The Scally Report on the inquiry into the CervicalCheck screening programme has been published.
The 170-page report was compiled by Dr Gabriel Scally and provides analysis of and recommendations on the crisis after it emerged that dozens of women had not been informed of an audit into cervical cancer results.
In his address to the Minister for Health Simon Harris, Dr Scally said the screening system was “doomed to fail at some point” and that “the problems uncovered are redolent of a whole-system failure”.
Dr Scally said the current policy and practice on open disclosure “is deeply contradictory and unsatisfactory” and that “there is no compelling requirement on clinicians to disclose”.
“I know, very well, from very many of the women themselves and the families, that the issue of non-disclosure is felt very intensely,” he said.
“They have expressed very clearly their anger at not being told at the time when the information from the audit became available, and they are equally as angry about how they were eventually told.
“In my view, the manner in which they were eventually told of their situation in many cases varied from unsatisfactory and inappropriate, to damaging, hurtful and offensive.”
He said there are “serious gaps in the governance structures of the screening services”, and in the case of CervicalCheck specifically, there was “a demonstrable deficit of clear governance and reporting lines between it, the National Screening Service and the higher management structures of the HSE”.
Dr Scally also said he was “satisfied” with the quality management processes in the labs.
He said that he had only become aware in recent weeks that slides which had been sent to a lab in the US had been sent for analysis in four labs across Texas, Hawaii and Florida.
Dr Scally said that this “needs further and detailed examination” but was clear that the lab in question is not a current provider, nor are any of the other labs to which they distributed slides.
“The continuation of cervical screening in the coming months is of crucial importance. My Scoping Inquiry team has found no reason why the existing contracts for laboratory services should not continue until the new HPV regime is introduced,” he said.
Dr Scally said that the “exciting prospect of turning cervical cancer into a rare disease” will need a “strengthened focus and skilled leadership”.
As dominated headlines yesterday following a leak of the report, Dr Scally said he had “reached the view that a Commission of Investigation would not be the best way to proceed” and instead outlined two tasks which should be given priority going forward.