Cervical Screening Inquiry

The Ministerial Inquiry into the under-reporting of cervical smear abnormalities in Gisborne (the Inquiry) was charged with finding the reasons for the apparently high under-reporting of abnormal smears in the Tairawhiti region, and whether there was evidence of wider systemic issues.

One of the main areas of focus for the inquiry was the level of quality assurance around laboratory cervical screening services, and in particular during the early years of the National Cervical Screening Programme.

Who conducted the inquiry?

Alisa Duffy QC was the panel's Chair. She was formerly of the Crown Law Office and is currently a Barrister practicing in Auckland, with experience in medico-legal matters. Druis Barrett, of Whangarei was appointed as the panel's consumer representative. Professor Maire Duggan M.D FRCPC from Calgary, Canada with experience in the practice of cytopathogy, and in particular quality assurance practices, was the third member of the panel. The inquiry also had two counsel assisting - Royden Hindle and Hanne Janes.

Who represented the women?

Five lawyers were appointed and funded by the Crown to represent all affected women in the Gisborne area - Stuart Grieve QC, Bruce Corkill, Antonia Fisher, Vicky Anderson and Pru Kapua - particularly for Maori women affected.

Over what period of time was it held?

The inquiry held public hearings from 10 April 1999 until 29 September 1999. In addition to this the inquiry team spent six months assessing the evidence and submissions, deliberating and preparing its report.

When was the inquiry originally planned for completion?

The first public hearing of the inquiry was originally scheduled for February 7 in Auckland. That was initially delayed after a request from women affected by the inquiry to allow more time for all parties to prepare. There were further delays when the venue was transferred from Auckland to Gisborne, and then when Australian pathologist Professor Gordon Wright withdrew from the inquiry team because of the changed dates. The inquiry began in April 2000. Extended hearings and time taken to consider the findings resulted in the report being delayed until April 2001.

Who appeared as witnesses at the inquiry?

There was evidence from 20 women who have been directly affected by the cervical smear misreading. There were also witnesses from a number of different organisations. These included Government agencies such as the Ministry of Health and the then Health Funding Authority, other organisations such as the Cancer Society and a number of expert witnesses.

What prompted the Gisborne Cervical Screening Inquiry?

In May 1999 the then Health Funding Authority (HFA) began an investigation into the reading of cervical smears by a community laboratory in the Tairawhiti region. This followed the raising of concerns about the work of Dr Bottrill - as a consequence of an interim decision of the High Court in March 1999 - who practised in the area until his retirement on 4 March 1996. As part of its investigation, the then HFA arranged to have almost 23,000 cervical cytology slides re-read by a Sydney laboratory. Early results from that re-reading indicated that the Sydney laboratory was reporting many more abnormalities than Dr Bottrill’s laboratory had reported.

The then Minister of Health announced the inquiry into the under-reporting of cervical smear abnormalities immediately after these early re-reading results were announced.

Who was affected by the then HFA’s investigation?

The 22,978 slides that were re-read belonged to 12,108 women who had had smears taken in the Tairawhiti region between 1991 and 1996. Of these women, 9,584 had all their smears originally reported and re-read as normal. However a large number of women (1,997) were advised of abnormalities, many of which were previously un-reported.

Of the women with abnormal re-read results, 616 were advised of ‘high grade’ results (cancer, high grade or ASCUS-H). For 519 of these women, none of the original results reported by Dr Bottrill’s laboratory had been high grade.

What happened to the women whose slides were under-reported?

With the exception of a small number of women who we have been unable to contact, all women have been advised of their re-reading results. After extensive searching, there are currently nine women with abnormal results who we would still like to contact. They are noted on the NCSR for follow-up should they have another smear.

All women with one high grade, or two or more low grade, abnormalities reported by the Sydney laboratory were referred for colposcopy if appropriate diagnosis and/or treatment had not already been provided. A range of services were provided to encourage women to access diagnosis and treatment services, and to support women with abnormal smears.

What steps did the then HFA undertake to assess the reporting rates of other laboratories around the country?

The then HFA completed a review of cervical cytology practice in all community laboratories in New Zealand. This review was begun once the scale of under-reporting in Gisborne became apparent, and following initial analysis of regional reporting rates which indicated other laboratories had reported similar levels of high grade abnormalities to the Gisborne laboratory.

In order to assess the risk that other laboratories may have substantially under-reported cervical cytology, the then HFA took advice from a range of international experts in pathology. This was later supplemented by a multi-disciplinary group of New Zealand experts. This advice resulted in the review of cervical cytology, which identified specific issues in a number of laboratories. These issues are being addressed in detail, and any women who have been directly affected have been contacted.

As was demonstrated in evidence given to the inquiry, it is extremely difficult to assess the extent of any under-reporting without re-reading large numbers of slides. The review process concluded that there was not sufficient concerns about any laboratory to warrant a major re-reading exercise such as that carried out in Gisborne.

Is the Government bound to act on any recommendations made by the inquiry panel?

The Minister of Health set up the inquiry to receive advice on any further safeguards that might be required to limit the risk of under reporting of cervical smears to the National Cervical Screening Programme in Gisborne and elsewhere. Although the Government is not bound by any recommendations made by the inquiry in its final report the Minister has accepted all the recommendations of the inquiry and in addition, will now be working through how best to implement them.

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