No money can compensate Alison Gough for not being able to have morechildren. But further actions are inevitable after her court victory over DrMichael Neary for negligently removing her womb, writes EithneDonnellan
Alison Gough became pregnant with her first child in 1992. Her expected delivery date was in autumn - October 15th to be exact. However, as with many first-time mothers, there was no sign of her baby on that date or for several days that followed. Ten days after her due date she was admitted to her local hospital, Our Lady of Lourdes in Drogheda, to be induced.
The following morning, October 26th, she met the consultant obstetrician and gynaecologist who was on duty. It was Dr Michael Neary. This man she'd never met before was to care for her for the duration of her delivery.
Dr Neary broke her waters and she was put on a drip. Her contractions started at 3 p.m. She was given an epidural at 7.45 p.m. but the labour didn't make much progress and in the early hours of the following morning, at approximately 1.27 a.m., it was decided by Dr Neary she should have a Caesarean section.
When she awoke after the operation, a nurse told her she had a baby boy and that he was fine. The child, whom she named Daniel, was not in the room with her, however, and she was in a lot of pain.
The next day Dr Neary walked by her bed and said "Hello". She told him she could not sleep because she was upset and he replied: "If you did not sleep, how do you think I slept?".
She was not to see her new baby until the following day however, two days after the birth. When Dr Neary visited that day she asked if it would be possible to have another section if she had more children. He replied: "What do you mean more? I had to do a hysterectomy."
Alison, who was just 27 years old, couldn't believe what he had told her and she broke down. He then said to her: "I saved your life". Furthermore, he told her he could have sent her son home without a mammy. He said she had lost so much blood he had never seen anything like it. Then he left.
"I was devastated," recalled Alison, who lives at Market House Lane, Ardee, Co Louth.
At her six-week check-up, she asked Dr Neary if she had done anything wrong and if he could explain what happened. She had not been sleeping and could not come to terms with the outcome. "He said that if he told me what happened that night I would never sleep again. He told me to go home and get on with my life."
Getting on with her life proved difficult, however. She went back to work in June 1993 as a domestic in St Brigid's psychiatric hospital in Ardee. "I was just there in body. I could not think for myself. I got no help and thought that these things happen and that I should be able to cope. I didn't feel like a woman. I felt very guilty that I hadn't asked questions," she said.
For the first two years of her son's life she had felt disconnected and felt no joy.
Six years after the birth, the media was full of reports that Dr Neary had stopped work in Our Lady of Lourdes Hospital and that he was under investigation. Alison hoped it had nothing to do with her.
She contacted a helpline established by the hospital and was told Dr Neary was being investigated for performing unnecessary hysterectomies. There was a significant number of other women in the same boat as herself. "I just cried and cried. I felt really I could have stopped it. I should have said something. I thought I was only the third person but there were so many other women."
Her solicitor obtained the hospital notes pertaining to her case and the full, awful, truth emerged. She decided to sue Dr Neary and the hospital for negligence and yesterday she won her action at the High Court in Dublin. In a reserved judgment, Justice Johnson awarded her just over €273,000 in damages. She was also awarded the costs of the case.
Unusually, Alison had relied on two Irish experts to back up her claim that the hysterectomy performed on her was unnecessary. Prof John Bonner, a consultant obstetrician and gynaecologist, told the court it was extremely rare that a woman having her first baby should have a Caesarean hysterectomy. So rare, in fact, that in his experience it had happened in only one in 100,000 births.
Dr Mary Wingfield, a consultant obstetrician and gynaecologist at the National Maternity Hospital, said that in the period from 1990 to 1998 there wasn't a single case of Caesarean hysterectomy in a first-time mother at the National Maternity Hospital.
In his defence, Dr Neary claimed he performed the operation because Alison Gough was bleeding excessively from her uterus after the Caesarean section. She lost up to 1.7 litres of blood and was still bleeding. He said doctors would have been more reluctant to give blood at the time as the hepatitis C story had broken and patients were reluctant to receive blood. This crisis, however, did not develop for some years later.
