In September 2002, Neary was struck off the Medical Register for professional misconduct. But many questions remained unanswered. So a non-statutory inquiry was established by the government in April 2004 to examine Neary's practices and the Maternity Unit at Drogheda from 1960 onwards. The inquiry, chaired by Judge Maureen Harding Clark, conducted 320 interviews with 280 witnesses. The inquiry's report concludes that "deficiencies of insight, judgement and training were the probable root to the serious limitations in some of Dr Neary's practices".

The report notes that when Neary arrived in Drogheda in 1974 his formal training ended. "He never attended any further training or competence assessment of assurance." The report says it is a "great pity" Neary did not remain at a larger hospital where "his deficiencies might have been recognised and put right and where his great selfbelief might have been moulded into a little more introspection".

Harding Clark's report, to be published in the next week, concludes that "this is not a simple story of a surgeon with poor surgical skills or a doctor deficient in academic excellence. . . It is a story of a committed doctor with a misplaced sense of confidence in his own ability."

THE FIGURES

A peripartum hysterectomy is an operation to remove a woman's womb within six weeks of a delivery. Michael Neary carried out his first peripartum hysterectomy at Lourdes Hospital in 1975.

According to the inquiry report, what changed in later years was "the profile of Dr Neary's patients" who were generally younger and with fewer children.

In the period 1974-79, Nearly carried out 20 of the 28 peripartum hysterectomies at Lourdes Hospital. In the 14 years before Neary's appointment in 1974 there had been 31 peripartum hysterectomies at the hospital. "We believe these findings go beyond bad luck or clusters, " the inquiry report concludes.

The numbers remained high throughout the following years. In all, between 1974 and 1998, the Maternity Unit carried out 188 peripartum hysterectomies . . . 129 of these can be attributed to Neary.

Most obstetricians carry out between two and 10 peripartum hysterectomies in their career. "It was difficult to fathom therefore how one obstetrician could carry out nearly 130 peripartum hysterectomies over 25 years without questions being asked." Some 40% of Neary's peripartum hysterectomies were on women having their first or second baby. The report concludes that "the numbers are truly shocking."

WHY?

The matron of the maternity unit raised her "unease" about Neary's high hysterectomy rate in the 1978-79 period but no subsequent action was taken. "It is the view of the inquiry that if there had been an analysis of Dr Neary's hysterectomy rate in those two years, legitimate queries would have been raised as to why he was carrying out hysterectomies so frequently for uncontrolled haemorrhage."

The inquiry report offers no single conclusion as to why Neary did what he did. The two most obvious explanations offered were his fear of blood and poor management structures at Drogheda hospital. "He seemed unusually intolerant of bleeding, " the report states, although this hardly explains why his approach went unchecked for so long.

The inquiry report recalls several instances of where patients and medical personnel witnessed Neary's unease with blood. One doctor "described how Dr Neary became quite animated when he saw heavy bleeding and began to sweat profusely".

One father at the birth of his fifth child recalled that Neary "was visibly stressed with sweat flowing from his brow. . .

both the witness and his wife had to reassure Dr Neary that everything was all right but were unable to relax him until the baby was born".

The inquiry concludes that Neary was "unable to deal conservatively with serious bleeding and saw every haemorrhage as inevitably life-threatening". Somewhere during his career, the inquiry states, Neary "lost sight of the norms operated in every other hospital in Ireland".

"It is highly probable that fear of losing a patient approached phobic dimensions and led him to practise defensive medicine in one of its most extreme forms and probably explains why. . . he expressed rather frequently to patients that the hysterectomy had 'saved your life'."

MANAGEMENT

The inquiry report points to a "question of leadership" at the Lourdes maternity unit.

There was no recognisable peer review of the unit during Neary's period of employment. With the exception of a few midwives who became concerned in 1998, no one had any knowledge of concerns about Neary or about peripartum hysterectomies. "No one saw anything out of the ordinary, no one heard anything, even a whisper of disquiet, and no one had been given any reason to say or think that any of the hysterectomies were questionable."

