Dr. Colm Henry:

I have no doubt in my mind that clinicians should be aware of their duty for open disclosure and their duty to tell patients in the timeliest manner possible. It should be ingrained in their clinical practice when they are relaying good and indeed bad news every day of their lives. It should be ingrained in their training.

In this case, my reading of this looking back is that there was an audit designed for quality assurance and learning, and that the linkage between that learning and quality assurance audit to the clinicians who are treating the cervical cancer patients was never closed.