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My name is headley Thomas. In 2005 my reporting exposed shocking medical negligence at the heart of a major health care system. An overseas trained surgeon who was nicknamed Dr. Death by the nurses, doctors and hospital administrators left patients mutilated, incapacitated, even dead. Sick to Death is based on my book of the same name and it's the true story of Dr. Jayant Patel's lies and manipulation and the herculean effort it took to finally stop him. We've used voice actors throughout this series and on occasion the real people from this story have read their words for us. It is brought to you by me and the Australian. Chapter 1 Happy Days January 2002 Jared Neville put the last bag in the family car as his wife Lorraine urged the three children to hurry downstairs. A fit, middle aged public health physician for Queensland Health, Gerard ran beside the Brisbane river most mornings, even in the subtropical humidity of summer, before going to work to plan policy for the well being of a few million men, women and children. They were known, in accordance with the corporate vernacular, as clients. The years had been kind to Gerard. He remained free of the stress of providing clinical care in an organisation starved of funds, while his friends, many of them fellow graduates of the University of Queensland's medical school in the leafy grounds of Hurston, had opted for careers in operating theatres with late night callouts, long hours and eventually private rooms. As highly paid specialists, Gerard enjoyed a steady public service routine. He was adept at his office job, never shirking unpopular assignments such as telling his political masters the unpalatable reality about the effect of their policies. He would never reach the top of a highly politicised bureaucracy, nor did he aspire to they made a handsome couple, Gerard and Lorraine. A tall and softly spoken teacher, she met Gerard when he was a rural GP, five years after his graduation. Their motto might have been permanence and stability. They were stylish but not flashy, professional but not elitist. They were Catholic with middle class values, healthy children, secure careers and a comfortable, newly renovated house on a hill in the Brisbane middle class suburb of Toowong. Laura, aged 14, Elise, 10, and Michael, eight, needed little encouragement to leave their Brisbane home at the height of the summer heat wave. Across the city, thousands of people without air conditioning were seeking refuge in shopping centres and cinemas. Temperatures were about to soar into the high 30s, with only limited relief from the scattered showers and afternoon storms. The Nevilles were going somewhere infinitely more appealing. In two hours they would arrive at King's beach in Caloundra for the start of an annual holiday ritual, exploring rock pools, swimming in the surf, blazing around the pool and choosing from the dinner specials at nearby restaurants. As Gerard nosed the car, one of the perks of his package with Queensland Health, down the neatly paved driveway and turned left onto Milton Road for the drive north, Lorraine felt uneasy. Usually the Neville family would stay at Pandanus Court in Caloundra for the Christmas holidays. Their familiarity over the years with the old block of units closest to the beach was part of the fun. Returning to Pandanus was a bit like visiting a favourite auntie. Notwithstanding her flaws, she was safe and would not produce any surprises. When Lorraine had called months earlier to make the usual holiday booking, the woman at Hensels Real Estate Agency explained that Pandanus would not be available this time. The old block was being redeveloped and Auntie was to receive an overdue facelift. Instead, Lorraine was offered a unit in Monterey Lodge, a block not known to her. The plan was to spend a week there, dash back to Brisbane the following Saturday, unload the car, water the garden, check the mail, feed the children, return calls, load the car again and drive across the city to catch the afternoon ferry from Cleveland to Stradbroke island for a further seven days holidaying. Lorraine's first impression of Unit 3 at Monterey Lodge confirmed her unease. The living space was long, dark and narrow. The floor throughout seemed to be hard concrete with a thin wood veneer surface. The place felt austere and uninviting before they had begun to unpack, before Lorraine could take in the natural beauty of the water beyond the buildings, the she had regrets. As Lorraine tried to bury her misgivings and put on a bright face and Gerard carried the bags inside. Elise ran to the second bedroom and squealed with delight. As expected, there was a set of bunk beds. They were unspectacular, lightly framed and well used. They stood exactly 1.43 metres high in one corner of the room. The top bunk had been promised days earlier to Elise, who excitedly told her friends and reminded Michael and Laura that she would soon be towering over them morning and night, a bright girl with sparkling blue eyes, a cherubic face and a gift for bringing calm and laughter into awkward situations. Elise looked at the top bunk and beamed. She clambered up and bounced on the mattress. A trundle bed had been stored under the lower bed. Lorraine dragged it out on the Saturday afternoon and put it against the wall, forming an L shape with the bunks. Lorraine frowned at the glass topped table in the room. It was an accident waiting to happen. She carried it into the main bedroom where she and Jared would be sleeping. Next, she hauled a low set of wooden bedside drawers from the main bedroom to the children's room. As Lorraine had feared, the unit was hot. Its bricks absorbed heat throughout the day. The windows missed the best of the sea breezes and there were no ceiling fans. Lorraine put one of the electric fans she had brought from Brisbane on the bedside drawers. At least the children would be comfortable as they slept. Lorraine took one more precaution before