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Health and Community Services
March 3, 2009

Government Releases Cameron Inquiry Report

The Provincial Government today released the report of the Commission of Inquiry on Hormone Receptor Testing. The Honourable Ross Wiseman, Minister of Health and Community Services, said the report presents a range of recommendations which will serve to strengthen the health care system for the people of the province.

"On behalf of our government, I thank Madame Justice Cameron, commission co-counsel and the staff of the commission for their work during the course of the inquiry and with respect to the completion of this report," said Minister Wiseman. "I would also like to extend my thanks and appreciation to the patients and those who testified during the inquiry for their time, commitment and contributions. These individuals had an important part in shaping the report. Their words and personal stories have helped construct these recommendations and will help determine our actions as we continue to work to strengthen the provision of health care in Newfoundland and Labrador."

The Provincial Government received the report from the office of the Commission of Inquiry on Hormone Receptor Testing late Sunday, March 1, 2009. Immediately upon receipt, a team was moved into action to begin the initial review process of the 60 recommendations contained in the three volumes presented to government.

"The recommendations in the report provide clear direction on the next steps to making enhancements to the health care system provincially," said Minister Wiseman. "And I have no doubt these recommendations will benefit other jurisdictions across the country that have experienced similar issues. Our government has already taken significant steps to address issues related to the hormone receptor testing issue, including but not limited to funding for enhanced data management and planning for the establishment of an accreditation system for laboratories and diagnostic imaging services. We have also released a comprehensive report from our task force on adverse health impacts that will certainly benefit patients and the health care system in this province.  We will work to take immediate action on the recommendations contained in Justice Cameron’s report that can be implemented quickly and will take the appropriate time to conduct a due diligence analysis of the other recommendations as we move to further enhance our health care system."

For a full copy of the report, go to: www.gov.nl.ca/releases/2009/health/CameronInquiry.pdf

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Media contact:

Ronalda Walsh
Director of Communications
Department of Health and Community Services
709-729-1377, 685-1741
ronaldawalsh@gov.nl.ca

 

BACKGROUNDERS

Key Provincial Initiatives to Date

  • $5.7 million annual investment in 2008 for pathologists and oncologists in Newfoundland and Labrador to ensure that their compensation package rivals what is offered anywhere in the country and increases the province’s strength to compete nationally and internationally to attract staff.
     
  • $2.3 million in 2008 to enhance data management capabilities and quality assurance measures within the regional health authorities. This investment includes a plan for the establishment of an accreditation system for laboratories and diagnostic imaging services, and an annual investment for Eastern Health to implement education training and quality assurance activities in immunohistochemistry (IHC).
     
  • Expansion of the Dr. H. Bliss Murphy Cancer Clinic.
     
  • Government established a Task Force on Adverse Health Events. A final report was presented to government and recommendations from the task force are currently being reviewed. www.gov.nl.ca/ahe/
  • Investments in Cancer Prevention and Treatment

  • $10.9 million was invested for the purchase of 12 digital mammography units for communities across the province.
     
  • Capacity for radiation treatment in the province is now doubled with two new radiation treatment machines (linear accelerators) now in operation as a result of a $10.6 million investment by the Provincial Government.
     
  • $1.55 million for a new cancer centre in Grand Falls-Windsor and renovations to the cancer centre in Gander.
     
  • $1.5 million in 2006 to upgrade the screening technology and make the cervical screening program province-wide by implementing it in the Labrador- Grenfell Health region.
     
  • $17.2 million to purchase an array of new medical equipment to treat cancer and other diseases such as Magnetic Resonance Imaging (MRI) and Computerized Tomography (CT) scanners. 
     
  • Initial planning has started this year for the acquisition of a Positron Emission Tomography (PET) scanner for the province.
     
  • In February 2008, the Provincial Government donated $500,000 to Daffodil Place.
  • Eastern Health Initiatives

  • Developed corporate wide policies, guidelines and checklists for Adverse Event Management. Disclosure policies and procedures implemented including a staff education plan and post-disclosure patient letters. A crisis communication plan has been developed. Established a Board Liaison Committee with the Canadian Cancer Society. Adoption of the Provincial Fixation Policy.
     
