Still no known cause for cancer test woes: Eastern Health CEO

The current head of Eastern Health has testified she still does not know exactly what caused a St. John's lab to produce hundreds of erroneous breast cancer test results.

Louise Jones began testifying Monday at the Cameron inquiry, which is examining how hundreds of breast cancer patients received wrong results on hormone receptor tests, which are used to guide treatment.

"People would say that there were many contributing factors," said Jones, who was appointed Eastern Health's acting chief executive officer last July, after former CEO George Tilley resigned under pressure from the Newfoundland and Labrador government.

"But [the] actual issue, there was never any conclusion as to this particular issue on this particular day or whatever, and I don't know whether we can say that yet."

Meanwhile, Justice Margaret Cameron challenged Jones over the authority's insistence on keeping some information confidential, even amid a conflict over disclosing problems to patients.

Jones referred at several points to reports by two external reviewers on the pathology lab, which she said were meant to be confidential and not shared beyond a small number of people.

That prompted some strong words from Cameron.

"If this whole process has taught me anything, as I've been looking at the reports from around the world, it's how often the same problems keep occurring over and over and over and over again," Cameron told Jones.

"And you gotta say to yourself, 'Doesn't anybody talk to anybody?'"

Eastern Health had gone to Newfoundland Supreme Court in an attempt to keep those reports confidential, but a judge ordered them to be made public during the inquiry process.

Cameron referenced a two-day symposium that the inquiry sponsored last week, which in part focused on transparency and sharing information in order to promote patient safety.

Cameron questioned whether it was right for Eastern Health to have received expert opinions on the lab without sharing that information with the very patients whose test results changed.

"I can't answer that," Jones said.

Equipment problems ruled out in external reviews

Those reports ruled out equipment as being at fault for the lab problems. Jones said she read the reviews after she was appointed CEO and questions were raised about whether they should be released publicly once the inquiry started.

Jones also testified that Eastern Health knew last year that it did not have the ability to contact all patients affected by the breast cancer test mistakes, even though its public stance was exactly the opposite.

She said that up to May and June 2007 — the same period when the inquiry was ordered — Eastern Health was not sure all patients had been contacted.

"Either it had been a patient who had not been identified to be sent for retesting, or a patient that — and it wasn't generally a patient that hadn't been contacted for results followup — but it was patients who had not been sent forward," Jones said.

Nonetheless, Eastern Health stuck to its position that all patients had been notified.

Earlier in the inquiry, Health Minister Ross Wiseman testified that during the spring and summer of 2007, he made that point on numerous times, including in the legislature, because he assumed that Eastern Health was correct.

He said he felt regret when he later learned it was not true, and that his statements may have caused more anxiety for patients.

Jones told the inquiry that there were warnings at the time from their own board of directors.

"The board was very clear that our using of the word 'all' was very problematic because every time we used 'all,' there was somebody else who came forward," she said.

"But in the context of talking to the people who were responsible for that, they would definitely say they made the contact."

Jones said authority managers now know that that was not correct.

108 patients dead, database found

Last year, the provincial government established a task force to create a new patient database.

In March, Wiseman said that the database showed that 383 breast cancer patients had been given incorrect results from hormone receptor tests. Of those patients, 108 had died.

Jones also told the inquiry that one of the lab problems had to with what's called fixation, or the preparation of lab samples from tissues taken through biopsy.

A memo showed that some samples were left uncovered overnight and on weekends before being tested. Staff were urged to prepare specimens early in the morning from Monday to Friday, and not on Friday afternoons.

Jones told the inquiry that there was much discussion inside the authority about improving the quality of the tests, which she said involve numerous steps.