‘An absolutely shocking indictment of the way Irish hospitals are run’: the ‘Neary’ Report Part 1
15 April 2006
‘The Lourdes Hospital Inquiry: An Inquiry into peripartum hysterectomy at Our Lady of Lourdes Hospital, Drogheda’ was published in January. It has been called a ‘shocking indictment’ on the ‘appalling and horrific’ way a hospital was run by a patients group representing many (at least 60) women who, over a 24 year period, had their wombs unnecessarily removed at the hospital.
Many women woke up from their labour having given birth totally unaware that the procedure had been carried out. One described how she woke up and ‘was shaking and shaking.’ Arriving home she ‘was all over the place. It was days before I was able to think clearly. I kept crying. I was so sore and I had such an empty feeling.’ The mother described how she was unable to properly bond with her baby and ascribed this to her hysterectomy and her ‘hormones being all over the place.’
The 364 page report of the inquiry provides all the raw material for these judgements and expressions of pain. The Inquiry’s author, Judge Maureen Harding Clarke S.C, clearly struggles to come to terms with how it happened even though this was her task – ‘we had to keep on reminding ourselves that the number of these procedures was extraordinary.’ (p. 49)
In seeking to find out why no one acted to stop what was happening she reports that ‘the findings here were quite extraordinary and difficult to understand.’ (Report p. 155) As an illustration of what was happening, at one point the Report records that a simple day procedure became major surgery involving the removal of the uterus, ovaries and tubes for cancer. Yet despite this major development ‘no discussion followed, no curiosity (had) been elicited …no one mentioned it to us, nor did anyone questioned have any knowledge of the incident.’ (p 159-160)
This search for understanding led the inquiry to explore the environment within which all this took place in order to seek out those factors that may have directly or indirectly led to, or facilitated, the practice of removing hysterectomies from young women who would only very rarely have expected to incur such a procedure. Judgements were made of the various actors in this environment after setting out what evidence the inquiry thought relevant.
Although the inquiry disliked the soubriquet ‘Neary’ because it too narrowly focused the question on the consultant responsible for the large majority of the procedures, the reader will sense that the inquiry struggled to break from this focus. It did however widen its lens sufficiently to allow us to form our own judgements on just what sort of environment allowed these events to happen.
This environment is what the Inquiry thought was important, hence its dislike of the ‘Neary Inquiry’ tag, and it is what socialists should also regard as primary. Individuals may be flawed, may be disturbed, unbalanced, irrational or malevolent but they exist within a society with an extraordinary measure of division of labour that allows no one to perform tasks without cooperation, assistance or obstruction. Individuals can therefore achieve little without this wider labour cooperation.
What matters is not an individual failing but the environment that nurtured and protected a practice that caused so many women so much pain and grief, in the process completely altering their lives.
The inquiry on its way thus makes comments on many aspects of the medical environment in which Neary worked, of medical governance in the hospital - including its Catholic ethos, of wider management of the health service and medicine, and even of the more political aspects of society that surrounded the hospital. In general the Inquiry’s judgements are weaker and more questionable the wider its focus but the failures of its diagnoses involve all these levels.
Reading the report should be a reminder that socialism is not (just) about greater resources to achieve the more humane society we want but is fundamentally about how we work together to create a society that can release those resources. The problems of the health service in Ireland and indeed across the world are not just questions of funding. In 1998 the US spent 13.6% of its GDP on health, by far the highest in the world, but it is no exemplar in how health care is delivered. In 1996 it ranked 26th of industrialised countries for infant mortality rates.
The Introduction and overview of the Report records that 188 peripartum hysterectomies (at or within six weeks of delivery) were carried out in the 25 years 1974 – 1998 and that 129 of these were attributed to Dr. Neary. (p.30). Although it quotes an earlier Medical Council report which noted ‘that Dr. Neary was by no means alone in having a high caesarean hysterectomy rate’ not much is made of this fact. (p. 15), nor of the fact that Dr. Neary’s colleague Dr. Lynch, who ‘carried out a significant number of hysterectomies’, refused to cooperate with the Inquiry. (p. 35)
The Report clearly rejects the view that Dr. Neary was a surgeon with poor surgical skills or deficient in academic excellence or that he was ‘an evil man or a bad doctor’. (p. 34) Yet the Inquiry is also clear that a number of the hysterectomies were ‘unwarranted’ (p.35) and that others were concealed sterilisations, made necessary by the strict Catholic ethos of the hospital which prohibited contraception or other procedures. This despite the fact that best medical advice was that hysterectomy was a procedure with a high complication rate and ‘exposes the patient to an unacceptably high risk of increased morbidity and mortality’ (p. 81). Unplanned, it is characterised as an ‘emergency’ operation with little or no time for the patient to consider her options, and irreversible compared with any other method. (p. 83)
The Report of the Fitness to Practice Committee of the Medical Council in July 2003 stated that the hysterectomy rate was over 20 times in Drogheda what it was in the Coombe or National Maternity Hospital in Dublin. ‘From these figures the Committee can only conclude that it is highly probable that the procedures carried out in Drogheda were largely unnecessary.’ (p. 84)
The Committee reported figures showing that while the rate of caesarean hysterectomy (carried out during a caesarean delivery and thus a sub-total of all peripartum hysterectomies) in the Coombe was 1 per 600 caesarean sections and 1 per 405 at Holles St. it was 1 per 42 in Drogheda and Dr. Neary’s rate was 1 per 20 and Dr. Lynch’s 1 per 21. (p. 85-86) In Airmount in Waterford, run by the same religious order as Drogheda – the Medical Missionaries of Mary, the rate was 1 per every 300 sections.
