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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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I don’t trust media-produced opinion or exit polls. They tend to carry something of a bias toward outcomes that the media themselves would like to see, such as the utterly contrived “green wave” that the monolithic, group-thinking Irish media have been salivating and manipulating about since the first exit poll was produced last Friday.
In reality, the vast majority of the Irish electorate did not vote for the Green Party in the 2019 Local and European Elections. The vast majority of voters voted for either Fianna Fail, Fine Gael or Independent candidates.
Media-produced opinion and exit polls tend to exaggerate scenarios that the media would be ideologically in favour of, and they downplay scenarios that the media would be less in favour of. Like most voters, I have never once been asked to contribute to an exit poll. Nor have I ever been asked to contribute to an opinion poll between elections.
@J. Reid: I think the main reason the exit polls predicted a green surge is that green voters vote later in the day and when you tip the box upside down their votes are at the top distorting the exit poll. But why do they vote later? Root cause analysis suggests they may not work 9 to 5 jobs as their principles restrict where they can work but further analysis suggests that those that do work, cycle to workplace and take longer to get there, get changed out if hi vis soaked lycra and thus leave work later, this voting later. Also the green voter will not waste paper by voting if they the know the seat is in the bag thus they wait and surge later. Once the box tips upside down you have the LIFO principles at play that media run with. QED.
@Chewey Bacca: ;)
@J. Reid: Agree 100%.
@Hatchjaw: the exit poll is done prior to boxes being opened i.e. pollsters on the ground all day grabing people as they ahem; exit
@J. Reid: I’m not saying it doesn’t happen, I’m just wondering what ‘the media’ would get out of distorting this information? They’d only have between polling and counting to enjoy their fabrication; no time to influence anything and a hit to their reputation when it becomes apparent they reported the wrong result. Seems very short-sighted.
@iohanx: So Red C wandered down to some South Dublin polling station, asked random hipsters how they voted and put it out as a national trend?
@J. Reid: That is very Trumpian attacking the media. This poll is not a media poll. They do multiple polling research, on a myriad of topics/products etc.
It appears that you and others are unawares to your mistake, as it appears to be an easy mistake to make.
A media produced poll is similar to the following
https://www.thejournal.ie/poll-does-the-price-of-sunscreen-influence-your-usage-4657168-May2019/
@J. Reid: wrong in so many ways.
@Chewey Bacca: LOL. So you get paid to write this crap?
So what we have learned is to not believe what we are told in the polls pre or post voting time
At the end of the day its an exit poll. Who cares. Its the actaul results that matter. Media frenzie comes to mind.
Polls are useful to keep the status quo going, they create voter apathy. People are told constantly that either FG or FF are going to win , so they don’t bother voting which helps keep the big parties in power.
Opinion and exit polls for all their claims to scientific accuracy and reliability are susceptible to one thing that can render them worthless and that’s human nature. Sometime people just don’t tell the truth…
The thing I don’t trust about the explanation is that if the numbers had gone the other way an equally valid explanation would have been provided. When science meets people things get messy.
Polls are used by media to maintain status quo.. Always has and always will..
@Willy: If I follow your logic Willy, you reckon there is a conspiracy by the polling companies to influence people to vote for SF by consistently showing their numbers as much higher than they actually are. The scoundrels. Thankfully the people didn’t fall for it.
The only thing the Poll has done is give Leo and Simon a few quotes to weasel around and unexpected representation for the greens. That has trown up two things, Saoirse McHugh, likely to stay un-elected but has shown her morale backbone whith her FF/FG statement, which do her self no harm next time around as an independent if that be her decision. While the greens leadership show, they are only too keen to to jump into junior government partnership again. Very good to know that about them.
Polls have been proven to be inaccurate many times now so most people don’t pay any attention to them apart from the media who need to fill out their news output with something. Like on a quiet news week, you will get a Sunday newspaper revealing the entirely predictable results of some poll
Varadkar out! The party of spin , lies, deceit and ineptitude out! They think not sinking the economy again is enough for them to retain power. You can disagree and send them packing!!!! Send the rats scurrying come election time. Fool me once ….
@Shane Murphy: the economy isn’t sinking, its the fastest growing in Europe
@Virgil: Heard that before, before the Celtic Tiger Crash, which was fueled by a housing shortage too
@Virgil: Stagnating at the moment, number of jobs advertised has dropped since the beginning of the year. Brexit will trigger downturn here, lack of government preparation for Brexit will make it worse
@Virgil: Means f–all if it only benifits the few.
Just a waste of time and money
The only Exit that matters is the Sf Exit
@pat seery: ??
We have no Green party representation on Sligo County council..I think if they had put up a candidate they would have got a seat after seen what happened around the country.
@Marty from Sligo: eh, there was a green candidate.
Where do they get their ‘margin of error’ from? They should just say this could be totally wrong, we just don’t now. We think it’s a ball park figure
@Virgil: That should be RTE’s Motto !
Morto for them and their Poll Guessers !
Media demanding on radio the minister to introduce carbon tax as if the entire country voted green. If Aontu had recieved the same share of the vote would they demand a new referendum on abortion. No the wouldn’t. Most of the media in this country are biased which is a very dangerous thing.
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