Cervical records reveal breadth of knowledge of unseen crisis
In the three weeks since Vicky Phelan exposed the failings in CervicalCheck cancer screening programme, a conveyor belt of health managers appeared before six Oireachtas committees.
The head of the health service and the clinical director of the cervical screening programme have resigned. And last week, hundreds of pages of records released by the Department of Health and the Health Service Executive (HSE) peeled back another layer of information, revealing the breadth of knowledge about the audit process and the problems that arose.
The records show that four of the HSE's 20-strong "leadership team" were told about the dispute between CervicalCheck and consultants over who was responsible for telling women with cancer of errors in their original screens.
The dispute over whether doctors or the screening service should inform the women with cervical cancer about screening errors dragged on from 2016 for more than a year and a half and effectively meant that 162 women with cervical cancer were not informed.
The dispute has its origins in Limerick, where Kevin Hickey, a consultant, was told by Dr Grainne Flannelly, clinical director of CervicalCheck, that he was to use his clinical judgment in informing 10 patients who had cervical cancer that the results of their original screenings were incorrect.
One these women was Vicky Phelan, who exposed the failings last month after settling her legal action against the US lab that missed the suspected squamous cell carcinoma in her original smear test.
Ms Phelan ensured that the "over and back" letters between Dr Flannelly and her consultant who insisted it was CervicalCheck's place to inform women were published after the settlement, largely because she resisted a confidentiality clause.
The records released last week show that this was not only a spat between two consultants. The new records show that Colette Cowen, chief executive of University Hospital Limerick, found the issue "very concerning". She emailed Liam Woods, the national director of acute hospitals, and Patrick Lynch, who was National Director, Quality Assurance Verification Division. Mr Lynch is now heading the Serious Incident Management Review Team that is organising the HSE's efforts to contact women and deal with the crisis. Colette Cowen copied them in correspondence and advised that the "issue" may arise in other hospital groups, too.
Minutes of a meeting in September show Kevin Hickey was not alone in his concerns. Nine consultant gynaecologists had "robust" discussion on the issue, according the minutes. One raised the difficulty in consultants communicating "complex information of this type" to women diagnosed with cervical cancer.
Consultants were being "put at a disadvantage" when deciding which women should or should not be "offered a close out meeting" - or in other words, should be told. The consensus at that meeting was that CervicalCheck should tell women about the audit process around the time they were diagnosed, and "if appropriate", communicate the results directly to her.
The two other members of the HSE's leadership team who knew about this issue were Dr Colm Henry, the HSE's chief clinical adviser, and Dr Peter McKenna, who heads the HSE's Women and Infants Programme. They were made aware of the row through Limerick Hospital last July.
A fifth member of the HSE's leadership team, Dr Stephanie O'Keeffe, the national director of Health and Wellbeing, who was CervicalCheck's line manager, knew nothing about the row at all. None of the four national directors informed her and nor did anyone at CervicalCheck, she told the Oireachtas committee last week, despite attending monthly meetings and receiving regular briefing documents that she shared with the then director General, Tony O'Brien and the Chief Medical Officer in the Department of Health, Tony Holohan. She thought that legal cases outlined in one briefing document - four solicitors' letters from women seeking their files and a fifth who was taking legal action - meant the "process was working" because women were being told. "I did not think anything was going wrong. Perhaps I should have, but I didn't," she said.
The Oireachtas meetings last week heard management speak about failures of "closing out" and "feedback loops" in explaining why no one ensured that women had actually received the information health managers claimed they always intended to give them.
Jonathan O'Brien, the Sinn Fein TD, asked John Gleeson, programme manager of CervicalCheck, and Dr O'Keeffe, effectively his boss, whose responsibility it was to ensure that "the loop was closed". Neither acknowledged responsibility.
"Mr Gleeson is not sure it was his responsibility. Dr O'Keeffe is saying it was the responsibility of the people under her to pass that information up to her," he said.