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Independent Rapid Review of Specific Issues in the CervicalCheck Screening Programme

HSE Statement in response to the MacCraith Review

6 August 2019


On July 11th 2019 the CEO of the HSE - Paul Reid - commissioned Professor Brian MacCraith to conduct an independent and rapid review of delays in issuing cervical screening HPV retest results to a large cohort of women and their General Practitioners.

These delays related to one of Quest Diagnostics’ laboratories based at Chantilly in Virginia USA. Professor MacCraith was asked to examine the series of events within the CervicalCheck programme that occurred following the delays.  His terms of reference were as follows:

  1. To determine the complete chronology of events from the time the IT issues first emerged up to the public reporting of these issues on the 11th July 2019.
  2. To establish the agreed process for the communication of results to women and their GPs, how this was planned and managed and how this process worked in practice.
  3. To determine the adequacy of the response put in place once these issues emerged and to determine where and what the learning is for the management and communication processes within and from the Screening Programmes.
  4. To determine if the relevant procedures as set out in the HSE’s Incident Management Framework and Integrated Risk Management policy were followed and implemented.
  5. To examine the appropriateness of the escalation and if, how and when the communication of the incident within the HSE’s governance structures and between the HSE and the Department of Health, and the relevant CervicalCheck committee structures was managed.
  6. To provide a report to the HSE’s CEO setting out the facts relating to the incident and to make recommendations for any appropriate further actions and future learning.

Professor MacCraith presented his report to Paul Reid, CEO of the HSE, at 22:00 on Friday, August 2nd.

“The Health Service Executive acknowledges that ’Sharon’ referred to in the ‘Independent Rapid Review of Specific Issues in the CervicalCheck Screening Programme’ by Professor Brian MacCraith dated 2nd August 2019 has withdrawn her support for the review on the basis that there is a dispute in the accounts of a phone call which took place between herself and a Department of Health Official at 5.30pm on the 9th July 2019.”

HSE Response                                   

CEO of the HSE, Paul Reid said;

“Firstly, I want to thank those women, particularly Sharon, whose persistence ensured that this matter was brought into the public domain. Their determination will ensure that we have a better screening service in the future. 

While much work and many improvements have taken place in the CervicalCheck service over the past 15 months, it is unacceptable that women should have to wait so long for important information about their health.

I want to thank Professor MacCraith and his team for their diligence in completing this important work in a timely fashion. Brian’s recommendations will allow the cervical screening programme to address the failings that led to these issues quickly and definitively. 

The HSE accepts entirely the findings of the MacCraith Review. The HSE commits to a careful and expeditious implementation in full of each of his recommendations. The HSE wishes to reiterate its apology to all of the women impacted by the delays in issuing important information to them.

On foot of Professor McCraith’s report, I have set out a number of immediate actIons including;  Strengthening the management, leadership and organisation of CervicalCheck; developing a culture of putting women first; establishing a clinical evaluation and assessment of the women impacted; establish an audit of Quest’s IT processes and interfaces.”


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