These figures are important because they provide a yardstick to measure whether and to what extent the hysterectomy rate at Lourdes Hospital, and Dr. Neary’s in particular, would give cause for concern. It is a central part of the evidence and argument in the Report.
Yet a few pages later the Report states that ‘there is a lurking suspicion that the operation (peripartum hysterectomy) may have been underreported in some hospitals . . . because of cultural objection to tubal ligation, resort to hysterectomy may be more common than statistics indicate. Prior to 1998 most Maternity Units did not routinely collect or include statistics which showed the numbers of peripartum hysterectomies carried out.’ This is in contrast to Lourdes Hospital, and ‘particularly Dr. Neary, which was ‘most consistent and open in publishing total numbers of caesarean hysterectomies.’ (p. 98)
What this implies is not any sort of exoneration or mitigation of what happened at Lourdes, which can be condemned without comparison, but a suspicion that problems were not confined to this hospital even if it could be claimed that they did not reach the dimensions examined by the Inquiry.
This is not pure speculation on our part. The author of the Report goes as far as she could, given the limits of her terms of reference, in raising this question: ‘It is difficult to believe that similar adverse outcomes and outdated practices that we uncovered were confined to this unit. The rate of caesarean and peripartum hysterectomy reported to us for provincial units were frequently very low or non existent… At the start of this Inquiry, some obstetricians suggested to us that the number of hysterectomies carried out at the Lourdes Maternity Unit was not so out of line with figures from other Maternity Units..’ (p. 99). The report even states that ‘there is suspicion that given the same set of circumstances, what happened in this hospital in Drogheda could be replicated in other hospitals…’ (p. 317)
In the media coverage of the Inquiry nothing is made of all this yet it calls into question medical practices across the State. The influence of Catholic Church teaching in limiting the availability of contraception or other sterilisation procedures may have led to many, many unnecessary hysterectomies carried out in lieu of these measures. In Lourdes this practice greatly assisted covering up hysterectomies that were not carried out for this purpose and were unjustifiable on any grounds. Could this have occurred elsewhere?
What we can say is that the scarcely concealed incredulity of the Inquiry that this practice should have continued for so long, involving so many different people – midwives, junior doctors, anaesthetists etc, without someone saying stop! has parallels now with reaction to claims that practices elsewhere have not been honestly reported. No one it seems wants to open this particular can of worms. Why?
It is not just a question of the difficulty of assigning individual responsibility. Again this is, in this case, of limited value. The issue is that the only assignment of responsibility for widespread medical practices that should never have occurred, and never been tolerated, is a Catholic Church which so strongly influenced medical practice; a medical profession that supported or went along and refused to challenge this influence; and a State that presided over the system that operated in such a manner.
Far, far easier is it to emphasise the ‘fault lines’ of an individual and discuss the ‘Neary’ report rather than wider issues that bring others into the picture.
The history of how even the practices at Lourdes were uncovered gives no grounds for certainty that problems elsewhere, even if not so appalling, could not also remain hidden.
Dr. Neary was struck off the medical register only after three previous medical inquiries into his conduct. In the first, carried out by three obstetricians, one stated that ‘the mothers of the North Eastern Health Board are fortunate in having the service of such an experienced and caring obstetrician’ (p. 6). The second, by an English obstetrician did record major concerns, prompting a demonstration by Dr. Neary’s supporters, rumoured to include at least one fellow obstetrician, midwives, nurses and nuns. The third was a review by the Institute of Obstetricians in April 1999 which advised ‘retraining for a period of six months.’ (p. 13)
Just like the numerous child abuse scandals, it was a TV programme on RTE that accelerated events, and the Medical Council’s Fitness to Practice Committee became involved leading to his suspension and later resignation.
This train of events was initiated however in October 1998 when two midwives, one trained in the North, reported their concerns to the solicitor working for the Health Service Executive (HSE). The HSE only became a route for possible action because the religious order that had owned the hospital had suffered decline and had been compelled to hand over ownership of the hospital to the State.
Only the State Inquiry looked beyond the
very narrow practices of one consultant to the wider environment which
allowed him to proceed in the way he did for so long. This Inquiry
looked at the role of the wider medical profession, hospital management
and religious control. It also had to face concerted attempts to
cover up what had happened, and it is to these aspects that we will turn
in the second part of this article.