Mr. Cian O'Carroll:

In the committee's considerations and in its questioning of other witnesses one thing that occurred to us was that there has been an awful lot of talk about the statistical issues in screenings, the problems and the occurrences of false negatives. Perhaps the committee members could be mindful in their questioning that this can be used as a major distraction. I cannot speak about Irene's medical records but what happened to Vicky Phelan, and what I have seen in other situations, is that an error occurred in the reading of the original smear which was of an unacceptable magnitude. While technically it may be correct to call that a false negative, if one simply rests on it as a false negative and a statistical occurrence one closes one's mind to the necessary investigation of the cause of that failure.

It would be beneficial for patient safety if there was some questioning of the relevant key witnesses as to why clinical directors and other clinical people involved in CervicalCheck and the Department of Health appeared to have closed their minds to the magnitude of the errors which were coming back to them through the audit. They were largely doctors and it must have been quite evident to them, from these 209 cases which involved a significant delay in the commencement of treatment, that there might have been someone in those laboratories who was simply incompetent or that there might have been other factors causing this. The fact that only a month ago a memo from the senior medical people involved in cancer screening in Ireland to the Minister for Health stated that an error of that magnitude in Vicky Phelan's case was not a patient safety incident confirms that they have never investigated the error in her case. In the absence of investigation, clearly there is no intention to learn.