Thursday, 9 March 2006
Seanad Eireann Debate
Minister of State at the Department of Health and Children (Mr. T. O’Malley): The Government last week published Judge Maureen Harding Clark’s report on peripartum hysterectomy at Our Lady of Lourdes Hospital, Drogheda. In launching the report, the Tánaiste and Minister for Health and Children was conscious that the last few years have been particularly difficult and traumatic for many former patients of the maternity unit at Drogheda. I also want to express my deepest regret and to apologise to these women and their families for what happened. I assure the women involved that many lessons will be learned from this report, and I equally assure them that the Government will respond fully to the report’s findings.
On the day following publication, the Minister met Patient Focus, the group that represents many of the former patients of Dr. Neary, to express her concern and to discuss the report. The Minister and I appreciate the manner in which Patient Focus assisted the work of the inquiry, which was conducted on a non-statutory basis. I hope the publication of this report will in some way help to give answers to the questions that have been asked concerning events at the Lourdes hospital.
I also want to thank Judge Maureen Harding Clark and the inquiry team for the work that they have done in the preparation of what has been widely received as an excellent, fair and comprehensive report.
Since publication of the report, the Tánaiste has had a number of meetings with key agencies to discuss the findings. Steps must now be taken to ensure that its findings are quickly taken on board by the health system. The task facing us is to ensure that the failures found to have occurred at Drogheda in the past are never allowed to recur.
One of the issues discussed with Patient Focus was the question of redress for the women involved. The Government has considered the matter and agreed that Judge Harding Clark will advise on an appropriate scheme of redress arising from the findings of her report. She will also advise on the cost of such a scheme and on a mechanism for ensuring the maximum recoupment of such costs from wrongdoers and indemnifiers.
The Tánaiste is convinced that Judge Harding Clark is the best person to advise the Government on the issue of an appropriate redress scheme based on her discussions with Patient Focus and the reaction of various other parties to the report of the Lourdes hospital inquiry. The quality of her work and report has been widely acknowledged. Her unique insights and skills can be brought to bear on the issue of redress and she has the respect and confidence of the women affected and the other parties involved. Judge Harding Clark will commence her work immediately and will bring her proposals to the Tánaiste as soon as possible.
The recommendations in the report will act as a significant catalyst in the reform agenda. They confirm the appropriateness of the actions being taken in the preparation of the new medical practitioners Bill, the reform of the current consultant contract and the changes in management systems within hospitals.
Yesterday the Tánaiste announced the establishment of a new national perinatal epidemiology centre at Cork University Hospital, that will be up and running in the autumn of this year, with annual funding of €630,OOO. Every time a mother gives birth in this country, the important interventions, the good outcomes and the complications will be recorded and analysed at a national specialist centre. Unusual trends will be easily and quickly observed and, most important, acted on.
International experience of health service failures demonstrates the value of reviewing mechanisms to ensure clinical governance and quality throughout the health service. The report of the Lourdes hospital inquiry should cause us to deal clearly with the implications that its findings have for the health service as a whole. It is the Tánaiste’s intention to come back to Government shortly with proposals to establish a mechanism to ensure that, in particular, clinical governance arrangements are strengthened throughout the health system. This will entail the fostering of a continuing culture of openness, preparedness to acknowledge errors and an ability to analyse clinical practice in an environment that does not resort to blame and recrimination.
The Department is to develop proposals to address the need for stronger clinical governance arrangements throughout the health system. In addition to the actions already being taken in the preparation of the new medical practitioners Bill, the reform of the consultant contract and changes in hospital management systems, there is a need to analyse the implications of the report for the health system as a whole.
We need to address the risk of such a level of malpractice happening again in the future. This means we need to identify and tackle weaknesses in any part of our health system, whether regulatory, governance, organisational, managerial or clinical. The Tánaiste intends to bring proposals to Government shortly to establish a process that ensures the lessons of this report are built into stronger clinical governance arrangements throughout the health system.
Work on the forthcoming medical practitioners Bill is well advanced. This Bill will completely update the Medical Practitioners Act 1978 and will address the recommendations arising from the Lourdes hospital inquiry report in the following ways. It will underline the Medical Council’s role as the body in this State which acts to protect the public by way of regulation of the medical profession: it will introduce more streamlined and transparent procedures for the processing of complaints; it will modernise registration processes to allow for flexibility where required; it will integrate registration, education and training, ongoing competence and fitness to practise processes; it will clearly define the responsibilities of the Medical Council with regard to the education and training of medical practitioners; it will provide for the first time a legal framework for the Medical Council’s implementation and administration of a system of competence assurance; and it will make continuing professional development and education compulsory for medical practitioners.
Systems should be in place within the hospital setting to allow management, medical practitioners or other health care professionals to raise concerns about aspects of practice. Such concerns should be capable of being addressed in the context of rigorous processes of audit, peer review and external evaluation.
The purpose of the Medical Council is not only to provide a registration service for medical practitioners. It must also be seen as the competent authority for dealing with serious allegations of professional misconduct. Patients require assurances that their interests are paramount and override any sectional concerns. While the medical practitioners Bill will be an important piece of legislation, it is only one part of a suite of legislative instruments which is now being put in place to ensure greater accountability of all health care professionals.
The Lourdes hospital inquiry report has affirmed the approach being pursued by the Government in the context of negotiations for a new contract for hospital consultants. The necessity for improvements in teamworking by consultants is underlined, but it also reinforces Government proposals on the contract on the need for clear clinical leadership which will ensure that individual clinical practice is in line with acceptable standards of practice. The report highlights the necessity to have clear responsibility for the training of non-consultant hospital doctors. It is from these specialist trainees that we will be provided with consultants who will be clinical leaders in our future health service.
The Government has approved the publication of the general scheme of the Bill providing for the establishment of the health information and quality authority, HIQA, on a statutory basis as part of a publication process on the proposals in the general scheme. The HIQA will set standards for most services provided by or on behalf of the HSE and monitor those standards with powers to investigate, at the request of the Minister or the HSE, the safety, quality and standards of any such service. The House will be aware that the Tánaiste has expressed the view that there should be a licensing system in place for all hospitals and she intends to consider the mechanisms required to put in place such a system.
It may be useful to briefly remind the House of the background that led to the establishment of the Lourdes hospital inquiry. The Medical Council found that the facts with regard to ten complaints against Dr. Neary of unwarranted peripartum hysterectomy were proven. Dr. Neary was found guilty of professional misconduct and in September 2003 was struck off the Register of Medical Practitioners.
The Government decided in April 2004 to establish the Lourdes hospital inquiry to examine the matters raised by the findings of the Medical Council. Anybody who has read the inquiry’s report will have been struck by the phrase used by Judge Harding Clark when she referred to the number of peripartum hysterectomies performed at Drogheda as “truly shocking”.
A total of 188 peripartum hysterectomies were carried out in a 25-year period from 1974 to 1998. Of this figure, 129 are attributed to Dr. Neary alone, 53 of which were carried out from 1990 to 1998 following the transfer of the obstetric service to a new unit. Dr. Neary’s caesarean hysterectomy patients had a different profile compared with the rest of the unit. They were younger and were of lower parity, that is, they had a lower number of pregnancies. The rate of caesarean hysterectomy at the hospital for the period 1974 to 1998 was one for every 37 caesarean sections. In contrast, the rate per section at other hospitals of similar ethos and over a similar period was one for every 300 at Airmount Hospital Waterford, owned by the Medical Missionaries of Mary, and one for every 254 at Portiuncula Hospital, Ballinasloe, which was Franciscan. The rate per section in two other non-Dublin maternity hospitals was one per 315 at St. Finbarr’s Hospital and the Erinville Hospital, both in Cork.
The inquiry found that the facts were there for all to see and the operations were openly recorded. This is not the story of a surgeon with poor surgical skills or a doctor deficient in academic excellence. It is the story of a doctor who, at critical points during his training, was inadequately supervised. Dr. Neary came to work in a unit which lacked leadership, peer review, audit or critical capacity. It is the story of a doctor with a deep fault line and a misplaced sense of confidence in his own ability. The inquiry found that no one who worked with Dr. Neary suggested that he had any ulterior motive for what he did.
Mr. T. O’Malley: One of the most remarkable findings in the report is that few people complained or questioned. Management and staff reasoned that they did not deal with the high rate of peripartum hysterectomy at Drogheda because they were not informed, all the hysterectomies were carried out for a very good reason, there was no audit and because no one knew what was an acceptable rate.
The inquiry found that none of the obstetricians who worked with Dr. Neary at Drogheda was aware that there was a culture of early resort to hysterectomy. The inquiry was critical of the extent to which the anaesthetists present at the procedures failed to question the obstetric practice. The pathologists assumed that some hysterectomies were sterilisations.
Some junior doctors felt a special gratitude to Dr. Neary for his time in assisting them with obstetric emergencies, while others were disturbed by the lack of meetings, teaching and discussion. In common with some of the midwives and anaesthetists, they described how Dr. Neary could not adapt to new procedures and did not find it easy to delegate.
Mr. T. O’Malley: The number of caesarean hysterectomies carried out by Dr. Neary in 1978 and 1979 caused the matron of the time some concern but her concerns were not heeded. No other person or institution raised any issues until October 1998 when two midwives, who were consulting the health board solicitor on an unrelated matter, sought his advice on serious concerns which one of them had about Dr. Neary’s practices.
