Speaker 1: My name is Hedley Thomas.
Speaker 2: Sick to Death is based on my book of the
Speaker 2: same name, and it's the true story of doctor Jan
Speaker 2: Patel's lies and manipulation and the herculean effort it took
Speaker 2: to finally stop him. We've used voice actors throughout this series,
Speaker 2: and on occasion the real people from the story have
Speaker 2: read their words for us.
Speaker 1: It is brought to you by Me and the Australian.
Speaker 2: Chapter nineteen The Messenger, eighteen March two thousand and four.
Speaker 2: Rob Messenger wanted to start with a few home truths.
Speaker 2: He looked up and smiled at his supporters in the
Speaker 2: public Gallery of State Parliament in George Street, Brisbane. It
Speaker 2: had been a hard slog to arrive in this place.
Speaker 1: He hoped it would be worth it.
Speaker 2: Nobody had ever accused Messenger of being born with a
Speaker 2: silver spoon in his mouth. At four thirty pm on
Speaker 2: eighteen March two thousand and four, as the National Party's
Speaker 2: new member for Burnett prepared to deliver his first speech,
Speaker 2: he felt unbeatable.
Speaker 3: I have to confess my journey to this historic chamber
Speaker 3: was not planned. As a child and teenager playing in
Speaker 3: the red did cane fields of South Clan. I never
Speaker 3: harbored dreams of becoming a politician, and I'll be the
Speaker 3: first to admit that I'm only standing here before you
Speaker 3: because of God's grace.
Speaker 2: With a nod to the gallery, Messenger explained how he
Speaker 2: drew inspiration from his father Dez when self doubt and
Speaker 2: fatigue set in. Des had been a cane cutter in Bunderberg.
Speaker 2: Like the Kannakas a century ago. He had the backbreaking
Speaker 2: job of cutting and loading tons of caine a day
Speaker 2: for a meager one dollar sixty a ton. Rob Messenger
Speaker 2: still marveled at how his father Deares managed to feed, clothe,
Speaker 2: and shelter him and his two brothers.
Speaker 1: Greg and Danny.
Speaker 2: When Messenger was a teenager, he danced and sang to
Speaker 2: the evocative lyrics of Australian band Ganga Jang's anthem sounds
Speaker 2: of them about growing up in Bunderberg. Out on the
Speaker 2: patio we'd sit and the humidity we'd breathe, We'd watch
Speaker 2: the lightning crackover cane fields, laugh and think this is Australia.
Speaker 2: He remembered his mother Irene, laughing and joking with the
Speaker 2: other women of the district while they picked tomatoes in
Speaker 2: thirty five degree tropical heat. Irene lived for Rob's regular
Speaker 2: visits to her bedside at Bunderberg Hospital in the weeks
Speaker 2: before she finally succumbed to a particularly aggressive bow cancer.
Speaker 2: In September two thousand and two. Messenger watched his well
Speaker 2: known mother die at the hospital after an eighteen month battle.
Speaker 2: He came to know the doctors and nurses. Some of
Speaker 2: them began confiding a few secrets and worries. The hospital
Speaker 2: was running on empty. It had been managed to a
Speaker 2: standstill and starved of funds as the district manager, Peter Leck,
Speaker 2: enforced rigid budgetary controls. Specialists and the best doctors were
Speaker 2: leaving disillusioned and distressed at the deteriorating levels of care.
Speaker 2: All the while, public announcements and press releases from Queensland
Speaker 2: Health's Brisbane headquarters spewed positive but wholly misleading guff about
Speaker 2: the hospital in which Messenger had been born. Messenger used
Speaker 2: his first speech to underline what he knew from his
Speaker 2: months on the campaign trail. The hospital was sick. It
Speaker 2: was a diseased limb of a very sick body, whose
Speaker 2: staff had been cowed into silence.
Speaker 3: These dedicated professionals must be allowed to tell the truth
Speaker 3: while avoiding any possibility of placing their careers with Queensland
Speaker 3: Health in jeopardy. These workers' stories must be heard and
Speaker 3: acted on if the people of the Bernet are ever
Speaker 3: to enjoy the level of health care that they richly deserve.
Speaker 2: The parless condition of the health system was a major
Speaker 2: feature of the state election campaign in early two thousand
Speaker 2: and four. The opposition coalition, of which Rob Messenger was
Speaker 2: a member, had paid for hard hitting advertisements depicting people
Speaker 2: who had waited years for straightforward surgery, while the Australian
Speaker 2: Medical Association ran a highly effective campaign to highlight secrecy
Speaker 2: and underfunding in the health system. Stung by the constant
Speaker 2: stories and revelations from clinicians about how patients were so
Speaker 2: offfering because the hospitals could not cope with demand, Premier
Speaker 2: Peter Beatty threw money at the problems. The waiting lists
Speaker 2: for surgery were a significant part of Beattie's electoral strategy.
Speaker 2: He pledged a one hundred and ten million dollar injection
Speaker 2: of extra funds to pay for thousands of extra operations.
Speaker 4: This new initiative will be the biggest effort to reduce
Speaker 4: elective waiting lists that Queensland has ever seen. People have
Speaker 4: made it clear to me over a period of time
Speaker 4: they want these lists tackled. We have done well, but
Speaker 4: clearly we can do better. We will be making health
Speaker 4: our number one priority.
Speaker 2: The Health Minister Wendy Edmund had retired from politics. By then,
Speaker 2: Beatty had kept a straight face while commending her as
Speaker 2: the country's best health minister. The new Health Minister, Gordon Nuttle,
Speaker 2: was telling his executive team to put every public hospital
Speaker 2: on notice the waiting lists were critical. In the internal
Speaker 2: confidential briefing paper he received after being sworn in, Nuttle
Speaker 2: was worn that Queensland Health had become extremely reliant on
Speaker 2: overseas trained doctors, who comprised thirty percent of the medical workforce.
Speaker 5: Employment of overseas trained doctors provides a short term solution
Speaker 5: to doctor shortages. However, this approach brings with it a
Speaker 5: range of skill and competence issues.
Speaker 2: Messenger hammered health issues as stubbornly and relentlessly as he
Speaker 2: had during his electoral campaign. He repeatedly called for an
Speaker 2: independent investigation into Bunderberg Hospital, its procedures and practices. The
Speaker 2: attempts by the Beatty government to silence him became farcical.
Speaker 2: At one point, Messenger had said.
Speaker 3: Rather than pulling back from this issue, I intend to
Speaker 3: turn up the blow torch.
Speaker 2: The metaphor was too much for Nuttle, who called for
Speaker 2: a formal investigation into whether Rob Messenger planned to commit
Speaker 2: arson or burn alive any bureaucrats. Messenger was industrious and
Speaker 2: highly effective. He uncovered figures showing the hospital had just
Speaker 2: one hundred and thirty six beds, eighty one fewer than
Speaker 2: in nineteen eighty nine, despite the region's steady growth. The
Speaker 2: door of his electorate office at Bagara, near Jayant Patel's
Speaker 2: home apartment, was always open to hospital staff with stories
Speaker 2: of crises. Doctors came to tell him how they had
Speaker 2: been forced to work twenty four hour shifts, compromising patient
Speaker 2: care through sheer exhaustion. The regular outpourings were embarrassing for Nuttle,
Speaker 2: and they were infuriating the new Director General of Health,
Speaker 2: doctor Steve Bucklin, who had angrily banged the desk and
Speaker 2: abused Messenger in one memorable meeting. During a short stint
Speaker 2: as acting Director of Nursing, Tony Hoffman was surprised to
Speaker 2: see Peter Leck, who read the speeches on the parliamentary
Speaker 2: website as soon as they had been posted, furiously denouncing
Speaker 2: something Messenger had said. Peter Leck and Darren Keating stood
Speaker 2: at the computer screen and ridiculed the politician. An unprecedented
Speaker 2: meeting of the executive staff was called by Lek to
Speaker 2: discuss what effect having a National Party member would have
Speaker 2: on the hospital. Lek expected Rob Messenger to create trouble.
Speaker 2: Lek wondered if the parliamentarian was upset about the hospital's
Speaker 2: treatment of his mother. Hoffman realized that Messenger had become
Speaker 2: a major thorn in their side. She liked his courage
Speaker 2: and stamina. He was like a dog with a bone
Speaker 2: in relentlessly exposing the hospital's ills. He spoke of patients
Speaker 2: dying unnecessarily due to a dangerous culture, borrowing from one
Speaker 2: of the maxims of Anglo Irish statesman, politician and philosopher
Speaker 2: Edmund Burke, a leading light in the House of Commons
Speaker 2: more than two hundred years ago. Messengers spoke of evil
Speaker 2: prospering while good men remained silent. Hoffman wondered if she
Speaker 2: might one day pluck up the courage to go to
Speaker 2: Messenger about Jayant Patel good.
