Press Release - Issued by the Lourdes Inquiry - Chairperson Judge Maureen Harding Clark

29 June 2004

The Minister for Health and Children, Mr. Micheál Martin, T.D., has established an independent Inquiry into certain matters arising from the Report of the Fitness to Practice Committee of the Medical Council into complaints against Dr. Michael Neary. The Report found Dr. Neary guilty of professional misconduct in relation to ten patients, and the Medical Council erased his name from the Register of Medical Practitioners.

The Inquiry is being chaired by Judge Maureen Harding Clark and, having conducted extensive preliminary investigations, is now inviting members of the public with information relevant to its Terms of Reference to come forward in order to make statements, and to be available for interview.

The Inquiry can be contacted at 31-35 Bow Street, Dublin 7, Tel: 01-8146410, or by e-mail at info@lourdesinquiry.ie. The Inquiry website is www.lourdesinquiry.ie

The Inquiry´s legal team has prepared Guidelines for Interview, emphasising the non-adversarial nature of the Inquiry, and which are designed to put witnesses at their ease.

The Terms of Reference of the Inquiry and Guidelines for Interviews are attached.

The Lourdes Hospital Inquiry

An Inquiry into peripartum hysterectomy at Our Lady of Lourdes Hospital, Drogheda

Background

The Fitness to Practise Committee of The Medical Council conducted an inquiry into 12 complaints including 10 complaints alleging unwarranted perinatal hysterectomies against Dr. Michael Neary, Consultant Obstetrician at Our Lady of Lourdes Hospital, Drogheda. Most of the complaints involved women in their 20s and early 30s. The inquiry commenced on 6th June, 2000.

On 14th July, 2003 the Medical Council´s Fitness to Practise Committee found that the facts in relation to 10 of the 12 complaints were proved and that Dr. Michael Neary was guilty of professional misconduct. The Medical Council determined that his name should be erased from the General Register of Registered Medical Practitioners. This Order was confirmed by the President of the High Court, Mr. Justice Finnegan on the 2nd day of September, 2003.

The Fitness to Practise Committee found that, in 10 cases of hysterectomy in pregnancy carried out in 1986 and between 1992 and 1998, what happened, simply should not have occurred.

The Fitness to Practise Committee found that statistics from Our Lady of Lourdes Hospital, Drogheda, for the period 1993-1998 indicate that hysterectomies associated with pregnancy, and, in particular, caesarean hysterectomies were carried out over 20 times more frequently at the hospital than in the Coombe Women’s Hospital or in the National Maternity Hospital, and that such a substantial deviation from the norm must be of a very serious concern.

In most of the 10 complaints proved, the anaesthetic record indicated no cause for concern at the time the decision to proceed to hysterectomy was made. Although blood was cross-matched and available, most of the patients were not transfused before the decision was made.

Dr. Neary reported to several of those patients’ general practitioners that the patient had very severe bleeding, was lucky to survive and that resort to hysterectomy was a life saving procedure.

Although there was a substantial patent of discrepancy between the pathological and clinical findings, the Committee found little evidence of substantial dialogue between Dr. Neary and consultant pathologists. In most instances, a uterus without significant pathology was removed.

Following the publication of its decision, the Medical Council met Mr. Micheál Martin TD, the Minister for Health and Children, on 2nd September, 2003 and advised that a broad inquiry was needed to explore the context of the tragic events at Our Lady of Lourdes Hospital, Drogheda, Co. Louth.

The Department of Health and Children has been informed by the North Eastern Health Board that in reviewing the incidence of peripartum hysterectomy at the Hospital the Board was unable to locate or identify certain medical records.

Judge Maureen Harding Clark of the International Criminal Court has been appointed by the Minister for Health and Children to conduct the inquiry.

Terms of Reference

  1. 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 relating to Dr. Michael Neary ("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.

  2. 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.

  3. To inquire into whether Dr. Neary´s practice in relation to peripartum hysterectomy was commented on or acted upon by Consultant or other medical staff, by midwives and other nursing staff within the hospital, or by the management of the hospital.

  4. To inquire into what, if any, review and consultation took place, either within the hospital, or externally following peripartum hysterectomy.

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. 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.

Guidelines for interviews

  1. The Inquiry is non-adversarial. Its workings are informal and will be undertaken in private. Statements will not be sworn, but will be obtained on a voluntary basis. The Inquiry will seek to observe fair procedures. While witnesses have no obligation to make statements or provide information and cannot be obliged to answer any question, it should be noted that if co-operation is withheld Judge Clark has a duty in accordance with the Terms of Reference (Clause 8) to report that to the Minister for Health and Children.

  2. The Terms of Reference will be made available to every witness before interview. Witnesses may be invited to submit a written statement in advance of interview.

  3. Initial interviews will usually be undertaken at the Inquiry offices by two of the Inquiry legal team, and generally will be recorded. Interviews may take place elsewhere eg. Drogheda, as the occasion demands.

  4. Witnesses may be accompanied e.g. by a colleague, friend or lawyer, but such persons will not have the right to examine the witness or make submissions to the interviewers or participate in the interview. However the interview may be temporarily suspended to allow the witness to consult with such companion.

  5. Witnesses may be re-interviewed by the Inquiry team as the occasion requires. Any person being re-interviewed will be provided with the record of their previous interview(s) or relevant portion(s) thereof, if requested.

  6. The identity of the witness and the information given will be received in confidence by the Inquiry subject to the following:-

    1. Judge Clark´s duty to report to the Minister for Health and Children.
    2. When a witness provides relevant information critical of a third party, that information will be furnished to such third party for response. The disclosure of the identity of the person making such relevant criticism will not be disclosed unless absolutely necessary in the interests of fair procedures.
    3. Insofar as it is necessary and appropriate, the third party´s response, or the relevant portion, will be furnished to the witness for further response/comment.


  7. Information obtained at interview or statements furnished to the Inquiry legal team will be submitted to Judge Clark. Thereafter:

    1. Judge Clark may request witnesses to attend before her. Witnesses may be accompanied at such time, and Clauses 4 to 7 above will apply as appropriate. Judge Clark reserves the right to allow full or limited legal or other representation of witnesses.
    2. While it is not anticipated that there will be any occasion for cross-examination of witnesses by third parties or their representatives, Judge Clark reserves the discretion to permit same if required in the interests of fair procedures.


  8. The Inquiry has no power to award legal fees or costs.

  9. Unless motivated by malice, all information and statements relevant to its terms of reference which are provided to and received by the Inquiry, are subject to qualified privilege. Insofar as any such information or statements, or their source, are published by the Inquiry to third parties seeking their response, such publication will be by the Inquiry not by the witness and such publication is protected by qualified privilege. Any publication in Judge Clark’s report will be a publication by her in accordance with her terms of reference and is protected by qualified privilege.

  10. This document is for guidance only and the Inquiry reserves the right to amend or alter these guidelines or adopt whatever procedures it deems appropriate to further the course of its work.