Cervical records reveal breadth of knowledge of unseen crisis
If this is how officialdom behaves when it is in the spotlight, what the hell happens in private, asks Brendan O’Connor
IN the three weeks since Vicky Phelan exposed the failings in CervicalCheck cancer screening programme, a conveyor belt of health managers appeared before six Oireachtas committees.
The head of the health service and the clinical director of the cervical screening programme have resigned. And last week, hundreds of pages of records released by the Department of Health and the Health Service Executive (HSE) peeled back another layer of information, revealing the breadth of knowledge about the audit process and the problems that arose.
The records show that four of the HSE’s 20-strong “leadership team” were told about the dispute between CervicalCheck and consultants over who was responsible for telling women with cancer of errors in their original screens.
The dispute over whether doctors or the screening service should inform the women with cervical cancer about screening errors dragged on from 2016 for more than a year and a half and effectively meant that 162 women with cervical cancer were not informed.
The dispute has its origins in Limerick, where Kevin Hickey, a consultant, was told by Dr Grainne Flannelly, clinical director of CervicalCheck, that he was to use his clinical judgment in informing 10 patients who had cervical cancer that the results of their original screenings were incorrect.
One these women was Vicky Phelan, who exposed the failings last month after settling her legal action against the US lab that missed the suspected squamous cell carcinoma in her original smear test.
Ms Phelan ensured that the “over and back” letters between Dr Flannelly and her consultant who insisted it was CervicalCheck’s place to inform women were published after the settlement, largely because she resisted a confidentiality clause.
The records released last week show that this was not only a spat between two consultants. The new records show that Colette Cowen, chief executive of University Hospital Limerick, found the issue “very concerning”. She emailed Liam Woods, the national director of acute hospitals, and Patrick Lynch, who was National Director, Quality Assurance Verification Division. Mr Lynch is now heading the Serious Incident Management Review Team that is organising the HSE’s efforts to contact women and deal with the crisis. Colette Cowen copied them in correspondence and advised that the “issue” may arise in other hospital groups, too.
Minutes of a meeting in September show Kevin Hickey was not alone in his concerns. Nine consultant gynaecologists had “robust” discussion on the issue, according the minutes. One raised the difficulty in consultants communicating “complex information of this type” to women diagnosed with cervical cancer.
Consultants were being “put at a disadvantage” when deciding which women should or should not be “offered a close out meeting” — or in other words, should be told. The consensus at that meeting was that CervicalCheck should tell women about the audit process around the time they were diagnosed, and “if appropriate”, communicate the results directly to her.
The two other members of the HSE’s leadership team who knew about this issue were Dr Colm Henry, the HSE’s chief clinical adviser, and Dr Peter McKenna, who heads the HSE’s Women and Infants Programme. They were made aware of the row through Limerick Hospital last July.
A fifth member of the HSE’s leadership team, Dr Stephanie O’Keeffe, the national director of Health and Wellbeing, who was CervicalCheck’s line manager, knew nothing about the row at all. None of the four national directors informed her and nor did anyone at CervicalCheck, she told the Oireachtas committee last week, despite attending monthly meetings and receiving regular briefing documents that she shared with the then director General, Tony O’Brien and the Chief Medical Officer in the Department of Health, Tony Holohan. She thought that legal cases outlined in one briefing document — four solicitors’ letters from women seeking their files and a fifth who was taking legal action — meant the “process was working” because women were being told. “I did not think anything was going wrong. Perhaps I should have, but I didn’t,” she said.
The Oireachtas meetings last week heard management speak about failures of “closing out” and “feedback loops” in explaining why no one ensured that women had actually received the information health managers claimed they always intended to give them.
Jonathan O’Brien, the Sinn Fein TD, asked John Gleeson, programme manager of CervicalCheck, and Dr O’Keeffe, effectively his boss, whose responsibility it was to ensure that “the loop was closed”. Neither acknowledged responsibility.
“Mr Gleeson is not sure it was his responsibility. Dr O’Keeffe is saying it was the responsibility of the people under her to pass that information up to her,” he said.
IT’S all getting real for Leo and the guys. The dissatisfaction rate, which is the difference between those who are satisfied with how the Government is doing its job and those who are not, tripled among women in the last month according to the MRBI poll in The Irish Times. So it was 10 points in the negative a month ago and now it is 29 points in the negative. Government satisfaction among women has plunged 12 points, to 29pc, in that same month. That is a fall of nearly a third in women’s confidence and trust in this Government. That’s freefall territory.
We are all clear by now — this story is just tragic. So, so sad. But equally, we need to be fair and clear. The Government is not responsible for giving people cancer. The HSE’s apparent inability to inform women who had false negative smear tests, when they already had cancer, did not generally make a material difference to their treatment. Screening is not an exact science or a fool-proof diagnostic test, and there are many legitimate reasons why it may not pick up abnormalities or potential cancers. We know all that now.
The nature of screening, was not, we now know, generally made clear to those participating in the screening process. It was probably in the small print that passed for informed consent. There is no doubt many women took unjustified assurance from screening, but the Government did not give them cancer.
