A review system is needed to ensure that patients are protected from misconduct, writes Dr Muiris Houston
In the wake of the striking off by the Medical Council of Dr Michael Neary, a former consultant obstetrician in Our Lady of Lourdes Hospital, Drogheda, the question on many lips this week is: why did he do what he did?
There is no easy answer. It is significant that Medical Council members themselves, including some who sat on the Fitness to Practise Committee inquiry over the past three years, were still asking afterwards, why did he perform so many Caesarean hysterectomies?
When Mr Justice Johnston delivered his judgment in the case of Alison Gough, one of Dr Neary's patients who was awarded damages against the obstetrician last November, he stated: "Dr Neary was very unconvincing in his explanations" as to why he performed a hysterectomy after the birth of her first child. Perhaps even Dr Neary cannot answer the "why" question.
Probably a more realistic question, and one which offers a better return in terms of preventing such a tragedy occurring again, is how was Dr Neary's exceptional practice allowed continue for so long? Or more specifically, how could an obstetrician be so out of line in his practice over a period of time without either his nursing or medical colleagues raising the alarm?
One of the answers lies in the hierarchical nature of medical practice. At the time of Dr Neary's professional misconduct, Our Lady of Lourdes Hospital was under the management of the Medical Missionaries of Mary. Its obstetrics unit was staffed by two to three consultant obstetricians, junior hospital doctors, midwives and other ancillary staff. The picture is one of a small unit within a larger hospital where someone with the authority of a consultant could wield enormous power. In a crisis, it was to the consultant on duty that everyone looked for a decision. Was it time to perform an emergency Caesarean section to save this baby? And if during the section the consultant announced that he had to proceed to hysterectomy, it could have been difficult for a theatre nurse or anaesthetist to question that decision.
Such was the power of hierarchical medicine - and some observers would argue that this power has only slightly diminished in the last 10 years - that it would require numbers of people standing together to question a consultant's decision.
Certainly, any expectations that a lone nurse or doctor would point to the minimal blood loss during a Caesarean operation and question the consultant's reasons for proceeding to an unnecessary hysterectomy are impractical. It would have taken an unusually heroic individual to stand up and start questioning Dr Neary on a solo basis.
The procedure of hysterectomy following Caesarean section is rare. According to medical evidence at the Alison Gough trial, the procedure is usually necessary only for one in 100,000 patients, when continuous bleeding from the woman's womb threatens her life. This is where the failure of the system becomes obvious. If there had been a mechanism in the hospital for the regular review of Caesarean sections and other activities within the obstetrics unit, Dr Neary's high rate of hysterectomy would have come to light. The problem could then have been dealt with in a number of ways; the end result would have been the protection of pregnant women within the north east region.
The North Eastern Health Board has outlined the measures it has introduced to prevent a recurrence. All Caesarean sections are now reviewed weekly; staff are trained to operate in a multi-disciplinary way, team decision-making is encouraged and a forum for the open and confidential airing of professional concerns has been created.
In effect, the North Eastern Health Board has introduced proper procedures for clinical governance in Drogheda. Clinical governance is the somewhat unwieldy term used to describe a health system designed with the patient at its centre. It includes proper and formal accountability procedures for all health professionals.
A national goal in the Government's 10-year health strategy is labelled: responsive and appropriate care delivery. And while it had missed its target date for achieving some of these clinical governance proposals, they are nonetheless there in black and white for health boards and hospitals to implement. Certainly no agency delivering healthcare in the Republic today could claim to be ignorant of where the system is heading.
While it is reassuring to know that the deficiencies that led to the Neary case have been identified and remedied, there must be some lingering concern that, somewhere out there, similar if less dramatic deficiencies remain unaddressed. It is certainly a cause of concern for the chair of the Medical Council's Ethics Committee, Geraldine Feeney. She told The Irish Times this week: "I am not sure that the problem is confined to obstetrics and that it could not happen in another discipline of medicine".
A new Medical Practitioners' Act has been promised for some time now. It is badly needed if stronger systems of competence assurance for doctors are to be introduced. For clinical governance to be copper fastened, the new Act must signal a different culture of accountability for the medical profession. And it is time that more lay members - some would say a majority - be introduced as part of a Bill now expected before the Oireachtas in the autumn.
This weekend, the Minister for Health, Micheál Martin, is considering whether to institute a judicial inquiry into the events at Our Lady of Lourdes Hospital.
Feeney, a Fianna Fáil member of the Seanad, was in no doubt what needed to be done: "The Neary Report is bigger than the Medical Council - there are more serious issues arising from the report - and there is an onus on the Medical Council to send it on to another authority".