Early last October Dr A performed a caesarean section on a 20-year-old woman. According to his notes he had first noted placenta praevia, which means the placenta was positioned ahead of the baby inside the womb. This would make a normal vaginal delivery very difficult and would often indicate that a caesarean section should be performed.
Dr A also wrote in his notes that he had found placenta increta, meaning some of the placenta had gone through the wall of the uterus and become attached to the myometrium - the uterine muscle. The right side of the uterus was very spongy and very thin and there was "massive non-stop arterial bleeding".
Eighteen minutes after the birth he decided to perform a hysterectomy. Forty minutes later the woman was transferred to the recovery area.
A midwife approached him and asked him to sign the form necessary to have the removed uterus subjected to a pathology examination. He allegedly refused. She and a colleague took the initiative to arrange to have it examined anyway.
The results were striking. The placenta was allegedly normal. It was not attached to the myometrium. A later independent evaluation is understood to have concluded that the decision to perform hysterectomy was taken very rapidly. Blood loss was not excessive and the patient was stable. The hysterectomy appeared not to have been necessary.
A caesarean hysterectomy is a radical and uncommon procedure, performed when there is uncontrollable haemorrhage from the uterus following birth by caesarean section. It is performed only when other measures to control the bleeding have failed and there is concern for the woman's life.
One such procedure a year would be normal in a hospital the size of the one in which Dr A worked and was indeed the rate in 1994 and 1995. However, in the 1996-98 period some 27 were carried out, 21 by Dr A. The average increased suddenly from one a year in 1994 and 1995 to nine a year in the 1996-98 period.
A number of midwives at the hospital had not enjoyed working with Dr A. They said the working environment in the maternity unit was unpleasant and that Dr A had not kept up with the most modern maternity practices. On October 25th two midwives were having a legal discussion about another matter with a solicitor retained by the health board. When it was finished they raised their concerns about Dr A. The midwives said that Dr A was carrying out a high number of obstetric hysterectomies at the hospital, particularly in the cases of young mothers.
By coincidence, that day back at the hospital, Dr A was performing another caesarean hysterectomy. The patient was 33 weeks pregnant and had been admitted bleeding to hospital two weeks earlier.
Dr A's notes said she had placenta praevia increta, the same as the earlier case. He decided to perform a caesarean. The baby was delivered, and 12 minutes later he decided to perform a hysterectomy. He wrote that she had massive bleeding from the right and left uterine artery veins. He also decided to remove an ovary.
The histology report, however, found no abnormal implantation of the placenta. The later independent assessment is believed to have concluded that there was no reason to deliver the baby at 33 weeks and that this put the baby at unnecessary risk. It said the decision to perform a hysterectomy was taken quickly although there was no extensive blood loss and the patient was stable, and that the decision to remove an ovary was surprising.
The report is understood to suggest that this was part of a pattern. The doctor allegedly removed uteruses he judged were abnormal, yet later examination found no apparent abnormality. But the caesarean hysterectomy he performed the day the midwives reported their concerns to the solicitor was to be his last one. The following day the solicitor notified the health board of what he had been told. The same day a group of senior health board officials met, and that night three officials met the midwives.
Four days later, following another meeting of the senior health board executives, a number of them met Dr A. Dr A was accompanied by a colleague obstetrician and Mr Finbarr Fitzpatrick, the Secretary General of the Irish Hospital Consultants Association.
Dr A rejected all the concerns expressed by the deputy chief executive. He said he only performed caesarean hysterectomies to save lives and there was a high rate of caesarean hysterectomies because: some of his patients were having third or fourth caesarean sections, therefore bleeding was more likely; most patients requesting caesarean sections attended his clinic; the most difficult cases attended his clinic.
Dr A had invited three Dublin-based consultants to review nine cases, and it is understood that these consultants were not critical of his decisions. This report is understood to have been seen by the chief executive of the health board and another senior official.
Mr Fitzpatrick said, however, that Dr A would submit his practice to a review conducted by personnel from outside the health board area. Two days later Dr A agreed to take annual leave from October 29th to November 9th.
The health board commissioned an outside review of nine of Dr A's cases. The Irish Times understands this was carried out by a professor from Manchester University who advises the British government on infant mortality, on the recommendation of the Royal College of Obstetricians and Gynaecologists, who wrote a report. Yesterday week, Monday December 7th, the health board received this report.
It said that many of Dr A's findings as reported in his notes were not confirmed by pathology examinations. It suggested that greater effort should have been made to maintain the fertility of these young women. It was concerned at the decision to remove ovaries in four of the nine cases.
The health board's solicitors wrote to Dr A's solicitor asking that Dr A cease practising and setting a deadline of noon last Friday for a reply. The board has now written to Dr A asking him to take paid "administrative leave" while a further review is carried out.