'We did not consider it an adverse incident' – CervicalCheck manager on smear slide audit results

CervicalCheck programme manager John Gleeson told the High Court open disclosure requires an adverse event – but the upgrading of the results of a woman’s smear slides from negative was not considered an adverse incident.

Mr Gleeson was asked if the Vicky Phelan case never happened, when would Ruth Morrissey, who is suing the HSE over alleged misreading of herCervicalCheck tests, have found out about the audit reviews on her smear slides.

Mr Gleeson said: “If she had chosen to ask us.”

Mr Gleeson was giving evidence in Ms Morrissey’s case against the HSE and two US labs over the alleged misreading of her smear slides in 2009 and 2012.

Ms Morrissey (37) who has cervical cancer and at maximum has only two years to live, did not find out until May last year the results of audits on those cervical smear slides which showed they had been incorrectly reported as negative.

Mr Gleeson wrote the letter to Ms Morrissey’s consultant in 2016 in relation to the audit results on her previous smears of 2009 and 2012 and which revealed  the smear tests had been reported incorrectly as negative.

The CervicalCheck Programme manager was being questioned about governance in particular in relation to Ms Morrissey’s 2009 and and 2012 smear slides as part of her claim for exemplary damages as well as compensatory damages.

Ms Morrissey’s counsel Patrick Treacy told the court the Vicky Phelan case settled on April 25, 2018.

He asked Mr Gleeson was it fair to say we don’t know if Ms Morrissey ever would have found out about the smear slide audit results .

Mr Gleeson replied correct, it was not an adverse incident and open disclosure required an adverse incident.

Mr Justice Kevin Cross asked Mr Gleeson was he saying that it was not an adverse incident, Mr Gleeson replied “No we did not consider it an adverse incident.”

He added the HSE are reviewing its open disclosure policy and he was sure we will see changes.

It was the eight day of the action by Ms Morrissey and her husband Paul Morrissey of Kylemore, Schoolhouse Road, Monaleen, Co Limerick.

They have sued the HSE and the US laboratory Quest Diagnostics Ireland Ltd with offices at Sir John Rogerson’s Quay, Dublin along with Medlab Pathology Ltd with offices at Sandyford Business Park, Dublin 18.

It is claimed there was an alleged failure to correctly report and diagnose and there was an alleged misinterpretation of her smear samples taken in 2009 and 2012.

A situation allegedly developed where Ms Morrissey’s cancer spread unidentified, unmonitored and untreated until she was diagnosed with cervical cancer in June 2014.

The HSE the court has already heard admitted it owed a duty of care to Ms Morrissey but not to her husband. The laboratories deny all claims.

Mr Treacy asked Mr Gleeson about a letter Ruth Morrissey’s treating consultant wrote to him in May last year in which they asked questions about the reporting of the smear slides, when the audit results were made knownm and looking for feedback on the upgrading of the slides.

Mr Gleeson said he did not recall seeing the letter but it  was stamped as having been received on June 1 last year and passed on to the State Claims Agency legal team.

Earlier, Mr Justice Cross warned there are not enough judges to hear the cases of women suing over the alleged misreading of their CervicalCheck smear slides.

He said he may be faced with having to hear two actions in one day, one in the morning and switching to another in an afternoon as the cases mount up.

“I can’t see a way around it,” he said. He added if cases don’t settle, the court will have to do something.

The case continues.

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