Rather than rebuild trust, top brass in health just eroded it further
‘IN hindsight” was inevitably the most used phrase when the top brass of the health service were called to account for their part in the CervicalCheck scandal yesterday.
But members of the Oireachtas Health Committee were clearly impatient with their handwringing.
And they pointed out the health officials were all in highly paid jobs to anticipate and act to avert a crisis – not to arrive with any acts of contrition after a catalogue of failings.
Much of their evidence defied belief. Chief medical officer Tony Holohan and a whole tier of other Department of Health and HSE officials knew for months in 2016 there were reviews on more than 200 women who developed cancer after getting an incorrect smear result.
Although the issue occupied several meetings and memos that year, he believed it was reasonable not to bring it to the attention of the ministers for health. They included Leo Varadkar and Simon Harris.
We learned there were meetings with the minister and the management board of the department every six weeks.
It was never on the agenda despite the agonising situation that was going on at CervicalCheck.
When the individual patient reviews were eventually sent to the women’s 29 treating doctors in hospitals across the country, the former HSE director of health and wellbeing, Stephanie O’Keeffe, admitted she did not track to see if they were handed over to the patients.
We already know Ms O’Keeffe was the co-author of stark memos in 2016 on the difficulties in releasing the reports to more than 200 women.
When asked why she did not pursue the whereabouts of the reviews, she said she relied on monthly management reports saying
“things were going well”. This level of distance came after the warnings about the potential damage to the reputation of CervicalCheck if one of the reviews was made public.
Most of the reviews sat in some doctor’s filing cabinet until the last two weeks when the scandal broke. In the meantime 18 of the women died, 15 of whom were oblivious to the fact they were the victim of a mistake.
As members of the committee reminded the officials, it was clear that these doctors would inevitably be slow to get involved in relaying information about a mistake they were not directly involved in. It was pointed outthatitwasa small medical community and word would surely be spreading through the grapevine.
We now know that there was much to-ing and fro-ing between the consultant of Vicky Phelan, who has cervical cancer, and CervicalCheck over who would tell her about her review.
It was also disappointing how Dr Holohan appeared to say a different form of open disclosure – where patients are told when an adverse incident happens – applies to screening. He was asked what he thought of the approach of CervicalCheck, which advised doctors to use their own judgment about telling women about the reviews and just put the existence of the report of a
patient who had died on their file. He said it was the exception rather than the norm for screening programmes to tell patients about a review of smear results. CervicalCheck was making an “honest attempt” to implement open disclosure which has been HSE policy since 2013.
We also learned that the laboratories used by CervicalCheck to analyse results were working to an “acceptable manner” but validation of this is needed by outside experts who are to look at standards.
Instead of restoring trust, the officials succeeded in eroding it even further if we are to believe people in key positions can be so naive and lacking in vital antenna.