Readers ought to be aware that the editor may have a new bee buzzing about his bonnet. To add to his usual mix of fretting over Digital Rights and access to the Four Courts he has decided to take a closer look at the Lourdes Hospital Inquiry Report.
I have attempted to find a copy of this report online. I have failed. Anyone who can point it out to me wins some kind of prize. Probably a Caffrey’s Macaroon Bar. Yesterday I trudged up to Molesworth St. to the Government Publications Office and bought a copy for myself.
I admit to having been enraged by listening to the parade of institutional worthies on RTE’s Five Seven Live on the day the report was published. You may enrage yourself as well, by listening to the archived reports here.
I wasn’t sure that the reaction wasn’t falling into the pattern of blaming one bad apple for a problem, instead of acknowledging and then addressing the institutional failures which allowed the rotten apple to continue working long after it began to stink. But the only way I can see if that has actually happened is to read the whole report for myself. This will likely take me all Summer, given other priorities. However, I hope that I can share with you some portions of the report along the way which may not fit the picture you may have received from other sources.
We’ll start with the most frequently quoted portion of the entire report. This is Para 3.19 on Page 34.
The story of Dr. Neary’s fall from grace is one of enormous tragedy for the hospital at which he worked for 25 years, for the staff who worked with him and supported him and especially for the women who entered the maternity hospital to face the joy of a new baby and who returned home to recuperate from a hysterectomy. It has also had a profound affect on Dr. Neary’s life and on his family. This is not a simple story of an evil man or a bad doctor, nor is it a story of wholesale suppression of facts. the facts were there for all to see. There was no attempt to hide the procedures or pretend they were something else. The operations were carried out in the presence of consultant anaesthetists, assisted at by trainee obstetricians who had all the textbooks available to them and frequently observed by spouses and partners. The operations were openly recorded.
Para 3.20 continues
Neither is it the story of a surgeon with poor surgical skills or a doctor deficient in academic excellence. Dr. Neary completed his professional qualification examinations on the first attempt and did well. His trainers speak very highly of him and have universally expressed amazement that he was struck off the register. It is the story of a doctor who, at critical points during his training, was inadequately supervised. He 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 a 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.
I’ll be posting extracts from the Inquiry Report. I may comment on some or conterpoint them with quotes from elsewhere.
However I’ll close this post with some quotes I haven’t seen reported anywhere else.
This is paragraph 3.14 from pages 32 and 33 of the report.
Few complained or questioned (Footnote 2)
-not the patients, their partners nor their families;
-not the obstetricians who worked in the Maternity Unit and who knew of the operations carried out;
-not the junior doctors not the post membership registrars;
-not the anaesthetists, who received the patient, administered the anaesthesia, wrote up the operation notes and spoke to each patient in the recovery room and were always present at the operations (Footnote 3);
-not the surgical nurses who were frequently midwives, and always women, who handed the hysterectomy clamps to the surgeons and counted the swabs (Footnote 4);
-not the midwives who cared for the women after their operations and who recorded each day the women stayed in the post natal ward that the fact that they had had a peripartum hysterectomy;
-not the pathologists and technicians who received the wombs and specimens from the maternity theatre, who dissected, examined and reported (Footnote 5);
-not the Matrons who made ward rounds and who contacted the public health nurses (Footnote 6);
-not the sisters of the Medical Missionaries of Mary who owned the hospital and employed the obstetricians (Footnote 7)
-not one of the various FPs whose patients attended the IMTH and underwent caesarean hysterectomy;
-not any of the parties who read the maternity hospital’s biennial reports in the years when it was published.
No one made a formal complaint and no one questioned openly.
Footnote 2: A patient complained about Dr. Neary through her Solicitor in 1980. She did not proceed as she had been assured in legal correspondence that an obstetric hysterectomy was extremely rare and only carried out in the presence of an intractable haemorrhage. Another patient engaged a Solicitor 1998 complaining of her treatment, including peripartum hysterectomy, carried out in January of the same year.
Footnote 3: A junior anaesthetist who had completed 6 months training at the Coombe was very seriously concerned in early 1998.
Footnote 4: Several junior midwives were concerned from 1996 and especially when a midwife who had trained outside the Lourdes joined the staff in 1997.
Footnote 5: One of the pathologists had concerns in 1981. Another and recently appointed pathologist had serious concerns in 1998.
Footnote 6: The Matron of the Maternity Unit was concerned in 1979 and 1980 and again in the mid 1990s
Footnote 7: A temporary tutor who was also a sister in the MMMs tried to voice concerns in 1980
The Royal College of Obstetricians and Gynaecologists inspected the Maternity Unit in 1987 and 1992 and found it to be suitable for training obstetric registrars. On each occasion deficits in the training programme were noted and the approval for training was lukewarm. In 1992 the report of the visiting committee of the RCOG made 8 recommendations to the Maternity Unit. No return visit was planned to ensure implementation and no efforts were made to determine whether the recommended changes here effected. It was advised that tubal ligation be introduced as a choice for patients. On neither occasion were the recommendations made by the RCOG fully implemented.
The medical school at the Royal College of Surgeons in Ireland approved the Maternity Unit for undergraduate training.
An Bord Altranais carried out periodic assessments of the midwifery school at the maternity hospital for accreditation pruposes. They advised as far back as 1980 that women should be offered a full choice on contraception and that midwives ought to be fully trained on those methods. Nothing happened.
No person or institution raised any issues until October 1998 when two experienced midwives, who were consulting the Health Board Solicitor on an unrelated matter, sought his advice on serious concerns which one of the midwives had about Dr. Neary’s practices.
What a lot of worthy and august institutions to have fallen asleep at the wheel.