satisfying herself that she had made the best of things. She spread quilts and blankets along the floor below the bunk beds. Michael, who would be in the bottom bunk, was a restless sleeper, though neither he nor Elise had any history of falling out of bed. But just in case, the quilts might soften an unlikely accidental fall. The family woke to a glorious Sunday morning and devoted it to the beach and the pool. Lorraine's worries eased as the sun disappeared behind the Glasshouse Mountains. The family walked to Bullcock beach for fish and chips at a sidewalk table. After they returned to the unit, Michael went to bed first. He was sleeping soundly by 9pm When Lorraine checked on him. Elise, nestled beside her mother on the sofa, stayed contentedly reading her novel. From time to time, she looked up at the tv. An hour after Michael had turned in, Elise was ready for bed. She kissed her parents and smiled as Lorraine tucked her in for a second night in the top bunk. Lorraine, who had made a point of picking the children's clutter off the floor to prevent a stumble in the dark, did not notice something amiss as she turned out the lights. The family had no experience with bunk beds. The safety rails that prevent a child from rolling out were not there. As they were on holidays, Laura was allowed to stay up with her parents until the late movie ended. Shortly before midnight, they all went to bed, and within minutes everyone was sleeping. At 1:50am Lorraine woke up. Suddenly, Gerard sat upright. They had both heard it. A loud noise, a heavy thud. In the seconds that followed, moaning noises drifted from the bedroom and instantly Lorraine guessed what had happened. Oh, my God. Jarrad. I think Elise has fallen out of bed. They hurried to the bedroom where Elise was lying curled up on her right side. She was on the quilt on the floor with her head towards the narrow shelf and doorless cupboard in the room. Lorraine frantically moved the small drawers with the fan on top so she and Gerard could both fit in the room more easily. To tend their stricken child, Lorraine needed immediate affirmation that Elise had not broken any limbs. Elise, are you okay? Can you move your arms? And legs. Elise could move her limbs, but. But Lorraine's relief was tempered by a new fear. Elise was in great pain. In the half light she cried out, my head hurts. Gerard tried to contain his own anxiety in the gloomy bedroom as Elise lay on the floor with her Winnie the Pooh teddy bear, rubbing her head and whimpering softly. He took charge. He was the doctor. He might not have practised medicine for 18 years, but he knew something about head injury. He spoke in as measured a tone as he could manage. Try and keep calm. I'll take her to our bed and have a look at her. Gerard checked Elisa's limbs, neck, chest and stomach for breaks or pain. He carried her to the main bedroom and brought the mattress from her top bunk. They lay her down on it on the floor in their room. She continued moaning in obvious pain. She was touching the left side of her head. My head hurts a lot here. Lorraine, shaking with worry and fear, wanted to rush Elise to hospital. She was becoming frantic. Gerard resisted. He doubted Elyse had been unconscious after the fall. He persuaded Lorraine that they could safely watch her in the unit for the time being. Stop panicking. Everything will be okay. Elise piped up. Yes, Mummy. Don't panic. You're making me worried. I'm sorry. Everything will be alright. No it won't, Mum. There's something really wrong. Chapter 2 the Shift January 2002 Andrew Donovan looked at the clock on the wall above one of the Caloundra Hospital ward beds. It was almost 3am he sighed with relief. He wouldn't wish the graveyard shift on his worst enemy. He knew exactly how long he had been going without a rest. Having come on duty at 8am the previous day, he was at the 19 hour mark of a 24 hour shift. Donnerman, a father of two young children, was exhausted. He would never touch alcohol while at work, but the effect of his fatigue equated to a blood alcohol reading of 0.05%. Long distance truck drivers could be forced off the road if found working dangerously long hours, economic necessity and demanding bosses forced the drivers to stay awake with amphetamines as they hurtled down the country's highways. Airline operators had much more to lose. The repercussions from carnage caused by a Mack truck colliding with a family car were nothing compared with those that might follow a Boeing 747 ploughing into a mountain. Due to pilot fatigue, Australian pilots were permitted a maximum number of hours in the cockpit on long haul flights, after which strict regulations stipulated a lengthy rest in the bunks Nurses too were banned from working excessive hours. Yet doctors like Donnerman in Queensland's public hospitals were given no choice. At this time of year, when many of the senior doctors were holidaying with their own families, those on the bottom rung were in greater demand than usual. The chronic shortage of doctors nationally was worse in Queensland, which had the lowest number of registered doctors per head of population of any state or territory. There were about 2,500 more doctors in Victoria, a state with a similar population but without the challenges unique to Queensland of decentralisation, poor working conditions and remote and indigenous communities. Andrew Donnerman had few complaints. He would do the hours, a rite of passage, and move up the ranks. He was not the most junior doctor in Queensland, but he was the least experienced doctor to be put in charge of the 80 bed Caloundra Hospital overnight. For the duration of this shift, he was the only doctor on duty. A quietly ambitious 37 year old, Donovan did not look like a newcomer to medicine. But he only began studying medicine in his late 20s. His confidence and age sometimes made his patients suspect, wrongly, that he was experienced. Just two years after receiving his Bachelor of Medicine and Bachelor of Surgery from the