Rob Messenger (4:06)

These dedicated professionals must be allowed to tell the truth while avoiding any possibility of placing their careers with Queensland Health in jeopardy. These workers stories must be heard and acted on if the people of the Burnett are ever to enjoy the level of health care that they richly deserve.

Headley Thomas (4:26)

The parlous condition of the health system was a major feature of the state election campaign in early 2004. The opposition coalition, of which Rob messenger was a member, had paid for hard hitting advertisements depicting people who had waited years for straightforward surgery, while the Australian Medical association ran a highly effective campaign to highlight secrecy and underfunding in the health system. Stung by the constant stories and revelations from clinicians about how patients were suffering because the hospitals could not cope with demand, Premier Peter Beattie threw money at the problems. The waiting lists for surgery were a significant part of Beattie's electoral strategy. He pledged a $110 million injection of extra funds to pay for thousands of extra operations.

Gerard Neville (5:22)

This new initiative will be the biggest effort to reduce elective waiting lists that Queensland has ever seen. People have made it clear to me over a period of time they want these lists tackled. We have done well, but clearly we can do better. We will be making health our number one priority.

Headley Thomas (5:43)

The Health Minister, Wendy Edmond, had retired from politics by then. Beattie had kept a straight face while commending her as the country's best health minister. The new Health Minister, Gordon Nuttall, was telling his executive team to put every public hospital on notice. The waiting lists were critical. In the internal confidential briefing paper he received after being sworn in, Nuttall was warned that Queensland Health had become extremely reliant on overseas trained Doctors who comprised 30% of the medical workforce.

Tony Hoffman (6:21)

Employment of overseas trained doctors provides a short term solution to doctor shortages. However, this approach brings with it a range of skill and competence issues.

Headley Thomas (6:33)

Messenger hammered health issues as stubbornly and relentlessly as he had during his electoral campaign. He repeatedly called for an independent investigation into Bundaberg Hospital its procedures and practices. The attempts by the Beatty government to silence him became farcical. At one point, messenger had said, rather.

Rob Messenger (6:58)

Than pulling back from this issue, I intend to turn up the blowtorch.

Headley Thomas (7:03)

The metaphor was too much for Nuttall, who called for a formal investigation into whether Rob Messinger planned to commit arson or burn alive any bureaucrats. Messinger was industrious and highly effective. He uncovered figures showing the hospital had just 136 beds, 81 fewer than in 1989, despite the region's steady growth. The door of his electorate office at Bagara, near Jayant Patel's home apartment, was always open to hospital staff with stories of crises. Doctors came to tell him how they had been forced to work 24 hour shifts, compromising patient care through sheer exhaustion. The regular outpourings were embarrassing for Nuttall, and they were infuriating the new Director General of Health, Dr. Steve Buckland, who had angrily banged the desk and abused messenger in one memorable meeting during a short stint as acting director of nursing, Tony Hoffman, was surprised to see Peter Lech, who read the speeches on the parliamentary website. As soon as they had been posted furiously denouncing something messenger had said. Peter Lech and Darren Keating stood at the computer screen and ridiculed the politician. An unprecedented meeting of the executive staff was called by Leck to discuss what effect having a National Party member would have on the hospital. Leck expected Rob messenger to create trouble. Leck wondered if the parliamentarian was upset about the hospital's treatment of his mother. Hoffman realised that messenger had become a major thorn in their side. She liked his courage and stamina. He was like a dog with a bone in relentlessly exposing the hospital's ills. He spoke of patients dying unnecessarily due to a dangerous culture, borrowing from one of the maxims of Anglo Irish statesman, politician and philosopher Edmund Burke, a leading light in the House of commons more than 200 years ago. Messengers spoke of evil pro prospering, while good men remained silent. Hoffman wondered if she might one day pluck up the courage to go to messenger about Jayan Patel. Good men had done nothing. It might be left to a good woman. Chapter 20 the Catalyst July 2004 Des Bramwich liked to stay busy. If a job was worth doing, he reckoned it was worth doing straight away. He was the sort of bloke who would happily do a good deed for family and friends without expecting anything for himself. A little after 4.30pm on Sunday 25 July, Des Bramwch, age 56, was doing one of those good deeds. It had been a glorious day in Agnes Water, a sleepy seafront community about an hour and a half's drive from Bundaberg. Bramwich, who ran an earthmoving business with his son Mark, was beneath a caravan. He was helping to remove one of its tyres for his youngest son Luke, before the sun disappeared. On one of the shortest days of the year. Mark was walking back to the Land Rover to get some tools when the caravan fell from its supports. The muffled thud as the weight came down onto his father's chest sounded ominous. Mark looked back and saw his father conscious but gasping. He was clearly having trouble breathing, unknown at the time. Two of his ribs were badly fractured. A pleural membrane lining the inside of the chest wall was torn on the right side. The upper part of his sternum was also fractured, probably damaging arteries running down either side of his breastbone. Mark rushed to get a jack from the car to try to lift the caravan off his dad's crushed chest. In the panic and fading light on an afternoon that had become suddenly bleak and foreboding, he fumbled to grip and lift the heavy steel contraption. Thankfully, help arrived quickly. A local medic, Dr. Sailasa Vuti, one of the town's overseas trained doctors, inserted a tube to help Bramwich breathe. The ambulance rushed to the accident site to provide emergency backup and transport. A rescue helicopter arrived to airlift him to Bundaberg Hospital. Mark spoke quickly to his father's wife.

Dr. Andrew Donner (12:10)

Pack your bags and go to the hospital, Tess. Dad's had an accident.

