Issues that emerged in April 2018 in relation to CervicalCheck

What happened in April 2018?

In the cases of 1,482 women who had received a diagnosis of cervical cancer from 2008 to 2018, CervicalCheck carried out an audit of their previous cervical screening tests. The audit found that 221 of these women could have been provided with a different result.

The objective of audit and quality review at CervicalCheck was to facilitate continued improvement and ongoing learning within the programme.

In August 2015, a decision was taken by the HSE, in line with international best practice, to provide information on the outcome of the audit for onward communication to patients but the intention to disclose this information was not followed through.

When the issues relating to CervicalCheck emerged in the media in late April 2018, the HSE set up a Serious Incident Management Team (SIMT) at the direction of the Department. The SIMT identified that of those women, many had not been informed about the results of the audit. This lack of communication caused widespread concern.


Are there other women who went on to develop cervical cancer who could have had a different screening result in the past?

Around 1,075 women who were screened and who later developed cervical cancer have consented to be part of the Independent Clinical Expert Review led by the Royal College of Obstetrics and Gynaecology. It is expected that the Royal College will find other cases where a different interpretation is placed on the slide, on review.

When slides are being reviewed by screeners who know the woman went on to develop cancer, they are more likely to find abnormalities in the slide. One reason for this is review bias. Review bias occurs when the person reviewing the slide knows that the woman whose slide they are reviewing subsequently went on to develop cancer.

For example, in a study of 3,759 slides originally assessed as normal from women who subsequently went on to develop cervical cancer in the UK, only 45% were normal on review. Dr. Scally includes information about review bias in his report.


What is the 221+ Patient Support Group?

221+ Patient Support Group was set up in July 2018, with a view to providing structured support and services for the 221 women identified by the CervicalCheck audit, and their families. The Group is funded by the Department of Health.