University of Queensland, he was making clinical decisions without having to defer to senior colleagues. Donovan had worked in hospitals known as God's Waiting Rooms because they catered to a large population of elderly retirees who had moved to the Sunshine coast for its warm climate, beaches and lawn bowls. As a junior house officer, almost the lowest ranking doctor on the scale, he had treated worn out knees, supporting the overweight and the sedentary. He had treated gynaecological issues common to elderly women who had born children during rotations in paediatrics, orthopaedics, anaesthetics, obstetrics, gynecology and emergency medicine. He had seen dozens of bright eyed babies at the start of life and the old and frail who were soon to depart. Maybe they sensed in his bedside manner a contagious energy and enthusiasm for medicine. After driving taxis to pay his way through medical school, he had large bills and a meager salary. But he was doing what he loved. His colleagues had noted the positive feedback from his patients. Somewhere within the Queensland health bureaucracy, a secret document headed Review of Emergency Services Sunshine Coast Health Service District flagged potential dangers at Caloundra Hospital. The review had been compiled by a small team of experts who had been investigating the resources, safety and performance of emergency departments along the coastal strip. It was conducted on a confidential basis. Its author, Dr. William Rogers, found that the Caloundra Emergency department needed a minimum of four principal house officers. A principal house officer is a doctor in her third year of practical experience, postgraduate. Further, their responsibilities should not be stretched to looking after inpatients as well as those coming into the emergency department during normal working hours. Dr. Donnerman, who knew nothing of the three month old report and its unheeded recommendations, was two years away from being made a principal house officer when he began his fateful shift in early January. He had responsibility for the entire hospital. The nurses in the emergency department, Beverly Duncan and Diane Forbes, who had come on duty at 10:45pm were taking a break after a busy few hours. The patients were presenting with relatively minor ailments and certainly none with emergencies. Most simply sought free treatment, uniquely, with beds in short supply and resources strictly limited. The hospital also had a bizarre practice. It did not admit children. Chapter 3 We Need Help January 2002 Elyse was talking a little as Lorraine held an ice pack to her head. Around 3am she became agitated, flailing her arms and crying out with the pain. Laura and Michael, who had woken in the frantic commotion after the fall, looked on helplessly. Elise vomited. It was the last sign Jered needed. He knew then that she had to go to hospital urgently and would probably need a CT or computerised tomography scan with detailed two dimensional computer enhanced X ray images. A CT scan could highlight any abnormalities such as bleeding in Elisa's brain or a fracture in her skull. He was about to tell Lorraine of his decision. She beat him to it as Elise moaned and complained about the yucky taste of vomit in her mouth. Right, we're going to the hospital now. Lorraine was emphatic as she cleaned Elise's face and clothes and quickly got changed. Gerard's appearance of calm had dissolved. Now he too was shaking. The fear was sensed by Laura and Michael, who huddled together on the trundle bed. They were frightened for Elise and worried about being in the unfamiliar unit alone. Lorraine cradled Elise in the back seat of the car as her head rested on a pillow that had been snatched up on the way out. Gerard drove to the nearby Caloundra Public Hospital in West Terrace but later would not even remember the route he took. He jabbed the illuminated night bell outside the emergency department until Beverly Duncan answered through the intercom and then opened the door. Gerard quickly explained what had happened. A fall, a head striking a hard floor, ongoing pain, headache, vomiting. They were directed to a room in the emergency department where Elise lay very quiet on the bed. During a brief examination by Duncan, a United Kingdom trained nurse who scrawled details on a clipboard and peered at the frightened child's pupils while shining a torch. Elise's pulse rate measured 54, a low reading. An oximeter on her finger measured her oxygen saturation levels. As Duncan made small talk with Gerard, he explained that he was a non practising doctor, one of the 60,000 staff of Queensland Health. They were colleagues. Duncan noted a child who was quietly spoken and unhappy. Where does it hurt? I'm aching all over, but mainly I've got a headache. Duncan found the aching all over answer strange. There was no obvious deformity to any limbs, no swelling and no specific pain suggestive of a fracture. Lorraine was asked to leave the room to fill in forms at the front counter. I can hardly write as I'm shaking so much. Duncan, it seemed to Lorraine ignored her and walked away, leaving the distraught mother wondering what she had done to receive a cold reception at 3:25am with an injured child. Lorraine returned to the assessment room to remark to Gerard the lack of empathy. She weighed their options. They were in an open, functioning emergency department, staffed by health professionals. Complaining might be counterproductive. It could lead to a lease being ignored. The alternative of leaving to find other medical help seemed impossible. So they waited. Dr. Andrew Donovan was at a bench writing up his notes for another patient, a man in a wheelchair, when Duncan explained the basics. A 10 year old girl on holidays, a fall from a top bunk, generalised aches and pains, vomiting, no loss of consciousness. In the central area of the emergency Department, Nurse Duncan, Dr. Donnerman and Nurse Diane Forbes discussed Elise's vital signs. The chit chat seemed interminable to