Health – Recall for repeat cervical smear

Health and Disability Commissioner Anthony Hill today released a report finding the Ministry of Health National Screening Unit (NSU) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for a misalignment of the National Cervical Screening Programme (NCSP)’s system, meaning that a woman was not recalled for a repeat cervical smear test.

The woman, in her sixties, was enrolled in the NCSP. In October 2013 she had a cervical smear test and the results were normal. In those circumstances, the NSU guidelines recommended that she needed two repeat smears 12 months and 24 months after the negative result.

The woman had a repeat smear 12 months later and the result was negative. However, instead of scheduling the second repeat smear for the following year, as its guidelines recommended, the NCSP scheduled the woman for a smear three years later. NSU told HDC that there was a misalignment in the NCSP system, and it took into account the woman’s first smear test in 2013 as the first of the two repeat annual smear tests. Before the three years elapsed, the woman developed vaginal bleeding, and testing revealed that she had cervical cancer.

Mr Hill considered that the NSU had an organisational duty to ensure its services complied with its guidelines.

“I acknowledge that the system and pathways tracking processes are complex, and that an appropriate failsafe mechanism has been put in place. Nevertheless, NSU should have had a system in place to ensure that the IT register rules aligned with the Guidelines,” Mr Hill said.

Since the incident, NSU has implemented a new failsafe workaround mechanism to align the NCSP system with the guideline, and it has initiated a clinical audit for the previous five years.

Mr Hill recommended that NSU report back to HDC regarding the result of its audit and the progress of the changes it is implementing, and that it apologise to the woman.

The full report for case 18HDC01371 is available on the HDC website.