The Royal College of Obstetricians and Gynaecologists inspected the maternity unit in 1987 and 1992 and found it to be suitable for training obstetric registrars but made a series of recommendations. No return visit was planned to determine whether any recommended changes had been effected. The Royal College of Surgeons in Ireland approved the maternity unit for undergraduate training. An Bord Altranais carried out periodic assessments of the midwifery school at the maternity hospital for accreditation purposes. It advised in 1980 that women should be offered a full choice of contraception and that midwives ought to be fully trained in these methods. Nothing happened.
Among the many disturbing findings in the report is the fact that three consultant obstetricians from Dublin maternity hospitals, having examined a number of examples of his practice, found that Dr. Neary had no case to answer. In considering their report, prepared at Dr. Neary’s request, the inquiry concluded that it may well have been the intention of his union advisers and his three colleagues to enable Dr. Neary to continue working, pending the review of the Institute of Obstetricians and Gynaecologists. This raises major concerns about the methodology employed in the peer review.
The inquiry found that management’s initial response to the revelations about Dr. Neary’s practice was prompt and appropriate. The decisions made and the procedures introduced to deal with the situation at the time were courageous and correct. Now most of the elements are in place and the importance of quickly completing the process has been stressed to the National Hospitals Office.
The inquiry found that over 23% of obstetric hysterectomy records, representing 44 cases, for the period 1974 to 1998 are missing and were intentionally and unlawfully removed from the hospital. The inquiry is satisfied that a person or persons unidentified, who had knowledge of where records were stored and who had easy access to those records, was responsible for a deliberate, careful and systematic removal of the key historical records which are missing, together with master cards and patient charts. Alterations were made to the maternity theatre register after complaints were made against Dr. Neary. Most of the missing records refer to Dr. Neary’s patients. The Tánaiste has invited the Garda Síochána to read the report in order to determine whether any further action is warranted in the light of Judge Harding Clark’s findings.
Among the many other disturbing findings is that a number of the patients were not told of their hysterectomies until some time had elapsed. Very few patients questioned Dr. Neary for carrying out a hysterectomy, but those who did found that his attitude became defensive and unfriendly when he was challenged. The most common complaint from patients was how the doctor carried out procedures on them without discussion beforehand.
As for the hospital today, the inquiry found that the possibility of the maternity unit falling behind in current practice is now remote. However, we cannot be complacent regarding this finding and must ensure that all necessary measures are taken on foot of the report’s findings. There have been major changes in practice in the maternity unit to minimise or entirely remove the climate of isolation referred to in the Medical Council report. The incidence of peripartum hysterectomy has fallen precipitously and now accords with national rates.
A team of consultant obstetricians is now in place, which should facilitate improved clinical audit and governance. The current consultants have developed a strong collegiate approach to practice. The unit is moving forward and offering care that is evaluated against known benchmarks. The inquiry found the medical board and the new consultants to have the motivation, skills and energy to move the hospital forward as a fully recognised teaching hospital with specialist registrar training in all its departments. The Tánaiste met the medical board following the publication of the report and was impressed with its obvious commitment to ensuring that the very highest standards of care prevail in the unit.
Members of this House will agree that this is a most comprehensive and fair report but it is also clear that many lessons need to be learned and changes made to ensure that such events do not happen again in Irish hospitals. The findings and recommendations are being examined in detail by the Department of Health and Children, in consultation with the Health Service Executive, the Medical Council and the other professional regulatory bodies.
The report’s recommendations will act as a significant catalyst for the reform agenda. They confirm the appropriateness of the actions taken in the preparation of the new medical practitioners Bill, the reform of the consultant contract and the changes in management systems in hospitals. They also confirm the importance of establishing the new health information and quality authority to set standards in health services and the provision of information, as well as to provide an early response to any suggestion of systems failure.
Ms Terry: I welcome the Minister of State at the Department of Health and Children, Deputy Tim O’Malley. I welcome the report, published by Judge Maureen Harding Clark on peripartum hysterectomy at Our Lady of Lourdes Hospital, Drogheda. It makes shocking reading as the judge said. I sympathise with those women involved, who were violated in a most appalling way. All Members, both women and men, must have great sympathy with them.
The appalling substance of the report is that these practices were allowed to happen and continue for several years unchecked. One man in particular, Dr. Neary, was in a position to be able to carry out those acts. For many young women hoping to have several more children, the consequences were devastating. It must not be forgotten that older women were also involved. Unnecessary peripartum hysterectomies carried out on those women were crimes. We must now ensure they get some satisfaction as a result of the report’s recommendations. We must also ensure no other woman, man or child, ever suffers at the hands of a medical person. Putting in place the report’s recommendations will help to ensure it never happens again.
From my experience, and that I gained from listening to my mother, the culture surrounding Dr. Neary also surrounded many other consultants. Many, but not all, always had an arrogant air about them. They were the lords and no one could question them. At Our Lady of Lourdes Hospital, no staff member dared question a consultant. If a staff member did, he or she suffered for it. Although many must feel sorry for not questioning the events in question, at the time they would have lost their jobs or been barred from promotion. People in authority at the hospital knew what was done by Dr. Neary was not right. Many of them have a responsibility to face up to what was done. They have a case to answer which must be properly investigated and people must be held accountable.
Many young medical professionals have a different attitude from that of senior consultants some years ago. They do not have that air of superiority about them; they keep the patient’s interests to the fore. Unfortunately, some aspects of the culture still exist. The structures we put in place must weed out those consultants who think themselves as gods in the hospitals. They must be reminded that they work in the public sector, are paid by taxpayers’ money, and must work for the public. They have a duty to look after the patient first. Structures and proper audits must be in place to ensure consultants are held to account. George Bernard Shaw once said, “Every profession is a conspiracy against the layman”. Some years ago that charge could be laid against the medical profession. I fear the culture of superiority has still not gone away.
Did the report consider if there were differences in Dr. Neary’s treatment of public and private patients? From my experience, I know there is one. One will still notice the difference between treatment meted out to a public and private patient in hospital.
I was first pregnant when I was 20 years old. Living in Dublin with no family around me or a GP, someone at work advised me to present at a certain hospital. I will never forget the treatment I received as a public patient at that hospital. When I came out, I told my husband I was never going back to it, that there must be another way of being looked after. Along with many other women, we were put into cubicles, set up on the high stools with our legs splayed out. The senior doctor came along with his trainee. To them I was just an object, I was not even spoken to. I had an internal examination from the senior doctor. He then turned to the junior doctor and said, “Now, you have a go”. That was my experience of having my first baby as a public patient.
I was lucky that my husband and I could manage, but with some difficulty, to join the VHI. From then on, I went private. My next visit to a consultant was held in a private room. It was all very nice, like going to a hotel and being treated with respect. My experience of the difference between public and private treatment was no different from that of many others. Although I had my last baby in 1981, when I pass a hospital it often crosses my mind how public patients who are pregnant are now treated.
Private female patients can have a sterilisation carried out because they can afford it. The Minister of State said An Bord Altranais carried out assessments of Our Lady of Lourdes Hospital. In 1980, it advised that women should be offered a full choice on contraception and that midwives should be trained in these methods. That is not good enough. I want to ensure that happens. Not long ago I asked for a debate on sexual and reproductive health in this House. Such a debate is still necessary. Sterilisation should be available to every woman if she wants it. We are talking about patient choice and making that service available. While these issues may be relevant indirectly to the report, they must be examined when we are dealing with the recommendations in the report.
Religious ethos should not be a factor in a patient’s treatment in hospitals that receive State funding. It is taxpayers’ money and if a patient requires a particular treatment he or she should be given it. Religion should not come into it. In a recent case in the Mater Hospital religious ethos was a factor in whether women should get certain treatment if they were taking contraceptives. That is dark ages stuff. I am glad that issue was resolved at the time.
The report focuses on what was done to women at a time when they are more vulnerable because they are pregnant. Women at that time put their trust in the medical profession — the doctor treating them, the nurses and the anaesthetist. Many of them had great respect for Dr. Neary. They believed he looked after them but we now know that in many cases he did not or he had some ulterior motives, on which I am still not clear.
This report does not explain the reason Dr. Neary carried out so many of these type of hysterectomies. Despite the excellent report on the failures of the system within the hospital, I still do not understand the thinking behind Dr. Neary’s actions. Dr. Neary’s victims need to know that. We all need to know his motives. Any structure that is put in place to ensure this does not recur must provide that a person who has any knowledge of wrongdoing has the ability to come forward with information and that they will be protected, regardless of whether it is a nurse starting off her training or the most senior person in the hospital. A person wishing to make a complaint must have somewhere to go to with that complaint. The complaint must be dealt with and they should not be treated in the fashion the people in Our Lady of Lourdes Hospital were treated.
Ms Terry: They may not be maternity cases but may concern other areas. It may be women with breast cancer having their breast removed unnecessarily. Who knows the other cases that will come to light down the road? It is vitally important, therefore, that we have structures in place now and if they are not in place, that should be done at the earliest opportunity to ensure this never happens again, that the victims get the compensation they deserve as quickly as possible and that we do not make them suffer any more than they have done already. Looking after these women must be the number one priority, and that must be done as speedily as possible.
Ms Feeney: I welcome the Minister of State to the House for this important debate. I am delighted the Upper House has an opportunity to debate what the Minister described as an excellent, fair, comprehensive report. We thank Judge Maureen Harding Clark for the speedy report she has presented. Before I begin I want to congratulate Patient Focus, particularly Sheila O’Connor, who stuck with this issue and counselled very vulnerable women when nobody else was available to listen to them.
