How could this happen, and why were the warnings brushed aside for so long?

Dr Jayant Patel is being investigated over the deaths of 87 patients in a public hospital in country Queensland.

He started work on April 1, 2003, but he was no fool, Jayant Patel assured the locals. They were lucky to have him. Nothing was beyond him, though he sneered that after operating in New York and Oregon, the “Third World” facilities in provincial Queensland could have cramped his style. Charming, brash, loud, confident, hard-working – he operated on 867 patients in Bundaberg over two years, many of them several times – a surgeon with just the right blend of arrogance and assurance. Only he wasn’t, strictly speaking, a surgeon at all.

On April 1, 2005, Patel’s bosses at Bundaberg hospital signed off on a $3547 business-class, one-way air fare for him to travel to the United States, despite him being, by then, up to his neck in accusations of fatal incompetence. By then they had also learned that Patel had been forced to hand in his practising licence in New York state and had been found guilty of gross negligence in Oregon. An angry posse of bereaved families and damaged patients was forming outside the hospital, but in a development that will no doubt consume many hours of the commission of inquiry now investigating his activities, Patel – already dubbed “Dr Death” in local headlines – simply flew away, and the hospital picked up the tab. Where he is now, no one is sure. Maybe he’s still in the US, maybe he is back in his native India.

There’s no harmless resolution to this April Fool’s hoax. In a Brisbane courtroom, an inquiry with the sweeping powers of a royal commission began hearings this week with the revelation that it is now investigating the deaths of 87 of Patel’s patients – 20 more than previously known.

But it is not only concerned with fatalities. In the Bundaberg High School auditorium on Thursday night, 80 people, many of them patients who now claim needless suffering under Patel’s scalpel, gathered for their weekly update from the hospital’s acting general manager, Michael Cleary, and from the Brisbane lawyer representing them in a medical negligence class action, Ian Brown. These are the hardcore angry ones, but there are many others. The hospital has written to 2332 ex-patients advising them of concerns about Patel, and received 1264 calls back so far. Nearly 300 have been advised to revisit their GPs, and more than 200 referred back to specialists.

“What happened here is appalling,” says Ian Fleming, one of the co-founders of the fledgling Bundaberg Patients’ Support Group, to the people gathered in the school auditorium. He has endured almost two years of pain, debility and internal bleeding since the surgical wound on his abdomen “blew out” as he sat on the couch at home one night – a post-operative glitch that occurred at a high rate among Patel’s patients.

Maria Bramich, 10, with a photo of her father, Des Bramich, who died after being treated by Dr Jayant Patel.

All who have suffered must find the strength to speak up, Fleming tells the assembly. All but a handful of them are sunburned 50-somethings and beyond. Many have the wounds and weariness and cautious gait of the chronically unwell. What is emerging here, says Fleming, is a health scandal of unprecedented scale in Australia, “maybe the Western world”. It could be dismissed as the hyperbole of a bitter man with a nasty bowel complaint and a grudge against the doctor who didn’t fix it, were it not for the courtroom full of lawyers and doctors back in Brisbane, the eight other inquiries investigating Patel’s legacy (including one by homicide squad detectives), the forthright mea culpas of spinmaster and Queensland Premier Peter Beattie, and the increasingly vicious finger-pointing of doctors, politicians and bureaucrats.

This is not just an inquiry into the possibility of large-scale death and injury through medical negligence. It is about the health of the public hospital system in Australia, in particular in regional areas, where doctors are scarce. It will probe accusations of bureaucratic malaise and cover-up, and of the failure of medical systems and fraternities to sound the alert on one of their own. It will investigate the pressures on a health system struggling to find the resources and expertise to meet community demand, and claims that the system turned a deaf ear to the protesting screams of patients because it simply couldn’t afford to hear them.