Headley Thomas (12:14)

Tess trembled with worry as her friend Agnes Smythe gunned the white commodore, beating the helicopter by 15 minutes. Tess was told her her husband had suffered severe internal injuries, but that the prognosis was good. Once he had been stabilised in the trauma room, there were tests and scans of his chest. Des was thirsty and with a nurse's approval, Tess gave him an ice cube to wet his mouth. One of the doctors told Tess there was no reason why a fit middle aged man, a non smoker and and non drinker, would not make it. She was greatly comforted by the reassuring words. Even as they transferred her husband to the intensive care unit, she watched the nurses there, hooking him up to machines to monitor and assist his heart and breathing. They gave him morphine intravenously and an oxygen mask. Tess, who was born in the Philippines and and Des had wed a decade earlier. Tess was Des's third wife. They often joked about how at age 33 she was younger than Mark, even though she was step grandmother to Mark's kids. Des and Tess had not looked back. The Bramwich father and son business was doing well. The couple had great friends in the town where everybody knew each other. Their young daughter Maria, a quiet beauty with Tess's brown skin and smouldering dark eyes, was a family treasure. Now at 1am Tess kept a vigil in the hospital. When Des suggested that she should leave to get some sleep, the staff agreed, although they were more concerned about his rest. When Tess returned at 6am and saw him smiling in bed with most of the colour returned to his face, her spirits rose. By 9am Some of his extended family were perched around his bed. In the icu, Des spoke to Mark's visibly distressed wife, Fatima. Don't cry. I'm alright. He was making jokes at his own expense and wisecracking about being far too young to die. I'm like a cat. I have nine lives. After X rays and a cup of tea, he spoke about the accident. His son beamed when Des said that had it not been for Mark, the crush from the caravan would have put him in a coffin. Tony Hoffman was touched by the natural affection and love enveloping her patient who exuded a cheerfulness she put down to genuine family contentment. She chatted freely to Dez and Tess. Their daughter, 10 year old Maria, gazing at her dad with those liquid eyes was gorgeous. Hoffman gave her a soft white toy, the seal that she kept in the bottom of the filing cabinet for young children who came into the unit. At times like this, Tony Hoffman regretted some of the choices she had made. She looked at Des Bramage as the easygoing patriarch of a happy and loving clan. Hoffman wished things had turned out differently with some of the men she had loved. Her career had been fulfilling, but at home after the shift ended, she sometimes felt desperately lonely. By the time Tess returned from lunch, the bed in the ICU was empty. She was immediately worried, but Des was fine. He was doing so well that he had been wheeled into the surgical ward that afternoon. After he had been helped into the chair beside his bed, Tess stayed and chatted with him until evening. When she returned early the next morning, the 27th of July, Des was in a bad way. Darl, I really didn't have a good sleep last night because I was in pain all night. Tess was confused. She had been assured that the morphine trickling into his veins would deaden the pain. She examined the intravenous connection and saw that it had become loose and it was dripping.

Lorraine Neville (16:41)

Could you just please fix that properly?

Headley Thomas (16:44)

They waited impatiently for a junior doctor to come by and reattach the line. Des was encouraged to walk around the hospital corridors with a few physiotherapist and an assistant. He hobbled in pain as they supported him under his armpits, then returned to bed and spoke by telephone to his worried mother and sister. When the Bundaberg News Mails reporter arrived, Des recounted the accident. Mark is my hero. Tess returned from lunch to discover that he had suddenly collapsed and been rushed back to the intensive care unit. Hoffman, shocked at how rapidly he had deteriorated, calmly organised her staff. The nurses rushed to save his life. Des could not breathe and his blood pressure had plummeted. His heart was racing and the pain in his chest had become unbearable. He was slipping in and out of consciousness. Doctor. Dr. Iftikar Yunus, one of the anaesthetists, was attempting to resuscitate him with the help of three nurses. Dr. Martin Carter, the anaesthetist in charge of the ICU was clear. If the patient is going to need blood products, he'll need to be flown out. Carter decided that as Bramwich might need thoracic surgery, long term ventilatory support and access to a blood bank, he should be rushed to one of the larger hospitals in Brisbane. There were urgent efforts to find a bed in Brisbane. Prince Charles Hospital was full but a bed might be available. At Princess Alexandra Hospital. The Royal Flying Doctor Service was readied for the Mercy Mission. Hoffman relayed the message from the bed coordinators in Brisbane to Dr. Carter, Dr. Jim Gaffield and Dr. James Boyd, a principal house officer working under Dr. Jayant Patel's supervision. Hoffman was ecstatically relieved.

Tony Hoffman (18:51)

They've got a bed.

Headley Thomas (18:53)

She could see that Des Bramwch needed to be in a hospital which practiced thoracic surgery. Under no circumstances did she want to see Bramwidge fall into the hands of Jayan Patel. The director of Surgery had been absent from the hospital for all of May and June. He had taken study leave and holidays to return to Jamnagar in India to see his mother and then to Portland in the United States to spend time with his family. The run of complications, the conflict in the wards and the fears of the staff had disappeared. Dr. Patel's holiday was a blessing for all. Tony Hoffman recalled the plight of Oona Connors, whom Patel operated on for cancer of the sigmoid colon in April. The woman had to be rushed back by ambulance after a complete evisceration of the wound and her intestines being almost fully exposed. Hoffman had grown unusually fond of Des Bramwch and his family in the few hours she had spent with them in the ICU. But his perilous condition was worsening. As Dr. Yunus tried to put in a central line to convey drugs, the gravely ill man experienced ventricular standstill. His heart was refusing to pump blood. Dr. Gaffield asked Patel to look at the X rays of his chest. Patel seized the offer and in his booming voice started undoing the plans to transfer Bramage from Bundaberg.

Dr. Jayant Patel (20:33)

The patient doesn't need to go to Brisbane. He isn't sick enough. If we can't care for such simple things as fractured ribs, there is no point in doing any sort of trauma surgery at the hospital.

Headley Thomas (20:43)

Hoffman, stricken with fear, waited for Gaffield to take charge. Bramwich was Dr. Gaffield's patient. Dr. Carter had already come to the view that the best course was urgent transfer. Dr. Yunus agreed. Arrangements had been made, but Patel's dominant personality was assuming control.

Dr. Jayant Patel (21:07)

He doesn't need to be transferred. I've been a cardiothoracic surgeon for 20 years. If he needs anything, I can do it here.

