HSE refusal to apologise for cervical smear inaccuracy that led to a woman's death.

political analyst · 28-10-2022 4:15pm #1

https://www.rte.ie/news/courts/2022/1025/1331295-elaine-flannery/

From what I've read about this case, it seems obvious that the smear test wasn't analysed properly. To say that there's no proof that the inaccuracy of the smear test led to this woman's death is like saying that Earth is flat.

So why is apologising for failure of duty of care an alien concept to the HSE? What happened to doing the honourable thing?

Overheal · 28-10-2022 4:17pm

https://www.boards.ie/discussion/2058269488/hse-refusal-to-apologise-for-cervical-smear-inaccuracy-that-led-to-a-womans-death

No modern orgs admit fault in a settlement. It's half the pleasure of reaching the settlement.

Gregor Samsa · 28-10-2022 4:37pm

It’s the same way that your car insurance policy tells you not to admit liability in the event of an accident - even if you were at fault. It’s not the HSE that’s going to pay any settlement, it’s their insurers (Irish Public Bodies Mutual Insurance Ltd).

While I can completely understand the poor family wanting an apology, looking at it objectively, the HSE can’t reasonably be expected to undermine their own insurance cover.

jmayo · 28-10-2022 4:53pm

People should not forget the HSE and government's hero of the covid pandemic response, Tony Holohan, was one of those who decided it best not to inform women of their false negative smear test results.

I wonder if he ever thought differently after his own wife passed away due to cancer.

The HSE and Irish dept of health is littered with what they term systemic failures.

Harry Truman would never have worked in either as the buck never seem to stop anywhere in the organisations.

political analyst · 28-10-2022 4:54pm

https://www.boards.ie/discussion/comment/119805405#Comment_119805405

It was the audit of smear slides that was kept secret - women were told that they had cervical cancer as soon as their doctors became aware of it.

Faugheen · 28-10-2022 4:57pm

https://www.boards.ie/discussion/comment/119805405#Comment_119805405

That’s not what happened here at all.

jmayo · 28-10-2022 4:58pm

https://www.boards.ie/discussion/comment/119805416#Comment_119805416

Oh we know that.

But it was really an attempted cover up of the fook ups.

Say nothing was the order of the day.

Otherwise why would all these women, and sadly in some cases their families, be winning awards against the HSE and smear test organisation if there wasn't gross fookups with their smear tests.

Faugheen · 28-10-2022 5:05pm

https://www.boards.ie/discussion/comment/119805434#Comment_119805434

Nobody is saying that.

You claimed that the women weren’t told. That’s grossly untrue.

Its already horrific enough without painting it differently.

jmayo · 28-10-2022 5:07pm

Didn't take long for the HSE apologists to arrive.

https://www.boards.ie/discussion/comment/119805427#Comment_119805427

Pray tell us then why Tony Holohan expressed huge regret at the way the thing was handled.

One might think that his wife's imminent passing might make him cop on what a fook up he was involved with and what hurt was caused?

https://www.irishtimes.com/news/health/holohan-has-huge-amount-of-regret-over-cervicalcheck-issues-1.4476515

But no he still didn't have the guts to apology to a dying woman.

Asked if he would apologise to Ms Bennett, Dr Holohan said he did not know the details of the case.

He said he was aware that a letter from the clinical director of the programme had been read out in court, which had addressed the issue.

Asked if he would apologise to other women affected by the controversy, Dr Holohan said the State and the Taoiseach had apologised for the “significant harm” done through non-disclosure of clinical audits.

The issues involved had been investigated in great detail in two investigations, but no findings of “adverse functioning” had been made against the programme.

He described the failure to deliver on commitments to share information with women was a “substantial wrong”.

Pressed further to apologise, he said: “I have a huge amount of regret at to what happened to women in those situations”.

emo72 · 28-10-2022 5:08pm

They outsourced the reading of the smears to the US I think, some staff advised against it saying it wouldn't work for us here because we had a different set up. But they wanted to save money and went ahead with it anyway. You know, it's only women at the end of the day. Money's more important. I hate the people that done this.

Faugheen · 28-10-2022 5:11pm

https://www.boards.ie/discussion/comment/119805475#Comment_119805475

HSE apologist? Far from it.

