The Gisborne Inquiry

The Gisborne Cervical Screening Inquiry

One of the legacies of the Cartwright Inquiry and resultant report, was a promise to the women of Aotearoa New Zealand that precancerous cervical lesions would be identified through participation in the National Cervical Screening Programme (NCSP) that started in 1990, and treated in order to prevent many cases of invasive cervical cancer.

Incidence of and mortality from cervical cancer in Aotearoa New Zealand have declined dramatically since the implementation of the NCSP. However, like all large pieces of health machinery, the NCSP has its frailties, not the least of which are human errors and failures.

Ten years after the ‘promise’ delivered by the Cartwright Report and the NCSP, it was discovered that for the women of Tairawhiti/Gisborne the promise had been broken. Hundreds of women who had been told that their cervical smears were normal actually had cervical abnormalities. Between 1991 and 1996, Dr Michael Bottrill – pathologist and owner of the Gisborne Medical Laboratory and the person who ‘read’ the smears – misread/failed to detect abnormal cervical smears. His laboratory identified only 0.53% of smear tests as having high-grade abnormalities, compared to the national average of 1%.  After Dr Bottrill retired in 1996, the rate of high-grade abnormalities found in smears taken in Tairawhiti/Gisborne jumped to 1.71%.

In May 1999 the then Health Funding Authority (HFA) began an investigation into the reading of cervical smears by a community laboratory in the Tairawhiti region. This followed the raising of concerns about the work of Dr Bottrill – as a consequence of an interim decision of the High Court in March 1999 – who practiced in the area until his retirement on 4 March 1996. As part of its investigation, the then HFA 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.

The then Minister of Health announced an Inquiry into the under-reporting of cervical smear abnormalities immediately after these early re-reading results were announced. The Inquiry eventually determined that not only had the health of the women of Tairawhiti/Gisborne been put at significant risk as a result of the failings of one man, but that systemic failings in the NCSP had implications for the health of all New Zealand women. In the end the failures of the NCSP in Gisborne/ Tairawhiti exposed significant issues in the whole programme and this ultimately lead to substantial changes to the what in which the NCSP was monitored and evaluated including legislative changes.

“The majority of individuals appearing before this Inquiry have never experienced direct contact with women with cervical cancer, and in this group I include Public Health professionals, MOH/HFA personnel and those working in or associated with laboratories. Those of us who deal with real women with cancer, understandably have different perspectives and a more emotional approach to the gross failure of the government sponsored screening programme in Gisborne. There is a world of difference between sitting behind a computer screen tinkering with cancer data or sitting on an ethics committee with a cup of tea, to actually facing a woman with cancer. I have a sense of déjà vu as I sit here today. A number of us are for the second time in little over a decade involved in a major cervical cancer inquiry.”

— Dr Ron Jones in evidence to the Inquiry

‘Mrs A’

Gisborne woman, ‘Mrs A’ had four smear tests that were misread or misreported between 1990 and 1994. Her first three should have been reported as high-grade intraepithelial lesions, and the fourth as invasive cancer. Eventually, a gynaecologist diagnosed her with invasive cervical cancer and she had a hysterectomy and radiotherapy treatment.

In September 1995 ‘Mrs A’ successfully lodged a claim with ACC for medical misadventure then she filed a complaint with the Medical Council. Her complaint was upheld and Dr Bottrill was found guilty of conduct unbecoming a medical practitioner.

Subsequently, Mrs A filed a civil claim against Dr Botrill in the High Court arguing that the misreading of her cervical smear tests was negligent. On the 19th of March 1999 the High Court found that Dr Bottrill had acted negligently and that were it not for the ACC scheme, which prohibits awards of compensatory damages for personal injury, she would have been awarded substantial compensatory damages.

The case was widely reported and although Mrs A’s identity and where she lived were suppressed, other women whose cervical smear tests had been read by Dr Bottrill began to come forward.

The Health Funding Authority Investigation

In May 1999 the Health Funding Authority (HFA) began an investigation into the reading of cervical smears in Tairawhiti/Gisborne. The HFA sent almost 23,000 cervical cytology slides to a Sydney laboratory to be re-read. Early results from that re-reading indicated that the Sydney laboratory was reporting many more abnormalities than Dr Bottrill’s laboratory had reported.

The slides that were re-read belonged to 12,108 women who had had smears taken in the Tairawhiti region between 1991 and 1996. Of these women, 9,584 had all their smears originally reported and re-read as normal, but 1,997 women were advised of abnormalities, many of which were previously un-reported.

Of the women with abnormal re-read results, 616 were advised of ‘high grade’ results (cancer, high grade or ASCUS-H). For 519 of these women, none of the original results reported by Dr Bottrill’s laboratory had been high grade.

As a result of the HFA’s interim results of the re-reading of Dr Botrill’s smear slides, then Minister of Health, Wyatt Creech, announced an Inquiry into the under-reporting of cervical smear abnormalities in Tairawhiti/Gisborne.