Headley Thomas (21:15)

He repeated the confident boasts to members of Bramwich's family as Hoffman quietly pleaded for the transfer to go ahead.

Tony Hoffman (21:23)

Please, Dr. Gaffield, send this man through to Brisbane. Even if you think he doesn't need a cardiothoracic surgeon. I'm really afraid that he's going to.

Headley Thomas (21:33)

Die, Dr. Gaffield replied. No, that won't happen. He won't die. He said he wanted to do a CT scan to provide definitive information for the handover to the surgeons in Brisbane. Patel disappeared back into the operating theatre to perform a colonoscopy on a patient. But in the course of that procedure, he perforated the bowel. He insisted his injured patient should have a CT scan of the bowel before the gravely ill Bramage. Patel yelled.

Dr. Jayant Patel (22:09)

A perforated bowel takes precedence over a non urgent CT scan at all times.

Headley Thomas (22:14)

The latest botch up, a rarity for most doctors, but a common occurrence for Patel meant that another doctor was needed to help him repair the bowel. Tony Hoffman asked Dr. Martin Carter, who was due to leave to give a lecture, to accompany Bramwich for the CT scan. He agreed. By the time they returned to the intensive care unit, the scan showed three litres of blood pooling in Bramwich's chest. As Hoffman left the intensive care unit at 7:30pm to go home, the Royal Flying Doctor aircraft was being readied for the trip to Bundaberg. Hoffman had stayed back for three hours to ensure des Bramwch would get away for the help he so desperately needed. She walked to the hospital car park, confident that Bramwich would survive in Brisbane. Despite his problems, Hoffman felt sure he would wake up in the morning 370 kilometers from Patel. Chapter 21 the stabbing late July 2004.

Tony Hoffman (23:31)

Oh, did Mr. Bramage get off all right?

Headley Thomas (23:35)

Outside the hospital elevator at the start of her shift the morning after the frantic efforts to save his life and move him to Brisbane, Tony Hoffman had bumped into Dr. Martin Carter. She popped the question after a quick exchange of pleasantries. No. He died. When the flying doctor had finally arrived after 10pm with flight nurse Sunita Carr and Dr. Jackie Butler, their patient was closer to death than he had ever been. Patel had remained in control and declared him to be too sick to be transferred. Des Bramwich died a little after midnight, despite frantic resuscitation efforts by Dr. Iftikar Yunus. The nurses were in tears. The flying doctor staff wept. Tess, Maria and Mark huddled together, shocked, crying and wondering what had gone wrong. Hoffman was devastated. She thought of the beautiful little girl who no longer had a father. She guessed immediately that Patel's decision to halt the transfer was all about Patel and his determination to flaunt himself. It had little to do with the the welfare of patients. Despite mounting evidence of needless deaths and injuries, the director of surgery remained delusional about his own abilities. The death of Bramwich was the turning point. Hoffman decided from that moment to do everything in her power to highlight Patel's lethal menace. She told Martin Carter, we have to.

Tony Hoffman (25:20)

Do something about this. We cannot let this happen any longer.

Headley Thomas (25:24)

She went to her office and broke down in tears. The Bundaberg News Mail that day had a bright picture story about Des Bramage's near death experience. He was sitting up in the photograph, looking larger than life. In the article, Bramwich says, I thought I was going to die because I couldn't get any air. It never hit me until the next morning, the reality of it, that I was in the hands of the gods. Dr. Martin Straughan, a general physician in private practice who worked part time as a visiting medical officer at the hospital, saw Hoffman sobbing and gently asked what was wrong. She told him about the Bramwich case and the circumstances of several other deaths, and she recounted the startling rates of wound breakdowns and complications. She told him how Dr. Carter referred to Patel behind his back as Dr. Death, how the nurses were distraught with worry for the patients, how in the renal unit he had flouted basic anticontamination standards, and how the Director of Medicine, Dr. Peter Miak, refused to let Patel anywhere near his patients. Dr. Straughan promised to go away and talk to some of his colleagues about Patel to and his competence. Two days later he told her, there's widespread concern, but nobody is willing to stick their neck out. Yet the untimely death of Des Bramwich galvanised the nurses. Several of those nurses who had witnessed the last agonising hours of his life, Karen Fox, Vivian Tapiolis, Daniel Aitken and Sandra Sharp, were appalled at the turn of events. The ICU staff mourned in the beginning, and then they became angry as they reflected on all the patients Patel had harmed since he came to the hospital. They did not know the extent of Des Brammach's internal injuries. It was probable that these injuries were so severe he may have died even if he had been transferred. But they understood that he had been robbed of at least a fighting chance by a bombastic surgeon who threw his weight around to prevent a transfer. First, Patel had insisted that Des Bramwich was not sick enough to go, and then he was too sick. They understood that Patel had spoken callously to the family, telling Tess that she should start praying because her husband would surely die. Telling Tess and her daughter to stop crying at the bedside, telling anyone who cared to listen how his experience in trauma surgery made him better qualified than anyone in Brisbane to manage the care. At one point, another nurse, Sharon Cree, had to move away from Patel because he was talking so obnoxiously about his wealth of experience and expertise. Karen Fox was tormented by the death she could not erase from her mind and an image of Patel stabbing Bramwich with a large needle. For some unexplained reason, Patel had decided that Bramitsch's critical condition might be due to blood between the two layers of the pericardium, a protective sac around the heart. Although an ultrasound had already proved there was no fluid there, Patel had diagnosed a cardiac tamponade. He decided to perform a pericardiocentesis using a wide bore needle. He wanted to puncture the sac to drain non existent blood. The invasive procedure requires skill and strength. Patel botched it. The needle is supposed to go in within a few attempts. Patel stabbed the needle violently and repeatedly into the semi conscious Brammage's chest. After flailing away in a frenzy, Patel finally extracted a minuscule few millilitres of blood. Nurse Fox had never seen anything like it. Dr. Carter and Dr. Iftikar Yunus were also confused. They knew the ultrasound results gave no indication of blood in the Sacred. There appeared to be no good reason to be adding to Des Brammage's distress and pain. Eunice was angry about it. He suspected Patel might have punctured a coronary vessel with his repeated stabbing motions. Nurse Fox told Hoffman, during this procedure.