I am aware of the personal circumstances of the Neary women because I sat on the Medical Council’s inquiry which lasted three years and I have a particular knowledge of events covered in Judge Maureen Harding Clark’s report. I listened with great sadness to the story of the victims of Our Lady of Lourdes Hospital. As a woman and a mother, I empathise greatly with the pain and suffering that was so evident in all their stories. Some of these women told their stories ten years after the event. I remember thinking at the time that it could have happened yesterday, last week or last month because the pain was so evident in the voices and faces of these women.
The Medical Council acted swiftly in December 1998 when it received the prima facie evidence from the health board at the time. It went to the High Court to obtain a section 51 order under the Medical Practitioners Act. Section 51 of the Act will render a doctor unfit to practise and he will be taken out of commission pending a full Medical Council fitness to practise inquiry. Following that inquiry, Dr. Neary was struck off the medical register, and rightly so.
Michael Neary was a deeply flawed practitioner whose actions were unforgivable. Senator Terry said we have to know why he acted as he did. I attended that inquiry over a three year period and on many occasions I looked across at the man to try to gain some insight into what might have gone wrong for him but I saw no remorse nor did I gain any insight. When women broke down giving their evidence, I bit the inside of my lips and felt a lump in my throat as I held back tears. I find it difficult to talk about it even today. Their stories were horrific. In the nine cases I heard, not one of those women had a hysterectomy for sterilisation purposes. They ranged in age from a teenager of 19 having her first baby to a woman of 32 years of age. Women today do not even start having their families at 32 years of age.
On the high number of caesarean hysterectomies carried out by Michael Neary — I will continue to call him Michael Neary because it is a shame to the profession of medicine that this man was called “Doctor” for so long — I was told by Dr. Eamon McGuinness, an obstetrician-gynaecologist who sat on the inquiry with me, that in his 30 years of practice he had carried out one caesarean hysterectomy on a woman in her mid-30s who had five children. He worked on that woman for eight hours. He massaged and packed the uterus and did everything medically possible to try to preserve it. She received 11 or 12 units of blood and, after nine hours, the doctor called in one of his senior colleagues to help with the operation. I tell this story because Dr. Neary never called in any of his colleagues to help. He proceeded to perform a hysterectomy within minutes of delivering babies. The babies were delivered, the hysterectomies were carried out and the women were back in recovery within an hour to an hour and a quarter. The hair is standing on my head recalling the horrific events about which I have heard.
It is worthwhile recalling a few of the women’s stories. I will not name any of them but I will never forget their names. The first woman I want to talk about delivered a little baby girl on 18 August 1986. One might ask how I can remember the date; I remember it because my fourth baby, a daughter, was born the very same day in the north west in Sligo General Hospital. I was ten years the woman’s senior — she was 19 and I was 29. My baby was born perfectly healthy at 7 a.m. and the woman’s little baby girl was born at 2 p.m. Her baby, who was called Eileen, had spina bifida and died six weeks later. I will never forget the mother’s tears and those of her husband as they told us their stories. She is still married to her lovely husband but her life is a living hell. She has been robbed of the most vital thing any woman has, that is, the facility to procreate.
Another lady, who lost her first baby at 23 weeks, had her second baby delivered by Dr. Neary at full term. She begged him from the operating table not to carry out a caesarean hysterectomy. She had asked her husband before her baby was delivered not to let the doctor take away her womb. Dr. Neary told her, after delivering her little baby boy, that he had to proceed to hysterectomy within ten minutes or she would die. She felt perfectly well and there was no way she would have died within ten minutes, as he told her. He told her husband that if he did not sign the consent form she would be dead within ten minutes. The other midwives all knew the woman and one cried and asked the doctor to go for Dr. Lynch, but Dr. Neary said the woman would be dead if the hysterectomy was not carried out immediately.
I query the consent Dr. Neary received to remove any of these uteri. I do not believe he had consent but that he robbed the women of their uteri. When the Medical Council conducted its inquiry, I spoke on “News at One” and stated the report should be handed over to the Garda and that a criminal investigation should be carried out.
Another story concerns a lovely young girl in her late 20s who delivered her third baby. In this case Dr. Neary also proceeded to perform a hysterectomy. The woman did not want to be involved in the Medical Council’s inquiry and we respected that. However, when Dr. Neary gave evidence and it was adduced by his senior counsel that the lady was a Jehovah’s Witness, and that, for religious reasons, she had asked that blood not be given to her and that her uterus be taken, if necessary, I could not sit and listen to that kind of evidence. I asked that the lady be subpoenaed and when she came before us her evidence directly contradicted that of Dr. Neary. I tell these terrible stories to afford Members an insight into what occurred. On reading the report one would never know the horrific nature of the procedures to which the women in question were subjected.
I mentioned Sheila O’Connor earlier in my address and I am delighted to see her and some of the women from Patient Focus, who have been affected by Dr. Michael Neary, in the Visitors Gallery. They are very welcome. How and why did these procedures on the part of Dr. Neary occur? We will never know and I do not believe anybody will ever get through to that man’s mind to know why. This is poor consolation to the women affected.
We all know pregnancy and the birth of a baby comprise a very joyous occasion. Pregnancy is not an illness but a condition one enjoys from the minute one is told one is carrying a baby until one delivers it. Pregnancy represents a family time, but the women in question have been cruelly denied the possibility of ever experiencing it. There are women who have had one baby but who will never have another. I know of one woman whose little baby girl died and she will never have another to replace her, not that one can ever replace a child.
I find this very upsetting. As I said to Sheila O’Connor last night, I have had sleepless nights for the past week and had them all through the inquiry. If that is how I am feeling, how in the name of God are the women Dr. Neary butchered and violated feeling? What happened to them is beyond belief. They have been let down by us all, and such a system should never have been in place.
Dr. Neary played God and nobody ever said to him he could not do so. The sisters who ran the hospital looked up to him as God, as did the junior staff he was training. On reading the records of the women involved in the nine cases I know about, I noted that Dr. Neary really did play God with them. He wrote in their charts statements such as “Lucky to survive the night”, “Thank God I was able to save her”, “Got away with this one — baby and mother alive” and “Uncontrollable bleeding, couldn’t stop it, spent all night in theatre”. I know that none of this was factual. Dr. Neary never spent all night in the theatre and there was never any uncontrollable bleeding, as we now know.
The people to whom I really point a finger are Dr. Neary’s senior colleagues, the pathologists and anaesthetists, who should not have been afraid to address the matter. The anaesthetists were in the delivery rooms and operating theatres and saw there was no raised blood pressure or increased pulse rates and they knew the women would not die in 15 or 20 minutes. The pathologists who examined the uteri and sent them back to Dr. Michael Neary saying no abnormality could be found in them have many questions to answer.
The “three wise men” sent to Our Lady of Lourdes Hospital by the Irish Hospital Consultants Association — Drs. Prendiville, Stuart and Murphy — issued a report giving Dr. Neary a clean bill of health, as implied in Judge Harding Clark’s report. She adduced that they did so out of congeniality and compassion for Dr. Neary. They must have told her so. Shame on those men. If I had a stronger word or if I were permitted to use offensive language in this Chamber, I would certainly use it in respect of them. Shame on them.
If a man had a minor procedure carried out on his reproductive organ and he emerged from the operating theatre minus that organ, there would be outrage. It might happen once but would never happen 188 times. The women in question were vulnerable and were robbed of their internal reproductive organs. There is no other word but “robbed”.
Can it happen again? Unless we change the Medical Practitioners Acts, it will happen again. It is possible that it is already happening in another discipline. I am aware of the Tánaiste’s interest in this matter because I have spoken to her. I compliment and praise her on the humane way she has dealt with it since the publication of the report last week. I note that Ms Sheila O’Connor of Patient Focus, who is in the Visitors Gallery, is nodding her head. Patient Focus has been in contact with the Tánaiste on many occasions. I am confident the Tánaiste will act effectively and efficiently to bring legislation to both Houses so that there is change in this regard. I am sure I have gone over time.
Ms Feeney: I am glad that Judge Maureen Harding Clark has pointed her finger at the people at whom I have pointed my finger — the anaesthetist and the pathologist. Her recommendations represent a blueprint which should be taken on board by all medical specialties in all hospitals. There needs to be a change of attitude so that the medical profession cannot continue to lord it over members of the public.
I could speak for another hour on this matter, but I will conclude by thanking Judge Maureen Harding Clark for her great report and wishing her well in her deliberations on the redress issue. From the bottom of my heart, I wish the women affected well with the rest of their lives.
Dr. Henry: As Senators can imagine, it is difficult for me as a member of the medical profession not to hang my head in shame, having read this report and listened to the contributions of Senators Feeney and Terry, as I speak in front of some of those who have been so grievously injured by a member of my own profession. No adequate reason can be given for the behaviour of Dr. Michael Neary. This has been an appalling tragedy. I am glad that the Minister of State, Deputy Tim O’Malley, apologised on behalf of all of us, not just to the women in question but also to their families. The women and their husbands were denied children, their parents were denied grandchildren and the children they already had were denied siblings. A substantial number of people were affected by the appalling operations that took place at Our Lady of Lourdes Hospital in Drogheda.
Whoever stole the huge volumes of birth registers and charts which comprised the maternity theatre register should send them back at once, anonymously if necessary, as I am sure they have not destroyed them. The charts in question are of great importance to the 44 women to whom they relate, not just as they take legal cases, etc., but also as they try to get some kind of satisfaction in their attempts to find out exactly what happened. The registers contain details of the stillbirths which took place during the period in question, which means that women who had stillbirths at the hospital during that time are not in a position to register their cases. A national stillbirth register has since been put in place, fortunately. I assume that the theft of the registers and charts was done by someone with a misguided sense of loyalty to Dr. Neary, but it was a dreadful thing to do. They should be sent back at once. I hope the Garda investigation into the robbery will be satisfactory.