The Gisborne Cervical Screening Inquiry

On the 15th of October 1999, the Wyatt Creech appointed Ailsa Patricia Duffy QC, Druiscilla Kapu Barrett and Gordon Wright as a committee of inquiry under section 47 of the Health and Disabilities Act 1993. In February 2000 Gordon Wright resigned and the Minister appointed Máire Angela Duggan in his place.

The purpose of the Inquiry was to determine the reasons for the apparently high level of under-reporting of abnormal smears in the Gisborne/Tairawhiti region, and to determine if there were other areas that may have similar levels of under-reporting. One of the main areas of focus for the Inquiry was to ensure that all of the necessary safeguards were in place for the National Cervical Screening Programme. The Inquiry had a national focus and was concerned with how the NCSP operated and delivered cervical screening services to women throughout Aotearoa New Zealand, and how other professional bodies related to and interacted with that Programme.

Witnesses at the Inquiry included: 20 women who were affected by the cervical smear misreadings; representatives of the Ministry of Health and Health Funding Authority; Professor David Skegg; Dr Euphemia McGoogan (expert on cervical cytopathology, UK); the Cancer Society; Women’s Health Information and Resource Trust; Royal College of Pathologists of Australasia; Medical Council of New Zealand; the Association of Community Laboratories; Telarc/IANZ; a representative from the reviewing laboratory in Sydney; Tairawhiti Healthcare Ltd; the Iwi Health Authorities; Medlab Gisborne/Hamilton; Women’s Health Action Trust.

Lawyers were appointed to represent the women affected by the mis-read smear tests, including Prue Kapua whose focus was be on the concerns specific to Māori women and their whānau.

AWHC made a written submission regarding the terms of reference of the Inquiry.

The Committee of Inquiry held public hearings at Gisborne between April 2000 and September 2000. The hearings were largely conducted in public. A website was set up to provides transcripts of each day’s proceedings. The website no longer exists but all the documents and evidence from the website were archived and can be found here.

High Rate of Cancer

Concerns were expressed at the area’s rate of cervical cancer. Gisborne gynaecologist Dr Diane Van de Mark was reported as saying that the rate was many time higher than it should be for a screened population. “I think there are lots of factors that go into this. I don’t know yet what all the factors are. Bottrill is one of them,” she said. At the time, Dr Van de Mark was compiling the cancer figures for the Inquiry.

Outcomes of the Inquiry

The Inquiry concluded that there was “ample evidence to show that there was an unacceptable level of under-reporting at Gisborne Laboratories between 1990 and March 1996. The extent of this under-reporting can be seen from the smear tests of 16 women from the Gisborne region who have developed cervical cancer. Gisborne Laboratories had read their smear tests as normal. When the same smear tests were re-read in Sydney by Douglass Hanly Moir Pathology, they were all reported as cervical cancer or high-grade abnormalities.”

The Inquiry also found that “the under-reporting which occurred in the Gisborne region 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.”

In further conclusions the Inquiry found:

  • Ultimately, it was the flaws in the National Cervical Screening Programme that permitted Dr Bottrill to practise as he did.
  • It is unfortunate that the recognition in 1989 of the importance of a screening programme’s management system did not flow through to ensure that it was well designed and well implemented.
  • The systemic problems occurred because there was a failure to appreciate that a cervical screening programme has certain essential features – quality control of laboratories reading cervical cytology, quantitative performance standards, a central computerised registration system linking cytology, histology and cancer morbidity and mortality data, easy access to relevant reliable statistical information, routine monitoring and evaluation – and that these must be in place from the outset for the National Cervical Screening Programme to be effective.

The Inquiry panel made 46 recommendations and at the time of it’s release then Health Minister, Annette King, said that 27 of the recommendations were already completed or were in the process of implementation.

“”Work will continue or begin on all the recommendations as a high priority, but before some of them can be put in place, legislative changes are needed. This refers particularly to effective auditing, monitoring and evaluation of the programme,” she said.

“The Government has agreed to introduce an Omnibus Bill this year. It will be split into two parts. The first part will be passed this year, and it is anticipated it will deal with amendments necessary to evaluate and audit the programme effectively, and it will also deal with the immediate amendments proposed by Helen Cull’s report on adverse events, including mandatory reporting of bad practice and temporary suspension of practitioners. The second half of the Bill will deal with less pressing issues.”

The Government accepted a recommendation by Director-General of Health, Dr Karen Poutasi, to invite international expert,  Dr Euphemia McGoogan, who gave evidence at the Inquiry, to review implementation of the recommendations in six months and again in a year.

Auckland Women’s Health Council Reporting on the Inquiry

In lieu of attending the Inquiry hearings in Gisborne, the AWHC made good use of the website that was been set up, and used it to read the evidence carefully and reflect on the transcripts of the cross examinations of the witnesses in a thoughtful and considered way. The Inquiry was regularly reported on in the AWHC Newsletters and the reporting and analysis here comes from those Newsletter updates, written by Lynda Williams.