Dr. Peter McKenna:

I will answer on one facet of the questions about the audit process and how a slide for a patient who turns out to have an interval cancer is reviewed. To date, all of the reviews have been made in an unblinded manner. They include the Royal College of Obstetricians and Gynaecologists, RCOG, review where the people looking at the slide know that the patient has developed cancer. The environment in which the review is taking place is very important. It also depends on who a person asks. If, for example, the slide is shown to a consultant cytologist and they are given unlimited time, in telling the doctor that the woman has cancer and asking them if they can, please, find the abnormal cells, that is an entirely different environment from that of a screener who has received many slides that day to go through and who has to pick out the abnormal cells. None of the reviews about which we have spoken, whether they have been in court, at the RCOG or the original review, has been carried out in an unblinded manner. It appears to us that the only fair way to do it is in a blinded manner, that a panel of individuals be included which would include a number of primary screeners, in addition to more senior ones, and that the abnormal smear be mixed in with a number of normal ones, for example, ten or 20. There would then be an individual report from each of the people who had looked at it and an aggregate and agreed report.

The reason we believe it is so important to go into this detail is that it does not really matter how one looks at a slide if the patient is not to be told. In many countries patients are not informed of the result of a review; therefore, the slide can be given to ten professors who will have a week to look at it for one of them to find the abnormal result. That will have no implications if the patient is not to be told the result. Similarly, it will have no implications if the patient is to be told and there will be no financial repercussions for the system. In Ireland, up to now, the patient has been told and it appears as if it will have financial repercussions. That is why it is very important to design a review system that will be entirely fair to the programme, the screener and the patient's expectations.

That is only a small element of the questions asked by the Chairman. There were many others.