The Bundaberg Hospital Commission of Inquiry heard on Wednesday that one nurse who tried to raise interest from local politicians in problems at the hospital found her complaints would “sit like a dead mullet on their floor”. It heard that senior medical staff first tried to warn hospital administrators about Patel within two months of his starting work, yet he continued to operate for two years.

Bundaberg is a city built on sunshine. Clear skies nurtured the sugar cane, the happy byproduct was the rum. And even as international markets undercut the once-sweet profits of the plantations, the sunshine continues to deliver prosperity in the form of cashed-up south-erners who swap their city mort-gages for a quiet life and a mild climate. The smiling, sunglasses-wearing sun logo beaming from the masthead of the local News Mail – “weather fine, max 26, min 12” – is pretty much a per-manent fixture.

Cabbie Maurie Hall points out the estates of three-bedroom brick veneers springing up on the town’s periphery, where the sugar cane that was his family’s livelihood once grew dense and tall. Noosa-esque apartments and brasseries replace the fibro shacks along the nearby coast. Here, property values have risen 104 per cent in three years, says Mayor Kay McDuff. In some places – such as the coastal neighbourhood of Bargara, where Patel lived – prices have “gone nuts”, she says. Bundaberg, four hours’ drive north of Brisbane, is quietly booming.

In the heart of town, on one of the broad, flat, impeccably clean thoroughfares the city prides itself on, Bundaberg Base Hos-pital reflects much of the city’s fortunes. At the hospital’s core is a once-elegant old building, gradually dwarfed by utilitarian brick boxes constructed to meet the needs of the growing popu-lation last century. And just on the edge, a mere hint of glassy, modern architecture marks the latest extensions.

In a courtroom in Brisbane this week, Tony Morris, QC, now charged with investigating the legacy of Patel’s two years in Bundaberg, was told that while the population has swelled by 40 per cent since 1999, the num-ber of beds at Bundaberg Base had fallen from 216 to 138 in 2004. “That’s practically halved the ratio of beds to population in the catchment area,” Morris says. Demand for the beds was so high that people who managed to get into them used to think they were lucky.

In an environment of tight budgets, expensive procedures, growing demand and scarce medical skills, hospital manage-ment has evolved into an art form. Surgeons are traded on the international market like precious resources, and the exchange rate and annual salaries offered in places like regional Queensland won’t buy you a whole lot, says Queensland AMA chief Dr David Molloy. An operator like Patel was the beancounter’s dream, he says, because by performing so many procedures, many of them quite complex (and many, it is now emerging, quite beyond his expertise) he was able to bring in lots of cash. Patel, whose pay-ment package was worth about $200,000 a year, used to boast to hospital colleagues that he was worth $500,000 a year in extra funding to the hospital’s coffers.

Bundaberg Hospital director of medicine and renal specialist Dr Peter Miach – formerly of Melbourne’s Austin Hospital – twigged to troubles with Patel quite early. He told the inquiry this week that he had seen so many examples of Patel’s incompetence that he would not let him touch his patients. But his calls for hospital management to act were ignored. On Wednesday he recalled going to the hospital’s director of medical services, Dr Darren Keating, with concerns about hospital matters, only to be told by Keating that “you have to understand this is a business”. “That’s the problem, I think it’s a hospital,” Miach said he responded.

Over the first four days of hearings by the Morris inquiry, a picture has emerged of a deeply dysfunctional management structure, one where the people looking after the books and the people looking after the patients operated in parallel universes, rarely co-operating or talking. Somewhere in that void between management and the medical workers, rumblings and complaints about gun surgical import Jayant Patel just disappeared.

Intensive care nurse Toni Hoffman – whose evidence opened the inquiry this week and who is hailed locally as the Erin Brockovich of this story – sent an email to Keating complaining about Patel 10 weeks after his arrival. “The behaviour of the surgeon in ICU needs also to be discussed as certain very disturbing scenarios have occurred,” she wrote. Nothing happened. She kept complaining and was admonished for being racist, or for not being able to manage Patel’s “difficult” personality.

