A stark culture of misogyny and paternalism left 221 women in the dark on their smear test audits, Dr Gabriel Scally has found.

Dr Scally has uncovered a widespread disregard for patients which was “damaging, hurtful, and offensive”, with “no compelling requirement” on doctors to provide information to women.

The 170-page document reveals a “total systems failure” with no one person in charge of the cervical screening service.

Health Minister Simon Harris has given Dr Scally additional time to examine the revelation that a US lab outsourced smear sample testing to four other facilities without informing CervicalCheck.

Victims Vicky Phelan, Stephen Teap, and Lorraine Walsh, have called for the complete implementation of all 50 recommendations contained in the Scally review, which they said also raises more questions about how their own cases were handled.

Among the key recommendations in the report are:

The “urgent” revision of the HSE’s disclosure policy to reflect “primary right of patients to have full knowledge of their healthcare”;

A requirement that medical staff, as a condition of employment, complete training in open disclosure;

That the health minister gives consideration to how women’s issues can be given “more consistent, expert, and committed attention” within the health system;

The appointment of two patient advocates to the new board of the HSE;

A single agreed terminology for reporting of results, and specific criteria for defining the different grades of abnormality;

A statutory duty of candor on individual healthcare professionals and the groups where they work.

Nearly 13,000 documents were viewed, all of the key people in CervicalCheck interviewed, and all of the labs used both here and in the US were visited as part of the inquiry.

After publishing his report, Dr Scally called on the treating doctors who failed to disclose smear check audits to personally apologise to each woman as a letter from the HSE is nowhere near adequate.

He recounted the experience of the family of a deceased woman who were recently told of the smear test audit.

Dr Scally added: “This whole episode of poorly handled open disclosure created enormous psychological difficulties and, in some cases, mental illness amongst women.”

Mr Teap, whose wife Irene died last year, said: “Going through this inquiry, it is horrific for us to read, particularly for myself when I see exactly how the ending of Irene’s life now can be summed up in this.

“She did everything right. She got her smear test done. She put her 100% trust and faith in the system. She worked for the HSE for 15 years, everything, everything let her down.”

He vowed to ensure that the recommendations are now implemented so that no other family goes through a similar situation to the 221 impacted by this scandal.

Taoiseach Leo Varadkar said “all of the pain” endured by those impacted by the scandal should now lead to a new “culture in our health service of open disclosure, of grace, of candour, and compassion”.

Mr Harris said: “Extra harm, extra pain, extra suffering was added to women who already had cervical cancer and, in many cases, a devastating diagnosis” through the non-disclosures of smear test audits.

Cabinet approved all of the recommendations in the report yesterday — Mr Harris will return to Government in December with a full implementation plan.

Opposition parties insisted the families of women who have died or been damaged by the scandal should make the ultimate decision on whether a commission of investigation is still needed.

Fianna Fáil leader Micheal Martin said there is a clear need to “talk to the families and the victims”. Labour health spokesman Alan Kelly agreed that affected women need to advise on holding a full-scale commission of investigation.

The comments came as it emerged Mr Varadkar is considering setting up a “leak inquiry” to uncover which high-level official told media the Scally report had advised against a commission of investigation before victims were informed.

By Elaine Loughlin, Daniel McConnell, Fiachra Ó Cionnaith, and Noel Baker – Irish Examiner