The Black Death of Queensland Health
Speech by Tony Morris QC
Chairman, Ladies and Gentlemen.
The O’Rourke Family has made an exceptional contribution to surgery in this State. Recently, Dr Michael O’Rourke was “press ganged” by Queensland Health to take over as Director of Surgery in Bundaberg, after Jayant Patel fled back to the United States. His nephew, Dr Nicholas O’Rourke, is one of the outstanding surgeons of the current generation. Another of his nephews is Mr Richard Douglas SC, Senior Counsel assisting the Davies Inquiry. But I want to begin by saying something about the late Dr Des O’Rourke, brother to Mick and father of Nick.
Des O’Rourke is remembered as one of the great Hospital Superintendents, both in Bundaberg and subsequently in Toowoomba. He was also a real doctor.
I have been criticised for using the expression “real doctor” to distinguish medical practitioners who actually practise medicine, from those who hold purely administrative posts. According to my dictionary, the word “doctor” has two primary meanings. One meaning refers to individuals who are awarded university doctorates – not mere bachelor’s degrees, such as the standard MBBS held by most medical graduates in this State. The other applies to individuals who treat the sick. To my knowledge, people like Steve Buckland and John Scott – as employees of Queensland Health – did not fall within either definition. But I digress.
The point I was making is that, despite holding the position of Medical Superintendent, Des O’Rourke was a “real doctor” in the latter sense: he not only ran those hospitals; he actually performed surgery and treated sick people. These days, his kind of Medical Superintendent has become unfashionable in larger Queensland public hospitals. And Des O’Rourke is probably a good example of why it has become unfashionable – he had this bizarre notion that the health of patients was more important that bureaucratic paperwork or balancing budgets. No wonder he had to go. In the end, the mandarins of Charlotte Street had him frog-marched from the grounds of Toowoomba General.
I am told that, when Des O’Rourke was Superintendent in Toowoomba, the hospital experienced a problem with an antibiotic-resistant bacteria infecting one of the wards. His solution was typically practical, although somewhat unorthodox. He acquired a number of mirrors, and had them set up throughout the ward to shine sunlight into every nook and cranny. He reasoned – correctly, as it turned out – that the infectious bacilli could only survive in the dark.
Today, new and much more virulent organisms are threatening the health of this State’s public hospital system. These pathogens have evolved an immunity to even the most powerful remedies.
There are several species involved. The more widespread, low level infections consist of two in particular – Mathematicus fabarum vulgaris, the common bean counter, and Propellor papyri molestus, the officious paper pusher. Less common, but more dangerous, are Simulatus census, the falsifier of statistics, and Medicus maledictus, the spin doctor. However, the very worst outbreaks have been associated with Procurator malignus – the mordacious bureaucrat.
Any attempt to control these infections by conventional means is worse than useless. Even if you get rid of significant numbers, you are left with the strongest and most harmful. Those remaining are hardier, and even more resistant to control.
The only treatment which has any chance of success is the treatment pioneered by Dr Des O’Rourke. These organisms, inhabiting the dark recesses and crevices of the public hospital system, are susceptible only when exposed to direct light. Experimentation which I have conducted over recent months shows that even the threat of exposure sends them into frenzied paroxysms - like Dracula, they crumble to dust when subjected to direct sunlight.
Professor Con Aroney has described the conduct of such creatures as “sociopathic”. To understand what Professor Aroney means by that, I have done a little research of my own. According to one source, a sociopath appears normal, and is therefore not easily recognisable as deviant or disturbed. Although only a trained professional can make a diagnosis, the clinical indicators associated with this personality type include: glibness or superficial charm; a grandiose sense of self; a lack of any remorse, shame or guilt; callousness or a lack of empathy; and a failure to perceive that anything is wrong with them. Sociopaths are described as authoritarian, secretive, manipulative, paranoid, and pathological liars.
Those who think that Professor Aroney was guilty of exaggeration when he applied the expression “sociopath” might care to look at a particular document generated out of Queensland Health’s headquarters in Charlotte Street – a so-called “risk rating matrix”. This document, we were told, is designed to assist staff in categorising the seriousness of an adverse incident. A death – whether resulting from medical malpractice, or resulting from a workplace health and safety incident – is regarded as a “major” issue. On the other hand, “significant damage” to Queensland Health’s own reputation is an “extreme” issue. Who, but a sociopath, could have designed an official document which regards the death of a human being – any human being, whether a patient in one of the Department’s hospitals, or even an employee of the Department – as a less serious matter than an injury to the Department’s own enviable reputation?
