The report on the high level of peripartum hysterectomies carried out at Our Lady of Lourdes Hospital in Drogheda says that the facts were there for all to see but that few complained or questionedthem.
The inquiry, headed by Judge Maureen Harding Clark, says that the number of such hysterectomies carried out at the hospital was "truly shocking".
Between 1974 and 1998 a total of 188 such procedures were carried out, a far higher rate than in other centres. Of these 129 were carried out by obstetrician Dr Michael Neary.
Other consultants at the hospital also carried out peripartum hysterectomies, but the report says that his Caesarean hysterectomy patients were younger and had had fewer children.
The inquiry says it uncovered a complex story with many strands tangled in the personalities of the participants and the difficult relationship between religious beliefs and human reproduction.
This was overlaid with a sense of intense loyalty to the maternity unit in the hospital.
It maintains that there had been no attempt to hide the procedures or to pretend that they were something else. They had been carried out in the presence of other senior medical staff and were openly recorded.
However, it says that nearly 24 per cent of the obstetric hysterectomy records had subsequently gone missing, and the conclusion that these were intentionally identified, traced and removed from the hospital is inescapable.
It maintains that there is no evidence that Dr Neary had been protected by the former owners of the hospital, the Medical Missionaries of Mary.
"It is the story of a doctor who, at critical points during his training, was inadequately supervised. It is the story of a doctor with a deep fault line and a misplaced sense of confidence in his own ability."
It says that he had worked in a unit which to some extent was caught in a time warp. It lacked leadership, peer review, audit or critical capacity.
The report maintains that Dr Neary had a morbid sensitivity to haemorrhage when carrying out surgery and that it was highly probable that his fear of losing a patient approached phobic dimensions.
Somewhere along his career he perceived hysterectomy as a haemorrhage preventive and lost sight of the norms that operated in every other hospital.
It says that none of the other obstetricians at Drogheda were aware of a culture of early resort to hysterectomy. The prevailing insular atmosphere never questioned or audited outcomes.
The anaesthetists felt in retrospect that Dr Neary may have been a little hasty in resorting to hysterectomy. However, none was consulted about the procedure in advance nor would expect to have been.
The report says that the pathologists assumed that some of the hysterectomies were actually sterilisations (which were not allowed under the hospital's ethos). However, they were unaware of the cumulative numbers.
The report reveals that some concerns had been raised on occasion. The matron of the maternity unit had raised the issue with the then senior obstetrician, Dr Gerard Connolly, around 1980 but he had told her not to worry, that Dr Neary was "afraid of haemorrhage" and that anyway these were clinical matters.
The report says that the other obstetrician, Dr Liam O'Brien, had indicated by gesture that she should not persist.
Around the same time a temporary midwifery tutor, a member of the religious congregation, had serious reservations about two Caesarean hysterectomies carried out by Dr Neary in 1979.
However, she did not raise the issue with the congregation, Dr Neary or other doctors. It says she sought advice from a theologian friend, whom the inquiry identifies as "the cardinal", who said that it was a matter for the doctors.
The report rejects the evidence of Dr Neary that if he had had the right to advise in favour of contraception and sterilisation for women whose health would make further pregnancy dangerous his hysterectomy rate would have been reduced by 75 per cent.