The commission that inquired into the practices at Our Lady of Lourdes Hospital has done an incredible job. I compliment Judge Maureen Harding Clark on what she has done. Not only did she have to deal with the information she could get, but she also had to try to cross-reference it with other records to ensure that each of the horrific number of the cases was accounted for. The vast majority of cases involved Dr. Neary although some of them involved Dr. Finian Lynch. During the period in question, an excessive number of peripartum hysterectomies was carried out at Our Lady of Lourdes Hospital, compared to any other hospital in this country or any other part of the world. It beats me how members of the medical profession who were working at the hospital at the time can say they did not know anything unusual was happening.
The issue of gender has been raised in the context of the debate on this report. The membership of the Institute of Obstetricians and Gynaecologists during the timeframe under discussion was almost entirely male. The men in question were in a position of great power, whereas a degree of hierarchical obedience was expected of the women involved, who were either patients or nurses and were in a subservient position to the consultants.
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.
Dr. Henry: I knew some of the Medical Missionaries of Mary quite well because they used to accompany me to meetings in London and elsewhere. They were kind and good women who were very determined in their religious beliefs. The mixture of religious beliefs and human reproduction can sometimes lead to serious situations which are perhaps not to the advantage of patients, who may not share such religious convictions. The Minister of State said that “patients require assurances that their interests are paramount and override any sectional concerns”. That principle should be at the forefront of whatever happens.
When Dr. Neary arrived in Our Lady of Lourdes Hospital, it was one of the major hospitals in the country for carrying out symphysiotomies. The others were the National Maternity Hospital in Holles Street and the Coombe Hospital. I do not know the exact number of symphysiotomies that were carried out in the hospital, but I have been at meetings where patients wept about them to me. This procedure was carried out by cutting the front of the pelvis to allow a vaginal delivery, rather than carrying out a caesarean section. Therefore, there was a culture of applying the Catholic ethos in a very strict manner when Dr. Neary arrived.
He claims that this fact was important in explaining why he carried out so many peripartum hysterectomies, but this claim cannot be taken seriously. It is true that he objected and was allowed not to take part in tubal ligations in England, but when he arrived in Our Lady of Lourdes Hospital, both he and Dr. Lynch asked the Medical Council and the Medical Defence Union about the situation regarding tubal ligation, and they were told they would have to abide by the ethos of the hospital.
We should recall that these issues were not just due to the ethos of the hospital, but to the culture at the time. That is why the pathologists frequently reckoned that the perfectly normal uteri they examined were being removed for sterilisation purposes. These procedures were referred to as “compassionate hysterectomies” in the report. The figures at the Coombe had to be revised upwards when Dr. James Clinch became master there. He added another 70 cases to the list of what was described as compassionate hysterectomies. There were no pathological problems, yet serious operations were carried out to remove the uterus.
I was appointed to the Rotunda Hospital and to Sir Patrick Dunne’s Hospital to look after women who had previously suffered from deep vein thrombosis. This can occur when a person gets a clot in the legs which goes to the chest and it is still a high cause of maternal mortality, but it is nothing like it was then. It occurred much more frequently to women who were older and who had many pregnancies. I looked up the maternal mortality figures for the years 1966 to 1973. A total of 23 patients had died from pulmonary emboli in those years. Their age and parity for a sample went as follows: age 33, 11 children; age 40, 12 children; age 43, nine children; age 42, 13 children; age 31, eight children; age 33, 12 children and so on.
One woman was 48 years old and was on her 19th pregnancy. I wrote this paper in 1975 and I thought that someone at least would comment on it, but nobody did. I presented it at a meeting which I believe was of the Institute of Obstetricians and Gynaecologists. I asked what could be done about it because I was seeing women who badly needed tubal ligation and the only contraceptive available at the time was a high dose pill, which was described as a cycle regulator and which was totally unsuitable for such women. One person replied from the floor, saying that surely I knew some friendly gynaecologist who would carry out hysterectomies on these patients for me.
That was the culture of the time and it cannot be allowed to continue. Senator Feeney stated that she fears such an issue could arise again and I feel the same way. I read reports recently about women with seriously advanced carcinoma of the breast. A multicentred trial was carried out where these women were given combined chemotherapy in the hope that they might last another few months, which might mean a lot to them and their children. Patients in the Mater Hospital were delayed and may have been disallowed completely from taking part in the trial because of the insistence that they use contraception unless they abstained from sexual activity. Who has the right to tell women what they must do to be allowed to have a few more months of life? If the women think it is all right then they should be allowed to do it. There should be no interference between them and the clinicians involved. The Mater Hospital is one of the leading institutions for treating women with breast cancer and people should not be put in a situation like that.
A medical practitioners Bill is absolutely vital, but I have been promised such legislation for more than six years. If it is not brought before the House immediately, we will not be able to deal with it before the next election. We must also address the danger of small units. I have implored people in this House to stop asking for the retention of small units for political purposes. The report recommended that small units in different areas should compare their results. It was suggested that hospitals in Cavan and Drogheda should compare results and I suggest that Daisy Hill Hospital also be included, even though it is outside the jurisdiction. The courageous women who eventually blew the whistle came from outside the jurisdiction and had also been trained outside the jurisdiction.
This issue can occur again. We must have people who are prepared to work together as teams, but that has not been sorted out yet. We must have proper peer review, rather than review by friends. We must also introduce a medical practitioners Bill which allows the Medical Council to act swiftly and courageously, as it did in this case. The solicitor for the health board and the lay staff at the time also acted very swiftly. Unfortunately, the medical profession comes out worst from this investigation for not trying to stop a man, with some obvious kind of phobia and personality disorder, from doing dreadful damage to a great number of people. As a member of the medical profession, I apologise profusely to all those who have been so grievously affected by his actions.
Ms O’Rourke: I welcome the Minister of State and the representatives of Patient Focus who are in the Gallery. This has been an amazing debate. We decided this morning that the lead speakers would be women because this is an issue about women’s bodies. I am sure that the men who contribute will do a good job as well.
I praise Senator Terry for speaking about her first pregnancy in such an open manner and without drama. I am so proud of Senator Feeney for her work on the Medical Council. I stand in awe of her knowledge, as I do of Senator Henry, who is a member of the profession which we are calling to order today.
Each of us speaks from our experience. I physically had a child and we adopted a second child. I suppose giving birth once is the same as giving birth many times. I was married for four years yet I was not pregnant. In my time, it was expected that one would have a child soon after marriage. My brothers and sisters were married before me and they had many children, yet there was no sign of a child for me. It was not for lack of activity because we were mad about each other. I do not know if we overdid it, but I became pregnant. It was only once in my life but how lucky I was. I was luckier again with my second child.
I recall having the baby as if it was yesterday. I kept asking for the specialist I had attended every month, travelling on the train from Athlone to Dublin as we did not have a car. I thought I was important and that it was important to have the specialist there but he arrived when it was all over. He told me I had a fine son but I already knew that because I had borne him. That was the situation. One attended this man’s clinics for nine months and paid him a fat fee. I am sure he was well worth it but he had nothing to do with having the baby because he was not there. In fact, I remember that he arrived wearing tennis shorts and a white singlet. He had been playing tennis as it was a lovely day. Of course, I thought I was the most important woman in Ireland after having a baby boy.
This report is born out of the fact that so many consultants were and are men. This is not an anti-male rant but it is a fact of life. One always went to a male consultant. I do not know if there were women in that speciality at that time. I believe there are very few now; I do not hear of that many. I know how the women who found themselves hearing their cases being discussed in 1998 on “Morning Ireland” must have felt. Many patients found out what happened to them as a result of their cases being discussed on the radio or in The Irish Times or the Irish Medical Times.
One’s womb is one’s potential fecundity. It is there to harbour an embryo and bring forth a baby. That is so important to a woman. However, this fecund place was annihilated without any consultation or without an attempt to save it and to give the woman involved a future with more babies and a more fulfilled life. I was convinced I would never have a child. One man in Athlone who was not particularly nice used to say to me if I happened to meet him: “No child yet. There is a clocking hen in every family”. I have never forgotten him. He took delight from the fact that I had not become pregnant. I can imagine what these women felt.
A 19 year old woman — a teenager — had her womb removed. A future 25 years of fecundity, if she and her partner wished for it, was whipped away from her as if it was something that did not matter. She had it stolen from her at a point when one is low anyway after having a baby and a caesarean section, both of which leave one vulnerable. Then this man loomed over her to perform another operation.
Everybody asks why Michael Neary did this. I am convinced it was due to a wish to dominate women. The woman was on the operating table after having her caesarean section and her lovely baby and now he wanted to rob her of joy and elation and leave her barren. It was biblical in its proportions and in his mind I believe he saw himself as some type of biblical seer who had control over women. He had performed the caesarean section and brought forth the child, which expressed one part of his personality. The other part was the wish to dominate. He had her laid low and she would continue to lie low. He would ensure she would because she would not have another child. It was an awful barrenness of belief and humanity within him.
I do not know how women put up with it. When I could not get pregnant, every day was a barren day for me. Every day I felt I was not fulfilling the role for which I was put on earth. No matter what heights one obtains in every other part of life, the most important part of life is one’s family. It is the constant thing one clings to and vice versa. It is the main thing one has from life. Imagine not being able to fulfil that and not being able to plan for a child. The planning is what is important. It means looking forward to it, feeling movement within the womb and the knowledge that one has conceived and can have a child. That is a lovely feeling. Consider how one must feel to be robbed of it forever because of the megalomania of one person who decided one would have no more children and he would see to it that one did not. Imagine a girl of 19, herself a child, having that happen to her.
