The wall of shame

Over the last decade I have submitted an endless stream of complaints about my patients’ care to our local public health system.

Each time the response was similar – the junior doctors involved would sometimes be counselled on their management of a patient, sometimes a mistake would be rectified or I would be told that the matter was being investigated only to never hear anything further.

These fixes would last a few weeks/months and we would be back to the drawing board.

My concerns had gone to the current and past ACT Health Ministers, the current and past ACT CEO, opposition health spokespeople and the various departments and Consultants at the two hospitals. We have even had meetings at our Practice with various officials over this in the past.

Sadly things seem to be going from bad to worse – my most recent concerns were met with a brief “we have received your letter” type response and nothing else happened. This was from the Health Minister’s office.

(addendum 07/09/15 – a reply was received six weeks later. I was invited to send details of any concerns I have to specific officials within the department. This will be done although it should be noted that every single case listed on this page was reported to the hospitals)

Both hospitals do have GP Liaison Officers and these people do a sterling job – they are however the meat in the sandwich and the responses to our requests appear to be more and more muted.

It would appear that nothing will ever change – we have an entrenched culture amongst the current group of Hospital based Specialists that are being taught to the next generation of doctors. This involves a range of issues that could be anything from a total disrespect of elderly patients to inappropriate use of drugs of addiction to the total disregard of what GPs have been doing resulting in errors and duplication of services.

I have thus decided to create my own wall of shame – I am placing the de-identified details of my patients that I have complained about over the years on this wall. My aim is to hopefully shame those in the know into action and make patients and their relatives aware of what is happening to patients in Canberra’s public Hospitals.

My archived records of complaints start in 2007. It is by no means complete and only represent a small portion of these issues that I see.


  • Middle-aged man with severe intellectual disability requiring regular scheduled medical procedures under general anaesthetics. Recurring systemic failures to do procedures on time leads to renal failure.   Protocols to ease his fear during the procedures are ignored and when this kind and gentle soul panics he is classed as a “code black” patient requiring security guards when he attends. Reported to ACT CEO and Health Minister.


  • 90+y old Nursing home patient. All communication from GP ignored during admission to hospital. Multiple life threatening medication errors during admission and upon discharge. Reported to hospital and Health Minister
  • 75+y old patient who resides at home presents to ED with pancreatitis. GP attempts to hand-over pre-admission details is a total failure, public patient is sent back to GP to organise endoscopies from Rooms, very incomplete written feedback sent to a different GP that patient had never seen. Reported to hospital and Health Minister
  • 70+y old patient residing at home presents and admitted to hospital. Known osteoporosis and cancer and presented after 150kg object fell on his head. Multiple injuries but they stopped assessment once his broken neck was identified. No other x-rays done. Significant other soft tissue injuries diagnosed and managed by GP weeks later. Reported to hospital and Health Minister
  • 85+y Nursing patient admitted with chest infection to hospital. No attempt to verify pre-admission drugs and relied instead on old hospital records. Severe low Bloodpressure as result – discharged and collapses in corridor. Placed back in ward and kept overnight – NONE of these events document in any discharge to GP. Reported to hospital and Health Minister
  • 55+y old renal transplant patient with recent complications requiring surgery gets admitted to hospital with pneumonia. Treating team wants to stop all of his immune suppressants without any input from renal team. The renal team only became involved after strong protest by family. Discharged while still unwell and GP advised to follow-up – paperwork only arrived several weeks later. Reported to hospital and Health Minister
  • 65+y old patient with extensive investigations of his recurring chest infections admitted to hospital. Family attempts to present them with copies of the investigations done pre-hospital. Team refuse to look at these and repeated the entire work-up. They also completely messed up his chronic diabetic medication and his wife had to remain at his bedside and give him his medication. Reported to hospital and Health Minister
  • 25+y old presented to hospital post-ictal. Seen by an intern and diagnosed with sleep apnoea with no further investigations and sent home. GP did full work-up and found him to be severely hypertensive, in renal failure and having nocturnal seizures. Reported to hospital and Health Minister
  • 65+y old admitted for Gynaecological procedure to hospital. Develops a painful red eye while in-patient – discharged and sent home with instructions to see her GP about the eye. GP sees her and she is admitted the same day to different hospital with a severe peri-orbital cellulitis. Reported to hospital and Health Minister
  • 60+y old in Oncology ward at hospital. Severe confusion regarding treatment options and family calls GP out of desperation. I arrange to see him at the hospital and drive 30km to hospital only to be told he has been sent home an hour before I arrived. Staff refuse me access to his medical file despite knowing I was heading back to see him at home. He died two days later.  Reported to hospital and Health Minister
  • 35+y morbidly obese woman with young baby at home admitted to hospital with pancreatitis. Sent home on high doses of opioids. Has a very high risk of blood clots genetically yet no prophylactic measures implemented. The opioids does not get recorded in the discharge we received. Reported to hospital and Health Minister
  • 50+y old very brittle insulin dependent diabetic bipolar patient presents unwell at ED – lithium levels are taken but never followed up until review at GP several days later – toxic high levels. Reported to hospital and Health Minister
  • 80+y old female admitted from home to hospital. Discharged to a Nursing home without any attempt to coordinate with her GP. We could not attend this facility which meant the family had to run around and find a new GP that was closer to the facility
  • 80+y old male repeated admitted to hospital with severe dementia and each time sent home. It was only after we refused to accept his care if he was discharged again that the hospital helped us to find a Nursing home where he passed away a few months later Reported to hospital and Health Minister
  • 85+y  old housebound patient with severe emphysema  that is on continuous oxygen and gets regular home visits – very stable INR until admitted with chest infection to hospital. During admission Warfarin is given anytime between 4PM and 10PM – this results in her INR becoming very unstable. She is also given her inhaler, Spiriva, as an oral medication to swallow – which she did. All of these errors were witnessed by her daughter but not reported anywhere to the GP. Reported to hospital and Health Minister
  • 80+y male seen at Nursinghome and found to have gangrenous foot. Confirmed with Surgical registrar that patient needs to go to Vascular surgery at TCH. Discussed with Vascular Surgery consultant who accepted care. Sent by ambulance with letter. He then disappears and we discover him at Calvary (that has no Vascular Surgery) in a ward several days and many phone calls later. After a lot of calls he is transferred to TCH. When we call several weeks later, after being told by relatives that he had surgery, they refuse to give us any information on his status. Reported to hospital and Health Minister
  • teenager with fractured hand presents in the morning at GP – plastic surgery registrar refuse to see him acutely and will only see him the following day in outpatients


