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<p>Ella Rubeli</p>

Ella Rubeli

Misleading Healthcare Register Puts Patients at Risk

Disciplinary records for dozens of doctors, nurses, and other health practitioners don’t show up on the national register – a new tool meant to improve transparency and public safety.

The sound of a thud from a nearby room alerted a nurse at Caloundra Nursing Home in Queensland, that something was wrong. When she went to investigate, she found her supervisor standing above an elderly resident, who was lying on the floor.

The supervisor, a registered nurse named Christopher James Jones, yelled at the resident, and kicked him, according to a decision of Queensland's Nursing Tribunal, which was at that time responsible for oversight of nurses in that state. The nurse said she also heard Jones call the resident an "old fool."

<p>Photo by Ella Rubeli</p>

Photo by Ella Rubeli

The violence so shocked the nurse that she couldn't eat or sleep for days. Yet Jones was not stripped of his duties at the home. In fact, less than a week later, on March 12, 2004, he kicked another frail, elderly resident in his left hip, after pushing the man to the ground with a stool. This time, three staff members witnessed the incident, according to the judgment.

It was more than two years before the tribunal handed down its decision to discipline Jones. In that time, he was caught with pornography at work, and broke the requirements placed on him to tell his new employers - in Caloundra and Dicky Beach - of the conditions on his registration, which meant he could only work under supervision, the tribunal said.

The tribunal reprimanded Jones and banned him from working as a nurse for 18 months, imposing extensive conditions if he ever wished to work in the field again.

Today, though, a check of Australia's national register of health practitioners makes no mention of Jones's disciplinary record. Indeed, it says he has no reprimands or other limitations on his registration.

Set up by Australian state and territory governments at a cost of $20 million to taxpayers, the online register is billed as a one-stop-shop for employers, professionals and the public to look up reliable and complete information about the registrations of their doctors, nurses, dentists, pharmacists and a range of other health workers.

"If you're a member of the community who wants to know about your practitioner, you can use that information to make decisions about your own health," says Martin Fletcher, chief executive of the Australian Health Practitioner Regulation Agency - known as AHPRA - which has run the register since it went live in July 2010. "We believe there can be a high level of confidence in the accuracy and completeness of the register."

But an examination by The Global Mail has identified nearly 100 instances where formal reprimands delivered by courts, tribunals or other oversight bodies across the country are not reflected on the register. For the most part, practitioners can continue to work despite these sorts of sanctions. And in many cases we have been able to confirm that the practitioners are back at work. Jones told Queensland's Nursing Tribunal in 2009 that he was working as a personal carer, documents show. The tribunal allowed him to reregister at that time. Our efforts to contact Jones were unsuccessful, but his registration is current, which would entitle him to work as a nurse anywhere in Australia, an AHPRA spokeswoman says.

The register covers more than half a million health workers, listing their names, profession, current location and registration number. It also says it lists "conditions, undertakings or reprimands" that have resulted from a disciplinary proceeding.

One of the most serious sanctions a health worker can receive is a reprimand; reprimands, according to the AHPRA website, are "formal rebukes" or "chastisements for conduct" that "must appear" on the national register.

In reality, many reprimands do not appear on the register. Fletcher notes the law only requires the register to include current conditions and sanctions that were handed down after July 1, 2010. As for reprimands that occurred before that date, no matter how grave the conduct might have been, they may not appear. And under the legislation, the new oversight boards can remove reprimands from the register if they see fit.

"We weren't responsible for the registers before July 1, 2010," Fletcher told The Global Mail. "What we have sought to do is make sure that everything since the first of July [2010] - in terms of reprimands and everything that is current in terms of conditions - is accurately reflected in the national registers."

Yet in five cases we found dated after July 1, 2010, AHPRA conceded the register was missing key information and corrected the mistakes.

Experts told us the register is misleading because it states that reprimands "must" appear, but often they do not - either through mistakes, or because they occurred before July 2010. They said that casts doubt over its reliability, and could put the public at risk.