The Caesarean section, Justice Johnson found, appeared to have been completed at 1.44 a.m. and Dr Neary decided she needed a hysterectomy some 41 minutes later. The hysterectomy was completed at about 3.05 a.m.
Both Prof Bonner and Dr Wingfield had argued this was too hasty and that other measures should have been used to try to halt blood flow before a decision was taken to perform a hysterectomy. Mr Justice Johnston agreed. "In my view (their) evidence can only mean that had he persisted longer on the conservative methods, on the balance of probabilities the hysterectomy would not have been necessary," he said.
There was, he added, "no indication whatsoever of any emergency" in the the woman's medical records. It was "inconceivable" that a case which would occur in less than 100,000 births would not have merited notes from either Dr Neary, the anaesthetist or from the nursing staff, he said.
Furthermore, the judge said he had observed Dr Neary's body language and the tone in which he spoke and he found his explanations very unconvincing. On the other hand, seeing Alison Gough in court was sufficient for him to appreciate the depths of despair to which she had been put. The effect on her had been "catastrophic".
There were but a handful of people in Court 1 when Justice Johnson made his ruling. Alison, sitting next to her husband, was hugged so hard her mobile phone fell to the floor and shattered in pieces. Looking pale and shocked, she said she felt justice had been done. "I'm very relieved. It's justice I looked for. Money never came into it. I'm very happy," she said.
Her solicitor, Sara McDonnell, afterwards read a statement in which she said Alison, now aged 37, took the case to obtain answers, and in that she was successful. She thanked the judge, her legal representatives and her family, particularly her husband Fergus and her son Daniel who, she said, "was the one good thing to come out of this".
In addition, she thanked the doctors who counselled her and "restored her faith in the medical profession" and the members of Patient Focus for the help they gave her and many of the other women who went under Dr Neary's knife.
"Finally she would like me to seek your understanding of her desire to put the whole matter behind her and to get on with her life in privacy and peace," the solicitor added.
Two other young women on whom Dr Neary performed Caesarean hysterectomies were in court with their husbands. Julie Reilly and her husband William from Lucan said they were very happy for Alison. "She deserved to win after all she went through but money can never compensate the woman. If she got €10 million it would not put things back as they were," William Reilly said.
The other couple present, who have one child and live in Louth, didn't want to be named. While "elated" at the Judge's finding of negligence, they said they were disappointed with the damages which they considered to be very low.
"How can you put a price on not being able to have more children. There have been some serious compensation awards for other things," they remarked.
Another woman, also operated on by Dr Neary, heard news of the judgment on local radio in Co Louth. She described it as a precious moment. "There are so many emotions going around in my head, I just can't identify them."
The patient advocacy group Patient Focus, which represents up to 60 women who had Caesarean hysterectomies at the Drogheda hospital, said it was overwhelmed by the verdict. "We always knew we would see this day. We had no doubt about that because when you know you're telling the truth you know that if you just hang in there it will work out right in the end," its chairperson, Sheila O'Connor, said.
"The judicial system and the legal system came up trumps this time. The women in our group are so totally pleased about that. We're just so sorry there couldn't have been more of them here today but the weather unfortunately conspired against them," she added.
Dublin-based GP Dr Tony O'Sullivan, who is affiliated to Patient Focus, said it was important lessons were learned. He said the case called into question the hierarchical system in hospitals, where the actions of a consultant at the head of the team weren't being questioned by those under him.
"We need a system that allows whistleblowing," he said. "To some extent there are signs of improvement as this is the first case I'm aware of where Irish expert witnesses stood up in court against a fellow consultant and you have to give them credit for that," he added.
He also called for better record-keeping in hospitals and for a competence assurance system for specialists to ensure they remained competent years after qualifying.
Sociologist Marie O'Connor said the Gough case was "almost a logical outgrowth of a system without locks". She said maternity hospitals should be obliged to publish their annual statistics in relation to Caesarean sections and hysterectomies. Such reports were published, she claimed, by Our Lady of Lourdes Hospital in the late 1980s but then they stopped. "Had it continued to be produced it would at least have saved some of these women because it would have become known that the rate of Caesarean hysterectomy at the hospital was extraordinarily high," she added.
