Mr. Stephen Teap:

No worries. Thanks very much for the opportunity to speak to you all today. I am here representing my late wife, Irene, who died in July last year at the age of 35. I am going to begin just over two weeks ago when the HSE first contacted me. It was Tuesday, 1 May, around 2.30 p.m. I was in work and got a call from a non-clinical adviser from the HSE. I was advised that Irene was one of the 17 women at the time whose name had come up in the most recent audit. We now know that is 18.

I requested there and then - there is obviously no good time to receive a call like that - a face-to-face meeting. I said I could not have that conversation over the phone. I did ask what smear tests were being referred to in respect of this audit and I was told 2013 and 2010. I asked whether they going back as far as 2010. The woman on the phone pointed out that she was not a clinical adviser and that I needed to come in and meet a consultant next Thursday night at 7.30 p.m.

I asked on Thursday night why a non-clinical adviser was phoning to tell us this. Why was it done over the phone? Why could someone not have called out to my house? I was told then that a decision had been made that no medical staff were going to make the phone calls because they did not want us asking any questions over the telephone when we received those calls on Tuesday, 1 May.

On Thursday, 3 May, at 7.30 p.m. we arrived in St. Finbarr's Hospital in Cork. I was there with Irene's mum and dad. We were brought into a waiting room within the hospital. It was just a standard hospital waiting room. We were passing women on the way out the doors of St. Finbarr's who were upset. We were brought into an empty waiting room with vending machines in the corners and a television on and just told to wait there. A girl walked in with her mum and dad. I would say if she was 30 that would be a lot. They sat down behind us. I was trying to get my head around the fact of whether we were actually being brought in with all of the other victims of this audit. Surely not, that would have been a bit insensitive. I turned around to that family and asked were they one of the 205 or 206, as it was at the time. The mother turned to me and said "yes, we are. And you?". I said that we were one of the 17. The daughter of that family just got up then and left the waiting room. She was clearly upset by that.

We waited there alongside that family for the next half hour. Then we were brought in to see the consultant. He was actually the consultant that Irene was referred to on day one. There was just him, a nurse and Irene's mum and dad. We sat down. Irene's file was open on the table with the CervicalCheck audit on it. The last time I saw that file was 14 July last year, when we were given Irene's terminal diagnosis in hospital. It was the same bulky file with all of her information in it. The consultant started reading through the audit with us. It was like the piece of paper that was shared a minute ago. He shared with us that were two sides to the page. On the left-hand side were the smear tests which Irene had done and the results that her GP would have been given. On the right-hand side of the page were the results from the audit carried out on these two smear tests.

Obviously, Irene was led to believe that both of these smear tests came back clean. The 2010 test said to call back in three years and the 2013 test said to call back in three to five years' time. When these were audited, it turned out that the 2010 test had pre-cancerous cells in it. That was the result from the audit. I asked what this would have triggered if Irene had got these results on day one. I was told they would have brought her back in, they would have done a physical examination and would have performed a procedure where they would have burned away the cells. The chances are that would have been it then. She would have been told to go and live the rest of her life. As the consultant pointed out to us, 2013 was the most concerning of the two smear tests because this had the beginnings of cancer. This was the biggest concern because Irene would have been called in straight away. She would have gone through treatment. Again, she could have gone on to live a happy life with us - with me and my two boys.

The question is how did Irene find out she had cancer. It was not from a screening process. Irene had two missed opportunities for cancer to be identified in her smear tests. If it had been identified in either one, she would still be here with us today. I have heard through different sources and through the media that these smear tests are accurate up to 70% or up to 90%. They might have 10% inaccuracy. In Irene's case it was 100% inaccurate. Two consecutive smear tests were missed and two opportunities to save her life.

On 21 April 2015, Irene gave birth to our youngest boy, Noah. Soon after that, Irene noticed she was not recovering from childbirth. She was still bleeding. About five or six weeks after Noah was born, she went back into Cork University Maternity Hospital, CUMH, for an examination. She was given some statistic. I am not sure what it was but it was on the lines of so many women can bleed up to eight weeks and ten weeks after birth. It was a rarity but did happen. At eight weeks, Irene was still bleeding. She went back to the GP and got an appointment to go back in to see a consultant in CUMH and at 12 weeks she went back in.

At that stage, her cervix was looked at. There was nothing wrong with it. It was going along the lines of maybe Irene had some kind of hormone imbalance and that was why she was not recovering from childbirth. They were going to write her a prescription to balance her hormones. Essentially that prescription would have been for the contraceptive pill. Irene was breastfeeding Noah. He was 12 weeks old. Irene knew that this medicine that she had been prescribed would dry up her milk supply and she would be unable to feed Noah. She refused it straight away.

