An obstetrician in a unit of the size in which Dr A was working might expect to perform an average of three caesarean hysterectomies during his or her career, ac cording to medical sources. At the hospital where he worked, however, there was a sudden increase in the number of hysterectomies during caesareans.
A review of records showed one consultant obstetrician, Dr A, performed 21 of 27 procedures carried out in the hospital. The average jumped from one a year in 1994-1995 to nine a year in 1996-1998.
It is understood that the external report commissioned by the health board for which he worked said caesarean hysterectomies might need to be performed by a doctor occasionally, and that one case a year might be expected at a hospital this size, as opposed to nine a year.
"The Rotunda [hospital in Dublin] would hardly do that in a year," one consultant obstetrician who did not wish to be named told The Irish Times yesterday. Another obstetrician, speaking about the number of procedures carried out, described it as "bizarre practice".
The jump in figures for caesarean hysterectomies, the report said, should have been a cause for concern in the hospital. In obstetrics, it is very important to monitor complicated cases, particularly where such procedures result.
It would have been anticipated, according to the report, that some time during 1997, the hospital would have carried out a review to assess whether anything should be done to reduce the number of caesarean hysterectomies. It seems clear that this was not done.
"It would be very unusual to have three in six months, because you do everything to save the womb," said an obstetrician who works in a large maternity unit, "but it could happen. If you did have a bad run, the thing to do is to sit down and review it and see if something was done incorrectly or if it was just bad luck."
It is of concern, but not unusual in an Irish context, that the hospital did not carry out clinical audits of Dr A's work. It is questionable whether this practice will be allowed to continue after this case.
Sources in the Medical Council say they were unaware of the case when it published a discussion paper on Friday, to be submitted to the Minister for Health, recommending that doctors should have to be certified every five years under the terms of legislation allowing them to practise in the State.
The international trend, said council president Prof Gerry Bury, was towards pro-active assurance of doctors' competence. In the UK, new rules governing the performance of surgeons were announced recently in the wake of the crisis at Bristol Royal Infirmary in which 29 babies died following heart surgery.
The UK-based Royal College of Surgeons made its recommendations following a call by the General Medical Council there to restore public confidence in the profession.
In that case, unusually high numbers of small children and babies died following hole-in-the-heart surgery at the infirmary in the late 1980s and early 1990s.
The eight-month GMC inquiry centred on 29 deaths between 1988-1995. Three doctors and the chief executive of the United Bristol Healthcare Trust were found guilty of serious professional misconduct by the GMC in June 1998. The Royal College of Surgeons was the first professional medical body to report back on the GMC's call to tighten up rules monitoring surgeons' standards and performance.
The GMC also said doctors needed to take prompt action as quickly as possible when a colleague was in difficulty, that there should be reliable and valid data monitoring a surgeon's performance, and more "openness and frankness" in the profession about a doctor's personal performance.
The Royal College of Surgeons recommended that performances would be scrutinised using a national database, listing the types, numbers and outcomes of operations.
An obstetric hysterectomy is performed because of uncontrollable bleeding from the uterus following birth, usually associated with a caesarean section.
According to one gynaecologist, it is performed in "an absolute emergency. You move like lightning to save the mother and to get the baby delivered." It is not routine to remove ovaries during this procedure, as performed a number of times by Dr A.
"If you perform a caesarean hysterectomy, you are not in a situation at that time where you have had concerns about the health of the ovaries. These are young women at a stage in life where ovarian disease does not affect them. You should not be doing caesarean hysterectomies in the first place if you cannot work your way around an ovary and leave it there."
He said if a woman was in her mid-40s and unlikely to have any more children, the doctor may then decide on ovary removal. In the past, one ovary may have been removed to reduce the risk of disease, such as cancer, by 50 per cent. To remove both would send a woman into "crash" menopause because no oestrogen would be produced. This results in hot flushes, breast shrinkage, vaginal dryness, accompanying psychiatric problems, loss of libido, rapid onset of osteoporosis and related heart disease.
While ovary removal in older women is a point of debate among the medical profession, the availability of hormone replacement means that doctors may remove both ovaries and put the woman on the hormone replacement medication straight away.
A caesarean hysterectomy is carried out only when the various measures which have been taken to control the bleeding have failed and there is concern over the woman's life.
However, The Irish Times understands that the outside examiner who looked again at Dr A's cases said that while such a decision was taken by the consultant, another consultant may sometimes be called in to assist. This was not done by Dr A.
A hysterectomy prevents the woman having any more children and therefore with young women who have not completed their family, great efforts would usually by doctors to avoid it. Delaying a hysterectomy with continued bleeding would cause its own problems - another reason, it is believed the report concluded, why a second opinion should have been considered.
At the hospital where he worked, concern was also expressed about perceived out-of-date practices with regard to Dr A's surgical techniques and the use of episiotomies. An episiotomy is the making of an incision to facilitate the delivery of a baby. After delivery, the cut tissues are stitched back together.
It was advocated almost routinely until recently on the grounds that a surgical cut would heal better than a tear. However, the majority view now is that episiotomies should be performed only when there are clear reasons for it. It is often necessary in a forceps delivery or if the baby is suffering from foetal distress, to speed delivery.