Lorraine, who was near breaking point. Sensing no urgency among the staff, she pleaded with Gerard, who still felt guilty for keeping Elyse in the Monterey unit for the first hour. She wanted Gerard to beg for action. Gerard directed a question to the nurse Forbes, who was sitting back at the nursing station. How long will the doctor be? Please, Is anyone going to come and see my daughter? We are very worried. My wife is very concerned. Can you come now, at least for her sake? Nurse Forbes had heard the questions a thousand times before. Everyone wanted to be seen. Yesterday it was as if nobody else mattered or even existed. The patients, emotional and sometimes abusive, had no idea how busy the staff were and knew nothing about the pressures of competing priorities, like paperwork. No, there was no point in arguing. Forbes nodded towards the bench where Dr. Donnelman was writing notes. He's just there. He'll be with you shortly. As the doctor walked into the assessment room, time was running out for Elise. A drop or two of blood had already seeped into her left ear. The fall from the bunk had fractured Elise's skull and damaged the middle meningeal artery in her brain. Without surgery to drain the blood, which might have been obvious during a thorough examination, the growing clot would force the soft tissue in Elisa's brain against the immovable bones in her skull. If left untreated, her brain could herniate, causing catastrophic injury. Chapter 4 the Nursing Life Tony Hoffman went to the thesaurus just to be sure. Maverick. She liked the word, but as with many nicknames, it could be misconstrued. What else might it mean? Independent, non conformist? Individual. Yes, Hoffman had to agree that she was something of a maverick. The nickname had been given to her in circumstances that were moderately controversial. As the senior nurse in charge of Bundaberg Base Hospital's combined intensive care and coronary care units since her arrival in 2000, Hoffman made a strong case over unsafe hours being worked by her staff. Most of the 15 nurses in the intensive care unit were exhausted. The fatigue, which stemmed from their early morning starts and late finishes, was affecting clinical care. A tired nurse could be dangerous, particularly in the ICU or intensive care unit, where the critically ill patients had the most tenuous hold on life. The nurses were not meant to leave the bedsides of patients being helped to breathe by ventilating equipment. It only took a short lapse in concentration or momentary inattention for a fatal mistake to be made. Without fuss or rancour. Hoffman had argued a case for more nurses and safer hours. Glenys Goodman, the director of nursing at the hospital, took Hoffman's submission to the next level. Eventually, the logic and common sense of the argument were accepted. More nurses were employed. The dangerous shifts were abolished. The patients in the ICU did not know that a fundamental change to the nursing roster gave them better odds of survival. But the staff knew Hoffman won immediate and long lasting respect from the other nurses for her willingness to back them as well as the patients. Tony Hoffman was a rarity, a middle manager prepared to raise her head above the parapet and speak out against convention and systems that had been imposed by her superiors and grudgingly accepted by the staff. But in Queensland Health, an organisation run down by political interference and financial neglect, Hoffman's style of robust outspokenness was rarely rewarded. The mavericks who agitated for something outside the square were usually the first to be muzzled. Rebel, loner, misfit. Although it pained Hoffman to admit it, she probably was a loner, maybe even a misfit. She did not have a boyfriend yet. All her best friends were married. They spent every spare moment with their children talking about their children or planning events around their children. Her younger sister, Marie, was run off her feet with her two kids. At times when the demands of parenthood seemed limitless, Hoffman felt fortunate to have avoided those responsibilities. When the challenges in the ICU were unrelenting and the deadlines for her university assignments seemed impossible, she consoled herself that her life's journey was as it should be. At least she had her freedom. At least she had the time after work to devote to study, even if there were occasional bouts of loneliness. Still, pragmatism could not change the fact that Hoffman loved children and regretted not having her own. Although several of her long term boyfriends would have made her happy as partners for life, Hoffman had always hesitated when things became serious. Marriage frightened her. It seemed like the end of the world. As a girl growing up in Ingleburn, south west of Sydney, she had missed her father, Warwick, during his long road trips hauling freight in the truck owned by the family business, W and M Hoffman Transport. She was 15 when her father decided to try his hand at growing potatoes, pumpkins, tomatoes and cabbages. Hoffman briefly resented him for taking the family from the outskirts of Sydney to a little community halfway between Brisbane and Toowoomba, where almost everyone had unusual European surnames and spoke with a strange accent. On her first day at Lockyer Valley State High, one of the students assumed she was a child of itinerant fruit pickers. Will you be staying just a little while? He asked the newcomer. I hope so. Tony sniffed, and the class booed. Her first instinct had always been to speak her mind. Rebel, renegade, dissident. Over time, the open spaces, summer days spent swimming in the local waterholes, and camping with her new boyfriend made her grateful for the move away from Sydney. At the end of year 12, she chose nursing. It offered accommodation, study, and a salary. Having been accepted by the three major public hospitals in Brisbane, she opted for the Princess Alexandra Hospital. Hoffman hated nursing. As a young woman, she missed her animals, her