Jim Glennon (Dublin North, Fianna Fail)

I join my colleagues in complimenting Judge Harding Clark on her excellent report and the manner in which she conducted her inquiry. I also compliment the brave midwife who stood up and shouted "stop". I welcome members of Patient Focus to the House and particularly compliment and congratulate them on their resilience, persistence and, above all, dignity in the face of significant personal adversity. I do not intend to go into detail on the report but to briefly examine the culture that brought us here today.

We know the midwife shouted "stop", but we must examine who knew but did not shout "stop": the obstetricians who worked in the unit and who knew of the operations; the junior doctors and the post-membership registrars; the anaesthetists who received the patients, administered the anaesthesia, wrote the operation notes, spoke to each patient in the recovery room and were always present during the operations; the surgical nurses, frequently midwives, who handed the hysterectomy clamps to the surgeons and counted the swabs; the midwives who cared for the women after their operations and who recorded each day, with the honourable exception of the lady who called "stop"; the pathologists and technicians who received the wombs and specimens from the maternity theatre to be analysed; and the Medical Missionaries of Mary, who owned the hospital for most of the period involved.

There are also some people whose silence I find particularly difficult to understand. Not one of the vast range of GPs for the women, each of whom treated the individual patients and was detached from the circle of immediate influence in the hospital environment, raised a question. None of the parties who read the maternity hospital's annual reports shouted "stop". As for the visits to Drogheda from the "gentlemen" of the royal college, where they had lunch with Dr. Neary in his home and dealt with files selected by Dr. Neary, I wonder what they thought they were doing. Were they acting in their professional capacity or were they there for a day out? I wonder if they took in a round of golf at Baltray. Reading the report it appears that these so-called inspections took place in such an atmosphere. The word "royal" raises questions. Why do we not have our own Irish institute? We do not have to do our own inspections but could get inspectors from outside. A "royal" institute having an input in this country is an anachronism.

The anaesthetists described Dr. Neary as a "safe pair of hands". They thought Dr. Lynch was professional and competent, a quick and clean worker. They thought Dr. Neary might have been a little hasty to resort to hysterectomy. One suggested to the inquiry that obstetricians had gone the other way and were too slow to resort to hysterectomy. Incredibly they were unaware of comparative statistics. Pathologists seemed to know the number of hysterectomies but did not know of any benchmark figure to use as a comparator and had no concerns regarding surgeons. The newest pathologist was concerned about the number of uteri and ovaries he saw in the laboratory. In the final nine months he had resolved to discuss the matter with Dr. Neary but, unsurprisingly, that never took place. These are the fellow consultants of Dr. Neary. One would not expect they could be easily cowed or intimidated. They are of equal rank in the medical hierarchy: anaesthetists, pathologists, obstetricians and gynaecologists.

One aspect of the report staggered me. The medical board, again made up of consultants, was unaware of what went on in the maternity units. That begs the question what is the function of the medical board of any hospital if it is not to oversee the medical work there. Here we have a board made up of consultants unaware of what went on in the units. I have dealt with the outside obstetricians briefly. It is interesting that nobody to whom any of the annual reports were sent raised queries. Dr. Neary informed the inquiry that no queries were ever put to him arising from the annual report. Amazingly the reports in the 1970s through to 1984 were published openly, including the number of Caesareans and hysterectomies. It was confirmed to the inquiry by the royal college in London that these reports were archived and not read. What is the point in furnishing the reports to an outside body if they are just to be filed? They could be filed in the hospital, although they could then be easily removed, as many of the files were. Maybe they could be filed in the Drogheda library for all the good the forwarding to London provided.

On justice for these dignified ladies, I agree with my colleagues who suggest that the Alison Gough case should be the benchmark for compensation and that the same criteria used in that case should be applied in all other cases. I suggest that the role of the MDU not only in Drogheda but in the Irish medical system generally should be examined. It is anachronistic that discretionary cover is provided for all our consultants and the majority of GPs and that no contract of insurance is required for registration with the Medical Council. A hearing is an essential and integral part of the process for the ladies.

It is ironic on International Women's Day that I suggest the role of the husbands and partners, who have also suffered to a significant degree, should be recognised in whatever process is agreed. The Medical Council should immediately reopen an investigation into the 59 cases other than Dr. Neary's, mainly Dr. Lynch's. I recently listened to the chairman of the Medical Council, a man for whom I have high regard, discuss its forthcoming reform. He mentioned that there should be more lay involvement in the Medical Council, with which we all agree, but set the limit at 12. The Medical Council consists of 25 members. Why should there not be a majority of lay people on the Medical Council? Why should the profession which is being policed by the council, as it were, retain a majority on it? I do not know. I am asking the question. I will be interested in the debate on the Medical Council and I look forward to it.

The Director of Public Prosecutions should review all the files again and I understand that moves are afoot in this regard. We have heard much of the phrase "meaningful audit in the future". The important word is "meaningful". As for the storage of records some back-up system must be introduced to obviate the ridiculous situation of missing records. We cannot have the scenario, which is now in prospect, where each patient seeks his or her records on leaving a doctor's surgery. Unless we come up with an appropriate system, that could well be the situation.

I again compliment and congratulate the midwife who shouted "Stop". I congratulate Patient Focus and wish it well for the future. I also compliment the Tánaiste on the sensitive manner in which she has dealt with this matter so far. We look forward to that continuing into the future.

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