"The whole point of the system is to protect the public," says Cameron Stewart, law professor at the University of Sydney. "But if the register is unreliable, or it's missing very important pieces of information, the public won't be empowered. In fact, they'll be misled."

Indeed, a former customer of a pharmacist whose record we examined said she was alarmed to hear that the register did not list a reprimand that resulted from a complaint she made many years earlier.

“Unless we’ve got an accurate, reliable register, it undermines the public confidence in all practitioners.”

The pharmacist was reprimanded by the Pharmacy Board of New South Wales for the way he had dispensed medication to three patients, including the woman's 10-year-old daughter.

"I would never go back to him," says the woman, who asked to remain anonymous because, she said, the pharmacist had become aggressive towards her when she questioned his conduct.

The fact that the altercation had occurred in 2004 did not change the patient's view that the reprimand - which related to dispensing medication in an inappropriate way, not to his alleged aggression - should be noted.

"I think it should never be removed," she says. "They're a professional person and I think the public have a right to know that this person has made mistakes in the past."

A Uniquely Ambitious and Far-Reaching Idea

For a nation with a relatively small population, Australia had, until recently, a bewildering proliferation of bodies that regulated health workers. Each profession - doctors, nurses, dentists, pharmacists, chiropractors, optometrists, psychologists and more - operated independently and was governed by different laws in each state and territory. There were 85 boards in all, overseeing some half a million practitioners, which the AHPRA website says accounted for one in 20 Australian workers.

In June 2004, the federal government - at the behest of the Council of Australian Governments (COAG) - asked the Productivity Commission to look at ways to improve the nation's health workforce. Balkanized oversight was just one of the problems. There was also concern over persistent shortages of health workers, a problem predicted to worsen with the ageing population; the difficulty of attracting doctors to rural and regional areas; as well as the lack of doctors in or near hospitals on the weekends and after hours.

The commission delivered its report in late 2005. Its slate of proposals was aimed at developing "a more sustainable and responsive health workforce, while maintaining a commitment to high quality and safe health outcomes."

The national registration and accreditation scheme was one of the key recommendations, and after an intense period of negotiations that required health ministers in the states and territories to agree on a common scheme, the national register emerged.

The register is unique, in terms of both the number of professions it covers and the extent of its reach, according to Fletcher, AHPRA's chief executive, who says no other country has attempted a national scheme across this number of professions.

"Some governments have done incremental changes, or tinkered around the edges," he says. "In Australia, to their credit, health ministers had a real ambition and sense that public protection and patient safety had to be at the core of quite a revolutionary change."

<p>Photo by Ella Rubeli</p>

Photo by Ella Rubeli

The new scheme created national standards of accreditation for the fields it covers. It allows users to check the registration of a doctor who may have gained his or her qualifications in a different state or country. And it focuses on the importance of transparency: "We deliver services that protect the public and build their confidence in the health professions by upholding the highest levels of probity, integrity, honesty and transparency," the agency's 2011-12 business plan says.

"There is no other country in the world where you can go to a single website and look at all these professions the way you can do in Australia," Fletcher says. He calls the national register, "the envy of the world."

Creating the register was by no means a simple task. For starters, agency staff had to transfer 1.5 million records from existing systems - from large, sophisticated online databases, all the way down to hard-copy files - which operated under different privacy laws.

Problems began to mount almost immediately. Overnight, the new register extinguished many of the existing laws and the bodies that oversaw practitioners across the country, leaving thousands of workers angry and confused.

Doctors were wrongly dropped from the register, recent graduates missed out on jobs because of delays in processing their registrations, and those who called to complain reported receiving inconsistent or incorrect advice from AHPRA staff, according to industry groups.

"When the amalgamation took place, that was a debacle," says Steve Hambleton, president of the Australian Medical Association, which made a scathing submission to a Senate inquiry established in early 2011 to look into AHPRA's ability to run the register, and its impact on health practitioners.