Speaker 1: Men had done nothing. It might be left to a
Speaker 1: good woman.
Speaker 2: Chapter twenty The Catalyst, July two thousand and four. Dares
Speaker 2: Bramich liked to stay busy. If a job was worth doing,
Speaker 2: he wrecked it was worth doing straight away. A little
Speaker 2: after four point thirty pm on Sunday, twenty five July,
Speaker 2: Des Bramage, age fifty six, was doing one of those
Speaker 2: good deeds. It had been a glorious day in Agnus Water,
Speaker 2: a sleepy seafront community about.
Speaker 1: An hour and a half's drive from Bunderberg.
Speaker 2: Grammage, who ran an earth moving business with his son Mark,
Speaker 2: was beneath a caravan. He was helping to remove one
Speaker 2: of its tires for his youngest son Luke, before the
Speaker 2: sun disappeared. On one of the shortest days of the year.
Speaker 1: Mark was walking back to.
Speaker 2: The land rover to get some tools when the caravan
Speaker 2: fell from its supports. The muffled thud as the weight
Speaker 2: came down onto his father's chest sounded ominous. Mark looked
Speaker 2: back and saw his father conscious but gasping.
Speaker 1: He was clearly having trouble breathing.
Speaker 2: Unknown at the time, two of his ribs were badly fractured.
Speaker 2: A plural membrane lining the inside of the chest wall
Speaker 2: was torn on the right side. The upper part of
Speaker 2: his sternum was also fractured, probably damaging arteries running down
Speaker 2: either side of his breastbone. Mark rushed to get a
Speaker 2: jack from the car to try to lift the caravan
Speaker 2: off his dad's crushed chest.
Speaker 1: In the panic and fading light.
Speaker 2: On an afternoon that had become suddenly bleak and foreboding,
Speaker 2: he fumbled to grip and lift the heavy steel contraption.
Speaker 1: Thankfully, help arrived quickly.
Speaker 2: A local medic, doctor, Salassa Vouti, one of the town's
Speaker 2: overseas trained doctors, inserted a tube to help Bramwich breathe.
Speaker 2: The ambulance rushed to the accident site to provide emergency
Speaker 2: backup and transport. A rescue helicopter arrived to airlift him
Speaker 2: to Bunderberg Hospital. Quickly to his father's wife, pack.
Speaker 6: Your bags and go to the hospital.
Speaker 7: Tests dad's had an accident.
Speaker 2: Test trembled with worry as her friend, Agnes Smythe gunned
Speaker 2: the white commodore, beating the helicopter by fifteen minutes. Tess
Speaker 2: was told her husband had suffered severe internal injuries, but
Speaker 2: that the prognosis was good. Once he had been stabilized
Speaker 2: in the trauma room, there were tests and scans of
Speaker 2: his chest. Des was thirsty, and, with a nurse's approval,
Speaker 2: test gave him an ice cube to wet his mouth.
Speaker 2: One of the doctors told Tess there was no reason
Speaker 2: why a fit, middle aged man, a non smoker and
Speaker 2: non drinker would not make it. She was greatly comforted
Speaker 2: by the reassuring words. Even as they transferred her husband
Speaker 2: to the intensive care unit, she watched the nurses there
Speaker 2: hooking him up to machines to monitor and assist his.
Speaker 1: Heart and breathing.
Speaker 2: They gave him morphine intravenously and an oxygen mask. Tess,
Speaker 2: who was born in the Philippines, and Des had wed
Speaker 2: a decade earlier. Tess was DES's third wife. They often
Speaker 2: joked about how, at age thirty three, she was younger
Speaker 2: than Mark, even though she was step grandmother to Mark's kids.
Speaker 2: Des and Tess had not looked back. The Bramich father
Speaker 2: and son business was doing well. The couple had great
Speaker 2: friends in the town where everybody knew each other. Their
Speaker 2: young daughter, Maria acquiet beauty with Tess's brown skin and
Speaker 2: smoldering dark eyes was a family treasure. Now At one am,
Speaker 2: Tess kept a vigil in the hospital. When Dez suggested
Speaker 2: that she should leave to get some sleep, the staff agreed,
Speaker 2: although they were more concerned about his rest. When Tess
Speaker 2: returned at six a m. And saw him smiling in
Speaker 2: bed with most of the color returned to his face,
Speaker 2: her spirits rose.
Speaker 1: By nine a m.
Speaker 2: Some of his extended family were perched around his bed
Speaker 2: in the ICU, Des spoke to Mark's visibly distressed wife, Fatima.
Speaker 8: Don't cry, I'm all right.
Speaker 1: He was making jokes at his own expense and wise
Speaker 1: cracking about being far too young to die.
Speaker 8: I'm like a cat, I have nine lives.
Speaker 2: After X rays and a cup of tea, he spoke
Speaker 2: about the accident. His son beamed when Des said that
Speaker 2: had it not been for Mark, the crush from the
Speaker 2: caravan would have put him in a coffin. Tony Hoffman
Speaker 2: was touched by the natural affection and love enveloping her patient,
Speaker 2: who exerted a cheerfulness she put down to genuine family contentment.
Speaker 2: She chatted freely to DEAs and Tess, their daughter, ten
Speaker 2: year old Maria, gazing at her Dad with those liquid
Speaker 2: eyes was gorgeous. Hoffman gave her a soft white toy,
Speaker 2: the seal that she kept in the bottom of the
Speaker 2: filing cabinet for young children who came into the unit.
Speaker 2: At times like this, Tony Hoffman regretted some of the
Speaker 2: choices she had made. Hoffman wished things had turned out
Speaker 2: differently with some of the men she had loved. Her
Speaker 2: career had been fulfilling, but at home after the shift ended,
Speaker 2: she sometimes felt desperately lonely. By the time Tess returned
Speaker 2: from lunch, the bed in the ICUU was empty. She
Speaker 2: was immediately worried, but Des was fine.
Speaker 1: He was doing so.
Speaker 2: Well that he had been wheeled into the surgical ward
Speaker 2: that afternoon. After he had been helped into the chair
Speaker 2: beside his bed, test stayed and chatted with him until evening.
Speaker 2: When she returned early the next morning, twenty seven July,
Speaker 2: Des was in a bad way.
Speaker 8: Dahl, I really didn't have a good sleep last night
Speaker 8: because I was in pain all night.
Speaker 2: Tess was confused. She had been assured that the morphine
Speaker 2: trickling into his veins would deaden the pain. She examined
Speaker 2: the intravenous connection and saw that it had become loose
Speaker 2: and it was dripping.
Speaker 9: Could you just please fix that properly?
Speaker 2: They waited impatiently for a junior doctor to come by
Speaker 2: and Reattach the line.
Speaker 1: Des was encouraged.
Speaker 2: To walk around the hospital corridors with a physiotherapist and
Speaker 2: an assistant. He hobbled in pain as they supported him
Speaker 2: under his armpits, then returned to bed and spoke by
Speaker 2: telephone to his worried mother and sister. When the Bunderberg
Speaker 2: News Males reporter arrived, Des recounted the accident.
Speaker 8: Mike is my hero.
Speaker 2: Tess returned from lunch to discover that he had suddenly
Speaker 2: collapsed and been rushed back to the intensive care unit. Hoffmann,
Speaker 2: shocked at how rapidly he had deteriorated, calmly organized her staff.
Speaker 2: The nurses rushed to save his life. Des could not
Speaker 2: breathe and his blood pressure had plummeted. His heart was racing,
Speaker 2: and the pain in his chest had become unbearable. He
Speaker 2: was slipping in and out of consciousness. Doctor if Ta
Speaker 2: Carr Eunus, one of the anesthetists, was attempting to resuscitate
Speaker 2: him with the help of three nurses. Doctor Martin Carter,
Speaker 2: the anesthetist in charge of the ICU, was clear.
Speaker 7: If the patient is going to need blood products, he'll
Speaker 7: need to be flown out.
Speaker 2: Carter decided that as Bramwich might need thoracic surgery, long
Speaker 2: term ventilatory support and access to a blood bank, he
Speaker 2: should be rush to one of the larger hospitals in Brisbane.
Speaker 2: There were urgent efforts to find a bed in Brisbane.
Speaker 2: Prince Charles Hospital was full that a bed might be
Speaker 2: available at Princess Alexandra Hospital. The Royal Flying Doctor Servis
Speaker 2: was ready for the mercy mission. Hoffman relayed the message
Speaker 2: from the bed coordinators in Brisbane to doctor Carter, doctor
Speaker 2: Jim Gaffield and doctor James Boyd, a principal house officer
Speaker 2: working under doctor Jayant Patel's supervision. Hoffman was ecstatically.