At 18 weeks, Irene was still bleeding and she went back to her GP. Her GP referred her back to the CUMH to see the same consultant again. They decided then to do a dilation and curettage, D and C, procedure because they were thinking that maybe some elements of childbirth still left in her womb might be causing an infection. They said that if they carried out a D and C that might get rid of the bleeding. When they were doing the D and C on Irene, the consultant that had seen her at 12 weeks noticed there was a change in her cervix at that point, at 20 weeks.

They took a sample and tested it. It was then that Irene was diagnosed with cervical cancer. At this point, we had a five-month-old boy being breast-fed and a two-and-a-half-year-old boy and Irene needed to start that gruelling treatment that Vicky went into detail about - radiotherapy, chemotherapy and brachytherapy at the end - for eight weeks. As Vicky mentioned, this is a horrible experience - all of it. The eight weeks of treatment are gruelling. The medication and steroids - everything you are put on just makes you sick. It was a very difficult time for all of us but we are fighters. Irene led the pack and we just got on with it. When you have two small children, you have to fight this. At the end of the eight weeks, you have the horrible wait of three months for that scan to review how this treatment has gone. That brought us up to around February when we had that scan. In March, we were told the treatment went very well. When Irene had been diagnosed that previous September, she had been diagnosed with stage 2 cancer and they told us they would be treating for cure. So when they told us in March that all that was left was scar tissue from the tumour on her cervix, obviously we were delighted with that. Everything seemed to be working fine.

During the summer, Irene started to get progressively sick again with back pain and pain down her legs. It go so bad that she was getting up in the middle of the night to take pain medication and to make up water bottles. When we went back for our appointment in September 2016, after a couple of weeks of testing, Irene was told that she had secondary liver cancer and tumours in her lungs. They did not discuss treating for cure at this point. They never said it was terminal. They just said we would now be living with cancer, that they had a very aggressive chemotherapy treatment plan, that after that, they had plan B and that after that, they had plan C. Irene went through this chemotherapy involving one day of chemotherapy and going back every three weeks. You are floored in the first week of this chemotherapy. In the second week, you are coming back together and in the third week, you are up and running again. Then you get slammed again with another dose of this chemotherapy and you are wiped out again. It is just a continuous cycle for 12 weeks. After a second dose of chemotherapy, Irene lost all her hair. She said "I am now a sick person" because, as Vicky said, you do not lose your hair the first time and can still blend into the crowd and nobody knows what is going on but this time, as she said, people were giving up their seats for her and opening doors. You are now sick. This treatment lasted until January. We had a scan that said the tumour on her liver was shrinking. Less than a month later, we had another scan saying it was growing again. Irene spent every second or third week in hospital in early 2017 - infection after infection after infection - up to the point of 14 July 2017 when they sat us down and said there was no more they could do for us and were stopping all treatment. When we asked how long we had, they said a few short weeks and that they hoped we would get to the end of the summer. Irene's only ambition there and then was to see our eldest guy start primary school at the end of August. Irene only lasted a week and a half later. She passed away on 26 July.

The HSE received the audit results on 3 July last year - just over three weeks before Irene died. It decided there and then that it was not going to share that information with Irene or me. At that meeting on the evening of Thursday, 3 May, I was told a team of counsel made the conscious decision not to share the information with Irene or me. They thought she was a bit too sick. This was 3 July. She did not get her terminal diagnosis until 14 July. They did not know if she was going to live for three weeks. They did not have a clue at that point. We told him that this was not his decision to make - how dare he? If he knew Irene at all, he would know that if she had three minutes to live and this information landed across her desk, she would want to know exactly what that was about. The next morning, 12 hours later, I got another call from this consultant. He said to me that he gave me misleading information at our meeting the previous night. He did not do it deliberately but he wanted to correct it. He said that the counsel - the team of people he met - did not actually tell him not to pass on the information to Irene or me and that they actually said that it was about open disclosure and told him to contact CervicalCheck. Somewhere within the 12 hours, this consultant was clearly reminded of the company line and made a conscious effort to get in touch with me quickly just to correct exactly what he said. When I asked him what happened when he did contact CervicalCheck, he said he did not know, which was odd because you would think that would be the first question I was going to ask. He did not have that information for me. I politely reminded him that this was a big part of the puzzle and that I wanted to know exactly what conversation he had. I said that he was told about open disclosure and then told to contact CervicalCheck so I asked the conversation was. I told him he needed to find this out to which I got the smart response that he would have a look and that he needed to trawl back through 2,000 or 3,000 emails but that he would have a look. I told him that he had better do that and that I wanted to know that. He replied that it may have been a verbal communication and that he did not know 100%. I think we can all take it that I will probably never find out the answer to that question. That is a problem.

