'Serious gaps' in governance throughout CervicalCheck programme
The Scally Review into the cervical smear controversy in the Republic found there were "serious gaps" in governance and expertise and failure across the whole system of the CervicalCheck programme.
The scandal saw 221 women with cervical cancer not informed that smear test results showing them to be clear were inaccurate and that revised test results were kept from them.
The controversy emerged after Vicky Phelan (43) settled a court action against a US lab in April for ¤2.5m after her cancer was missed in a smear test taken by CervicalCheck programme.
Dr Gabriel Scally said there was a "demonstrable deficit of clear governance" and reporting lines within the National Screening Service and the higher management of the Republic's Health and Safety Executive.
In his 170-page report, Dr Scally said that there were problems in every area he examined but added that there was "no evidence" of a cover-up or conspiracy.
Dr Scally said that he believes there is not a need for a commission of investigation, adding that he has outlined what his priorities are.
He has made 50 recommendations, which the Irish government has accepted in full.
Speaking about his report, Dr Scally said that the issue of non-disclosure was felt "very intensely" by the women and their families who expressed anger at not being told about the test results when it became available.
"In my view the matter in which they were eventually told about their situation, in many cases varied from unsatisfactory and inappropriate to damaging hurt and offensive," he said.
Dr Scally also said that the relationship between the women involved and the clinicians were "doomed to be bad", criticising the manner in which they were told about their incorrect results.
He said that women involved described how they were "shut down" by clinicians over simple questions and were ushered out the door.
When some of the women asked clinicians why they were not told, some consultants said they "didn't know the protocol" while others claimed it was lost in files, while another said it was "caveated" not to disclose.
The report described how some women were brought into disclosure meetings in the same room as they were diagnosed and, in the case of one woman, the same room her mother died in.
Irish health minister Simon Harris said that he would bring a plan forward for implementing the Scally recommendations before the end of the year.
He added: "The voice of the patient needs to be embedded in our health care system."