Heart surgeon allowed to operate after patients die
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 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