Conclusions report does not reach may be most important

There are a few remarkable things about the report published this week on the medical practice of a Drogheda obstetrician, Dr Michael Neary. Chief among them is what the report does not say, and the conclusions it does not reach.

The report, which took four months to complete, will provide little comfort to the hundreds of women who have made contact with the North Eastern Health Board in recent months to complain about their experiences with Dr Neary at Our Lady of Lourdes Hospital.

The board is to set up a panel of obstetricians which these women may visit for advice. As well as those who now question whether they needed to have their wombs removed, there are others, hitherto unknown, whose cases have come to light. They came forward after The Irish Times revealed the doubts about Dr Neary in December. A number wrote to the board telling of their difficulties with bladder and bowel function, and a litany of other gynaecological problems.

They may take some comfort from the fact that the case is due before the Fitness to Practise Committee of the Medical Council in the next few months. Earlier this year the council went to the High Court to have Dr Neary suspended from the medical register.

This week's report by three members of the Institute of Obstetricians and Gynaecologists has no legal standing, but it is an assessment by colleagues, working as a review group within terms of reference laid down by the board and agreed by Dr Neary. Views differ on whether a doctor whose medical practice is in question should have his work reviewed by colleagues working in the State, or by an independent expert from outside. The institute's report could be used as a good example of the latter being the most advisable course.

Dr Neary is a member of the Institute of Obstetricians and Gynaecologists, as are the majority of Irish doctors who have specialised in this area of medicine. Three members of this institute were asked to carry out the review of his work, after a previous report, by a British expert, revealed that he performed an abnormally high number of Caesarean hysterectomies. The review group comprised three obstetricians, Prof Graham Harley, from Belfast, Dr Dermot MacDonald, former master of the National Maternity Hospital, now retired, and Dr Edgar Ritchie, from Cork, also retired.

Their report begins with the rate of Caesarean hysterectomy carried out by Dr Neary. A Caesarean hysterectomy is performed because of uncontrollable bleeding from the uterus following birth, usually associated with a Caesarean section.

The group examined the clinical notes of all patients who had had this surgery from the beginning of 1992 through to the end of 1998. The group stated that it decided against referring to any patients' letters submitted to it by the NEHB, because they were outside the terms of reference.

The group reviewed 39 cases. Dr Neary had a Caesarean hysterectomy rate of 5 per cent, i.e. one for every 20 Caesarean sections he carried out. This was 20 times the recorded rate in one Dublin maternity hospital, the report said. Dr Neary performed 39 of these procedures between 1992 and 1998 in a small maternity unit, compared with eight of the procedures in the large Dublin hospital, making it one in 441 Caesarean sections.

It found that in 46.2 per cent of cases the decision to perform such a procedure was "not acceptable clinical practice", In 41 per cent of cases it was considered acceptable, and in 12.8 per cent it was "doubtful". Essentially they found there were question marks over almost two-thirds of the Caesarean hysterectomies the doctor carried out.

As part of his explanation Dr Neary told the group that there were difficulties in getting blood for transfusion at the hospital, which led to him often making an early decision to carry out a Caesarean hysterectomy.

Dr Neary and his obstetric colleague, when questioned, said they had consulted with each other about difficult cases. The group stated that "there was little evidence in the patients' records to confirm this". Within the maternity unit the frequency of the procedure was seen as "just one of those things" and accepted without question.

The group said it was unfortunate that it had found no evidence that senior midwives in the maternity unit noted the high rate of Caesarean hysterectomy, or asked other consultants the reasons for it.

The group concluded that the high rate of Caesarean section performed by Dr Neary for delivering babies in the hospital was in itself a matter for concern, and it was "a subject which might benefit from future audit".

Explaining his position, Dr Neary told the group that on several occasions he had found abnormalities in the muscles of the uterus which resulted in poor or no ability to contract when delivering a baby. The obstetricians had many theories on this. One was that it was possible that whatever was responsible for the high incidence of leukaemia and cancers in the Drogheda population "might also be a factor in the high incidence of abnormalities of the uterine musculature".

For their part the review group felt the theories were "unproven and theoretical, but were nevertheless possible".

The group said that, like the NEHB, it was anxious to preserve the good reputation Dr Neary and the hospital had enjoyed in the past.

The group did not explicitly state that Dr Neary should return to work at Our Lady of Lourdes Hospital. However, it was implicit in its recommendations that the obstetrician should have to undertake "a supervised postgraduate programme for a continuous period of six months" in another hospital. This would give him the opportunity to "observe colleagues at work in theatre".