Many of the other more than 60 women on whom Caesarean hysterectomies were allegedly performed by Dr Neary were patiently awaiting the outcome of the Gough case. While all cases are bound to be different, a flood of actions is inevitable.
Colm MacGeehin of MacGeehin & Toale Solrs, represents more than 30 of the women. He expects dates for some of his cases to be fixed early next year. "While the details of this case are quite horrific, I've even worse cases where women's ovaries were also removed during Caesarean hysterectomies," he said.
He noted that the medical records of some of the women were no longer available and he said it would be a terrible injustice if these women were unable to take actions for damages as a result. He called for a compensation tribunal to be established to save the women the trauma of going to court to seek damages.
Patient Focus has also sought such a tribunal. In addition, it wants the Minister for Health, Micheál Martin, to establish a judicial public inquiry into the numbers of Caesarean hysterectomies carried out over 20 years at Our Lady of Lourdes Hospital. "This is a national scandal," Sheila O'Connor said, adding that it had been a difficult journey for the women concerned. In the early days there were marches in support of Dr Neary and people didn't believe the women, she added.
A spokeswoman for the Department of Health said the Minister had met the women concerned a number of times. She explained, however, that he could not do anything until the Medical Council had completed its investigations into allegations of misconduct against Dr Neary. "The Minister can't intervene until it reports its findings," she said.
The Medical Council's fitness to practise committee is conducting an inquiry at present, a spokesman for the doctors' regulatory authority said. However, it is not known when the committee will conclude its work. In the meantime, Dr Neary stands suspended by the High Court from the medical register, but he has not been struck off. This could only happen if the Medical Council voted to do so after completing its inquiries. Dr Neary could not be contacted for comment last night.
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How did it happen - and could it happen now?
The judgment in the case of Alison Gough, who had her womb removed after a Caesarean section to deliver her first child 10 years ago, reflects a personal tragedy for her and raises questions about the practice of obstetrics at Our Lady of Lourdes Hospital, Drogheda. Dr Neary, a former consultant obstetrician at the hospital, was found negligent in his duty of care to Gough and in his judgment, Mr Justice Johnson stated: "Dr Neary was very unconvincing in his explanations" as to why he performed a hysterectomy in her case.
The hearing earlier this year was noteworthy in that two medical colleagues gave evidence against Dr Neary. Prof John Bonnar, Emeritus Professor of Obstetrics at Trinity College Dublin and Dr Mary Wingfield, consultant obstetrician at the National Maternity Hospital, Dublin, both indicated that Dr Neary's hysterectomy rate following Caesarean section was excessive. The procedure is usually necessary only for one in 100,000 patients, when continuous bleeding from a woman's womb threatens her life.
But how could an obstetrician be so out of line in his practice over a period of time without either his nursing or medical colleagues raising the alarm? There are a number of possible explanations.
The obstetrics unit in Drogheda was small, relative to those in dedicated maternity hospitals elsewhere in the State. A unit with two or three consultants could have an environment which would make it difficult to question the actions of someone at the top of a hierarchical system.
The question of systems failure also arises. Did the hospital have any mechanism to audit the performance of its obstetric unit and the staff working within it? Mr Justice Johnson's comment that "it is further inconceivable that a case which would occur in less than 100,000 births would not have merited a note from either Dr Neary himself or from the anaesthetist or from the nursing staff", suggests a culture of self-appraisal or peer review did not exist in the hospital.
Sheila O'Connor of the advocacy group Patient Focus said yesterday that no records were available for 20 per cent of the women who were concerned at the treatment they received from Dr Neary. If this is indeed the case, it reflects poorly on the level of record keeping at the hospital.
Could such events happen in 2002? It is unlikely for several reasons. Team work within hospitals has replaced a system of "doctor knows best". Doctors in all specialities now undergo continuous medical education, part of which includes the analysis and discussion of cases randomly picked from their practices.
But participation in such activities is not yet compulsory, although the Medical Council here has committed itself to introducing a system of competence assurance for all doctors.
Dr Muiris Houston