What drives nurses and midwives to turn whistleblower and report wrongdoing outside their organisation? What ramifications surface personally and professionally in the aftermath? Robert Fedele investigates.

If you’ve got a gut feeling that something is wrong it probably is wrong,” says Toni Hoffman, perhaps Australia’s best-known nurse whistleblower.

“Even if it takes a bit of investigation and it’s not wrong, well that’s fine, at least you’ve checked it out.”

Ms Hoffman made national headlines in the mid-2000s after she blew the whistle on the lack of action by the Bundaberg Base Hospital in Queensland after she and other nurses reported concerns about the poor surgical outcomes and patient deaths related to surgeon Dr Jayant Patel.

She was the Nurse Unit Manager (NUM) of the Intensive Care Unit (ICU) at the hospital at the time. She felt compelled to act in a bid to protect patients following a string of ‘disastrous events’ related to Dr Patel’s clinical and surgical competencies.

Ms Hoffman lodged numerous complaints internally, beginning just six weeks after the US trained Dr Patel started at the hospital, which fell on deaf ears.

“What they [the hospital] did was they tried to discredit me and turned on me and said I had poor communication skills and gave me a book to read on how to deal with difficult people,” she tells the ANMJ.

Ms Hoffman still vividly remembers the extensive harm caused by Dr Patel. Like the middle-aged man who had a caravan roll on his chest needing transferring to Brisbane that Dr Patel put a stop to who later died from serious complications.

Or the teenage boy who presented to Bundaberg following a motorbike accident and after three unsuccessful operations at the hospital failed to restore his circulation was flown to Brisbane where he lost his leg.

“In two years he had operated on 1,400 or so patients and out of them 1,200 had to have some form of corrective procedure. If you think of that statistically that’s just phenomenal,” Ms Hoffman claims.

Ms Hoffman did not plan on becoming a whistleblower and says reporting her concerns outside the hospital was a last resort.

While she was supported by the then Queensland Nurses Union (QNU, ANF Queensland Branch) after she spoke out, she recalls feeling undermined by management and fellow nurses because of her actions.

At that point, she turned to MP Rob Messenger for assistance as she had already followed the appropriate channels, including her Director of Nursing (DON), and had even phoned the police and the Coroner.

“We sort of knew that whatever we did [the complaints] wasn’t going to help,” she says. Mr Messenger raised the issue in March 2015 in a Matters of Public Interest speech in the Queensland Parliament.

Anomalies in Dr Patel’s registration became public when Courier Mail journalist Hedley Thomas published them in a front-page article later that year.

The actions triggered Commissions of Inquiry that investigated malpractice allegations against Dr Patel, the Director of surgery at Bundaberg Hospital between 2003 and 2005, and led to his eventual resignation and downfall.

The Davies Inquiry found the hospital executive repeatedly failed to act on dozens of serious complaints against Dr Patel and highlighted nine separate findings including performing surgical procedures restricted by previous medical boards, negligent treatment of 13 patients who died and others who suffered adverse outcomes, and failure to report 13 deaths to the Coroner.

Other findings showed he worked as a general surgeon without being registered in Queensland and failed to perform surgical audits.

The Davies Inquiry recommended Dr Patel be investigated for fraud, assault and manslaughter.

After being extradited back to Australia from the US in 2008 to face charges, he was eventually convicted of three counts of manslaughter in 2010 and sentenced to seven years jail.

But after serving two years behind bars, Dr Patel appealed to the High Court of Australia and the process eventually led to him being given a two-year suspended sentence after he pleaded guilty to four counts of fraud for failing to disclose his previous deregistration in the US.

In the end, Ms Hoffman’s actions helped change the system, with subsequent healthcare deaths requiring reporting to the Coroner and nurses given the power to report to a Member of Parliament.

“I felt vindicated but I also felt very angry and upset that what happened didn’t have to happen if a lot of people had done their jobs,” says Ms Hoffman, who was named Australian of the Year Local Hero in 2006 and received the Order of Australia (AM) for her part in advocating for patient safety.

Ms Hoffman continued to work clinically at Bundaberg up until 2012 before she took a voluntary redundancy and became a lecturer in nursing at CQUniversity.

While she would ‘absolutely’ blow the whistle again if it meant protecting patients, the impact of her decision more than a decade ago has taken an immeasurable toll. These days, she refers to herself as ‘still a work in progress’.

“The personal toll has unravelled as the years have gone on. I’ve always worked in intensive care and I was always a really good nurse, a really good clinician, and I lost all that,” Ms Hoffman says.

“The effect on me professionally, personally, financially… it’s just been horrendous. It really more or less just stops your life and you have to start over again.”

Ms Hoffman believes in the importance of nurse whistleblowing but warns it can prove catastrophic for everyone involved and should not need to happen.

“I think that our organisations should be robust enough that we should be able to deal with internal complaints correctly.

In a robust organisation whistleblowers aren’t necessary.” Dr Sonja Cleary, Associate Dean Student Experience, in the School of Health and Biomedical Sciences at RMIT University, and a practicing clinical nurse, was lecturing in Bundaberg as the hospital was thrust into the limelight.

She saw an opportunity to follow the events taking place and use the thought-provoking publicly available data at her fingertips to compile her PhD thesis, Nurse Whistleblowers in Australian Hospitals: A Critical Case Study, published in 2015.

“It occurred to me that on very few occasions will you ever get to see that level of organisational structure put in the public domain, to help us understand why it occurred,” Dr Cleary recalls.

“I remember at the time when it hit thinking nurses don’t go outside the hospital for no reason. We’re very loyal to the organisation and the medical team and you can question them inside the hospital, but it’s a significant action to go outside.”

