Analysis: Why did Dr Michael Neary do what he did? Answers are difficult to find, writes Dr Muiris Houston, Medical Correspondent.
The Medical Council report into the professional practice of Dr Michael Neary, the former consultant obstetrician at Our Lady of Lourdes Hospital, Drogheda, does not make for pleasant reading. Set up specifically to look at the management of 10 women who underwent hysterectomy immediately following Caesarean section, it is a damning indictment of Dr Neary's later professional life.
With phrases like "tended to exaggerate or over-dramatise blood loss", "substantial and continuing discrepancy between pathological and clinical findings" and "a pattern of rapid recourse to Caesarean hysterectomy", the image is of a consultant who had lost touch with reality.
Rather than the calm, reassuring figure the public would expect in a medical crisis, the impression is of a man given to hyperbole and overreaction.
However, the Medical Council's Fitness to Practise Committee's (FTPC) report on Dr Neary in no way helps to answer why he acted as he did - a question people are still asking.
Despite the overwhelming evidence against him, Dr Neary instructed his legal team to contest every one of the 10 cases. It would appear that even Dr Neary cannot answer why he did what he did.
The report also provides no answer to the question on how his exceptional practice was allowed to continue for so long. At the time of his professional misconduct, the obstetric unit in Drogheda was staffed by two consultants and a number of junior doctors.
Others were directly involved in his operating theatre activities. Pathologists looked at the wombs he removed.
Yet, in the words of the FTPC inquiry report: "it is deeply regrettable that it was not until this inquiry that the statistics ... came to light fully".
And how awful these statistics look in the cold light of analysis. Dr Neary's personal Caesarean hysterectomy rate at 1 per 20 Caesareans performed compares with a rate in the Coombe Woman's Hospital of 1 in 600.
But perhaps the most worrying evidence to emerge from the inquiry - and that is not to play down or denigrate the awful damage dome to those women whose stories emerge in the report - is that Dr Neary's personal practice was mirrored by that of the Drogheda unit as a whole.
At one Caesarean hysterectomy per 179 total births, the procedure was carried out over 20 times more frequently in Drogheda than it was in the Coombe Women's Hospital or the National Maternity Hospital.
Commenting on this finding, the FTPC report said: "Clearly such a substantive deviation from the norm must be a source of very serious concern. From these figures the committee can only conclude that it is highly probable that the procedures carried out in Drogheda were largely unnecessary."
Even if the Minister for Health was not motivated by the tragic stories of the women themselves to institute a full inquiry, this bald conclusion must result in an extensive inquiry into obstetric practice at Drogheda during the 1990s.
It is clear also that even the most basic peer review and competence assurance was not part of the routine of Drogheda's obstetrics unit. Rather than a picture of collegiality and problem-solving, the image is one of professional isolation and a slide into incompetence.
While maternity hospitals in Dublin and elsewhere were reviewing their statistics and critical incidents on a weekly and monthly basis, the Drogheda unit slid into questionable obstetrics practice.
That this could continue for so long is a significant indictment of the current methods of assessing doctors' performance.
In fairness to the current Medical Council, it has been looking to improve competence assessment throughout its lifetime.
So far there is little sign of political reaction.
We have been promised a new Medical Practitioners Act at the start of each parliamentary session for the last couple of years.
Reform of the 1978 Act is long overdue and must be forthcoming if public confidence in the medical profession is not to be damaged further.
Even before the Dr Neary case, accountability emerged as a key issue in healthcare.
As Ms Geraldine Feeney, the chair of the Medical Council ethics committee, told The Irish Times last month: "I am not sure that the problem is confined to obstetrics and that it could not happen in another discipline of medicine."