In 2000 a government ordered inquiry into cervical screening in the Gisborne/Tairawhiti region was initiated. After a long struggle to bring the issue to light, it was discovered that a local laboratory had failed to identify hundreds of abnormal smears. The inquiry examined the practices of pathologist Dr Michael Bottrill, who owned the laboratory and was responsible for reading the smears. His laboratory identified 0.53% of smear tests with high-grade abnormalities, compared to the national average of 1%. Once Dr Bottrill retired in 1996, the rate of high-grade abnormalities found jumped to 1.71%. In his evidence at the inquiry, Dr Bottrill accepted that he had misread smears.
The struggle to bring the issues with Dr Bottrill’s practice to light highlighted professional self-interest, a lack of quality assurance in the National Cervical Screening Programme, and a health system in disarray, unable to coherently respond to a significant public safety issue. Barely a decade following the Cartwright Inquiry, it was a re-run of the issues highlighted there – the failure of health professionals to deal with a problem, the closing of medical ranks, the inertia of health authorities, the vulnerability of health consumers, and the incredible effort needed to get the facts out and then get action taken.
On this page you will find information about the background, findings, and recommendations of the Gisborne Cervical Smear Inquiry.
Background
It was the persistent efforts of one woman that finally brought the issue in Gisborne to light.
1990 to 1994 the woman received four misreported smear tests. The first three smears should have been reported as revealing high-grade intraepithelial lesions, and the fourth as invasive cancer. Eventually, she was diagnosed with cervical cancer by a gynecologist and had a radical hysterectomy and extensive radiation therapy. By the time she had treatment, her prognosis was a 40% chance of the cancer recurring or metastasising, whereas had she been treated when the high-grade abnormalities were first detected, her chance of cure would have been virtually 100%.
1996 the woman took her case to ACC and was successful, with ACC concluding “that the misdiagnosis/ misreporting of cervical smears is considered to have been due to a failure by [Dr Bottrill] to observe a standard of care and skill that was reasonable in the circumstances and in this case was negligent.”
1997 the case was taken to the medical disciplinary system and Dr Bottrill was found guilty of conduct unbecoming. However, the fine for Dr Bottrill was only $400 and the case was not reported in the New Zealand Medical Journal. Furthermore, no action was taken by the Medical Council to ensure the Director of Health investigated the issue further.
1999 the woman sought exemplary damages in the High Court – an action for ordinary negligence being prohibited under New Zealand’s ACC scheme – and narrowly failed.
Investigation and inquiry
The Health Funding Authority began an investigation and arranged to have almost 23,000 cervical cytology slides re-read by a Sydney laboratory. Early results from that re-reading indicated that Dr Bottrill’s laboratory had underreported the rate of cervical abnormalities. This prompted the then Minister of Health to announce an inquiry into the under-reporting of cervical smear abnormalities. The inquiry was charged with finding the reasons for the high under-reporting of abnormal smears in the Gisborne/Tairawhiti region, and one of the main areas of focus was the level of quality assurance around laboratory cervical screening services.
Inquiry Findings
The Gisborne Inquiry delivered 46 recommendations to ensure the safety and quality of the National Cervical Screening Programme, and the government committed to implementing them. The committee concluded there was ‘ample evidence’ of Dr Bottrill’s under-reporting, with a wide discrepancy between the results of the Gisborne lab and the Australian labs used for the reread. At least 16 women had developed cancer because of the under-reporting.
Who was responsible?
The committee concluded that Dr Bottrill used deficient practices in his lab, was not accredited, and lacked quality control. However, they also noted that the National Cervical Screening Programme was responsible for not detecting his failure. Criticisms of the programme included a lack of clarity about accreditation processes for labs, a lack of performance standards, a ‘sub-optimal’ regionally-based register, the lack of reliable data, and the failure to conduct comprehensive audit, monitoring and evaluation, all of which contributed to Dr Bottrill’s poor practice not being picked up.
Recommendations
While Dr Bottrill was an ‘extreme case’, the report said that it could not conclude that he was an isolated case without a comprehensive evaluation of the programme. It emphasised that a planned audit and evaluation take place. The report also recommended that the National Cervical Screening Programme be managed within the Ministry of Health, and that the programme register be moved towards being a population-based register. Finally, GPs needed to be reminded that they must be alert to symptoms of cervical cancer and not place too much reliance on smear tests in the face of symptoms.
Useful links
The National Screening Unit provides information about the inquiry, the full text of the inquiry report and follow-up reports including the implementation of the inquiry recommendations.
A website established to provide information on the inquiry (archived website).