Mr. Patrick Lynch:

When we examined this, we noted the primary issue was that these women, who already had a smear and went through the review process, were entitled to any new information we had about their original smear. They were entitled to know that information. These were women already diagnosed with cancer but they were entitled to know. In 175 cases, when the review team reviewed the smears its clinical interpretation was different and it would have recommended a different escalation of clinical management. Yes, they should have known. The process was in place to achieve this. It fell down somewhere.