The Cameron Report is available to the public as of 2:00 p.m. today, which is the time at which I post this Blog.  The Commissioner pulls her conclusions together in the Chapter “Terms of Reference and Recommendations”, starting at page 451.  The highlights:

(a)        The primary causes of the testing failures were faulty lab procedures

(b)        The high rate of conversions was caused by a lack of quality assurance and the failure of pathologists to pay attention to internal controls.

(c)        Had occurrence reports been filed a review of testing would have been triggered in 2003.  Even Dr. Cook agreed that the problem should have been detected by an investigation of the Purcel case in 1999.

(d)       Any case of invasive lobular carcinoma (such as that of Mrs. Deane) should have been questioned by both pathologists and oncologists and triggered a re-test for these patients, which may have uncovered the larger global problem.

(e)        No one was keeping track of positivity rates or any other metrics, and if they had been it would have been obvious that an investigation for the source of the problems was indicated.

(f)        “The procedures and protocols within Eastern Health for ER/PR testing during the period from 1997 to 2005 were so deficient as to be practically non-existent.  They were neither reasonable nor appropriate.”  (p453)

(g)        Prior to the ER/PR issue becoming public, patients were not advised of the fact that a re-test was to take place.  They should have been so informed. 

(h)        The panel process itself caused undue delay.

(i)         There are blatant examples of a failure by Eastern Health to communicate with other regional heath authorities in an appropriate and timely manner.

(j)         “Eastern Health certainly failed in its duty to be forthright with Government, as on a number of occasions it withheld relevant information as to the extent and the cause of the problem from those charged with political responsibility for the quality of heath care in the province.” (p456)

(k)        “Eastern Health also failed in its communications with the media and the public at large.  The communications to the public minimized and obfuscated both the scope of the problem and the potential seriousness of its consequences for the patients affected.” (p457)

(l)         “The Minister of Health and Community Services had an obligation to act in an over-sight role… in 2007, as a result of the indiscriminate acceptance by the Minister of information provided to him by Eastern Health, he communicated to the public inaccurate information regarding patient contacts and the quality of laboratory services. The Minister’s duty of due diligence demanded more.” (p457)

The report can be accessed by clicking Volume I here Volume II here Volume III here