The report of Judge Maureen Harding Clark maintains that Michael Neary was not an evil man or a bad doctor. It says neither was it the case of a consultant with poor surgical skills.
Rather it is a story of a doctor who at critical points during his training was inadequately supervised and who came to work in a unit which lacked leadership, peer review, audit and critical capacity. It describes Dr Neary as a doctor with a "deep fault line" which was recognised early, but never corrected.
"It is a story of a committed doctor with a misplaced sense of confidence in his own ability. It is a story of deep misunderstandings and misapplication of clinical independence," it says.
Dr Neary was appointed consultant obstetrician to Our Lady of Lourdes Hospital in Drogheda in 1974, at what would now be considered the relatively early age of 31.
He had studied medicine at University College Galway and previously worked in a number of hospitals in the UK. However, the report points out that he had only seven years post-graduate specialist training in obstetrics - something which would not be acceptable for a consultant post today. The report says there is a suspicion that Dr Neary's obstetric training was "considerably less developed than his gynaecology surgery skills".
It says that for a crucial part of his training in an English hospital, his supervisors had been absent. It adds that it is a pity he had not remained working in a large centre where his deficiencies might have been put right. Dr Neary's training in England had not been altogether happy. He first worked in Manchester, where he had a conscience clause inserted permitting him to opt out of involvement in abortions or contraceptive sterilisations. He believed his stand had prejudiced his career there. He later trained in Portsmouth and in Hammersmith hospital in London under an eminent gynaecologist who had a strong moral position against abortion.
Former colleagues told the inquiry he was a skilled surgeon and "a safe pair of hands" who never lost a patient.
However, some non-consultant medical staff who worked with him described him as having "a personality disorder, rather than a skills deficit".
Virtually everyone acknowledged that Dr Neary was a tireless worker who was always available day and night.
The report maintains that the major flaw in his practice was an inability to deal conservatively with serious bleeding and that he saw every haemorrhage as inevitably life-threatening. It suggests that he had an acutely heightened sense of danger and a morbidity to haemorrhage when carrying out surgery.
"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, from an early stage in his career, he expressed rather frequently to patients that the hysterectomy had saved your life."
