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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