Speaker 10: Relieved They've got a bed.
Speaker 2: She could see that des Bramwich needed to be in
Speaker 2: a hospital which practiced thoracic surgery. Under no circumstances did
Speaker 2: she want to see Bramwich fall into the hands of
Speaker 2: Jayant Patel, the director of surgery, had been absent from
Speaker 2: the hospital for all of.
Speaker 1: May and June.
Speaker 2: He had had taken study leave and holidays to return
Speaker 2: to Jamnagar in India to see his mother, and then
Speaker 2: to Portland in the United States to spend time with
Speaker 2: his family. The run of complications, the conflict in the wards,
Speaker 2: and the fears of the staff had disappeared. Doctor Patel's
Speaker 2: holiday was a blessing for all. Tony Hoffman recalled the
Speaker 2: plight of Una Conners, whom Patel operated on for cancer
Speaker 2: of the sigmoid colon in April. The woman had to
Speaker 2: be rushed back by ambulance after a complete evisceration of
Speaker 2: the wound and her intestines being almost fully exposed. Hoffman
Speaker 2: had grown unusually fond of Desbramach and his family in
Speaker 2: the few hours she had spent with them in the ICU.
Speaker 2: But his perilous condition was worsening. As doctor Eunice tried
Speaker 2: to put in a central line to convey drugs, the
Speaker 2: gravely ill man experienced ventricular standstill. His heart was refusing
Speaker 2: to pump blood. Doctor Gaffield asked Patel to look at
Speaker 2: the X rays of his chest. Patel seized the offer
Speaker 2: and in his booming voice, started undoing the plans to
Speaker 2: transfer Brammage from Bunderberg.
Speaker 11: The patient doesn't need to go to Brisbane. He isn't
Speaker 11: sick enough. If we can't care for such simple things
Speaker 11: as fractured ribs, there is no point in doing any
Speaker 11: sort of drama surgery at the hospital.
Speaker 1: Hoffman, stricken with fear, waited.
Speaker 2: For Gaffield to take charge. Brammage was doctor Gaffield's patient.
Speaker 2: Doctor Carter had already come to the view that the
Speaker 2: best course was urgent transfer. Doctor Eunice agreed arrangements had
Speaker 2: been made, but Patel's dominant personality was assuming control.
Speaker 11: He doesn't need to be transferred. I've been a cardiothoracic
Speaker 11: surgeon for twenty years. If he needs anything, can do
Speaker 11: it here.
Speaker 2: He repeated the confident boasts to members of Bramich's family,
Speaker 2: as Hoffmann quietly pleaded for the transfer to go ahead.
Speaker 10: Please Dr Gaffield fin this man through to Brisbane, even
Speaker 10: if you think he doesn't need a cardiothoracic surgeon. I'm
Speaker 10: really afraid that he's going to die.
Speaker 1: Dr Gaffield replied, No, that won't happen. He won't die.
Speaker 2: He said he wanted to do a CT scan to
Speaker 2: provide definitive information for the handover to the surgeons in Brisbane,
Speaker 2: Patel disappeared back into the operating theater to perform a
Speaker 2: colonoscopy on a patient, but in the course of that
Speaker 2: procedure he perforated the bow. He insisted his injured patient
Speaker 2: should have a CT scan of the bowl before the
Speaker 2: gravely ill Brammage.
Speaker 11: Patel yelled a perforated both takes precedence over a non
Speaker 11: urgency scan at all times.
Speaker 2: The latest botch up a rarity for most doctors, but
Speaker 2: a common occurrence for Petel, meant that another doctor was
Speaker 2: needed to help him repair the bow. Tony Hoffman asked
Speaker 2: doctor Martin Carter, who was due to leave, to give
Speaker 2: a lecture to accompany Bramwich for the CT scan.
Speaker 1: He agreed.
Speaker 2: By the time they returned to the intensive care unit,
Speaker 2: the scan showed three liters of blood pooling in Bramich's chest.
Speaker 2: As Hoffman left the intensive care unit at seven point
Speaker 2: thirty pm to go home, the Royal Flying Doctor aircraft
Speaker 2: was being ready for the trip to Bunderberg. Hoffman had
Speaker 2: stayed back for three hours to ensure des Bramwich would
Speaker 2: get away for the help he so desperately needed. She
Speaker 2: walked to the hospital car park. Confident that Bramwich would
Speaker 2: survive in Brisbane despite his problems, Hoffman felt sure he
Speaker 2: would wake up in the morning. Three hundred and seventy
Speaker 2: kilometers from tell chapter twenty one, the stabbing, late July
Speaker 2: two thousand and.
Speaker 10: Four, Oh did mister Brammage get off all right?
Speaker 2: Outside the hospital elevator At the start of her shift
Speaker 2: the morning after the frantic efforts to save his life
Speaker 2: and move him to Brisbane, Tony Hoffman had bumped into
Speaker 2: doctor Martin Carter. She popped the question. After a quick
Speaker 2: exchange of pleasantries.
Speaker 1: No, he died.
Speaker 2: When the Flying Doctor had finally arrived after ten pm
Speaker 2: with flight nurse Anita Carr and doctor Jackie Butler. Their
Speaker 2: patient was closer to death than he had ever been.
Speaker 2: Patel had remained in control and declared him to be
Speaker 2: too sick to be transferred. As Bramich died a little
Speaker 2: after midnight, despite frantic resuscitation efforts by doctor if T
Speaker 2: Carr Eunice, the nurses were in tears. The Flying Doctor
Speaker 2: staff wept. Tess, Maria and Mark huddled together, shocked, crying
Speaker 2: and wondering what had gone wrong. Hoffman was devastated, she
Speaker 2: thought of the beautiful little girl who no longer had
Speaker 2: a father. She guessed immediately that Patel's decision to halt
Speaker 2: the transfer was all about Patel and his determination to
Speaker 2: flaunt himself. It had little to do with the welfare
Speaker 2: of patients. Despite mounting evidence of needless deaths and injuries,
Speaker 2: the director of surgery remained delusional about his own abilities.
Speaker 2: The death of Bramich was the turning point. Hoffman decided
Speaker 2: from that moment to do everything in her power to
Speaker 2: highlight Petel's lethal menace. She told Martin Carter.
Speaker 10: We have to do something about this, so we cannot
Speaker 10: let this happen any longer.
Speaker 2: She went to her office and broke down in tears.
Speaker 2: The Bunderberg newsmail that day had a bright picture story
Speaker 2: about des Bramich's near death experience. He was sitting up
Speaker 2: in the photograph, looking larger than life. In the article,
Speaker 2: Bramwich says.
Speaker 8: I thought I was going to die because I couldn't
Speaker 8: get any air. It never hit me until the next morning,
Speaker 8: the reality of it that I was in the hands
Speaker 8: of the gods.
Speaker 2: Doctor Martin Strawn, a general physician in private practice who
Speaker 2: worked part time as a visiting medical officer at the
Speaker 2: hospital saw Hoffman sobbing and gently asked what was wrong.
Speaker 2: She told him about the Bramwich case and the circumstances
Speaker 2: of several other deaths, and she recounted the startling rates
Speaker 2: of wound breakdowns and complications. She told him how doctor
Speaker 2: Carter referred to Patel behind his back as doctor Death,
Speaker 2: how the nurses were distraught with worry for the patients,
Speaker 2: how in the renal unit he had flouted basic anti
Speaker 2: contamination standards, and how the director of medicine, doctor Peter Meak,
Speaker 2: refused to let Patel anywhere near his patients. Doctor Strawn
Speaker 2: promised to go away and talk to some of his
Speaker 2: colleagues about Patel and his competence.
Speaker 1: Two days later, he told her.
Speaker 8: There's widespread concern, but nobody is willing to stick their
Speaker 8: neck out yet.
Speaker 2: The untimely death of des Bramitch galvanized the nurses. Several
Speaker 2: of those nurses who had witnessed the last agonizing hours
Speaker 2: of his life, Karen Fox, Vivian Tapiolis, Daniel Aitken and
Speaker 2: Sandra Sharp, were appalled at the turn of events. The
Speaker 2: ICU staff mourned in the beginning and then they became
Speaker 2: angry as they reflected on all the patients Patel had
Speaker 2: harmed since he came to the hospital. They did not
Speaker 2: know the extent of des Bramitch's internal injuries. It was
Speaker 2: probable that these injuries were so severe he may have
Speaker 2: died even if he had been transferred. But they understood
Speaker 2: that he had been robbed of at least a fighting
Speaker 2: chance by a bombastic surgeon who threw his weight around
Speaker 2: to prevent a transfer. First, Patel had insisted that Desbramitch
Speaker 2: was not sick enough to go, and then he was
Speaker 2: too sick. They understood that Patel had spoken callously to
Speaker 2: the family, telling Tess that she should start praying because
Speaker 2: her husband would surely die, telling Tess and her daughter
Speaker 2: to stop crying at the bedside, telling anyone who cared
Speaker 2: to listen how his experience in trauma surgery made him
Speaker 2: better qualified than anyone in Brisbane to manage the care.
