(iii) regardless of history however, Dr Korda has expressed his disagreement on the course of surgical intervention in this case. There are other expressions in his report about this, but it suffices for present purposes for me to record what Dr Korda said at p 6 of his report of 4 April 2001:
"I disagree with Professor Hacker's conclusions that a hysterectomy was a perfectly reasonable option for Mrs Booth. The presence of adenomatous hyperplasia in a woman with a long history of pelvic pain, two previous Caesarean sections, a previous uterine perforation requiring laparotomy and oversew, a previous anterior vaginal repair, a long history of pelvic pain and documented endometriosis are all warning that surgery should be avoided at all costs. In view of the fact that Mrs Booth did not have a malignant condition, the chances of adenomatous hyperplasia turning malignant were between 0-3%, that she was not given a reasonable option of observation but was strongly advised to undergo surgery and the trial of progestogens was short and sub-optimal in dose, the advice to undergo a hysterectomy was not in accordance with proper standards of specialist gynaecological practice."
16 Whilst perhaps expressing himself less forcibly than Dr Korda, Dr Lyneham, in his report of 31 May 2001, made it clear, at least on my reading of his report, that the extensive operative procedure undertaken was not appropriate. He wrote ( at p 8 of his report):
"Mrs Booth's lesion was of the more minor form, limited in extent and symptomatically of very brief duration. If it was going to develop into endometrial cancer, it would not be a rapid change but rather would afford a gynaecologist ample opportunity to continue surveillance and reassess when appropriate. The risk of hysterectomy was increased in Mrs Booth, an increased risk that was recognised by Dr Di Francesco and led to his having a consultant surgeon in theatres with him. On that basis, it would be my view that total abdominal hysterectomy and bilateral salpingo-oophorectomy was not properly required to treat Mrs Booth's 'adenomatous hyperplasia'."
17 Dr Lyneham went on to say this:
"If, after a full and detailed explanation of the therapeutic options and risks of hysterectomy, Mrs Booth was of the strong view that she wanted to have a hysterectomy performed, to remove any risk of endometrial cancer in the future, and remove any need for ongoing gynaecological surveillance, then hysterectomy would have been reasonable. Such a decision would have had to have been made by Mrs Booth following a detailed explanation by Dr Di Francesco, preferably on more than one occasion. She would have needed to have been advised that the abnormality that was in the uterus was a mild form of abnormality, limited in its extent within the uterus and overwhelmingly likely to resolve spontaneously; it was even more likely to resolve with hormonal treatment; and very unlikely to develop into cancer, but with plenty of time to detect premalignant changes before cancer developed, if surveillance was pursued. With hysterectomy likely to be associated with an increased risk of intraoperative complications, performing a total abdominal hysterectomy with bilateral salpingo-oophorectomy without Mrs Booth's clear understanding of this clinical setting would, in my view, be a departure from acceptable standards of care."
18 The opinion expressed in the last paragraph above set out once again emphasises the importance of establishing the advice which was given by the defendant to the plaintiff, and the resolution of this issue, of course, cannot be assisted by anything that occurred at a conference of experts.
19 In his later report of 25 October 2001, Dr Lyneham made this observation on the report of Professor Hacker:
"On page 2 Professor Hacker states that 'I not infrequently see patients whose curettings show some type of endometrial hyperplasia, but when the hysterectomy is performed, there is invasive cancer present, (in addition to the hyperplasia)'. This is not altogether surprising, but as I have discussed already, the likelihood of there being cancer present when there is adenomatous hyperplasia without atypia, is probably less than 1%. Indeed, in the case of Ms Booth, there were areas of focal adenomatous hyperplasia with most of the endometrium showing either proliferative or early secretory endometrium. I would be surprised if Professor Hacker sees unexpected invasive cancer in the hysterectomy specimens of patients such as these 'not infrequently'."
20 Professor Hacker, in his report of 5 December 2000, opined that the surgical procedure "was entirely reasonable for the following reasons":
"(i) the patient was given the option of observation, but elected to have surgery.