Wednesday 14 November 2018

'Fair and reasonable' - Chief medical officer defends decision not to alert Simon Harris to CervicalCheck audit in 2016

Defended not alerting Simon Harris or his predecessor Leo Varadkar

Dr Tony Holohan, chief medical officer at the Department of Health Photo credit: Martin Nolan
Dr Tony Holohan, chief medical officer at the Department of Health Photo credit: Martin Nolan

Kevin Doyle and Eilish O'Regan

THE country’s chief medical officer has said it was a “fair and reasonable decision” not to alert the Health Minister to the CervicalCheck audit in 2016.

Dr Tony Holohan, who was briefed on the processed, has today said that officials didn’t realise women weren’t being told about missed abnormalities in their smear tests until Vicky Phelan’s €2.5m court settlement.

He told the Oireachtas Health Committee that in his 10 years as Chief Medical Officer he “can’t remember a time when patients were gripped with such fear as now”.

“We know that things went wrong. Lessons must be learned,” he said.

Dr Holohan said the memos which have come into the public domain in recent days were seen at the time as “evidence of ongoing improvements” to the National Screening Service rather than a problem.

He defended not alerting Simon Harris or his predecessor Leo Varadkar.

Tony O'Brien quit over the scandal (Niall Carson/PA)
Tony O'Brien quit over the scandal (Niall Carson/PA)

Documents released yesterday show he was present at meetings in 2016 where CervicalCheck and other HSE officials discussed the women’s audits and the delay in releasing them.

The reviews were released in mid 2016 to the women’s treating doctors who were told by CervicalCheck to use their judgment about telling the patients about the them.

It in the last two weeks it emerged that 162 of 209 women with cervical cancer had not been informed about the audit results and mistakes in their smear test results which wrongly gave them the all clear,

He told the committee:“I can provide assurance that the Department was not aware of these issues until this controversy arose. We have since had the opportunity to engage directly with a view to understanding, directing and investigating what happened.

"So let me spell it out clearly; firstly, no Minister was advised. Secondly, the decision not to escalate was a fair and reasonable decision," he said.

"It was reasonable because the information provided in the briefing notes provided by the HSE to the Department was evidence of ongoing improvement to how the service was being delivered, rather than the identification of a problem which, of its nature, required escalation to Ministerial level. The HSE has and will confirm that within their systems no escalation of concern in relation to the implementation of this audit programme took place."

At the same meeting, John Connaghan who has taken over as Interim Director General of the HSE, apologised for the “confusion and alarm” created in recent weeks.

“This failure has ultimately impacted on every female in Ireland, their families, their spouses and their children. Irrespective of the original, well-intentioned undertaking by the CervicalCheck Programme to conduct an audit of invasive cervical cancers and communicate the results to the patients affected, the organisation (in that respect both CervicalCheck and the HSE) have failed by any measure,” he said.

Mr Connaghan said the failures had “impacted on every female in Ireland”.

He admitted the language used in briefing notes was “very functional and somewhat lacking in empathy for the women”.

“The CervicalCheck Programme did not escalate the issues that were subsequently encountered regarding the breakdown in the process of treating clinicians discussing audit findings with their patients.

“Indeed, it is not clear to me that the staff within the programme were aware of the scale of the difficulty in terms of the proportion of women who had not been communicated with,” he said.

Addressing the question of the HSE’s open disclosure policy, Mr Connaghan said it exists “to provide an ethical response and to promote a fair, open and just culture within healthcare organisations”.

“However any policy which is not set in legislation requires to be closely monitored in terms of delivery and to have swift dispute resolution and escalation processes where professionals disagree on the correct course of action.”

The interim boss said it is “quiet clear in hindsight” that women were not told about their audit results “in a timely and effective manner”.

He described what has happened as a “collective failure” to ensure the effective follow through on “good intentions”.

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