Speaker 2: At one point, another nurse, Sharon Cree, had to move
Speaker 2: away from Patel because he was talking so obnoxiously about
Speaker 2: his wealth of experience and expertise. Karen Fox was tormented
Speaker 2: by the death she could not erase from her mind.
Speaker 2: An image of Patel's stabbing Brammage with a large needle.
Speaker 2: For some unexplained reason, Patel had decided that Bramach's critical
Speaker 2: condition might be due to blood between the two layers
Speaker 2: of the peri cardium, a protective sack around the heart.
Speaker 2: Although an ultrasound had already proved there was no fluid there,
Speaker 2: Patel had diagnosed a cardiac tamponade. He decided to perform
Speaker 2: a peri cardio sentisis using a wide born needle. He
Speaker 2: wanted to puncture the sack to drain nonexistent blood. The
Speaker 2: invasive procedure requires skill and strength. Patel botched it. The
Speaker 2: needle is supposed to go in within a few attempts.
Speaker 2: Patel stabbed the needle violently and repeatedly into the semi
Speaker 2: conscious Brammage's chest. After flailing away in a frenzy, Patel
Speaker 2: finally extracted a minuscule few milli liters of blood. Nurse
Speaker 2: Fox had never seen anything like it. Doctor Carter and
Speaker 2: doctor iftekar Unus were also confused. They knew the ultrasound
Speaker 2: results gave no indication of blood.
Speaker 1: In the sack.
Speaker 2: There appeared to be no good reason to be adding
Speaker 2: to des brahmages to stress and pain. Eunus was angry
Speaker 2: about it. He suspected Patel might have punctured a coronary
Speaker 2: vessel with his repeated stabbing motions. Nurse Fox told Hoffman.
Speaker 12: During this procedure, doctor Pateel was loudly making comment that
Speaker 12: the patient will die and does not need to go
Speaker 12: to Brisbane. I asked doctor Peateell to mind what he
Speaker 12: was saying as the family were in the hallway.
Speaker 2: Patel had told Fox that the family members needed to
Speaker 2: know the seriousness of the situation, but Fox replied.
Speaker 12: They need to be told face to face, not overhearing
Speaker 12: what's being said behind the curtains.
Speaker 1: Fox told Hoffman all the distressing details, including how Patel
Speaker 1: had inserted a chestrain and.
Speaker 12: Poked and prodded using his fingers through the incision.
Speaker 2: Tony Hoffman was so frustrated and worried about the situation
Speaker 2: she telephoned the acting coroner, Neil Lavering and explained the
Speaker 2: concerns over Patel's competence. She described the brammished death and
Speaker 2: the interference by Patel. Lavering replied, well, that confirms some
Speaker 2: of the things I've been thinking about what has been
Speaker 2: going on at the hospital. He said he would await
Speaker 2: the documentation. Hoffman also telephoned the Bunderberg police station and
Speaker 2: was put through to a senior officer. He asked if
Speaker 2: the hospital held morbidity and mortality meetings or had any
Speaker 2: other mechanisms that would identify negligence causing deaths, but neither
Speaker 2: the coroner's office nor the police followed up. Hoffman next
Speaker 2: prepared a sentinel event report. This was a major step.
Speaker 2: According to the protocol, a sentinel event is rare, serious
Speaker 2: and requires prompt and in depth investigation. Hoffman's accompanying memo
Speaker 2: to management described how Patel bullied staff, misused the intensive
Speaker 2: care unit, compromised care, and constantly threatened to quit because
Speaker 2: he did not want his patients transferred. Tony Hoffman wrote this.
Speaker 10: The director of the union, Dr Carter, is usually supportive
Speaker 10: and proactive about transferring patients, except when doctor Petel's patients
Speaker 10: are concerned. Dr Patel creates such an atmosphere of fear
Speaker 10: and intimidation in the unit that his behavior is rarely challenged.
Speaker 10: On several occasions, when doctor Petel's patients have been in
Speaker 10: the ICU, he has refused to transfer his patient to Brisbane,
Speaker 10: even when the patients have deteriorated and have been in
Speaker 10: ICU for much longer than twenty four to forty eight hours.
Speaker 10: He has done this when a bed has already been obtained.
Speaker 10: This has on several occasions placed the patient in jeopardy
Speaker 10: as they have further deteriorated.
Speaker 2: Hoffman repeated the concerns that she had expressed more than
Speaker 2: twelve months earlier to Darren Keating about the dangers inherent
Speaker 2: in the esophagectomy procedures that Patel had been determined to perform.
Speaker 2: She said Patel's interference in the care of des Brammage
Speaker 2: may have led to his death. She ended the two
Speaker 2: page document by saying Patel.
Speaker 10: Actually endangers the lives of the patients.
Speaker 2: The acting Director of Nursing, Patrick Martin, who perused the document,
Speaker 2: gave Tony Hoffman some feedback.
Speaker 1: Wow. Love, that's all pretty heavy. It's very good, though.
Speaker 6: My experience with Darren is to stick to facts and
Speaker 6: figures and not be a motive.
Speaker 13: He absolutely turns off a motive.
Speaker 6: Approaches quote, percentages and figures to him, and he responds
Speaker 6: much more favorably.
Speaker 2: Hoffman had lost confidence in her own line manager the
Speaker 2: new director of Nursing, Linda Mulligan. She was a stickler
Speaker 2: for the memo and formal appointments for meetings, but when
Speaker 2: it came to ward rounds, Mulligan was rarely seen by
Speaker 2: the nurses. She operated very differently to Glennis Goodman, who
Speaker 2: had retired.
Speaker 1: A few weeks earlier.
Speaker 2: When Hoffman went to Mulligan to voice concerns about Patel,
Speaker 2: she left the executive office feeling more powerless than ever.
Speaker 2: Mulligan had given her a book called Coping with Difficult
Speaker 2: People by doctor Robert Ranson to take home to read.
Speaker 2: She had suggested that Hoffman should consult a psychologist and
Speaker 2: undergo training in conflict resolution.
Speaker 1: Chapter twenty two, Justice for Elise.
Speaker 2: Late July two thousand and four, the files describing ten
Speaker 2: year old Elise Neville's final few hours moved me to
Speaker 2: tears in the public area of the District Court Registry
Speaker 2: in George Street, Brisbane, as Tony Hoffman and the other
Speaker 2: nurses at Bunderberg Hospital seethed and grieved over the death
Speaker 2: of Desbramitch. I became absorbed in the story of a
Speaker 2: little girl who had rolled the wrong way in her
Speaker 2: sleep and fallen out of a bunk bed during a
Speaker 2: holiday with her family on the Sunshine Coast. Leaning over
Speaker 2: a large folder laid out on a chipped counter, I
Speaker 2: read hundreds of pages of witness statements and medical reports
Speaker 2: that helped reconstruct seven January two thousand and two and
Speaker 2: the ensuing forty eight hours. Although some of the accounts differed,
Speaker 2: they documented the seriousness of Elisa's head injury when she
Speaker 2: was rushed to Caloundra Hospital shortly after three am, the
Speaker 2: deficiencies of the examination by doctor Andrew Donovan and Nurse
Speaker 2: Beverly Duncan's examination in the emergency department, the inevitable brain injury,
Speaker 2: and the agony of Elisa's parents, gered and the rain.
Speaker 2: There was something primal about Jered's pain on raw display,
Speaker 2: as graphically as if he had spilled his own blood
Speaker 2: throughout the folder.
Speaker 1: This is what he wrote.
Speaker 14: We will pursue this while there is still breath in
Speaker 14: our bodies and blood flowing in our hearts. The whole
Speaker 14: episode is an absolute scandal, and there is no way
Speaker 14: that we will ever let them get away with it.
Speaker 2: Jered believed he had failed in his duty as a
Speaker 2: father and as a doctor, to protect his daughter from palm,
Speaker 2: and he blamed himself, the fatigued doctor Donovan, the nurses,
Speaker 2: the system, and the hospital. Jered further wrote.
