YESTERDAY, THE HSE apologised after a rapid review identified over 4,000 cases where women who’d had smear tests weren’t told of their results through a combination of IT issues and human error.
In 873 of these cases, no letters about test results were issued to the women or their GPs. In the other 3,200 cases the results were issued to GPs but not to the women involved. The HSE stressed yesterday that the women affected in these cases were at “low clinical risk”.
One of the major findings of Professor Brian MacCraith’s review was that there was a “constant theme” of women frustrated by poor service and lack of information.
He said that perhaps the “most significant” impact from the IT problem was that many women waiting for test results received no communication for a period of six months.
Professor MacCraith used the story of one woman – named Sharon – to detail how women who followed up to try to receive the results of their cervical screening were denied information, and how the issue could have been resolved a lot sooner.
Backlog
Sharon was diagnosed with pre-cancerous cells 10 years ago.
She’d had annual screening since then, and had previously received the results within six weeks of the sample being taken.
On 3 December 2018, she had a smear test. She didn’t receive her results within six weeks, and followed up with her GP. Sharon was told the current waiting time was up to 14 weeks “due to issues over the past year”. (You can read more on these well-publicised issues here).
On 26 March 2019 – a full 16 weeks after her smear test – she called the CervicalCheck helpline and was told her results weren’t available. This was escalated to a CervicalCheck doctor, but he couldn’t tell her where her results were when he called her back on 3 April.
Her sample was transferred to Quest Diagnostics’s Chantilly laboratory in the US on 26 March. The review later found that due diligence and risk management hadn’t been performed on this facility operated by Quest – the company that tests smear samples on behalf of the HSE.
This was done to prevent the expiration of her sample. If it expired, it’d mean she’d have to get a smear test done again.
The test was carried out on 27 March at the lab but the test result report which is sent to GPs was not created.
Frustration
Still in the dark on her results, Sharon emailed the Department of Health on 3 April detailing what had happened so far. In the email, she said she was dissatisfied and said she’d bring her concerns to the media.
She received a reply that day from Minister Simon Harris’ private secretary acknowledging receipt and advising she’d receive a reply shortly.
Sharon emailed the minister’s office on 14 April, and again on 28 April. She said that her 5-month wait for these results was “totally unacceptable”.
On 30 April, she received a reply from Harris’ private secretary. It said: “The Minister acknowledges there has been an increase in the time taken to receive cervical smear test results, and would like to apologise for any distress this has caused you and assure you that this is a priority concern for his Department and the HSE.”
The private secretary also said actions were being taken to address the backlog but it would take some time to resolve. The letter also referenced how – in the context of cervical cancer normally developing over a period of 10-15 years – a delay in results “whilst undesirable is not necessarily dangerous and poses a very low risk”.
‘Insensitivity’
Sharon replied to this mail on 9 May, expressing dissatisfaction at its “insensitivity” to her condition in particular.
She contacted the department again on 16 May and 4 June as she still awaited her results.
In a phone call with the department on 5 June, Sharon was asked to contact CervicalCheck directly. She did so, and was advised that the wait time for results is 33 weeks. She asked her case be escalated.
On the following day she received an email from Minister Harris’ private secretary in which the department official requested her personal details to that the department could engage directly with the National Screening Service on her behalf.
Sharon thanked the department official and said she felt the person she spoke to from CervicalCheck “didn’t care” about her situation.
With the case now escalated, the department contacted CervicalCheck which in turn contacted Quest Diagnostics to request an update on Sharon’s case.
On 17 June – almost three full months after the test was done – a result was obtained from her sample and a report was sent to her GP.
A week later, CervicalCheck told the department that Sharon’s test had been processed and the result was with her GP but due to an “IT issue” she hadn’t received a letter which would have been the normal process.
CervicalCheck then said it was addressing the problem and all affected women would be contacted. The follow-up queries to Sharon’s case had led to the discovery that around 800 women hadn’t been informed of their results in the normal manner.
Sharon was told her results by a CervicalCheck doctor on 26 June. When she asked why she hadn’t received a letter, she was told of an “IT issue”. She spoke to her GP the following day, and then contacted the CervicalCheck doctor to ask him to escalate the issue as her GP had no idea letters “were not being sent to women”.
‘Rude’
On 8 July, Sharon phoned the Department of Health and raised a number of issues, including the delay in receiving her results, the non-issuing of letters to women and the “rude” encounter with the CervicalCheck helpline staff member.
The department official said they would follow up and have an update for Sharon the next day. That afternoon, the department sought an urgent follow up from CervicalCheck on these matters.
Also on 8 July, Sharon contacted RTÉ’s health correspondent Fergal Bowers to advise him of these matters.
The report from Professor MacCraith notes different versions offered by Sharon and the Department of Health official as to what happened next.
According to Sharon, she received a phone call at 5.30pm on 9 July from the department official and was told the HSE’s report was back and was awaiting sign off from the “department head”.
She said she asked if Minister Harris was aware of the content of the report, and was told he’d been fully briefed.
According to the department official, it is “likely” Sharon was told the current status of the report and that it awaited sign off from the Head of the National Screening Service within the HSE rather than anyone at the Department of Health.
“No report from the HSE would ever go to the Department Head for sign off. In any event, we don’t use that terminology,” the official said.
Documents meanwhile, show that Minister Harris wasn’t delivered the report until 10 July. Harris subsequently told media he wasn’t aware of the issue until this date.
‘Treated with respect’
In any case, RTÉ’s Fergal Bowers began to make enquiries to CervicalCheck and the Department of Health on these matters on 10 July.
RTÉ ran the story on the Six One News the following day.
On 26 July, Sharon received a letter from CervicalCheck. The letter did not note any abnormalities and she was was recommended a three-year recall and annual check ups.
When asked to summarise the experience, she said:
There is an absence of customer service from CervicalCheck. If I had been treated with respect, this may not have evolved like this. And also, if the Department of Health had responded to my email of 3 April, things would have been discovered earlier.
The CEO of the HSE Paul Reid told reporters yesterday that some of the women affected by this weren’t even aware yet, and would be contacted in the coming weeks.
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