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Lessons have been learned, says health trust after 86 women are recalled over smear test results

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In late January and early February 2019 a total of 86 women were recalled for smear tests

In late January and early February 2019 a total of 86 women were recalled for smear tests

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Dr Anne Kilgallen

Dr Anne Kilgallen

In late January and early February 2019 a total of 86 women were recalled for smear tests

A health trust has apologised over the incorrect reporting of cervical smear tests.

The Western Trust (WHSCT) said lessons had been learned, amid claims that delays in contacting patients had been caused by "workload and staffing challenges".

In late January and early February 2019 a total of 86 women, tested between April and June 2018, received letters from the trust stating that variances were detected in their results and further tests should have been carried out.

For some women the notification came 10 months after their original test, causing considerable distress.

It was categorised as a Serious Adverse Incident (SAI), leading to a review, with a subsequent report containing recommendations and actions.

Last March the trust's chief executive Dr Anne Kilgallen told a WHSCT Board meeting upon detection of the variances: "The trust immediately set up a review team, alerted the Public Health Agency (PHA) and Department of Health and initiated a review process."

However, on enquiry, the PHA confirmed it was first informed of the review in January 2019 - seven months after the last smear test had been carried out.

It was expected the review recommendations and actions would be shared by the Trust to provide reassurance, but despite numerous requests, the trust refused.

This was challenged by media representatives, because of issues around public interest and information sharing under accountability and transparency.

The trust has now released a statement which outlines the problems and offers assurances that lessons have been learned.

It said a review was conducted of cervical smear tests screened and reported at its pathology laboratory between April and June 2018, after variances in the reporting of a number of tests were identified during routine performance checks. The variances were not detected until January 2019 "due to service pressures at that time".

The trust immediately set up a review team, alerted the PHA and Department of Health and initiated the review process.

As a result, 86 women were asked to arrange a repeat test.

A small number of women required further investigation and treatment, but no cancers were detected.

The trust added: "The (SAI) review contained a number of recommendations and conclusions some of which are local to the trust (six recommendations) and others are regional for the HSCB/PHA (five recommendations) to address."

The statement does not disclose the nature of the recommendations.

However, it confirms: "The trust is currently in the process of implementing the recommendations for which it is responsible... feedback was provided to the trust in September advising the directly responsible officer and other relevant officers had reviewed the SAI report and were satisfied the incident could be closed... all recommendations/actions from this report are being monitored through the trust's governance arrangements."

Explaining why the SAI happened, the trust said: "No screening test is 100% accurate. However, the quality checks help to identify variances and assist with putting in place corrective action. In this situation there was a delay of three to four months in identifying the variances."

It was claimed that "staffing levels and continuity in management, combined with increases in workload, impacted on the running of the department and the frequency of quality checks".

"Having now completed the review, the trust can confirm that a small number of women required follow-up procedures, but no cancers were detected," it added.

The trust apologised for the delay in identifying the problem.

It added: "We now have measures in place that ensure our quality assurance system is fully operational at all times and will pick up error as it did on this occasion.

"We recognise it is critical these systems are maintained despite workload and staffing challenges.

"On this particular occasion these pressures delayed identification of the problem and we are sorry for that and have learned from this."

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