The CervicalCheck crisis has been a bruising period for patients, their families and also the vital screening service on which people rely.
The recent death of Vicky Phelan and the final Scally Report this week has refocused minds on outstanding reforms that need to be put in place.
There was a poignant moment, among many such moments recently, at the 221+ support group press conference on Wednesday, in the wake of the publication of the final Scally Report into CervicalCheck.
Someone very special was missing from the room, having been taken from those who loved her, just nine days earlier.
It was Lorraine Walsh who put the feelings into words. This was the first time that the 221+ group did not have Vicky Phelan to forensically parse and analyse the final report by Dr Gabriel Scally on the implementation of the 58 recommendations from his original inquiry.
'The best way of honouring Vicky is by implementing the recommendations of the scoping inquiry'— RTÉ News (@rtenews) November 23, 2022
Dr Gabriel Scally paid tribute to Vicky Phelan at the publication of a review into changes made in the wake of the CervicalCheck controversy | Read more: https://t.co/maOupIeE02 pic.twitter.com/DNQsVQ3Bei
While the report recorded very significant progress, one issue that stands out to be resolved is the need for statutory open disclosure by doctors and hospitals, or in the words of Dr Scally the need for a statutory duty of candour.
He was critical of the delay in introducing a legal framework for ensuring patients are told the truth about possible errors in their care.
In this regard, he was talking about the Patient Safety (Notifiable Patient Safety Incidents) Bill 2019, which is still before the Oireachtas, and for some, it has moved at a glacial pace.
The proposed legislation introduces a new requirement for mandatory open disclosure of specific serious patient safety incidents, referred to as notifiable patient safety incidents in the draft legislation.
It sets up a new process by which the Minister for Health will, through regulations, regularly update the list of serious patient safety incidents subject to mandatory open disclosure, in line with advancements in clinical practice and international developments.
The planned law will require health service providers (not doctors) to notify serious notifiable patient safety incidents to either the Health Information and Quality Authority, the Chief Inspector of Social Services, or the Mental Health Commission.
Examples of these kinds of incidents would include death due to surgery on the wrong part of the body, or the wrong procedure; maternal death; perinatal death (a stillbirth or death of a baby shortly after birth); death due to a surgical operation, medical procedure or anesthesia; death due to a medication error, blood transfusion or retention of a foreign object.
The list of reportable events is contained in Schedule 1 of the planned legislation.
The 221+ group has major problems with the Bill as it currently stands.
Lorraine Walsh says that for an adverse event to take place, in 12 out of 13 cases, the patient has to die before there is a disclosure of a serious adverse event.
So there is pressure now on the Government to amend the proposed new law.
Dr Scally also criticised the Medical Council, which is the policing body in Ireland for doctors' ethical behaviour.
He said that the council needs to amend its rules to say doctors "must" be open and honest with patients rather than using the word "should" which leaves some wriggle room.
In response to the issue, the Medical Council this week said that it supports the call for systems that support good communication, compassion and open disclosure and that this must be at the absolute core of the relationship between the patient and doctor.
It also added that there are extremely limited grounds for a doctor to refuse to treat a patient and that membership of a patient advocacy organisation was not one.
That was a reference to claims that some women were finding it difficult to access medical care if they were members of 221+.
Dr Scally was on the General Medical Council in the UK so he knows how this works. He is also one of the most trusted figures in the whole controversy.
The issues around CervicalCheck have been with us for almost five years. When the Covid-19 pandemic arrived, a lot of unfinished business may have been put on the back burner due to the impact of the pandemic.
Indeed, CervicalCheck had to pause screening for a time due to Covid-19.
In his report this week, Dr Scally said he found it "extraordinary" that in the Health Act 2004, there is a legal prohibition on anybody making a complaint to the HSE about the clinical judgement of a doctor, or other health professional providing care funded by the HSE.
He points out that the absence of a complaints system means an over-reliance on regulatory bodies like the Medical Council, or the judicial system as a means of solving problems that arise in clinical care.
Patients or their families who take these routes can encounter long delays, high costs and great uncertainty as to the outcome.
The other big issue for patients affected by this controversy is the fact that screening continues to be conducted in the US.
Dr Gabriel Scally says he is extraordinarily pleased in the progress that has been made in women's health. He was speaking at the publication of a review into changes made in the wake of the CervicalCheck controversy | Read more: https://t.co/maOupIwNea pic.twitter.com/KbYvTvUFQV— RTÉ News (@rtenews) November 23, 2022
There have been calls for screening to return to Ireland.
The good news is that a new National Cervical Screening Laboratory has been completed at the Coombe Women & Infants University Hospital in Dublin.
It is due to open before the end of the year but doubts have been expressed that that timeline can be met as it must be fully staffed and accredited first.
Dr Scally's report says that the US service being provided to Ireland is safe and accredited.
He also believes that it is important not to put "all the eggs in one basket" meaning that there needs to be a backup system in case any lab runs into problems.
The Coombe laboratory will be a relatively small facility and so there will continue to be a reliance on the US service, currently being provided at one laboratory in New Jersey.
The good news is that substantial change in the screening system has dramatically reduced the volume of cytology slides (smear samples) that require viewing by cytology screeners.
Now the initial screening test and for most women the only test they will need is a test for the HPV (Human Papilloma Virus) which is linked to cervical cancer.
This HPV test is automated and has a very low false negative rate.
That means the chance of a wrong result where the presence of HPV is missed is low.
Only where the HPV virus is detected does the sample go on to be examined for the presence of abnormal cells.
The other key point made this week by Dr Scally is that CervicalCheck must acknowledge past failings, so everyone can move on.
In 2019, Sharon Butler Hughes blew the whistle that over 4,000 women had either received the wrong letters or got no results at all from CervicalCheck in relation to their smear tests.
She was one of those caught up and in his 2019 Independent Rapid Review of Specific Issues in CervicalCheck Screening, Professor Brian MacCraith recommended there should be an examination by the HSE into this issue.
In the Dáil on Thursday, Aontú leader Peadar Tóibín asked Tánaiste Leo Varadkar what the delay was in the HSE fulfilling this recommendation.
Last week, after she had enquired about the issue, the Department of Health emailed Sharon Butler Hughes to say it understood that the HSE has undertaken a process to complete Recommendation six in the MacCraith report.
I asked the HSE about the issue yesterday and in a statement, they said that Recommendation six is complete.
They said the clinical risk is deemed low and the individual conversations between a small number of women and the lead clinician involved are ongoing and part of continuing care "and will be completed in the coming weeks".
CervicalCheck is also designing a new Patient Requested Review process and has been consulting with the 221+ group.
The HSE has said that in their new process for these reviews, all slides will be disclosed to women.
However, it is understood that the HSE has concerns that under the proposed new law, a request for a slide review in itself would be a notifiable patient safety incident, regardless of whether the latest slide examined did or did not differ from an earlier one.
The HSE has welcomed Dr Scally's report and his finding that women can have confidence in and should take full advantage of the screening programme.
It has saved many women's lives and will continue to do so.
There is a public memorial taking place for Vicky Phelan tomorrow in her native Mooncoin, Co Kilkenny.
She always called for action, not praise.