Cancer inquiry: deciding what is wrong and what can be done

By FRANCESCA MOLD

The panel heading the Gisborne inquiry into the cervical smear scandal will spend the next three months preparing its report for Health Minister Annette King.

It is expected to contain a plethora of criticisms and recommendations.

Herald reporters, who have covered the inquiry extensively, have picked some of the main points they predict will be in the report.

POSSIBLE CRITICISMS

*Dr Michael Bottrill underreported smears to an unacceptable level. He worked alone, without a primary screener, had no external quality assurance, failed to ensure his laboratory was Telarc accredited and continued to work despite ill health and memory loss.

*Health sector restructuring impeded the development of the cervical screening programme, caused loss of institutional knowledge and created split and dysfunctional accountability.

*Politicians rushed into setting up the programme without ensuring all components, including evaluation, were in place.

*Medical practitioners lacked understanding of the screening process. They failed to act when women had symptoms of cervical cancer because they were falsely reassured by normal smear reports.

*Pathologists focused on defending their profession rather than patient safety.

*Pathologists other than Dr Bottrill appear to have misreported smears.

*Medlab Hamilton, headed by pathologist Brian Linehan, failed to ensure Gisborne women's smears were available to look-backs.

*Ethics committees have treated research applications in a narrow and rigid way.

*Tairawhiti Healthcare failed to adequately resource the programme or hire staff with the necessary expertise.

THE MINISTRY OF HEALTH and HEALTH FUNDING AUTHORITY

*Failed to establish a fully resourced, central unit with strong leadership.

*Failed to adequately finance the programme.

*Set up the initial screening register in 14 separate sites against advice.

*Set up expert advisory groups but failed to implement their advice.

*Wrote policy about the programme but failed to carry out what it contained.

*Failed to record histology (tissue results) on the screening register which meant smear reading accuracy could not be assessed.

*Failed to link the cervical screening register with the cancer register.

*Failed to make Telarc accreditation of laboratories compulsory until 1996.

*Failed to monitor and evaluate the programme since it began a decade ago.

*Did not act in 1989 when visiting officials found Dr Bottrill "laidback to the point of falling over."

*Failed to act on a letter from Dr Bottrill in 1994 which said he did not participate in external quality control.

*Did not provide adequate statistical information for those leading or participating in the programme.

POSSIBLE RECOMMENDATIONS

*A standalone cervical screening unit be set up as part of a cancer control agency.

*Women enrolling on the register be made aware their medical records could be used for evaluating the programme without their consent.

*A watchdog to ensure the inquiry recommendations are implemented.

*An urgent evaluation of the programme, and law changes to allow evaluation and monitoring to be done annually.

*Specific standards and benchmarks to allow for adequate monitoring.

*A multi-disciplinary advisory group should be convened to oversee work on the programme.

*Laboratories must read a minimum of 15,000 smears a year to ensure competency.

*Annual statistical reports must be produced, with advice from epidemiologists, statisticians, pathologists, gynaecologists and other specialists.

*An independent monitoring group to conduct quality assurance of all aspects of the programme.

*Guidelines should be developed for doctors reporting incompetent colleagues.

*A way must be found to flush out concerns about bad practice without relying on one woman taking a doctor to court.

*Women must be fully informed of the limitations of screening, including error rates for slide reading.

*Maori statistical caretaker group Kaitiaki should be streamlined to expedite research applications.

*The Government must address shortages of pathologists and cytotechnicians.

*Super-cyto labs should be set up, so that only a few specialise in reading smears.

*A culture change among the medical profession so they are more open to raising concerns about colleagues' competence.

*A formal requirement that copies of complaints about medical practitioners go to ACC, disciplinary tribunals, the medical council and the Health and Disability Commissioner.

*Advisory groups should not be bound by confidentiality clauses.

*The programme must develop a system for handling complaints.

*National guidelines for ethics committees must be improved.

Herald Online feature: Gisborne Cancer Inquiry

Official website of the Inquiry