I fault those around him, his peers and others, who thought he was wonderful and walked on water. However, I also fault the deference, which still exists, in medical circles. There is huge deference on the part of the patient before the consultant. When my husband was very ill he was lucky with his consultant because there was none of that deference. My husband and I were treated as equals and we were told every medical fact we wished to know. Nevertheless, that huge deference exists. One does not question the consultant, least of all when one is a woman. She does not ask what is wrong, what is her diagnostic outlook and what the future holds. One bows to the consultant and, of course, one writes the cheque. One is simply another person in his busy diary.
There are many good consultants but this is a story of deference. One had to bow and scrape to those who were, as it was put, above one. When the legislation is being framed, I hope it deals with issues such as undue deference, the right to know what is wrong and the vulnerability of women who having had one operation faced another one immediately, presumably through the same wound. I hope the Bill can in some way capture that deference. The patient has the right to know everything about his or her body. After all, he or she cannot have any other body.
I cannot envisage the empty feeling of the women who had this procedure performed unnecessarily on them. They woke up each morning to the knowledge that they would never again feel life within them. It must have given them, particularly young women, an awful outlook. I praise Judge Maureen Harding Clark for the concise, analytical way in which she went about her business. I also praise the Tánaiste. I was well able to do otherwise on the Order of Business with regard to accident and emergency units but in this case she addressed the issue swiftly and concisely.
Ms Tuffy: I sympathise with the women and their families who were affected by this. I share everybody’s horror at what happened in the Our Lady of Lourdes Hospital. I also commend Judge Harding Clark on her report and Patient Focus on its work. I welcome the members of Patient Focus who are in the Visitors Gallery for this debate.
The report has implications for the health system as a whole. Judge Harding Clark made the point that as her inquiry was restricted to the examination of the maternity unit at Our Lady of Lourdes Hospital, it was unclear whether that unit was unique in its practices or whether similar practices and attitudes were to be found in other hospitals in the State. The report states: “The recommendations are directed to the Lourdes Maternity Unit but may have relevance for other similar sized units.” This might even be an understatement of the position. I believe the recommendations have relevance for the health system as a whole.
Judge Harding Clark raised the issue of the numbers of personnel. She stated that matters had greatly improved when she returned to the maternity unit at Our Lady of Lourdes Hospital even though much remained to be done. What had made the difference was having extra personnel. The title of that chapter of the report was: “2005 AND FINALLY A FULL TEAM WITH LEADERSHIP”. The report also stated: “The biggest difference in the hospital at the present day is the presence of so many new consultants.” It points out that teamwork had replaced the old hierarchical systems that were in place. Among the recommendations was that the changes “require the attendance and involvement of rested and unstressed hospital personnel who work in a safe environment”.
The need for additional doctors has been apparent for many years and it is only now that the Government is addressing this need. It is too little too late. Much more needs to be done in this regard. The report stresses the need for support services so that people do not need to carry out non-nursing duties. At the heart of the issue was the problem of small departments, which may be a problem in other hospitals today. It is an obstacle to honest peer review. The report recommended that the expansion of consultant numbers would help. The issues of personnel and teamwork are a key in the report on the particular hospital involved and are key for the health system in general.
Some people spoke about their personal experiences. While this issue affected women, it is an issue for everybody. In my case I was very happy with my treatment in the Coombe. However, I was a semi-private patient and was supposed to be part of a consultant-led team. When I asked who my consultant was, nobody could tell me; they never knew. I never saw a consultant from the time I had my first visit to the time I left the hospital. The only time I ever saw a consultant was when one came in to talk to a private patient in my ward. I never got the name of my consultant and when I asked I was not told. The answer was that I was part of a team, without any particular consultant. When I was in having the baby I never saw a doctor, except just before being discharged when a junior doctor briefly spoke to me. The midwives and nurses were excellent and I was very confident in their care. Even though I had the luxury of being a semi-private patient, I never saw a doctor when in hospital having my baby, which I find incredible.
The report makes many recommendations which have general application. The Minister of State referred to continual professional development, which should be underpinned by legislation. Such a requirement has existed for solicitors for some years and it needs to be introduced for all professions. The report refers to the medical practitioners Bill and giving professional bodies more powers. That legislation has been promised for some time and is long overdue. It is important that it is introduced. The report states in bold that we should introduce “a wide-ranging new Medical Practitioners Act”.
We also need an independent authority to investigate complaints against the medical profession. New Zealand has a health and disability commissioner, an independent and well-resourced office. As a solicitor, I agree with having an independent body to take complaints against solicitors. The report refers to the need for a national reporting system. While the Minister of State has referred to a new initiative in Cork, we need a national system underpinned by law. I am not clear how the Cork unit will operate in that regard.
The findings of the report have general application. What happened in the maternity unit at Our Lady of Lourdes Hospital is extremely distressing. However, it is not the first issue regarding how patients and their families have been treated by hospitals. We know of cases where practices have existed without proper oversight and accountability. An obvious example was the removal of children’s organs in children’s hospitals. No record exists of where those organs went. Questions have not been answered in this regard and people have not been brought to account. We have had the scandal of MRSA with patients and their families not being informed. Many other issues exist regarding how people are treated in our health system.
This will not be the last scandal in our medical system. The Labour Party has pointed out the need for whistleblower legislation and a Private Members’ Bill on the matter was discussed in the Dáil this week. Such legislation has been delayed by the Government and action must be taken. The Tánaiste and Minister for Health and Children has outlined her plans for hospital inspectors, which the Labour Party has sought for some time. A few years ago a patients’ charter was introduced outlining the rights of patients. While that was a move in the right direction, much more needs to be done to put the patient at the heart of the health system. Patients have a right to be informed and to ask questions. They need accountability on their behalf.
Mr. Browne: I welcome the Minister of State and his officials to the House. I thank Senator Tuffy for sharing time with me. While I will not go over what has already been said, this report is truly shocking. This week on Vincent Browne’s radio programme, there were readings from transcripts of real life cases, which brought the matter home to us all. Yesterday’s “Five Seven Live” programme also played some of those excerpts. Obviously, no level of compensation can be given to those victims now to make up for the wrong done not just by Dr. Neary, but by the whole system. The longer I am in this House the more I realise that politicians, for all our faults, are not the worst offenders.
Unfortunately, a golden rule that applies to everyone is “man, protect thyself”. That emerges loud and clear in this report too, which concerns cover-up, oversight and people who should have known better but neglected to call a halt. The worrying question for us as legislators is how to ensure that this can never recur. I am disappointed that the Government did not back a joint proposal in the Dáil last night from the Labour Party and Fine Gael, the Whistleblowers Protection Bill 1999. I would have been reassured to some extent if it had been accorded Government co-operation, but that was not the case.
I know that the medical practitioners (amendment) Bill is still being prepared, and we have no definite date for when that will be introduced. Senator Henry has been raising the issue in the House for the last six years. This case highlights the urgency of that legislation, which I hope we will see before the summer recess. It is vital for everyone involved in the medical profession that legislation be enacted without further delay to ensure both their rights and those of patients.
There is a great deal of arrogance in the medical profession. As Senator Glynn and others will know, I have some knowledge of MRSA, which I am glad Senator Tuffy has raised today. It is a case in point, since patients are not being informed of the fact that they have the condition. It is a basic right that if anyone ends up in hospital and tests positive for an ailment, he or she should be informed immediately. I meet many patients and former patients who discover they have had MRSA. Sometimes their families find out after a patient’s death. That leads to the need for such groups as Patient Focus and MRSA and Families, which do great work. It is regrettable that we need them regarding the health service, but that is unfortunately the case.
Patients are not being put first, something incredible in an economy such as ours, where one would imagine that a patient would be told everything. Information is the key to success. There is a degree of snobbery in the medical profession in its belief that patients will not understand big words. Thankfully, we are all able to use dictionaries and if we cannot go on the web ourselves, we have family members who can do so. If we are told that we have some condition with a long name, we can look it up and find out what it is.
We must re-emphasise to the medical profession that patients must at all times have information. That clearly did not happen in the case of Lourdes hospital, neither is it occurring with MRSA and certain other issues. My mother was in hospital a few years ago, having lost the use of her leg. If one leg is not fully in action and one is taken for a walk, one must be accompanied by two people, one on each side to offer support. Without that, the danger is that a person will topple over, not only falling but perhaps even pulling the other person down on top of him or her with the result that he or she breaks a hip. My mother fell but, thankfully, did not break her hip.
Having heard of the incident, I asked a nurse in the corridor if only one person had accompanied my mother when she was walking. I was not being aggressive or accusatory, but a junior doctor who happened to be passing stopped. I had not even been talking to him, but he butted into a private conversation, telling me the bare-faced lie that he had witnessed the incident and that my mother had had two people with her.
My mother is not perfect, but neither is she the world’s worst, and I believed her rather than him. I was very annoyed but made the mistake of not taking the doctor’s name. Unfortunately, when one has a relative in hospital, one is more concerned about his or her welfare, not thinking about such matters. One tends to assume that the medical profession knows best. It was a classic case that proves the culture of cover-up to protect one’s colleagues at all costs, even where something is wrong.
