Report: Eight Women Developed Cancer After Smear Tests Misread

A significant review of cervical screening practices at the Southern Health Trust has determined that eight women developed cancer after their smear tests were incorrectly interpreted by screeners. Additionally, during the review, pre-cancerous cellular changes were identified in the slides of 11 other women, necessitating treatment. Upon re-examination of their smears, all these women were found to have either pre-cancerous cervical changes or another serious gynaecological condition. The Southern Health Trust has issued an apology to everyone impacted. The investigation was initiated after the diagnoses of three women were examined as a Serious Adverse Incident. Lynsey Courtney and Erin Harbinson, two of these women, have since passed away. Over 17,000 individuals were contacted regarding the re-examination of their smear tests. The 13-year examination of cancer screening within the Southern Health Trust revealed that numerous women were let down due to the long-term underperformance of some screeners, which remained unmonitored by management for an extended period. Stella McLoughlin of the campaign group Ladies with Letters characterized the events as unforgivable and advocated for a public inquiry. She stated, “This has been an absolute scandal from start to finish and was allowed to go on for 10 years.” McLoughlin further commented, “Smears being misread, people not being held to account, screeners not being managed properly – all of this is affecting real people.” The trust’s cervical screening review encompassed two distinct cohorts of women. The initial group comprised 207 women with prior cervical cancer diagnoses. The slides of the eight women who subsequently developed cancer were re-evaluated within this cohort. The review concluded that earlier diagnosis and treatment would have been possible had their tests been interpreted accurately. The second group consisted of 17,425 women who were requested to return for a re-examination of their smears. The 11 women presently receiving treatment for non-cancerous conditions belonged to this group. The trust stated that it could not be definitively concluded that the eight women developed cancer specifically due to missed abnormalities on their smear tests. In October 2023, the Southern Trust declared a precautionary review of cervical screening results for 17,425 women screened from 2008 to 2021. This action followed an independent report by the Royal College of Pathologists (RCPATH) which identified “persistent underperformance” among certain laboratory screeners. BBC News NI can additionally disclose that one of the four screeners under scrutiny has been suspended, and a second has had conditions of practice imposed by the regulatory body, the Health and Care Professions Council, after hearings. During an interview with BBC News NI, the Southern Trust acknowledged the difficulty of this period for all affected families and the anxiety generated by the process. Dr Steve Austin, Medical Director, noted that most of the slides examined were normal, but recognized that some women received an altered reading, leading to subsequent treatment. Dr Austin stated, “We have learned lessons from everything that has happened. HPV screening is now in operation and the laboratory services have now been centralised in one location and other improvements have been made across the system.” In February 2023, BBC News NI first reported on the Southern Trust cervical scandal, revealing that a woman diagnosed with cervical cancer had three prior abnormal smear tests that were overlooked. Following contact from the woman and information provided by a whistleblower, BBC News NI also disclosed that concerns regarding the performance of some screeners had been raised prior to 2022, and a review of their work was planned. The Southern Trust conceded “failings” within the cervical testing laboratory, but indicated these issues went beyond individual staff and represented “wider system failings.” Slightly less than 94% of the identified women participated in the review, with the trust successfully locating 513 patients who had relocated outside Northern Ireland. Joanne McClean, Director of Public Health at the Public Health Agency (PHA), expressed regret for all the hurt, distress, and grief experienced by individuals. She stated that the decision regarding a public inquiry rests with the health minister. The highly critical report from the Royal College of Pathology identified a “persistent failure” to address underperformance among certain cervical screening personnel. It further noted that policies for managing poor performance were substandard and the screening laboratory was unsustainable. The college concluded that management’s actions were insufficient over many years. Throughout the entire review period from 2008 to 2021, Northern Ireland employed cytology-based screening, which entails preparing a slide from a smear test sample for microscopic examination. Cytology screening identifies approximately three out of four abnormalities. Northern Ireland aligned with the rest of the UK in December 2023 by implementing primary HPV screening, a method that detects the human papillomavirus (HPV), the cause of nearly all cervical cancer cases. This screening approach is more sensitive and is anticipated to identify nine out of 10 abnormalities. The findings are now slated for an independent expert review, which will soon begin under the direction of Allan Wilson, a senior biomedical scientist at NHS Lanarkshire, who possesses over 45 years of experience with Scotland’s cervical screening program. The health minister will determine whether to initiate a public inquiry based on these findings. Copyright 2024 BBC. All rights reserved. The BBC bears no responsibility for the content of external websites. Information regarding their approach to external linking is available.