In 2000, after a long struggle to bring the issue to light, a government ordered inquiry into cervical screening in the Gisborne/Tairawhiti region was initiated after 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 found 0.53 high-grade abnormalities compared with a 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.
It was the persistent efforts of one woman that finally brought the issue in Gisborne to light. Between 1990 and 1994 four of her smear tests were misreported. The first of three smears should have been reported as revealing high-grade intraepithelial lesions and the fourth as invasive cancer. Finally she was diagnosed with cervical cancer by a gynaecologist 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 change of cure would have been virtually 100%.In 1996, the woman took her case to ACC and was successful. In 1997, she was also successful in achieving a finding of conduct unbecoming through the medical disciplinary system, although the fine for Dr Bottrill was only $400 and the case was not reported in the New Zealand Medical Journal and no action was taken by the Medical Council to ensure the Director of Health investigated the issue further. Finally, in 1999 she sought exemplary damages in the High Court – an action for ordinary negligence being prohibited under New Zealand’s ACC scheme – and narrowly failed. The case was made public in the media and the woman sought suppression of her name and the judge said to be fair he would also suppress that of the doctor, although he had not sought this. He also suppressed the name of the town in which the doctor practiced on the grounds that this would identify him. The then Health Funding Authority (HFA) claimed that this hampered efforts to investigate the issue further but urged women to have regular smears.It was left up to Alliance MP Phillida Bunkle to reveal the town using Parliamentary privilege. Some weeks later the judge lifted the suppression order saying that it had not been brought to his attention that there might be a danger to other women. The HFA then 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 the Sydney laboratory was reporting many more abnormalities than Dr Bottrill’s laboratory had reported. In September 1999 the then Minister of Health announced the inquiry into the under-reporting of cervical smear abnormalities immediately after these early re-reading results were announced. The Inquiry was charged with finding the reasons for the apparently high under-reporting of abnormal smears in the Gisborne/Tairawhiti region, and whether there was evidence of wider systemic issues. One of the main areas of focus for the Inquiry was the level of quality assurance around laboratory cervical screening services, particularly in the early years of the National Cervical Screening Programme. The Inquiry was chaired by Alisa Duffy QC, with other members Druis Barrett, representing Maori and consumer interests, and Dr Marie Duggan, a pathologist from Canada. The committee heard from 58 witnesses including Women’s Health Action, and lasted for 18 months.
The Gisborne Inquiry delivered 46 recommendations to ensure the safety and quality of the National Cervical Screening Programme, and the government of the day committed to implementing them. The committee concluded that 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. The committee concluded that Dr Bottrill used deficient practices in his lab, was not accredited and lacked quality control, but 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. 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, and set a six month timeframe for this to occur and recommended that legislation be urgently passed to remove any impediments to this. The report also recommended that the National Cervical Screening Programme be managed within the Ministry of Health as a separate unit with a separate budget and a manager, specialised in public health, who had the power to contract directly with providers. The programme register should be moved towards being a population-based register. 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.
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 copy of information):