Everyone makes mistakes, myself included, and I hope that if I fail on behalf of a constituent, I will be big enough to admit it and attempt to correct the problem. It is vital that the medical profession opens up rather than protects itself. What is really shocking in this report is the fact that three consultant obstetricians backed Dr. Neary in 1998. I understand from “Five Seven Live” yesterday that they have now gone to ground. I was amazed to learn that one individual has been a frequent attender of Oireachtas committee meetings, mainly regarding the abortion referendum. A week on, there has still been no sighting of him, and that is not good enough. We have also witnessed systemic failure by anaesthetists, as Senator Feeney pointed out.
We must ensure that this cannot recur. The Government has handled the matter well thus far, something seen in the appointment of a new chairman to the compensation tribunal. The victims can never be adequately compensated, but I urge it to bring forward the whistleblower legislation and the medical practitioners (amendment) Bill. We must learn from this to move forward.
Mr. Minihan: I too welcome the Minister of State and his officials to the House. I praise this morning’s contributions, which have made this debate very informative. I single out Senator Feeney for her contribution and the knowledge she has brought to bear.
I appreciate the opportunity to speak on a truly grave and horrifying topic. Not since reading the Ferns Report and making a statement in the House last November have I felt such dismay at the words before me. We are presented with a similar dilemma today, namely, how one adequately expresses one’s revulsion without being accused of hand-wringing or chest-beating to the detriment of action to ensure there is no recurrence. Judge Maureen Harding Clark, whom we thank for her report into peripartum hysterectomies at Our Lady of Lourdes Hospital in Drogheda, describes a nightmare. To use the words of the Tánaiste and Minister for Health and Children, Deputy Harney, it is painful, hard to believe, shameful and distressing.
Judge Harding Clark uncovered a very complex story, many strands of which remain tangled in the participants’ personalities and the difficult relationship between religious beliefs and civil authority. There are also the various beliefs on human reproduction, overlaid by intense loyalty to a maternity unit. The story was set in a time of unquestioning submission to authority, religious and civil, resulting in a health system that continually failed women. The victims had a miraculous and irreplaceable gift taken from them, one unique to their gender and unmatched in nature or science, that of bearing human life. The system allowed that atrocity to happen and justice to be denied.
What are we to do with the awful truth before us, and how will we respond now that we have expressed our revulsion, regret and apologies? How do we provide redress for the loss of something irreplaceable and protect women in future? Let me address each point in turn. I commend the work of Patient Focus, which represents many of Dr. Neary’s former patients. In doing so, it has also represented the future interests of many women and of society in general. I commend it on co-operating with Judge Harding Clark, which can only have been traumatic and distressing. The Tánaiste and Minister for Health and Children, Deputy Harney, who deserves immense personal credit for the manner in which she has dealt with the fall-out from this horror, has discussed redress for the women involved with Patient Focus. The Government was correct to act quickly and appropriately in requesting Judge Harding Clark to advise it on a proper redress scheme. I thank her for agreeing to do so.
What has happened to the victims renders discussing the cost of a scheme completely inappropriate at this juncture. I specifically support Judge Harding Clark’s efforts towards effecting a means of ensuring the maximum recouping of costs from wrongdoers and indemnifiers. Ultimately, she must be guided by the pursuit of whatever maximises redress for, and, if possible, mitigates the pain of the victims of this tragedy. I understand that she is to begin her work immediately and I am sure Members will join me in hoping that she can bring proposals to the Tánaiste as quickly as possible.
As for the second point as to what can be done to prevent a recurrence, the Government has committed itself to implementing the findings of the Lourdes hospital inquiry in a manner reflecting the private and public outrage being experienced and expressed. One key finding of Judge Harding Clark’s report is that the incidence of isolated hospitals or practitioners permits a degree of ignorance which can ultimately endanger life. Neither institutions nor individuals should be allowed to operate or be perceived to operate in isolation and the system must not force such isolation. Instead, it should make all relevant information available and must allow outcome review of that information by peers. Crucially, the system must practise analysis, questioning, comparison and review of that information. I cannot stress enough my appreciation and relief that concrete steps have been taken to ensure that this will happen with immediate effect.
Yesterday, the Tánaiste announced the establishment of a national perinatal epidemiology centre in Cork University Hospital. The commitment and sense of urgency on the part of the Government is made evident by the fact that the centre will be operational by the autumn of this year. Its establishment will mean that each time a baby is born, important interventions and good outcomes, as well as complications, will be recorded and analysed at a national specialist centre. Even a cursory knowledge of the events in Drogheda would convince anyone to welcome this centre’s establishment, as it will allow the rapid identification of unusual or worrying trends and, crucially, a rapid response to such trends.
The national specialist centre in Cork University Hospital will propel Cork to the top of the list as a location for state-of-the-art facilities for mothers and babies. The announcement yesterday was a major endorsement of the staff in the hospital, which henceforth will be a flagship location for maternity services on a par with the world’s leading facilities. I pay tribute to Professor John Higgins and all the staff who continually perform to the highest standards. They have continually sought to improve the facilities they provide to the people of Cork in the first instance and on a national basis henceforth.
The centre will be a cornerstone of obstetrics and gynaecology practices in Ireland. It will enable the benchmarking and evaluation of perinatal outcomes in all obstetric and gynaecological units. It will also facilitate research and clinical practice developments in maternity care. In line with my party’s policy of seeking to emulate global best practice and experience, the centre’s design is based on models from Australia. It will devise a single identical maternity chart for every maternity hospital in Ireland as a measure aimed towards the re-establishment of trust and towards ensuring that services to mothers and their babies born in Ireland are based on the best possible research. This is an important and welcome step.
I will make some points concerning the response to the report. The steps towards redress, the establishment of the new centre and the planned response to the tragic events in Our Lady of Lourdes Hospital are all evidence of action by the Government. While timely action is required, it must be the correct action. Members’ desire to respond quickly should not prevent a correct response. As I noted, Judge Harding Clark correctly outlined the complex story of what happened and stated that many strands remain tangled.
I am aware of some confusion in respect of the adequacy of earlier investigations into the Neary case and with regard to what was discovered by which investigation. I understand the first report by three obstetricians was extremely poor. It appears that the obstetricians concerned have had serious regrets for their part in producing reports which were motivated by compassion and collegiality. However, the Institute of Obstetricians and Gynaecologists also established a group to review Dr. Neary’s practices. Judge Harding Clark described it as a fairly robust and comprehensive analysis of his practices in the new maternity unit. She was much impressed by its findings, which differed little from her own conclusions which encompassed a much larger group of witnesses. I therefore wish to make it clear that a robust and impressive review of what happened in Our Lady of Lourdes Hospital was carried out before Judge Harding Clark undertook her important work.
As a final point regarding the requirement for an appropriate response to the report, to an extent Opposition parties have portrayed a single Bill solution to protect so-called whistleblowers as something of a panacea. However, this is not the case. It is regrettable to imply that the absence of such a Bill has in some way facilitated scandalous behaviour. Judge Harding Clark’s report makes it clear that a sea-change in the health sector’s culture is required. It is incredibly difficult to challenge someone in the workplace, particularly a superior, about his or her behaviour regarding bullying, harassment or sexual harassment. I suggest that legislative protection for whistleblowers would not provide the reassurance sought or required by such a person. From their experiences of cases of bullying, harassment and sexual harassment, Members must be aware that the culture of a workplace or organisation must change.
I share the Tánaiste’s view that a culture of openness, preparedness to acknowledge errors and an ability to analyse clinical practice in an environment that does not resort to blame or recrimination is required. Blame-free reporting is vital in the health sector. The Tánaiste correctly stated that this constitutes much more than whistleblowing. It is a systematic, continuous and open approach to error reporting and correction involving everyone in the health care setting. It involves a rigorous process of audit, peer review, and external evaluation.
I believe the Opposition’s intentions are correct. While all Members seek to do the right thing as quickly as possible in the light of Judge Harding Clark’s revelations, for the sake of those who suffered and to prevent future suffering, they should get it right. While the Government should do what it can in terms of redress and the new centre, rather than employing a blunt instrument like the Whistleblowers Protection Bill, considered and nuanced provisions should be included in legislation in response to the specific needs of workers who see something amiss. Painfully, the Lourdes hospital case has taught Members that this is the correct course of action.
Mr. Glynn: I have been in public life for a long time. I am a parent, a brother and, like all human beings, I have a mother. It was important this morning that all the parties represented in this House deferred to the ladies. This was done not because they are ladies or because it was mannerly, but because it was the right thing to do. Primarily, this issue concerns the mutilation of women. I particularly welcome the contributions of all the female Members, as well as those of other Members. I am delighted to defer to my colleague, Senator Feeney, with regard to this extremely important, yet heart-rending subject.
I welcome the representatives of Patient Focus who are in the Visitors Gallery today. I well remember its contribution some years ago to the Oireachtas Joint Committee on Health and Children. I stated recently in this Chamber, as I said on that occasion, that this was a script for a horror film. It is outrageous.
When we talk about professions, we talk about what is fundamental and essential to good practice. We are talking here today about what is fundamental to malpractice. A number of terms come into focus — abuse, betrayal of trust by a professional, audit, accountability by other members of that profession working alongside them and then the professional’s accountability. None of those terms seems to have any kind of role in the matter that is under discussion here today.
The three professionals who gave a report certainly did not do their profession any good. The women were denied what is held dear by every woman who enters into a relationship, namely, the right to bear children. That, in a willful and premeditated way, would appear to have been denied to them. That is the real tragedy of what is under discussion here today.
The profession involved is the loser. That the records were removed — we will not say lost — brings into focus another low. This entire saga, and the various chapters pertaining to it, is a race to the bottom for the people involved. I am perfectly familiar with Our Lady of Lourdes Hospital because, as a former member of the nursing profession, I supervised examinations for An Bord Altranais there. Little did I know at that time what was happening in the very place where young enthusiastic women and men — not so many men — were taking their examinations to enter a caring profession.
