In a public statement in February, hospital management said "no patients appeared to have suffered any negative impact as a result of the dosage issue". Dozens of previously unidentified patients underdosed by Dr John Grygiel face uncertainty. Credit:Joosep Martinson But the hospital could not have known if some patients had been adversely affected because it did not examine individual patient data, according to the inquiry co-chaired by the Cancer Institute and the Clinical Excellence Commission. "Failure to adhere to protocols is likely to result in higher rates of local recurrence and higher overall mortality," the report read. Of the 78 head and neck cancer patients treated with the flat dose of carboplatin, 23 have died of cancer, three have died of non-cancer causes and four have died of an unspecified cause.

"At this point in time, the Inquiry is unable to quantify the impact of this prescribing," the investigators said. Oncologist Dr John Grygiel. St Vincent's public statement also indicated that Dr Grygiel had been "immediately counselled and placed under supervision", but the inquiry found "this did not occur". "We have to apologise to the patients for getting things wrong," St Vincent's Health Australia group chief executive Toby Hall said on Tuesday. "We should have reacted earlier, we should have reacted faster and brought more professionals in, and again we have failed on that," he told Fairfax Media.

In an alarming finding, the report revealed Dr Grygiel had also administered the same "off-protocol" doses to a small number of patients with other cancers, affecting more families. "The extent of this is yet to be determined," the report concluded. The inquiry found hospital management significantly delayed disclosing information to patients, with almost all those affected being told only after media reports exposed the errors. The hospital failed to demonstrate an understanding of the distress this issue was likely to cause patients and their families, according to the report. "There was no sense of urgency about the internal or external reviews that were undertaken ... there was no urgency to review the patients," the report read.

The inquiry confirmed doctors, nurses and junior pharmacists had challenged Dr Grygiel's flat dosing and were aware of the practice since 2005. "The practice was widely known, and senior pharmacy and nursing staff either knew, or should have known, it was occurring," according to the report. But senior staff were unaware of the "off-protocol" treatment as proper reporting protocol was not followed, the report read. St Vincent's failed to escalate the issue to the Health Ministry. NSW Greens health spokesperson Jeremy Buckingham said "it is clear that St Vincent's lied in their initial public statements and failed to implement the Open Disclosure Policy Directive".

"The interim report indicates a cover-up was attempted by St Vincent's Hospital. It is therefore essential that there is an external and public inquiry, said Mr Buckingham, whose mother-in-law was treated for cancer at St Vincent's hospital under Dr Grygiel. Health Minister Jillian Skinner said the findings were concerning, "particularly in relation to the failure to communicate accurately and promptly with affected patients, inadequate clinical governance, incident notification and management practices in the oncology department at St Vincent's Hospital". She noted the Health Care Complaints Commission was conducting its own investigation into the treatment of patients under Dr Grygiel. "I have full confidence these independent investigations will address the issues arising from this case transparently, fairly and comprehensively," Mrs Skinner said. Mr Hall said he accepted the hospital had failed to foster a culture that allowed doctors to be challenged and issues to be escalated to senior management.

"We have worked very hard on bringing in a new regime" to deal with these failures, he said, including a new head of oncology, electronic management software for monitoring dosing, and an internal whistleblowing system. Lawyer for Dr Grygiel, Stephen Blanks said his client was looking forward to giving his evidence to the inquiry when he returned from overseas in just one one week. Mr Blanks declined to comment on whether Dr Grygiel stood by his treatment regime while the inquiries were under way.