However, we also know that there were women who should not have got false negatives, whose abnormalities should have been spotted. Vicky Phelan seems to be one such woman. And it seems as if there are more to come. Equally, not every woman who was part of the screening programme and who went on to develop cancer is a victim of negligence.
So then, what is the problem here? Why have so many women so suddenly lost faith in the Government? After all, despite a frenzy to make this contagion spread to a politician, asses have been successfully covered, and no smoking gun has yet to be found. So why? Why has female trust in the Government plummeted?
Trust is a tricky commodity for any brand. It takes years to build and one second, one experience, to shatter it. Trust is also a hugely important commodity for any brand, especially for a political brand. Also, any marketing person will tell you that you can do all the advertising, and indeed all the paid-for advertorial in the world to support your brand, but much more important than all that is people’s experience of your brand.
Every single tiny point of contact you have with a brand will determine whether you trust it. The first guy you meet in a hotel, the person you ask to find something for you in a shop, the young person nattering on the phone while you are waiting to be served. These are the small things that create and shatter trust, that determine your feeling towards a brand.
So is it that women have observed the point of contact women like Vicky Phelan had with the State, and have been watching how the State has reacted to this whole scandal, and they don’t like what they see? Most people don’t think about the Government a lot until it intrudes on their life in some way, and women are having cause suddenly to pay attention to how things work in officialdom, and they don’t like it. This is a sudden point of contact, and it’s not a good one.
People are sophisticated, cleverer than you think. These women who no longer trust the Government do not think in anyway that the Government has killed women, or given them cancer, or lied to them about the fact that they have cancer, or any of the other confused notions that have been doing the rounds. These women understand that screening is an imperfect science.
But the women of Ireland have seen what happened next. And that’s where the problem lies. First they saw that Vicky Phelan, a woman who potentially is dying, was dragged through the courts. They didn’t like that.
And then, last week, they witnessed the disgrace that was the Public Accounts Committee hearings with people from the HSE and the Department of Health. They heard that CervicalCheck and the Department of Health didn’t think originally that this whole matter was impor- tant enough to ‘escalate’. They heard how a leaflet telling women about the audit was in preparation for two years. They heard how the likes of Stephanie O’Keeffe, who had the title of Head of Health and Wellbeing in the HSE, did not realise that doctors were not telling the affected women.
In more of the corporate speak that people lapse into when they don’t want to tell you things straight, she said she saw, “no systemic errors arising from the audit”. This is despite the fact that there was clearly a major row between one doctor and the head of CervicalCheck that went on for over a year and was escalated to the HSE, about who should tell Vicky Phelan about how her cancer was missed. Stephanie O’Keeffe, despite attending monthly meetings with CervicalCheck management, despite being copied on communication strategy circulars and despite being aware of legal cases, never suspected a problem.
She wasn’t alone. Some of the HSE people actually saw the whole audit and communication issue as a really positive thing. Because they just assumed the doctors were telling the patients. Until of course, they stopped sending the letters to doctors because of legal issues with the labs.
And these women who have lost trust are picking up other bits and pieces, too. Like that CPL labs in the US, who settled with Vicky Phelan, have been offering more effective testing for potentially pre-cancerous abnormalities since 2002. Co-testing, where women are also tested for the HPV virus, is far more effective than a pap smear on its own. But the HSE did not avail of the better testing. Indeed, the HSE didn’t even pay for computer imaging. The HSE standard was just manual examination of slides. So this notion that America had lower standards of testing is not true. We were the ones who went for the lower standards.
So the Government did not kill anyone or give anyone cancer, and screening is not perfect. These women who have lost trust know all this, but they also know there is a catalogue of cack-handedness and arse-covering here.
And women can see too that these people can’t help themselves, that they keep delaying and denying even when they are caught out. The infamous memos that showed the shocking disregard for patients only spilled out almost by accident in the PAC. And then, despite all the promises made publicly, even Vicky Phelan or Stephen Teap hadn’t heard from anyone regarding the care packages when they appeared before PAC last week.
You would think, if your brand was in freefall, and you were in damage-limitation mode, and two of the people who had caught the imagination of the public were going to appear before a Dail committee, hugely in the public eye, that you would ensure you were all over offering them what they needed, if only purely for optics. But it seems these people couldn’t even manage that bit of basic management of the crisis, to make themselves look good.
And what about the very ill women without time on their side, who were denied their files at the CervicalCheck HQ in Limerick, even though they had been promised access to them, and then escorted from the premises, apparently in the presence of John Gleeson, the CervicalCheck programme manager? Clearly there was, in Mr Gleeson’s own words, when he spoke about not knowing about the doctors not passing on information to patients, “an error in closing out the loop here”.
It just makes you wonder, if this is how these people behave when they have been caught and the eyes of the whole country are on them, how the hell do they behave in private?
And these women who have lost trust see Leo & Co letting all this spin out, and seeming to play catch up, on humanity, on outrage, and on taking effective action, and they think there is contagion to politicians. They think it’s all just one seamless web.
Why would any woman trust these brands any more — brand CervivalCheck, brand HSE, brand Leo? There may be no smoking gun to link this to the Government, but there is certainly a bad smell around them.
‘There may be no smoking gun but there is certainly a bad smell’