What is the extent of this pestilence? To describe the situation as a pandemic is no exaggeration. The best figures I have been able to obtain suggest that the total staff of Queensland Health is about 64 thousand. Of these, fewer than 15 hundred are doctors, and some 13 thousand are nurses. For every single medical professional who actually provides clinical services to patients, there are four other people on the Queensland Health payroll. To be fair, these include some people who perform vital functions – wardsmen and catering staff, cleaners and laundry staff, gardiners and maintenance staff, laborotory technicians, electrical and mechanical engineers, and so forth. But the fact remains that four out of every five employees are performing non-clinical duties.
What are the consequences of this plague? Seventy years ago, Queensland led – not only Australia, but the entire English-speaking world – in the provision of a universal free public hospital system. As recently as thirty years ago, we not only had the best such system in Australia – in fact, we had the only such system in Australia. In a mere three decades, Queensland has gone from the top to the bottom of the list – from the best to the worst – regardless of what comparative criteria you use.
Our doctors and nurses are amongst the lowest paid in the country. Our waiting lists are amongst the longest. The ratio of medical practitioners to population is amongst the worst. Mortality rates are amongst the highest. Per capita expenditure on public health is amongst the least.
There are good demographic reasons why Queensland should be spending more on medical care than any other State or Territory. Geographically, we are one of the largest and most decentralised States – the only mainland State in which more than half of the population lives outside the capital. We have an ageing population, fuelled by retirement refugees from the Southern States; but, at the same time, our workers are more likely to be employed in physically arduous and dangerous occupations, such as the mining and agricultural industries. We face the unique challenges of sub-tropical and tropical diseases – the health consequences of being the “Sunshine State”. We are exposed to both the epidemiolocical factors affecting major population centres an the South-East of the State, and the very different (but equally significant) challenges involved in the provision of health-care to regional, rural and remote centres – centres which are as far from Brisbane as Moscow is from London, as remote from Charlotte Street as Hong Kong is from Singapore.
In the 1930s, when Queensland established the first universal free public hospital system in the English-speaking world, we were one of the poorest States in the nation. Since the 1970s, the Federal Government has taken over responsibility for a large proportion of the cost of providing public medical services. We are now, on a per capita basis, one of the richest States. That we have allowed our public hospital system to fall into this state of decrepitude, in just three decades, is an indictment on governments of all political complexions. And it is a seering indictment on the bureaucrats who have presided over the collapse of a medical infrastructure which, at its prime, would truly have justified us in calling ourselves the “Smart State”.
When we come to the Jayant Patel phenomenon, what we should understand, very clearly, is that it was never more than a secondary infection – an opportunistic or adventitious disease, which took advantage of a body already weakened and debilitated by years of under-nourishment, and invalided by the primary infection which had destroyed all of its defence mechanisms.
Jayant Patel could have caused no harm, in Bundaberg or anywhere else in Queensland, if our public hospital system was not already moribund. There was no shortage of safety measures, supposedly in place to prevent such a biomedical disaster. Even if one or two had failed, others should have cut in. For Patel to have practised as a surgeon at Bundaberg for two whole years, killing and maiming dozens of patients, required an environment in which every line of defence had been breached – or had simply disintegrated through neglect.
To start with, it required a Medical Board which made no serious attempt to check out his credentials – despite having documentation, provided by Patel himself, which, on close scrutiny, would have alerted any careful enquirer to unresolved problems in Patel’s professional background. It required a Medical Board which was content to take the word of Patel that he was duly qualified and fit to practise surgery in Queensland; a Medical Board which was content to take Patel’s word, just as it had taken the word of a man named Borg – an alleged paedophile, convicted thief, and self-proclaimed Bishop of the Russian Orthodox Church – that he was duly qualified and fit to practise psychiatry in Queensland; a Medical Board which seemingly learn nothing from its past mistakes, even after Berg was exposed as an alleged fraud. It required a Medical Board willing to assume than a private employment agency – a private employment agency which was expecting to earn about $13,000 for placing Patel in Bundaberg – had conducted all the necessary checks with Patel’s previous employers and professional referees.
