Case Study: Patient G was a 20-year-old woman in her first pregnancy. Because of a breech position, Dr Neary decided to admit her in October 1998 at 39 weeks gestation for a Caesarean section.
She was taken to theatre at noon and her baby was delivered at 12.47 p.m. by section. A hysterectomy was decided on at 13.05 p.m.
In the delivery note, Dr Neary noted the following: "Placenta increta. Very thin right side of uterus. Massive non-stop arterial bleeding".
The Fitness to Practice Committee (FTPC) considered three issues in the case of Patient G.
Did Dr Neary proceed too quickly to Caesarean hysterectomy? Was there an overestimate as to the amount of blood loss and the rate of such blood loss? Was the finding of placenta increta correct?
With regard to the issue of haste, the committee decided that Dr Neary had, at most, waited for 8 minutes to conserve the uterus prior to making a decision to proceed to hysterectomy.
Although the anaesthetist in the case became concerned about Patient G's increased blood pressure and pulse rate, an expert witness called by the Medical Council gave evidence that "there was nothing in the records of the anaesthetist or the nurses which would give rise to cardiovascular concern".
The committee also found that the first unit of blood received by patient G was directed to be given over 1 to 2 hours.
"In a life-threatening situation, one unit of blood may be administered in as little as 5 minutes", the report notes, adding that "there was no convincing evidence ... that a risk amounting to a substantial risk existed to the patient's life".
When considering the issue of blood loss in the case of patient G, the committee noted: "pre-operative haemoglobin (blood count) was 10.6; the post operative haemoglobin following two units of blood was 10.3".
In conjunction with expert evidence of the typical blood loss for a Caesarean section followed by hysterectomy, the committee found that "to describe the haemorrhage in this case as being 'massive' is unsustainable and constitutes a gross exaggeration".
Placenta increta/accreta are conditions in which the afterbirth is so adherent to the wall of the womb as to make it unremovable in the usual, manual way.
The FTPC emphasised the findings of a pathologist who examined the womb and placenta after the procedure and who "found no evidence of placenta accreta". Nor did the pathologist find any abnormality to the uterus to explain Dr Neary's note of a "very thin right side of uterus".
In its conclusion to the case of patient G, the committee states: "there was an overstatement in Dr Neary's diagnosis and finding that the placenta was accreta and/or increta ... the evidence regarding the rate of blood loss is not sustained on any of the objective evidence.
"The Committee further considers that the time sequence in this case, taken together with the other factors outlined, leads to the unfortunate conclusion that the Caesarean hysterectomy was carried out with undue haste, and that there was an overestimate of the blood loss and the rate of blood loss and that Dr Neary's clinical findings regarding the placenta increta were in error.
"Having regard to the foregoing, the Committee considers that the facts are proved and that the same constitutes professional misconduct".
