The former head of Newfoundland and Labrador's largest health authority did not ask for extra lab assistance to review questionable breast cancer tests, an inquiry has been told.

Former Eastern Health CEO George Tilley: 'Clearly we ran into challenges with the execution.'
(CBC)

As well, George Tilley, who resigned under pressure last July as chief executive officer of Eastern Health, testified Thursday that initial plans for quick retesting in the summer of 2005 were followed instead by delays, overworking of staff and internal dissension about what the authority should do.

Tilley said one of his priorities was not to place blame, but to correct problems.

"It was a blameless environment," Tilley said during his third day of testimony at a judicial inquiry in St. John's that is examining what went wrong with hormone receptor tests used to guide the treatment of hundreds of breast cancer patients.

"The point is that it's very unfortunate that [various adverse effects] happen, but the idea of having a blameless culture is really to focus in on making things better, not to turn around and focus in on who did something wrong."

But as the magnitude of the problems of the lab tests became clear in 2005, Eastern Health staff found themselves overwhelmed.

There was obvious tension among staff at the pathology lab, information on many patients turned out to be harder to track than foreseen, and retesting took significantly longer than predicted.

"The original objectives [were to] shut down the system and then start making patient followup," Tilley testified.

"But clearly we ran into challenges with the execution. And they were unanticipated challenges, but they occurred."

Assumed organization could handle work

To accomplish the work, lab staff worked a tremendous amount of overtime, sifting through data on thousands of patients, while still keeping up with regular work.

Tilley, though, believed his organization could handle it.

"If we needed additional resources to help us move that, we weren't going to wait to knock on the Department of Health's door," Tilley said.

"We were a billion-dollar organization, we managed our resources efficiently, but this was a very important issue and if we needed more resources, we would simply have dedicated them to it."

Tilley said John Ottenheimer, the minister of health when the issue was brought to government attention in July 2005, offered extra resources. Tilley, though, said he did not think it was necessary. However, he also said that the authority did not add any full-time resources to assist with the extra work.

Deferred to oncologists on patient notification delay

Tilley said again that while he wanted to notify patients immediately about the testing errors, he deferred to the view of oncologists, who, he said, did not want to notify patients while the retesting process was still underway.

"It would have been unacceptable in retrospect not to have consulted the health professionals, who are the ones that are dealing with these patients," Tilley said.

Inquiry co-counsel Bern Coffey then asked, "In deferring to their view, and their view was pretty well contrary to a number of other views, in effect they decided it then for all concerned?"

"Yes," Tilley said, "I think that concern about the patient would be primary in everybody's interest."

But Tilley acknowledged that there was strong disagreement among different parts of the Eastern Health team. At an Aug. 1, 2005, meeting, various professionals — including oncologists, pathologists and others — argued about how to resolve the problem.

"I remember thinking that, here I am as a CEO of a new organization that's just trying to get its legs off the ground, and here's this major issue and I'm starting to feel some of the disagreement," said Tilley, referring to the fact that Eastern Health had only been formed months earlier from several different health boards.

"I remember at the end of it having to draw some conclusion to it … to say we got to forget about sort of who owns what piece or, you know, shifting some of the blame to someone or another," Tilley said.

"What was important here was to work for a resolution and that the patient had to be in the forefront of that resolution."

Among those attending that meeting was breast cancer pathologist Dr. Beverley Carter, who later wrote memos criticizing how the lab was operated, and who just this month tendered her resignation at Eastern Health. Carter has not yet testified at the inquiry, but an exhibit discussed Wednesday showed that Carter called in July 2005 for immediate patient notification and a broad-based review of hormone receptor tests dating back to 2005.

Tilley said that looking back, he would have done things differently. He said he would have hired someone to deal exclusively with what he acknowledged was the largest health crisis he had seen in his three-decade career.