DR GABRIEL SCALLY has said “substantial progress” has been achieved in the CervicalCheck programme, as he published a report into the implementation of recommendations from the 2018 report into the CervicalCheck scandal.
In 2018, Dr Scally conducted a sweeping, four-month inquiry into the CervicalCheck screening programme, finding significant failures in its governance structures.
He said the biggest failure he identified was the non-disclosure of information from audits to patients – the same devastating error discovered by Vicky Phelan as she studied her own medical files.
In the foreword to his 170-page report, Scally said there were many indications that the programme was “doomed to fail at some point”.
He made a series of recommendations, including for the Department of Health and HSE to revise their document management policies; the Minister of Health to consider how women’s health issues could be given more consistent and committed attention; and for the governance structure of CervicalCheck to be reviewed.
At the end of 2021, 166 of 170 actions arising from the report had been completed, with the remaining four marked as ‘in progress’, according to an update earlier this year.
In today’s report, Dr Scally looks at the progress achieved to the end of October 2022 in respect of the recommendations made across the four reports published to date.
A large number of the recommendations have now been marked as blue, meaning “action completed”.
Dr Scally said he is “happy to confirm that substantial progress has been achieved and, in many ways, the CervicalCheck programme has improved substantially as a result of the coordinated efforts of the staff of the various organisations involved”.
CervicalCheck is a “substantially better screening programme today than it was in 2018″, Dr Scally said.
“In my view, women can have confidence in and should take full advantage of the cervical screening programme. It has saved many women’s lives and will continue to do so,” he said.
“But it isn’t perfect. As with any other screening programme, research is continually being conducted to improve the accuracy of testing, improve the effectiveness of treatment and reduce the anxiety involved in taking part.”
Concerns
In the report, Dr Scally highlighted a number of concerns about the progress of the implementation of some of the recommendations.
A number of recommendations have been marked in today’s report as red, meaning “action has not started, stopped or is seriously off target”.
One of the recommendations that had been made is that “the option of a decision not to disclose an error or mishap to a patient must only be available in a very limited number of well-defined and explicit circumstances such as incapacity”.
Today’s report marked that recommendation as red, outlining that “there has been very limited progress on this extremely important issue”.
“The Patient Safety Bill has only reached the fourth stage of an 11 stage legislative process. The Bill only makes provision for mandatory open disclosure in a limited number of circumstances, nearly all of which are associated with the death of a patient,” the report said.
Earlier in the report, Dr Scally said:
Patients should be told the truth when things go wrong. If they are concerned that their treatment may have been deficient, patients should also have a clear and consistent route to bring forward their concerns and have them investigated.
Looking at the recommendations, most are marked blue for completed or yellow for “slippage”, but here are a few red ones where “action has not started, stopped, or is seriously off target” pic.twitter.com/OBrQ6d8Omc
— Lauren Boland (@laurenanna_1) November 23, 2022
Dr Scally marked red the recommendation that “a governance framework for open disclosure must be put in place that includes evaluation and audit”.
He said: “It is not possible to have a governance framework for open disclosure given the lack of definitive policies in place and the complication posed by the stalled and not yet properly formed Patient Safety Bill”.
He marked red the recommendation that “the Department of Health should enter into discussions with the Medical Council with the aim of strengthening the guide for registered medical practitioners so that it is placed beyond doubt that doctors must promote and practice open disclosure”.
He said that the guidance for pracitioners on open disclosure and duty of candour “has not yet been strengthened by the Medical Council and open disclosure remains optional”.
Dr Scally said there had been no progress on the recommendation a statutory duty of candour must be placed both on individual healthcare professionals and on the organisations for which they work.
No progress had been made on the recommendation that this duty of candour should extend to the individual professional-patient relationship.
Dr Scally also wrote elsewhere in today’s report that “there remains concerns about the level of staffing, retraining screeners after a long break, laboratory information systems, data provision and formal quality management processes”.
