Eilish O'Regan: 'A year of death and sadness but CervicalCheck questions linger'
You would think we would be beyond responses like "disturbing" and "upsetting" at this stage, more than a year on from the CervicalCheck scandal.
But the revelations that smear tests from women in Ireland who took part in the screening programme were being read not in six known labs but also in another 10 unapproved, mostly dotted around the United States and the UK, will do little to ease the lingering doubts about the safety of the service.
Dr Gabriel Scally, who investigated these labs, stretching from Hawaii to Manchester, does his best to calm fears, saying he found no evidence they were sub-standard.
However, it is deeply worrying CervicalCheck was not aware the slides were being ferried to labs which officials in Dublin had never inspected.
And there are gaps in Dr Scally's information. Some of these smaller labs are closed and his exercise was a look back at some facilities that read tests from Ireland nearly a decade ago.
It means key questions have yet to be satisfactorily answered. Were women in Ireland compromised by the outsourcing of tests abroad? Were some women disadvantaged and put at risk because CervicalCheck, up to last year, has such poor oversight of labs and had such weak systems of quality assurance?
All focus now is on the findings of the Royal College of Obstetricians and Gynaecologists, which is carrying out a review of the slides of more than 1,000 women who went through the CervicalCheck screening service.
It is examining whether they were properly read, if abnormalities should have been picked up, and other trends.
It will be the best insight available on what went on beyond the microscope and should be available at the end of the summer.
Dr Scally said he was impressed by the improvements made in CervicalCheck in the past year.
But it cannot absolve the deficiencies in the operation of the service in the past, allowing for the fact that it has saved many lives and should continue to be used by women.
CervicalCheck has to shoulder much of the blame for not knowing tests were being sent to other labs. If it had a more robust system of vetting the labs and proper surveillance systems in place, it would certainly have had a better chance of discovering they were being outsourced.
There is also the ongoing question posed by Dr Scally about the use of the lab in Manchester by Medlab in Dublin.
It was only accredited retrospectively in April this year, a failure of another Irish watchdog, the Irish National Accreditation Board. It has been reading tests from Ireland since 2016.
There are just four staff in the facility.
But Dr Scally believes this remote working by such as small number of staff should be avoided.