The disclosure of the findings of clinical audits into the cases of women who developed cervical cancer was handled badly – sometimes very badly – and was responsible for much hurt and anger, Dr Gabriel Scally concludes.
The report says that when more than 200 women and their families were informed about the CervicalCheck audit results during the summer, the process was hurried and took place against "a fevered media and political backstop".
Most seriously of all this resulted in a loss of confidence by many women in the clinician who was responsible for their treatment, he adds.
Dr Scally said the development and implementation of the audit process and the disclosure of its findings by CervicalCheck was compromised by inadequate staffing levels, the skill mix of personnel and the management arrangements in place.
“Women were left wondering if a doctor who could not be trusted to tell them the honest truth about their screening, could be trusted to provide them with the best care.”
The report recommends that a statutory duty of candour be placed both on individual healthcare professionals and on the organisations for which they work and that this duty of candour should extend to the individual professional-patient relationship.
“A situation where an organisation can be allowed to impede the speaking of truth to patients in relation to their healthcare is totally unacceptable. Nor should it be acceptable for an organisation to give permission to health professionals, of whatever seniority, to withhold the truth from patients.”
The report also says that HSE policy on open disclosure and HSE/State Claims Agency guidelines – which it described as "unhelpfully equivocal" – should be revised as a matter of urgency.
Dr Scally says says there had been a genuine desire on behalf of CervicalCheck to give women who had developed cancer “the opportunity to learn about the audit that had taken place, that there had been a different interpretation placed on at least one of their earlier cervical slides, and that this might have altered their treatment if it had been the original finding”.
The report says it was “extremely unfortunate that this policy was not pursued in a structured and planned fashion, using an approach that consulted interested parties, including patient advocates, and took into account the readily available evidence and guidance on how this type of exercise should be conducted”.
“Despite the fact that funding for the colposcopists’ time in providing care to patients referred after screening is attributable to CervicalCheck, they didn’t regard themselves as part of CervicalCheck,” Dr Scally says. “They had not been involved in designing the audit, or in the discussions leading up to the decision to disclose the results of the review of slides by the laboratory.
“There was only one official meeting (as distinct from educational events) between the senior staff of CervicalCheck and the lead colposcopists in the entire history of the screening programme, further contributing to the general failure by many of those involved, whether employed by CervicalCheck or funded by them, to engage fully with their patients.”
He says the “disconnect was added to by a letter from CervicalCheck” which left the judgement to the consultant as to whether or not disclosure was appropriate”.