younger brothers, Andrew and Matthew, and her baby sister, Marie. In the first six months, she thought she had experienced the worst things a nurse might be expected to do. Everything from changing the dressings on severed limbs to helping pack a deep abdominal wound in which the intestines could be seen glistening. She received another surprise when one of the nurse educators stood up and asked the class, how do you wipe a patient's bottom? At the time, Hoffman knew little about what she was letting herself in for after three years of work and study, she travelled overseas for three months and then returned to nurse in Tasmania. By 1981, she had gone back to the United Kingdom to do midwifery at Taunton in Somerset. While she was there, Hoffman was woken by the telephone at 5:17am, when one day she snuggled deeper under the covers, hoping the telephone was ringing for one of the other nurses who shared the hospital's accommodation. A short while later, someone was turning the handle on her door. You need to ring home, the supervisor told her in a grave tone. Tony's mother, Mari, answered the telephone at the family farm. Andrew's dead. He had a motorbike accident. Tony's younger brother had been visiting wineries near Stanthorpe with friends when he struck a power pole while rounding a corner. He had suffered a major chest wound and died at the scene. Partly as a result of the accident, Hoffman realised that she wanted to specialise in intensive care. Although the patients wheeled into the ICU were often near death, they had at least been stabilized. Unlike in the emergency department, where the doctors and nurses struggled with drugs and electric paddles to maintain life, the prognosis of patients in the ICU could be more accurately predicted. There was relative calm in the icu, which was necessarily staffed by the best doctors and visited regularly by specialists. Hoffman took great satisfaction in standing beside patients as they stared death in the face, then seeing them return to their families. She obtained her first qualification in intensive care at King's College Hospital in London and went on to work in the intensive care wards at the Harley Street Clinic in London. Later, she was to work at Tasmania's Launceston General Hospital. Wanderlust took her to Riyadh in Saudi Arabia, where she was a senior nurse for six years. The children in the paediatric wards quickened the ticking of her biological clock. She was 30 and in a secret relationship with a Saudi man. If ever she was going to surprise her family and friends by marrying, it was then. When Hoffman returned alone again from Saudi Arabia after the first Gulf War, she settled in Caloundra, a relaxed beachside town on the sunshine coast. She threw herself into her studies by correspondence, working towards gaining qualifications as a Bachelor of Nursing from Monash University. By the middle of 2000, when she pipped one other senior nurse on the short list to win the job as nurse manager of the ICU at Bundaberg Base Hospital, Hoffman had found a substitute for children and married life. Happily. Hoffman had moved north to the sugar town of Bundaberg. It was home now. She spent most Nights and weekends in her rented cottage in Grimsted street, surrounded by textbooks and determined to graduate from Monash University with a master's in bioethics, she decided that her thesis would examine how health professionals involved in treating critically ill patients were subjective in determining quality of life. In Hoffman's experience as a nurse, perceptions about quality of life too often depended on the individual values of the carers, the doctors and the nurses instead of the patient. She believed that a young and fit doctor who ran marathons would be less likely to appreciate how an elderly cripple might have an acceptable quality of life merely watching grandchildren run around the yard. Tony Hoffman decided that decisions about quality of life were best left to the patients and their next of kin. She enjoyed excellent working relationships with the doctors, but she hated it when they justified poor care leading to death as a path to a better outcome. How would they know? She asked. As far as Hoffman was concerned, every life was precious, no matter how poorly compromised the patient's health. She believed that the best possible care should be provided until the patient drew a final breath. The hospital on Bourbong street beside the Burnett river had seemed backward when she first arrived, and in many ways it was. The medical staff was largely made up of overseas trained doctors, some of whom could barely be understood because of their broad accents or their inadequate command of English. The district manager, Peter Leck, had no clinical qualifications, but he knew the key to success for him was staying within budget. The strict financial parameters were well understood by administrators who were remote from the patients. The easiest way to deal with a problem was to dismiss it with the excuse that there was no money to fix it. Lech's job was not necessarily a job for life. A budgetary blowout or a failure to get on top of the surgery waiting lists could mean the sack. On the other hand, the doctors and nurses were united in the belief that public hospitals were for the sick and injured. The unforgiving economic rationalism of Premier Peter Beattie's labor government, Health Minister Wendy Edmond and her top bureaucrats in Queensland health headquarters in Brisbane was distressing. Staff who for years had been dedicated to the public system were giving up, preferring to work in the better funded private sector. As more and more demoralised clinicians quit, those left behind were increasingly pressured by administrators. The hospitals were infused with business strategies. Where once the medical superintendent concentrated on patient outcomes, the new priority was cutting costs and increasing potential revenues. Nowhere was this more obvious than at Bundaberg Base Hospital. In the months