Meeting of the Parliament 15 September 2021 (Hybrid)
The audits, incidents and reviews that previously took place were all more limited in scope, with very different starting points from the current incident and a narrower focus of investigation. Because of that, those historical audits could not have picked up the wider issues that we have now identified. In particular, none of the previous reviews would have picked up the small number of cases that first brought the incident to light when they were discovered by one health board in December 2020.
Furthermore, and importantly, there was consensus among Scottish screening exercises that the errors that had been identified in the earlier audits had been corrected, and that the issues that had caused them had been resolved. We have been advised by clinicians who are involved in the screening programme that, given the available evidence at the time, the audits were considered to be an appropriate and proportionate response.
However, like Jackie Baillie, with the benefit of hindsight, I can say that it is important to ask whether opportunities were missed to look further and to identify wider issues earlier. I understand that and agree that questions can and should be asked about whether opportunities were missed, which is why we are dealing with the matter as we are.
I, too, want the questions to be answered, which is why I have commissioned Healthcare Improvement Scotland to undertake a thorough review of the processes, systems and governance of exclusions in the cervical screening programme. That will include understanding how the processes have developed over time, and learning lessons from past audits and the adverse events. That will help to establish whether the issues could have been uncovered sooner.