"The integrity of the register has been corrupted and employer confidence in the information on the public register is significantly diluted," the group wrote in a submission to the inquiry.

The committee published its report in June 2011, recommending a suite of changes to how AHPRA managed the register. AHPRA has adopted a number of those ideas and has taken some additional steps to improve its data, Fletcher says. "We've had a program of audit and improvement to make sure the data that we've inherited from these previous systems is as accurate as possible."

But none of the recommendations directly addressed the sorts of problems identified by The Global Mail, and when told of our findings, Hambleton, of the AMA, said the deficiencies casts doubt on the register once again. "Unless we've got an accurate, reliable register, it undermines the public confidence in all practitioners," he says.

“Taking medications from aged people that can’t respond, can’t complain or wouldn’t even know they’ve been given aspirin instead of pain killers, is outrageous.”

Serious Problems Persist

The Global Mail was able to identify many of the 100-plus cases of reprimands and suspensions we examined using records from bodies whose decisions are public and online. It is impossible to say how many other cases might exist from boards that kept their decisions private.

Examples of inappropriate, unethical or illegal conduct abound in the cases we found - which do not include mere complaints or even cautions. The cases in question involve reprimands, and in some cases suspensions, which do not appear on the register.

Peppered throughout the dozens of cases are stories of pharmacists doling out a smorgasbord of drugs. A pharmacist at Bondi Beach, NSW, was found selling hundreds of tablets of the so-called "date rape" drug, Rohypnol, to people who did not have prescriptions. Others were caught dispensing huge quantities of stimulants to truck-drivers. Some provided the notorious painkillers OxyContin and Endone, known as much for their addictive qualities as for their soothing effects, to people without prescriptions. And one was handing over methadone syrup without a proper script from a doctor. In all these cases, the practitioners' registrations are current, meaning the practitioners are eligible to work.

In one case, a nursing-home worker stole highly addictive pain medication from two residents, and falsified records to cover her tracks, according to a 2010 decision of the Nurses and Midwives Tribunal of New South Wales. The nurse had endangered one of the patients by substituting aspirin for the painkiller OxyContin, which she took herself. The nurse's registration is active, but The Global Mail's efforts to locate her were unsuccessful. A spokeswoman for AHPRA says it does not keep tabs on where practitioners are working, unless the practitioners have been required to inform the agency of that information.

The register's failure to note this reprimand tarnishes its reliability, and could create a false sense of security for those who rely on it, says Peter Dodd, spokesman on health policy and advocacy at the Public Interest Advocacy Centre in Sydney. "Taking medications from aged people that can't respond, can't complain or wouldn't even know they've been given aspirin instead of pain killers, is outrageous," he says. "That information has got to be accurate, otherwise how can the public have confidence in the whole system?"

The cases against doctors and nurses often hint at failures in the nation's education and training systems, especially when it comes to overseas-trained doctors. Sometimes workers injured or neglected patients because they didn't know how to use equipment, or were simply not trained for the procedures they were expected to perform. A 2008 case involved an overseas-trained doctor whose failure to properly use heart-monitoring equipment led to the death of an unborn child. Another involved two Korean nurses who were reprimanded in September 2011, and suspended for a month for helping friends become registered by cheating on their English test.

Until last week, none of these reprimands appeared on the register. After we alerted AHPRA, they corrected the records for the two nurses, whose cases occurred after the register went live. The doctor's record remains clear.

In handing down reprimands, the oversight bodies frequently refer to the importance of maintaining public trust.

<p>Photo by Ella Rubeli</p>

Photo by Ella Rubeli

Take the case of three pharmacists from Campbelltown, in southwestern Sydney, who dispensed steroids to more than 100 so-called "patients," despite several red flags about how the drugs were being used, according to a 2006 decision of the Pharmacy Board of New South Wales.

The pharmacists admitted giving male patients certain drugs that were "clearly only for treatment for females."

