Joe Craig

17 April 2006

The State Inquiry into the unwarranted number of hysterectomies carried out at Lourdes Hospital over nearly a quarter of a century faced a number of obstacles to its task.  These included opposition by some members of staff and lack of cooperation from the wider medical profession which the Inquiry makes nothing of but which reveals continuation of some of the problems that caused the scandal in the first place.

One of Dr. Neary’s fellow consultants refused to cooperate with the Inquiry, many staff refused for a very long time to believe anything was wrong and no local GP whose patient had had a hysterectomy responded to the Inquiry’s request for information.  No junior doctor who had worked with Dr. Neary contacted the Inquiry.

The premises of the Inquiry were subject to three criminal forced entries but it was the issue of missing records that itself became a subject of the inquiry.

Missing Records

The Inquiry found that records of 44 hysterectomy cases were missing and of these cases a substantial number of birth registers were also missing.  The theatre register for the pre-1991 period was missing.  Of the latter the Inquiry Report rightly stated, these ‘are immensely important and valuable documents.’  It characterized the disappearance of the pre-1991 register as ‘highly suspicious,’ believing ‘that it was deliberately taken from the Hospital.’ (p. 107 & 109)  In addition the 1991-2000 register had ‘some very alarming alterations’ indicating ‘deliberate attempts to prevent a full determination of the number of peripartum hysterectomies carried out in the unit’ (p. 110).  Where the register was altered the birth register was also missing.

In those cases were the birth registers were missing all contained details of a hysterectomy and there were no missing registers which contained no hysterectomy.  Of the 44 hysterectomy patients whose charts were missing the corresponding birth register was missing on 41 occasions.  Just to check that all this was not just an unfortunate coincidence the Inquiry carried out a couple of surveys of records and found little problem in gaining access to them.  The Inquiry thus concluded that the charts ‘were unlawfully removed from the hospital with the object of protecting those involved in the hysterectomies or in protecting the reputation of the hospital.’ (p. 147)

For the women to whom these records belonged their loss ‘is a huge disappointment and, in some instances the absence of these records has been traumatic.  They will never know precisely what happened to them and what caused the operating surgeon to proceed to hysterectomy.  They will never be able to have an expert review of their file to advise whether the operation was justified or not.’ (p. 147-148)

Undoubtedly this was an inside job as it would have taken knowledge of where the records could be found and hours spent retrieving birth registers from one room and patient charts from another.  The culprits would have had to know where keys were held and aroused no suspicion by their presence.

Questioning

Of more interest however is how all these hysterectomies took place without anyone calling a halt.  Many explanations are presented for this but before we come to these we must note that none of the doctors who worked with Dr. Neary or the various medical bodies such as the Royal College of Obstetricians and Gynaecologists who in 1987 and 1992 reviewed and approved the hospitals suitability for medical training raised the issue.  The anaesthetists, fellow obstetricians, junior doctors and pathologists all claimed not to be aware of just how high the number of hysterectomies was.  This was put down to the lack of communication that characterised the maternity unit, not just internally but between it and the rest of the Drogheda hospital.  Lying behind this however is the widespread assumption of clinical independence which makes consultants a law to themselves and which is the foundation of self regulation of the profession.  Unfortunately, but not unexpectedly, this is not challenged by the Report.

On pages 32 and 33 the author lists 11 groups of people from patients to the Medical Missionaries of Mary who failed to complain about what was happening. Incredulity that no one intervened runs like a thread right through the Report’s 364 pages.  A few however did see that all was not right and their fate when they tried to do something about it goes some way to explaining why so few tried.

One patient complained through her solicitor in 1980 but was assured in legal correspondence that obstetric hysterectomy was extremely rare; another complained in 1998.  Unfortunately the secrecy that normally surrounds medical practice was maintained, even more regrettably this is also endorsed by the Inquiry.

One temporary midwife tutor who was also a member of the Medical Missionaries of Mary was concerned but did not speak to anyone in authority within the hospital because her religious order had strict rules about talking about patients.  Instead she spoke to the Cardinal who told her it was a matter for the doctors.

When this became known within the hospital a ‘robust discussion’ (p. 180) involving the tutor and the Matron eventually ended with the disclosure that the Matron also shared her concerns and would take the issue forward herself.  There then followed a disputed account of events over which the Matron nevertheless maintained she had an ‘unshakeable memory’ (p. 181)

She states that she spoke to the Tripartite management Committee of the hospital, made up of three members of the Medical Missionaries of Mary (MMM), although the two surviving members of this committee deny this.  Dr. Neary on the other hand recalled meeting this committee once but only to be warned not to carry out tubal ligations, which were ruled out by the Catholic ethos of the hospital.  The Matron made various other attempts to raise the issue but she feared the reaction of Dr. Neary and nothing came of them.