Tony Hoffman (30:11)

Dr. Patel was loudly making comments that the patient will die and does not need to go to brisbane. I asked Dr. Patel to mind what he was saying as the family were in the hallway.

Headley Thomas (30:21)

Patel had told Fox that the family members needed to know the seriousness of the situation. But Fox replied, they need to be.

Tony Hoffman (30:30)

Told face to face. Not overhearing what's being said behind the.

Headley Thomas (30:34)

Curtains, Fox told Hoffman all the distressing details, including how Patel had inserted a chest drain and poked and prodded using.

Tony Hoffman (30:44)

His fingers through the incision.

Headley Thomas (30:47)

Tony Hoffman was so frustrated and worried about the situation, she telephoned the acting coroner, Neil Lavering, and explained the concerns over Patel's competence. She described the Bramh death and the interference by Patel. Lavering replied, well, that confirms some of the things I've been thinking about what has been going on at the hospital. He said he would await the documentation. Hoffman also telephoned the Bundaberg police station and was put through to a senior officer. He asked if the hospital held morbidity and mortality meetings or had any other mechanisms that would identify negligence causing deaths. But neither the coroner's office nor the police followed up. Hoffman next prepared a sentinel event report. This was a major step. According to the protocol, a sentinel event is rare, serious and requires prompt and in depth investigation. Hoffman's accompanying Mimo to management described how Patel bullied staff, misused the intensive care unit, compromised care and constantly threatened to quit because he did not want his patients transferred. Tony Hoffman wrote the director of the unit.

Tony Hoffman (32:13)

Dr. Carter is usually supportive and proactive about transferring patients, except when Dr. Patel's patients are concerned. Dr. Patel creates such an atmosphere of fear and intimidation in the unit that his behaviour is rarely challenged. On several occasions when Dr. Patel's patients have been in the ICU, he he has refused to transfer his patient to Brisbane even when the patients have deteriorated and have been in ICU for much longer than 24 to 48 hours, he has done this when a bed has already been obtained. This has on several occasions placed the patient in jeopardy as they have further deteriorated.

Headley Thomas (33:00)

Hoffman repeated the concerns that she had expressed more than 12 months earlier to Darren Keating about the dangers inherent in the esophagectomy procedures that Patel had been determined to perform. She said Patel's interference in the care of Des Bramage may have led to his death. She ended the two page document by.

Tony Hoffman (33:21)

Saying Patel actually endangers the lives of the patients.

Headley Thomas (33:28)

The acting Director of nursing, Patrick Martin, who perused the doctor, gave Tony Hoffman some feedback. Wow, love, that's all pretty heavy. It's very good though. My experience with Darren is to stick to facts and figures and not be emotive. He absolutely turns off emotive approaches. Quote percentages and figures to him and he responds much more favourably. Hoffman had lost confidence in her own line manager, the new Director of Nursing, Linda Mulligan. She was a stickler for the memo and formal appointments for meetings, but when it came to ward rounds, Mulligan was rarely seen by the nurses. She operated very differently to Glenys Goodman, who had retired a few weeks earlier. When Hoffman went to Mulligan to voice concerns about Patel, she left the ex executive office feeling more powerless than ever. Mulligan had given her a book called Coping with difficult people by Dr. Robert Ranson to take home to read. She had suggested that Hoffman should consult a psychologist and undergo training in conflict resolution. Chapter 22 justice for Elise late July 2004 the files describing 10 year old Elise Neville's final few hours moved me to tears in the public area of the District Court Registry in George Street, Brisbane. As Tony Hoffman and the other nurses at Bay Thunderbird Hospital seethed and grieved over the death of Des Bramwich, I became absorbed in the story of a little girl who had rolled the wrong way in her sleep and fallen out of a bunk bed during a holiday with her family on the Sunshine Coast. Leaning over a large folder laid out on a chipped counter, I read hundreds of pages of witness statements and medical reports that helped reconstruct struck 7 January 2002 and the ensuing 48 hours. Although some of the accounts differed, they documented the seriousness of Elisa's head injury when she was rushed to Caloundra hospital shortly after 3am the deficiencies of the examination by Dr. Andrew Donner and Nurse Beverly Duncan's examination in the emergency department these the inevitable brain injury and the agony of Elisa's parents, Gerard and Lorraine. There was something primal about Jared's pain on raw display as graphically as if he had spilled his own blood throughout the folder. This is what he we will pursue.

Gerard Neville (36:25)

This while there is still breath in our bodies and blood flowing in our hearts. The whole episode is an absolute scandal and there is no way that we will ever let them get away with it.

Headley Thomas (36:38)

Gerard believed he had failed in his duty as a father and as a doctor, to protect his daughter from harm. And he blamed himself, the fatigued doctor, Donnerman, the nurses, the system and the hospital. Gerard further wrote, the doctor came probably.

Gerard Neville (36:57)

