Meeting of the Parliament (Hybrid) 24 June 2021
As I explained, with regard to the invasive cancer audits, new national methodology was introduced in 2014, and health boards were doing audits prior to that. In 2020, that new methodology of auditing invasive cervical cancer identified the problem. The Scottish Government has known about the incident only since March.
The adverse event management team, which the NHS established to deal with the issue, met for the first time on 9 March and set to work immediately to determine the scope of the incident and how best to support those who were affected. As I have said, that expert group brings together senior gynaecologists, pathologists, public health experts and senior system leaders in screening. It established that the immediate priority was to find out how many of those who were excluded from the cervical screening programme had had a subtotal hysterectomy.
Multidisciplinary teams were established in every NHS board in Scotland, and they looked in detail at the medical records of those who had been excluded from the cervical screening programme despite their records indicating that they had undergone a subtotal hysterectomy. That painstaking process involved cross-checking a range of electronic and older paper records, including operation notes, pathology reports, hospital discharge letters and GP records. That took several weeks to complete.
As well as establishing who had been affected, the group determined the correct care pathways and ensured that arrangements are in place so that everybody receives the same information and treatment, wherever they are in Scotland. As I mentioned before, that included making an IT update to flag the records of anyone affected, so that any further investigation of whether treatment is required as a result of the incident will be prioritised. That took several weeks to arrange.
It was absolutely vital that the NHS took the time to accurately understand each person’s circumstances and to make sure that arrangements were in place before we wrote to anyone to make them aware that they might have been excluded in error. To do otherwise, I believe, would have compounded people’s anxiety with long delays or uncertainty about how their cases would be managed.