A failure of accountability and oversight "at all levels" led to hundreds of breast cancer patients in Newfoundland and Labrador being given inaccurate test results, a public inquiry has concluded.
"The whole of the health system, to varying degrees, can be said to have failed the ER/PR (estrogen receptor/progesterone receptor) patients," Justice Margaret Cameron wrote.
The 495-page inquiry report includes 60 recommendations to ensure what went wrong won't happen again, including:
- more training for clinicians
- mandatory continuing education for laboratory technologists
- improved record-keeping
Breast cancer survivor Marie Hickey, who was among hundreds of patients to receive a botched test, said the report has given her "great expectations" the same problems will not happen again.
"I have confidence now that this how come to light in such a big way," she told NTV News. "I think people will be more careful and will be more accountable."
Cameron has asked the provincial government to report by March 31, 2010, on how her recommendations have been implemented. The province's health minister Ross Wiseman promised to do just that at news conference later in the day, where he apologized again on behalf of the provincial government to those affected.
"The recommendations in the report provide clear direction on the next steps to making enhancements to the health care system provincially," said Wiseman. "And I have no doubt these recommendations will benefit other jurisdictions across the country that have experienced similar issues.
The seven-month-long inquiry looked into why almost 400 breast cancer patients received the wrong results on tests that were intended to determine the appropriate treatment for their breast cancer.
The inquiry heard testimony about inept work at the lab that processed the botched tests, and poor communication between health authorities and the government. Former employees testified that staff were improperly trained, handled the samples incorrectly, allowed poor quality control and had inadequate supervision.
But because the errors are thought to have begun in 1997 and weren't revealed publicly until 2005, there must have been "not only deficiencies within the laboratory but also the failure of Healthcare's management system," the report reads.
Even after the problems became public, the health board, Eastern Health, continued to fail to notify affected patients, the inquiry found. One patient told the inquiry on its last day of hearings that she had only learned she was affected by the scandal last summer - eight years after her tests.
The provincial government also shares some of the blame, the inquiry heard, since it allowed several warnings from Eastern Health about problems at the lab to go largely unheeded.
"It really was a disaster for the health authority here," Peter Dawe of the Canadian Cancer Society said Tuesday afternoon on 麻豆影视net.
"They withheld information from individuals, they withheld information from the general public, they actually withheld information from the minister of health at times."
Dr. Jagdish Butany of the Canadian Association of Pathologists, says the problems that occurred at the St. John's lab could have happened anywhere in Canada.
"The major problem was there were no standards for this particular type of test. Keep in mind that this is an extremely complicated test," he told 麻豆影视net, adding that his group began setting standards for tests two years ago to ensure they are done uniformly across the country.
Louise Sellars was one of those who received incorrect test results. She was diagnosed with breast cancer more than six years ago. After undergoing surgery, radiation and chemotherapy, she was told that her cancer was receptor-negative and that she didn't need to take further medication, such as tamoxifen.
But the lab in St. John's that had performed her hormone test had gotten her results wrong -- along with the results of at least 385 others. Sellars was in fact receptor-positive and had already missed out on three years of medication that might have kept her healthy.
"It's been horrendous," she told Canada AM of the years that have passed since. "Terrible, sleepless nights. It never leaves you. It's there 24/7."
She says she still worries that her cancer may come back, even six years later, because she didn't go on the medications that could have helped her particular form of cancer.
Myrtle Lewis, whose tests were also botched, told Newsnet she underwent a double mastectomy and six months of chemotherapy but learned later she only had pre-cancerous cells and that her treatments were unnecessary. She says she was sickened by what she heard from the inquiry.
"Hearing all this bickering back and forth, with one who don't know what the other one is doing and putting the blame on one another, I've got no faith in (the health care system) whatsoever," Lewis said.
Premier Danny Williams launched the inquiry in 2007, after documents filed with the provincial Supreme Court as part of a class-action lawsuit against Eastern Health revealed the full extent of the errors.
Williams has been critical of the way the inquiry has operated, accusing it of conducting an inquisition in the way it questioned government officials.
