When gynaecologist Graham Reeves was found guilty of mutilating a woman’s genitals, sexually assaulting patients and failing to get consent before performing surgeries, health authorities in New South Wales vowed to reform the complaints system to prevent similar atrocities from ever happening again.
Reeves, dubbed by his victims the “Butcher of Bega” after the rural NSW town in which he worked, was not charged until 2008, by which time he had harmed dozens of women over almost two decades. In June 2008, the medical practice amendment bill was passed making it mandatory for doctors to report serious misconduct on the part of their colleagues.
But despite regulatory reform another obstetrician and gynaecologist, Emil Shawky Gayed, has been revealed by Guardian Australia to have performed needless surgeries on the reproductive organs of women over almost two decades. Doctors and nurses who worked with him knew he was a problem.
Four public hospitals in NSW are now the subject of a major independent inquiry and Gayed’s victims are questioning how it took more than two decades for regulators to stop him.
Marie Bismark is a doctor and a health lawyer who had spent many years researching clinical governance, regulation and patient complaints. She said catastrophes such as the Gayed scandal rarely occurred without red flags being raised along the way.
“But these are often missed due to information silos between regulators, employers, insurers, colleges and complaints commissions, which means no one has the full picture,” she told Guardian Australia.
There were also “very real barriers to patients raising concerns”, she said, including not wanting to disrupt treatment relationships, not knowing where to go, not being supported through the process and not being treated as a valued voice.
“There are also still barriers to practitioners raising concerns, including organisations turning a blind eye if the problem doctor is a high earner or in a hard-to-fill role, repercussions for whistleblowers, and concern about future career implications.”
Both Reeves and Gayed built their careers working in small regional and rural Australian towns where it can be hard to attract specialist doctors. While many compassionate and highly qualified doctors are attracted to such areas, it can also be where doctors who have failed to get positions in leading tertiary hospitals in capital cities end up.
Gayed usually worked in these towns as a “visiting medical officer”– a doctor who often has his or her own private practice and works as a contractor in public hospitals. It meant that consultations and errors that occurred behind closed doors in his private clinic were not detected or reported. But it is also clear that many medical errors were also occurring while he performed surgery in public hospitals, and at least some of those staff around him witnessed his professional incompetence.
Bismark’s research found that following an adverse event only a small proportion of patients will bring a legal claim or make a complaint. There are also significant differences between those who take legal action and those who do not, she said. The odds of complaining are significantly lower for patients who are elderly, of minority ethnicity, or living in low socioeconomic areas.
“Under current approaches, medico-legal agencies are blinkered in their ability to see how a complaint fits in with a particular practitioner’s history, wider feedback from other patients and peers; and information held by other agencies,” Bismark said. “International research suggests that under-reporting of adverse events is rife.”
The number of prior complaints doctors had was a strong predictor of subsequent adverse events, she said. But important patterns of negligence are overlooked because agencies lack the time, resources and analytical skills to make sense of population-level data.
“The claims and complaints we reviewed are a rich and nuanced source of data on risks to patient safety and sources of patient dissatisfaction,” Bismark said. “But once an individual file has been closed, it is usually archived without further analyses of how it contributes to broader patterns of concern.”
Bismark and her colleagues conducted a review of all notifications about health professionals lodged with the Australian Health Practitioner Regulation Agency (Ahpra) over 24 months, and followed the outcome of those complaints. There were 8,307 notifications, with complaints highest among doctors and dentists and lowest among nurses and midwives.
One in 10 notifications resulted in restrictive action against the practitioner such as banning them from performing certain procedures; fewer than one in 300 notifications resulted in suspension or cancellation of registration, the research published in 2016 found.
“The odds of action against a practitioner were higher when the report was made by another health practitioner or employer rather than a patient or relative,” the study found.
Bismark said there was much resistance from the medical profession to any suggestion that more information about previous concerns be made available to the public. Once restrictions placed on a doctor expire, those restrictions are removed from the Ahpra public register so patients are unaware of previous disciplinary action.
“It always seems odd to me that in the process of giving informed consent doctors disclose some pretty rare risks, but patients can’t access information about the doctor’s complaints history or experience that may well have a much more significant impact on their decision regarding a particular procedure,” Bismark said.
A spokesman for the Health Care Complaints Commission (HCCC), which investigates doctors in NSW, said the complaints system had been improved over the past decade. The commission must consider previous complaints associated with a practitioner, and any tribunal decisions are now made available publicly.
The HCCC is conducting its own second investigation into Gayed, separate to the independent NSW inquiry, and the spokesman said if that investigation identified other practitioners with knowledge about Gayed, the commission had powers to compel them to give evidence.
A professor of midwifery at the Western Sydney University, Hannah Dahlen, agreed there was now more opportunity to report doctors to Ahpra and the HCCC, but she said prior to 2010 this was much less common.
“There are internal critical incidence forms that get put in and if these mount up, it should trigger a review,” she said.
But the Manning Rural Referral hospital in the NSW town of Taree where Gayed spent seven year working as a visiting medical officer said it first became aware of a complaint against Gayed in 2015. He resigned in 2016, once an investigation was already under way. By the time he was banned in June from practising for three years, he had already handed in is license and closed his private practices.
Bill Madden is a lawyer with the firm Carroll and O’Dea which is representing some of Gayed’s alleged victims. What remains unknown at this stage is whether there have been civil claims against Gayed which were settled out of court, he said.
“There are no reported decisions,” he told Guardian Australia. “Medical defence organisations traditionally resist the proposal that they should notify such claims and settlements to Ahpra. However my personal view is that this requires further examination. Otherwise there is a gap in the collection of data which may well improve patient safety.”
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