CervicalCheck erred in ‘not closing loop’ with patients

Programme’s manager concedes mistake in not telling women of incorrect smear tests

Stephanie O’Keeffe, the HSE’s national director of health and wellbeing, said she did not know most patients were not being told about issues with smear tests until Vicky  Phelan’s case emerged. File photograph: Aidan Crawley.

Stephanie O’Keeffe, the HSE’s national director of health and wellbeing, said she did not know most patients were not being told about issues with smear tests until Vicky Phelan’s case emerged. File photograph: Aidan Crawley.

 

CervicalCheck committed an “error in not closing out the loop” when it failed to inform women about a clinical audit showing incorrect false negative smear tests, the programme’s manager has said.

John Gleeson was testifying during a marathon hearing of the Dáil Public Accounts Committee on Thursday as TDs questioned senior Health Service Executive and Department of Health executives about who knew what and when around the failure to disclose clinical audits of cases to cervical cancer patients.

Mr Gleeson was asked about internal CervicalCheck memos dating back more than two years which showed the programme suspended letters informing the women’s doctors about the incorrect smear tests.

“I know now that the disclosure didn’t happen,” he said. “I didn’t know at the time it wouldn’t happen.”

The committee heard that doctors treating only a fifth of the women diagnosed with cervical cancer at the centre of the audits were told about the audit showing a revised outcome on past smear tests.

Under questioning, Mr Gleeson said CervicalCheck believed that the “best channel” to inform women was through their clinicians and that it then “tried to deal with any potential blockages to that.”

Not told

A year-long row between CervicalCheck and the women’s doctors about who should tell them meant at least 162 were not told until the case of Limerick woman Vicky Phelan revealed the scale of non-disclosure.

“There was an error in closing out the loop,” said Mr Gleeson. “That is a mistake.”

“That term, ‘closing out the loop,’ doesn’t cut it for those women,” said Sinn Féin TD David Cullinane.

Deputies raised questions around testimony given the previous evening to the committee by Ms Phelan and Cork man Stephen Teap, whose wife Irene died in 2015 after two undisclosed false negative smear tests.

Mr Cullinane noted that Mr Teap said that if his wife had only five minutes to live, she would have wanted to have the information about the false tests and asked whether Mr Gleeson stood over the communications strategy pursued by CervicalCheck to “pause all letters” about the audits.

He replied that the memos he wrote at the time were “consistent” with the guidance around open disclosure, the Government’s policy since 2013, and the information was “biased” towards wanting where possible to disclose the information to the women.

Stephanie O’Keeffe, the HSE’s national director of health and wellbeing, said she did not know most patients were not being told until the Phelan case, despite monthly meetings with CervicalCheck management and being aware of the legal issues with communicating results to women from February 2016.

‘Improvements’

She told the committee that she was repeatedly told by the national screening service that the audit process “was going well” and that “improvements were being made.”

“I did not think anything was going wrong. Perhaps I should have, but I didn’t,” she said.

In a statement to the committee, John Connaghan, interim director general of the HSE, said that he had listened to Ms Phelan and Mr Teap’s testimony to the committee and told them that he was “listening intently” to her calls for accountability.

He said that he wanted to reassure her that was “determined to take on board all the lessons that are learned from this unacceptable chain of events.”

Labour TD Alan Kelly said that there was “arse-covering” going on within the HSE amid the scrutiny on the organisation in light of the controversy.