Pathologist's mistakes go under microscope

By FRAN MOLD and FIONA BARBER

From Monday, the track record of the man accused of botching cervical cancer tests comes under the nation's microscope.

Depending on the findings, so may the public health system that paid him to check the health of thousands of women.

The Gisborne cervical screening inquiry will examine the cancer scare hanging darkly over some of the area's residents.

The region is home to most of the almost 1500 women who have now been told that official rereading of their cervical slides has revealed discrepancies.

Their smear tests done by Gisborne pathologist Dr Michael Bottrill between 1991 and 1996 have been re-examined by a Sydney laboratory and found to show a range of cell abnormalities not originally picked up.

For some of the women, several slides are in question.

But the inquiry, moved from Auckland to Gisborne after passionate pleas from Gisborne women and a change of Government, must decide for itself whether Dr Bottrill's level of missing signs of cancer is "unacceptable."

Much will be at issue: there are the very basic questions of what constitutes a mistake (a false negative) and what level of such mistakes should be accepted because of human error.

And how do the Sydney figures compare with the overall New Zealand situation?

If the inquiry, expected to cost $900,000, finds that Dr Bottrill's under-reporting was unacceptable, it will have to decide whether Gisborne was an isolated case.

If it was not, was it a problem with the whole cervical screening programme? Was Gisborne a symptom of a system devoid of adequate safeguards and mandatory reviews?

A document expected to be submitted to the inquiry catalogues successive calls from health watchdogs for thorough evaluations of the programme. And that in turn raises the question of under-reporting elsewhere in the country.

Some closely observing the Gisborne situation point out that had it not been for one woman launching civil litigation against Dr Bottrill last year, scrutiny of his reporting might never have occurred.

And without that desperate action, it is unlikely that the inquiry would have been ordered, putting the nine-year-old $25 million national cervical screening programme under the microscope.

On the surface, the scenario appears simple - an ageing, sick and isolated pathologist who did little to keep himself safe, combined with a publicly funded system which did little to ensure that he did.

If the inquiry reaches that conclusion - or something similar - then a much more complicated search to discover underlying factors begins.

Beneath a veneer of simplicity lurks a dense mass of politics, bureaucracy and history.

It includes the 1988 Cartwright report into cervical cancer treatment at National Women's Hospital, which recommended a national screening programme. Cartwright's lessons of accountability, say some, have gone unheeded.

It is likely that the role of health professionals and their governing bodies will come under scrutiny. So too may political changes, including the splitting of the health system into agencies which either bought services or provided them.

Did fragmentation of the system have a bearing on the success or otherwise of the national programme and supervision?

Some who will assert that Dr Bottrill was guilty of widespread misreading - of excessive rates of false negatives - fear that he will end up carrying the can for flaws in the system.

Whatever the outcome, ACC has so far accepted 10 medical misadventure claims from women.

The hearings will be headed by a panel of three women with a variety of expertise. They will be responsible for compiling a report into the issues raised and making recommendations to the Health Minister.

The panel will be chaired by Ailsa Duffy, QC, who is extremely experienced with controversial, complex commissions of inquiry.

She was counsel assisting an inquiry into patient death at Carrington Hospital in 1991 and aided an investigation into a hepatitis C "bad blood" scandal a year previously. She was with the Crown Law Office for eight years.

Also on the panel is a prominent Maori health promoter and former president of the Maori Women's Welfare League, Druis Barrett, who will contribute a lay perspective.

The third member is Canadian pathologist Professor Maire Duggan, replacing Australian Dr Gordon Wright, who resigned in February. Professor Duggan heads the cytopathology division at the pathology and laboratory medicine department of the University of Calgary. Cytopathology is the study of the pathology of cells.

Professor Duggan is also involved with two cervical cancer prevention and guideline groups.

The panel will be assisted by a legal duo responsible for ensuring the inquiry is run properly. Royden Hindle and Hanne Janes will make sure all relevant documents and information are brought to the panel's attention. They will also have the right to raise questions or introduce evidence.

A bevy of lawyers will represent the affected women. Antonia Fisher, a partner at Auckland's Brookfields law firm, high-profile lawyer Stuart Grieve, QC, Wellington's Bruce Corkill and Gisborne-based Victoria Anderson will act on behalf of about 80 women who wanted to be represented.

Ms Fisher said women she had spoken to had decided to have varying levels of involvement with the inquiry. Some just wanted to be kept up-to-date with progress.

However, nine women are expected to give evidence and are likely to be heard in the first week.

Ms Fisher said the team had spent a great deal of time working with the women so they understood their concerns in depth.

"We are there to represent their interests. They want to know how this could have happened, and how it could have gone on for so long unchecked."

Last month Health Minister Annette King appointed another lawyer, Prue Kapua, of Auckland, who will concentrate on concerns relating specifically to Maori women, their whakapapa and the wide-ranging effects on whanau, hapu and iwi.

