BishopAccountability.org
	Mutilated by Brutal "Surgery of Last Resort" Irish Independent September 7, 2008 http://www.independent.ie/opinion/analysis/mutilated-by-brutal-surgery-of-last-resort-1470985.html Collective silence ensured no one was ever made accountable for the butchery of Lourdes. Marie O'Connor reports The Lourdes outrage was in the same class, arguably, as the Bristol child heart surgery deaths. Only the scandal of infected blood exceeds the horror of what became known, wrongly, as the Caesarean hysterectomy scandal. The focus on Michael Neary has obscured wider issues. Our Lady of Lourdes Hospital shared the ethos of the wider society: conservative, patriarchal and Catholic. Decades of State lethargy gave the nod to medical power, consultant hubris, midwifery subservience and an obstetrical culture that objectified and demeaned women. The sheer scale of abuse at the Lourdes has yet to be comprehended. Decades of symphysiotomy -- a birth operation permanently widening the pelvis -- paved the way for decades of female organ removal. Symphysiotomy was often preferred to Caesarean, the norm for obstructed labour: Catholic thinking viewed Caesarean section with suspicion, associating it with sterilisation, contraception and abortion. But symphysiotomy tended to maim women, leaving them incontinent, in pain, and unable to walk properly. Hundreds of these 18th-Century birth operations were done at the Lourdes from the 1940s to the 1980s. In all, around 500 women had their symphysis pubis filleted, or their reproductive organs removed gratuitously, at the hospital -- not in error, but by design. How could this have happened? Clinical practice was a matter of personal preference. Some of the unit's birthing practices bordered on medieval. Episiotomy was the norm: even mothers whose bodies had already been stretched by childbirth were routinely cut during the act of giving birth. Trainees were taught to do vertical incisions, rather than the usual horizontal cuts, for Caesarean section. These incisions left women with long, disfiguring scars down the middle of their abdomens. Women complained about the fact that doctors carried out medical procedures without their consent. To no avail. In a hospital run by nuns, the culture was one of obedience: showing respect was what was required, not taking responsibility. From 1974 to 1998, the Caesarean rate rose sevenfold in the Drogheda hospital, from four per cent to 27 per cent. Hysterectomy rates shot up. Caesarean hysterectomy is surgery of last resort, done to stem uncontrollable bleeding. Obstetricians used to say they might do two or three in a lifetime. By the 1990s, the Lourdes Caesarean hysterectomy rate was 20 times that averaged by the big Dublin maternity hospitals. The Medical Missionaries of Mary, who were the hospital's owners, seemed oblivious. A patient complained in 1979, a matron in 1980, a pathologist in 1981. Nothing happened. But surgery is not a solo run, carried out by a single doctor: it is a team effort. Surgical nurses who handed the hysterectomy clamps to obstetricians , midwives who acted as scrub nurses in theatre, would all have been present. Registrars or senior registrars in obstetrics or anaesthetics, also, at one stage or another. Consultant anaesthetists have a special role in theatre too. The fact that wombs were being removed routinely was no secret. Staff recorded Caesarean hysterectomies in the postnatal ward daybook, for example. Midwives looked after the injured women post-operatively. Everyone -- the labour ward superintendent, the matron's assistant, the matron -- knew exactly which mothers had had their wombs and/or ovaries removed -- and when. Consultant pathologists must also have been aware of the phenomenal number of excised organs arriving down to the lab that dissection later found to be healthy. From 1974 to 1998, the record shows that 188 women had Caesarean hysterectomies at the Lourdes. One obstetrician, Neary, did 129 of these double operations. We know now that a large number of Neary's operations were carried for complications later found to be unfounded. Also, ovaries were removed arbitrarily -- singly, or in pairs -- in addition to wombs, some during routine gynaecological procedures. One woman, admitted to the Lourdes for a miscarriage, emerged minus her uterus, as did two others who had simply gone in for a D&C (dilatation and curettage). One mother woke up in the recovery room to find both her ovaries removed; another, who had had a slow third stage (of labour), awoke to find her womb stripped out in addition to her placenta. Until 1984, the maternity unit published statistics detailing the number of Caesarean hysterectomies performed there annually. Medical bodies asked no questions. Regulators failed to notice. The Medical Council confined itself to visiting the general hospital, which was in a separate building. The Royal College of Obstetricians and Gynaecologists visited the hospital twice, lunching at Dr Neary's house, and accrediting the unit for training. The visiting specialists did not reportedly concern themselves with clinical practice, nor did they spot-check the medical records. The non-appearance of the unit's annual report after 1984 went unremarked. Five inspections made by the Nursing Board failed to uncover anything untoward. As did a school of midwifery at the hospital, which was, and is, linked to Trinity College. General practitioners in the region whose patients were rendered infertile and/or catapulted into premature menopause apparently noticed nothing, either. The Lourdes continued to be a danger to women's health until October 1998, when the whistle was blown. The desire to protect led to theft on a grand scale: medical records were traced and removed, deliberately and systematically, over a number of years, in what gardai believe was an inside job, hiding the identity of those who had carried out, collaborated or colluded with these operations. The Medical Council struck off Dr Neary in 2003, after he was found guilty of having unnecessarily removed the wombs of 10 of his patients. Dr Michael Neary had performed 129 of the Caesarean hysterectomies at the Lourdes. The 2004 inquiry was not empowered to hold hearings in public, nor could it compel witnesses to give evidence. The terms of reference did not cover the maternity unit as a whole; nor did it cover cases where women had been stripped of their ovaries or their wombs in gynaecological procedures unrelated to Caesarean hysterectomy; nor did it cover the custom of making vertical incisions in Caesarean section. Some senior staff declined