leading up to the arrival of doctors Jayant Patel, the Administrators were measuring performance not by lives saved, but by dollars saved. The hospital had become a lean, mean business. Chapter 5 grim in January 2002, before Dr. Charles Nankavel walked away for the last time from the Bundaberg Hospital on Bourbong street, he hoped that the crisis in healthcare he was witnessing and repeatedly warning his managers about might still be corrected. If the administrators who controlled budgets and human resources truly valued their highly skilled and passionate direct director of surgery, now was the time to show it to him. He hoped someone from head office would ring and say, we hear you're leaving. We're sad about that. Would you like to talk to us? But nobody called. Nankavel had been pushed to the brink of a physical and nervous breakdown. Despite the excessive hours he had been working, the patients were suffering. They were waiting too long for surgery. Nankevel was regularly spending 14 hours a day at the hospital, then being woken at home and asked to come in for a critical case or unexpected emergency. The weekends offered no relief. Nankevel had to work most Saturdays and Sundays. As one of two hospital surgeons serving a growing and aging population of almost 80,000 people, most of whom were not privately insured, Nankevell needed urgent backup. He had pleaded his case with everyone from his district manager, Peter Lech, to the head of Queensland Health, Dr. Rob Stable. Nenkavel wrote to Dr. Stable in a confidential memo in late 2001.
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I had my resignation letter ready one year ago. As it turned out, the same day I signed my resignation, Dr. Anderson was stood down, so was not handed in. I stayed on in BundaBERG an extra 12 months to try to help the patients here and with hope that things might improve. I suffered enormous physical and mental exhaustion and was operating on patients when I was totally unfit. I will not allow any other person to go through this. This very ugly episode is well known throughout Queensland and is a big turn off for surgeons thinking of coming to Bundaberg. Our clinicians meetings with Queensland Health have identified the problems with the Department of Surgery as the number one problem affecting the Bundaberg base hospital. For several years there's been no effective response to our concerns. This has flabbergasted the staff. We seem to have no effective communication with Queensland Health. Clearly identified issues are not addressed and we don't seem to get appropriate feedback on why not.
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Nankavel warned of numerous examples of unnecessarily delayed diagnoses of cancer, massively overbooked clinics, an emergency department in a shambles and an inability to meet guidelines for the surgical waiting lists. But his memo was to no avail. Instead, his letters and telephone calls branded Mancavel as a complaining clinician. There was no extra funding because nobody was prepared to insist that extra funds be provided. Nankevelle was livid. Whenever the quality assurance data arrived from the statisticians in the administration, they would dwell on statistics showing, for example, that his patients stayed an average of 4.3 days. When in Brisbane, the average was slightly less constant. Pressure was exerted to move the patients through faster. Time is money. But Nankebel's priority was to make his patients better. If that meant a longer stay, so be it. He should not have been surprised by his failure to achieve change. The culture of Queensland Health was being distorted by a management model that described the patients as clients. It was a culture which nurtured the creation of committees. Rarely was anything resolved. Decisive action on even minor matters was frowned upon. Clinicians were expected to prepare a submission or a business case. The pointlessness of it all infuriated Nankebel. After careful consideration, he eventually decided not to follow through with a plan to tell all to the local newspaper, the Bundaberg News Mail.
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If I tell the truth to the media, I get sacked. But if people in administration spin doctor the media, they get promoted.
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Nankavel had examined Queensland Health's code of conduct. In one part, it states, all employees are reminded that irresponsible discussion of any matters regarding the health service facilities, staff and most importantly, patients is regarded as an offence. Nancabel regarded that statement as a gag. He dubbed the code of conduct the code of silence. Dr. John Youngman, the second most senior administrator in the Queensland Health organisation, responded to Nankevell's and Bundaberg's crisis with a brief letter which made scant mention of the unsafe working practices that Nankevell suspected would kill either him or a patient. When he received Dr. Youngman's letter, Dr. Nankevell decided the hospital was a lost cause.
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That's it. I'm finished. I'm out of here.
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His immediate predecessor, Dr. Peter Anderson, had suffered a worse fate for being outspoken about life threatening problems. Anderson and the director of medical services, vascular surgeon Dr. Brian Thiel, had built up a strong surgery department. Thiel had an almost magical touch. Even after major operations, his patients were always in relatively great shape when taken from theatre to the icu. Tony Hoffman marvelled at their robust condition. But the constant struggle against an administration they regarded as closed and secretive eventually wore both specialists down. They abandoned the hospital when Anderson went public in the Bundaberg News Mail to warn of the dangers posed by exhausted surgeons. He was subjected to a scathing attack by Health Minister Wendy Edmond in State Parliament.
