Patient A (20)
She was having her first baby, which was in a breech position. It was planned to deliver the baby by caesarean. According to Dr A she had a placenta praevia (when the placenta is placed ahead of the baby, blocking the outlet that so the baby cannot, or has difficulty in, travelling down the birth canal. It is possible sometimes to get a normal delivery, depending on how much it is obstructed.)
Dr A also said the placenta was increta (had grown into the muscle of the uterus). Her uterus, he said, was spongy on the right side and she was suffering from "massive non-stop arterial bleeding". He decided to perform an obstetric hysterectomy, removing her womb.
However, according to the subsequent histology report, the placenta was normal and had not adhered to the muscle of the uterus. It is believed the outside health board report found that the decision to perform the hysterectomy was taken rapidly when (blood) loss was not excessive and the patient was stable.
According to medical sources a praevia is usually associated with previous surgery and would be "almost unheard of" in a 20-year-old woman.
Patient B (29)
She was 22 weeks pregnant when her membranes ruptured. Admitted to hospital, she was treated with antibiotics. It was subsequently discovered that there was no foetal heartbeat.
The woman was left with a dead foetus and with ruptured membranes for about 60 hours after septicaemia was diagnosed.
It is believed the report said that the woman was put at "unnecessary risk" of dying from septicaemia (blood poisoning) which was avoidable, and that leaving her for so long with a dead baby in her womb was inhumane.
Medical sources explained that when a baby dies and the membranes have ruptured there is a direct tract "between the vagina and the cavity of the uterus where the dead baby is. The baby becomes colonised with bacteria from the vagina, it becomes infected and this gets into the mother's bloodstream."
In his explanation Dr A apparently said that after this delivery there was sudden massive bleeding. He attempted to control it using a clamp, but said that within five minutes the woman was ex-sanguinated (dying from lack of blood). Her placenta, he said, was still firmly in the uterus and there were other complications.
The report, which re-examined several of Dr A's cases, apparently found that he had delayed inducing labour in the woman despite the death of the baby and septicaemia (blood poisoning).
There was no use of antibiotics before delivery and no apparent attempt to remove the placenta while the woman was under general anaesthetic. Neither, apparently, was there any subsequent confirmation of difficulties with the placenta.
A medical source questioned "where all the blood had come from if the uterus was stuck." He said it would be normal practice for an obstetrician to attempt to remove the placenta manually by placing a hand in the uterus and peeling it off. "Nine times out of 10 it comes away."
Patient C (33)
She was having her second child delivered by planned caesarean section when, according to Dr A, complications occurred. It is believed he said that following the surgery he had found weakness of the fundus in the uterus.
The fundus is the bulbous part at the top of the uterus. According to medical sources it would be extremely unusual to have a weakness there unless there had been previous surgery, perhaps a classic caesarean, involving a longitudinal incision. (In the UK it is necessary for obstetricians to report to the health authorities if such a procedure is done, so that it is known if the woman has another child.)
Dr A's patient was not given a blood transfusion, which one gynaecologist described as "very strange given the circumstances described".
It is believed the report into Dr A commented that despite the procedures carried out by him, and his assertions about weakness in the fundus, there was no obvious uterine abnormality and it was not felt necessary to carry out a blood transfusion.
Patient D (26)
She had her labour induced and Dr A performed an emergency caesarean, using a suction cap. His registrar apparently said afterwards that they found the uterus ruptured at the left side.
Dr A said there was uncontrollable bleeding and went on to perform a hysterectomy, as well as removing the woman's left ovary. He said he had spent most of the night in theatre.
It is believed the report found that there was discrepancy between what Dr A found during the operation and what was contained afterwards in the pathology report from the laboratory.
Patient E (28)
She was having her baby by a planned caesarean section when Dr A said he discovered she had a fundal defect and was bleeding. The fundus is the bulbous part at the top of the uterus.
The report commented, apparently, that there no obvious uterine abnormality was discovered subsequently.
Patient F (33)
She was admitted when she was 31 weeks pregnant with bleeding from placenta praevia. She remained in hospital with slight blood loss, which was the reason for a decision for a caesarean at 33 weeks. During the delivery, Dr A said, there was massive bleeding, including of the right ovary. He apparently said it was the most difficult obstetric case he had ever seen.
It is believed the report stated that there had been no need to deliver at only 33 weeks, when the mother was not bleeding significantly at the time, and that Dr A had put her baby at unnecessary risk.