How three senior obstetricians exonerated Michael Neary
Compassionate collegiality was how the Inquiry described his exoneration but the Institute of Obstetricians and Gynaecologists also recommended he continue in practice. By Mary Raftery
"Motivated by compassion and collegiality." This was the view expressed by Judge Maureen Harding Clark on the three obstetricians who produced a report in 1998 concluding that Michael Neary had no case to answer on his frequent practice of removing the wombs of women during childbirth at the Lourdes Hospital in Drogheda.
Their report confirms the widely-held view that when dealing with error and damage to patients, the medical profession closes ranks to protect its own.
Maureen Harding Clark described the three consultants who exonerated Neary as "established, eminent and practising consultant colleagues attached to the major teaching hospitals in Dublin". Harding Clark did not name them and did not offer any explanation as to why they remained anonymous in her report.
However, their names do appear in the transcripts of evidence presented at the Medical Council's Fitness to Practise Committee hearings on the behaviour of Michael Neary. They are Professor Walter Prendiville and Dr Bernard Stuart of the Coombe Hospital, and Dr John Murphy of the National Maternity Hospital, Holles St.
The three had been chosen by Neary and his representative organisation, the Irish Hospital Consultants Association. They were given 17 files of patients on whom Neary had performed caesarean hysterectomies. They immediately ruled out examination of eight cases on the basis that Neary claimed that the women concerned had consented to the removal of their wombs as an alternative to sterilisation, which was banned at the hospital until 1997. There is no evidence that any of them questioned this claim by Neary.
This left them with nine patient files to examine. These were critical cases. Most concerned very young women and they were among Neary's most recent caesarean hysterectomies, dating from the mid to late 1990s.
Prendiville, Murphy and Stuart reported promptly and were unanimous in their view that that Michael Neary should immediately be allowed return to work at the Lourdes Hospital.
When presented with this report, the health board felt legally obliged to allow Neary back to work, in spite of profound reservations. However, it then did what most patients are forced to do in any legal action – it sought independent medical expertise from abroad.
Dr Michael Maresh, a Manchester-based consultant obstetrician, examined the same nine patient files and confirmed the health board's anxiety. He expressed major concerns about allowing Neary to continue in practice, indicating that this might put women at risk. He also believed that Neary's clinical judgement was significantly impaired.
Armed with this report, the health board finally felt on secure enough legal ground to instruct Neary to take administrative leave and thus cease working at the hospital.
It is worth looking at exactly what Neary's three colleagues said about him in their report. It was marked confidential, and was clearly never intended for public release. Judge Harding Clark said, "the report may have been prepared for limited viewing but the language, which is not qualified, is regrettable".
Two of the obstetricians (we are not told which two) reported that "we are of the opinion that all of the nine cases reviewed can be justified in the prevailing situation". They added: "We find no evidence of questionable clinical judgement, poor operative ability or faulty decision making. Quite the contrary, we find that Dr Neary, in the exercise of his clinical judgement, has under difficult circumstances probably saved the lives of several mothers". They concluded: "On the evidence presented we find no grounds to suspend Dr Neary or to place any restrictions on his practice (public or private)".
The third obstetrician (again, we do not know which of the three) was even more enthusiastic about his Drogheda colleague: "It is my firm conclusion that Dr Neary should continue to work in Our Lady of Lourdes Hospital pending any formal investigation. It would be wrong to put restrictions on his practice and it is my view that the mothers of the North Eastern Health Board are fortunate in having the service of such an experienced and caring obstetrician".
While these three obstetricians did give evidence to the Harding Clark inquiry, the judge's report does not provide any details of their testimony. She does say that she believes that they "have had serious regrets for their part in producing these reports". She adds that "they ought to have been alarmed that one obstetrician carried out 17 caesarean hysterectomies in three years in a middle sized Maternity Unit."
Far from showing any alarm, one of them, Bernard Stuart of the Coombe Hospital, testified on Neary's behalf during the Medical Council hearings. He engaged in a robust defence of Neary. Summarising his opinion of the ten cases which the Council examined, he stated that "the treatment is not bizarre and out of kilter with what other people would do with the similar case mix. So I don't think we are talking about a situation where an unusual or unique operation was applied to the patients".
We now know that in 2003 the Medical Council rejected this view and struck Michael Neary off the medical register. However, back in 1998, when he was fighting to keep his job, the intervention on his side of Walter Prendiville, Bernard Stuart and John Murphy was a serious blow to the health board in its efforts to curtail his practice.
It is worth considering the enormity of what these three obstetricians actually did: they recommended the return to work, without restrictions, of a doctor who was subsequently struck off the medical register for engaging in practices which these three colleagues clearly deemed acceptable. Their conclusion that Neary was fit to practise had the potential to put many more women at risk from his activities.
But questions arise also in connection with the involvement in this fiasco of The Institute of Obstetricians and Gynaecologists. It carried out its own review of what was going on in Lourdes hospital, based on an assessment of 39 cases of women who had had their wombs removed during childbirth by Neary.