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B
I can understand Dr. Anderson's need to constantly criticise the Bundaberg Hospital administration since they are the ones who exposed his double dipping and disservice to the public patients whom he was employed to care for.
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A
It was a typical Queensland health ploy. Discredit the whistleblower by raising untested claims, then create a diversion from the fundamental problems plaguing the system and make sure other staff who might have been thinking of going public know they will face public censure. After the departures of Dr. Anderson and Dr. Nankevel, a new Director of surgery came to the job, Dr. Sam Baker. He too tried to ensure management understood how dangerous the hospital had become because of its focus on the bottom line instead of outcomes for patients. In an internal assessment memo, Dr. Baker was very candid.
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B
There is little direction from management with regards to strategic direction. They refused to clearly define the hospital's operational role in delivery of special services and the critical mass of medical staff required to meet this role. They appear more interested in making targets than delivery of Quality Healthcare.
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Dr. Chris Jeliffe, an anaesthetist at the hospital, was deeply concerned for the well being of the staff and the patients. He had seen Nankeville deteriorate to the point where he looked like a beaten man, broken by the punishing hours hours he had to work. Dr. Jelliffe was also in a bad way due to the demands. He was sure that his own decision making processes were impaired. He could not sleep despite being exhausted. His appetite had waned. But the hospital's waiting lists for surgery were lengthening and management had little interest in excuses. Dr. Jeliff decided, decided over Easter 2002 that his fatigue and the lack of staff made it unsafe to continue operating and anaesthetising. He cancelled any surgery that could safely wait for a couple of days. He was told to come to Peter Leck's office. Peter Leck, who had the anesthetist personal file on his desk, began the conversation with an unusual question.
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Chris, just by the way, remind me.
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A
Of your visa status as a United Kingdom trained doctor. Dr. Jelof's visa to live in Australia was tied to his contract as an overseas trained doctor. Queensland Health had special leverage over the imports. They were also cheaper to employ. Jelof felt threatened by the district manager. He was certain Leck had asked the odd question at the start of a meeting about the cancellations of surgery to warn Jeliffe that his livelihood and aspirations to live in Australia were now on the line. Under different circumstances, Jeliffe might have felt bound to go back to theatre, notwithstanding his exhaustion. But as he had recently married his Australian girlfriend, a fact Leck was not aware of, Dr. Jeliffe no longer relied on Queensland Health as a visa sponsor. He left the meeting and he told Dr. Baker about how LEC had tried to intimidate him.
- [48:19]
B
Jesus Christ, that's a bit rough.
- [48:22]
A
Baker was surprised. Jeliff could not stomach it for much longer. He quit in late 2002 after repeated but unheeded pleasure to management for help. Dr. Baker too decided the hospital was unsalvageable. He moved on in November 2002. On 13 February 2003, some six weeks before Dr. Jayant Patel would arrive from the United States to fill the newly vacated Director of Surgery position at Bundaberg Base Hospital, seven specialists, surgeons on the local medical advisory committee wrote a memo. The memo was condemnatory. It raised the dictatorial, unresponsive, myopic and inflexible approach of management who have little regard or respect for specialists, their needs or aspirations. Chapter 6 My Brilliant Career Portland, Oregon, United States January 2002 as thick snow blanketed the wide lawn fronting his two story house in Beaverton, a suburb of professionals and middle class millionaires on the edge of Portland, Dr. Jayant Mukandre Patel, aged 51 and newly unemployed, reflected on his troubled past. It never snowed in Jamnagar. When the heavens above the dusty, overcrowded city in the far west of India's Gujarat province brought the seasonal monsoon rains, impoverished farmers celebrated their good fortune. There would be another harvest, food for the family and the prospect of money from the maize to buy essentials for the next crop. Too much rain and there would be floods, death and destruction on a massive scale. Hundreds, sometimes thousands of lives would be swept away with the flimsy homes and ragged belongings of the province's poorest wretches. Their misery would feature prominently in the local media. For a few days, loved ones would mourn. There would be renewed calls from ambitious legislators and community leaders for an inquiry into lax building standards. Somebody might flag a new approach to shanty housing to keep the most disadvantaged out of harm's way. But ultimately nothing would change. It just made everyone feel a little better in the teeth of tragedy before moving on. This was their fate. Not only did Jamnagar never see snow, its doctors, some of the most privileged and respected citizens in the province, were never subject to the same accountability as the hoi polloi. Dr. Patel sometimes wondered whether he would not have been better off had he stayed in his homeland. His superior family name, caste, academic excellence and status as a specialist surgeon meant something among his own people. There, colleagues at the MP Shah Medical College and Guru Govind Singh Hospital had never dared question his judgment or aptitude with a scalpel. The patients did not complain. Deaths and injuries were an inevitable consequence for the patients of every hard working surgeon. What part of this unquestionable logic did the American regulators of medicine and surgery not understand? The latest gratuitous Insult had cut Dr. Patel deeply. He knew it must have been a source of gossip among his friends and colleagues in the medical community at least. The little BME report, published twice a year by the Oregon Board of Medical Examiners for the benefit or in Dr. Patel's case, public shaming of registered and paid up practitioners would not be read in Jamnagar, where he was still hailed as a genius.
