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 colonsoscopist which 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 over 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 lookback began.
A number of recommendations made by a Safety Incident Management Team are also being implemented.
The 24 page review was conducted by Professor Robert J C Steele, senior research professor prevention, early detection and treatment of colorectal cancer, at the University of Dundee.