  • 65+y old who has not seen a GP for six months. Discharged day before a long weekend with three days’ medications, seven pages worth of drug changes and told to see GP over long weekend to organise all his medication. No communication with GP over this.


  • 4o+y old with chronic leg ulcers sent home from hospital with multiple conflicting errors in discharge document and complete refusal to assist in clarifying matters when GP called.
  • 50+y old patient diagnosed by GP with chronic leukemia – referred to hospital outpatients and told she would wait 27 months before they saw her to assess.
  • 45+y old diagnosed with thrombosis of splenic vein. GP spends an hour on the phone to hospital. Admitting Officer refuses to accept the patient unless the Vascular Registrar has accepted the patient. The Vascular Registrar refuses to see the patient unless the patient comes in through the ED and is reviewed by them. Patient sent in with paperwork in the end without either doctors agreeing to see him
  • 40+y old presented to ED with a septic foot. This is missed and he is instead repeatedly given more and more opioids for his pain over several visits to ED. He presents to his GP where he collapses due to opioid sedation and septicaemia. He is sent by ambulance to different hospital where is ends up for months losing tendons in his foot and requiring skin grafts with permanent disability in his foot
  • 80+y old male sent in to hospital by ambulance after arranging admission for his heart failure with his usual cardiologist. Ambulance elected to drop him off at different hospital instead. He was admitted to ICU and wards for two months during which I visited several times. At no stage could a treating doctor be found to talk to. He ends up being discharged in a very unsafe manner despite GP calling the team twice to object about the risk for him and his wife. He died a few weeks later
  • 65+y old pt with very complex history. Represents several time to ED and sent home each time. GP reviews and calls hospital admission officer insisting he needs admission. Faxes a coverletter and hands the patient a detailed sixteen page referral letter with important information. Patient admitted for over a month including in ICU. Upon his discharge he is handed back an unopened envelope with the GP referral still in it – all investigations and background information by the GP had been ignored