About 15 minutes after we first arrived at the hospital. His name was Andrew, as we recall. We didn't catch his surname. He took a very brief history. I told him that I was medically trained but that I had not done clinical work for many years. We soon began a discussion about the need for a CT computerised tomography scan. He said, you can't CT everyone who hits their head. We returned to a discussion about going to Nambour Hospital. We ask how far it is and how long it will take to get there. He still hasn't really examined Elyse and he says something like, lots of kids hit their head. Namba will probably send you home too. We say that Elise has vomited and he says, lots of kids vomit at night. We say that Elise rarely vomits. He keeps reassuring. We keep sending signals of worry and concern. The discussions have gone on for some time and we are at an impasse. He then says something along the lines of, Look, I will do a neurological examination if that would make you feel better. He gets a tendon hammer to go with his torch. Elise has her eyes closed and won't cooperate with him. She is in pain and acting nothing like her normal self. We tell him that she is not normally like this. He then says coldly in front of Elise as Well, she's a 10 year old girl, it's late, she has had a disturbed night and she is pulling the wool over her parents eyes. By this stage we have a child with a head injury, a large contusion over her left temple, a history of vomiting and developing uncooperation. He finishes with something like, I don't think there will be any problems in your case. You're a sensible father. Take her home and watch her. Even if she starts to have problems, there will be plenty of time to do what needs to be done. We didn't want to go home, but we had nowhere else to go as he and the hospital had totally rejected us. I kept checking Lisa's pulse, eyes, breathing and movement as she lay next to me on our bed. She was restless and kept moaning, crying and complaining about her sore head. I kept trying to diagnose what might be going on, but it was all a blur and nothing made any sense to me. I convinced myself that Elise must just have a minor concussion at the very worst and we would see how she was a bit later and probably get Some more medical attention in the morning. Eventually, it was now sometime after 6am Elise seemed to finally settle. Thinking that Elyse was finally sleeping. I started to doze on and off as I lay next to her. I was never actually asleep, more just lying next to her with my eyes closed and trying to calm down. It had been a harrowing night. I suddenly jolted up from my dozing when I felt something was very wrong with Elise. So did Lorraine. At the very same time. I looked at Elise and screamed, oh my God. Oh my God. It looked like she had a rash down the left side of her body. I rolled Elise on her back and saw it there too. Elise's eyes looked like they were popping out. Her jaw looked like it was rigid. I thought Elise was dead. I yelled to Lorraine, get an ambulance. I was absolutely distraught. From that moment, Lorraine couldn't turn on her mobile phone, so she ran to the next door unit for help. I carried Elise from our room to the living room and then back to our bedroom. I didn't know what to do. At about 7.30am, the ambulance took Elise, Lorraine and me. The first face I saw was the same doctor from earlier in the night. He saw me and said, what happened? He was visibly shocked and became very pale. I frantically said something like, she's gone right off. She needs a neurosurgeon. At one stage he said, was it to himself or to us? Something like, I'm so sorry. It's all my fault. What have I done? Oh, fuck.

Headley Thomas (40:55)

Annette Thompson, one of the nurses who helped with the resuscitation, saw Lorraine Neville lying on a bed in a waiting area for rel relatives. The nurse recalled she was in a.

Nurse Michelle Hunter (41:07)

Fetal position and was cuddling a stuffed toy, which I assumed to be Elise's. Her eyes were shut and her physical appearance suggested that she'd totally withdrawn into herself. Mrs. Neville was making no sound, but responded to my questions in a quiet voice. She told me that Elise was a lovely girl and things like this shouldn't happen to someone like her. She approached Elise's bed and spoke in whispers to her. Dr. Neville was very upset and cried loudly as the helicopter departed. Mrs. Neville began crying as well.

Headley Thomas (41:40)

From Dr. Donovan's account of events, starting with Elise's first presentation at 3.25am she had been lying on her side facing away from him when he started a physical examination.

Dr. Andrew Donner (41:54)

I coaxed her two to three times to turn and face me so that I could look into her eyes. Elise then rolled over and opened her eyes freely. I examined Elise's pupils and noted that they were equal and reactive to light. I noticed some swelling and bruising lateral to her left eye. I felt the area of swelling and did not palpate a skull fracture. Elise then said words to the effect I want some sleep and pulled her sheet up and rolled back onto her left hand side. I did not consider the swelling to the side of the head to be unusual as in my experience it is not uncommon for children to suffer bruising to the head even after a short fall onto a soft surface. Mr. Neville and I had a conversation regarding the indications for performing a CT scan and whether Elyse required a CT scan. I had treated a few children with vomiting and diarrhoea at Caloundra Hospital and had been told that the hospital did not admit children for observation. Therefore, I was of the impression that Elise could not be admitted for observations and I explained this to Mr. Neville. I told Mr. Neville to keep an eye on Elyse. For the next day or so the Neville's left the hospital amicably. Mr. Neville carried Elyse from hospital. After the Neville's left the hospital there were no further patients so I went to sleep. At about 0700 hours I rose and got dressed and literally as I was walked out of the room. Mr. Neville arrived in the emergency department in a very distressed state. He was followed by the ambulance officers with Elise on a trolley. I was shocked that Elise's condition had so radically deteriorated. Mr. Neville was extremely distraught. While resuscitation procedures were taking place he said words to the effect of it's my fault, it's a curse being a doctor and I fell asleep on two them of three occasions. I assured Mr. Neville that it was not his fault, but my fault. In saying this I did not intend it as an admission of fault but as a feeling of personal responsibility. As the last doctor to have attended Elise.

Headley Thomas (44:02)

I had first read something about Elise in the Courier mail in late 2003. The description of her parents relentless efforts to force Queensland Health, the Medical Board, the Nursing Council and the Health Rights Commission into rigorous self examination was a small part of a much larger story. I spoke about the case to Dr. David Malloy, who had taken over from Dr. Ingrid Tall as head of the Australian Medical association in Queensland, Dr. Malloy told me it is one of those tragic issues that brings everything to the system. The junior doctor at the end of a very long shift in a small hospital, the lack of supervision and the protocols. There is significant concern that in any hearing of this case the system itself will be under scrutiny and if so, Queensland Health will have to take a good hard look at its systems. My earlier investigations into Queensland Health Health had made me deeply suspicious of its management and culture. In November 2003, after my stories were published on the concerns over the standards of overseas trained doctors in Queensland and the lack of checking of their credentials and skills, Gerard Neville emailed me.

Gerard Neville (45:22)

I am not seeking anything from you but I certainly encourage you and the Courier Mail to keep the heat up up in regards to professional health standards, I have absolutely no doubt there are real issues in regard to the competence of some health professionals. These issues are not being given the attention required to protect the community. It's just part of the bigger picture about the effectiveness of the system of ensuring that health professionals, whether trained overseas or locally, are competent and not putting their patients patients lives at risk.