In a coffee shop in Bundaberg’s main street yesterday, a group of nurses relate anecdotes that support that picture. They do not want to be named, as they still work for the hospital, and are likely to be called to give evidence to the Morris Inquiry. They are plainly traumatised by what they have seen, and wonder guiltily what more they could have done. They have all worked in hospitals outside Bundaberg, in “normal hospitals”, says one, but say the culture here is something else.

They had all complained about Patel. They talk about hiding patients from Patel, of pulling strings to make sure friends or family were kept well out his way. Word spread among the hospital community about Patel’s behaviour, and sometimes beyond. One local woman recalls being tipped off last year by her Hash Harriers group (“a drinking group with a running problem”), not to let Patel operate on her gall bladder. But Mayor McDuff, a regular visitor to the hospital in her official capacity and a person plugged into Bundaberg’s social, civic and professional circles, never heard a whisper.

The nurses say they tried to support the increasingly frustrated Hoffman as she fought to have Patel’s conduct reviewed. “Toni threatened to hang herself naked outside Red Rooster, if that would get attention,” says one.

But the turning point came with the death of Des Bramich, 56, an earth-moving contractor from Agnes Water who ended up in Bundaberg Hospital last July after a friend’s caravan fell on him, crushing his chest. He seemed to be recovering, and the NewsMail even visited him to do a picture story on his surviving the freak accident, but by the time the story was published he was dead.

Hoffman told the Morris Inquiry on Tuesday that medical staff were traumatised after witnessing Patel stab Bramich in the chest up to 50 times in an apparent attempt to drain suspected fluid from a sac near his heart. “The whole thing was like a nightmare,” Hoffman’s colleagues say. “He was really out of control.”

Hoffman wrote a letter of complaint detailing the incident and 13 other cases of concern and sent it to Queensland Health district manager Peter Leck. It was this letter that eventually found its way to local National Party member Rob Messenger, who raised the concerns in State Parliament in March, finally exposing the scandal at Bundaberg Base. By then, Queensland Health had started an investigation of the complaints – but only just.

Despite the cloud over him, Patel was still operating, and telling his colleagues he was so valuable to the hospital that he was untouchable. Until, on April 1, he resigned and vanished, courtesy of the air fare approved by Peter Leck.

Leck, who has stood aside from his position, told an incredulous Morris on Thursday that he could not recall signing off on the ticket because it was “not of specific significance”. Morris accused Leck of knowing that Patel was not qualified to practise surgery in Australia. He admitted he had never checked.

“You’re just far too busy, are you, to trouble yourself with whether or not people being held out as surgeons in your hospital are actually qualified?” Morris asked.

“It’s not my role,” Leck said. “It’s Dr Keating’s responsibility.”

Keating, it emerged, gave Patel a glowingly worded letter of thanks for his services, on Queensland Health letterhead, before he departed.

Morris questioned Leck about the delays in investigating Hoffman’s complaints. “It doesn’t worry you that patients may be dying, that 15-year-old boys may be losing their legs, it’s not your role?”

“It’s the role of the director of medical services,” Leck responded. “I’m not a clinician.”

As the evidence filtered out this week, there was a lot of buck-passing going on. Premier Peter Beattie, who has admitted the inquiry will damage his chances at the next election, has had a shot at the doctors.

He thinks the AMA should be held accountable for failing to act on concerns about Patel, and has called for a “frank debate” about the role of doctor groups in controlling the number of specialists.

“There are not enough Australian doctors, there are not enough university colleges, and the specialist colleges have operated like a closed shop,” Beattie said.

BUT the doctors say the lack of surgeons is the result of a failure of governments to fund specialist training places. College of Surgeons president Russell Stitz says doctors are desperate to see more specialists trained. “And we’ve got to learn the lessons from this situation in Victoria, too – there are quality issues here to be addressed. What we hope is that the system gets overhauled significantly, rather than just looking for scapegoats.”

