Dr. Gabriel Scally:

Improving confidence in the process is extremely important. One of the most distressing aspects was the degree to which many of the women with whom I interacted had lost confidence in their treating clinicians. I was really disturbed by that. It was brought home to me in the first of the meetings I had with the women in Dublin early in the process. Two young women came to that meeting and sat down beside each other, purely by accident, and found that they knew each other, were from the same place and had been at school together. They were both in the same boat with having cancer. Both of them believed that they had not been told or disclosed to properly when they should have been. They had both lost confidence in their clinicians who had been looking after them. As they were discussing this, they discovered that they had both decided to shift to the other's clinician. They thought this was very funny. It was the only light-hearted moment in the meeting. It brought home to me how difficult this is for many women, and we are still not through that at all.

At the outset I said, and I hold it even more strongly to be true, that when things go wrong, there are three things patients want to happen. First, they want to be told what went wrong and why. Second, they want someone to say sorry for something having gone wrong, and they want it to be someone who means it. Getting a letter from the chief executive, or the same letter being sent to all those affected, really does not cut it in this regard. Things went wrong, people were not disclosed to and those who did not do the disclosing, the people who probably should have done the disclosing, should be the ones saying sorry-----