The review looked at the management of a 'serious incident' of missed cancers at Wexford General Hospital
A review into how 13 cases of bowel cancer were missed following routine screening at Wexford General Hospital has found there were a number of missed opportunities in responding to the concerns of a staff member.
A report into the issue finds shortcomings in the performance of a colonoscopist were not identified in 2014.
Following a review, a new early warning system has now been implemented by the bowel screen programme.
The review was ordered after 615 patients had to be recalled. That led to more than 400 patients being called for a repeat colonoscopy.
13 cancers were detected as part of the process, including the case of one man who died before the review began.
A number of recommendations made by a Safety Incident Management Team (SIMT) are also being implemented.
The review found that there were missed opportunities to address concerns raised by a staff member, but adds that there were also mitigating factors - such as the good reputation and training of the colonoscopist in question.
Professor Robert JC Steele, who carried out the review, explained: “While recognising the significant effect of this incident for the patients and families affected, it is clear that the bowel screening team has learned a great deal to the benefit of the bowel screening programme in Ireland.
"I want to reassure the Irish public that all Quality Assurance processes were appropriate at the time of the review and that BowelScreen has committed to the introduction of further measures to enhance programme quality and patient safety."
Reporting by Sinead Spain and Stephen McNeice