We owe women more than to merely marvel at institutional failures
Responding to the news that hundreds of women may be ensnared in a living nightmare over smear test failures, Taoiseach Leo Varadkar said he did not want to condemn any individual. He would wait until he knew the full facts. He may be waiting some time.
Remember Vicky Phelan, the woman whose mistreatment brought this scandal to light? An error first identified by an audit in 2014 took two years to be even reported to Ms Phelan's physician and a further year to be communicated to her.
Even with life and death issues at stake, process and protocol seems to have taken precedence and the needs of the patient got lost along the way.
Scandalously and shamefully, it is still not certain if the 206 women possibly involved in this debacle are even at this point aware of their situation.
Health Minister Simon Harris may have added to the apprehension by declaring he does not have confidence in the management of the CervicalCheck programme.
While fully supportive of the programme, he could not say the same for its leadership. If that is the case, then he and the Government had better intervene, taking every possible action to guarantee the safety of this vital service. Indeed, it is impossible to imagine a more urgent priority, for we owe these women more than merely to marvel at our serial institutional indifference.
Open disclosure is supposed to be a central tenet of the HSE. A guarantee of consistent communication to patients is crucial.
So while it is deeply disturbing to learn that more than 206 cervical cancer victims should have had earlier intervention, it is astonishing to discover that all may not know about it.
Things have to be pretty perverse when we are more shocked by openness than by being drip-fed and dissembling.
Yet the health service has ignored patients' rights to information in the past. Where innocent victims such as those contaminated by infected blood products were misled, mistreated and bullied by the State and only the most torturous and emotionally draining legal battles brought the truth to light.
One of the many alarming aspects in this tragedy centres on CervicalCheck's protocols which set out how quality issues, such as how reviews are handled, are dealt with. A woman's doctor may be involved in the management of cases but does not play a part in decisions to withhold information.
Evidently the time has come for us to follow the UK and introduce a duty of candour. Proposed new patient safety legislation will include mandatory open disclosure here.
In institutions a single decision has the power to spawn a thousand others. Transparency and responsibility are pivotal if there is to be an appropriate response anywhere commensurate to the catastrophic harm that has been done.
If we finally accept - as we now must - that trust has been breached and enormous damage has been done, we have an ethical responsibility to act.
Destructive, defensive State silos of secrecy and obstruction must be exorcised. Where compassion care and candour should have been a given there was obfuscation and withdrawal.
But at what point can we expect the HSE to take on board that the only shock worse than the totally unexpected is the expected for which one has wilfully refused to prepare?
Progress is seldom inevitable and never automatic. If we are going to have change there must be a revolution in overturning institutional cultures of concealment.