Heart sur­geon al­lowed to op­er­ate af­ter pa­tients die

The Weekend Australian - - FRONT PAGE - NATASHA ROBIN­SON

One of the na­tion’s most pres­ti­gious heart surgery units has been rocked by al­le­ga­tions that hos­pi­tal ad­min­is­tra­tors en­dan­gered pa­tient safety by al­low­ing a doc­tor who had failed to meet sur­gi­cal stan­dards to con­tinue to op­er­ate on pa­tients un­su­per­vised.

The car­dio­tho­racic surgery de­part­ment of Royal Prince Al­fred Hos­pi­tal in Syd­ney has been the sub­ject of mul­ti­ple probes dur­ing the past three years, with al­le­ga­tions of eight pre­ventable pa­tient deaths dur­ing or fol­low­ing heart surgery.

The sur­geon at the cen­tre of the in­ves­ti­ga­tions was al­lowed to re­turn to surgery de­spite ini­tial in­ves­ti­ga­tions — over­turned by a later re­view — find­ing that his prac­tice did not meet ex­pected stan­dards.

That prompted the res­ig­na­tion of two con­cerned sur­geons who have es­ca­lated their com­plaints to the NSW Med­i­cal Coun­cil and the Health Minister.

The sur­geons have claimed to the NSW gov­ern­ment that their for­mer col­league, car­dio­tho­racic sur­geon Michael Byrom, is “not fit to op­er­ate” and re­ported con­cerns about the Syd­ney Lo­cal Health Dis­trict’s al­leged “knowl­edge and con­ceal­ment of the risks to pa­tients and the fail­ure of proper pro­cesses”.

The health dis­trict says it has ex­haus­tively re­viewed the mat­ters, and is re­ly­ing on the re­sults of a Health Care Com­plaints

Com­mis­sion in­ves­ti­ga­tion that found there were no grounds to re­strict Dr Byrom’s prac­tice.

“The Health Care Com­plaints Com­mis­sion, as the rel­e­vant ex­ter­nal in­ves­tiga­tive au­thor­ity, has ex­am­ined these is­sues and found the clin­i­cian is fit for prac­tice and that there are no grounds for dis­ci­plinary ac­tion or sus­pen­sion,” a spokesman said. “The dis­trict ac­cepts those find­ings.”

The con­cerned sur­geons have doc­u­mented the deaths of eight of Dr Byrom’s pa­tients and mul­ti­ple al­legedly ad­verse sur­gi­cal out­comes over a three-year pe­riod, dur­ing which Dr Byrom re­peat­edly sur­ren­dered his ad­mit­ting rights but was sub­se­quently al­lowed to con­tinue to op­er­ate.

A sur­geon fa­mil­iar with the events said: “I have never en­coun­tered cir­cum­stances pre­vi­ously where a sur­geon is in­ter­nally sus­pended or vol­un­tar­ily stood down in a unit on mul­ti­ple oc­ca­sions and yet con­tin­ues to op­er­ate.”

The Week­end Aus­tralian is not sug­gest­ing Dr Byrom’s level of care is sub­stan­dard, nor that he con­trib­uted to the deaths, only that there are rea­son­able grounds for in­ves­ti­gat­ing his level of care, and the hos­pi­tal’s han­dling of the

The In­ves­ti­ga­tion Team finds that Dr Byrom does not meet the stan­dard rea­son­ably ex­pected of a car­dio­tho­racic sur­geon of an equiv­a­lent level of train­ing or ex­pe­ri­ence.

Ex­tract from the Royal Prince Al­fred Hos­pi­tal in­ves­ti­ga­tion re­port

sit­u­a­tion. Dr Byrom de­clined to re­spond to de­tailed ques­tions from The Week­end Aus­tralian. “As Syd­ney Lo­cal Health Dis­trict has pro­vided a re­sponse to the al­le­ga­tions, I will not be pro­vid­ing fur­ther com­ment,” he said.

In June, three sur­geons lodged a manda­tory re­port with the NSW Med­i­cal Coun­cil, de­tail­ing “se­ri­ous con­cerns we have over Dr Byrom’s per­for­mance pro­vid­ing an on­go­ing threat to pa­tient safety”. The sur­geons fear a back­lash from within the med­i­cal fra­ter­nity if their iden­ti­ties are made pub­lic and The Week­end Aus­tralian has agreed not to name them.

The sur­geons al­leged in the re­port that Syd­ney Lo­cal Health Dis­trict chief ex­ec­u­tive Teresa An­der­son had failed to pro­tect pa­tient safety.