Ms Kapua said members of community organisations which women had chosen to be their "voice" would speak at the hearing, and several of the women affected would give evidence. She also hopes to cross-examine witnesses for the Health Ministry and Health Funding Authority.

She said she would deal with wider cultural issues, rather than focusing on the clinical debate which has been in the foreground so far.

Finally, the man at the centre of the inquiry, Dr Bottrill, will be represented by Christopher Hodson, QC, who has a great deal of experience with issues surrounding cervical cancer after involvement in the Cartwright inquiry.

Mr Hodson said Dr Bottrill would be represented throughout the entire hearing.

"He's stated that he will assist the inquiry, and his advisers are doing what they can to support the search to establish what actually happened.

"The first part of the inquiry will hear from the women and from the institutions, but it's not until the inquiry resumes in July that the clinical evidence will actually be available. It would be quite wrong to reach any conclusions about Dr Bottrill's standards of practice or the effects on the women until that evidence is in."

The spark which fired the investigation came five years ago when one woman went seeking answers.

She had been diagnosed with invasive cervical cancer early in 1995 despite earlier smear tests which had not picked up cell abnormalities. After a radical hysterectomy and heavy doses of radiotherapy, she began a fight for her life and a battle for answers.

She called into question four smears read by Dr Bottrill between late 1990 and late 1994.

Later in 1995 "Jane," who has name suppression from the High Court, applied to ACC for damages for medical misadventure.

Accident Compensation's investigating committee ruled that Dr Bottrill had shown a failure "to observe a standard of skill that was reasonable in the circumstances." It referred the matter to the Medical Practitioners Disciplinary Committee, as required by law.

In 1996 Jane filed High Court proceedings against Dr Bottrill for gross negligence, claiming exemplary damages. It was the same year that Dr Bottrill retired and sold his laboratory to what became Medlab Gisborne.

The next year the disciplinary committee found Dr Bottrill guilty of conduct unbecoming, fined him $400 and ordered him to pay $7910 in costs. They found that all four slides were under-reported, but the reading of two was seriously deficient.

Late in March last year, Jane's case came before the High Court in Auckland, and after a weeklong trial Justice Young found for Dr Bottrill.

He said that although he had no doubt the pathologist had been guilty of negligence and that some of his care had been sub-optimal, his actions narrowly did not fall into the category that warranted exemplary damages.

He thought that if Dr Bottrill had been seriously incompetent or under-trained it would have become apparent long before now.

Soon after the trial, one of Jane's lawyers, Stuart Grieve, QC, wrote to health officials pointing out that other women could be in jeopardy. In April, the Health Funding Authority announced it was investigating.

Soon after, it said it would look into the national cervical screening register for women whose slides were tested by Dr Bottrill.

Alliance MP Phillida Bunkle revealed in Parliament that the cancer scare centred on Gisborne and demanded to know what was being done for the women there.

Until that time, suppression imposed as a result of the court case meant that neither the name of the pathologist nor the place he had practised could be mentioned.

In May the Herald successfully filed a court application seeking to lift the pathologist's name suppression.

In lifting the order, Justice Young voiced fears that the cervical screening programme might never live up to public expectations - a concern subsequently challenged by health professionals and advocates.

In mid-May, the Health Funding Authority announced that it would have 30,000 slides (the figure was later revised to almost 22,000) originally read by Dr Bottrill rescreened. A deal was struck with a Sydney laboratory, Sonic Healthcare, to reread the Gisborne slides.

Jane renewed her battle for exemplary damages, and in August she lodged an application for retrial on the grounds of new evidence.

In September, the first of the results from the Sydney rereading were released, revealing 157 slides showing high-grade abnormalities or slides in which high-grade abnormalities could not be ruled out. Dr Bottrill's results showed he had picked up 28.

At the same time, then Health Minister Wyatt Creech announced he was setting up a ministerial inquiry and proposing a series of law changes to extend safeguards against incompetent doctors.

In January, his successor, Mrs King, announced that the inquiry would be shifted from Auckland to Gisborne and put back from February to April.

In February, Jane's application for a retrial was heard in the High Court at Auckland and Justice Young reserved his decision.

Early last month, almost 1500 women received confirmation that their cervical smear test results from Sydney did not match those reported by Dr Bottrill. A range of cell abnormalities from high to low-grade had been missed.

The final tally from Sydney was 581 slides with high-grade abnormalities, 276 in which high-grade could not be excluded and 1837 with low-grade. That compared with Dr Bottrill's results of 123 high-grade, 472 low-grade and 71 outside normal limits.

Health authorities announced in mid-March that all medical errors would have to be automatically reported under new guidelines being prepared.

At the end of last month, Justice Young granted Jane's application for a retrial.

ACC has confirmed it has 36 medical misadventure claims arising from the Gisborne situation: 23 are under consideration, 10 have already been accepted and three have been declined.