A pathologist said he may have raised concerns but ‘felt that any problems that he raised with MMM management were ignored and he felt powerless to effect any change in the hospital.’ (p. 201)

In Charge

So some attempts were made but failed.  Why did they fail?  The Report recounts the views of many that consultants could not be questioned.  Indeed much of the Report deals with this, as does wider coverage of the report, although not to draw the conclusion that any democratic control mechanisms should be introduced.  In particular the strong personality of Dr. Neary is held up as a significant contributory factor to events.  On the other hand, however much this may have been true, Dr. Neary was not in charge of the hospital and was not responsible (beyond requirements of a personal and professional nature) for the way the hospital was run.  Yet this elementary question is not clearly and decisively asked and answered.

The answer of course is that the Catholic Church, in the shape of the Medical Missionaries of Mary, was responsible for the hospital and thus responsible for the failure to prevent the appalling medical practices that took place.  In fact its responsibility went further - through the effects of the positive medical practices it promoted and those it prohibited.  This included the forbidding of tubal ligation.

Dr. Neary recounted one incident from 1980/1981 when he sought permission to carry out this procedure on the basis that it was not primarily intended as a means of sterilization but to prevent the death or serious ill health to the woman in a future pregnancy.  Dr. Neary consulted and received the approval of a professor of moral theology at Maynooth.

The MMMs were unhappy and sought the opinion of a Bishop and a Cardinal who ruled it out.  The Bishop stated that ‘the Church’s thinking regarding this operation is very clear.  It does not depend on circumstances nor on certain thinking among some theologians.’ (p. 244)

This is an extraordinary statement.  A medical intervention does not depend on the circumstances!

The Report notes that ‘There appeared to be an absolute horror of performing tubal ligation but an insouciant acceptance of hysterectomy, a much more invasive operation which for the patient was a major procedure with likelihood of psychological consequences,’ (p. 244)

One sister from the MMMs told Dr. Neary that the hospital was ‘very Catholic and we don’t do that thing here’ (p. 245).  Dr. Neary stated that ‘he was summoned to a meeting with the Cardinal when it was explained to him what the consequences of performing a tubal ligation would be.  The Cardinal told him that he was aware of where his siblings worked and where his nephews were at school.  If he carried out any tubal ligation in the hospital, he had the power to ensure that consequences would follow for his siblings’ jobs.’  The Report stated that ‘we are satisfied that Dr. Neary’s fears that any observed deviation from the ethos of the MMMs would result in dismissal were well founded.’ (p. 246)

The Inquiry was therefore satisfied that hysterectomies had been carried out as a means of sterilisation when tubal ligations or safe methods of contraception could have been offered instead.  ‘Compassionate’ hysterectomies thus became accepted as sterilisations not only in this hospital but in others – ‘an unspoken Irish solution to an Irish question’ (p. 236) –  In this case helping lower the threshold on when they were performed and then masking completely the fact that these unwarranted operations were carried out. (see the Report page 249)

What this incident shows is that contrary to the Reports contention that there was a lack of clarity over who ran the hospital- ‘it was next to impossible to establish where exactly the power in this hospital lay’, it was very clear who was in charge. (p. 50)  ‘The consultants and most of the administrative staff felt it lay with the MMMs’ (p. 50). The senior Pathologist believed ‘that the nuns ran the hospital and that the Medical Board had no power other than to advise the nuns‘ (p. 199).  The second pathologist was of the ‘view that the nuns in the hospital were aware of everything that went on in the hospital and ran it with an iron fist.’ (p. 201)

‘Dr. Neary was very aware from his first day at the hospital that a strict Catholic code applied.  The MMMs occupied almost all the key positions in both the Maternity and the general hospitals at the time…The MMMs ran a tightly controlled hospital in accordance with their ethos’ (p. 234). Yet the Medical Missionaries of Mary were ‘unaware of the number of hysterectomies’ (p. 248). ‘…Almost every MMM interviewed stated that she had no knowledge of the peripartum hysterectomy rate.’ (p. 252)

This failure of the Report to state plainly who was in charge and who was therefore ultimately responsible for the failings that occurred culminates in its   examination of the role of the Medical Missionaries of Mary and its recommendations for the future.  It is these issues that the final part of the article will address.