A review of the latest CervicalCheck scandal has found more than 4,000 women were not given their smear test results due to an IT glitch.
The report, which will be published this afternoon, recommends significant changes to how the national screening programme operates.
When this latest CervicalCheck controversy emerged last month, it was thought it was confined to 800 women.
However, a rapid review into why some women were not given their test results now finds the total number affected is over 4,080.
For nearly 900 of them it meant their results were not issued to them, or their GP in many cases.
For around 3,200 women, their doctors got the letters, but the women did not.
New HSE chief Paul Reid ordered the review by DCU Professor Brian MacCraith into who knew what and when regarding the IT glitch at a Quest lab in the US.
Its findings focus on when the HSE knew about it, when the Department of Health was informed, and when Minister Simon Harris was actually told.
It also recommends major changes to the oversight of CervicalCheck, which campaigners hope will have a positive impact.
According to the review, within CervicalCheck there are too few people handling too many significant projects.
Dr MacCraith recommended that the HSE act quickly to ensure CervicalCheck becomes a well-structured organisation and recruitment is given the highest priority.
His review also recommends recognising the important role of patient representatives and should adopt an International Advisory Group for CervicalCheck to ensure best practice.
The HSE made a number of significant announcements in the wake of the publication, and said it accepts “entirely” Dr MacCraith’s findings.
HSE director Paul Reid said the organisation was “developing a culture of putting women first”.
Acting on Dr MacCraith’s recommendations, a new smear test tracking system which would allow patients to know what stage their test was at, as well as a new structure for CervicalCheck, are set to be investigated.
Internal audits are to be implemented for Quest Systems, where the IT glitch occurred, and the development of a national cervical screening centre at Coombe Women’s Hospital will continue to be accelerated.
The HSE also said it will strengthen the management, organisation, resourcing and capability of the CervicalCheck programme, beginning with the selection process for a new chief executive for screening programmes and the immediate appointment of Celine Fitzgerald as an interim CEO.
The nine recommendations are:
1. The HSE needs to move quickly to ensure that CervicalCheck becomes a well-structured, strongly-led organisation with good management practice and an active culture of risk management.
2. A strengthened CervicalCheck needs to adopt a ‘Women First’ approach as a matter of priority. This initiative will have a primary focus on the continuous flow of information to women, customer relationship management and trust-building measures. The feasibility of sample tracking at every stage of the process from woman to result should be pursued actively. Human resource needs to be dedicated solely to this ‘Women First’ approach.
3. The HSE needs to ensure that Quest Diagnostics delivers on its commitment to appoint a ‘Dedicated Project Manager’ for Ireland. A matching Programme Manager at CervicalCheck needs to be appointed as a matter of urgency. (This position is currently vacant).
4. All recruitment for a strengthened CervicalCheck needs to be given the highest priority and facilitated with an accelerated process.
5. In order to ensure the efficient implementation of these recommendations, it would be prudent to integrate them into the remit of the existing Oversight Group for Scally Report Implementation.
6. Although the clinical risk is deemed to be low for the patients in the cohort covered by this review, for complete assurance more detailed evaluation of the referred history and subsequent findings should be carried out for this cohort.
7. The HSE, with the support of Government, needs to accelerate progress towards the establishment of a National Laboratory for Cervical Testing, encompassing state of the art informatics, analytics and sample / result tracking. This will remove Ireland’s current high risk dependence on a single outsourced supplier.
8. The issue of recognising the important role of patient representatives should be addressed with a view to placing it on a more stable footing and enhancing relationships with all relevant elements of the healthcare system.
9. The HSE should appoint an International Advisory Group for CervicalCheck to ensure that it is adopting and implementing best international practice.