This lack of open disclosure within the HSE is clearly a problem. The communication between senior management and consultants is an issue. Communication between senior management and the Department of Health is an issue. From what we have learned in the past 24 hours, communication between the Department of Health and the Government is clearly an issue. While it exists with a fantastic nursing staff and the majority of consultants - I have to give credit to the nursing staff who took really good care of my wife - clearly patient care is diluted up the ladder and the element of protect and deny is introduced. That is basically what we have seen in the past few weeks when it comes to all of this communication or the lack of communication we are being fed, the lack of communication with Irene, the lack of communication with me and the lack of communication with her GP. I had to inform Irene's GP that she was one of the 17 women who were audited. I had to inform Irene's GP about the results of the audit. Irene's GP is not only her GP but the GP of her three sisters, her mother and father, my two boys and my niece and nephew. He is the family doctor and he was never consulted about any part of this. I have copies of the smear tests he performed in his clinic and they could not even give him the audited results of the tests he conducted. Information was clearly withheld from him and it looks like information was clearly withheld from the Ministers. We have to take them at their word that they did not receive this information.

It seems that the people in these senior positions who knew about all of these memos in 2016 are the same people in senior positions today who need to be questioned when it comes to these inquiries. I do not understand how they can sit in these positions while inquiries are ongoing. We have dead women here. We have women who have been given terminal diagnoses - death sentences. We are talking about 209 women, of whom 18 are dead. We still do not know how many of the rest have a terminal diagnosis, how many are still going through treatment and how many have finished treatment and are lucky enough to be out the other side. It is how many weeks later and they still cannot give us this information.

We have two people gone but more need to go now. They need to step aside. They have to get out of the way so these inquiries can take place. Right now, they know where all the answers to the questions lie. They know the places not to look or to keep us away from and they are clearly sitting on this information, preventing us from getting it. It is obvious that this is going on from the drip-drip feed that Oireachtas Members seem to be getting at these committee meetings. I welcome the Scally inquiry. It is important that we have a third party inquiry on this. He needs to speak to the same people that are sitting in these senior positions who are deliberately covering up information. If someone knows something about another department and mistakes are being made, and that information is not being passed on, that is a cover-up. If other people are involved in not sharing that information, they are now part of that cover-up too, yet they all remain in senior positions in the HSE. That is a huge concern of mine.

Last Thursday, when I left the meeting, I left with nothing. Nothing was offered. There were no support services, nothing for me to help my kids through their bereavement. Oscar was four when his mum died and Noah was two. They are five and three today. Ten to 15 years from now, they will be reading all about this in the papers and they will look at what their dad was doing here today. What is there to help me prepare them for that? What is there when they see two missed opportunities to save their mother's life? How do I communicate that with them?

I am one of now 17 families. There are close to 200 women. We do not know how many are terminal and how many are going through cancer treatment. When one is going through that horrible process of treatment for cancer, one's mental attitude towards that treatment is very important. How do you think these women feel in the last couple of weeks after having these meetings and being told that a few smear tests were missed that could have saved their lives? Maybe they would not have to go through cancer treatment, maybe they are not terminal and maybe they do not have to die.

On top of that, they have to fight for their life while having to process that information. When the HSE informed them of this audit, it just sent them back out the door with no support services. There was absolutely nothing but a "Goodbye, there you go". This is why, from the beginning, I decided to share Irene's story because that is exactly what she would have wanted. If she got this information three weeks or three minutes before she died, we would all know about that story. She would have been shouting the same thing that I am shouting. The support services took almost a week to be put in place from the second I started roaring and shouting about it. We heard the announcement last Friday of all these support services, which I welcome. They are great. The problem is that I still have not heard anything. I know you have not heard anything. I do not think anybody has heard anything. Will this come in for us in 2020 or 2021? Those support services should have been in place two or three weeks ago when we were sitting with the HSE, and they were not. It is another example of the lack of patient care within the HSE.

The HSE needs to be reformed, particularly at the senior level. It needs to start looking at how it is run from the ground up and the staff that are there today, looking after patients. Patient care needs to be put in the backbone of the HSE, right up to senior management. Communication is key.