  • 85+y old from Nursing home admitted to hospital with pneumonia – discharged with history of a stroke during admission but not documented anywhere despite his mobility being greatly decreased and being unable to swallow properly. No communication to GP about any of this from the hospital.
  • 25+y old morbidly obese severely intellectually impaired patient seen at ED with gout and sent home with regular doses opioids to self administer every 3 hours despite staying alone, having a pre-schooler’s level of intelligence and being unable to read
  • 40+y old immunesuppressed patient seen at ED with acute parotitis – treated with high doses opioids and presents with decreased consciousness secondary to the medication to GP. No investigation or management at ED despite such severe swelling that she cannot open or close her mouth more than 1 cm. Send back to hospital and admitted and transferred to other hospital by ambulance
  • 65+y old patient with chronic hand arthritis sent to Orthopaedic Clinic – instead seen by Allied Health workers and sent for multiple Physio interventions instead of seeing the Orthopaedic surgeon. Surgery only booked two years later
  • 75+y old demented wheelchair bound man sent home a long weekend to his elderly wife with instructions for her to apply a very potent steroid cream all over his body twice a day for his chronic rash. No diagnosis in the discharge on what was being treated and how his wife is supposed to manage this.
  • 20+y old with chronic pain. Written management plan in place at both EDs yet repeatedly given more opioids when she presents despite the plan that states otherwise
  • 40+y old with a past history of opioid addiction that her GP managed to wean her off from over several years. Has a minor surgical procedure and is discharged on a significant amount of oral opioids with total disregard to the warnings by GP
  • 55+y old man presents to ED midday with a painful leg and a pulsatile abdominal mass – discharged and referral letter sent to GP to urgently organise a CT to exclude an aneurysm.
  • 60+y old demented patient presents to ED with sudden onset balance disturbance. Family told by ED doctors he should be urgently referred to a Neurologist and sent back to his GP with minimal paperwork and no explanation
  • 55+y old with recent initiation of antidepressant and several fainting episodes. Given a script of Endone for sinus headaches and sent home
  • 55+y old man sent in with GP with severe pneumonia. Discharged after four weeks and told to see GP with 2-3 days. No handover despite significant abnormal results and still being very unwell – died a few months later from cancer
  • 90+y old farmer admitted to Calvary in heart failure. Discharged after a week with very poor instructions regarding medication and develops very low bloodpressure nearly causing a car accident
  • young child sent to Orthopaedic clinic with concerns about a malignant mass behind knee. Sent back to GP with handwritten note to organise MRI and biopsy and then send to private Specialist instead.
  • Elderly male sent by GP for a review of his sleep apnoea to outpatient clinic in Sept 2013. Seen in November and the chest x-ray shows possible lungcancer. Letter is only typed up in January 2014 and mailed to GP in March 2014. By that time the GP had long sorted out the cancer investigations


  • Ongoing problems with the same intellectually impaired man referred to in 2007. Care arrangements repeatedly fall apart
  • 65+y old male sent home to hospital in the home after a lengthy admission with bone infection. No communication with GP so not aware of any of this when patient attended for his routine prescriptions – advised GP would only be contacted once all treatment are completed despite patient being at home.
  • 75+y old non-English speaking demented insulin dependent patient staying with elderly mild dementia and non-English speaking husband. Became too unsettled in ward at hospital and sent home on oral antibiotics. GP advised by discharging junior doctor to check her sugars at home in the morning and at midnight as they are concerned her readings might be too high. Concerned that she may be delirious and GP instructed to do a full work-up at home to exclude this – after being discharged from hospital.
  • 65+y old man discharged after major abdominal surgery. Advised to attend his GP every second day for wound dressings with no contact with GP. GP does not have these dressing materials at Surgery nor can the patient afford to purchase it privately. Unwell patient advised by discharging team to call the Specialist, under whom he was admitted, for a an appointment – nothing done while he was still an in-patient
  • 65+y old man admitted with multiple serious issues. Team blames his respiratory failure on his opioids. GP calls multiple times and pleads that the inpatient time is used to rationalise and reduce his many medications. This is all ignored and patient is discharged on 50% more opioids than he went in on. This resulted in a lengthy re-admission within days of being discharged.
  • 70+y old obese alcohol dependant man is admitted for repair of a hiatus hernia. He has severe sleep apnoea that he is refusing treatment for. Despite several phone calls to treating team by GP he is discharged on large doses of opioids to an un-monitored situation at home with only his elderly wife to take care of him.
  • 20+y old with severe psychiatric disorder and chronic pain issues. Everytime she presented to the hospitals over the last eight years she is given escalating doses of opioids. GP spends an enormous effort on weaning her off these drugs and arranging a management plan in conjunction with chronic pain unit. This is discarded after a few years at ED and patient is again given opioids when she presents – GP complains and tasked to draw up new management plans with no explanation  provided why the existing plans were discarded