"It crossed my mind that [body building] was one of the outcomes being achieved by using such products," one of the pharmacists, Nicholas Pahos, told the board.

Calling their conduct "improper and unethical," the board held that all three had demonstrated a lack of "experience, judgment and skill in the practice of pharmacy, and a lack of care for the health and well-being of their patients."

Each pharmacist was reprimanded and fined thousands of dollars. The board also ordered them to do education courses and prove to the board that they were keeping up their memberships of professional pharmacy groups.

Yet the only trace of these proceedings that appears on the register is three conditions placed on one pharmacist, which expired early in 2011. In line with AHPRA's policy, there is no mention of the severe reprimands Pahos or the others received.

In Pahos's view, there's no problem with that. "That 2006 case was dealt with at the time, and the penalty was served. All the undertakings have been completed for that. That's why it comes up nil," he says. Pahos says he continues to work at the pharmacy, which all three still own.

Many Professionals Agree That The Register is Misleading

To be sure, some of the cases identified by The Global Mail occurred several years ago, and doctors told us they had paid dearly for their mistakes, both professionally and personally. Several said they had admitted their wrongdoing, and had otherwise unblemished careers. Others said that while their patients often found the disciplinary proceedings through online searches, they would prefer those reprimands to remain absent from the register - though they conceded the register appeared to be inaccurate, or at least, misleading.

“What we have sought to do is make sure that everything since the 1st of July [2010] – in terms of reprimands and everything that is current in terms of conditions – is accurately reflected in the national registers.”

Some practitioners readily accepted that their past was a matter of public interest. One of these practitioners is Douglas Charles Leslie Smith, who was reprimanded in December 2010 for what the Pharmacy Tribunal of New South Wales described as a "cleverly executed exercise of defrauding the Commonwealth of Australia by abusing your access to the Pharmaceutical Benefits Scheme." Over the course of two years, Smith altered and forged dozens of prescriptions to falsely claim payments for medications he never dispensed, the tribunal said. Some of the prescriptions were for customers who were dead.

It was the second time Smith had been reprimanded. The first occurred in 1998, after a woman died and a man was found unconscious after consuming "poisons and restricted substances" Smith had thrown in a garbage bin near a car park outside his pharmacy in Thirroul, NSW, in what the then-Pharmacy Board of NSW described as "an unfortunate set of circumstances." Making clear they could not make any direct connection between Smith's conduct and the woman's death, the board castigated Smith for failing to see that "people might rummage through other people's waste materials."

In the recent decision, the tribunal suspended Smith for six months, noted his criminal conviction for fraud, and said that while the condition placed on his practice might be removed once it expired, "the fact of this reprimand will remain on your registration."

But until The Global Mail alerted AHPRA of this error, Smith's registration said he had no reprimand.

"That was human error," said spokeswoman Nicole Newton. "We apologise for that and we are grateful to you for bringing that to our attention."

Smith, who still owns the pharmacy at Thirroul, told us he regretted what he had done, and says he believes it's only fair that practitioners' disciplinary histories appear on the register. "If you were a member of the public and you wanted to weigh up, 'What risk does that person pose to me?', well, you have to be able to have that information and make that judgment, don't you?"

Smith's registration now reflects his condition and reprimand.

A Tricky Balance Between Transparency and the Right to Privacy

Publishing these records raises many thorny questions of public policy and highlights a conflict between the need for transparency on one hand, and the understandable desire of medical professionals to keep their past private, on the other.

<p>Photo by Ella Rubeli</p>

Photo by Ella Rubeli

"Health professionals should be encouraged to admit mistakes and learn by those mistakes," says Peter Dodd, of the Public Interest Advocacy Centre. "The public interest in that overrides any public interest that there might be that entitles the public to know every complaint against a health professional."

However, when it comes to official decisions from oversight bodies, Dodd says the public right to know wins out.

"There is a balance, but if doctors have been inappropriate, unethical or doing illegal things, that's easy," he says.