Next, it required a public hospital system to employ Patel as a surgeon, without making even the most rudimentary inquiries or investigations regarding his previous employment or professional standing. A private company would be expected to take more care in employing a night-watchman. It would have been harder for Patel to get a job, stacking shelves at Woolworths.
Above all, Patel’s employment in Bundaberg required a health system which was driven by budgets, statistics, and other bureaucratic falderal – a health system which was totally oblivious to the welfare of patients. The primary object in appointing Patel to the vacant surgical position was to find somebody – anybody – who could be relied upon to work long hours for a modest salary, without making waves with his bureaucratic masters. The standard of his surgical skills was an irrelevancy.
There is no other explanation for the fact that Patel was appointed to Bundaberg as an “area of need”. Even to describe Bundaberg as an “area of need” is laughable. Bundaberg not only possesses one of the top dozen public hospitals in Queensland; it also has two private hospitals, which surely would have closed their doors long ago, if it were truly an “area of need”. First class surgeons – surgeons of the calibre of Dr Brian Theile and Dr Pitre Anderson – were living and working in Bundaberg, but were not welcome at the public hospital. Other surgeons – competent and even outstanding surgeons like Dr Charles Nankivell, Dr Sam Baker, and Dr Lakshman Jayasekera – had been willing to work in Bundaberg, but were driven away by a public health system which did not value their qualities. Dr Geoffrey de Lacy – an exceptionally competent surgeon and former director of surgery at the QEII Hospital – arrived in Bundaberg shortly after Patel, but was excluded from the Bundaberg Base Hospital because they already had what they wanted in Jayant Patel.
They, the bureaucrats, had exactly what they wanted: a compliant surgeon. A surgeon who could be trusted to fill in the right forms – no matter whether the information which he entered into the forms bore any resemblance to the truth. A surgeon who would show respect, deference even, to the non-clinicians who presided over the hospital’s administration – no matter that he was intolerably rude to lesser mortals amongst the hospital staff, such as the nurses and junior doctors who actually looked after patients. A surgeon who was ready to move into action at a moment’s notice, even if there was no time to wash his hands after going to the toilet, or to change his surgical gown after slipping out to the carpark for a quick fag – even if there was no time to ensure that the patient was properly anaesthetised before Patel started to work with the scalpel. A surgeon who not only operated within his budget, but even made a positive contribution to the budget, by achieving the hospital’s quota for elective surgery, and by helping to educate a new generation of surgeons with his own unique insights into surgical practice.
Why would any bureaucrat want to work with Brian Thiele, or Charles Nankivell, or Sam Baker, or Geoff de Lacy – Australian-trained surgeons of impeccable standing and ability – when they had the choice of a Jayant Patel ? All else aside, just think of the money which Patel generated for the Bundaberg Base Hospital. Under the Byzantine system of “weighted separations” adopted by Queensland Health, hospitals are rewarded for doing especially difficult or dangerous elective surgery, and the rewards are even greater if the patient is seriously ill. Who but Patel could have been trusted to perform unnecessary and impossibly complex operations on patients who were already close to death’s door, thereby filling the hospital’s coffers with much-needed pieces of silver ? And if the patients died – as they often did – so much the better: post-operative care is an expensive business, and Queensland Health offers no financial incentives to hospitals which actually keep their patients alive.
But that only got Patel to Bundaberg. For him to be appointed as Director of Surgery, the local hospital administration had to break every rule in the book. Patel’s employment at Bundaberg had been approved by the Medical Board on the condition that he be supervised by the Director of Surgery – nobody thought to mention to the Medical Board that Patel was in fact going to be employed as the Director of Surgery, not supervised by anyone. Credentialling and privileging procedures, which are supposed to ascertain a specialist’s level of competence and to set limits for the procedures which he or she is permitted to undertake, were simply ignored. There was not even an interview panel – or any of the other usual and proper processes – to fill the vacancy.
