‘Serious work to be done’ around open disclosure in Ireland’s healthcare system

There is “unfinished business” and “serious work to be done” around the area of open disclosure in Ireland’s healthcare system, Dr Gabriel Scally has said.

Publishing his 39-page report on the implementation of recommendations from his 2018 scoping inquiry into the Cervical Check screening programme, Dr Scally said issues remain around resolution and other areas.

He said that there is still a lot of work left to do around open disclosure and achieving resolution.

The health specialist said that the treatment of some women in the healthcare system remains “completely unacceptable”.

He was also critical of healthcare staff who have claimed in the past that CervicalCheck was as good as any other cervical screening programme in the world, describing the comments as “entirely reprehensible”.

“If you can’t bring yourself to acknowledge past failings, why would anyone trust you today? Some of the things that have been extraordinarily hurtful and damaging,” he said on Wednesday.

He said some of these attitudes are “still prevalent” in the health system, and that the treatment of some women remains completely unacceptable.

Dr Scally was tasked with reviewing the cases of more than 200 women who were not informed that their smear test results had produced false negative results.

Assessing the progress made in implementing his 50 recommendations, Dr Scally said: “The whole area of open disclosure I think is unfinished business.

“There is work to be done and some serious work about the whole way in which things are dealt with.

“We have issues around resolution, clearly in terms of how to deal with these things.

“The court system is not the right place to achieve a resolution that is imbued with grace and compassion.

“I think there is a lot to be done still there and I’ve been very moved by some of the women involved.

“Some of them are now dead and took it into their own hands to achieve resolution by sitting down with the consultants, that they had a legitimate grievance about their behaviour in terms of non-disclosure and discussing that with them face to face, and hearing and exchanging views and hearing how each of them felt.

“I know that made a difference.

“We need to engage much more and facilitate much more that form of resolution.

“The whole area of open disclosure which of course was at the very centre of the cervical screening problem, where the poorly designed audit results in some women not being disclosed as they should have been.

He also said that the best way to honour cervical cancer campaigner Vicky Phelan, who died last Monday, is by implementing the recommendations of the scoping inquiry, both in the letter and in the spirit.

Dr Scally was critical of the wording around open disclosure in guidelines provided by the Medical Council.

He added: “One of my recommendations in 2018 was that the Medical Council should put into effect its stated support for the concept of a duty and culture of candour by insisting that doctors ‘must’ be open and honest with patients rather than using the word ‘should’, which leaves it to the doctor’s judgment as to what, if anything, happens.

“Unfortunately the working in the Medical Council guidelines remain unchanged.

“We should start on the basis that we expect all of our health professionals in this country to be open and honest when an error has happened.

“The regulatory bodies need to waken up to that and I’m disappointed that since my first report came out, that that word remains as ‘should’, that open disclosure remains for the Irish Medical Council a discretionary matter.

“There is no discretion in my view.”

He also said the limited of scope of the Patient Safety (Notifiable Patient Safety Incidents) Bill was “problematic”.

“The Bill only specifies the mandatory requirement for open disclosure in the case of 13 categories of incidents. 12 out of the 13 high specific incident where notification would be mandatory relate to the death of a patient,” he added.

“This, under any circumstances, represents a tiny proportion of harm caused to patients through clinical error.”

He said the enactment of a statutory duty on healthcare professional “remains unaddressed”.

He also said it was “extraordinary” that there remains a legal prohibition on anybody making a complaint to the HSE about the clinical judgment of a doctor or other health professional providing care funded by the HSE.

The legal prohibition remains as part of the Health Act 2014.

“I’ve never come across that and I was astounded and I checked it multiple times, of anywhere else where there’s a law prohibiting people from making a complaint to the health of their health service provider.

“I find that very puzzling,” Dr Scally added.

“An adequately constituted clinical complaints system is one thing that might help address the serious problem of patients being left with no choice but to take legal action if they are concerned that their clinical care may have been deficient.”

He said he was “happy to confirm” that substantial progress has been achieved through his recommendations.

He said that the CervicalCheck programme has “improved substantially” as a result of the coordinated efforts of the staff of the various organisations involved.

“What was revealed in the aftermath of Vicky Phelan’s court case was that Ireland had a cervical screening programme that was deeply flawed,” Dr Scally added.

“The cervical cytology slides of Irish woman had been sent to far distant laboratories abroad that were entirely unknown to the CervicalCheck programme.

“There was a quality assurance system within the Health Service Executive that was not fit for purpose.

“Some, but not all of the doctors working for CervicalCheck communicated to women and families the findings of an ill designed audit in ways that were at times obstructive and callous.”

Speaking after the publication of the report, the patient advocacy group 221+, said it had “mixed feelings” about the report.

“This report is not looking at the system through our eyes, or in language that we would be comfortable with,” the group said in a statement.

“We respect that Dr Scally was confined to operating within the frame of reference established by the previously published Scoping Inquiry into the CervicalCheck Screening Programme.

“That notwithstanding it still highlights a range of continuing shortcomings, and actions that have not been addressed.

“We thus have mixed feelings about today’s report. It commends fair progress made that is important because protecting and strengthening the future of screening is critically important.

“It also reflects our long-expressed concerns that there remains an active determination within the Irish healthcare system to avoid dealing up front with things that go wrong and with respecting those who point out those missteps.”

The clinical director of CervicalCheck Professor Noirin Russell said the programme is listening to patients to improve the programme.

“In designing our new Patient Requested Review process we are working extensively in partnership with patients, including the 221 group, who have told us how we can improve on the previous audit process.

“We are listening to patients and embedding the patient voice in our processes ensuring women can have trust and confidence in our service now and in the future.”

Minister for Health Stephen Donnelly said he believes Dr Scally’s Scoping Inquiry will be seen “as a seminal moment in the history of Irish healthcare”.

He added: “I’d like to acknowledge Dr Scally’s concerns around open disclosure. Honesty and transparency are vital in healthcare and should be embedded in the culture of the health service.

“Patients and carers have the right to know when mistakes are made, what the consequences are, or may be, and what action has been taken not only to correct mistakes but to prevent similar occurrences in the future.”