While reprimands are a serious professional rebuke, some experts point out that other serious disciplinary actions - such as suspensions and cancellations of a person's registration - may also be missing from the register.

In fact, a number of the practitioners included in our reporting had been suspended for periods ranging from two months to more than a year, and sometimes on multiple occasions.

"I think those details should be available," says Cameron Stewart, of Sydney University. He says AHPRA should put the old databases on their website:

"Extremely serious concerns - impropriety, misuse of drugs, sexual misconduct - I think they're the sort of things that should remain on the form."

One such case involves Dr Michael Koutsoukis, an obstetrician and gynaecologist in Bowral, about an hour-and-a-half's drive south of Sydney. Koutsoukis, who until recently taught maternal and women's health at the University of Wollongong, was reprimanded in 2002 for events that occurred at his Geelong clinic in 1997.

In a hearing before the Medical Practitioners Board of Victoria, Koutsoukis admitted to snorting cocaine with his 23-year-old receptionist, who was also a former patient. The receptionist told the board that Koutsoukis kept his stash in a glass jar with a gold lid on his desk. The two snorted the cocaine off a piece of cardboard, upon which the doctor had placed the drugs, using one of his surgical instruments, she said. Koutsoukis, who was around 40 years old at the time, also made sexual advances on the receptionist, the judgment said.

“If you were a member of the public and you wanted to weigh up, ‘What risk does that person pose to me?’, well you have to be able to have that information and make that judgment, don’t you?”

Koutsoukis was found guilty of two criminal charges by the Magistrates' Court of Victoria at Geelong in relation to that incident, according to the decision. He was also reprimanded and suspended from practice for two months by the medical board. Koutsoukis confirmed to The Global Mail that he had been subject to the disciplinary proceedings, but declined to comment further.

A spokeswoman for Koutsoukis's current employer, Bowral & District Hospital, did not directly answer our questions as to whether they were aware of Koutsoukis's earlier reprimand from Victoria, which is not listed on the register. She said: "All appropriate checks were made as per the NSW Health policy," when Koutsoukis was hired in 2010. The hospital, which is part of the South Western Sydney Local Health District, does use the AHPRA register to "verify the registration of specific clinical employees and clarify if they have any restrictions on their registration," the spokeswoman said.

The University of Wollongong was not aware of the previous sanction, a spokesman said.

AHPRA is actively encouraging employers to rely on the register to check their employees' credentials, and so far, more than 850 hospitals, universities and other entities have done so, Fletcher says.

He defended the register's exclusion of past suspensions or reprimands, including Koutsoukis's. "At the end of the day, we have to work within the law," which only requires the register to note decisions that occur after July 1, 2010, he says. "If that suspension is no longer needed because the issues have been addressed, then the suspension is lifted and no longer appears on the register."

Agency Says It Is Working to Improve The Register

As a result of the cases we identified, the agency will "consider making changes to the register," Fletcher says. It's now deciding whether the website should make clear that it only contains reprimands that were handed down after July 1, 2010, and only lists conditions while they are in place.

After correcting the mistakes we identified, the agency said in a statement it is "now refreshing staff training about the need for vigilance in recording on the register reprimands that have been issued by a panel or tribunal."

Fletcher also encourages the public to notify the agency if they find more examples of practitioners whose records don't reflect sanctions that have been handed down after that date.

<p>Photo by Ella Rubeli</p>

Photo by Ella Rubeli

And Fletcher says AHPRA staff now are working through the records of some of the defunct state and territory boards to ensure that conditions imposed on practitioners show up on the new register if they are still current. In at least 500 instances, the full record of current conditions placed on practitioners does not yet appear; users are instead told to contact the agency, a spokeswoman says.

One of these registrations included a nurse who was a key figure in the "kerosene baths" episode at a Victoria nursing home, which received immense media attention in 2000. The home was shut after residents were found with oozing, fly-blown wounds that staff was attempting to treat by bathing them in water laced with kerosene.