Dr Byrom was al­lowed to re­turn to sur­gi­cal prac­tice shortly af­ter an in­ves­ti­ga­tion re­port found, for the sec­ond time, that he “did not meet the stan­dard rea­son­ably ex­pected of a car­dio­tho­racic sur­geon of an equiv­a­lent level of train­ing or ex­pe­ri­ence”.

“We have se­ri­ous con­cerns over the ac­tions of the CEO, hav­ing sup­pressed and mis­rep­re­sented crit­i­cal se­nior med­i­cal ad­vice and rec­om­men­da­tions, ex­ac­er­bat­ing that threat (to pa­tient safety) whilst en­abling it to con­tinue,” the manda­tory re­port said.

The NSW Med­i­cal Coun­cil’s per­for­mance di­vi­sion is mon­i­tor­ing Dr Byrom’s prac­tice. In cor­re­spon­dence seen by The Week­end Aus­tralian, the coun­cil said it had “de­cided to work with Dr Byrom to pro­tect the health and safety of the pub­lic”.

In­ves­ti­ga­tions into Dr Byrom’s prac­tice have de­liv­ered con­trast­ing find­ings over the past three years. Two re­views in 2016 and 2018 by in­de­pen­dent se­nior in­ter­state sur­geons Ju­lian Smith and Michael Gard­ner both con­cluded that Dr Byrom “did not meet the stan­dard rea­son­ably ex­pected of a car­dio­tho­racic sur­geon of an equiv­a­lent level of train­ing or ex­pe­ri­ence”.

The in­ves­ti­gat­ing sur­geons heard an ex­plo­sive al­le­ga­tion from one sur­geon within the car­dio­tho­racic unit that Dr An­der­son had “ex­pressly told the sur­geons in the unit not to put in In­ci­dent

In­for­ma­tion Man­age­ment Sys­tem re­ports if they had clin­i­cal con­cerns”. IIMS re­ports are the for­mal sys­tem of in­ci­dent no­ti­fi­ca­tion within hospi­tals. Dr An­der­son de­clined to re­spond to the al­le­ga­tion.

The pa­tient deaths

The first Smith-Gard­ner in­ves­ti­ga­tion fol­lowed the deaths of four pa­tients within two months.

The re­view found mul­ti­ple is­sues with Dr Byrom’s per­for­mance, in­clud­ing that he failed to seek help when com­pli­ca­tions oc­curred, that he ex­pe­ri­enced tech­ni­cal is­sues and dif­fi­cul­ties in de­ci­sion-making dur­ing op­er­a­tions, and that he had a lack of in­sight into his short­com­ings.

Fol­low­ing the first re­view, Dr Byrom un­der­took a pro­gram of re­me­di­a­tion, dur­ing which he op­er­ated un­der su­per­vi­sion and re­ceived ex­tra train­ing. He re­turned to un­su­per­vised clin­i­cal prac­tice in Oc­to­ber 2017 but a se­ries of ad­verse events oc­curred, in­clud­ing an in­ci­dent that shocked se­nior clin­i­cians at RPA.

On Novem­ber 22, 2017, a pa­tient who had un­der­gone rou­tine tho­racic surgery at Con­cord Hos­pi­tal in Syd­ney’s in­ner west sus­tained heavy bleed­ing dur­ing surgery. The pa­tient was given large vol­umes of blood prod­uct post-op­er­a­tively but con­tin­ued to bleed in the ICU for a fur­ther 24 hours.

The fol­low­ing day, Dr Byrom handed the crit­i­cally ill pa­tient’s care over to another doc­tor and caught a plane over­seas. The pa­tient had to be trans­ferred by he­li­copter to RPA, where another sur­geon op­er­ated and stemmed the bleed­ing. By the time he sta­b­lised, the pa­tient had lost 14 litres of blood.

The in­ci­dent was one of sev­eral ad­verse out­comes that prompted a sec­ond in­ves­ti­ga­tion of Dr Byrom’s prac­tice. The sec­ond re­view by Pro­fes­sor Smith and Dr Gard­ner again found, in Au­gust 2018, that Dr Byrom did not meet the stan­dard rea­son­ably ex­pected of a car­dio­tho­racic sur­geon of an equiv­a­lent level of train­ing or ex­pe­ri­ence. The re­view­ing sur­geons said fur­ther re­me­di­a­tion of the sur­geon’s per­for­mance was not rec­om­mended.