Many reasons were advanced in the report as to why nobody checked Neary's behaviour. There is a litany of excuses . . . people were not on duty on the days the operations took place; they were very busy; Neary was a very competent surgeon. This lack of action led the inquiry to record, that "the strangest finding which this inquiry has made is that . . . apart from the matron of the maternity unit and a tutor in 1980 . . . no one had any worries, concerns, apprehensions, unease or disquiet until the very late 1990s."

The maternity unit was "unusually self-contained and isolated with a strong unvalidated belief in its excellence".

The matron lacked the authority to question the consultants and she lacked the support of the hospital owners. "The sad reality was that the matron of the maternity unit was not given the power to property administer the maternity unit." Nurses and midwives were trained to be obedient. "The nurses were trained that anticipating the consultant's needs was the sign of a well-trained nurse, " the inquiry observes. Nobody questioned Neary's judgment.

"Several junior doctors found that while Dr Neary claimed to be very up-to-date on obstetric literature, he followed several outmoded practices, " the inquiry notes.

"He was inclined to follow certain procedures because of personal experience rather than from evidence-based trials." One anaesthetist told the inquiry that Neary "had a strong personality and would make a decision to proceed to hysterectomy without consulting his anaesthetic colleague. It was unheard of for an anaesthetist to challenge a surgeon."

Alongside poor management practices, the inquiry notes, "the personality of the consultants played a role".

The power of the consultant is clearly evident in the report. "The ethos of the hospital was that consultants were respected. Respect was number one on the agenda and that came before anything else, " the inquiry report states.

EXPOSURE

By the late '90s there were increasing "deep misgivings" among some medical staff about the high number of hysterectomies carried out by Neary, especially on younger woman. Several midwives at Drogheda hospital chose to have their babies at other hospitals especially after the experience of one of their colleagues in the latter half of 1996. This midwife was a private patient of Neary and was seen as one of his "favourites". There was heavy bleeding during the caesarean birth and . . . despite the patient "pleading with Dr Neary" . . . he opted for a hysterectomy. It was the woman's first child. Some staff saw this operation "as proof that Dr Neary could not legitimately be criticised".

Neary was only exposed when a midwife, called Ann in the Harding Clark inquiry report, made a complaint to the North Eastern Health Board solicitor in 1998. She had trained and worked in Northern Ireland before starting to work in Drogheda in September 1997. "She did not share her colleagues' admiration of Dr Neary and found him opinionated and difficult. She found his practices were outdated and too interventionist. . ."

Ann was "particularly upset when she saw that hysterectomy was carried out with some regularity, and that some of the patients were young women". But when Ann raised her concerns, she was told that consultants were "clinically independent.

They could not be questioned about their procedures. In particular, one could not interfere with the treatment of private patients." However, on 28 October 1998 when making a statement to the health board solicitor about another matter, Ann used the opportunity to formally raise her concerns about Neary.

THE CLARK INQUIRY

A series of investigations followed Ann's complaint, leading eventually to the government's non-statutory inquiry. The range of opinion about Neary is evident from the statements received by Harding Clark's inquiry team.

On one side there were those who argued that Neary hated women, had a fear of uterine cancer in women (which had killed his own wife), panicked when he saw blood, was protected by the nuns who thought he walked on water, took sadistic pleasure from mutilating women and thought he was God and could decide which women should have children.

The alternative view was that Neary was incredibly good and hard working; saved many women's lives and did his best in very difficult conditions. Many colleagues saw Neary as a "skilled surgeon".

Many recalled Neary's "attention to his patients". But as the inquiry report concludes, "a caring doctor should have been able to recognise that hysterectomy in a young woman was a heartbreak. . .

He should have had the capacity to reflect and ask why so many of his patients ended up with hysterectomy when most patients of other consultants did not die or have a hysterectomy".

When confronted with the number of hysterectomies, that the Harding Clark inquiry had attributed to him, Michael Neary was "visibly taken aback and shocked".

But most worryingly of all is the inquiry report's observation that "there is the suspicion that given the same set of circumstances, what happened in this hospital in Drogheda could be replicated in other hospitals where loyalties to staff might be stronger than duty to patients and the profession of medicine".