Dr Scally wrote that one particular concern is the role of the Lead Pathologist for cervical cytology triage.
“The requirements of this role are not currently met by any member of staff at the Coombe and it is imperative that a qualified individual is appointed as soon as possible,” he said.
“The role is critically important to assuring the quality of the cytology element of the new pathway. These issues will need to be addressed before the service resumes.”
Vicky Phelan
Well-remembered today is Vicky Phelan, who died aged 48 last week after years of spearheading the fight to bring attention to the injustices experienced by cervical cancer patients whose audited results were not communicated to them.
Her family held a private funeral on Friday and have invited the public to a celebration of her life this Sunday in her native town of Mooncoin in Co Kilkenny.
In the forward of today’s publication, Dr Scally outlined that as part of the terms of reference of his scoping inquiry, he was expected to engage directly with Vicky Phelan and the other women and families affected.
“I have continued to do so in producing reviews of the implementation of the recommendations,” Dr Scally said.
“The recent death of Vicky has been a moment of national sadness, a sadness which I share. She was the first person I spoke with after my appointment to carry out the Scoping Inquiry,” he said.
“Vicky’s enormous courage, dignity and determination changed cervical screening in Ireland for the better. In addition, she pushed forward the whole arena of women’s health and highlighted the crucial issues of openness, truth and honesty in communication between health professionals and patients. I am, as are we all, in her debt.”
Reaction
The National Women’s Council (NWC) welcomed Dr Scally’s report and urged that follow-up actions be taken based on the gaps he identified.
“The country owes a debt of gratitude to Dr Gabriel Scally for his initial report on the cervical check scandal, which identified a culture of misogyny and paternalism that dismissed women’s voices and experiences,” NWC CEO Orla O’Connor said.
“It paved the way for the Women’s Health Action Plan, a milestone in women’s health, and which has significant potential to address systemic deficits. To truly create a culture of care which listens to women and recognises them as experts by experience, we need to revisit the training and supports given to professionals working in healthcare. As the Action Plan acknowledges education and training are the key levers for change.”
The NWC said it echoes Dr Scally’s statement that the best way to honour Vicky Phelan is by implementing his recommendations in full, particularly on mandatory open disclosure for patients.
It also urged professional medical bodies to affect a culture change around duty of candour, and called on Taoiseach Micheál Martin to progress the Patient Safety Bill.
NWC’s Women’s Health Coordinator Alana Ryan said: “Women shouldn’t have to go to court to achieve the truth, an apology or guarantees that what happened to them won’t happen again.
“The Patient Safety Bill will be a welcome first step towards mandatory open disclosure, but it must be matched by reform from the professional regulatory bodies. There must also be a culture shift towards supporting patient feedback and resolving complaints swiftly.
Social Democrats health spokesperson Róisín Shortall called on the government to ensure that a policy of open disclosure becomes mandatory within the health service.
“Regrettably, the progress of the Patient Safety (Notifiable Patient Safety Incidents) Bill – which is intended to make open disclosure mandatory rather than discretionary – through the Oireachtas has been glacial,” Shortall said.
She added that it is concerning that Dr Scally states in the report that the Bill in its current guise will “not move the system forward to the extent needed”.
“The Health Committee has already discussed the need for amendments to be tabled to the Bill, to ensure that failings, like those identified in CervicalCheck, are notified to patients. The Minister should move quickly to introduce those amendments.”
Former Labour leader Alan Kelly called on the Taoiseach to introduce open disclosure before Christmas.
“The Taoiseach has promised that open disclosure will be introduced before Christmas. He needs to deliver on that and honour his promise,” he said.
The Bill as it is currently constituted is not fit for purpose. It is bad legislation. For 12 of the 13 conditions in relation to open disclosure the person would have to have passed away. That is not good enough.
“Vicky Phelan didn’t want tributes, she wanted action and delivery and this is a real way the Taoiseach can make that happen and strengthen her legacy to the women and people of Ireland.”
With reporting by Lauren Boland
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