In June 2013, a woman known only as Patient B was in the back of an ambulance being raced to Sydney's St George Hospital as she bled uncontrollably following uterine surgery.

Key points: Gynaecologist Dr Peter Petros has been found guilty of professional misconduct

Gynaecologist Dr Peter Petros has been found guilty of professional misconduct He is the inventor behind the TFS device, commonly known as transvaginal mesh

He is the inventor behind the TFS device, commonly known as transvaginal mesh Patient groups say authorities should have taken action sooner

She had just come out of elective surgery at a private hospital, but while in recovery, her condition deteriorated. She needed 12 units of blood and to be resuscitated.

The doctor who had agreed to take over her care at St George Hospital suggested that given her case had become critical, she would be better sent to the emergency department at Royal Prince Alfred Hospital, which was significantly closer.

But instead, the doctor in the ambulance beside her, Peter Petros, claimed they were already on their way to St George.

Once there, Dr Petros failed to tell treating physicians the woman had just undergone a new treatment.

She had been fitted with a Tissue Fixation System (TFS), commonly known as transvaginal mesh, which Dr Petros himself invented and which he and his family had a significant financial interest in.

The woman, who cannot be identified for legal reasons, had actually sustained a major arterial bleed during the new procedure and spent the next four weeks in hospital.

But the doctors who took over this critical patient's care were not made aware of some key measures doctors had already taken to manage her bleeding.

They were also working under an assumption that she had undergone a more typical procedure used to treat vaginal prolapse, known as a sacrocolpopexy.

It is for these reasons Dr Petros has been the subject of a damning ruling by the NSW Civil and Administrative Tribunal after a case was brought by the Health Care Complaints Commission.

The tribunal found the surgeon, who has practised in Western Australia and New South Wales, guilty of professional misconduct.

In its decision, the tribunal found the account given to it by Dr Petros at one point was a "reconstruction and cannot be treated as a true account of the actual details which occurred in June 2013".

One expert for the tribunal found the experienced gynaecologist's handover to his colleague at St George Hospital "was significantly below the standard expected".

However, because Dr Petros is now retired, he will not face any official sanctions.

The tribunal found that if Dr Petros, now aged 78, was still registered, his registration would have been cancelled and he would have been disqualified for being a doctor for two years.

During the case, Dr Petros denied his handover explanation at St George Hospital was inadequate.

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Doctor failed tell patients device was no longer approved

The tribunal heard the case of Patient B was not the only reason authorities had concerns about Dr Petros's behaviour.

Gynaecologist Dr Peter Petros has been found guilty of professional misconduct ( ABC News )

As recently as November 2014, Australia's regulator of medical devices, the Therapeutic Goods Administration, cancelled the registration of Dr Petros's TFS device.

But despite being aware his product was no longer approved for the use, he failed to tell nine patients who had the device implanted between November that year and February 2015.

Dr Petros was a surgical assistant in those procedures but took control in two cases.

It further found that between 2013 and 2014, Dr Petros failed to tell 113 patients who had surgery with the TFS device about his or his family's financial interest in the product.

Complex financial structure obscured financial interest

The case also detailed the complex structure of the company behind the TFS and how Dr Petros used a series of companies and trusts to obscure his involvement in the company.

The TFS device is fixed inside the pelvic region by the barbed anchor at each end. ( www.tfssurgical.com )

It also detailed a litany of loans between the companies that ultimately saw Dr Petros benefit from the interest on loans from his trust to the company that registered the patent for TFS.

The tribunal heard these interest payments on $1.6 million in loans amounted to at least $482,346, but Dr Petros denied the loans accrued that interest.

Dr Petros told the tribunal he felt the links were indirect and he was not required to disclose his involvement to his patients, but the tribunal disagreed.

It was the third time Dr Petros had faced medical authorities, but the first time there was an adverse ruling against him.

Dr Petros has been credited as an inventor of one of the first mesh devices, which paved the way for similar products to explode onto the market.

While for some women the products have been able to successfully treat incontinence and prolapse following childbirth, for many it has led to crippling chronic pain and associated medical conditions.

It has been the subject of a Senate inquiry in Australia, class actions, and has been banned in some countries.

The cases have also exposed serious flaws in the way medical devices make their way onto the market after the original design that led to the TFS was only tested on 13 large dogs while he was working Perth.

Bittersweet victory for all mesh victims

For women like Perth mother-of-three Tracey Whyte, the tribunal's decision brings an end to one of many campaigns to achieve justice for victims of surgical mesh.

Ms Whyte has been crippled for two decades since having a TFS device implanted to treat mild incontinence when she was just 35. She was not a patient of Dr Petros.

Now aged 55, she has had to give up many activities in her life after having five types of mesh implanted inside her.

"I woke up with five different meshes inside me. I was immediately sick. I literally went to bed for four years," she said.

"I wasn't told there'd be any complications. I was just told I'd have a little bit of tape around my bladder."

She now lives with chronic pain, has extreme difficulty urinating and said her health has been on a "constant downhill slide" since then.

Ms Whyte hopes the Senate report will lead to more assistance for women injured by mesh implants. ( ABC News: Hugh Sando )

"I had an entrapped clitoral nerve which no-one can really explain unless they're living with it."

She said women in her support group had been experiencing a range of emotions from anger to complete loss and sadness following the tribunal's decision.

"We thought here you go, someone's going to be held accountable, but it didn't really turn out that way.

"I'm just happy someone finally has been brought to task."

Ms Whyte was particularly critical of the time it took medical authorities to act on many fronts.

"When you look at the damage that was being done to women and seemingly being completely ignored, it just doesn't seem right that it wasn't investigated or wasn't brought into the light way before that."

She was also concerned about some of the financial arrangements exposed during the case.

"It just goes to show the corruption that is endemic and surrounds mesh," she said.

"It's just a boys' club of denial."

Ms Whyte said the decision reinforces the need for the Federal Government to act quickly to enact the recommendations of the Senate inquiry into the scandal.

"The only way they can stop this is to make further legislation."

Ms Whyte is also part of legal action against medical practitioners involved in her case.