Headley Thomas (45:56)

Now we were in July 2004 and the Medical Board of Queensland had decided that Dr. Andrew Donner, who had treated Elise Neville at Caloundra Hospital, would be prosecuted for unprofessional conduct in the Health Practitioners Tribunal, a part of the District Court. Queensland Health's dangerous policies had forced Dona to work a 24 hour shift on the day Elise was brought into the hospital by her worried parents. Yet the same organisation was now hanging him out to dry, having refused to fund his legal defence. The Director General, Dr. Steve Buckland, was silent on the stupidity of the 24 hour shifts and the hospital's policy not to admit children. Nowhere in the file, a public document at the court's registry was the confidential and damning Queensland health report by Dr. William Rogers about the need for several experienced doctors to staff the emergency department at Caloundra hospital. By late July 2004, there was enough material on the public record to write several balanced and detailed stories about the haphazard culture in Queensland health and its devastating effect on at least one family. An emergency helicopter had taken Elise from Caloundra Hospital to the paediatric intensive care unit at the Royal Children's Hospital in Brisbane. But even the transfer was bungled. It took twice as long as a road trip. In Elise Neville's chart at the Royal Children's, Dr. David Komen noted unstable day irretrievable brain injury with brain death the most likely outcome. Not responding to voice or head and neck stimuli. Jennifer Rich, a social worker who had been counselling Elisa's parents as well as her older sister Laura and younger brother Michael, wrote, this father is experiencing a lot of guilt associated with the accident, given his profession. Jennifer Rich's last entry in the hospital's electronic diary reported the family's request that foot and handprints as well as a.

Tony Hoffman (48:18)

Lock of hair be taken for themselves.

Headley Thomas (48:22)

One of the treating doctors would later break down over the waste of young life. A police officer wrote out a receipt for Elise's property. A blue hat, white socks, statue of Mary, a Winnie the Pooh teddy bear, blue and white shorts, pink top, hair clips, hair bands and a white ribbon.

Gerard Neville (48:44)

Gerard wrote this later that day, Lorraine and I decided to turn off Elise's life support. Elise died at 5.45pm on 9 January 2002. As she died, peace came to her tormented face and her spirit and beauty. Rose reigned over us all. She showed us she had gone to somewhere nice and safe where people care for each other. Wherever heaven might be. I know it is certainly not in Caloundra Hospital, a dangerous place that should be closed.

Headley Thomas (49:24)

And Elisa's mother, Lorraine added, she shone.

Lorraine Neville (49:28)

With happiness and a beauty of nature and soul that are irreplaceable and which will continue to be our inspiration and guiding light.

Headley Thomas (49:37)

There was A report by Dr. Michael Redmond, a neurosurgeon who it is considered.

Gerard Neville (49:44)

Unacceptable for a patient following head injury to talk and die. Elise Neville is one who talked and died in a responsible medical system such as we enjoy. With such access to hospitals of ascending levels of sophistication, it is tragic and unacceptable that an event such as this should occur.

Headley Thomas (50:07)

And Dr. Johannes Wenzel, a specialist in emergency medicine, wrote, I see it as.

Dr. Andrew Donner (50:14)

A system problem that our public hospitals put junior doctors into positions where they have to deal with presentations beyond their expertise. Combined with the fact that working long shifts reduces the decision making ability to to a similar level as a person with 0.05% alcohol blood content.

Headley Thomas (50:33)

According to two independent medical experts who studied all the case notes and statements, Dr. Donnerman had made a tragic wrong call. He had done an incomplete examination of Elise, although he must have been fatigued after working 19 hours of a 24 hour shift. If he had thoroughly questioned and examined Elise or urged her parents to go to another hospital for a CT scan of her skull, its fracture and the haemorrhage would have been obvious. There still would have been time to relieve the pressure building from the accumulation of blood before her brain's soft tissue was crushed. In his defence, Dr. Andrew Donen wrote.

Dr. Andrew Donner (51:21)

I would sincerely hope that doctors are not rostered on for any longer than a 12 hour shift. 24 hour shifts without a break are excessive and dangerous and no patient or doctor should ever be put through the devastation that both the Nevilles and my family have had to endure.

Headley Thomas (51:40)

When I called Gerard Neville to tell him that I plan to write several lengthy stories about the case, he he agreed to a meeting. I went to the suburb of Toowong and Lorraine served tea and biscuits. As we talked about Elise in the family home, filled with her image and memory, but cloaked in quiet sadness, we.

Lorraine Neville (52:02)

Live with the ongoing trauma. We ask ourselves, what could we have done? What did we miss? How could we let this happen? It is so cruel for Jared. He had the very best of intentions. Fate had something else in mind. We do not want to be seen to be vindictive and nasty to certain individuals. In this, it's more about the bigger picture and how it can be improved. Elise was just as perfect a child as you could ever have. The last thing she would have remembered was putting her head on Daddy's shoulder as he carried her in from the car to the unit.

Headley Thomas (52:42)

Jared's grief was still angry. He looked like a man who had lost much of his will to live.

Gerard Neville (52:49)

I know people look at me and say, how did this happen? How did you let this happen? Of course I have blamed myself. I'm a doctor and I'm a father. It's tragic. It's a cancer. It eats away at you. I don't trust health at all. I don't respect health and I work there. It's a terrible dilemma. Now I have a more important job to do. I'm trying to bring the Queensland health system into the 21st century. I want to see some honesty in the health system. If this can put pressure on the system to respond in a learning way, then it is worth it. Maybe I have been relentless, but I'm going to stay that way because the truth leads to findings and they will lead to recommendations that can improve things. We will get comfort knowing that something good will come out of this. I know for a fact that if we did nothing, nothing would change. Elise and I have made up. We have worked it out. She's forgiven me. I know this sounds nuts, but one day when I sat next to her grave, I saw her and she was deliriously happy. But I still want her back. It shouldn't have happened. She wasn't given a chance.

