Rogues and bureaucracies

James Dunbar, Prasuna Reddy and Stephen May, Deadly Healthcare (Australian Academic Press, 2011)

A book review published in The Whistle (Newsletter of Whistleblowers Australia), No. 68, October 2011, pp. 9-10

Reviewer: Brian Martin

In Bundaberg Base Hospital, in a regional area of Queensland, there was difficulty in recruiting good doctors. Decisions on staffing were made through Queensland Health's hierarchical system based in Brisbane. In 2003, Jayant Patel became director of surgery. Totally self-confident, he was ready to put in long hours, and especially eager to undertake surgery. Patel endeared himself to administrators: his many operations brought money to the hospital, helping to balance the budget.

[District Manager Peter] Leck, ever the responsible business manager, would later caution against moving too quickly on any complaints about Patel lest the hospital lose the financial benefits he brought it. (p. 26)

Toni Hoffman, nurse unit manager of the intensive care unit, saw the results of Patel's surgeries and was disturbed by his rude manner and apparently outdated knowledge. She reported her concerns, but nothing was done. She persisted, with the same response. "She again followed up the meeting with a written report. Again she heard nothing." (p. 27) Patel had too many friends in the right places. Hoffman continued to document problems and make reports, watching too many botched operations to remain complacent. She was a model whistleblower who, unlike most, had the satisfaction of complete vindication.

As is so common, her efforts took a long time to have any impact. Complaining to officials up the system didn't work. What broke the case open was publicity. Hoffman contacted Rob Messenger, her local member of state parliament, who raised concerns under the protection of parliamentary privilege. Journalists then pursued the story over many years.

Even after the story broke, Queensland Health officials tried to contain it.

Leck was communicating with a zonal manager about the release of Hoffman's letter to the public and told him that the minister had told everyone that leaking confidential information including patient information was unacceptable and that whilst he supported freedom of speech in terms of raising matters with MPs, he would not tolerate the leaking of such information. (87)

However, these regard actions were insufficient to contain the emerging scandal. It turned out that two US health systems had put restrictions on Patel performing certain surgical procedures. He lied on his application to Queensland Health and, due to lack of scrutiny, the black marks on his track record slid through the vetting system. After being exposed, Patel went back to the US. It took years for his extradition, trial and appeals. He is now in prison.

The three authors of Deadly Healthcare provide a vivid picture using several perspectives. They delve into Patel's training in India and his appointments in US states, showing how a certain type of grandiose personality can win powerful allies despite poor performance. They examine Queensland Health's dysfunctional management systems. They look closely at how Patel was able to get into a position for which he was not qualified and where, against regulations, he had no supervisor, setting the scene for disastrous consequences for patients. They look at research and practice on building robust medical systems and at what can be done in Queensland and elsewhere to prevent abuses.

Deadly Healthcare tells the story of Patel and Queensland Health in an accessible, informative fashion. The media most common portrayed Patel as a rogue doctor. That is accurate on its own, but is only a partial picture. Patel wreaked damage because he operated in a bureaucratic system in which high-level decision-making driven by financial considerations was largely divorced from on-the-ground health needs. The Queensland state government didn't provide enough funding for the health sector, and decisions about operations were often made for the wrong reasons.

The Patel saga can be interpreted as a symptom of a sick medical system. Toni Hoffman made a difference by blowing the whistle on Patel, though it was a long struggle. The bigger problem is how to challenge such a system as a whole, to bring about beneficial change so that fewer cases like Patel ever arise. This suggests that whistleblowing needs to be supplemented by organisational activism. However, this will never be easy when even well-documented damage from a rogue surgeon is not enough to trigger change internally and publicity is the only thing that will make anyone take notice. Publicity was abhorred by Queensland Health.

Leck testified himself that they were required to make decisions according to a risk management matrix which rated significant statewide adverse publicity at the same level as loss of life. Loss of reputation of Queensland Health was equated with the loss of a patient's life. (87)

Based on examination of a number of rogue-doctor cases, the authors sum up some of the lessons and dilemmas.

An outstanding feature of the case histories of most rogue doctors is that early concerns were not investigated to the satisfaction of the whistleblowers. Consequently, whistleblowers are forced to go outside the system, using the media, public protest or political lobbying to have their concerns properly investigated. Patel's case is clear example of how such actions, while well-intended and indeed necessary, can erode confidence in an entire hospital, placing immense stress on staff, patients and families. This is not to blame the whistleblowers but to make the point that open, honest and timely investigation undertaken within an organisation avoids the potentially damaging aftermath - an aftermath which, paradoxically, can make people fearful of disclosing mistakes in the future. Unfortunately, many modern health organisations are renowned for their gap between rhetoric and reality. Some may even have a long-standing culture of concealment, blame and scapegoating. (110)

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