Dr Gabriel Scally's report into the Cervical Check scandal has found “many indications” that the State screening programme was “doomed to fail at some point.”
He said the scandal as a whole has indicated the presence of a ‘whole systems failure’ at the screening programme - but insisted there was no evidence of a conspiracy, corruption or cover up.
He warned that there was a "demonstrable deficit of clear governance" at the State's cancer screening services - with "serious gaps in the range of expertise" among Cervical Check staff and management.
Dr Gabriel Scally’s Scoping Inquiry into CervicalCheck is now available on our website https://t.co/AShKvXR0TV
— Department of Health (@roinnslainte) September 12, 2018
Dr Scally has been reviewing the cases of 209 women who received false negative results from the State’s national screening programme – and were not informed when the issues were brought to light by an internal audit.
His report warns that the current “policy and practice” regarding open disclosure at State Screening services is “deeply contradictory and unsatisfactory.”
He said the system as it stands provides “no compelling requirement” for doctors to disclose, adding that it is currently “left up to their personal and professional judgement.”
“I know, very well, from very many of the women themselves and the families, that the issue of non-disclosure is felt very intensely,” he said.
He said women involved had “expressed very clearly” their anger at not being informed about the original audit – and the way they were eventually told.
“In my view, the manner in which they were eventually told of their situation in many cases varied from unsatisfactory and inappropriate, to damaging, hurtful and offensive,” he said.
Dr Scally warned that it is of “crucial importance” that women continue to go for cervical screening in the coming months.
He said the inquiry found no reason why the State should not continue using the labs it has been using to analyse the smear tests.
Dr Gabriel Scally is giving his briefing into the cervical cancer controversy. He says there was a whole systems failure but no evidence of a conspiracy, corruption or cover up . pic.twitter.com/i0Wqw57HKM
— Stephanie Rohan (@StephGrogan3) September 12, 2018
Speaking outside Government buildings this morning, Minister Simon Harris admitted that the failure to tell patients about the audit had caused a lot of pain and suffering for vulnerable women.
"Certainly harm was done to women in terms of the non-disclosure," he said.
"Dr Scally was very clear on that.
"Extra harm, extra pain, extra suffering was added to women who already had cervical cancer - in many cases a devastating diagnosis."
Minister for Health Simon Harris briefs the media on the Scally Report, 12-09-2018. Image: Leah Farrell RollingNews
The minister welcomed the report and confirmed that the Government is committed to implementing the 50 recommendations it contains.
He will present Cabinet with a full implementation plan for putting the recommendations into action before the end of the year.
As part of his investigation Dr Scally interviewed “all key stakeholders” and examined nearly 13,000 pages of documents.