The report was released in Gisborne today by Health Minister Annette King, who was to meet women affected by the under-reporting this afternoon.
It comes a year to the day after the three-member inquiry team, comprising lawyer Ailsa Duffy QC, Canadian pathologist Maire Duggan and Maori Women's Welfare League former president Druis Barrett, began hearing evidence from women who developed cancer as a result of having smears misread.
Key recommendations from the report include:
1. A complete national evaluation of the National Cervical Screening Programme;
2. A further review of the programme to be undertaken in six months and in a year;
3. The Cancer Register and NCSP to generate regular statistical reports, to include laboratory reporting rates;
4. All cytology laboratories to comply with minimum yearly numbers of tests;
5. The NCSP to have its own consumer complaints system;
6. Performance standards to be implemented for the NCSP;
7. Only appropriately trained practitioners to read smears.
The number of women who died or developed cancer as a result of the misreading has not been identified.
However, at least two women are known to have died - one, Kathleen Ward, gave evidence to the inquiry last year.
The report refers to 16 women who were known to have developed cancer as a result of Dr Bottrill's mistakes.
Dr Bottrill reported all the women's smear tests as normal. A Sydney laboratory which checked his work found all tests showed cervical cancer of high-grade abnormalities.
The report said Dr Bottrill had failed to ensure quality controls within his laboratory, inadequately continued his medical training and failed to realise his practices put patients at risk.
But the inquiry panel made it clear the Gisborne situation might not be an isolated case.
The report said that, because the panel found systemic failures in the National Cervical Screening Programme, "...it has reached the conclusion that the possibility that unacceptable under-reporting has occurred elsewhere in New Zealand cannot be excluded".
During the inquiry, five laboratories were identified as having lower rates of reporting cervical cancer than Dr Bottrill's Gisborne Laboratories.
The report is heavily critical of the National Cervical Screening Programme, set up after a 1988 inquiry into the cervical cancer experiments conducted at National Women's Hospital.
Gisborne's inquiry shows the NCSP was, from the outset, inadequately set up and poorly monitored, while its administration was fractured.
"The committee has concluded that the under-reporting which occurred in Gisborne is evidence of a systemic issue for the National Cervical Screening Programme.
"Dr Bottrill's practice at Gisborne Laboratories cannot be seen as an isolated case of under-reporting."
From 1993, the report said, it was clear the national cervical screening register was not functioning optimally.
There were no performance standards for laboratories and no monitoring or evaluation of laboratories. The health authorities had not heeded warnings provided by the failures of screening programmes in other countries.
The panel also found there was a failure to design and deliver a soundly-based system.
That poor design was blamed partly on the disruption caused by health reforms undertaken over the past decade.
Management for the programme was split between various health agencies "which resulted in confusion and consequent failure to discharge responsibilities".
The committee said it had been asked to consider compensation for the women, but the inquiry's terms of reference did not allow it to do so.
However Neil Kirton, a former MP who represented the Women's Health, Information and Research Trust at the inquiry, said women could seek redress if the Government was found to have failed to deliver on its promises.
"It was a national programme. At the end of the day, the Crown is responsible for the publicly provided national screening programme.
"If the Crown hasn't followed it through, then it could be argued that the Crown is liable."
- NZPA
Full report of the Inquiry
