The Southern District Health Board should not have refused to
release the report which sparked an urgent review of some
breast cancer diagnoses last year, ombudsman Ron Paterson
This week, the board released the anonymised internal audit
report by unidentified radiologist (Dr Y) some 17 months
after the original Official Information Act query.
Prof Paterson did not accept the board view that making the
internal report available would adversely affect public
confidence in the Ministry of Health.
The ministry's urgent review report, published in April last
year, cleared the southern screening service, Breast Screen
Health Care, of concerns its rate of ''false negatives'' was
Prof Paterson found there was a public interest in the
release of the internal report to promote understanding of
why external reviewers concluded the initial audit overstated
concern about false negatives.
''There is also a more general public interest in the quality
of screening services funded or provided by district health
boards, and in oversight by the Ministry of Health.''
There had already been significant evaluation and critical
comment released publicly about Dr Y's report, with credible
information identifying and discussing the audit's
shortcomings. It was difficult to see how disclosing the full
report would ''have any negative effect''.
Prof Paterson said while he agreed with the board clinical
audits should be carried out without fear of any
inappropriate or unlawful disclosure, the release of the
report without identifying any individuals would be neither
''unlawful nor inappropriate''.
There would be cases where full disclosure of an anonymised
clinical audit would be ill-advised and in those cases the
public interest balance would determine whether some
information should be released.
Dr Y, who was formerly employed by Southern screening service
Breast Screen Health Care, raised concerns about possible
systemic problems with the quality of reading screening
The purpose of her audit was to provide ''some kind of
numerical evidence that there are problems with the screening
In an overall comments section, she said her report ''does
not tell us specifically what the problems are, some of which
I had been trying to discuss or solve prior to discovering
the roadblock of not believing that there is a problem to be
Her ''audit'' of 136 cancer cases suggested cancers detected
in 47 women during the two years to June 2010 could have been
detected at their routine screenings two years earlier. A
subsequent rereading of the mammograms of these women by
another radiologist indicated 28 of these women might have
had delays in identification of cancers.
The ministry review found 28 women given a false clearance
within a total of 32,000 screened women was an
internationally acceptable false negative rate.
Prof Paterson said while the tenor and content of Dr Y's
report might make disconcerting reading, he considered the
author's general cynicism and her own reference to the audit
being ''an attempt at a step towards proving there was a
problem'' was more likely to undermine Dr Y's credibility
than that of the ministry.
''In the circumstances, I very much doubt that the report
could be held up to suggest that the ministry's decision not
to undertake further investigation'' to establish whether
there was systemic failure of screening mammograms at BSHC -
Overall, it remained difficult to see how the public could be
fully satisfied the decision not to undertake an
investigation was justified without disclosure of the report
in its entirety, he said.
If the board had not agreed to release the report, he would
have considered making a recommendation that the information
be released, he said.
The ministry report released in April 2012 included an
external peer review of Dr Y's report by chairman of
BreastScreen Aotearoa independent monitoring group chairman
Richard Taylor. He referred specifically to parts of Dr Y's
report, although her report was not included in the material
made public then.
In his detailed and technical appraisal of the audit report,
Prof Taylor was critical of the methodology used by Dr Y, the
presentation of data (including the lack of comparative data)
and conclusions drawn from it. He described some information
as difficult to follow. He said there was also a significant
issue of observer bias in her report and that of the second
radiologist as both were aware cancers had been diagnosed
when they looked at the earlier mammograms.
Dr Y suggested if the cancer detection rate for BSHC was
poor, then the interval cancer rate (those cancers found
between routine screening times) should be high, ''and this
is not the case''. (Prof Taylor said monitoring evidence did
not suggest the BSHC cancer detection rate was poor according
to the standards set.)
She asked if Otago and Southland women were ''non-breast
aware'' and not finding their lumps.
''. . . are GPs struggling to get patients into the
diagnostic clinics and therefore telling their patients not
to tell us about their palpable lumps?''
She questioned whether ''if the screening programme is not
doing its job picking up small, impalpable cancers before
they spread, it may be doing more harm than good in the
community. This is particularly true in a non-breast-aware
community that may be reassured by screening and not have
their lumps checked out.''
Referring to Dr Y's concern about the number of women in the
programme presenting with lumps palpable to surgeons, Dr
Taylor said palpation by the surgeon was presumably informed
by knowledge from the mammogram.
''Without knowledge of the distribution of sizes of breast
cancers and the sizes of breasts they were in, it is
difficult to determine what proportion should have been
palpable to women or clinicians.''
Her hypothesis about the breast awareness of Otago and
Southland women was something which would need to be tested
through a properly constructed study.