Beverley Flynn (Mayo, Independent)

Like previous speakers, I welcome the opportunity to speak on this shocking report. It is a shame that we are obliged to discuss a report of this nature on International Women's Day. All we can hope is that lessons will be learned from the horrific experiences outlined in the report.

Before discussing the detail of the report, I compliment Patient Focus, which represents the patients involved who outlined their personal experiences, and Judge Maureen Harding Clark who produced the report. It must have been a difficult experience for the women involved and what they endured should not be underestimated. I compliment the Government on having moved quickly to establish a redress mechanism for the victims in this report. It is important that the issue be dealt with swiftly and that adequate compensation be paid to all the victims involved in a sensitive manner. I welcome the fact that Judge Harding Clark will ensure that this happens.

One need not delve deeply into the report to be quite shocked at the history and background to the events. The historical part of the report points out that 15 complaints were made to the Medical Council between 1986 and 1998. However, it took until June 2000 before an inquiry began. Considering the length of time involved and the fact that complaints were being made in respect of a matter of such a serious nature, that delay is shocking. It took three more years, until July 2003, for the fitness to practice committee to find the case against Dr. Neary proven and to find him guilty of professional misconduct. The delay covers almost 17 years from the first complaint. A number of hysterectomies carried out in the years afterwards may have been avoided if action had been taken sooner.

In this regard, I welcome the fact that a new medical practitioners Bill will be introduced. I welcome the Tánaiste's indication that she will make the heads of this Bill available to all interested stakeholders as soon as possible in order that a complete overhaul of the Medical Practitioners Act can be carried out and the new Bill can come before the House. The new legislation will introduce more streamlined and transparent procedures for the processing of complaints. Given the length of time it took to investigate in this particular case, that is necessary. Another scandal is the missing charts, which are referred to in the report and give cause for concern. The last page of the report states the removal of old maternity theatre registers, the selective removal of master cards and birth registers, which contained details of 40 Caesarean hysterectomies, and the culling of corresponding charts are attributable to a deliberate removal of information on those hysterectomies. The sad result of that is there are over 40 women looking for details on their own cases who may never know the truth about their personal situation. It is an absolute scandal that, as is clear from the report, this was a deliberate act to misrepresent the situation and blot out the truth. Fortunately the judge has revealed it and the truth will not be obliterated. Hopefully a Garda criminal investigation will get to the bottom of it.

The table of clusters of procedures on page 62 of the report shows a shocking number of hysterectomies. For example, on 3 October there were two on one day. This happened on three separate occasions, the others being 3 December 1983 and in October 1980. Obstetricians might only carry out between two and ten hysterectomies of this type during their entire career. In this case, on three separate occasions from 1976 to 1998 there were two on one day.

The report also highlights the complete lack of communication between the anaesthetist and the pathologist and among the various categories of consultants that allowed the situation to develop. A doctor might carry out a Caesarean hysterectomy but not communicate with the pathology department to ascertain the reasons for it. We know from an analysis of the various files that many of these hysterectomies could have been avoided. It is nothing short of an absolute scandal that consultants with God complexes made it virtually impossible, certainly for a lower ranking member of staff, to even question their activities. Let nobody be under any illusion, God complexes still exist in hospitals today. That is why I also welcome the announcement this morning by the Tánaiste of the setting up of the perinatal epidemiology centre in Cork, which will bring together statistical information from all the different units throughout the country to identify unusual trends so this can never happen again. The devising of a single maternity chart for all maternity hospitals is also critically important.

When something like this comes into the public domain people start asking questions. Gone are the days when they take the word of a doctor on anything. Now people have the right to question, which is as it should be. In my local hospital the obstetricians meet on a weekly basis to discuss the various outcomes in their cases and an independent audit is critically important.

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