Speaker 14: The doctor came probably about fifteen minutes after we first
Speaker 14: arrived at the hospital. His name was Andrew, as we recall,
Speaker 14: we didn't catch his surname. He took a very brief history.
Speaker 14: I told him that I was medically trained, but that
Speaker 14: I had not done clinical work for many years. Soon
Speaker 14: began a discussion about the need for a CT computerized
Speaker 14: tomography scan. He said, you can't see tee everyone who
Speaker 14: hits their head. We return to a discussion about going
Speaker 14: to Nambole hospital. We ask how far it is and
Speaker 14: how long it will take to get there. He still
Speaker 14: hasn't really examined Lease, and he says something like lots
Speaker 14: of kids hit their head. Namble will probably send you
Speaker 14: home too. We say that Elise has vomited, and he says,
Speaker 14: lots of kids vomit at night. We say that Elise
Speaker 14: rarely vomits. He keeps reassuring, We keep sending signals of
Speaker 14: worry and concern. The discussions have gone on for some
Speaker 14: time and we are at an impasse. He then says
Speaker 14: something along the lines of look, I will do a
Speaker 14: neurological examination if that would make you feel better. He
Speaker 14: gets a tendon hammer to go with his torch. Elise
Speaker 14: has her eyes closed and won't cooperate with him. She
Speaker 14: is in pain and acting nothing like her normal self.
Speaker 14: We tell him that she is not normal like this.
Speaker 14: He then says coldly in front of a lisea as well,
Speaker 14: she's a ten year old girl. It's late, she has
Speaker 14: had a disturbed night, and she is pulling the wool
Speaker 14: over her parents' eyes. By this stage, we have a
Speaker 14: child with a head injury, a large contusion over her
Speaker 14: left temple, a history of vomiting, and developing uncoperation. He
Speaker 14: finishes with something like, I don't think there will be
Speaker 14: any problems in your case. You're a sensible father. Take
Speaker 14: her home and watch her. Even if she starts to
Speaker 14: have problems, there will be plenty of time to do
Speaker 14: what needs to be done. We didn't want to go home,
Speaker 14: but we had nowhere else to go, as he and
Speaker 14: the hospital had totally rejected us. I kept checking Lisa's pulse, eyes, breathing,
Speaker 14: and movement as she lay next to me on our bed.
Speaker 14: She was restless and kept moaning, crying, and complaining about
Speaker 14: her sore head. I kept trying to diagnose what might
Speaker 14: be going on, but it was all a blur and
Speaker 14: nothing made any sense to me. Convinced myself that Elise
Speaker 14: must just have a minor concussion at the very worst,
Speaker 14: and we would see how she was a bit later
Speaker 14: and probably get some more medical attention in the morning. Eventually,
Speaker 14: it was now some time after six am, Alise seemed
Speaker 14: to finally settle. Thinking that Elise was finally sleeping, I
Speaker 14: started a doze on and off as I lay next
Speaker 14: to her. I was never actually asleep, more just lying
Speaker 14: next to her with my eyes closed and trying to
Speaker 14: calm down. It had been a harrowing night. I suddenly
Speaker 14: jolted up from my dozing when I felt something was
Speaker 14: very wrong with Leise. So did Lorraine at the very
Speaker 14: same time. I looked at Elise and screamed, oh my god,
Speaker 14: Oh my god. It looked like she had a rash
Speaker 14: down the left side of her body. I rolled a
Speaker 14: lease on her back and saw it there too. Elisa's
Speaker 14: eyes looked like they were popping out. Her jowel looked
Speaker 14: like it was rigid. I thought Elise was dead. I
Speaker 14: yelled to Lorraine get an ambulance. I was absolutely distraught
Speaker 14: from that moment. Lorraine couldn't turn on her mobile phone,
Speaker 14: so she ran to the next door unit for help.
Speaker 14: I carried Lease from our room to the living room
Speaker 14: and then back to our bedroom. I didn't know what
Speaker 14: to do. At about seven thirty am, the ambulance took
Speaker 14: a Lease, Lorraine and me. The first face I saw
Speaker 14: was the same doctor from earlier in the night. He
Speaker 14: saw me and said what happened? He was visibly shocked
Speaker 14: and became very pale. I frantically said something like she's
Speaker 14: gone right off. She needs a neurosurgeon. At one stage
Speaker 14: she said was it to himself or to us? Something
Speaker 14: like I'm so sorry, It's all my fault. What have
Speaker 14: I done?
Speaker 15: Oh?
Speaker 1: Fuck?
Speaker 2: Anette Thompson, one of the nurses who helped with the resuscitation,
Speaker 2: saw Lorrain Neville lying on a bed in a waiting
Speaker 2: area for relatives.
Speaker 16: The nurse recalled she was in a fetal position and
Speaker 16: was cuddling a stuffed toy, which I assumed.
Speaker 17: To be Elise's.
Speaker 16: Her eyes were shut in her fis appearance suggested that
Speaker 16: she'd totally withdrawn into herself. Missus Nevill was making no sound,
Speaker 16: but responded to my questions in a quiet voice. She
Speaker 16: told me that Elise was a lovely girl and things
Speaker 16: like this shouldn't happen to someone like her. She approached
Speaker 16: Lisa's bed and spoke in whispers to her. Doctor Nevill
Speaker 16: was very upset and cried loudly as the helicopter departed,
Speaker 16: missus Neville began crying as well.
Speaker 2: From doctor Donovan's account of events, starting with Elisa's first
Speaker 2: presentation at three twenty five am, she had been lying
Speaker 2: on her side, facing away from him when he started
Speaker 2: a physical examination.
Speaker 7: I coaxed her two to three times to turn and
Speaker 7: face me so that I could look into her eyes.
Speaker 7: Alise then rolled over and opened her eyes freely. I
Speaker 7: examined Elsa's pupils and noted that they were equal and
Speaker 7: reactive to light. I noticed some swelling and bruising lateral
Speaker 7: to her left eye. I felt the area of swelling
Speaker 7: and did not palpate a skull fracture. Alise then said
Speaker 7: words to the effect, I want some sleep, and pulled
Speaker 7: her sheet up and rolled back onto her left hand side.
Speaker 7: I did not consider the swelling to the side of
Speaker 7: the head to be unusual, as in my experience it
Speaker 7: is not uncommon for children to suffer bruising to the
Speaker 7: head even after a short fall onto a soft surface.
Speaker 7: Mister Neville and I had a conversation regarding the indications
Speaker 7: for performing a CT scan and whether a lease required
Speaker 7: a CT scan. I had treated a few children with
Speaker 7: vomiting and diarrhea at Caloundra Hospital and had been told
Speaker 7: that the hospital did not admit children for observation. Therefore,
Speaker 7: I was of the impression that Elise could not be
Speaker 7: admitted for observations, and I explained this to mister Neville.
Speaker 7: I told mister Neville to keep an eye on Elise
Speaker 7: for the next day or so. The Nevills left the
Speaker 7: hospital amicably. Mister Neville carried a lease from hospital. After
Speaker 7: the Nevills left the hospital, there were no further patients,
Speaker 7: so I went to sleep. At about seven hundred hours,
Speaker 7: I rose and got dressed, and literally as I walked
Speaker 7: out of the room, mister Neville arrived in the emergency
Speaker 7: department in a very distressed state. He was followed by
Speaker 7: the ambulance officers with Elise on a trolley. I was
Speaker 7: shocked that Elise's condition had so radically deteriorated. Mister Neville
Speaker 7: was extremely distraught. While resuscitation procedures were taking place, he
Speaker 7: said words to the effect of it's my fault. It's
Speaker 7: a curse being a doctor, and I fell asleep on
Speaker 7: two or three occasions. I assured mister Neville that it
Speaker 7: was not his fault, but my fault. In saying this,
Speaker 7: I did not intend it as an admission of fault,
Speaker 7: but as a feeling of personal responsibility as the last
Speaker 7: doctor to have attended Elise.
Speaker 2: I had first read something about Elise in the Courier
Speaker 2: Mail in late two thousand and three. The description of
Speaker 2: her parents' relentless efforts to force Queensland Health, the Medical Board,
Speaker 2: the Nursing Council and the Health Rights Commission into rigorous
Speaker 2: self examination was a small part of a much larger story.
Speaker 2: I spoke about the case to doctor David mcloy, who
Speaker 2: had taken over from doctor Ingrid Tall as head of
Speaker 2: the Australian Medical Association in Queensland. Dr mcloy told me.
Speaker 17: It is one of those tragic issues that brings everything
Speaker 17: to account.
Speaker 1: The system.