to appear before the judge. The Harding Clark Report heard the various excuses proffered: staff were too busy, too overworked, too tired, the hospital was under-funded, the unit too small. Junior hospital doctors blamed the fact that they depended on consultants for job references; midwives and nurses said they feared for their positions. Midwives blamed medical consultants' "personalities". They were not to be questioned, they said. Others said that they did not know what the statistical rate of Caesarean hysterectomy ought to be. The tribunal dissected in considerable detail the hospital's Catholic ethos. "Compassionate" hysterectomy fudged the picture. Neary argued that he had performed a significant number of hysterectomies as a covert form of sterilisation, a procedure forbidden in the Catholic hospital. Six Irish obstetricians reviewed Michael Neary's practices: no less than two reviews failed to appreciate the extent of his malpractice. Following Neary's enforced administrative leave in 1998, the Irish Hospital Consultants' Association invited three prominent obstetricians from the main Dublin maternity hospitals to examine a small sample of Neary's cases. The three agreed to set aside eight of the 17 files selected by Neary for review, on the grounds that they were "consent" hysterectomies. One of the assessors concluded: "It would be wrong to put restrictions on [Neary's] practice and it is my view that the mothers of the North-Eastern Health Board are fortunate in having the services of such an experienced and caring obstetrician." The other two found "no evidence of questionable clinical judgement, poor operative ability or faulty decision-making. Quite the contrary". Reviewing the same nine cases, Manchester obstetrician Dr Michael Maresh reached radically different conclusions. Neary's suspension followed. The Institute of Obstetrics and Gynaecology also reviewed a number of Neary's cases. Three obstetricians -- Dr Dermot MacDonald (Dublin), Dr Edgar Ritchie (Cork) and Dr Graham Harley (Belfast) -- found his practice acceptable in 41 per cent of cases: they concluded that a period of "retraining" was necessary. They also refused to criticise his predilection for vertical incisions for Caesarean, saying that, in many cases, "his patients have been of an age where that type of incision was irrelevant to them". In 2006, the Medical Council instituted disciplinary proceedings against Dr John Murphy of the National Maternity Hospital and his colleagues, Prof Walter Prendiville and Dr Bernard Steward, both of the Coombe Women's Hospital, arising out of their 1998 review of the Neary cases. Dr Murphy and Dr Prendiville subsequently applied to the High Court to have the council's finding of professional misconduct overturned. Mr Justice Peter Kelly ruled in their favour in December 2007, finding the council's procedures deficient. The efforts of Patient Focus, which has represented the Drogheda victims from the beginning, finally bore fruit when the Government set up a compensation package for the injured women in April 2007. Its terms were judged by some to be as meagre as they were mathematical, however. A points-based system, it was loaded against older women, and those of higher parity. Mothers who were both older and had larger families -- age and family size run together -- were doubly discriminated against. Around 40 women believed to have been injured at the Lourdes remain without compensation. The Government scheme excludes those who lost a single ovary, unless the remaining ovary was non-functioning; and women who did not have a Caesarean hysterectomy but were left without a womb and without a working ovary, unless they were under 40 at the time of the excision. Others excluded from compensation included several mothers whose babies died under circumstances they believed warranted further investigation, as well as those scarred by vertical Caesarean incisions. The redress board, presided over by Judge Harding Clark, is still sitting. No one was tried; no one was jailed. A police investigation, failing to trace the stolen hospital records, ran into the sand. The courts, on the grounds that they were "statute barred" or out of time, threw out actions for civil damages taken by mothers -- at that time, a three-year deadline applied to personal injury claims. Despite the sterling example set by former Medical Council President Dr John Hillery, the medical profession has been slow to take responsibility for the sentinel events at the Lourdes. Indeed, sections of the profession are widely believed to have seen off Dr Hillery as President because they disagreed with his views as to how the profession might implement new standards of transparency and accountability. What steps have been taken by regulators and trainers, such as the Institute of Obstetrics and Gynaecology, to address these issues? Other actors include the College of Anaesthetists and its parent body, the Royal College of Surgeons in Ireland, the Faculty of Pathology, the Royal College of Physicians in Ireland (parent body of both the Institute of Obstetrics and Gynaecology and the Faculty of Pathology), the Irish College of General Practitioners and An Bord Altranais. What have they done since 1998 to deal with the fall-out from the Lourdes? In 2004, the Government brought in a health act excluding from the HSE's "grievance and review" procedures all "matters" relating to "clinical judgement". Hospitals and administrators now have no legal obligation to review complaints made by patients about decisions relating to their care. The Act squares the circle by forcing patients to take their complaints about the medical profession to the Medical Council. No inquiry into the abuse suffered by over 100 symphysiotomy survivors is in contemplation, still less their compensation. Judged by international standards, the State oversight of our hospitals continues to be grossly inadequate. An Orwellian bureaucracy has grown up in health care in recent years. Bodies such as the Health Information and Quality Authority are perceived to focus on compliance, not quality of care. Ten years on, there are still no inspectors for acute hospitals, such as the Lourdes. There are no plans to introduce whistleblower legislation, and Government stalling on a hospital licensing system continues. Despite the best efforts of some, doctors, administrators and others, reform seems a long way off. Marie O'Connor is the author of 'Emergency: Irish hospitals in chaos'
Any original material on these pages is copyright © BishopAccountability.org 2004. Reproduce freely with attribution.