The Scally Report on the inquiry into the CervicalCheck screening programme has been published today.
The 170-page report was compiled by Dr Gabriel Scally and provides analysis of and recommendations on the crisis after it emerged that dozens of women had not been informed of an audit into cervical cancer results.
In his address to the Minister for Health Simon Harris, Dr Scally said the screening system was “doomed to fail at some point” and that "the problems uncovered are redolent of a whole-system failure".
Dr Scally said the current policy and practice on open disclosure "is deeply contradictory and unsatisfactory" and that "there is no compelling requirement on clinicians to disclose".
"I know, very well, from very many of the women themselves and the families, that the issue of non-disclosure is felt very intensely," he said.
"They have expressed very clearly their anger at not being told at the time when the information from the audit became available, and they are equally as angry about how they were eventually told.
He said there are "serious gaps in the governance structures of the screening services", and in the case of CervicalCheck specifically, there was "a demonstrable deficit of clear governance and reporting lines between it, the National Screening Service and the higher management structures of the HSE".
Dr Scally also said he was “satisfied” with the quality management processes in the labs.
He said that he had only become aware in recent weeks that slides which had been sent to a lab in the US had been sent for analysis in four labs across Texas, Hawaii and Florida.
Dr Scally said that this “needs further and detailed examination” but was clear that the lab in question is not a current provider, nor are any of the other labs to which they distributed slides.
“The continuation of cervical screening in the coming months is of crucial importance. My Scoping Inquiry team has found no reason why the existing contracts for laboratory services should not continue until the new HPV regime is introduced," he said.
Dr Scally said that the “exciting prospect of turning cervical cancer into a rare disease” will need a “strengthened focus and skilled leadership”.
As dominated headlines yesterday following a leak of the report, Dr Scally said he had “reached the view that a Commission of Investigation would not be the best way to proceed” and instead outlined two tasks which should be given priority going forward.
The first action should be ensuring that the women affected, and their families, “are given the maximum amount of support in dealing with the difficulties that they now face arising from these complex and distressing events”.
The second task, he said, should be to implement the recommendations of the Scoping Inquiry and he warned against a “ prolonged investigation" which “would consume valuable energy and resources that would be better devoted to the implementation of recommendations and achieving progress”.
Dr Scally asked the Minister to instead consider commissioning a progress review which would involve an independent review within three months of the report’s publication of the plans to be implemented by the State bodies involved.
He also asked that there should be a further review of progress reported to the Minister at six-monthly intervals and that these would be published.
Finally, following earlier praise of the “extraordinary determination of Vicky Phelan not [to] be silenced”, Dr Scally suggested that the women and families affected by the scandal “should play a prominent part in the oversight of these reviews”.