  • 75+y old presents to ED with septicaemia after an overseas trip and injury. Provided with a script for Endone – not documented on his discharge at all. Sent home on some oral antibiotics and presents very unwell a few hours later at GP. Has to struggle to convince hospital team to admit him but when they do he remains an in-patient on IV antibiotics for several weeks
  • 90+y old admitted to hospital with infective exaccerbation of emphysema and a bladder infection. Severe very longstanding anxiety disorder. Treated for infection but anxiety medication ceased by hospital team as it could suppress her breathing. At the same time the team tells her that she is severely unwell and likely to die from her lung disease. the only communication with GP is by a hospital pharmacist who wants to clarify what her allergies were. No attempt is made by any hospital doctor to contact GP and discharge letter is sent to current GP but addressed to a previous GP elsewhere. Nothing is done to address the anxiety which was worsened by the news the team gave the patient. Patient sent back to nursinghome with instructions for care that is not available at the nursinghome. No attempt at a proper handover to the GP despite contact by GP’s Registrar prior to admission.
  • 90+y old admitted to hospital with broken hip. X-rays on admission shows he has pneumonia. Hip is operated on and he is sent back to Nursinghome a few days later without the pneumonia ever being treated. He is sent back on oxygen, on a Friday morning without advanced warning resulting in the facility not having access to oxygen for the patient. The discharge summary contains a multitude of errors and completely ignorers his inability to walk prior to the fall and previous strokes  affecting his swallowing. Despite this he is placed on treatment for osteoporosis (takes years to start working, large tablets that he cannot swallow and life expectancy weeks at most). Family is not informed about his pneumonia and hospital even loses his dentures. Patient dies three weeks later.
  • 65+y old presents by ambulance unwell with chest symptoms to ED. Known to have lymphoma in remission and past chemotherapy. discharge states he has flu and sent home on Paracetamol. Patient re-presents to GP and mentions that he had x-rays and bloods at hospital – not recorded in discharge. GP chases up these results and finds out patient has pneumonia and commences treatment. . Reported to ED and three weeks later still waiting for an explanation
  • 65+y old identified by GP as being seriously unwell and sent in to hospital. His various Specialists are advised and GP sends them written updates every time patients is seen at GP for the previous six months. He is admitted under one of these Specialists at Calvary for six weeks this time. Despite significant and serious ongoing health issues and major medication changes there is no attempt to coordinate his discharge with the GP – he is instead discharged on a Friday afternoon with instructions to make sure he saw the GP on the next work day (the Monday) and the patient is to make his own appointments with the Specialists under whom he had been admitted at their various private rooms. Patient is reviewed at rooms and is clearly narcotised by the 25% increase in opioid dosage from recent admission. He is re-admitted a few days later, discharged two weeks later with a further 40% increase in his opioid dosage. GP spoke to team three days before discharge and was advised incorrectly that opioid dose had not been changed
  • Adult female attends ED with kidney infection. Discharge states this diagnosis but givens no details at all of what was found on examination, what tests were done and how she was treated.
  • Young female admitted with possible rheumatic fever – discharged with her heart echocardiogram results pending – no attempt made to ensure these results are copied to GP and instead GP is instructed by Intern to “chase” the results.

(I thought I would give it a break but sadly we are having case after case of mismanagement so in 2017 I am adding the list