Dr Cleary’s thesis examined the ‘social phenomena of nurse whistleblowing’ by tracing over two high-profile Australian cases – Hoffman’s at Bundaberg and the Macarthur Health Service in New South Wales – to find out what drives nurses to expose the truth.

“The theme that came out of all of them was a failure to be heard and a willful blindness,” a term Dr Cleary identifies with organisations that ignore reports about sub-standard care out of fear of liability or reputational damage.

Key findings from Dr Cleary’s thesis suggest nurse whistleblowing occurs when there is a fundamental breakdown in clinical governance and incident reporting processes.

In the cases examined, organisational responses were retaliatory, leading to a ‘social crisis’ shaped by four elements – the need to assign blame, the exercise of wilful blindness on the part of the hospital administrators, the presence of a network of hierarchal gaze and discipline, and the use of confidentiality as a mechanism to silence dissent and prevent external disclosures.

The thesis found the need to find internal psychological peace emerged as the main motivation behind nurses taking action, which they believed would come from making ‘the choiceless choice’ to stand up for patient safety.

But nurses who blew the whistle were hampered by a ‘false consciousness’ that action would be taken to address their concerns.

Recommendations were headed by calls for more effective clinical processes, so whistleblowing need never occur and investing in further research into patient safety and the experiences of healthcare staff who report wrongdoing.

“If hospitals want to stem whistleblowing then they have the power to make sure their clinical governance systems are set up to allow nurses to be heard and feedback about what actions were taken to remediate the condition they had raised,” Dr Cleary argues.

Dr Cleary’s message to nurses contemplating blowing the whistle is do your homework and get early legal advice from professional and industrial bodies such as unions.

“If you take the step of going outside the hospital and you don’t have what I call objective evidence and just have hearsay from other people, then you are in an incredibly vulnerable position.”

While Dr Cleary agrees nurses who blow the whistle are undeniably inspiring she stresses their capacity for work in the aftermath is often compromised.

“It’s not a choice you take lightly because it’s going to affect every part of your future career.

“Healthcare in the context of reputation is risk-averse. If you have somebody who has demonstrated bringing concerns to light outside the organisation, despite the fact they are admired as heroes in protecting patient safety, there is something in the back of the mind of future employers who may think ‘would they do this in my organisation?’.”

Nurse whistleblower Alanna Maycock, who spoke out on Australia’s offshore detention policy and the horrors she witnessed on Nauru, concedes there is a stigma that comes with lifting the lid.

“People assume you’re a troublemaker,” she says. “Whistleblowers are demonised and belittled. I was told that I was “exaggerating” and even “sensationalising”.

It was made very difficult by the fact that I was exposing information about a group of people that at the time the Australian public weren’t that sympathetic about.”

A paediatric clinical nurse consultant, Ms Maycock spent five days on Nauru in 2014 providing healthcare to asylum seekers in detention after being recruited as a consultant by the Australian government and contractor International Health and Medical Services (IHMS).

She encountered shocking incidents including the rape of a mother, a guard assaulting the father of a child she was caring for, and a six-year-old girl attempting to hang herself with fence ties.

Ms Maycock helped write a 17-page report for IHMS that outlined recommendations on how to improve services on Nauru, but they were ignored.

Upon returning to Australia, she and colleague Professor David Isaacs turned to the media and began writing a series of newspaper articles exposing what they saw and the damage to the health of refugees, particularly children.

“It’s not a decision that was taken lightly [whistleblowing]. I lived in fear that I wouldn’t receive any support amongst my colleagues and may even lose my registration to practice,” Ms Maycock recalls.

“You’re encouraged to go up your usual reporting lines if you feel something’s incorrect in the workplace but actual whistleblowing is something very different. I was reporting a whole culture of abuse, not just a single incident.”

Ms Maycock continued to speak out despite facing the prospect of up to two years’ jail time when the Australian Border Force Act came into force in 2015 in an attempt to silence the reality experienced at the detention centres.

She was the sole nurse among 40 health workers and humanitarian staff, both former and current workers at Australia’s offshore detention centres, who wrote an open letter defying the government’s then-new law, emphasising the absence of adequate child protection and legal obligation to report abuse.
“This for me was more than just whistleblowing within the nursing profession,” Ms Maycock explains.

“I found myself involved in the politics of this issue. The Australian government had introduced a policy to suppress doctors and nurses, escalating incidents that would affect the health of their patients, such as child abuse. Nurses are mandatory reporters.” Ms Maycock admits blowing the whistle over the past few years has taken a toll both personally and professionally.

However, instead of wavering, her advocacy grew. Ms Maycock, who coordinates a Refugee Clinic at Sydney’s The Children’s Hospital at Westmead, last year recruited several paediatricians from across the country and trained them, along with her internal team, to undertake medical assessments via video link calls on children and families in detention on Nauru.

The medical assessments and medico-legal reports, which uncovered children as young as six not eating or drinking and “resigning from life”, were then used to assist lawyers in court to advocate that children were transferred from the island to Australia for lifesaving medical treatment.

“We said we are going to do them [the assessments]. This is the right thing to do. These children are dying and we need to get them specialist medical treatment immediately.”

The efforts contributed to major change and earlier this year the last of the remaining children in detention on Nauru were taken to safety. Reflecting on her experience as a whistleblower, Ms Maycock says it wasn’t easy but nurses have a duty of care to their patients.

“I really believe that we need to support nurses when they think about whistleblowing. We report because we care for our patients. Unfortunately, nurses are isolated and bullied when they blow the whistle. This has created a culture of fear in the nursing profession and if nurses are too scared to report, this will ultimately affect the health of patients.”

This article was republished with permission of the Australian Nursing & Midwifery Federation (ANMF)