As Lord Acton warned, power tends to corrupt and absolute power corrupts absolutely. I worked with many fine consultants over the years but there is a mindset among a certain number that they are omnipotent. It is the consultant and God, in that order. This is an opportunity missed on behalf of the three consultants who made the report. There was a prime opportunity of bringing audit and accountability centre stage. Regrettably, it was lost. One need not be a rocket scientist to say so. It is axiomatic that that would be the case.
On the 188 cases in the 25 year period from 1974 to 1998, the inquiry report describes the number of peripartum hysterectomies performed at Drogheda as “truly shocking”. Of the 188 cases, 129 cases were attributed to Dr. Neary and nobody said anything. The rate of caesarean hysterectomies at the hospital for the relevant period was one for every 37 caesarean sections. In contrast, the rate at other hospitals of similar ethos ranged from one per 300 to one per 254 caesarean sections. Did the disparity have to jump up and bite somebody on the nose?
The report states that Dr. Neary’s caesarean hysterectomy patients had a different profile compared with the rest of the unit. First, they were younger and were of a lower parity, that is, they had a lower number of pregnancies. Second, Dr. Neary’s antenatal clinic included a higher proportion of problem pregnancies and a higher proportion of repeat sections than that of other consultants. The problem was as plain as the nose on one’s face and yet nobody copped it.
It is stated that the number of caesarean hysterectomies carried out by Dr. Neary in 1978-79 caused the then matron some concern. Her concerns were ignored. No person raised any issues until October 1998 when two midwives who were consulting the health board solicitor on an unrelated matter sought his advice on serious concerns which one of the midwives had about Dr. Neary’s practices — may God reward that woman.
Many reasons were advanced by management and staff on the failure to act. On the first, that they were not informed, there are none so deaf as those who will not hear. On the second, that all the hysterectomies were carried out for a very good reason, I wonder whether this is true. The third, that there was no audit, was addressed in one of my earlier remarks. On the fourth, that no one knew what was an acceptable rate, the people concerned must think we are all devoid of intelligence. Anybody with anything approaching a brain would know that what was going on was totally wrong.
The report states that a person or persons unidentified, who had knowledge of where records were stored and who had easy access to those records, was or were responsible for a deliberate, careful and systematic removal of key historical records which are missing, together with master cards and patient charts. No doubt somebody knows where these are; there are people in jail for much less. Words like “apology” and “sorry” are always too late after the event.
I understand that Patient Focus found its meeting with the Tánaiste and Minister for Health and Children, Deputy Harney, in the wake of the report of Judge Maureen Harding Clark — whom I commend in the strongest possible terms — to be very constructive. I would not expect anything less from the Tánaiste. I gather that the group is confident that the needs of all women in the group will be looked after. I certainly hope so. It is nothing less than they deserve.
I, again, congratulate Judge Harding Clark on her report which has been recognised as incisive and thorough. It is damning, shocking and horrendous. It is obvious from the findings that many lessons need to be learned and changes made to ensure that what took place in Drogheda can never happen again in any hospital.
I referred to my time in the psychiatric nursing service. I had to sign for every tablet I gave out and there was a nurse with me to ensure that that is what happened. If there was a person on a particular preparation, I ordered a week’s supply and had that been exhausted after four days, one could be sure that questions would be asked. The first person who would ask where they were would be the nursing officer. When one would go down to the pharmacy, the pharmacist would say that a week’s supply had been given and would ask where it was. As Senator Feeney and others stated, this beggars description. That this could have happened without anybody being bothered to question it, except one individual, is incomprehensible.
What happened in the hospital in Drogheda was horrific and heartbreaking. The report regards it as a story set in a time of unquestioning submission to religious and civil authority, when nurses and doctors were in abundant supply and permanent jobs were few and to be treasured. It is clear the hospital operated under a separate and unique set of rules and did not hold itself accountable to objective medical standards. That is a superfluous comment because everybody knows that. It is necessary to learn from and understand what happened in Our Lady of Lourdes Hospital so hospital staff and obstetrics communities in all similar units never repeat these mistakes.
While the report acknowledges that no one died and that it is highly probable that some mothers’ lives were saved when a hysterectomy was the only procedure to stop haemorrhaging, this does not diminish its impact. They were the exception, not the rule. The deafening silence on the issue was truly remarkable and, as the report highlights, few complained and none questioned: not the patients, their partners or their families; the obstetricians who worked in the maternity unity; the junior doctors; the post-membership registrars; the anaesthetists; the surgical nurses; the midwives, except one; the pathologists and technicians; the matrons, except one; the sisters of the Medical Missionaries of Mary; or any of the GPs whose patients attended the hospital. I am reminded of the film “The Big Sleep”. This was inexplicable. No person or institution raised any concerns until October 1998 when two experienced midwives consulted the health board solicitor on an unrelated matter and one of them questioned what was going on. That was the launching pad for this report.
What was happening in Drogheda appeared to be normal and I find it hard to believe that, despite the contact between consultants on an ongoing professional basis, this never raised its head. There was a concerted and conscious effort to suppress what was happening in Drogheda. We recently passed the Health and Social Care Professionals Bill 2004. I am jealous of professional qualifications. They need to be protected and they should be accorded a uniqueness, authority and special place, but they are not omnipotent. Audit and accountability should be the norm. My heart goes out to the women who have been denied the opportunity to have children, particularly those who have none. May God forgive Dr. Neary for what he did because only He can.
Mr. O’Toole: I welcome the opportunity to contribute to the debate, although I am not sure I can add much to what has been said. I have listened to a number of discussions on this issue in recent days and Senator Feeney’s contributions were to the point and had an impact, which I will not attempt to match.
I would like to consider the issues in a cold light because the women who suffered have been left behind by the system and we must take responsibility for that. While I can blame Dr. Neary, these women and the people of Ireland depend on public representatives to ensure regulations are in place and protocols, strictures and processes are correct. However, they were not in this instance and that is the most shocking aspect.
This was not only a case of one guy getting it wrong. How did he ever come to be appointed to the Lourdes hospital, given that he did not meet the necessary criteria for the post? I have not read an account of the appointment process but he clearly did not meet the essential criteria, not to mind the desirable criteria. He should never have been employed by the hospital in the first place. He was inexperienced and so on.
I refer to the consultants who took him out to lunch before investigating him and who then came to a conclusion — surprise, surprise — that he had nothing to answer for. It is appalling that this should have been allowed to happen. I do not understand how people brought in to run the rule over the man would do so in this manner by creating a “palsy-walsy” ambience at lunch and conducting an examination afterwards. That should not have happened. No matter what conclusion they reached, one would have had to question the impartiality of the investigation. I do not know whether the investigating consultants are answerable. Has their work been checked?
The third issue that arises relates to records. The minute this issue was highlighted, the security of records should have been paramount. Crimes were committed and, ordinarily, the scene of a crime is preserved. If somebody touched evidence in any other court case, there would be outrage but the records were lying around in unlocked areas to which everybody had access. A protocol should be in place whereby all files should be copied and put away securely. This raises major concerns.
When I considered how this man dealt with the women and, as I listened on radio recently to people speak about what happened, I could not think straight because of the anger I felt welling up inside, given that this was going on for the past 20 years, 15 miles from my house. My first cousin died in the hospital arising from child birth but, while it had nothing with Dr. Neary, it brought back many memories. I cannot understand how these women could have been treated like this and why nobody shouted “Stop” for years.
The question of normality arises. What is the norm? As Senator Glynn said, this practice was the norm for the Drogheda hospital and, therefore, none of the staff knew the difference. The crudeness and insensitivity of this man’s language and approach to his patients was appalling. We often hear about the lack of manners on the part of consultants and their overbearing attitude and superiority when dealing with patients, but this man’s behaviour brought that to a new level. He conducted internal vaginal examinations while others were in the room, which meant the personal integrity of women was not preserved, their privacy was not respected and their sensitivities were not appreciated. This behaviour on its own was more than enough to tell me all I need to know.
I disagree with the polite interpretation of the horrible phrase attributed to the doctor. When he explained to the women what he had done, he said he took away the cradle but he left the playpen. The use of the word “play” is more crude than some of the benign interpretations put on this previously. It is far more crude than one would expect and has all sorts of unnerving sexual connotations. It is appalling that was said. If it was said in the workplace, people would argue the matter. It is also appalling that there was no communication or support for the women involved, and I will return to that issue.
There is a question as to whether religious philosophies or beliefs had a bearing on events. I believe they did, but I do not know why this man did what he did. Despite having read through the report and tried to come to a conclusion, I cannot. I know what happened and that is enough for me. I do not need to know his motivation. It might make it worse and certainly would not make it any better. I cannot think of any benign philosophical basis on which he might have done this that could make me feel it is not as bad as it looks. It is as bad as it looks.
I wish to give an example from the other side and hope the women involved will not take offence. I do this for the best possible reasons. Not all consultants are like this man. Somebody speaking about the Coombe Hospital said she never met a consultant like him there. I do not like to use family situations as examples, but I will break that rule for once. I was at the hospital when somebody very close to me was having her fifth child, having previously had caesarean sections and various difficulties. However, she had a superb, sensitive, caring and supportive consultant to deliver the child. He came out to me after the birth and said the situation was very bad as there was a serious haemorrhage. He knew me well and knew his patient. This happened at 12.10 a.m. and he went back into the theatre and returned 40 minutes later. When I asked if the situation was any better he said it was not. However, he said he would give her a second pint of blood.