Headley Thomas (54:05)

The unfairness and emotion of it all made the stories difficult to write. I knew that Dr. Donovan, a father of young children himself, was in agony and had been punishing himself over Elisa's death. I knew his sister Paula, a colleague at the Courier Mail, was not in favour of me exposing her brother to public scrutiny. But as a fellow reporter, I hoped she understood it was unavoidable. I talked over the angles with my wife Ruth. We pledged never to let our children, who yearned to know the story of the little girl, sleep in bunk beds. My daughter Sarah, aged three, came home from kindergarten with a drawing of Elise. She had been asking me to tell her bedtime stories about Elise for a week. Sarah told her teacher the story of the tragic accident. Before anything was published, I spoke to Dr. Steve Buckland, the Director General of Queensland Health, in his office with his media manager, Lisa Schiltz. Buckland did not appear overly concerned at the major Systemic issues the 24 hour shifts, the rostering of inexperienced doctors to take charge of emergency departments. It occurred to me that it was easier for Dr. Buckland and the regulatory system to punish Donnerman than to look at glaring and fundamental flaws that would take courage and money to remedy. Before I went to see Dr. Buckland, he had a meeting with Gerard Neville. Gerard wrote this in his diary that day.

Gerard Neville (55:46)

He clearly does not have a positive outlook on Hedley Thomas or what his motives might be. Says he is a grub.

Headley Thomas (55:56)

After seeing the photographs of Elise at her parents home, I asked Gerard and Lorraine for permission to publish one. They considered the request overnight and Gerard called me the next day to agree.

Gerard Neville (56:09)

I want every health professional in Queensland to stare into her eyes. Maybe it will cause them to search their conscience and appreciate what we are trying to do.

Headley Thomas (56:24)

When the main feature and several accompanying stories were published prominently on Saturday 31st July, the reaction was immediate and overwhelming. Many doctors were furious at the punishment of Donnerman. Staff and users of the health system were furious at its obvious shortcomings. A number of readers called me to say that they had wept for Elise and her parents. The Australian Medical association demanded action by the BT government to stop unsafe practices in the health system. Tony Hoffman had never contacted a journalist before. She cried when she stared into the eyes of Elise Neville on the newspaper's page. And then she sat down to write an email.

Tony Hoffman (57:12)

Dear Headley, I read your article in this morning's Courier Mail with dismay. I am one of the nurses who continues to work in the environment you describe. This week. I stayed three hours after my shift finished to try and ensure a patient was transferred to Brisbane from the provincial hospital where I work. One of the surgeons involved in the case insisted the patient did not need transfer despite the fact that our hospital does not have the facilities to care for such a patient. Finally, the retrieval team was on its way and I left When I returned in the morning, I expected that the patient would have been transferred, only to find he had died two hours after the team arrived. The intimidating, bullying surgeon, of course, was not wrong. He had delayed a transfer for several hours despite the pleas of the of the nursing staff. There is no one we can complain to. The hospital hierarchy believe this surgeon is doing a great job because he's making the hospital money and keeping the waiting lists down. If we complain, we're in danger of losing our jobs. No one will notice in the patient's notes the delay. It's not obvious except to those of us who were there. The nursing staff were so distraught. The next day we are told to follow the proper protocol to deal with such issues, only to find no one supporting us. The poor family of the patient will believe all was done for this patient when we know this is not the case. Keep up the good work at examining what's going on in our hospital. How dare Queensland Health make Dr. Donovan the scapegoat for a system which does not work. There are so many good, kind and caring people out there trying to do the best they can, but it is not working. Tony Hoffman.

Headley Thomas (59:15)

Chapter 23 Suspicious Minds late July to October 2004, Nurse Michelle Hunter was seeing too many surgical disasters with a common feature. There were more wound breakdowns, infections and complications connected to the surgery of Jayan Patel than all the other doctors in the hospital. She asked DI Jenkin, the manager of the surgical unit, about it.

Nurse Michelle Hunter (59:46)

Is anyone looking at what's going on here?

Headley Thomas (59:49)

Nurse Hunter, back in Bundaberg after a stint in the vascular surgical ward of a large hospital in Bath in the United Kingdom, was stunned by some of Patel's decisions, such as when he ordered that a plaster be put on a man's amputated leg stump. After several days, she asked Patel to look at the wound. It had completely fallen apart. He casually told her to to take out the stitches and remove the necrotic tissue as there was little he could do. The man died a few weeks later. Patel's lack of hygiene appalled the nurse. She told him, I want you to.

Nurse Michelle Hunter (60:29)

Go and wash your hands before you go to the next patient.

Headley Thomas (60:33)

But when Hunter was not around, Patel went back to his old habit of moving from bed to bed and touching wounds without once washing his hands. Hunter, who was harbouring serious doubts about Patel's competence, wondered if the surgeon had been involved in any negligence cases in Oregon, where he often boasted he had extensive experience. After a Google search linked her to the website for the Oregon Board of Medical Examiners. She put his name in the search field. The information that appeared was amazing. Dr. Jayant Patel had been subjected to recent serious disciplinary action. He had been barred from performing a wide range of surgery because of his proven incompetence. Although shocked, Hunter decided that information so easily discovered had to be known to the Medical Board of Queensland and the hospital's managers, if indeed it related to the same Jayant Patel. One evening, Karen Stuma, a nurse in the intensive care unit, received an unusual request from a theatre wardsman. He had rushed out of surgery and was in a state of mild panic. Can we have some mouth swabs? It's urgent. Stuma wondered why they were needed in surgery. She went to the stockroom and removed a handful of the swabs which were used in the ICU to clean patients mouths. What's the problem? We need them because Dr. Patel has flushed the bowel backwards. We have to clean out the patient's mouth before he wakes up. Stuma felt physically sick. Patel's bungled flushing technique meant the patient's faecal matter had gone the wrong way instead of being washed out at the lower end. By the end of July, amid serious disquiet among nurses and some of the doctors over Des Brammitch's death, Patel had been the Director of surgery for 16 months. Yet he had steadfastly refused to seek fellowship of the College of Surgeons, even though it would have given him formal specialist status, a hefty raise and more boasting rights. Patel kept making excuses. In truth, he must have known that fellowship would be granted only after a careful vetting and accreditation exercise. His United States bands would be discovered. His managers, Dr. Darren Keating and Peter Leck, did not twig. They were delighted that Patel had made such a significant dent in the waiting lists. But as both Tony Hoffman and Dr. Martin Carter had made known their worries about the Bramage case, Dr. Keating decided to look into it. He asked Patel, Carter, Dr. Jim Gaffield and Dr. Iftikar Yunus to supply reports on the care of Bramage. Their accounts were in conflict. When Patel saw the Sentinel event report by Tony Hoffman, he denounced it as based on misinformation, misrepresentation and personal bias. The email Hoffman had sent to me after reading the 31 July story about Elyse Neville, remained unopened until my return from a family holiday. The cabin we had booked into near Adaminaby, a 45 minute drive from the ski fields at Mount Selwyn in New South Wales, Kosciuszko national park, was cosy but when we saw the bunk beds for the children, we again thought of Elise. We covered the top bunk with suitcases and organised the bedding to ensure Sarah and Alexander would sleep together on the bottom bunk. On my return to work in mid August, I emailed Hoffman. I wrote, I'm very concerned by the situation you've described. How do you feel about me investigating it? In a way of course that does not affect you. Tony replied, I would be very grateful.

