Hundreds of thousands of women were unnecessarily worried when they were warned they could have missed their final breast cancer screening this year.
The scandal unveiled in May led 450,000 women to believe they had skipped a vital test, but the actual number was only 67,000, a report revealed today.
Former Health Secretary Jeremy Hunt had been wrongly informed, the independent report said, when he publicly blamed the issue on a ‘computer algorithm failure’.
Instead a ‘misunderstanding’ between official policy and the local NHS groups doing the real-world screening was the cause of the scare, which dated back to 2009.
It wasn’t clear whether women should stop receiving invites at the age of 71 or stop having routine mammograms when they were 70, the report said.
One expert who led the investigation said the level of confusion caused by whole fiasco has been ‘unacceptable’.
Former Health Secretary Jeremy Hunt was wrong when he blamed a ‘computer algorithm failure’ for causing women to miss out on breast cancer screening invites, an independent review has found
The NHS assured investigators there were a maximum of 67,000 women who could have missed screening appointments – 15 per cent of what was originally feared.
And it said they have all been contacted and invited for follow-up tests since the blunder was revealed seven months ago.
The screening scandal, unveiled in May this year, meant nearly half a million women aged between 68 and 71 were led to believe they were never invited to their final routine mammogram.
But the review, commissioned by Mr Hunt, found that his announcement was made following advice based on an incomplete understanding of what had happened.
The error was said to have potentially led to hundreds of lives being cut short when it emerged.
Then-Health Secretary Jeremy Hunt told the Commons a ‘computer algorithm failure’ dating to 2009 meant many women aged 68 to 71 were not invited to screenings.
But an independent review, published today, found there was no computer algorithm failure, and that the IT systems used – although described as ‘dated and unwieldy’ – had broadly operated as they were designed to.
Instead, it found the misunderstanding was because of a specification document written in 2013.
This said women should be invited for screening – which saves 1,300 lives a year – ‘within 36 months of their previous screening, until they reach the age of 71’.
However, this document was based on a misunderstanding of how the programme was being delivered in practice.
Local screening units continued instead to understand the upper age limit as 70, and to tell women this in their invitation letters.
This meant women screened after their 67th birthday may not have been invited again because clinics only tested women every three years up to the age of 70.
Baroness Delyth Morgan, chief Executive at Breast Cancer Now said: ‘After months of uncertainty, it is totally unacceptable – and extremely concerning – to learn that hundreds of thousands of women have been unnecessarily caused such significant distress.
HOW WAS THE BREAST SCREENING SCANDAL DISCOVERED?
The breast cancer screening scandal was only discovered thanks to an Oxford University trial into extra breast cancer screening for women.
The AgeX trial was set up in 2009 to find out whether cancers could be diagnosed with extra screenings ‘without undue harm’ in those aged 47 to 49 and 71 to 73.
Around 65 breast cancer units across the country then recruited women from these age groups with the computer programme supposed to select half at random to be given the extra screening.
But a computer glitch that was in the system from the start of the trial meant a large number of the older group had scans cancelled without ever knowing they were going to be arranged.
Once the Oxford researchers discovered the error, it soon emerged that the same mistake had affected women in the entire screening programme.
‘This has been nothing short of a system failure, precipitated by a lack of clear ownership and strong leadership of a world-leading programme.
‘It highlights a continued inability, amid structural confusion, to monitor what is happening in the screening service.
‘We are incredibly fortunate to have such a dedicated workforce, who at crisis capacity themselves have stepped up so impressively to support those affected – including in diagnosing some breast cancers earlier through catch-up screening.
‘But major lessons must now be learned, and it is clear that responsibility for the Screening Programme is too divided between different bodies.
‘We simply cannot let bureaucracy or a lack of leadership stall our progress on breast cancer, whether in adopting research advances or in ensuring a world-class early detection programme.’
The report said no one person, or body, was to blame for the confusion, but in the rush to announce and correct the issue, incorrect assumptions were made about how it had happened.
The report recommended clarifying the age when women should stop receiving invites and updating public information so women know what to expect.
It also said IT systems should be make easier to use and there should be a review of how all national cancer screening programmes are run.
These recommendations will inform the recently-announced review of national cancer screening programmes led by Sir Mike Richards.
The review team visited 10 breast screening units, where they said they found staff were skilled, experienced and worked hard to make sure women in their care received the best possible service.
The review was co-chaired by Lynda Thomas, chief executive of Macmillan Cancer Support.
Ms Thomas said: ‘We know that the announcement in May of a breast screening incident caused anxiety for thousands of women, sometimes unnecessarily, and it was of critical importance that their voices and concerns were heard as part of this independent review.
‘It is completely unacceptable that there was confusion about what the breast screening programme should have been delivering.
‘There needs to be clarity, and importantly women need clear information about what they should be able to expect.’
The review was commissioned by Mr Hunt in May.
Co-chairman Professor Martin Gore, of Royal Marsden NHS Foundation Trust, said: ‘The NHS breast screening programme is one of the best in the world, and the staff who deliver it work exceptionally hard to give women the best care.
‘However, the supporting systems and governance processes need to be updated.
‘It is essential that Public Health England as a matter of urgency works with the women they contacted and have been diagnosed with breast cancer, their families and their healthcare professionals, to find out whether they were harmed by any errors in the breast screening programme, and are given the support they need.’
‘I’M AMAZED IT TOOK THEM A DECADE TO SPOT THE PROBLEM’
Hundreds of thousands of women in England aged between 68 and 71 were never sent letters offering them a final routine breast screening because of an IT error lasting from 2009 until this year. The scandal was only unearthed in May.
Some 150,000 of these women died before the error was discovered and then-Health Secretary Jeremy Hunt admitted between 135 and 270 of them developed breast cancer that shortened their lives.
Brian Gough’s wife Trixie is among the women who never got a final scan and breast cancer would claim her life days after she turned 76.
Brian Gough’s wife Trixie, from Norfolk, died of breast cancer aged 76 in 2015, and Mr Gough this year realised she was one of the women who had missed out on the screening
Mr Gough ‘had no idea’ about the scandal until he saw Jeremy Hunt’s speech on TV in May and told MailOnline at the time: ‘I was completely gobsmacked and knew straight away Trix was one of the people never given a scan. I’m devastated.
‘I’m amazed that it has taken them the best part of a decade to spot the problem. It’s extraordinary.
‘There are thousands of real people involved in this, people like Trixie, who didn’t deserve to lose their lives.’