What a contrast that is to what we read in the report and to the quick in and out that was done on those poor women in Drogheda. At that stage, that doctor would have been home eating his dinner. In my situation a third pint of blood was given at 3.30 a.m. At 4 a.m the doctor said to me that he thought he would have to do a hysterectomy. I said that would be like a death. Although this was 20 or 25 years ago and I was much younger than I am now, I knew the impact a hysterectomy would have had, particularly as the patient was under anaesthetic and could not be told what was happening. I asked the doctor if he could make another effort and he agreed. He kept trying until 5.50 a.m. when he came out to me and said he had stopped the flow of blood. He fell into the bed outside the delivery ward and I fell into the one next to him and we slept for three hours. I was never so relieved. What a contrast that doctor was to Dr. Neary.
I think of that occasion every time I hear of a bad consultant and know there is another side and that decent people will always do the job properly. When we compare my experience with the way the women in Drogheda were treated, abused and disregarded, without any regard paid to their future, there is no way we can apologise to them. Dr. Neary’s apology is not worth seeking. I do not want to hear it as it is worth nothing and would only give him some dignity. My rule is never to seek an apology. I would only feel an apology was worthwhile if I had come to a good judgment about the person offering it. If it was somebody about whose judgment I did not care, I would not care for his or her apology. That is the case in this situation.
The area of compensation is sensitive. I do not know how we can calculate compensation. I am the vice-chairman of the Personal Injuries Assessment Board where we examine this sort of issue on a regular basis. However, I would not know where to start in terms of the traumatic impact on these women, not just psychological and physical, but in terms of relationships, self confidence and assertiveness as I feel these women have to rebuild their lives. I hope our discussion in the Oireachtas and the media will help them to see that people are trying to understand their trauma and be supportive. If we can offer nothing else, we can offer that.
With regard to compensation, we need to make early assessments and to deliver on them. I know this is not a payment and that “compensation” is probably the wrong word to use. It is an offering we need to make to these women. I would be appalled if along the way we come to a point where we have to ask could we not have done better by them. We should do what we think is right and do it in spades. An approach should then be made to the insurance companies. However, let us not wait.
I want us as the political system or face to make the gesture, to do the business and do what we can financially for these women, late as we are. Afterwards we can fight with the insurance companies or the various groups liable. We should proceed on that basis and not involve the women and mothers who have already suffered so much. We have a clear duty to show our good offices at this time.
There is not much more to add. This has been an appalling chapter. We see mistakes being made from which people suffer and we criticise the people who made the mistakes. We see people get things wrong and others die in accidents. However, the controlled, organised, manipulative and determined way in which these operations were carried out over decades is unmatched. It could not be worse. I heard somebody say that nobody died, but that is not the issue and has nothing to do with it. Some people who might have lived, never did. Some families never got to be the families they intended being.
If we look into the issue and see where people find themselves, we see that this has been an appalling, embarrassing chapter in Irish medical history and political life. We should bow our heads in shame and give our apology to these women.
Minister of State at the Department of Health and Children (Mr. T. O’Malley): It is difficult to try and sum up on this debate. I commend the Senators who have spoken on this difficult subject. When the history of medicine is looked at in the future, the Lourdes hospital report will be seen as a watershed for the practice of medicine in Ireland.
Many of us can only speak from our own life history. Last Sunday my mother was 93 years of age. She was a midwife all her life and I was brought up in a maternity home, a unique experience. Thankfully my mother is in great health. When I asked her what she thought of the Lourdes hospital report, she looked at me, shook her head and said: “God help us”. This was the reaction of a woman who practised as a midwife all her life and who brought hundreds, if not thousands, of babies into the world. It is some indictment on the medical profession.
I have listened intently to what was said during this great debate. For the past several years I have been advocating a new graduate school of medicine in Limerick. I worked as a pharmacist all my life and have been saying publicly for years that the standard of education of doctors must be examined. I do not want this statement to be taken out of context. We have great doctors here but, unfortunately, we also have many very poor doctors. I do not want to dwell on this, but the situation must change. This report gives impetus to the Government to drive forward change and reform of the health area.
It is right that should be said in the Dáil and the Seanad. We have many excellent consultants and doctors in the country but unfortunately, a considerable number of them are arrogant, do not play ball with their colleagues and treat their patients in an unacceptable fashion. For too long, we as a nation have allowed that to continue. This report will put an end to that type of practice.
We should think about some of the things doctors say, sometimes publicly, such as the fact that nobody can interfere in the clinical relationship between doctor and patient. We should dwell on that for a moment. Who decided that consultants and doctors have a God-given right to define, without recourse to best practice, what is right or wrong? They are not gods, although some of them think they are.
Speakers referred to the difference between public and private practice but all patients are the same and deserve to be treated with dignity, irrespective of income. Unfortunately, in trying to reform the health services, extraneous matters are brought into the process. The Government is trying to change the consultants’ contracts but is being thwarted and delayed at every step. The negotiations are moving very slowly but the Lourdes hospital inquiry gives the Government steel to move the reform agenda forward, which is necessary and the right thing to do.
Mr. T. O’Malley: I do not know how the Tánaiste and the medical profession will drive forward the findings of this report but that is indefensible behaviour and we must do everything to ensure it never happens again.
For too long we have allowed consultants to do what they like, not fulfilling their contracts or carrying out their responsibilities to teach, particularly in teaching hospitals. The report’s finding that the Royal College of Surgeons found the practice in Lourdes hospital to be acceptable is unbelievable. When one analyses this report in the clear light of day it is extremely difficult to understand.
The religious ethos of the hospital was mentioned by a number of speakers. I take the basic point about a religious ethos in an institution but with regard to Dr. Neary, the inquiry rejected his evidence that 75% of the hysterectomies performed were attributable to the ethos of the hospital. Senator O’Toole and others referred to Dr. Neary’s motivation but I do not know and cannot understand what motivated him. I do not know if it was religious belief but he certainly did not engage in acceptable practice.
Judge Harding Clark has produced an extremely comprehensive and fair assessment of the events at Drogheda. The challenge before us in the Dáil and Seanad is to ensure that the various lessons to be learned are quickly taken on board by the health system as a whole, and not just in respect of maternity services. I emphasise that it should not just be in respect of maternity services, because many speakers have referred to the fact that similar problems may exist in other specialities.
I assure the women involved in these events at Drogheda — I welcome them to the House — that many lessons will be learned by the Government from this report. Equally, I assure them that the Government will respond fully to the report’s findings. These findings state:
As the Tánaiste emphasised yesterday, action is being taken to learn the lessons and implement the recommendations of the report in order to ensure the safety of every patient and prevent the recurrence of such events. I will not discuss the redress board because the Tánaiste and others have spoken at length on the issue. I will, however, give a commitment that the Tánaiste and the Government will drive forward the redress board, which is in very good hands. We eagerly await the report of Judge Harding Clark on the matter.
The Lourdes hospital inquiry report has strengthened the Government’s determination that patients and the wider public will be the primary focus of decisions relating to health policy. The report will act as a significant catalyst in the reform agenda, in strengthening clinical audit, in the preparation of the new medical practitioners Bill, the reform of the current consultant contract and the improvement of management systems within hospitals. The Tánaiste will bring proposals to the Government to establish a mechanism to ensure that clinical governance arrangements are strengthened throughout the health system. This will entail the fostering of a continuing culture of openness, preparedness to acknowledge errors and an ability to analyse clinical practice in an environment that does not resort to blame and recrimination.
Several speakers referred to the medical practitioners Bill, preparation of which is well-advanced. The Government intends to make the heads of the Bill available to interested stakeholders and to publish the legislation later this year. The recommendations of Judge Harding Clark’s report will be addressed in the Bill in a variety of ways. It will underline the role of the Medical Council as the body in this State which acts to protect the public by way of regulation of the medical profession. It will introduce more streamlined and transparent procedures for the processing of complaints and modernise registration processes to allow for flexibility where required. It will also integrate registration, education and training, ongoing competence and fitness to practise processes.
The Bill will clearly define the responsibilities of the Medical Council with regard to the education and training of medical practitioners and provide, for the first time, a legal framework for the council’s implementation and administration of a system of competence assurance. The Government intends that the new legislation will make continuing professional development and education compulsory for medical practitioners.
Several Senators spoke about whistleblowing. The Government believes that whistleblowing is an inadequate term to reflect expressions of serious concern about aspects of medical practice. Systems should be in place within the hospital setting to allow managers, medical practitioners and health care professionals to raise concerns about aspects of practice. Such concerns should be capable of being addressed in the context of rigorous processes of audit, peer review and external evaluation. That is the best way forward.
The Lourdes hospital inquiry has affirmed the approach being pursued by Government in the context of negotiations for a new contract for hospital consultants. The days of consultants working in isolation without effective clinical leadership are now at an end. In the recently published report on mental health, A Vision for Change, the chairperson of the expert group, Professor Joyce O’Connor came to a similar conclusion about psychiatrists, that they found it extremely difficult to work in clinical teams. The challenge for the Government and the medical profession is to change that so that consultants can no longer be allowed to work in isolation. They must be compelled to work in teams with ongoing peer review. Members will agree that Judge Maureen Harding Clark’s report is comprehensive and fair. Many people must learn the myriad lessons of the events outlined in the report. Changes must be made to ensure the events that unfold in the report will never happen again in a hospital. The findings and recommendations are being examined in detail by the Department of Health and Children in consultation with the Health Service Executive, the Medical Council and other professional regulatory bodies. Action will be taken. The Government is determined to prevent any events such as these recurring.
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