Almost a year after being asked to detail the timeline of events surrounding the misreporting of 86 women’s smear test results, the Western Health and Social Care Trust has said “sorry”, after it admitted that staff shortages and continuity in management issues contributed to “a delay of three to four months in identifying the variances”.

The Trust also revealed that “a small number of women (single digits) required further local investigation and treatment to be carried out”, but that “no cancers were detected”.

In its original press release in February of last year the Trust claimed that “standard quality checks are carried out every three months in line with UK best practice” and that “variances in the reporting of a number of tests were identified” during these checks.

However, the Trust has now admitted that there was a delay and in a statement said: “Staffing levels (vacancies) and continuity in management issues combined with increases in workload impacted the running of the department and the frequency of quality checks.”

The Trust went on to say: “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 that it is critical that 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.”

In an interview with this newspaper this week Medical Director of the Western Health and Social Care Trust, Dr. Catherine McDonnell, was asked if the Trust knew in February of last year that there had been a delay in identifying the variances in the 86 smear tests.

However, Dr. McDonnell was unable to answer and said: “I cannot comment on that because I was not in post at the time.”

The variances detected in the 86 smear test results led to the issue being identified as a Serious Adverse Incident (SAI) and the Impartial Reporter can also reveal that despite clear guidelines that indicate that those affected be offered the opportunity to partake in a review into the SAI, that at least 76 of the 86 women affected were not given the opportunity to do so. In July 2019 the Trust, in a statement to this newspaper, stated that “the review team offered the opportunity to ladies to be involved in the investigation and sharing of the SAI report, no lady took up this opportunity”. However the Trust has now admitted that only “a small number of women” were offered the chance to give their views.

A Health and Social Care Board document that provides guidelines on engagement with “service users” by health organisations in the event of an SAI states that “where a number of service users are involved in one incident, they should all be informed at the same time where possible”. It also states that it is essential that there is “full disclosure of a SAI to the service user/family” and that the review process should be explained and that there is an acknowledgement and apology.

Dr. McDonnell admitted that there was “learning” for the Trust in how it carried out the review into the SAI and that she “absolutely takes on board” the feedback that has been received.

One of the 86 women affected found out in a letter ten months after her original smear test that her result should have been reported as having shown “borderline changes” and that further tests should have been carried out. She was not offered the chance to contribute to the review and this week spoke about her total frustration and anger at the process: “I would have loved to have had my say. I got the letter when I came home from work and there was a number to ring but no-one was available to take the call.

“So, I was so worried, I didn’t sleep at all and was panicking. I have a history and it made me think the worst. It was awful,” she said, before adding: “I was never asked to contribute to the review. I would have suggested that they have a 24-hour line set up for the first few days to explain what happened. And even when I did ring, I was given completely the wrong information. I was told that RQIA had detected the problems but when I contacted them, they knew nothing about it. I think every woman affected should have had the chance to say what they think, and I wonder about the completeness of the review when this did not happen.”