- [52:32]
B
Statement of Purpose the Board of Medical Examiners report is published to help promote medical excellence by providing current information about laws and issues affecting medical licensure and practice in Oregon.
- [52:49]
A
Dr. Philip F. Parshley had written the.
- [52:52]
B
Lead article headlined Responsibility Rests with Surgeon.
- [52:58]
A
It sounded ominous.
- [53:00]
B
In medicine, the physician is captain of the ship and the Board of Medical Examiners takes a strong position that doctors are responsible for the patients under their care, whether that care is rendered directly or delegated to others.
- [53:21]
A
There was another heading, Board Actions. The first column contained six names. There he was the third name down. Nobody could have missed the dishonourable mention of Jamnagar's finest in the professional journal of the Medical Regulatory Body of Oregon.
- [53:39]
B
Patel Giant M MD15991 Portland, Oregon.
- [53:46]
A
The entry disclosed an active order of vilifying and unambiguous text made by the Board of Medical examiners in late 2000 forbidding Dr. Patel from performing a wide range of surgery. It could have been much worse, though. A dreadful toll of death. Death and permanent life. Shortening injury suffered by patients of Patel in the years since he began practicing in Portland in 1989 went unreported by the newsletter. But the carnage had been noted in small, disparate parts. Elsewhere there were the findings of a confidential internal audit of the outcomes from surgery of 79 of Dr. Patel's patients. There were the subsequent investigative files of the Board of Medical Examiners. There were the legal depositions of the walking wounded whose financial settlements gave Dr. Patel the dubious distinction of being the most successfully sued physician of his employer, the huge Kaiser Permanente Healthcare group. And There were his colleagues who had expressed alarm at the lethal repercussions of his work. Impossibly complex procedures that should never have been attempted had led to patients like Marie Macicha, a retired restaurant owner with pancreatic cancer, dying unnecessarily. Patel had cut a critical vein and artery while trying to reach her tumor, causing massive blood loss. Maciccia needed transfusions of more than three times her body's volume of blood as other doctors tried desperately to save her life. Her blood, the post mortem report said, was pooling off the bed and onto the floor before she died that afternoon. Later, when her daughter, Sandra Ickett, asked Kaiser Permanente staff about Patel's competence, she was reassured that he was an outstanding specialist. Dr. Patel knew his surgical career in the United States was finished when the BME report published a clue to the truth about his surgery. In the months that followed, he came under mounting pressure to resign from Kaiser Permanente. To avoid further humiliation and dismissal. Jamnagar's most arrogant medical expert resolved to take his time talents to a fresh pool of admiring peers wherever they might be. He regarded himself as a stellar surgeon who had been grievously wronged. Before the snow melted outside his Beaverton mansion, he began using the Internet to look for opportunities abroad. The huge international demand for experienced doctors had spawned dozens of recruitment companies with sophisticated web based forums, search fields and even online application forms. It cost Patel nothing to start sowing the seeds for a new start in a country which knew nothing of his background. Patel read again the testimonials of some of his former colleagues mentors like Kaiser Permanente, Chief of Surgery, then retired Edward A. Arenylo.
- [57:11]
B
I feel that wherever he works or whomever he works for will be the beneficiary of his excellent skills and knowledge and will be all the better for it. He will be an asset to any group, hospital or organization.
- [57:29]
A
Patel particularly liked that last line. He could not have put it more succinctly himself. Sick to Death is written and presented by me, Headley Thomas, the Australian's national Chief Correspondent. Claire Harvey is the Australian's Editorial Director. Audio editing, production and music have been done by Jasper Leek with assistance from Leah Samaglu and Neil Sutherland. Our producer is Kristin Amyot Production management by Stephanie Coombs Artwork by Sean Callanan. Thanks to Ryan Osland, Matthew Condon, Karina Berger, Ellie Dudley, David Murray, Dominique McDermott, Zach Schoolander and all our family, friends and colleagues colleagues who helped in this series and contributed voice, acting and special thanks to Tony Hoffman and Rob Messenger. Subscribers to the Australian hear new episodes of Sick to death first@sicktodeathpodcast.com and on Apple Podcasts. You can get exclusive access to photographs, videos, timelines and more at the website.