You said the women weren’t told. That’s not true. Correct?

jmayo · 28-10-2022 5:25pm

https://www.boards.ie/discussion/comment/119805496#Comment_119805496

Lets look at the case of Vichy Phelan which actually was the one that brought all this to light.

Vicky's 2011 smear test, which showed no abnormalities, was found, in a 2014 audit of smear tests on a number of women, to be incorrect.

She was diagnosed with cervical cancer in 2014 but did not learn of the review or audit until 2017.

Here is story about the husband of a lady who died before ever learning their were misdiagnosis of her smear tests.

https://www.southernstar.ie/life/all-i-want-is-the-truth-for-irene-4251277

EVERYONE needs to go and see the documentary film Vicky that puts the spotlight on the CervicalCheck controversy.

So says Stephen Teap whose wife Irene died from cervical cancer in 2017 having twice received incorrect smear test results.

The controversy came to light in 2018 after Kilkenny woman Vicky Phelan, who has terminal cervical cancer, settled her High Court case for €2.5m after she was given incorrect smear test results.

She blew the whistle on the scandal, and an inquiry established that Cervical Check and its doctors failed to inform hundreds of women of an audit of their cervical smear tests after being diagnosed with cancer.

Some were already dead, including Irene Teap. The 35-year-old mum-of-two died not knowing she was given false negative test results in 2010 and 2013.

So remind us again hwo they were not informed there had been misdiagnosis of their smear tests?

I never said the women were not told they had cancer.

Most were properly diagnosed years after the misdiagnosis, unfortunately too late for some.

And they were diagnosed when the symptoms were more pronounced.

Jequ0n · 28-10-2022 5:35pm

You know exactly why the family want an apology, and it hardly going to be to you get closure.

marieholmfan · 28-10-2022 5:37pm

https://www.boards.ie/discussion/comment/119805427#Comment_119805427

You're replying to the living embodiment of dunning krueger.

marieholmfan · 28-10-2022 5:38pm

https://www.boards.ie/discussion/comment/119805477#Comment_119805477

It was that or nothing. Right now it's nothing.

Caledonia · 28-10-2022 5:40pm

I think the difference is the first screener is reading a slide from a healthy population, one of thousands. The second screener in audit or solicitor request knows the person has cancer so it’s totally different. It’s very easy to see it with that benefit. Called retrospective bias. So it’s not that slides were read wrong, it’s that the circumstances are totally different.

jmayo · 28-10-2022 5:57pm

https://www.boards.ie/discussion/comment/119805597#Comment_119805597

Wippee the chief has arrived.

Pray tell us then why government actually apologised to women for the way they were treated ?

I NEVER SAID WOMEN WERE NOT INFORMED OF POSITIVE CANCER TESTS.

I said they were not informed of misdiagnosis years before.

And speaking about my competence in light of how we are discussing the gross incompetence of the HSE, Dept of Health, etc is a tad ironic.

Anyway better things to do with my life than chatter with the likes of you.

Montage of Feck · 28-10-2022 6:55pm

Why should they apologise unless their was evidence of gross misconduct? Smear tests are not infallible, particularly as they are a subjective test.

All analytical work is done to an acceptable level of error. That level of error should be determined by cold hard stats not emotions.

Mrs OBumble · 28-10-2022 8:09pm

Cancer us not diagnosed from a smear test.

The test shows normal or abnormal results. If it's abnormal, further tests are needed for diagnosis.

Follow the science, instead of the gospel of St Vicky

Overheal · 28-10-2022 8:14pm

https://www.boards.ie/discussion/comment/119805927#Comment_119805927

and I mean the idea of settling is you may be unsure how strong your case is. Would a jury agree that it was criminal negligence or forgivable human error if the doctors had character witnesses etc.

SEPT 23 1989 · 28-10-2022 8:17pm

how can the bastards who are responsible for this sleep well tonight?

and they have the neck to turn up for work next week and take their wages

shameless total failures of human beings

MrMusician18 · 28-10-2022 8:39pm

https://www.boards.ie/discussion/comment/119805477#Comment_119805477

That's extremely unfair. If the health system didn't care about women there would never have been a cervical check or breast check.

My own fear was that after all these failures that the screening programmes would end up cancelled as they drew a liability on the State. To be fair though, that has not happened and screening has expanded.

political analyst · 28-10-2022 10:53pm

https://www.boards.ie/discussion/comment/119805477#Comment_119805477

It was outsourced because of quality-control issues with Irish labs. The only alternative would have meant women deciding by themselves whether to seek smear tests and lab technicians reading the data from smear tests on their kitchen tables at home. Perhaps cervical cancer wasn't as well understood then as it is now - a bit like Covid not being fully understood early in the pandemic.

