Mary Henry (Independent)

Our knowledge of the hierarchical structures which were in place does not make the whole procedure any less inexplicable.

It is most unfortunate that those who inspected Our Lady of Lourdes Hospital were Dr. Neary's peers. Ireland is a very small country with a small number of obstetricians. That there were under 100 obstetricians in the country at that time meant that such people were inspected by their friends, which was entirely unsatisfactory. When the Royal College of Obstetricians and Gynaecologists carried out inspections, they were carried out by its Irish members, which was also unsatisfactory. I share Senator Feeney's grave concern about the fact that three obstetricians gave Dr. Neary a clean bill of health, as it was described locally, in 1998. That caused enormous distress to those in the local area who had objected to his conduct. If peer review is to be meaningful, it needs to be impossible for people to be reviewed by their friends.

Some people objected to the procedures which were taking place at Our Lady of Lourdes Hospital. The hospital matron deserves great credit for making an objection. Midwives, including young student midwives in some cases, objected to the old-fashioned practices of Dr. Neary, who had never been retrained and had been appointed at a very young age, after limited training in the United Kingdom. Despite their criticisms, Dr. Neary was still able to make midline incisions for caesarean sections, to practise shaving and to examine women in the lithotomy position, as Senator Terry so well described. The people who raised concerns were told that their complaints were unjustified. They had to withdraw their complaints in tears. The anaesthetists are criticised in the report, which states that they should "recognise their professional obligations to fill in clinical incident forms" in the theatre when untoward events occur.

As I was reading the report, I started to wonder whether things went on in the Rotunda Hospital, where I worked for three and a half decades, which I simply did not realise were happening. It happened on three occasions that two peripartum hysterectomies were done in a single day at Our Lady of Lourdes Hospital without anyone taking any notice of it. When I worked at the Rotunda Hospital, such a procedure was second only to a maternal death and everyone in the hospital would know about it. I was relieved when I read the section of the report which mentioned that Dr. Peter McKenna, who is a former master of the Rotunda Hospital, had examined the incidence of peripartum hysterectomies between 1975 and 2001 and found that 52 such procedures took place in the hospital, which had an annual average of over 6,000 deliveries, during that time. Just 52 peripartum hysterectomies resulted from the many thousands of deliveries which took place in the hospital over that 27-year period, whereas there were 188 such procedures in the Our Lady of Lourdes Hospital, which had a much smaller overall number of deliveries in that time.

The staff of the maternity unit at Our Lady of Lourdes Hospital seemed to feel that loyalty to the unit was more important than loyalty to their patients or to the medical profession. They were under the impression that Dr. Neary, who I accept was a hard-working man with a very heavy workload, could not fail to do the right thing. It is suggested in the report that the nuns of the Medical Missionaries of Mary thought that Dr. Neary "walked on water". There are great dangers in small units; for example, there might not be anyone there of sufficient seniority to query the practices which might be taking place. When the matron complained to her colleagues in the unit, she was told by the consultants that it was none of her business. There seems to have been a bad atmosphere between the unit's consultants and the rest of the staff of the unit. The hospital's culture meant that no advice regarding contraception could be given. No tubal ligations could take place, for example.