In the wake of the find­ings, RPA head of car­dio­tho­racic sur

I am sure you recog­nise se­ri­ous con­cerns we have over Dr Byrom’s per­for­mance pro­vid­ing an on­go­ing threat to pa­tient safety. We have sim­i­lar se­ri­ous con­cerns over the ac­tions of the CEO, hav­ing sup­pressed and mis­rep­re­sented crit­i­cal se­nior med­i­cal ad­vice and rec­om­men­da­tions, ex­ac­er­bat­ing that threat whilst en­abling it to con­tinue.

Ex­tract of a manda­tory re­port to the NSW Med­i­cal Coun­cil

gery Paul Ban­non an­nounced Dr Byrom’s sus­pen­sion from surgery.

Weeks later, Dr Byrom was back op­er­at­ing. Two weeks af­ter that, another pa­tient died.

“It’s seems in­con­ceiv­able how a de­part­ment head could re­port­edly an­nounce that a sur­geon is in­def­i­nitely sus­pended over in­ves­ti­gated pa­tient deaths and for the same sur­geon to be back op­er­at­ing in the de­part­ment a mere two weeks later,” one sur­geon said.

Sound­ing the alarm

NSW Health Minister Brad Hazzard was no­ti­fied last year of con­cerns that Dr Byrom should not be op­er­at­ing on pa­tients.

The manda­tory re­port the three sur­geons lodged with the Med­i­cal Coun­cil in June de­tailed “se­ri­ous con­cerns we have over Dr Byrom’s per­for­mance pro­vid­ing an on­go­ing threat to pa­tient safety”. They said in their cor­re­spon­dence with reg­u­la­tors that a pa­tient, Dim­itrios Kyr­i­a­zopou­los, 72, had died in con­cern­ing cir­cum­stances within weeks of Dr Byrom be­ing re­in­stated.

When he re­turned to surgery, Dr Byrom did not have ad­mit­ting rights, and was op­er­at­ing on pa­tients who were ad­mit­ted un­der the care of another sur­geon.

In Oc­to­ber 2018, Kyr­i­a­zopou­los, who had lung can­cer, un­der­went chest surgery per­formed by Dr Byrom and sub­se­quently de­vel­oped a post-op­er­a­tive in­fec

The Med­i­cal Coun­cil has as­sessed the is­sues raised by your com­plaint and has de­cided to work with Dr Byrom to pro­tect the health and safety of the pub­lic

Ex­tract of a NSW Med­i­cal Coun­cil let­ter

tion. It is al­leged that, over the course of two weeks, the in­fec­tion was al­lowed to fes­ter, un­til Kyr­i­a­zopou­los de­vel­oped sep­sis. On Novem­ber 5, he was listed for an oper­a­tion to drain his in­fec­tion, but the surgery was can­celled at the last minute.

That evening, Kyr­i­a­zopou­los sus­tained an air­way haem­or­rhage and hy­poxic brain in­jury. He was taken off life sup­port on Novem­ber 11 and died. The death is now the sub­ject of a coro­nial in­quiry.

An in­ves­ti­ga­tion into the fa­ther of three’s death, known as a root­cause anal­y­sis, was con­ducted by the RPA, and found no cor­rectable, sys­tem-based cause of the death.

It ac­knowl­edged “it was not clear … which car­dio­tho­racic sur­geon was ul­ti­mately re­spon­si­ble for the pa­tient at times dur­ing the ill­ness”. The re­view found that “whilst there was con­fu­sion as to who was the ad­mit­ting car­dio­tho­racic sur­geon, this did not have an im­pact on the pa­tient’s care”.

One clin­i­cian in­volved in the care of the pa­tient told The Week­end Aus­tralian they held se­ri­ous con­cerns over the death.

“I was dis­ap­pointed be­cause I thought that this death was to­tally pre­ventable,” the doc­tor claimed.

Sub­se­quent to Kyr­i­a­zopou­los’s death, Dr An­der­son ini­ti­ated another re­view of Dr Byrom’s prac­tice. That re­view, by sur­geons David Marsh­man and Bruce French, found Dr Byrom’s prac­tice was safe, ap­pro­pri­ate and com­men­su­rate with his ex­pe­ri­ence, ac­cord­ing to an ac­count given by Dr An­der­son.

A widely dis­sem­i­nated me­moran­dum from Dr An­der­son in Fe­bru­ary this year said the third re­view “had no con­cerns about Dr Byrom’s clin­i­cal out­come data”.

The memo notes: “The su­per­vi­sion re­ports pro­vided to the panel did not raise any is­sues of con­cern and it is the panel’s view that Dr Byrom is fit to per­form his role as a car­dio­tho­racic sur­geon without re­stric­tions.”