And just to set the record straight, the college – the body that registers surgeons for practice in Australia – was never asked to assess Patel’s credentials, Stitz told The Age.

Molloy, of the AMA’s Queensland branch, wonders at the contribution of the Queensland Health bureaucracy to the scandal. “It’s like when an aircraft crashes. Sometimes your engine gives up, but sometimes a series of cascading faults causes that.”

The culture of Queensland Health, he argues, is flawed. Better systems of quality and medical auditing – checking where cases go wrong and why – would have exposed the problems at Bundaberg much earlier, he says. And then there is the ever-present pressure on public hospitals to meet budgets and bring in revenue. “Patel was churning through the work, so the administrators thought he was God’s gift.”

Solicitor Ian Brown, of Carter Capner, has documented the stories of about 100 of Patel’s patients and families in preparation for a class action. Clearly there was a failure by the medical board in not checking Patel’s credentials, he says.

A simple Google search would have turned up evidence of Patel’s problems practicing in the US, as The Courier-Mail newspaper discovered.

Many of the 87 patients whose deaths are being reviewed were very ill. Figuring out whether Patel’s treatment in any way hastened or contributed to their deaths will be an enormously difficult process, as will determining whether his surviving patients have received good quality or poor care.

But Brown argues that in many ways the issue is academic. None of Patel’s patients were ever informed of the questions over his credentials, therefore none of them could have given informed consent to going under the knife. This will be crucial to the negligence case.

But what Brown finds most remarkable is that despite evidence of growing concerns among other doctors and specialist surgeons over Patel’s handiwork, those concerns were not pursued with professional bodies. “Why didn’t one of them go to the Medical Board and put in a formal complaint?” he asks.

Beattie is hoping that an open, contrite approach will help salvage community respect for the health system. He has posted an apology on the Government website to Patel’s victims. He also posted a message imploring Patel to return to Queensland to face the inquiry. But the nurses and patients recalling Patel’s character this week doubt that they will ever see him again.

He was a man with plenty of charm and style at the bedside before the operation, though it was usually for the benefit of patients and family, rarely for nurses. But question him or criticise him and he would strike back angrily, forcefully and unequivocally. “A small man with a bad case of small man syndrome,” recalls one nurse.

Leck told the Morris Inquiry on Thursday that in hindsight he wished he had launched an investigation into Jayant Patel earlier. “I’m sure a lot of other people do too,” Morris replied.

The saga of Jayant Patel

1950

  • Born in India to wealthy parents.

1973

  • Qualifies as a doctor.

1977

  • Becomes intern in the US.

1981-84

  • Resident surgeon in Buffalo, New York. Disciplinary proceedings start.

1986

  • Surrenders physician’s licence, New York.

2000

  • Told by Oregon State Board of Medical Examiners not to perform certain surgery. He must get second opinion on cases, “based on gross negligence”.

APRIL 1, 2003

  • Starts work in Bundaberg Base Hospital in $200,000 position as director of surgery.

JUNE

  • Nurse Toni Hoffman sends an email to director of medical services Darren Keating, saying: “The behaviour of the surgeon in ICU needs also to be discussed as certain very disturbing scenarios have occurred.”

OCTOBER

  • Patient Ian Fleming makes verbal complaint about Patel to Bundaberg Hospital.

OCTOBER 2004

  • Hoffman writes to Queensland Health district manager Peter Leck detailing 14 cases of concern.

FEBRUARY 2005

  • Queensland Health begins to investigate.

MARCH

  • National Party local member Rob Messenger raises concerns in Queensland Parliament. Beattie Government says Patel has been denied natural justice and replacing him would be difficult.

APRIL 1

  • Patel resigns and flies to US on hospital-funded one-way business-class ticket.

APRIL 13

  • The Courier-Mail says a simple Google search shows that Patel had been banned from surgery in the US.

APRIL 19

  • Premier Peter Beattie agrees to a commission of inquiry, which began on Monday.