Speaker 17: The junior doctor at the end of a very long
Speaker 17: shift in a small hospital, the lack of supervision and
Speaker 17: the protocols. There is significant concern that in any hearing
Speaker 17: of this case, the system itself will be under scrutiny,
Speaker 17: and if so, Queensland Health will have to take a
Speaker 17: good hard look at its systems.
Speaker 2: My earlier investigations into Queensland Health had made me deeply
Speaker 2: suspicious of its management and culture. In November two thousand
Speaker 2: and three, after my stories were published on the concerns
Speaker 2: over the standards of overt trained doctors in Queensland and
Speaker 2: the lack of checking of their credentials and skills, Jered
Speaker 2: Neville emailed me.
Speaker 14: I am not seeking anything from you, but I certainly
Speaker 14: encourage you and the Courier Mail to keep the heat
Speaker 14: up in regards to professional health standards. I have absolutely
Speaker 14: no doubt there are real issues in regard to the
Speaker 14: competence of some health professionals. These issues are not being
Speaker 14: given the attention required to protect the community. It's just
Speaker 14: part of the bigger picture about the effectiveness of the
Speaker 14: system of ensuring that health professionals, whether trained overseas or locally,
Speaker 14: are competent and not putting their patients' lives at risk.
Speaker 2: Now we were in July two thousand and four and
Speaker 2: the Medical Board of Queensland had decided that doctor Andrew Donovan,
Speaker 2: who had treated a least Neville at Caloundra Hospital, would
Speaker 2: be prosecuted for unprofessional conduct in the Health Practitioners Tribunal,
Speaker 2: a part of the District Court. Queensland Health's dangerous policies
Speaker 2: had forced Donovan to work a twenty four hour shift
Speaker 2: on the day Elease was brought into the hospital by
Speaker 2: her worried parents, Yet the same organization was now hanging
Speaker 2: him out to dry, having refused to fund his legal defense.
Speaker 2: The Director General, doctor Steve Buckland, was silent on the
Speaker 2: stupidity of the twenty four hour shifts and the hospital's
Speaker 2: policy not.
Speaker 1: To admit children.
Speaker 2: Nowhere in the file, a public document at the Court's
Speaker 2: registry was the confidential and damning Queensland Health Report by
Speaker 2: doctor William Rodgers about the need for several experienced doctors
Speaker 2: to staff the emergency department at Caloundra Hospital. By late
Speaker 2: July two thousand and four, there was enough material on
Speaker 2: the public record to write several balanced and detailed stories
Speaker 2: about the haphazard culture in Queensland. Health and its devastating
Speaker 2: effect on at least one family. An emergency helicopter had
Speaker 2: taken a lease from Calandra Hospital to the pediatric intensive
Speaker 2: care unit at the Royal Children's Hospital in Brisbane, but
Speaker 2: even the transfer was bungled. It took twice as long
Speaker 2: as a road trip. In alease Neville's chart at the
Speaker 2: Royal Children's, doctor David Coman noted unstable day irretrievable brain injury,
Speaker 2: with brain death the most likely outcome. Not responding to
Speaker 2: voice or head and neck stimuli. Jennifer Rich, a social
Speaker 2: worker who had been counseling Elisa's parents as well as
Speaker 2: her older sister Laura and younger brother Michael, wrote.
Speaker 10: This father is experiencing a lot of guilt associated with
Speaker 10: the accident given his profession.
Speaker 2: Jennifer Rich's last entry in the hospital's electronic diary reported
Speaker 2: the family's request.
Speaker 17: That foot and hand prints, as well as a lock
Speaker 17: of hair, be taken for themselves.
Speaker 2: One of the treating doctors would later break down over
Speaker 2: the waste.
Speaker 1: Of young life.
Speaker 2: A police officer wrote out a receipt for Elisa's property,
Speaker 2: a blue hat, white sox statue of Mary A.
Speaker 1: Winnie.
Speaker 2: The Pooh Teddy Bear, blue and white shorts, pink top,
Speaker 2: hair clips, hair bands, and a white ribbon.
Speaker 1: Jerry wrote this.
Speaker 14: Later that day, Lorraine and I decided to turn off
Speaker 14: for Lisa's life support. At Least died at five point
Speaker 14: five pm on the ninth of January two thousand and two.
Speaker 14: As she died, peace came to her tormented face, and
Speaker 14: her spirit and.
Speaker 1: Beauty reigned over us.
Speaker 4: All.
Speaker 14: She showed us she had gone to somewhere nice and safe,
Speaker 14: where people care for each other.
Speaker 1: Might be.
Speaker 14: I know it is certainly not in Caloundra Hospital, a
Speaker 14: dangerous place that should be closed.
Speaker 1: And the Lisa's mother, Lorraine added.
Speaker 9: She shone with happiness and a beauty of nature and
Speaker 9: soul that are irreplaceable and which will continue to be
Speaker 9: our inspiration and guiding light.
Speaker 2: There was a report by doctor Michael Redmond, a neurosurgeon,
Speaker 2: who wrote, it.
Speaker 13: Is considered unacceptable for a patient following head injury to
Speaker 13: talk and die. At least Neville is one who talked
Speaker 13: and died in a responsible medical system such as we enjoy,
Speaker 13: with such access to hospitals of ascending levels of sophistication,
Speaker 13: it is tragic and unacceptable that an event such as
Speaker 13: this should occur.
Speaker 2: And doctor Johannes Wenzel, a specialist in emergency medicine, wrote, I.
Speaker 15: See it as a system problem that our public hospitals
Speaker 15: put junior doctors into positions where they have to deal
Speaker 15: with presentations beyond their expertise, combined with the fact that
Speaker 15: working long shifts reduces the decision making ability to a
Speaker 15: similar level as a person with point zero five percent
Speaker 15: alcohol blood content.
Speaker 2: According to two independent medical experts who studied all the
Speaker 2: case notes and statements, doctor Donovan had made a tragic
Speaker 2: wrong call. He had done an incomplete examination of Elise,
Speaker 2: although he must have been fatigued after working nineteen hours
Speaker 2: of a twenty four hour shift. If he had thoroughly
Speaker 2: questioned and examined a lease or urged her parents to
Speaker 2: go to another hospital for a CT scan of her skull,
Speaker 2: its fracture and the hemorrhage would have been obvious.
Speaker 1: There still would have.
Speaker 2: Been time to relieve the pressure building from the accumulation
Speaker 2: of blood before her rain soft tissue was crushed. In
Speaker 2: his defense, doctor Andrew Donnoman wrote.
Speaker 7: I would sincerely hope that doctors are not rusted on
Speaker 7: for any longer than a twelve hour shift. Twenty four
Speaker 7: hour shifts without a break are excessive and dangerous, and
Speaker 7: no patient or doctor should ever be put through the
Speaker 7: devastation that both the Nevills and my family have had
Speaker 7: to endure.
Speaker 2: When I called Jared Neville to tell him that I
Speaker 2: planned to write several lengthy stories about the case, he
Speaker 2: agreed to a meeting. I went to the suburb of
Speaker 2: Tuwong and the rain served tea and biscuits as we
Speaker 2: talked about Elise in the family home, filled with her
Speaker 2: image and memory, but cloaked in quiet sadness.
Speaker 9: We live with the ongoing trauma. We ask ourselves what
Speaker 9: could we have done, What did we miss? How could
Speaker 9: we let this happen? It is so cruel for Jared.
Speaker 9: He had the very best of intentions. Fate had something
Speaker 9: else in mind. We do not want to be seen
Speaker 9: to be vindictive and nasty to certain individuals in this
Speaker 9: It's more about the bigger picture and how it can
Speaker 9: be improved. Elise was just as perfect a child as
Speaker 9: you could ever have. The last thing she would have
Speaker 9: remembered was putting her head on Daddy's shoulder as he
Speaker 9: carried her in from the car.
Speaker 1: To the unit.
Speaker 2: Jered's grief was still angry. He looked like a man
Speaker 2: who had lost much of his will to live.
Speaker 14: I know people look at me and say, how did
Speaker 14: this happen? How did you let this happen? Of course
Speaker 14: I have blamed myself. I'm a doctor and I'm a father.
Speaker 14: It's tragic. It's a cancer. It eats away at you.
Speaker 14: I don't trust health at all. I don't respect health
Speaker 14: and I work there. It's a terrible dilemma. Now I
Speaker 14: have a more important job to do, trying to bring
Speaker 14: the Queensland health system into the twenty first century. I
Speaker 14: want to see some honesty in the health system. If
Speaker 14: this can put pressure on the system to respond in
Speaker 14: a learning way, then it is worth it. Maybe I
Speaker 14: have been relentless, but I'm going to stay that way
Speaker 14: because the truth leads to findings and they will lead
Speaker 14: to recommendations that can improve things. We will get comfort
Speaker 14: knowing that something good will come out of this. I
Speaker 14: know for a fact that if we did nothing, nothing
Speaker 14: would change. Elise and I have made up, we have
Speaker 14: worked it out. She's forgiven me. I know this sounds nuts,
Speaker 14: but one day, when I sat next to her grave,
Speaker 14: I saw her, and she was deliriously happy, but I
Speaker 14: still want her back. It shouldn't have happened. She wasn't
Speaker 14: given a chance.
