The Lourdes Hospital Inquiry – An Inquiry into peripartum hysterectomy at Our Lady of Lourdes Hospital, Drogheda
The Government today approved publication of the Report of the Lourdes Hospital Inquiry.
View the Report of the Lourdes Hospital Inquiry
Speaking at the publication of the Report the Tánaiste and Minister for Health and Children, Mary Harney TD said her first concern was for the women who had been patients of the Maternity Unit at Our Lady of Lourdes Hospital in Drogheda during the period covered by the Report. She said, “I am conscious that the last few years have been particularly difficult and traumatic for many former patients of the Maternity Unit at Drogheda and I want to express my deepest regret and apologise to these women and their families for what happened.”
“I will be meeting with Patient Focus, the group which represents many of the former patients of Dr Neary, tomorrow in order to discuss with them the findings of the Report, and the necessary steps that need to be taken now.”
The Tánaiste thanked the Chairperson, Judge Maureen Harding Clark and the Inquiry team for their work in conducting the Inquiry and in the preparation of this comprehensive Report. She acknowledged the cooperation given to the Inquiry over the course of its work and in particular acknowledged the co-operation of Patient Focus.
Commenting on the overall findings of the Report, the Tánaiste said:“This is a damning Report and it is clear from the findings 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 my Department which will consult with the Health Service Executive and the various professional regulatory bodies. 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 relation to the preparation of the new Medical Practitioners Bill, the reform of the current consultant contract and the changes in management systems within hospitals.”
“The forthcoming Medical Practitioners Bill will make continuing professional development and education compulsory. It will also ensure that competence assurance will be given a statutory basis. Furthermore, in the context of the consultant contract talks, the management side have put forward proposals to ensure that consultants work in teams with clear clinical leaders who will ensure that individual clinical pratice is in line with best practice.”
The Inquiry into peripartum hysterectomy at Our Lady of Lourdes Hospital, Drogheda chaired by Judge Maureen Harding Clarke S.C. was established by the Government in 2004 following the decision of the Medical Council to remove Dr Michael Neary from the Register of Medical Practitioners after finding him guilty of professional misconduct. The Terms of Reference of the Inquiry are attached at Appendix A.
The Inquiry Report states that:
- A total of 188 peripartum hysterectomies were carried out at Drogheda in the 25 year period 1974 – 1998 and describes the number performed at Drogheda as ‘truly shocking’.
- Of the 188 cases, 129 cases are attributed to Dr. Neary.
- The rate of caesarean hysterectomies at the Hospital for the period 1974 to 1998 was 1 for every 37 caesarean sections. In contrast, the rate at other hospitals of similar ethos ranged from 1 per 300 to 1 per 254 caesarean sections;
- Dr. Neary’s caesarean hysterectomy patients had a different profile compared with the rest of the unit. Firstly, they were younger and were of lower parity (i.e. had a lower number of pregnancies). Secondly, Dr.Neary’s antenatal clinic included a higher proportion of problem pregnancies and a higher proportion of repeat sections than the other consultants.
- The numbers of caesarean hysterectomies carried out by Dr. Neary in 1978/79 caused the then Matron some concern. Her concerns were not heeded.
- 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.
- There were many reasons advanced for this by management and staff, including:
- they were not informed;
- all the hysterectomies were carried out for a very good reason;
- there was no audit;
- no one knew what was an acceptable rate.
- The unit was passed for training by the Royal College of Obstetricians and Gynaecologists in 1987 and 1992 with some reservations.
- The unit was also passed by the Royal College of Surgeons in Ireland for undergraduate training and by an Bord Altranais for midwifery training.
- 23.4% of obstetric hysterectomy records (44 cases) for the period 1974-1998 are missing and were intentionally and unlawfully removed from the hospital with the object of protecting those involved in the hysterectomies or of protecting the reputation of the hospital. In 40 of the 44 cases, the birth registers are also missing.
- 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 key historical records which are missing, together with master cards and patient charts.
- The culture of hysterectomy was associated with a lack of understanding, knowledge or faith in methods of managing blood loss and preserving the uterus.
- The isolation of the unit played a large part in the lack of awareness.
- Any isolated institution which fails to have in place a process of outcome review by peers and benchmark comparators can produce a similar outcome to that which occurred in the Lourdes Hospital.
- Support systems must be in place to conduct regular and obligatory audit.
- There must be mandatory continuing professional development and skills assessment at all levels of healthcare and recognition that procedures should change in accordance with evidence based research. Hospital management should have more authority and training and should have medical input.
The Hospital Today
The Inquiry found that
- The possibility of this Unit falling behind in current practice is now remote. 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 current consultants speak through their lead clinician and have developed a strong collegiate approach to practice. There is now little doubt that the Unit is engaged in moving forward and offering care that is evaluated against known benchmarks.
- The Medical Board and the new consultants have the motivation, the skills and the energy to move the hospital forward as a fully recognised teaching hospital with specialist registrar training in all their departments.
- All hysterectomies carried out now involve teamwork and at least two obstetricians and two anaesthetists.
- Tubal ligations were introduced at the end of September/October 1999 without opposition from any quarter
Appendix A: Terms of Reference
- To examine the rate of peripartum hysterectomy at Our Lady of Lourdes Hospital, Drogheda (“the hospital”) with particular reference to the period covered in the report of the Fitness to Practise Committee of the Medical Council (“the report”) and the period since the publication of that report and to determine how this rate compared with the rate in other Maternity Units of similar status.
- To ascertain what system of recording of peripartum hysterectomy took place at the Hospital; to ascertain whether all expected records are now extant; and, if not, to inquire into what has become of such records.
- To inquire into whether Dr. Neary’s practice in relation to peripartum hysterectomy was commented on or acted upon by Consultants or other medical staff, by midwives and other nursing staff within the hospital, or by the management of the hospital.
- To inquire into what, if any, review and consultation took place, either within the hospital, or externally following peripartum hysterectomy.
- To ascertain whether periodical clinical reports were prepared by the Maternity Unit at the hospital and, if so, the purpose of those reports; to whom they were furnished; and the action, if any, which was taken on foot of those reports.
- To inquire into what practices and protocols have been adopted at the Maternity Unit of the hospital since October 1998 or arising from the publication of the Report.
- To advise the Minister for Health and Children on whether additional protocols and systems of control should now be put in place to prevent a recurrence of the events that gave rise to the findings of the Report.
- In the event of the withholding or withdrawal of full co-operation from the Inquiry by staff or former staff of the hospital, by the North Eastern Health Board, its servants and agents, the former proprietors of the Hospital or any State authority, or any suggestion that co-operation is being withheld, to report that fact immediately to the Minister.
- In the event that the Inquiry cannot produce a final report within 9 months of the date of appointment by the Minister, the Inquiry will submit a progress report to the Minister