Thames Valley Cytology Society

Joint responsibilities for cervical cancer in the NHSCSP

Report by Marilyn Catlow, Northwick Park Hospital

There is a cycle of responsibility involving the woman, primary carer, and other agencies relating to who does / acts on what. There is a lot around the edges that can go wrong. The purpose of the Marie Curie Foundation is to raise awareness of practice nurses of their responsibility to inform women, to record their actions, and to complete documentation.

Why do case reviews?
Clinical governance involves using the findings of critical incidence analysis to monitor compliance with quality standards. Critical incident analysis is enabled in case reviews. It is also a valuable educational exercise for all involved. Another reason-even though this requires an entirely separate review process-is the medico-legal aspect. The results of critical incident analysis and education will contribute to medico-legal issues-but will not stand in that context.

Review and disclosure has implications for women, smear takers and lab staff. Four cases of invasive cervical cancer described by Dr Havelock were prepared for those working outside a laboratory environment, to investigate whether appropriate systems were in place, and what possibilities might be implemented for doing better. These days, causes are usually not 'missed' cases.

Audit gives context to responsibility, and helps define joint responsibilities.

• Case 1 featured a well woman on HRT with irregular bleeding. The woman understood her bleeding as related to HRT and never discussed it with her GP. The GP never asked and therefore a discussion about disease development and management of symptoms never occurred.
• Case 2 involved a patient who had refused treatment in spite of a history of four abnormal smears. The lab was able to demonstrate satisfactory failsafe action, but the GP couldn't demonstrate discussion about treatment.
• Case 3 had an smear showing carcinoma in 1999. Some of her previous smears had been abnormal but she had moved a number of times and a full screening history had never been available.
• Case 4 was characterised by a documentation mess. The patient attended GUM clinic using an alias, and assumed negative results. GP held no documentation and no records were kept.

Disclosure of 'failures' features both positive and negative effects on perceived risks associated with the smear test.

Negative effects of disclosure
- confirms the uselessness of the test to patients; encourages doubt in participants in the scheme; demoralises staff; leads to defensive reporting, which in turn leads to over-treatment.

Positive effects of disclosure
- encourages accurate information for women; enables a realistic understanding of what can be achieved; reveals performance standards that can be monitored; continuous projection of quality improvement.

When adverse events in cytology occur screeners often feel that they are singled out for
malevolent scrutiny and blame. Our grateful thanks to Dr Havelock for showing us in such an interesting way how we fit into the whole context of shared responsibility.