Speaker 2: The unfairness and emotion of it all made the stories
Speaker 2: difficult to write. I knew that doctor Donovan, a father
Speaker 2: of young children himself, was in agony and had been
Speaker 2: punishing himself over Elisa's death. I knew his sister, Paula,
Speaker 2: a colleague at the Courier Mail, was not in favor
Speaker 2: of me exposing her brother to public scrutiny. But as
Speaker 2: a fellow reporter, I hoped she understood it was unavoidable.
Speaker 2: I talked over the angles with my wife Ruth. We
Speaker 2: pledged never to let our children, who yearned to know
Speaker 2: the story of the little girl, sleep in bunk beds.
Speaker 2: My daughter, Sarah, aged three, came home from kindergarten with
Speaker 2: a drawing of Elise. She had been asking me to
Speaker 2: tell her bedtime stories about Elise for a week. Sarah
Speaker 2: told her teacher the story of the tragic accident. Before
Speaker 2: anything was published. I spoke to doctor Steve Buckland, the
Speaker 2: Director General of Queensland Health, in his office with his
Speaker 2: media manager, Lisa Schultz. Buckland did not appear concerned at
Speaker 2: the major systemic issues, the twenty four hour shifts, the
Speaker 2: rostering of inexperienced doctors to take charge of emergency departments.
Speaker 2: It occurred to me that it was easier for doctor
Speaker 2: Buckland and the regulatory system to punish Donovan than to
Speaker 2: look at glaring and fundamental flaws that would take courage
Speaker 2: and money to remedy. Before I went to see doctor Buckland,
Speaker 2: he had a meeting with Jared Neville. Jered wrote this
Speaker 2: in his diary that day.
Speaker 14: He clearly does not have a positive outlook on Headley
Speaker 14: Thomas or what his motives might be. Says he is
Speaker 14: a grub.
Speaker 2: After seeing the photographs of Elise at her parents' home,
Speaker 2: I asked Jered and Lorraine for permission to publish one.
Speaker 2: They considered the request overnight, and Jered called me the
Speaker 2: next day to agree.
Speaker 14: I want every health professional in Queensland to stare into her.
Speaker 14: Maybe it will cause them to search their conscience and
Speaker 14: appreciate what we are trying to do.
Speaker 2: When the main feature and several accompanying stories were published
Speaker 2: prominently on Saturday thirty one July, the reaction was immediate
Speaker 2: and overwhelming. Many doctors were furious at the punishment of Donovan.
Speaker 2: Staff and users of the health system were furious at
Speaker 2: its obvious shortcomings. A number of readers called me to
Speaker 2: say that they had wept for Elise and her parents.
Speaker 2: The Australian Medical Association demanded action by the Beatty government
Speaker 2: to stop unsafe practices in the health system. Tony Hoffman
Speaker 2: had never contacted a journalist before. She cried when she
Speaker 2: stared into the eyes of Elise Neville on the newspapers page,
Speaker 2: and then she sat down to write an email.
Speaker 10: Dear Headley, I read your article in this morning's Career
Speaker 10: Mail with dismay. I am one of the nurses who
Speaker 10: continues to work in the environment you describe. This week,
Speaker 10: I stayed three hours after my shift finished to try
Speaker 10: and ensure a patient was transferred to Brisbane from the
Speaker 10: provincial hospital where I work. One of the surgeons involved
Speaker 10: in the case insisted the patient did not need transferred,
Speaker 10: despite the fact our hospital does not have the facilities
Speaker 10: to care for such a patient. Finally, the retrieval team
Speaker 10: was on its way and I left. When I returned
Speaker 10: in the morning, I expected that the patient would have
Speaker 10: been transferred, only to find he had died two hours
Speaker 10: after the team arrived. The intimidating, bullying surgeon, of course,
Speaker 10: was not wrong. He had delayed a transfer for several hours,
Speaker 10: despite the pleas of the nursing staff. There is no
Speaker 10: one we can complain to the hospital hierarchy. Believe this
Speaker 10: surgeon is doing a great job because his making the
Speaker 10: hospital money and keeping the waiting this down. If we complain,
Speaker 10: we're in danger of losing our jobs. No one will
Speaker 10: notice in the patient's notes the delay. It's not obvious
Speaker 10: except to those of us who were there. The nursing
Speaker 10: staff was so distraught the next day we are told
Speaker 10: to follow the proper protocol to deal with such issues,
Speaker 10: only to find no.
Speaker 18: One supporting us.
Speaker 10: The poor family of the patient will believe all was
Speaker 10: done for this patient when we know this is not
Speaker 10: the case. Keep up the good work at examining what's
Speaker 10: going on in our hospital. How dare Queen's that Health
Speaker 10: make Dr Donovan the escapegoat for a system which does
Speaker 10: not work.
Speaker 1: There are so.
Speaker 10: Many good, kind and caring people out there trying to
Speaker 10: do the best they can, but it is not working.
Speaker 18: Tony Hoffman, Chapter twenty three, Suspicious Minds, Late July to
Speaker 18: October two thousand and four, Nurse Michelle Hunter was seeing
Speaker 18: too many surgical disasters with a common feature.
Speaker 1: There were more wound.
Speaker 2: Breakdowns, infections, and complications connected to the surgery of J. M.
Speaker 1: Patel than all the other doctors in the hospital.
Speaker 2: She asked died Jenkin, the manager of the surgical unit.
Speaker 5: About it is anyone looking at what's going on here?
Speaker 2: Nurse Hunter, back in Bunderberg after a stint in the
Speaker 2: vascular surgical ward of a large hospital in Bath in
Speaker 2: the United Kingdom, was stunned by some of Patel's decisions,
Speaker 2: such as when he ordered that a plaster be put
Speaker 2: on a man's amputated leg stump. After several days, she
Speaker 2: asked Patel to look at the wound. It had completely
Speaker 2: fallen apart. He casually told her to take out the
Speaker 2: stitches and remove the necrotic tissue, as there was little
Speaker 2: he could do. The man died a few weeks later.
Speaker 2: Patel's lack of hygiene appalled the nurse.
Speaker 16: She told him, I want you to go and wash
Speaker 16: your hands before you go to the next patient.
Speaker 2: But when Hunter was not around, Patel went back to
Speaker 2: his old habit of moving from bed to bed and
Speaker 2: touching wounds without once washing his hands. Hunter, who was
Speaker 2: harboring serious doubts about Patel's competence, wondered if the surgeon
Speaker 2: had been involved in any negligence cases in Oregon, where
Speaker 2: he often boasted he had extensive experience. After a Google
Speaker 2: search linked her to the website for the Oregon Board
Speaker 2: of Medical Examiners, she put his name in the search field.
Speaker 2: The information that appeared was amazing. Doctor j. I. Patel
Speaker 2: had been subjected to recent serious discipline reaction. He had
Speaker 2: been barred from performing a wide range of surgery because
Speaker 2: of his proven incompetence. Although shocked, Hunter decided that information
Speaker 2: so easily discovered had to be known to the Medical
Speaker 2: Board of Queensland and the hospital's managers if indeed it
Speaker 2: related to the same Jayant Patel. One evening, Karen Stumer,
Speaker 2: a nurse in the intensive care unit, received an unusual
Speaker 2: request from a theater wardsman. He had rushed out of
Speaker 2: surgery and was in a state of mild panic.
Speaker 13: Can we have some mouth swabs?
Speaker 1: It's urgent.
Speaker 2: Stumer wondered why they were needed in surgery. She went
Speaker 2: to the stockroom and removed a handful of the swabs,
Speaker 2: which were used in the ICU to clean patient's mouths.
Speaker 1: What's the problem.
Speaker 13: We need them because doctor Patel has flushed the bow backwards.
Speaker 13: We have to clean out the patient's mouth before he wakes.
Speaker 1: Up physically sick.
Speaker 2: Betel's bungled flushing technique meant the patient's fecal matter had
Speaker 2: gone the wrong way instead of being.
Speaker 1: Washed out at the lower end.
