Veil of secrecy links terrifying health scandal with those that went before
In her annual report for 2009, then-ombudsman Emily O'Reilly described being led on "a sort of an 'Alice in Wonderland' trip" around the legal system by the HSE in a bid to get access to basic information.
She did not pull any punches as she described the health care executive as having something "rotten" at its core and accusing health chiefs of operating in "a parallel universe", while noting that her counterpart for children, Emily Logan, was also "blue in the face" from dealing with the HSE.
Even the health minister at the time, Mary Harney, "often struggled" to get information from the HSE, the ombudsman claimed.
"I think there's a huge issue around the excessive secrecy and legalism of the HSE. It strikes me that it is a cultural thing within the HSE," Ms O'Reilly said back then. For a body established to represent the public's interests, Ms O'Reilly said the HSE "sometimes sought to protect its own interests". This, she commented, was "very wrong".
Nine years on, can anything be said to have changed when it comes to the HSE's apparent corporate code of omerta?
Amid a sweeping torrent of fear and mounting disbelief this week as the details of the CervicalCheck scandal began to emerge piecemeal, it is clear the long-rooted toxic culture of secrecy has far from gone away. It is the single standout factor about this latest national health crisis that links it with all the others that have gone before.
The Taoiseach acknowledged so yesterday when he said that failure of open disclosure lay at the heart of the controversy.
Legislation will be brought soon for mandatory open disclosure for serious incidents, he said - but added that this was not enough; a culture change within the health service was also required. In fact, open disclosure has been official HSE policy since 2013, as Mr Varadkar pointed out.
The Government would do well to try harder to fix the culture because if the rot noted by the ombudsman at the heart of the HSE system is not diligently and forensically cut out to allow the fresh wood to thrive from root to branch, we will see many more reports like that of Emily O'Reilly's in 2009.
And what, crucially, of the individual women whose lives have been irretrievably shattered by the revelations about a health check which was supposed to provide reassurance?
Tuesday brought devastating news - 17 women had tragically died as a result of misread smears, of whom 15 had died without ever knowing they had been the victim of a misdiagnosis. Their families were informed this week. The deceased patients were among 209 women whose smear test readings missed abnormalities over the past 10 years, leaving them to develop cervical cancer.
Some 162 of these women were not told an internal review of their case was carried out by CervicalCheck.
The reason for the secrecy was not clear and the team who uncovered the files said it was not their job to speculate. The HSE culture of omerta had struck again.
"I never thought the problem would be of this magnitude. I really didn't think I'd be waking up this morning to this type of news," an emotional Vicky Phelan said on radio after the revelations. It was her courage in coming out about her own case that had broken open the shell of secrecy around the debacle. She called for the inquiry promised by the Government to be held in public and to be held swiftly.
Instead, they announced that a preliminary scoping inquiry would report by June, with the Taoiseach yesterday merely saying he was open to the possibility of a public hearing.
On Wednesday, it emerged that as many as 1,500 more women were at risk of being dragged into the escalating scandal, with the HSE confirming there were 3,000 cases of cervical cancer notified in the past decade but that just 1,482 of these cases had been reviewed.
Health Minister Simon Harris said a "potentially considerable number of cases" where women developed cancer were not subjected to an audit. The Government was by now fighting to save its own skin.
But going back a decade, concerns about outsourcing scans were raised at the time by a member of the National Cervical Screening Programme. Dr David Gibbons, chair of the cytology/histology group in the quality assurance committee of the programme, said that Ireland follows the same smear system as the UK - where deeper tissue samples are taken every three years.
However, America screens on the basis of a more shallow tissue sample taken on an annual basis. Meshing the two systems would pose great risks, he feared.
He expressed his concerns to Tony O'Brien, head of the HSE, but he failed to listen, and Dr Gibbons resigned from the committee.
Talented scientists from the committee had also resigned, he revealed.
"We thought it was dangerous, we thought the problems wouldn't become apparent for 10 years," he told RTÉ. Dr Gibbons's warning proved to be frighteningly prophetic.
But this week, Mr O'Brien had the gall to describe the scandal as a "personal blow".
He has only 12 weeks left in his post before heading off to a lucrative position in a US pharma company.
And for those who really matter - patients, their families and the wider public - the anxiety continues.
Virtually every woman in the country is enveloped with a sense of deep misgiving and unease.