It seems that Dr Michael Neary had developed a morbid sensitivity to and a phobia of haemorrhage when he performed surgery, writes Dr Muiris Houston
'I want to reiterate that this was a maternity unit that was to some extent caught in a time warp. There was no badness or cover up." So concludes Judge Maureen Harding Clark at the end of her extremely thorough inquiry into recent events at the maternity unit in Our Lady of Lourdes Hospital, Drogheda.
Whether this offers any sense of hope or restitution to the many women affected by this tragedy remains to be seen.
While the judge may have decided there was no malice intended by obstetric practices at the Drogheda hospital, the same cannot be said of the deliberate removal of key patient records.
Her conclusions will have major implications for the practice of medicine here and in the way that the health service will be governed in the coming years.
The Lourdes Hospital investigation is set to become the Republic's Bristol inquiry. That report into high death rates among children undergoing heart surgery at the Bristol Royal Infirmary was the starting point for tackling clinical governance deficiencies in Britain's National Health Service.
Although the Lourdes inquiry looked at peripartum hysterectomy practices across the entire hospital and was empowered by its terms of reference to advise on additional control systems that might be needed, the person at its centre is disgraced obstetrician, Dr Michael Neary.
Struck off by the Medical Council in 2003 after a fitness to practise inquiry found him guilty of unnecessarily removing the wombs of 10 women at the hospital, Dr Neary's rate of performing Caesarean hysterectomies was found to be way above national and international norms.
One of the key questions that has remained unanswered was, why did an experienced obstetrician like Dr Neary perform so may Caesarean hysterectomies?
According to Judge Harding Clark, "it is the story of a doctor who . . . came to work in a unit that lacked leadership, peer review, audit or critical capacity. It is the story of a doctor with a deep fault line . . . It is the story of a committed doctor with a misplaced sense of confidence in his own ability."
But fundamentally, it seems that Dr Neary was unable to deal with blood loss at the time of Caesarean section.
According to the report, one junior doctor said Dr Neary became quite animated when he saw heavy bleeding and he began to sweat profusely, indicating an inner fear.
It seems he had developed a morbid sensitivity to, and a phobia of haemorrhage when he performed surgery.
If this was the direct cause of Dr Neary's malpractice, the next question is how could an obstetrician be so out of line in his practice over a prolonged period of time without other health professionals raising the alarm? The culture of the hospital was a major factor, according to Judge Harding Clark. It tool a midwife trained in the Royal Victoria Hospital in Belfast to expose the unacceptably high rate of Caesarean hysterectomy at the Lourdes.
Up to the late 1990s, there was little nursing staff turnover in the maternity unit. A closed hierarchy emerged with a loyalty developing between senior nurses and consultant obstetricians. In addition, the maternity unit was physically removed from the rest of the hospital, contributing to its inward-looking ethos.
Anaesthetists there described Dr Neary as "a safe pair of hands" and seemed not to have noticed his unusual practices. As for pathologists and other laboratory workers, the report says: "None of the pathologists was aware of the cumulative number of hysterectomies carried out in the maternity unit. In the absence of annual reports or clinico-pathological meetings, they had no way of knowing".
Given the hierarchical nature of Irish medicine, it is not surprising that junior doctors did not blow the whistle.
This hierarchy was also illustrated by the responses of the sisters of the Medical Missionaries of Mary when they said it was their training as nurses never to question a consultant. While many patients continued to attend Dr Neary even after their hysterectomy, their main complaint was how doctors carried out procedures without explanation.
Not surprisingly, the report notes a management vacuum at the hospital, with no certainty among staff about who was in charge: "It was next to impossible to establish where exactly the power in this hospital lay."
The picture that emerges from the report is of an amorphous institution that rumbled forward with misplaced self-confidence and self-assurance. Even now, there are worrying signs for the future.
"Management's role and actions in addressing the major structural, operational and personal deficits in the maternity unit and the hospital since 1998 have been slow and unsatisfactory," Judge Harding Clark writes. Necessary change has only recently been put in place, although the judge is concerned that audit is still not seen as an imperative by management.
However, a huge amount of reform is needed, both in the Lourdes hospital and nationally if further clinical disasters of this magnitude are to be avoided.
Clinical governance, to include proper and formal accountability procedures for all health professionals, must be introduced across the health system.
Much delayed, the new Medical Practitioners Bill must be brought before the Oireachtas. It will enable a more robust competence assurance system, including the audit of a doctor's actual practice to be put in place as well as introducing system whereby doctors can bring professional concerns about colleagues to the Medical Council.
If there was legislative protection for whistleblowers, it would make it easier for healthcare professionals to articulate their concerns. Management structures and systems in hospitals must be the subject of compulsory audit and accreditation.
It is only through a combination of these initiatives, forming an effective system of defence, that healthcare error and malpractice will be reduced.