Dr. Peter McKenna:

That is a very perceptive question. There are many places in which a screening service can fall down. In the first place, one has to get the patient to the doctor or practice nurse. One has to get the practice nurse to take the sample correctly. One then has to get the sample to the laboratory where it must be processed correctly and then one has to get the information which the laboratory generates back to the referring doctor and to the patient. Clearly, in this process, where the system has broken down is beyond the steps which I have laid out. It broke down where a quality assurance programme was instituted, which was found to have failed. In its failure, that information was not passed on.

The steps I have pointed out have worked pretty well, but it is the step beyond that, which is the conveying of wrong information to the patient, is the reason we are here.