The problems uncovered in CervicalCheck suggest ‘a whole-system failure', and the way in which some women were told that they had cervical cancer was inappropriate, and in some cases, damaging and offensive, Dr Gabriel Scally has said.

The final report of his scoping inquiry into the CervicalCheck scandal has just been published. It was brought before the Cabinet this morning and the Government has accepted all 50 recommendations contained within it.

"This major crisis emerged into the public domain because of a failed attempt to disclose the results of a retrospective audit to a large group of women who had, unfortunately, developed cervical cancer...But there are many indications that this was a system that was doomed to fail at some point...The problems uncovered are redolent of a whole-system failure," Dr Scally said.

He pointed out that there were ‘serious gaps' in the governance structures of the service. Specifically, there was a ‘demonstrable deficit of clear governance and reporting lines' between CervicalCheck, the National Screening Service and higher management structures of the HSE.

"This confusion complicated the reporting of issues and multiplied the risks. It is clear that there are also serious gaps in the range of expertise of professional and managerial staff directly engaged in the operation of CervicalCheck. There are, in addition, substantial weaknesses, indeed absences, of proper professional advisory structures. These deficiencies played no little role in the serious issues that concern this Scoping Inquiry," Dr Scally noted.

He was highly critical of the way in which women were informed about their cancer diagnoses and he said the current policy and practice in relation to open disclosure ‘is deeply contradictor and unsatisfactory'.

"In essence, there is no compelling requirement on clinicians to disclose. It is left up to their personal and professional judgement. I know, very well, from very many of the women themselves and the families, that the issue of non-disclosure is felt very intensely.

"They have expressed very clearly their anger at not being told at the time when the information from the audit became available, and they are equally as angry about how they were eventually told. In my view, the manner in which they were eventually told of their situation in many cases varied from unsatisfactory and inappropriate, to damaging, hurtful and offensive," he said.

However, Dr Scally said that he was satisfied with the quality management processes in the current laboratory sites in the US. All are meeting the regulatory requirements required of them and all are recording performances which are deemed acceptable in their country. He said the inquiry ‘found no reason why the existing contracts for laboratory services should not continue'.

He also said that having considered the matter carefully, he had reached the view that a Commission of Investigation ‘would not be the best way to proceed'.

The Minister for Health, Simon Harris, had promised such a commission when the scandal broke earlier this year.

"In my personal view, there are two tasks that should now be given priority. One is ensuring that the group of women affected, and the relatives of the deceased, are given the maximum amount of support in dealing with the difficulties that they now face arising from these complex and distressing events. The second key task is in implementing the recommendations of this Scoping Inquiry," Dr Scally stated.

He said that there is a danger that a prolonged investigation ‘would consume valuable energy and resources that would be better devoted to the implementation of recommendations and achieving progress'.

The controversy came to light earlier this year when Vicky Phelan (43), a mother of two from Limerick, settled her High Court action against a US laboratory for €2.5 million. The settlement was made without an admission of liability.

It emerged that she had undergone a smear test in 2011 and was told that no abnormalities were found. However this was incorrect and by the time she had another smear test in 2014, she had cervical cancer.

A subsequent audit revealed that over 200 women diagnosed with cervical cancer should have received earlier intervention than they did. Eighteen of these women have already died from the disease.

Dr Scally's report can be viewed here

*Pictured is Dr Gabriel Scally