  • 80+y sent in for cancer surgery. Seen quickly and has major surgery quickly
    • Sent home two days after major surgery with only support person being demented partner at home. Poorly coordinated community nursing organised
    • Seen by us a week later with sepsis. Admitted to hospital for nearly two weeks
    • Minimal observations in hospital as too distressing for patients so just left it undone. Likewise woundcare and bloodtests
    • Distressed unwell patient concerned re demented partner at home and declines home support. Clearly a very bad decision but decision unchallenged and patient sent home 3PM on a Friday with NO communication with GP other than an electronic discharge letter that is found in inbox that evening
    • Patient has advanced cancer and probably unable to tolerate chemotherapy – despite this patient has not been told any of this formally a MONTH after surgery nor has anything about this been communicated to GP
    • Seen at home. Multiple dressings in place, large fluid collection in wound that needs draining, NO community nursing for woundcare in place.
    • Patient unaware of calls that has been made to demented partner regarding aged care assessment (and palliative referral probably more appropriate) nor of the specialist appointments that was supposed to be made.
    • Neither patient or partner can drive
    • GP and Practice Manager at our small clinic has spent over six hours in the last four days trying to sort all of this out – all unpaid time (for GP who is however paying the staff member’s wage) while other patients are kept waiting or until late in the night
    • Many more weeks of phone calls followed
    • A formal investigation is underway at the hospital after GP e-mailed CEO about the matter (although CEO did not bother directly advising GP this was the case) – deadline (as offered by hospital) for providing GP with feedback has passed and no report seen as yet.
    • Patient has seen Surgeon several times with no feedback to GP. GP finally received a call from Surgeon’s office and then discovered that there were letters dictated to the GP – that was sent to a GP interstate that the patient has never met. GP was promised copies of these letters – ended up receiving copies of one pre-operative letter and nothing else
    • GP was the first health professional to track down the results and sit the patient down for a frank discussion regarding poor prognosis – SIX WEEKS post surgery.
  • 80+y sent in for cancer surgery. Seen quickly and has major surgery quickly at private hospital.
    • No communication from surgeon and only paperwork is nursing discharge stating that referral is done for drain and wound care to community nurses and physios
    • Patient stays on farm just across border in NSW therefore ACT services refuse to see him and he is advised to attend closest NSW service 40km away. This all happens three days after discharge
    • Patient and elderly partner attends closest ACT public ED for woundcare – TURNED AWAY and advised to go the NSW service
    • NSW service helps once and then advise patient to make appointment for further services. Patient attends GP in ACT out of desperation
    • GP does not have the specialised equipment to deal with the drainage system and tries to do what can be done. Calls the private surgeon with no attempt from surgeon to take the care on other than advise what nurses should be doing
    • Multiple calls and letters later patient & partner still stuck with having to drive 40km to NSW facility and 40km back when care is required
    • Patient seen by Surgeon for follow-up. NO feedback of ANY sort to GP about the review or preceding concerns. All communications via the patient’s elderly, frail and often confused partner
    • Request from patient for more Endone – GP was totally unaware patient has been placed in Endone which was completely inappropriate given other health issues. Switched to plain paracetamol with good response.
    • GP sends surgeon yet another strongly worded letter advising that he considered any further referrals unsafe given the communication issues. Surgeon replied by text that issues would be addressed. Copies of letters received a few weeks later.


  • 71y with multiple serious health issues (featured a few times on this list). Unstable low bloodpressure, very severe osteoporosis, chronic leg ulcers, bone infections, grossly obese, huge pleural effusions, on bloodthinners, fall muscle tears and ? fracture during a two month’s inpatient care, renal failure, heart failure, traumatic head injury, longstanding opioid dependence. Patient usually housebound and gets fortnightly, pre-arranged home visits by GP and requires a bariatric ambulance to get to any other appointments
    • Only feedback to GP during the two months’ admission was feedback from elderly wife who is also very unwell
    • Was supposed to go into permanent nursinghome care on discharge
    • GP comes in to work on Monday morning to discover a discharge indicating the patient has been sent home 2PM on the preceding Sunday with:
      • Instructions to deal with his inadequate blood thinners via his GP on Monday
      • For GP to organise bloodtests within a week
      • To attend a fracture clinic review for a possible fracture in his hand on the other side of town in two weeks
      • To have physiotherapy (see above re. lack of mobility and ability to attend appointments)
      • For the GP to reduce his opioid use as they were unable to do this in the hospital – and sent him home with a ONE day supply of Endone
      • Advised to send him to a chronic pain unit (other side of town, twelve month wait)
    • GP sees the patient at home a week later, at night, to sort out the mess. An hour long consultation followed by another hour of paperwork to try and sort issues out. Significant discrepancies between the discharge documents and the patient & wife’s version.
    • Patient unable to find a bed in a nursinghome so expectation is that he will rebound into the hospital system within weeks. In the meantime GP is trying to persuade ACT Government’s Chief Pharmacist to allow the continued prescription of the opioids
This entry was posted in Communication, Discharges, Medical, Medical ethics and tagged , , , . Bookmark the permalink.

3 Responses to The wall of shame

  1. Bob Birks says:

    The local health public system is multiply deficient when it comes to longer-term care of the aged, infirm and mentally ill. I would suggest the following:
    Send a copy of every critical communication to a media address list, including local journals, TV and radio stations, and local public blogs. Be prepared to get in front of a TV camera on occasions. Also involve ACT Federal reps and senators, and ‘interested’ private organisations. No-one is going to pay attention until you shine a media spotlight on them, or there’s a parcel of votes at stake.
    It probably goes without saying that you must have your facts absolutely straight, and you should take great care to avoid the imputation of libel against particular individuals.

    • Thinus says:

      Sadly this has not worked in the past. One would think they would jump at the opportunity for such a juicy story but it appears to be a poisoned chalice. And I have taken great care to de-identify and be sure of the facts

  2. Pingback: Is being a diligent GP worth it? | Dr Thinus' musings

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