genital tract, and whether steps should be taken to improve this training or to inform previous trainees; To inquire into the relationship between the academic and clinical units at the Hospital Any other matter which is relevant. Procedure of the Inquiry The first preliminary hearing was held on 18 June 1987. Three medical advisers were appointed to assist and advise Judge Cartwright, Professor E V MacKay, Professor of Obstetrics and Gynaecology at the University of Queensland, Dr Charlotte Paul, Epidemiologist, University of Otago Medical School and Dr Linda Holloway, Pathologist, University of Otago Wellington School of Medicine. Counsel assisting the Inquiry were Lowell Goddard QC and Philippa Cunningham. Public hearings commenced on 3 August 1987 and ran for seven months. Evidence was heard from 59 witnesses, including from medical experts brought from around New Zealand, as well as from Australia, United States, Japan, UK, and Norway. Twelve patients or former patients, including ‘Ruth’, and two relatives of patients gave evidence in the absence of the public and the media. Judge Cartwright heard evidence privately from a further 70 patients. The medical advisers carried out a review and analysis of patient files. Overall 1200 patient files were reviewed. Report Findings in respect of Green’s study In respect of Term of Reference One (TR1), the Report defined ‘adequate treatment’ of CIS since the 1950s as being that based on generally accepted treatment [at NWH this was cone biopsy] together with evidence of eradication of the disease, and concluded that, by that standard, there had been a failure to adequately treat a number of women with CIS at NWH, For a minority of women, their management resulted in persisting disease, the development of invasive cancer, and in some cases, death. The reasons for the failure were the implementation of the ‘1966 trial’, failure to recognise the dangers for patients, failure to evaluate the risks to patients if Green’s hypothesis was wrong, failure to note the rising incidence of invasive cancer, to stop the trial and treat the patients as soon as cogent evidence of risk began to emerge, and failure on behalf of some colleagues and the NWH administration to impinge on Green’s clinical freedom and act decisively to stop the trial in the interests of patient safety. In respect of TR2, the Report found that the 1966 trial was a research study into the natural history of CIS. The 1966 trial was