Final Report

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FINAL REPORT - download full report here [ 2.23Mb]

Report Breakdown - download each Chapter

CHAPTER ONE - REPORT SUMMARY [ 71Kb]

The origin of the Inquiry
Bundaberg Base Hospital : Chapter Three
Conclusion with respect to Bundaberg Base Hospital
Hervey Bay Hospital : Chapter Four
Townsville Hospital : Chapter Five Part A
Charters Towers Hospital : Chapter Five Part B
Rockhampton Hospital : Chapter Five Part C
Cardiac Care at Prince Charles Hospital : Chapter Five Part C
Common problems, common causes : Chapter Six
Amendment to the Coroner's Act : Chapter Seven
Conclusion : Chapter Eight

CHAPTER TWO - BASE HOSPITALS, RECRUITING DOCTORS, AND AREA OF NEED REGISTRATION [ 102Kb]

Administrative structure of Base Hospitals
The role of the Base Hospital
Recruitment of doctors
Part recruitment of doctors
Staff shortages
Special purpose registration for an area of need
Defects in deciding that there is an area of need
Defects in area of need registration of the Medical Board

CHAPTER THREE - THE BUNDABERG BASE HOSPITAL [ 626Kb]

The History of the hospital
1994-1999: Poor budget and politicisation erode the quality of service
1999-2002: An unsafe system
Dr Jayant Patel
Defects revealed in the process of appointment
Dr Patel’s employment at the Bundaberg Base Hospital
The demise of Dr Patel
The competence of Dr Patel
Adverse findings and recommendations
Final Remarks

CHAPTER FOUR - THE HERVEY BAY HOSPITAL [ 273Kb]

A period of rapid growth
Orthopaedic staff
Administrators
Appointment of Senior Medical Officers
Credentialing and privileging
Supervision
Inaction by administration
Investigation
Clinical outcomes
The North Giblin report and aftermath
Findings and recommendations

CHAPTER FIVE - TOWNSVILLE, CHARTERS TOWERS, ROCKHAMPTON, AND THE PRINCE CHARLES [ 294Kb]

Part A - The Townsville Hospital [ 147Kb]

Part B: Charters Towers [ 64Kb]

Part C - The Rockhampton Hospital [ 63Kb]

Part D – The Prince Charles Hospital [ 81Kb]

CHAPTER SIX - COMMON CAUSES AND SUGGESTED REMEDIES [ 666Kb]

Part A – Introduction [ 18Kb]

Part B – A grossly inadequate budget and an inequitable method of allocation [ 95Kb]

Part C – A defective system of Area of Need Registration and its consequences; remedies [ 92Kb]

Part D – The absence of any adequate credentialing and privileging and its consequences; the remedy [ 43Kb]

Part E – Inadequate monitoring of performance and investigating complaints: inadequate protection for complainants [ 313Kb]

Part F - A culture of concealment and its consequences [ 179Kb]

CHAPTER SEVEN - AMENDMENTS TO THE CORONER'S ACT 2003 [ 71Kb]

Medical non-reporting of deaths to the Coroner
Proposals for change

CHAPTER EIGHT - CONCLUSIONS [ 13Kb]