It has been suggested that Patel was merely appointed as “the Acting Director of Surgery”, to circumvent the procedural requirements to fill such an important position on a permanent basis. But not a single piece of paper seems to exist, anywhere, in which Patel described himself – or anyone else described him – as anything other than “the Director of Surgery”.
Yet, even if Patel had somehow obtained that position through the appropriate channels, there were still further safeguards, supposedly in place, to protect the people of Bundaberg; indeed, the people of Queensland. Peer review systems, such as Mortality and Morbidity Committees – systems by which the performance of one surgeon was to be reviewed by his or her professional colleagues – ought to have picked up problems with Patel’s surgical practice. But Patel himself, as Director of Surgery, was put in charge of such systems for the Surgical Department at Bundaberg. Not surprisingly, the systems over which he was appointed to preside failed to detect his own incompetence.
On paper, Bundaberg had every safeguard imaginable – and then some – to detect and deal with such biomedical disasters: every committee, every clinical forum, every departmental meeting, every system for recording and documenting adverse events and complaints. Even the most fastidious bureaucrat, conducting an audit of Bundaberg’s quality assurance systems, could have ticked every box. Surely, with this state of the art array of alarm bells, one of them had to go off, sooner or later!
The truth is that the alarm bells did start to sound, perhaps faintly at first, but fairly quickly nonetheless, and with increasing volume as the body-count mounted. However, an alarm bell is utterly useless, unless someone is listening – someone, that is, in a position of authority, both willing and able to react. By Christmas of 2004, even the suite of executive offices at the Bundaberg Base Hospital – though protected behind glass doors to maintain an appropriate air-conditioned ambience for the delicate administrative staff who were stationed there, between 9.00 am and 5.00 pm on weekdays; and though far removed from the clinical departments of the hospital – must have been reverberating to the tintinnabulation of alarm bells. Yet nothing happened.
One of the ultimate protections against medical malpractice – at least in cases where it produces fatal consequences – is the Coroners Act, under which it is mandatory to report any death which (and I quote) “was not reasonably expected to be the outcome of a health procedure”. But even that did not stop the Patel juggernaut. Of the 13 deaths which have been identified as connected with sub-optimal care on his part, only one was reported to the coroner. Of the remaining 12, none was the result of emergency surgery – they were all “elective” operations, in the sense in which that term is used by Queensland Health: in other words, they were operations where the patient’s survival did not depend upon urgent surgery. Without the benefit of the Patel experience, one might have thought that any death resulting from “elective” surgery would be regarded as unexpected.
Sir Arthur Conan Doyle – the medical practitioner who created the character of Sherlock Holmes – observed that: “When a doctor does go wrong he is the first of criminals. He has nerve and he has knowledge.” The Coroners Actcertainly offered very little challenge to a man of Patel’s ingenuity. So what, if a patient died in the course of elective surgery ? The cause of death was clear enough – massive blood loss. And how could anyone say that a death is unexpected, when the patient has suffered massive blood loss – that is exactly what you would expect ! So, of course, there was no need to report the matter to the coroner ! But, just in case, we had better get the most junior and inexperienced doctor on the surgical team to sign the death certificate – after all, when you have a medical career as chequered as Jayant Patel’s, you don’t want to go around signing bits of paper which may come back to bite you.
There is one final line of defence in our medical system – indeed, most medical systems – against the likes of Jayant Patel. When all else fails, there remain the loyal, hard-working, competent and conscientious clinical staff – the Toni Hoffmans and the Peter Miachs of this world – to blow the whistle. They are the white blood cells in the medical system’s body politic – the final, natural, defensive barrier against dangerous pathogens.
Tragically, though, the most dangerous pathogens which have infected the body politic of Queensland Heath – Procurator malignus, the mordacious bureaucrat – is in the nature of a retrovirus: its first function is to destroy the body’s natural defences, to kill off the white blood cells which protect the body from infection and disease. Whistleblowers are lucky if they are just ignored – the moment they show any sign of being effective, the retroviruses go all out to destroy them first.
That is why it takes courage – extreme courage – for a Toni Hoffman or a Peter Miach to blow the whistle. They are acutely aware of the consequences: the risk of being sent to Coventry; the risk of facing trumped-up disciplinary complaints; the risk of having their work hours re-scheduled to less convenient times; the risks to their prospects of career advancement; indeed, the risks to their entire careers. But white blood cells are like that – they go into battle against dangerous pathogens, despite every risk that they will be destroyed in the process.