Smear tests are not diagnostic and so there's never certainty that they'll detect cells that can cause cancer. I'm not sure if there was any point in CervicalCheck to begin with. Perhaps it would have been better if women had followed their own intuition, i.e. electing to have smear tests if they had a suspicion that something was wrong.

political analyst · 28-10-2022 10:56pm

https://www.boards.ie/discussion/comment/119805551#Comment_119805551

Revealing the smear-test audit as soon as it had taken place wouldn't have saved Irene Teap's life.

Gusser09 · 28-10-2022 11:08pm

Mistakes happen but the hpv screening is a resounding success in the whole.

Its shocking what these girls were put throught. Sickening.

To try and scapegoat Tony Holohan isnt right though.

We need to try and move on from this scandal and ensure that confidence and trust is at the highest possible level in the program. We cant afford women not to take part.

Please god the hpv vaccination scheme puts an end to cervical cancer.

maninasia · 28-10-2022 11:24pm

If you are doing a retrospective audit its guaranteed for any screening program to then identify a number of false negatives, especially if you are auditing from a sick population .

All screening programs have a given false negative and false positive rate. Generally you want to have a balance between low number of false positives (which could jam up the system and cause huge unnecessary concern and surgical intervention) while at the same time trying to reduce the number of missed true positives . Remember yoo could be dealing with millions of people.

That is the way they are designed and there is no perfect approach to this.

To get a 100% false negative rate is impossible for any diagnostic test, there is no perfect test for any disease, and for cervical smears , like tests that depend on xrays, they depended on a lot of human judgment which can cause more variation to creep in.

I haven’t followed the procedural issues behind this so I wont comment on that part. Of course I feel terrible for those who have lost loved ones from misdiagnosis.

HSE has paid hundreds of millions, and possibly billions, out for different issues related to testing but I beleive it is largely due to issues in how the results were communicated rather than the tests themeselves having specific issues because, again, when you order a diagnostic test it comes with an inbuilt error rate assumed already. In other jurisdictions patients are not getting compensation to the same level as seen in Ireland.

Igotadose · 30-10-2022 9:13am

@maninasia

HSE has paid hundreds of millions, and possibly billions, out for different issues related to testing but I beleive it is largely due to issues in how the results were communicated rather than the tests themeselves having specific issues because, again, when you order a diagnostic test it comes with an inbuilt error rate assumed already. In other jurisdictions patients are not getting compensation to the same level as seen in Ireland.

Absolutely correct. HSE's solution to all problems once they're found out, is to buy silence. Cervicalcheck, Savita (that attempt failed), the recent youth mental health issues in Kerry.... Did you know Savita's doctor, the one that misdiagnosed her sepsis, is still practicing in Ireland? That's the HSE for you, never ever any consequences.

Plus, try bringing a complaint against them. The complaints department belongs to the HSE - effectively, they're incentivized to quash complaints.

rock22 · 01-11-2022 8:12am

https://www.boards.ie/discussion/comment/119806825#Comment_119806825

@political analyst said "It was outsourced because of quality-control issues with Irish labs."

That is not true.

political analyst · 03-11-2022 1:03am

https://www.boards.ie/discussion/comment/119818047#Comment_119818047

In 2018, Tony O'Brien said that the cervical smear test service in Ireland in 2008 was poor and that the only alternative to outsourcing was the leaving of tests unanalysed for a year and doctors examining tests on their kitchen tables at home.

https://www.irishexaminer.com/news/arid-20470111.html

Igotadose · 03-11-2022 3:17pm

HSE still not fit for purpose. 20 years on after an organ retention scandal,

The Doctor at the centre of it back then, is working again in pathology for the HSE
They're holding organs too long and surprising parents with horrible, callous communications "Hi, this is the HSE, you filled out the form wrong. What do you want to do with your baby's body parts?"
Investigations and recommendations in 2009, kinda not implemented yet.

At least Paul Reid's gone. Maybe they'll eventually have a doctor in charge of the HSE.

https://www.rte.ie/news/investigations-unit/2022/1102/1332885-organ-retention-scandal-parents-babies/