The report on the high number of Caesarean hysterectomies by Dr Michael Neary was carried out by his professional association, the Institute of Obstetricians and Gynaecologists.
Most of his colleagues here and in Northern Ireland are members of the institute, which is the governing body of the speciality in Ireland. The high rate of Caesarean hysterectomies performed by consultant obstetrician/ gynaecologist Dr Neary at Our Lady of Lourdes Hospital in Drogheda led to the institute carrying out the review.
However, it has been largely overtaken by the action of the Medical Council. Earlier this year it went to the High Court to have Dr Neary suspended. His case is due to come before the council's Fitness to Practise Committee shortly. The report presented yesterday is the view of three of Dr Neary's professional colleagues, examining the question hanging over his medical practice.
The terms of reference were drawn up by the North Eastern Health Board and agreed by Dr Neary. The report has no legal standing. It followed an independent assessment, ordered by the NEHB, of cases involving nine women, where Dr Neary removed the wombs immediately after the delivery of their babies.
An obstetric hysterectomy is performed because of uncontrollable bleeding from the uterus following birth, usually associated with a Caesarean section. One gynaecologist says it is performed in "an absolute emergency. You move like lightning to save the mother and to get the baby delivered. It is not routine to remove the ovaries during this procedure." This report was carried out by Prof Michael Maresh, professor of obstetrics at the University of Manchester. It is understood to have stated that a hospital the size of Our Lady Of Lourdes in Drogheda should see an average of one Caesarean hysterectomy a year, but for the past three years it had had an average of nine. Dr Neary performed 21 of 27 such procedures at the hospital. The average jumped from one a year in 1994-1995 to nine in 19961998.
Dr Maresh reported that in many cases the consultant's decision to perform these hysterectomies was taken too quickly and unnecessarily. In a number of the cases, surgical notes written by the consultant stating that there were uterine or placental abnormalities were not borne out by subsequent pathological examination of the removed uteruses.
Some time before this report by Dr Maresh was completed, Dr Neary obtained a review document from three Dublin consultants which is believed to have run counter to the subsequent assessment commissioned by the health board. It is believed these consultants did not have access to the full hospital charts.
The review group, which reported yesterday, has unsuccessfully sought this earlier report from legal counsel representing Dr Neary. The Medical Council received a similar response when it sought the report. However, when the council's Fitness to Practise Committee hears the case, it will be entitled to this document.
It is understood that the findings of this earlier report by Dublin colleagues meant Dr Neary was able to stay working at a time when the NEHB was examining ways of sending him on leave.
Instead he was monitored until the results of Dr Maresh's report were known in December. Dr Neary has been on paid administrative leave since. It is understood he had been seeing private patients until the Medical Council took its action in the High Court.
The review group was made up of members of the Institute of Obstetricians and Gynaecologists in Ireland: Dr Dermot MacDonald, a former master of the National Maternity Hospital, now retired, Dr Graham Harley, a Belfast obstetrician, and Dr Edgar Ritchie, a retired Cork obstetrician.
The institute's chairman, Dr Harith Lamki, a Belfast consultant obstetrician/gynaecologist, presented the report to the NEHB solicitor in Dublin yesterday, as well as giving a copy to representatives of the Irish Hospital Consultants Association.
As well as the nine cases examined earlier, the review group examined Caesarean hysterectomies carried out between 1992 and 1998 at the hospital, but it did not speak to any patients. The review found that Dr Neary's clinical practice was unacceptable in more than 46 per cent of cases relating to Caesarean hysterectomies, acceptable in 41 per cent and doubtful in 12 per cent.
In several cases, it found he had overestimated the blood loss suffered by patients, and his worries about the scarcity of blood for transfusions were unfounded.
The review group did not know whether Dr Neary's experience during operations, which described heroic measures, had been made known to the patient. However, the notes relating to the patient's welfare did not justify such measures. Dr Neary's descriptions include "one of the most difficult problems I have dealt with"; "uncontrollable and massive bleeding"; "most difficult obstetric case I have ever seen"; "lucky to get away with it".
Dr Neary's diagnosis of difficulties concerning the placenta or abnormalities to do with the uterus might have been incorrect in a number of cases, according to the group, but it found it impossible to confirm that. Diagnoses he made concerning the reasons for these Caesarean hysterectomies were not confirmed by subsequent pathological testing. Although he did not question this before being interviewed by the group, he did challenge those pathology reports while being interviewed.
It was also found that he rarely consulted another colleague before one of these procedures.
Our Lady of Lourdes Hospital was run by a religious order before being taken over by the NEHB, and sterilisation would not have been allowed. Dr Neary told the review group that he felt his job would have been in jeopardy if he had carried out tubal ligations rather than a hysterectomy for the purposes of sterilisation.
It is also believed that Dr Neary was found to have had, on occasion, an attitude problem with patients and staff and poor communication with hospital management. The review group did not find evidence of intimidation.
His frequent performing of episiotomies, the making of an incision to facilitate the delivery of a baby, as well as using a vertical incision for Caesarean sections, could not be interpreted as bad medical practice, it was found.
The review group found that in the case of a 20-year-old woman who lost her first baby and had a Caesarean hysterectomy performed by Dr Neary, the clinical practice was considered acceptable. This finding was at odds with Dr Maresh's earlier report.
The group also stated that if an audit had been carried out, the number of Caesarean hysterectomies might have been highlighted. It also found no organised training or education programme was apparent in the hospital.
A regular audit was one of the recommendations of the report. The group stated that Dr Neary had been working very hard for a number of years and his ready availability in the hospital exposed him to a lot of emergency work, leaving no time for other activities, such as study leave or postgraduate meetings. The group said it appeared he undertook work over and above his expected clinical responsibilities.
Regarding Dr Neary's future, the group was of the opinion that the best option was a six-month supervised postgraduate programme, where he would have the opportunity to observe colleagues at work in the operating theatre and delivery wards, as well as attending hospital conferences and visiting the laboratory.
Because of his high incidence of Caesarean hysterectomies, the group recommended that for one year he would consult a colleague before carrying out such a procedure. However, in the case of an unpredictable emergency, it would have to be dealt with without such a consultation.