In December 2019, an Independent Expert Panel of Cervical Screening in Ireland carried out by the UK based Royal College of Obstetricians and Gynaecologists (RCOG) published an aggregate report which reviewed the cases of 1,038 women diagnosed with cervical cancer since the national screening programme CervicalCheck was started in 2008. The aim of the panel was to provide women with an independent review of their diagnosis and treatment and to prepare an individual written summary for each woman. The panel found 159 missed opportunities to prevent or diagnose cancer earlier and its members disagreed with one third of smear tests results reviewed. The aggregate report includes 10 recommendations with the aim of improving screening services for women.
The RCOG Independent Expert Panel Review was established by the Irish government in May 2018 alongside the Scoping Inquiry into the CervicalCheck Screening Programme led by Dr Gabriel Scally. The inquiry was established after it came to light that women had developed cervical cancer having receiving false negative test results of their smear tests. However, the misdiagnoses were not disclosed to women affected, despite an internal audit conducted in 2014 which showed that their test results were incorrect. The lack of disclosure was made public by one of the women, Vicky Phelan, who took a court case against Health Service Executive and the Clinical Pathology Laboratories Inc, Austin, Texas, in April 2018.
Subsequently, the First Report and the Final Report were published in June and September 2018 respectively and came up with 56 recommendations, including changes to the information provided to women taking part in the screening programme. It also included recommendations on the organisation and governance of screening, standards and procurement process for external laboratory services, clinical audits, other screening programmes and revision of Health Service Executive’s open disclosure policy.
Speaking at the launch of the Final Report on 12 September, Dr Scally identified the non-disclosure of information from internal audits to women as the biggest failure and observed that the way in which some disclosures were eventually handled as “verging on misogyny”. The report recommended that the health minister “should give consideration to how women’s health issues can be given more consistent, expert and committed attention within the health system and the Department of Health”. It critiqued the earlier integration of Women’s Health Council (a body which advised the minister on the issues pertaining to women’s health) into the Department of Health and Children in 2008, as a “disappearance” rather than a “merger”.
The Implementation Plan for the recommendations of the above reports was published in December 2018.
This was followed by the Supplemental Report in June 2019 looking at additional laboratories undertaking work for CervicalCheck which came to light during the initial Scoping Inquiry. This report found no deficiencies in the quality of screening provided by those laboratories but concluded that the oversight for procurement and contracting arrangements was not sufficient.
Following the publication of the Supplementary Report in June 2019, the work of the Scoping Inquiry has concluded. However, a tribunal is being set up to process more than a hundred pending legal claims.