Since our inquiries, the register has been amended to show that the nurse, Michele Van Harten, "must not practise in aged care nursing." Before we asked, the register indicated there was a condition, undertaking or reprimand, but simply instructed users to contact AHPRA for more information.

Van Harten is currently working at a digestive health centre in Dandenong in Victoria. She declined to speak with The Global Mail, and her employer said she had complied with the conditions of her registration.

But Van Harten's case raises yet more troubling questions about the agency's records. The actual disciplinary records from the case were held by the Nurses Board of Victoria, whose decisions - like those of many of the old disciplinary boards - were considered private, according to AHPRA.

It was only because the "kerosene baths" scandal received such intense media coverage that Van Harten's name became public. In other words, it's impossible to know how many other records should show up on the new register, but don't. And an agency spokeswoman wouldn't say how many of the 85 defunct boards had a similar policy of keeping disciplinary records secret.

Federal health minister Tanya Plibersek said in a statement that she and her counterparts in the states and territories are closely monitoring AHPRA, and they will "pursue areas of concern if they arise."

According to Professor Stewart, the agency must act to improve what he called the main interface between AHPRA and the community.

"Perhaps the pressure to get the register up and running means we've accepted a system that has included some errors," he says. "Having said that, it's now been 18 months, and if a federal scheme is going to have the support of the public, they need to have confidence in it. And given your findings, that's going to be fairly damaging."

6 comments on this story
by Jill

Thank you for your excellent article. I have had a long-time interest in patient safety within acute hospitals; for example in some settings up to 29% of acute care admissions will acquire a preventable pressure ulcer which will cost up to $250K to be healed by major reconstructive surgery. A look at the conditions outlined by US Medicaid which will not attract funding should the injury be acquired in the hospital makes interesting reading.

February 7, 2012 @ 4:50pm
by Dwayne

The Australian Government has become such a joke that I'm positive 10 year old kids could run this country better than the Government has managed to do so for the last 30 or so years.

It's sad nothing will come of this article. Makes me wonder what other failures the Government has had its hands on will come to light sooner or later as well?

February 8, 2012 @ 4:09pm
by Trevor

Adds to an essential dimension in the running discussion on the PCEHR - Trust.

February 8, 2012 @ 4:14pm
Show previous 3 comments
by Tawanda

Great piece. Its encouraging to see this much time and resources being invested in investigative reporting on patient safety, one of the most pressing issues in healthcare today.

February 13, 2012 @ 8:37pm
by Bruce

The authors of the patient safety article have done excellent work. After making a complaint concerning the circumstances of my sons death to the HCCC and attending an (un)Professional Standards Committee hearing the public should be very concerned, as the article points out, how the medical industry view the safety of patients.
My issue concerned a Dr (obstetrician) taking 1 and a half hours to respond to his 'ON CALL' status. On the night we were told by the midwives that he was treating a private patient. The 23 page determination revealed where he wasn't .....but not where he was while 'on call'.

February 14, 2012 @ 12:49pm
by Sydney Guy

Firstly, I agree with the need for an improved and standardised registry as outlined, and in a country of 22 million people, we probably only need one, as long as it it well run. At present, AHPRA does not oversee all complaints of registrants - for example, the new Medical Council of NSW has governance over complaints and some disciplinary matters of medical practitioners in NSW, complaints in other states going to AHPRA.

Whilst much attention is given to unprofessional and inappropriate clinicians, certainly in the media, much less attention is given to much broader systemic issues within the health system that contribute to patient morbidity. The vast majority of adverse outcomes in healthcare are not due to the deliberate efforts of 'bad apples', but rather unintentional errors, often made by multiple people, due to lack of staffing, overcrowding, insufficient training, ambiguous communication, poor handwriting and so on.

Use of registries is a necessary part of healthcare regulation, but broader systems for safety, and the monitoring thereof, will save many more lives.

February 22, 2012 @ 6:05pm
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