  • Laboratory Medicine has been restructured, Laboratory/pathology Tumour Rounds initiated and a Breast Site Group established. Laboratory policies and standards reviewed (eg. Specimen fixation is standard across the region) and revised and EH has made a commitment to continuing education for staff including technologists/pathologists.
     
  • Information management systems have been improved in the laboratory area with the hiring of a Laboratory Information Systems’ coordinator to oversee the three laboratory meditech systems in the region. Cancer Registry development is ongoing. A death clearance mechanism is implemented which enables capture of all cancer deaths in the data base system. A Chief Information Officer for the region is being recruited. Created a new Vice-President position – Partnerships and Strategic Communications. In keeping with this, the Board of Trustees has identified the following three strategies as key directives in their Strategic Plan to 2011: partnerships and strategic communications, client safety and patient navigation. New resources have been added to the quality/risk management functions of EH (epidemiologist, researchers, decision support). A mandatory education program for all staff has been implemented with a focus on positive patient identification, staff role in patient safety and WHMIS.
  • Central Health Initiatives

  • Adoption of the Provincial Fixation Policy.
     
  • Continues to send specimens to Mount Sinai, Toronto. Regional pathologists have a mechanism for regular communication with other pathologists via the NL Association of Pathologists. A clinician satisfaction survey initiated. MAC reviews minutes of pathology department meetings. An audit of all unreported specimens completed every two weeks to ensure no specimens are missed.
     
  • A Quality Manager hired for each of the two laboratories in the region. IT staff for laboratory services hired for application support and searches, one cytotechnologist hired, a continuing education program with dedicated funding for training is implemented.
  • Western Health Initiatives

  • Preparing for Laboratory Accreditation. Adoption of the Provincial Fixation Policy.
     
  • Continues to send specimens to Mount Sinai, Toronto. Regular ongoing meetings with VP- Medicine, pathologists, directors and laboratory managers. Increased educational opportunities for all levels of laboratory staff
     
  • Laboratory staffing increased with the addition of two laboratory technicians, a Regional QA Manager, a cytotechnologist, administrative support, a clinical IT specialist and the recruitment of a 5th pathologist and approval for a 6th position. Recruitment is currently underway for a pathology assistant.
  • Labrador – Grenfell Health Initiatives

  • Developed a corporate wide policy, guidelines and checklist for Adverse Event Management. Policies on specimen handling developed and tissues are fixated according to recommendations of B. Hewlett at the Cameron Inquiry. Adoption of the Provincial Fixation Policy.
     
  • All ER/PR samples continue to be sent to Mount Sinai, Toronto. The pathologist routinely sends out random tissue samples for quality checks.
     
  • Laboratory Quality Assurance/Safety Manager, new technicians.
  • Commission of Inquiry on Hormone Receptor Testing

  • On May 22, 2007 the Provincial Government announced that it would undertake a Judicial Commission of Inquiry on estrogen and progesterone testing for breast cancer patients.
     
  • The Commission of Inquiry on Hormone Receptor Testing was established by the Government of Newfoundland and Labrador on July 3, 2007 under the Public Inquiries Act, 2006. The terms of reference for the commission were as follows:
  • 1. Inquire into why the estrogen and progesterone hormone receptor tests done between 1997 and 2005 in the Newfoundland and Labrador health system resulted in a high rate of conversions when re-tested;

    2. Inquire into why the problem with the estrogen and progesterone hormone receptor tests was not detected until 2005, whether it could have been detected at an earlier date, and whether testing protocols during that period between 1997 and 2005 were reasonable and appropriate;

    3. Inquire into whether, once detected, the responsible authorities responded and communicated in an appropriate and timely manner to those women and men who needed re-tests and those who were being tested for the first time;

    4. Inquire into whether, once detected, the responsible authorities communicated in an appropriate and timely manner with the general public and internally within the health system about the issues and circumstances surrounding the change in test results and the new testing procedures;

    5. Advise whether the estrogen and progesterone hormone receptor testing systems and processes and quality assurance systems currently in place are reflective of "best practice"; and

    6. Make the recommendations that the commission of inquiry considers necessary and advisable relating directly to the matters of public concern referred to in paragraphs (a) to (e).

     

    2009 03 03                                                      2:05 p.m.
     


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