Tony Hoffman (64:47)

On behalf of Queensland Health patients if you would investigate the situation that currently exists in Queensland Health, especially in the provincial areas where we are very much at the mercy of third world doctors and management who do not support the grassroots and who consistently lie to cover up what is really going on. I have invested a lot of time, money and study in my career, but I am increasingly concerned about the state of affairs and just wish management would be accountable.

Headley Thomas (65:19)

Hoffman had deliberately not disclosed the hospital or town in which she worked. She wanted to continue pressing her concerns about Patel through official channels in relation to a patient's death, which she described.

Tony Hoffman (65:34)

She said the surgeon continues to operate even though Queensland Health are doing a preliminary investigation. The coroner is investigating. I really feel Queensland Health is out of control with protecting incompetent doctors.

Headley Thomas (65:50)

Regardless, the lack of feedback from management to Hoffman gave her little confidence. At the urging of other nurses, she pleaded for advice from Vicki Smythe and Kim Barry of the Queensland Nurses Union. Hoffman had been going back over the records, looking at deaths and complications in the ICU in the previous 16 months. She revealed how concerned she had become. Kim Barry told Tony, you can't collect that sort of information and not act on it. Antoine Gautray asked his friends and family to wish him well before going into into the hospital in early September for a Whipple's procedure, an extremely complex operation to remove a tumour in the head of his pancreas. Although it was a procedure Patel had bungled in Portland, Oregon, with fatal consequences, resulting in him being specifically restricted from attempting it again, he decided to use Gautray as his guinea pig in a hospital ill equipped for the post office operative care that would be needed. Gautray was a seriously unwell man when he came out of theatre. The extent of his cancer was such that the operation would almost certainly kill him before the disease took his life. Few, if any surgeons would have operated on Gautray in his perilous condition, but in his trademark cocksure manor, Patel forged ahead. Gautray died in late September after a stormy and prolonged stay in the intensive care unit. His death Certificate stated Klebsiella. Towards the end, a dark brown and sticky sputum that Gautray had been coughing up caused pneumonia and pockets of pus in the lining of his lungs. The week after Gautray's death, Patel operated on Ian Vals, a cabinet maker who had a polyp in the lining of his bowel. Instead of simply removing the fleshy growth, Patel opted for drastic action removal of the entire bowel. Patel told him, well, the cyst is.

Dr. Jayant Patel (68:12)

Attached to the wall of your bowel and I cannot see what's in behind it. Your bowel does not like your body, but we will whip it out. I've done a lot of these operations before. People, after they get well again, they go skiing. You'll have no worries whatsoever.

Headley Thomas (68:28)

The operation was entirely unnecessary. The polyp was benign. At the time Patel did the operation, there was nothing to suggest it might develop into cancer. At 57, Fowles was fitted with an ileostomy bag. There were serious post operative complications. His quality of life was never the same again. Glenn Tatham usually tried to inject humour into his deadly serious talks for Queensland Health. A few jokes sprinkled here and there made the subject ethical awareness less foreboding for hospital staff. As a misconduct investigator based in Brisbane, Tatham went to Bundaberg Hospital to remind the staff of their obligations under the Code of Conduct.

Dr. Andrew Donner (69:23)

Some people think that people who complain are dobbers.

Gerard Neville (69:26)

Do you agree?

Headley Thomas (69:28)

Tony Hoffman and the other nurses were increasingly alarmed as they watched. One part of Tatham's PowerPoint presentation headed Breach of confidentiality, the small town scandal. Another part related to whistleblowing about serious threats to safety. Tatham and the explanatory material warned that a whistleblower who disclosed information to a union representative, the media or a member of Parliament could be sacked and even imprisoned for committing a criminal offence. Gail, Alma said to Hoffman, I'm so.

Tony Hoffman (70:06)

Glad you didn't do what you were going to do.

Headley Thomas (70:09)

The nurses were alarmed at the timing of the presentation and the consequences for staff who spoke outside the system, even though the system was not properly responding to complaints made internally. Until Tatham's sobering warning, Tony Hoffman had been ready to go to Bridge Brisbane with a union official to bring Jayant Patel to the Health Rights Commission's notice. But now she was scared. She wondered if the timing of the talk was more than a coincidence and whether she might already be in trouble for confiding information to me and the union. 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 Leake with assistance from Leah Samaglou and Neil Sutherland. Our producer is Kristen Amias. Production management by Stephanie Coombs Artwork by Sean Callanan. Thanks to Ryan Osland, Matthew Condon, Corinna Berger, Ellie Dudley, David Murray, Dominique McDermott, Zach Schoolander and all our family, friends and 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@sictodeathpodcast.com and on Apple Podcasts. You can get exclusive access to photographs, videos, timelines and more at the website. Sa.