Somebody working in Our Lady of Lourdes Hospital illegally removed records of patients who underwent obstetric hysterectomies, the inquiry found. These records have never been found and the identity of the culprit is unknown.
The inquiry's second term of reference was to ascertain what system of recording such hysterectomies existed, and to examine what became of the records.
The inquiry identified several different types of records: maternity theatre registers, which were held in the theatres; patients' charts; birth registers, where all births were recorded by midwives; and admissions registers, relating to the admission of patients to wards.
Because some of these were missing, the inquiry also consulted secondary records, such as pathology records, in its attempt to discover the extent of peripartum hysterectomies in the hospital.
There was one maternity theatre register from about 1957 until 1991, when a new one was opened. This register would have recorded the hysterectomies and who was present at them during this time. It was found to be missing, having been last seen in 1998, about the time inquiries into Dr Neary's activities began.
The new maternity theatre register, begun in 1991, showed evidence of crucial alterations of records of hysterectomies performed. A handwriting expert was employed, who concluded that the writing for all the alterations was similar. These alterations corresponded to the apparently deliberate removal of other records. For example, the charts and birth registers of two patients from 1993, whose records are altered, are missing.
The inquiry has established that 86 peripartum hysterectomies were carried out between October 1991 and June 2004. Only 72 of them are recorded in this maternity theatre register.
The inquiry also discovered that Dr Neary had a photocopy of this register for 1991, but that no one could identify who had asked for or made the photocopy, which it described as "worrying".
Certain hysterectomies were carried out in the gynaecological theatre. The inquiry team discovered that the register for this theatre for the mid-1980s was also missing, but it later turned up.
The birth registers were also found to be incomplete, with certain months when there was a high number of hysterectomies, missing. No registers are missing for months when there were no hysterectomies. In all, 40 out of a total of 266 birth registers, going back to 1970, are missing, in which 76 hysterectomies would have been recorded; 39 of the 40 are for the years 1978 to 1993.
All the patients' charts corresponding to these same birth registers are also missing, along with another three patients' charts.
The inquiry considered that "the person/s who removed the old maternity theatre register used the information contained in that register to identify obstetric hysterectomies, the patients' names and the dates of operation.
"Once that person had the date of the operation and the patient's name, the birth register would provide the patient chart number. This would lead to the location of the chart."