Speaker 2: By the end of July, amid serious disquiet among nurses
Speaker 2: and some of the doctors over dez Bramach's death, Patel
Speaker 2: had been the director of Surgery for sixteen months, yet
Speaker 2: he had steadfastly refused to seek fellowship of the College
Speaker 2: of Surgeons, even though it would have given him formal
Speaker 2: specialist status, a hefty rays, and more boasting rights. Patel
Speaker 2: kept making excuses. In truth, he must have known that
Speaker 2: fellowship would be granted only after a careful vetting and
Speaker 2: accreditation exercise. His United States bands would be discovered. His managers,
Speaker 2: doctor Darren Keating and Peter Leck, did not twig. They
Speaker 2: were delighted that Patel had made such a sky significant
Speaker 2: dent in the waiting lists, but as both Tony Hoffman
Speaker 2: and doctor Martin Carter had made known their worries about
Speaker 2: the Bramwich case. Doctor Keating decided to look into it.
Speaker 2: He asked Patel, Carter, doctor Jim Gaffield, and doctor if
Speaker 2: Deca Eunice to supply reports on the care of Brammage.
Speaker 2: Their accounts were in conflict. When Patel saw the Sentinel
Speaker 2: event report by Tony Hoffman, he denounced it as based
Speaker 2: on misinformation, misrepresentation and personal bias. The email Hoffman had
Speaker 2: sent to me after reading the thirty one July story
Speaker 2: about Elise Neville remained unopened until my return from a
Speaker 2: family holiday. The cabin we had booked into near adam Innabee,
Speaker 2: a forty five minute drive from the ski fields at
Speaker 2: Mount Selwyn in New South Wales's Cosiosco National Park, was
Speaker 2: but when we saw the bunk beds for the children,
Speaker 2: we again thought of Alice. We covered the top bunk
Speaker 2: with suitcases and organized the betting to ensure Sarah and
Speaker 2: Alexander would sleep together on the bottom bunk. On my
Speaker 2: return to work in mid August, I emailed Hoffman. I wrote,
Speaker 2: I'm very concerned by the situation you've described. How do
Speaker 2: you feel about me investigating it?
Speaker 1: In a way?
Speaker 2: Of course, that does not affect you, Tony replied.
Speaker 10: I would be very grateful on behalf of Queensland Health
Speaker 10: patients if you would investigate the situation that currently exists
Speaker 10: in Queensland Health, especially in the provincial areas, where we
Speaker 10: are very much at the mercy of third world doctors
Speaker 10: and management who do not support the grassroots and who
Speaker 10: consistently lie to cover up what is really going on.
Speaker 10: I have invested a lot of time, money and study
Speaker 10: in my career, but I am suddenly concerned about the
Speaker 10: state of affairs and just wish management would be accountable.
Speaker 2: Hoffman had deliberately not disclosed the hospital or town in
Speaker 2: which she worked. She wanted to continue pressing her concerns
Speaker 2: about Patel through official channels. In relation to a patient's death,
Speaker 2: which she described, she said.
Speaker 10: The surgeon continues to operate even though queens and Health
Speaker 10: are doing a preliminary investigation. The coroner is investigating. I
Speaker 10: really feel queens and Health is out of control with
Speaker 10: protecting incompetent doctors.
Speaker 2: Regardless, the lack of feedback from management to Hoffman gave
Speaker 2: her little confidence. At the urging of other nurses, she
Speaker 2: pleaded for advice from Vicky smy and Kim Barry of
Speaker 2: the Queensland Nurses Union. Hoffman had been going back over
Speaker 2: the records looking at deaths and complications in the ICU
Speaker 2: in the previous sixty months. She revealed how concerned she
Speaker 2: had become. Kim Barry told Tony, you can't collect that
Speaker 2: sort of information and not act on it. Antoine Gortray
Speaker 2: asked his friends and family to wish him well before
Speaker 2: going into the hospital in early September for a Whipple's procedure,
Speaker 2: an extremely complex operation to remove a tumor in the
Speaker 2: head of his pancreas. Although it was a procedure Petel
Speaker 2: had bungled in Portland, Oregon, with fatal consequences resulting in
Speaker 2: him being specifically restricted from attempting it again, he decided
Speaker 2: to use Gortray as his guinea pig in a hospital
Speaker 2: ill equipped for the post operative care that would be needed.
Speaker 2: Gortray was a seriously unwell man when he came out
Speaker 2: of theater. The extent of his cancer was such that
Speaker 2: the operation would almost certainly kill him. Before the disease
Speaker 2: took his life, Few, if any, surgeons would have operated
Speaker 2: on Gortray in his perilous condition but in his trademark
Speaker 2: cockshaw manner, Patel forged a head. Gortray died in late
Speaker 2: September after a stormy and prolonged stay in the intensive
Speaker 2: care unit. His death certificate stated clebsiella. Towards the end,
Speaker 2: a dark brown and sticky sputum that Gortray had been
Speaker 2: coughing up caused pneumonia and pockets of pass in.
Speaker 1: The lining of his lungs.
Speaker 2: The week after Gortray's death, Patel operated on In Vowels,
Speaker 2: a cabinet maker who had a polyop in the lining
Speaker 2: of his bowl. Instead of simply removing the fleshy growth,
Speaker 2: Patel opted for drastic action, removal of the entire bowel.
Speaker 2: Patel told him.
Speaker 11: Well, the sisters attached to the wall of your bower,
Speaker 11: and I cannot see what's in behind it. Jo Bowel
Speaker 11: does not like your body.
Speaker 1: We were work it out.
Speaker 11: I've done a lot of these operations before. People After
Speaker 11: they get welligan, they go skiing. You'll have no worries whatsoever.
Speaker 2: The operation was entirely unnecessary. The polyp was benign at
Speaker 2: the time Patel did the operation. There was nothing to
Speaker 2: suggest it might develop into cancer. At fifty seven Fowls
Speaker 2: was fitted with an illiostomy bag. There were serious post
Speaker 2: operative complications. His quality of life was never the same again.
Speaker 2: Glenn Tatham usually tried to inject humor into his deadly
Speaker 2: serious talks for Queensland Health.
Speaker 1: A few jokes sprinkled.
Speaker 2: Here and there made the subject ethical awareness less, foreboding
Speaker 2: for hospital staff. As a misconduct invests based in Brisbane,
Speaker 2: Tatham went to Bunderberg Hospital to remind the staff of
Speaker 2: their obligations under the Code of Conduct. Some people think
Speaker 2: that people who complain are dobbers.
Speaker 18: Do you agree?
Speaker 2: Tony Hoffman and the other nurses were increasingly alarmed as
Speaker 2: they watched one part of Tatham's PowerPoint presentation headed breach
Speaker 2: of confidentiality the small Town Scandal. Another part related to
Speaker 2: whistleblowing about serious threats to safety. Tatham and the explanatory
Speaker 2: material warned that a whistleblower who disclosed information to a
Speaker 2: union representative, the media or a member of parliament could
Speaker 2: be sacked and even imprisoned for committing a criminal offense.
Speaker 2: Dahela Alma said to Hoffman.
Speaker 12: I'm so glad you didn't do what you were going
Speaker 12: to do.
Speaker 2: The nurses were alarmed at the timing of the presentation
Speaker 2: and the con Quince's for staff who spoke outside the system,
Speaker 2: even though the system was not properly responding to complaints
Speaker 2: made internally. Until Tatham's sobering warning, Tony Hoffman had been
Speaker 2: ready to go to Brisbane with a Union official to
Speaker 2: bring jay N Pateel to the Health Rights Commission's notice.
Speaker 2: But now she was scared. She wondered if the timing
Speaker 2: of the talk was more than a coincidence, and whether
Speaker 2: she might already be in trouble for confiding information to
Speaker 2: me and the union. Sick to Death is written and
Speaker 2: presented by me Hedley Thomas, the Australian's National Chief correspondent.
Speaker 2: Claire Harvey is The Australian's editorial director. Audio editing, production
Speaker 2: and music have been done by Jasperlik with assistance from
Speaker 2: Leah Sammaglu and Neil Sutherland. Our producer is Christen Amias.
Speaker 2: Production management by Stephanie Coombs. Artwork by Sean Callanan. Thanks
Speaker 2: to Ryan Osland, Matthew Condon, Karina Berger, Ellie Dudley, David Murray,
Speaker 2: Dominique McDermott, Zach Sculander and all our family friends and
Speaker 2: colleagues who helped in this series and contributed voice acting
Speaker 2: and special thanks to Tony Hoffman and Rob Messenger. Subscribers
Speaker 2: to The Australian Here new episodes of Sick to Death
Speaker 2: first at Sick to deathpodcast dot com and on Apple Podcasts.
Speaker 2: You can get exclusive access to photographs, videos, timelines and
Speaker 2: more at the website