healthcare. And that means that doctors have a duty of candour to give information to patients.’
A Health Department source said last night that audits in the case of ten to 15 cervical cancer patients a year found that the original smear tests should have raised concerns.
He said: ‘These initial tests of the cancer patients were then reviewed as part of an automatic look-back after their diagnosis, and in ten to 15 cases each year it was ‘thought “okay, maybe they should have
said that there was a reason to send the woman further on those”. And that’s about ten to 15 cases every year is what they estimate, since it started [in 2008].’ Minister Simon Harris said he expects that, in the majority of cases, doctors had ‘these conversations with the vast majority of patients’.
‘I think it is really important that we don’t just presume everybody was told and we don’t presume Ms Phelan was an isolated case, that we actually take the concrete step of establishing has every woman been told. And then we don’t just stop there, but we make sure that it is automatic.’
He said this is one of the three ‘concrete’ steps he is taking as a direct and ‘swift’ action in relation to Mrs Phelan’s case. This includes a review of the Cervical Check programme ‘against best international practice’.
He apologised to Mrs Phelan and her family and hailed her ‘courage and bravery’.