The Health Service Executive confirmed on Monday that 162 women – including 17 who have died – were not informed of a delay in their cervical cancer diagnosis.
A review conducted by the HSE has confirmed 208 women should have received earlier intervention than they did but only 46 individuals were made aware of this.
The examination, conducted by national director of quality assurance at the HSE Patrick Lynch, confirmed 17 of these women have died. The cause of their deaths is not known.
Mr Lynch said he could not state if these women were informed of the delayed diagnosis before they died but insisted their next of kin would be contacted by Tuesday at the very latest.
All of the other women affected would also be informed by Tuesday and given an appointment with a clinician free of charge.
HSE director-general Tony O’Brien apologised to all of the women involved and to their families for the “completely unacceptable” practices.
Asked who was to blame for this failure, Mr O’Brien said he did not have sufficient information at present to state who had been at fault. However, it was “very clear” that there had been poor communication with the patients involved, he added.
Mr O’Brien said: “We are ensuring the loop is closed. Clearly what happened here was related to individuals being asked to pass on information and there being no closing of the loop as to whether that information had been passed on.
“From this point forward, that loop will be closed . . . This will not happen again.”
The controversy came to light through the case of Vicky Phelan, a terminally ill mother of two, who last week settled a High Court action against the US-based laboratory subcontracted by CervicalCheck to assess the smear tests.
Ms Phelan had a smear test in 2011 which showed no abnormalities. In 2014, an audit found this was incorrect but she was not informed of the outcome of that review until late 2017.
The legal case led to confirmation from the HSE that the CervicalCheck programme had been notified of 1,482 cases of women who had developed cervical cancer since 2008.
In the majority of these cases there had been no requirement for further review. However, the cases of 442 women were reviewed and for 208 women earlier intervention was suggested.
This information was given to 13 hospitals caring for the 208 women. These include Mayo University Hospital in Castlebar, the Coombe hospital in Dublin, Cork University Hospital, Louth County Hospital in Dundalk, the National Maternity Hospital in Dublin, Letterkenny General Hospital, University Hospital Limerick, the Rotunda in Dublin, Sligo University Hospital, Tallaght Hospital in Dublin, University Hospital Galway, University Hospital Waterford and Wexford General Hospital.
However, the outcome of the review in their cases was communicated to only 46 individuals, meaning 162 were kept in the dark until now.
Mr O’Brien stressed the review conducted by the HSE over the weekend could not determine why women were not notified but stressed the external review established by the Government should be able to answer these questions.
The issue has raised significant concern regarding the screening tests for cervical cancer.
Mr O’Brien acknowledged there were legitimate questions being asked of the programme but he stressed CervicalCheck was a very important tool, which has provided three million smears to over 50,000 women.
The screening is not a diagnostic test and is not 100 per cent accurate,he added. The issue here, Mr O’Brien said, was the delay in intervention in the cases of women who had developed cervical cancer.
Asked if he was confident such failures were confined to the CervicalCheck programme, he said he had no concerns regarding BreastCheck.
BreastCheck is a Government-funded programme that provides free mammograms to eligible women aged 50-69 every two years.
However Mr O’Brien said other screening programmes were newer and the HSE would move to satisfy itself in the coming weeks that there were no other gaps.