Part Two: Extraordinary Development: The Three Inquiries: How Far Does The Crisis Extend?

I recently suggested that the three separate public inquiries involving the work of pathologists which are currently under way in Canada reveal a crisis in Canadian pathology.

(See previous posting: "An extraordinary development in Canada: Three inquiries based on flawed pathology in one country at the same time; Crisis?" Tuesday, March 18);

The Gazette - a Montreal newspaper - goes even further;

The Gazette suggests that the crisis may extend to Canada's overall health care system in an editorial published on Monday March 24, under the heading "How good are our medical laboratories?"

"What a dreadful tale of incompetence and dismal medical practices is emerging from the Newfoundland inquiry on botched breast-cancer tests," the editorial begins;

"Perhaps most appalling is how long the debacle lasted -- from 1997 to 2005. Testimony from victims is now pouring out, and it makes for painful reading," it continues.

"It took Newfoundland and Labrador's health department far too long to advise the victims about the mistakes.

Beyond sadness and anger for the women involved, Canadians should all also be feeling alarm.

Are comparable laboratories elsewhere in the country more reliable?

In these days of long waits and an overburdened medical system, can we be sure there are not more such problems waiting to be discovered?

We think we can be confident in other labs, and we hope so.

But there is no acceptable threshold for system-wide ineptitude.

Over eight long years, hundreds of Newfoundland women were given wrong diagnoses from a lab in St. John's after breast-cancer screening tests.

That lab conducted the province's high-priority breast-cancer tests, the most urgent ones.

After problems were discovered with the lab's methodology, tissue samples were sent for retesting to Toronto's Mount Sinai Hospital, which unmasked the errors.

Since 2005, at least 108 of these women have died, although it's not known yet if their deaths can be surely linked to the botched tests.

What makes this so horrifying is that the tests largely determined what treatment the patients got.

One result would mean chemotherapy; another would steer the patient to hormone therapy. Many, given the wrong diagnoses, ended up taking the wrong treatment.

Beverly Green, 45, was told she was not a good candidate for Tamoxifen, so she did what anyone would have done under the circumstances; she underwent the ordeal of radiation chemotherapy.

Imagine being told after all that pain and emotional anguish that the diagnosis had been wrong and the pills would have been better treatment.

Also looming over the proceedings is the possibility of falsified evidence.

Several women insist that entries made in their medical files by doctors saying that they had been notified of wrong diagnoses or that they had refused a certain treatment, are wrong.

The conversations never happened, the women say.

That will demand its own investigation, which could lead to criminal charges.

Mistakes happen, but an eight-year mistake reveals serious flaws in the monitoring or accreditation process.

Confidence in the Canadian health system and related services has been shaken repeatedly in recent years by alarming errors - the blood supply crisis, the shocking record of Ontario coroner Charles Smith, this affair in Newfoundland, and more.

It would be soothing to believe that these have all been isolated incidents.

But it's hard to avoid the interpretation that they are all symptoms of a truly troubled public health system."

Harold Levy...hlevy15@gmail.com;