This was the second group of three obstetricians to examine Neary's practice. Selected by the Institute, these were Professor Graham Harley (Belfast), Dr Dermot MacDonald (Dublin) and Dr Edgar Ritchie (Cork). One of the extraordinary aspects of their review was that they did not interview a single patient during their investigations. Various medical personnel at the Lourdes Hospital, including Neary himself, gave evidence, but none of the women operated on was invited to speak about her experience.
Despite this omission, the Institute review did represent some advance on the findings of the earlier group of three. It determined that almost half of Neary's caesarean hysterectomies were unnecessary, and it found his rate of performing the operation to be 20 times greater than other obstetricians.
However, its conclusions were startling. "Dr Neary has obviously been working very hard for many years," reported Harley, MacDonald and Ritchie.
"This intense clinical involvement has not afforded him much opportunity for any other activities. There was no evidence that he had the opportunity to take study leave, and he has had little time to attend postgraduate meetings."
They recommended that Neary be permitted to return to work at the Lourdes Hospital subject only to a six-month period of postgraduate training. They added that for a period of a year he should consult with a colleague before carrying out any caesarean hysterectomies, except of course in an emergency, which "would be dealt with without such consultation". Given that Neary described all of these operations as emergencies, this stricture was virtually meaningless.
Aside from its remarkably lax recommendations concerning Michael Neary, another striking aspect of the Institute's report was its reference to the practice of a second obstetrician at the Lourdes Hospital, Dr Finian Lynch.
Finian Lynch, who continues in practice at the hospital, was also shown to have an alarmingly high rate of caesarean hysterectomy. Lynch is currently on leave from Lourdes hospital. During a period of six years in the 1990s, he removed the wombs of 22 women during childbirth, to Neary's number of 44. By their own definition, this meant that Graham Harley, Dermot MacDonald and Edgar Ritchie had discovered that Lynch's rate for this operation was ten times greater than the norm. It is incomprehensible that they neither commented on this, nor made any recommendations about the practice of Finian Lynch.
In fact, the relative silence surrounding the activities of Finian Lynch is one of the more puzzling aspects of the many reports into maternity care at the Lourdes Hospital. Maureen Harding Clarke concluded that of the 188 caesarean hysterectomies carried out at the hospital between 1974 and 1998, Lynch performed 40 of them. While considerably less than Neary, who was responsible for 129, it still represents a serious departure from the norm in what is generally an extremely rare procedure. Most obstetricians would perform one or two such operations in their entire careers.
The judge points out in her report that the women whose wombs Finian Lynch removed tended to be older and have had more children than those operated on by Michael Neary. She provides comprehensive tables giving the age of each woman who had a caesarean hysterectomy at the hospital. However, using these figures to calculate an average age for each of Lynch's and Neary's patients shows that while there was an age disparity, it was not in fact all that considerable.
The average age of the women whose wombs were removed by Neary was 32 years; for Lynch it was 37, just five years older.
It should also be noted that in the seven years since the beginning of the various investigations in 1998, Lynch has performed only one caesarean hysterectomy. During the previous eight-year period, he had carried out 29 (as compared with 53 by Neary).
Maureen Harding Clarke provides further comparative statistics for both obstetricians at the Lourdes Hospital and for other hospitals. Examining the rate of caesarian hysterectomy per caesarian section performed from 1993 to 1998 shows that Michael Neary had a rate of one hysterectomy for 17 sections performed. Finian Lynch's rate for the same period was one hysterectomy per 21 sections. In the Coombe it was one per 600, and in Holles St, one per 405.
Finian Lynch was the only doctor who refused to give evidence to the Harding Clarke inquiry. The judge states that "he declined for legal reasons, which I accept. He responded in a limited fashion to our queries and we remain at a disadvantage without his full cooperation".
His response was in writing, and he indicated that he had no concerns about Neary. He was not particularly conscious of any issues concerning the rate of caesarean hysterectomies at the hospital. According to Maureen Harding Clarke, "he had supported Dr Neary fully when the complaints were first made and at that time saw no substance in the complaints".
The judge states that Michael Maresh, the Manchester consultant obstetrician, examined 15 of Finian Lynch's cases between 1992 and 1997. His main concern "was what he perceived to be this consultant's practice of performing caesarean hysterectomies as a method of sterilisation." He had no major concerns about Lynch's technical competence or surgical decision-making.
It is worth noting, however, that by the 1990s a number of hospitals provided the much safer option of tubal ligation for female sterilisation purposes. Performing a hysterectomy to sterilise a patient is an extreme option, the practice of which should at the very least be subject to critical independent examination. It is also of interest that Judge Harding Clark in her report made no reference to the issue of consent in these cases.
It is an inescapable conclusion of all of the many reports into maternity practices at the Lourdes Hospital that the obstetric profession has been exposed as having dangerous deficiencies. The behaviour of Michael Neary and indeed others at the Lourdes Hospital, combined with the failure of his colleagues to expose his malpractice, must strike fear into the hearts of everyone in this country who intends to have a child. Parents might justifiably ask how many more obstetricians are there in the country whose practices are being treated with "compassion and collegiality" by their colleagues. The frightening reality is that until we have a fully transparent and entirely independent mechanism for regulating doctors, we will simply never know.p