In 2005, nearly three years ago, health officials suspended ER/PR tests at Eastern Health's pathology lab after a patient who initially tested "negative" was retested and found to be positive. All negative test results between May 1997 and August 2005 were re-tested at Mount Sinai Hospital in Toronto.
In December 2006, Eastern Health acknowledged that about 1,000 people were re-tested. They said 117 patients would have a change in treatment as a result. They did not release information on how many people who had been given the wrong treatment had died or how many people were no longer eligible for Tamoxifen because the cancer had spread. They also told the public that affected patients had been contacted. Much of the blame was placed on technical issues with equipment and imprecise science.
Since that time we have learned that not all patients have been contacted, that the number of people involved continues to grow, and that there was nothing wrong with the equipment. External audits of the facility, which Eastern fought being released, showed glaring problems at the lab which was working below standards. The reports spoke to staff incompetence, poor quality control, deficient procedures and a general negligence in keeping up with changes in science. The lab had no pathology reference books or even an internet connection!
Twice now information has been released that inflates the number of people impacted. The numbers of people affected who have died continues to grow and amazingly, 44 people have still not been contacted.
So in fact the government has been dealing with this fiasco since 2005 and they still do not have a handle on how big this mess really is. Yesterday the Minister said he found the information that he released to be "extremely troubling .... There's mothers, there's daughters, and they've all been impacted in a very profound way. Our thoughts are very much with them."
Somehow, three years after this began, despite the public uproar and on the eve of the start of the royal commission, we find out that 44 people have never been told that their tests had to be redone! That the number of people who have died is much higher than previously reported - almost a third of the patients who were tested between 1997 and 2005 have already died! And just to provide an extra measure of confidence, the number of patients whose hormone receptor tests were redone is 1,013, not 939 as reported last year.
The minister is troubled...he should be. He should be outraged! His boss should be outraged at the fact that health officials still do not seem to have a handle on the numbers, let alone that 44 people were left out of the loop. This is far from satisfactory.
I guess part of Justice Cameron's job is already answered: "whether, once detected, the responsible authorities communicated in an appropriate and timely manner with the general public." The answer to that is cover-ups, untruths and more incompetence. I am looking forward to learning who is responsible.
Yes the government is going to throw an extra $2.5 million at the lab to improve quality assurance and address short comings, but who is accountable for the communications mess since 2005? Why is the incompetence allowed to continue?