Victims of the CervicalCheck scandal have been let down by a litany of systematic failures, a damning report has revealed.
The report by Dr Gabriel Scally, which will be published in full today, condemns the HSE's failure to tell women who developed cancer despite CervicalCheck re-examining their test slides and finding they had been given the wrong result.
The Scally Report raises serious concerns about the way CervicalCheck was run and its internal culture, and warns of system-wide failings which impacted on the service.
It also points to a lack of understanding of responsibilities by people overseeing the scheme.
The scathing report is highly critical of governance and structures across the screening programme and within the HSE.
It is also critical of what a Government source described as the "contradictory nature of HSE policy" and its failure to follow its own patient disclosure rules.
The 170-page report, with 50 recommendations, is set to stir strong emotions in the 221 victims of the scandal, as well as the grieving relatives of those who died.
However, its failure to name any individuals involved in the scandal will be a major disappointment.
The report does recommend that the HSE can continue to outsource the testing of cervical smears to US and Irish laboratories
The report was at the centre of heated anger yesterday after the leaking of one of Dr Scally's conclusions that a full Commission of Investigation may not be needed to discover the truth in light of his own extensive findings over several months.
This type of investigation has been called for by victims, who want it held in public.
Health Minister Simon Harris was accused of the insensitive leak but he strongly denied responsibility.
Taoiseach Leo Varadkar said he was "disgusted" that people who were ill or bereaved had to hear about it in this way.
Vicky Phelan, the terminally ill Limerick mother-of-two who revealed the scandal, spoke of her distress and called the situation "a whitewash".
Stephen Teap, whose wife Irene died after two wrong test results, said he was "heartbroken" at the disrespect shown.
As the Government grappled with its latest mishandling they both received a private viewing of the report in Limerick, along with cancer survivor Lorraine Walsh. They declined to give their views last night on its findings but will give an opinion today when it is published.
Dr Scally was asked to do a scoping report in May and he was due to have it completed in weeks.
However, a lack of documents from the HSE delayed his investigation, with some of the 12,000 records that he eventually received arriving only recently.
The report is non-statutory and cannot point the finger of blame at any individual. However, it makes clear that CervicalCheck, which was set up in 2008 to reduce the 90 deaths from cervical cancer annually, was beset by serious problems. Since it was formed, CervicalCheck has detected over 50,000 high-grade pre-cancerous changes in women, reducing their risk of cervical cancer by 90pc.
Dr Scally, who visited the Quest laboratory used by CervicalCheck in New Jersey, as well as the Medlab and Coombe Hospital labs in Dublin, said that, in as much as he could ascertain, the current screening arrangements could continue.
It came as Emma Mhic Mhathuna, the mother-of-five who has advanced cervical cancer, said she "couldn't care less" about the leaked Scally Report.
She was diagnosed with terminal cervical cancer following an incorrect smear test result and is currently in hospital receiving further treatment.