A scathing 220-page report into several New South Wales hospitals and health districts has described how catastrophic failures allowed the gynaecologist Emil Shawky Gayed to harm scores of women – some of them irreparably – over the course of two decades. Concerns about his performance were raised yearly, and his actions may have contributed to the death of a baby boy.

“Of most concern is that a repeated theme has been the unnecessary removal of organs, unnecessary or wrong procedures, perforations of organs and reluctance to transfer to tertiary facilities,” the report by the barrister Gail Furness SC said.

The cases of 50 women have now been referred to the Health Care Complaints Commission for a fresh investigation. “The health system failed each of these women,” Furness said.

More than 250 women have called dedicated hotlines established in June to respond to concerns about Gayed after a Guardian Australia investigation revealed the significant harm experienced by his former patients.

The Furness report reveals that the hospital where Gayed spent the most time and inflicted the most harm, the Manning Rural Referral hospital in Taree, failed to carry out checks of Gayed’s registration status, or perform background checks with regulatory bodies such as the Medical Board or the HCCC. This was despite Gayed signing a consent form allowing them to perform the checks. Those checks would have revealed that numerous complaints had been made against him at Mona Vale hospital on Sydney’s northern beaches, and at Cooma hospital in the state’s south.

Gail Furness SC was counsel assisting the royal commission into institutional responses to child sexual abuse prior to her involvement in the Gayed report. Photograph: PR IMAGE

“In most years from 1999 to 2016 there was a complaint or concern raised about Dr Gayed’s clinical treatment of a patient,” the report found. “They were expressed by nursing staff, anaesthetists and other medical practitioners as well as, more recently, patients themselves.

“The inquiry has been informed that, prior to Dr Gayed’s temporary appointment at Mona Vale Hospital, the director of Medical Services obtained a positive verbal reference from Dr Jim Wills, the then director of medical services at Manning Hospital.”

Gayed remained at Manning hospital from 1999 until early 2016. In that time alone, Furness and her co-investigator, Dr Greg Jenkins, uncovered more than 50 women whose treatment warrants new complaints to the HCCC. There were many others who had complained directly to the HCCC at the time.

After a while, “staff became desensitised to his poor performance”, Furness found.

The stillbirth

Gayed worked mostly at Manning hospital from 2007 because he had resigned from Mona Vale hospital after learning that the Northern Sydney Central Coast area health service was investigating him. The surgeon told hospital management he felt reviews into his conduct were “personally motivated rather than being motivated by safety concerns”.

The Mona Vale investigation was triggered because of an unexpected stillbirth during labour, and after he perforated the bowels of two patients in his private surgery and they required emergency treatment at the hospital.

The stillbirth occurred in December 2006. While the woman was in labour Gayed failed to correctly interpret a cardiotocography monitor which suggested that the baby was in severe distress. He attempted to deliver the baby with a vacuum extraction, which detached from the baby’s scalp on three occasions.

Of most concern is that a repeated theme has been the unnecessary removal of organs Gail Furness SC

Gayed did not record what the vaginal examination findings were before applying the vacuum, and he did not record the vacuum detachments, as is standard procedure. The woman was transferred to theatre but incomplete note taking means it is unclear whether a caesarean or assisted vaginal birth with forceps was performed. Furness uncovered that the baby had ultimately been delivered with forceps, stillborn, and was unable to be resuscitated.

A professor of obstetrics, Michael Bennett, who conducted an external review of the case, found: “This baby was in pretty serious trouble for very nearly three hours before he died and there is to my mind no evidence that either the nursing staff or Dr Gayed had any appreciation of the seriousness of the situation.”

‘Borderline’ surgical skills

The subsequent investigation by the hospital and health district into Gayed found that he had “no competence” in performing even basic obstetric ultrasounds. There seemed to be a pattern of multiple operations on patients, all while demonstrating “borderline surgical skills for a senior gynaecologist”. His tissue handling was poor. He demonstrated inappropriate knot-tying technique. His infection control was suboptimal, with contamination of sterile equipment and inadequate hand washing. He failed to obtain informed consent from his patients and did not fully understand his professional responsibilities.

