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Gayed-Report.Pdf Review of documentary material in relation to the appointment of Dr Gayed, management of complaints about Dr Gayed and compliance with conditions imposed on Dr Gayed by local health districts Gail B Furness SC 21 January 2019 Table of contents Executive summary .............................................................................................................. 7 Chapter 1: Introduction ...................................................................................................... 19 1. Inquiry established under the s 122 of the Health Services Act 1997 (NSW)..... 19 1.1 Terms of reference .................................................................................................... 19 1.2 Dr Jenkins’ appointment........................................................................................... 20 1.3 Medical Council inquiry ............................................................................................ 20 1.4 Extension ................................................................................................................... 21 1.5 Assistance provided by NSW Health ........................................................................ 21 2. Contacts to the local health districts ...................................................................... 22 3. Local health districts ................................................................................................ 23 4. The Medical Council ................................................................................................. 24 5. Co-regulatory structure (1994–2018) ..................................................................... 24 6. Policies ....................................................................................................................... 26 7. Clinical privileges ...................................................................................................... 26 8. Reporting to the Medical Board / Medical Council .............................................. 27 9. Short-form chronology ............................................................................................ 27 10. Dr Gayed’s professional history .............................................................................. 27 Annexure 1: Short-form chronology ................................................................................ 28 Annexure 2: Dr Gayed—professional history .................................................................. 32 Chapter 2: Policy requirements .......................................................................................... 42 1. Department of Health / Ministry of Health policies ............................................. 42 2. Policies governing the appointment of visiting medical practitioners and delineation of clinical privileges ............................................................................. 42 2.1 Compliance with registration conditions ................................................................ 47 3. Policies governing the management of incidents or complaints about a medical practitioner ............................................................................................................... 49 3.1 Between 1993 and 2001 ........................................................................................... 49 3.2 Between 2002 and 2006 ........................................................................................... 50 3.3 From 2006 to date .................................................................................................... 54 3.4 Root cause analyses .................................................................................................. 59 3.5 Performance reviews ................................................................................................ 60 3.6 Service Check Register .............................................................................................. 61 3.7 Other policies about incidents ................................................................................. 62 2 Chapter 3: Grafton Base Hospital ....................................................................................... 63 1. Appointment ............................................................................................................. 63 1.1 Compliance with appointment policies ................................................................... 65 2. Complaints, adverse events and performance issues .......................................... 66 3. Conclusion ................................................................................................................. 66 Chapter 4: Cooma Hospital ................................................................................................. 68 1. Background ............................................................................................................... 68 2. Appointment ............................................................................................................. 68 2.1 Compliance with appointment policies ................................................................... 69 3. Complaints, adverse events and performance issues .......................................... 69 3.1 Incident reports ......................................................................................................... 69 3.2 Complaint .................................................................................................................. 72 3.3 Performance issues raised by staff .......................................................................... 73 4. Response of the Southern Area Health Service .................................................... 74 4.1 Suspension and withdrawal of suspension ............................................................. 74 4.2 Dr Gayed’s response to the Southern Area Health Service ................................... 74 4.3 Complaint to the HCCC ............................................................................................. 75 5. Monitoring and management of Dr Gayed ........................................................... 75 5.1 Should Dr Gayed’s clinical privileges have been restricted?.................................. 75 5.2 Monitoring compliance with conditions of appointment ...................................... 77 5.3 Consistency with any registration or other conditions or order ........................... 77 5.4 Compliance with reporting policies ......................................................................... 77 6. Conclusion ................................................................................................................. 77 Chapter 5: Professional Standards Committee decision ..................................................... 79 Chapter 6: Kempsey District Hospital ................................................................................. 82 1. Background ............................................................................................................... 82 2. Appointment ............................................................................................................. 82 3. Compliance with registration or other conditions ................................................ 84 4. Complaints, adverse events and performance issues .......................................... 85 5. Conclusion ................................................................................................................. 85 Chapter 7: Northern Sydney Area Health Service ............................................................... 82 1. Background ............................................................................................................... 87 2. Appointment of Dr Gayed to Mona Vale Hospital ................................................ 87 2.1 Observations on appointment ................................................................................. 91 3. Information sharing by the Medical Board............................................................ 94 3 4. Management of cluster of incidents in 2003 ......................................................... 96 4.1 Incidents raised by staff in June 2003 ..................................................................... 96 4.2 Further incidents raised by staff .............................................................................. 99 4.3 Response of Mona Vale Hospital to incidents in 2003: suspension and reinstatement .......................................................................................................... 100 4.4 Compliance with policy and adequacy of response by Credentials Committee / Medical Appointments and Credentials Advisory Committee in 2003 ............... 112 5. Monitoring of Dr Gayed following reinstatement .............................................. 113 6. Major clinical incident notified by nursing staff in 2004 .................................... 114 6.1 This inquiry’s review of this patient’s case............................................................ 115 6.2 Adequacy of response to this patient’s case: compliance with policy and reporting to the Medical Board ............................................................................. 116 6.3 Performance assessment by the Medical Board in September 2004 ................. 117 7. Staff raise further incidents in November 2005 .................................................. 119 7.1 Inquiry’s review of the
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