Tell us who’s to blame for cervical blunders

DR Gabriel Scally has done a superb job in his report on the Cervical-Check scandal, and the 50 recommendations he has made will, when implemented, make a massive difference to procedures.

However, in the document, Dr Scally describes a complete systems failure at the root of the service, a failure that saw women whose cells were abnormal being wrongly given the all-clear thanks to inadequate screening at laboratories in the United States.

This rather underestimates the problem, because systems don’t fail – people do.

In this instance, that might be a failure of the people who designed the system, or those who implemented it, or those who saw flaws but did not address them, whether through negligence or just the fear of consequences for anyone who rocked the boat.

CervicalCheck was not designed and run by computers. It was designed and run by people, and unless individuals are held to account for its failures, then failure will keep happening in all areas of the health service in this country.

It is absolutely vital that we find out who made critical decisions to award the contracts to the labs in question, to then exercise little oversight, to argue over who should tell women who received false negatives, to not inform at all the relatives of those who subsequently died. And when we have done that, it is equally important we find out why, if any real lessons are to be learned.

There is a long tradition in Ireland, when a problem arises, of circling the wagons to make sure no-one is scapegoated, when in truth individuals should be held accountable for their actions, or inaction.

If this scandal is to lead to any good, it must be a renewed focus on accountability, and a clear signal that anyone who fell short of a required standard be held responsible.