The harm at Taree

The entrance to the Manning Rural Referral Hospital, Taree. Photograph: Carly Earl/The Guardian

Gayed was employed at the Manning hospital, based in the small town of Taree on the mid-north coast of NSW, as a visiting medical officer in obstetrics and gynaecology. As a visiting medical officer, he was employed on a contractual, fee-for-service basis. He saw patients in his private rooms, where he performed tests, examined patients and made diagnoses. If he determined a woman required surgery, he booked them in at Manning hospital.

“They often returned to his private rooms and some were encouraged not to attend Manning Hospital after complications arose,” Furness found. “His medical records were not available to the hospital; nor were any test results. I am concerned about a situation in which a public hospital provides facilities for a visiting medical officer obstetrician gynaecologist to practise without the hospital having the capacity to ensure that those female patients are being cared for at the standard expected in a public hospital.”

Checks and balances in place to ensure that visiting medical officers are up to scratch were not carried out. Required, regular performance reviews were not conducted for Gayed. The hospital had a tool for recording errors and concerns, called the “incident information management system” – yet doctors did not record any of his mistakes in this system. Nurses did, although selectively.

There was also an attitude that what occurred in Gayed’s private rooms was irrelevant to hospital management.

The then director of clinical services, Dr Jim Wills, who also gave Gayed a positive reference before he began employment at Mona Vale hospital, was “unduly favourable to Dr Gayed, did not follow policy and minimised the seriousness of concerns raised”, Furness found.

Wills told Furness that he relied on the Medical Board and the Medical Council to determine whether Gayed was fit to practice, and did not consider that to be his role. Furness found while Wills was entitled to rely upon the regulatory bodies which had overall knowledge of Gayed’s errors, this did not relieve the hospital from properly reviewing Gayed’s performance on a regular basis.

“That was not done,” she found. “Hunter New England Local Health District told me that there are now a number of mechanisms in place which should identify a practitioner with similar problems. I am told that some of these processes were in place during the time Dr Gayed was working at Manning Hospital.”

The district did not carry out a review of Gayed’s clinical privileges even after it was notified by the Northern Sydney and Central Coast area health service that it had suspended Gayed.

This is despite the fact that the then director of clinical governance at the health service called Wills about Gayed’s suspension and resignation. The director was so concerned he sent a follow-up email which said: “There are unrelated concerns re Gynaecology, with two additional cases of surgical mishap in the last two weeks.”

Similar issues had arisen at Cooma hospital. There, nurses, primarily, completed incident reports recording 15 events concerning Gayed’s clinical treatment and conduct in the operating theatre. Five involved needlestick injuries. By the fourth, concern was being expressed about Gayed’s eyesight.

In November 1997 a nurse wrote a memo to the health services manager raising concerns about Gayed’s complication rate “and his haste and possible poor eyesight”. Gayed was temporarily suspended from Cooma health service on the basis of concerns raised, but he was reinstated following legal advice. Gayed resigned from Cooma hospital after the health district referred his case to the HCCC for investigation.

Recommendations

Furness has referred her investigation to NSW police. She referred the cases of 50 women to the HCCC for a fresh investigation. And she also made three recommendations which have been accepted in full by NSW Health.

A review of governance processes and the incident management reporting system was recommended and is now under way. Furness also said visiting medical officers needed to provide sufficient information about their patients to the public hospitals where they worked.

All local health districts in NSW have also been advised that if a hospital is reliant on a sole medical practitioner or a small specialist team, which is often the case in rural and regional areas, then external oversight from practitioners in other parts of the district is needed.

Law firm Carroll & O’Dea are representing dozens of Gayed’s victims and lawyer Justine Anderson said while the recommendations are “sound,” more detail is needed as to their implementation and communication to patients.

“For the first time women now have a clear and independent account of what has taken place,” Anderson said. “This is a significant step for the women affected by the advice from and treatment by Dr Gayed. Whilst these recommendations do not correct the errors of the past; our clients do not want history to repeat itself.”

Do you know more? melissa.davey@theguardian.com