It appears no concerns were raised at any time about the operation of thematernity unit in Drogheda, writes Finbar LennonNeary case has the potential to be a catalyst for change
The medical profession in general and the consultant establishment in Drogheda at the time have been subject to severe criticism over the Dr Neary case.
Much of it is valid. However, its focus in some important respects is misdirected and the resultant impression does not take account of the shared vocational commitment and team-based work ethic of the vast majority of doctors.
In seeking answers to what went wrong, a much broader perspective needs to be applied.
This will be painful for doctors because it exposes institutional weaknesses and lack of resolve at collegial level in tackling poorly performing units and individuals.
Most general concern is focused on how a large series of patient events over such a long time period went unnoticed and unchallenged.
The explanation that we, his fellow professionals, did not know or appreciate what was happening is a sad indictment of our medical system and how it is regulated.
His failure was our failure. We did not recognise his faultline, correct it and assist him.
The events in Drogheda represent both individual and collective professional failures as well as corporate and institutional failures.
The latter may well be the more significant.
No patient died. Some patients in Drogheda might have died in the event that a caesarean hysterectomy was not carried out.
It is the case that some patients have died in circumstances where if a caesarean hysterectomy had been performed, they might well have survived.
The threshold for resorting to caesarean hysterectomy in Drogheda was low.
This was clearly evident from the early 1970s and was remarked on by Dr Neary in his evidence.
This information was not hidden, but was recorded in the formal annual and bi-annual maternity reports which were published in Drogheda from the 1950s until at least 1982.
These reports were examples of clinical audit in practice.
They were standardised and therefore easily comparable with results in peer institutions.
The above reports were available and accessible to the obstetric and medical community.
Any careful inspection by the relevant professional college or regulatory authority at that time should have alerted them to this unusual practice in Drogheda.
Likewise the hospital in Drogheda and its clinical units are subject to regular visitation and inspection by the professional colleges.
The maternity unit continued to be recognised for training in obstetrics and gynaecology throughout this entire period.
Such recognition confers a significant status on a clinical unit.
Though technically these bodies' remits relate only to training, the quality and standard of care delivered must be satisfactory to permit such recognition.
It appears no concerns were raised at any time about the operation of the maternity unit in Drogheda.
It is important however in the interests of fairness not to overstate this point.
Only a very rigorous scrutiny by an external agency would have uncovered this problem.
Nevertheless, arising from the above and contrary to what is allegedly being suggested by the officers of the Medical Council, there are systems and mechanisms in place which if properly and robustly applied might have identified the abnormal practice in Drogheda at an early stage.
Unfortunately, the colleges and institutions still grant far too much deference and independence to the individual practitioner.
Because the hospital medical community is so small, there is a reluctance to criticise and give directive advice. This is at the root of the current dilemma.
The colleges must examine their respective roles in monitoring and supervising standards of clinical practice at both individual, departmental and hospital levels. Excusing relative inaction on the basis of not having the statutory authority to intervene is no longer acceptable.
The weight of institutional pressure and directional advice when applied in a timely and professional manner is difficult to resist.
The second lesson that needs consideration following the recent judgment is that reliance on qualifications, clinical audit activity and continuing medical education alone may not ensure competence.
Conduct may be just as important a performance indicator.
Conduct is not prescriptive and there are wide variations which are acceptable. Personal style and variety in behaviour must be respected and the medical profession has always been generously tolerant in this regard.
However, the limits of acceptable behaviour are readily recognised.
What is not fully appreciated is that abnormal behaviour compromises the day to day working relationship with colleagues and is potentially harmful to the welfare of patients.
If the profession is unable to deal with the above realities, then it does not deserve to retain the privileges of self-regulation. While the profession has much to ponder, the statutory employing authorities likewise must shoulder a significant responsibility for the failures which have been exposed in this case.
Medical care is frequently conducted and delivered in acute hospitals without the necessary consultant resource and infrastructure available on site.
Many clinical units still have very small consultant establishments. In such units consultants are over-worked and have little opportunity for continuing medical education.
As a result of heavy service commitments, some consultants are deprived of time for reflection and analysis of their own and their unit's performance.
In addition, a poorly-performing consultant in such a unit can go undetected.
If the other allied clinical units in the hospital are likewise under-staffed and over-worked, there is no local inter-collegial alarm or monitoring system in place.
There are recent examples where management systems within hospitals have failed to address such problems at an early stage.
The risks for the patient and the doctor of delivering acute services in inadequately resourced small hospitals in 2003 are very significant.
It is for this reason that many such hospitals should now concentrate on delivering elective services.
It follows from the above that larger properly-staffed and resourced clinical units are essential in our acute hospitals.
The employing authorities and the Department of Health will have the opportunity to remedy their own failures in this regard following the forthcoming publication of the Hanly Report.
The above perspective does not excuse or condone the individual failures in this case.
The medical professionals' duty of care including that of primum non nocere was not met.
The collective responsibility of the profession now is to recognise that it too failed these patients.
Mr Finbar Lennon is a consultant general surgeon in Our Lady of Lourdes Hospital, Drogheda.
Mr Finbar Lennon is an experienced consultant surgeon with a respected track record in postgraduate medical education.
He is also medical adviser to the North Eastern Health Board.
As such, he is privy to the many operational challenges faced by the health board over a number of years.
He has played a role in the high-profile baby Livingston and Neary cases. Mr Lennon has also been a key contributor as the NEHB attempts to rationalise services around the region's main hospitals in Drogheda and Cavan.
In the context of the demand by the representative group, Patient Focus, for a full inquiry into the Dr Michael Neary affair, Mr Lennon's personal contribution to today's Irish Times is significant.
Dr Neary was struck off by the Medical Council following a lengthy investigation into his treatment of women in Our Lady of Lourdes Hospital in Drogheda.
The council report into its decision found that the consultant obstetrician had unnecessarily removed the wombs of women under his care.
It also criticised the Drogheda obstetrics unit as a whole, saying, in reference to the high numbers of caesarean hysterectomies performed there: "Clearly such a substantive deviation from the norm must be a source of very serious concern.
"From these figures the [fitness to practice] committee can only conclude that it is highly probable that the procedures carried out in Drogheda were largely unnecessary."
So when Mr Lennon asks specialist medical colleges to examine their role in monitoring standards of clinical practice and suggests that an individual consultant's conduct is an important performance indicator, these are issues that require serious consideration.
Equally, employing authorities - as the final arbiters of resources and structures - must consider their responsibilities in terms of preventing future tragedies.
The Neary case has the potential to be a catalyst for change, just as the Bristol inquiry into inappropriate paediatric cardiac surgery helped improve standards in Britain.
Mr Lennon's observations deserve reflection and debate.
Dr Muiris Houston
Medical Correspondent