Le­gal ad­vice sub­se­quently pro­vided to the NSW gov­ern­ment by a se­nior coun­sel found there were con­cerns of potential ap­pre­hended bias in re­la­tion to the third re­view. One of the sur­geons on the re­view panel had pre­vi­ously acted as Dr Byrom’s su­per­vi­sor.

Fol­low­ing the FrenchMars­h­man re­view, Dr Byrom in Fe­bru­ary re­turned to un­re­stricted prac­tice at the RPA.

In April and May, two fur­ther deaths oc­curred fol­low­ing coro­nary by­pass surgery, both of which were re­ported to the HCCC.

The in­ves­ti­ga­tion

The com­mis­sion’s in­ves­ti­ga­tion into all eight of the deaths con­cluded that “there is not ev­i­dence of sig­nif­i­cant clin­i­cal de­par­tures or is­sues which if sub­stan­ti­ated would pro­vide grounds for sus­pen­sion or can­cel­la­tion”.

“On this ba­sis fur­ther for­mal in­ves­ti­ga­tion is not war­ranted,” said the com­mis­sion’s ex­ec­u­tive di­rec­tor of com­plaint op­er­a­tions, Tony Kofkin.

The HCCC in­ves­ti­ga­tion did not in­ter­view the three sur­geons who lodged the manda­tory no­ti­fi­ca­tion. “I was very sur­prised not to be in­ter­viewed by the HCCC,” said one of the three. “It beg­gars be­lief. It’s not a com­plete and thor­ough in­ves­ti­ga­tion. And you need a com­plete and thor­ough in­ves­ti­ga­tion to make sure the com­mu­nity is safe.”

A for­mer chair­man of the Aus­tralian Health Prac­ti­tioner Reg­u­la­tion Agency, Michael Gor­ton, also ex­pressed dis­be­lief that the sur­geons who lodged the manda­tory re­port were not in­ter­viewed.

The AHPRA is the in­ves­ti­gat­ing agency for no­ti­fi­ca­tions about med­i­cal prac­ti­tion­ers in all states ex­cept NSW.

“It would be sur­pris­ing that the com­plainants weren’t in­ter­viewed or fur­ther in­ter­viewed when the full in­for­ma­tion was re­ceived, which would be stan­dard prac­tice in most other states,” Mr Gor­ton said. “How can you make a proper as­sess­ment without do­ing that? I can tell you it would be nor­mal for AHPRA and the Med­i­cal Boards in other states. How can you not do that to get a full pic­ture of what has oc­curred?”

The HCCC de­fended its in­ves­ti­ga­tion, say­ing it had is­sued sev­eral for­mal no­tices to the com­plainants seek­ing fur­ther in­for­ma­tion.

“The com­mis­sion can ad­vise that it un­der­took a rig­or­ous and thor­ough as­sess­ment of the com­plaint con­cern­ing the care and treat­ment pro­vided to a num­ber of pa­tients by Dr Byrom,” the HCCC said in a state­ment.

Mr Hazzard said he had been ad­vised that the cur­rent staffing ar­range­ments at RPA were “meet­ing all re­quire­ments for pa­tient safety”.

“I di­rected the Min­istry of Health to work with Syd­ney Lo­cal Health Dis­trict to en­sure that all as­ser­tions were ap­pro­pri­ately con­sid­ered and pa­tient safety re­mains a top pri­or­ity,” Mr Hazzard said.

NSW op­po­si­tion health spokesman Ryan Park said there may be grounds for fur­ther in­ves­ti­ga­tion. “Some of the al­le­ga­tions raised in­di­cate that there could be man­age­ment and gov­er­nance is­sues that need to be sig­nif­i­cantly im­proved,” Mr Park said.

The Syd­ney Lo­cal Health Dis­trict said it was dis­turbed that is­sues were con­tin­u­ing to be raised about Dr Byrom’s prac­tice.

“While the dis­trict al­ways strives for am­i­ca­ble out­comes, it con­sid­ers the con­tin­ued ag­i­ta­tion re­gard­ing the prac­tice of the clin­i­cian, in cir­cum­stances where these mat­ters have been thor­oughly re­viewed by the bod­ies re­spon­si­ble for the reg­u­la­tion of the med­i­cal pro­fes­sion un­der the Health Prac­ti­tioner Reg­u­la­tion Na­tional Law, to be highly dis­turb­ing,” the dis­trict said in a state­ment.

“For this rea­son, the dis­trict and chief ex­ec­u­tive will not make any fur­ther com­ment.”

In The Aus­tralian on Mon­day, one of the cases ex­am­ined in depth

Car­dio­tho­racic sur­geon Michael Byrom

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