Gisborne Cervical Screening Inquiry Report Welcomed: Lessons Will Be Learned
Director-General of Health Dr Karen Poutasi welcomed the release today of the Gisborne Cervical Screening Inquiry
"This has been a very traumatic time for women in the Gisborne region and particularly those who have been directly
affected by the under-reporting of cervical smear readings by Dr Bottrill. The consequences of under-reporting have been
tragic for some women and their families. They have shown a great degree of courage during the Inquiry," Dr Poutasi
"I apologise for the distress caused by the events that led to the Inquiry. I acknowledge that women affected by the
misreading of cervical cancer screening slides feel that they have been let down by the health system.
"The Minister of Health has accepted the report's recommendations and in addition is actively looking at how to
implement them. Some of the recommendations have already been implemented and the Ministry is working to implement the
remaining recommendations, some of which require legislative change. The Minister has also accepted my recommendation to
appoint international expert, Dr Euphemia McGoogan to oversee their implementation."
Dr Poutasi said the Report provided a strong base on which to build. "It is clear that there is a need for continuous
improvement in quality assurance and monitoring systems. We have to learn from this and ensure that the actions we take
from here minimise the likelihood of this happening again. I have given a commitment to the Inquiry that the Ministry of
Health will ensure that the NCSP is appropriately administered and resourced.
"It is heartening that the Report has acknowledged that the National Cervical Screening Programme has made significant
progress in recent years. This is a credit to Clinical Director Dr Julia Peters and the National Screening Unit," Dr
Poutasi said. Work continues to strengthen the quality assurance processes and ensure national consistency within the
NCSP. In November the National Screening Unit distributed comprehensive operational policy and quality standards to all
6,000 providers to the National Programme.
"Expectations of smear-reading laboratories are now clearer and more detailed. Laboratories must meet specific
requirements in a range of areas including minimum staffing numbers, training of staff, minimum volumes for
laboratories, accreditation, internal and external quality control, lower and upper workload limits, cytology and
histology processing and reporting procedures. These standards are required of all laboratories who provide laboratory
and colposcopy services for the NCSP," Dr Poutasi said.
In addition an Independent Monitoring Group has been contracted to carry out routine monitoring of the Programme and
will provide their first quarterly report in May.
Dr Poutasi says work is underway on the two remaining aspects of the three-part evaluation of the programme highlighted
in the report. The second part will be completed within six months while the third part covering an audit of the
screening histories of women who have had cervical cancer will be completed 14 months later. "This timeframe compares
favourably with the best independent expert estimates incorporating the due care necessary to ensure an effective
approach," she said.
A consultation process is also planned on changes to legislation which would enable easier access to information for
essential audit and research on the National Cervical Screening Programme Register.
"We have statistics to show that cervical screening saves lives and NZ women have shown a long-standing commitment to
the programme. I want them to have confidence in the programme," Dr Poutasi said.
The Gisborne Inquiry followed interim results of the re-reading of Dr Bottrill's smear slides by the Health Funding
Authority, which showed significant under-reporting of abnormalities.
If you would like a copy of the report copies are available on the Inquiry web site www.csi.org.nz or from Bennetts