Neary–'nobody shouted stop'
By Niall Hunter-Editor
"Dr Neary’s fall from grace is not a simple story of an evil man or bad doctor; nor is it a story of wholesale suppression of facts…it is not the story of a surgeon with poor surgical skills or a doctor deficient in academic excellence…it is the story of a doctor who, at critical points during his training, was inadequately supervised."
This is a 'pen picture' in the Judge Harding Clark report, of controversial Drogheda obstetrician Dr Michael Neary, who carried out 129 out of a total of 188 peripartum hysterectomies at our Lady of Lourdes Hospital in Drogheda between 1974 and 1998,when most obstetricians would carry out less than 10 in their whole career.
The report describes the number carried out at the hospital, mostly on younger women with a low number of children, as 'truly shocking'.
Women damaged by Dr Neary's clinical practice are seeking a compensation tribunal.
Tanaiste Mary Harney, who is to meet the Patient Focus support group tomorrow, says the issue of compensation through this means does not arise 'at this stage.'
The Tanaiste at the launch of the Harding Clark report
Dr Neary was struck off the medical register in 2003.
The Tanaiste has called the 354 page report of the Lourdes Hospital inquiry as '‘damning' and hoped that its findings would act as a catalyst for change in the way clinicians practise and how they are monitored and audited.
Tellingly, one of the main messages in the report is , as the Tanaiste put it, 'no-one shouted stop'.
The high rate of caesarean hysterectomies carried on for many years at the hospital and, in Judge Harding Clark's words, 'few complained or questioned'.
While the issue of 'paternalism' and lack of questioning of doctors' decisions has been made in the Lourdes report and indeed in the recent Madden report on organ retention, it should be remembered that Dr Neary practised at the hospital until 1998,well into the supposed new era of patients adapting a more consumerist and questioning perspective on the provision of healthcare, and of doctors' allegedly being more receptive to patient’s queries and concerns.
The Harding Clark report, however, says the maternity unit at Lourdes Hospital, which was owned by the religious order, the Medical Missionaries of Mary, until 1997, appeared to be living in a 'time warp' to some extent.
The report says there was almost an 'epidemic' of peripartum hysterectomy there as late as 1996.
The issue of the hospital's ethical code and its bearing on the practices of Dr Neary is a key theme in the report, with the religious order refuting claims made by the inquiry in relation to this.
The report says Dr Neary’s trainers speak very highly of him and have universally expressed amazement that he was struck off.
It says this is the story of a doctor who came to work in a unit which lacked leadership, peer review, audit or critical capacity.
"It is the story of a doctor with a deep fault line, which was recognised early but never corrected. It is the story of a committed doctor with a misplaced sense of confidence in his own ability. It is a story of deep misunderstanding and misapplication of clinical independence."
The report reveals that Dr Neary had a 'morbid sensitivity' to the patient bleeding when carrying out surgery. It says Dr Neary perceived hysterectomy as something to prevent bleeding and lost sight of the norms operated in every other hospital in Ireland.
The report reveals how much havoc the doctor's 'fault line' and the inadequate controls on his clinical practice caused for patients.
But throughout the report, the key question running through it was why nobody shouted stop for such a long time.
The report also shows that another doctor at the maternity unit also carried out a significant number of hysterectomies, although his numbers were not in the same league as that of Dr Neary.
The Tanaiste said at the launch of the report that the practice of this consultant had been looked into and no wrongdoing was found.
The report says no person or institution raised any issues relating to Dr Neary's practice until October 1998 when two experienced midwives, who were consulting the then new owners of the hospital, the North Eastern Health Board, on an unrelated matter sought his advice on serious concerns which one of the midwives had raised about Dr Neary’s practices.
The report lists those who did not complain or question Dr Neary's clinical practice over the years as including the other obstetricians in the unit; the junior doctors; the anaesthetists; surgical nurses; pathologists, the Medical Missionaries of Mary, or the GPs of the caesarean hysterectomy patients.
The patients who had been operated on by Dr Neary too, did not complain until after the doctor’s suspension in 1998. However, individual patients at the time would not have been aware of the frequency of the usually rare peripartum hysterectomy operation among other patients attending the unit.
Subsequently, many women discovered to their horror that their wombs had probably been removed unnecessarily.
The Royal College of Obstetricians and Gynaecologists (RCOG) inspected the Lourdes unit in 1987 and 1992 and found it suitable for training obstetric registrars. In 1992 it made recommendations to the maternity unit, but no subsequent efforts were made to determine whether the recommended changes to the unit were made.
The ethical issue in relation to sterilisation is one of the themes in the inquiry.
The Harding Clark report says there is a very strong suspicion that a number of the hysterectomy procedures were carried out because of the ethos of the hospital.
"These hysterectomies, which were medically indicated sterilisations, masked unwarranted resort to hysterectomy."
The report indicates some caesarean hysterectomies, described as 'indirect sterilisations' were carried out for the purposes of female sterilisation to get around the ethos of Lourdes Hospital, which forbade contraception or direct sterilisation through tubal ligation.
Tubal ligation, the tying up of the woman's fallopian tubes, was not permitted at the hospital at the time.
The former owners of the hospital, however, the Medical Missionaries of Mary , in the report, strongly deny that the prohibition on direct sterilisation for contraceptive purposes played any part in the number of peripartum hysterectomies and say they were not aware that peripartum hysterectomies were performed as a form of sterilisation.
The report reveals considerable tensions between Dr Neary and the hospital's former owners over the years.
The report says the Royal College of Surgeons medical school approved the Lourdes unit for undergraduate training and the nursing regulatory body, an Bord Altranais, carried out periodic assessments of the unit. It advised that women should be offered a full choice of contraception and that midwives be fully trained in these methods but nothing happened.
The Tanaiste at the launch of the report, said that the culture at the Lourdes maternity unit was one of not questioning consultants, and this was not unique to Lourdes Hospital.
She said the hysterectomy scandal was probably a 'once-off' in terms of obstetrics and gynaecology but she could not definitively say that this might be the case with other specialties.
The Harding Price report puts it succinctly: "any isolated institution which fails to have in place a process of outcome review by peers and benchmark comparators can produce similar scandals as those which occurred at Lourdes Hospital."
While there is now a reportedly a different culture in the Lourdes maternity unit in terms of risk management and audit, the report notes that not everything has improved.
For example, it says there is a lukewarm application of risk management among some consultants and not all consultants share the burden of teaching and conducting audit at the unit.
For the hospital service in general, the report will put into focus the need for compulsory audit and monitoring of doctors' performance.
The Medical Council is currently planning for such schemes to be operated on a voluntary basis; it cannot make them compulsory under current legislation, but many doctors are happy to take part in competence assurance structures voluntarily.
The new Medical Practitioners Act, the heads of bill of which are to be produced shortly, will, however, make audit and monitoring of clinical performance and results compulsory.
The Harding Clark report also points to the need for legal protection for 'whistleblowers' , so that staff can raise concerns about clinical practice without threat of victimisation.
These will be important developments, but will come too late for many damaged women.
Discussions on this topic are now closed.