As I have said, the only treatment which can work against these dangerous pathogens is the treatment pioneered by Dr Des O’Rourke – to expose them to light. That is what Toni Hoffman did, with the assistance of Mr Rob Messenger and Mr Hedley Thomas. I am confident that there are many others out there – nurses and doctors – prepared, if necessary, to take the same risks and make the same sacrifices as Toni Hoffman, for the ultimate protection of patients. But the viability of our public health system cannot be left to depend on individuals willing to take such risks or to make such sacrifices.
Mr Peter Forster has suggested some changes to our public health system. He has suggested that more money is needed, and he is undoubtedly right. He has suggested that some bureaucrats have to go, and again he is undoubtedly right. But he does not seem to have suggested any systemic changes which will ensure a full and permanent recovery. He has offered symptomatic relief, but he has not treated the disease. He has prescribed a course of antibiotics, which may reduce the number of dangerous pathogens, but will not eliminate all of them – and which may well leave the most viralent even stronger, and more resistant to control.
What Queensland Health really needs is systemic reform – changes which will ensure that the curtains are torn down, and that light floods in to every dark corner and corridor, so that the pathogens can no longer fester in the impenetrable gloom which is their natural habitat:
We need added protection for “whistleblowers” in the public health system, including provisions enabling people to report their concerns to Members of Parliament, unions, professional associations, and the media.
We need to address the impossible conflict of interest which exists within Queensland Health, which is currently both the largest provider of healthcare services, and also the principal regulatory body overseeing the provision of healthcare services, in this State.
We need to create both the appearance and reality of genuine independence, by stripping away from Queensland Health, and investing in a separate commission, responsibility for matters such as the registration, credentialling and accreditation of health practitioners and health facilities; monitoring of internal and external complaints; clinical audits and reviews; maintenance of institutional standards across all Queensland Hospitals and healthcare institutions; and oversight of professional standards and disciplinary issues.
We need to give local communities, particularly outside Brisbane, “ownership” of their own hospitals, and a genuine role in the decision-making process.
We need need to ensure that practising clinicians – doctors and nurses, and allied healthcare professionals – have genuine representation in hospital management.
We need to address the reputation of Queensland Health for “bullying” staff, and for adopting a “shoot the messenger” attitude.
We need to re-educate – or replace – administrative and managerial staff, particularly at District and hospital level, to be an effective part of the clinical team, rather than remote and aloof from the day-to-day clinical activities undertaken within a hospital.
More than anything else, we need to change the culture within the Department’s administration, so that clinical problems are addressed in an open, frank and honest way, so that members of the general community are not given unrealistic expectations as to the services available to them from the public health sector; so that individuals can plan their own health needs and requirements in full knowledge of any limitations or delays existing in the public sector; so that members of the community who are dissatisfied with the level of services available in the public sector can express their concerns, in the appropriate democratic way, through the ballot box; so that administrators and clinical staff can sensibly plan and budget to provide the best healthcare service possible within available funding; and so that individual clinicians, both within and outside the public sector, can provide meaningful and realistic advice to patients regarding their prospects of receiving appropriate and timely treatment in the public sector.
Such measures are a very minimum. But they are required, not only to ensure that a Patel-like situation never occurs again. Without such measures, Queensland will never again have the world-class healthcare system which is appropriate for a community in which the expression “Smart State” is something more than a glib political catch-phrase.
I imagine that most of you have come here today in the hope – possibly even the expectation – that I will say something controversial. Far be it for me to disappoint you. Given that all I have said so far is fairly uncontroversial, I should like to end by saying something about the circumstances of my removal as Chair of the Bundaberg Hospital Commission of Inquiry.
It would, of course, be completely inappropriate for me to question the correctness of Justice Moynihan’s decision. But what I wish to say is this: on the assumption that decision of Justice Moynihan correctly states the law in Queensland, the law must be changed.
Over the past quarter-Century or so, serving judges have withdrawn from participating in public inquiries, here in Queensland and elsewhere in Australia. There is a good reason for that. Such inquiries deal, almost invariably, with matters of intense public controversy. For a serving judge to participate in the public airing of controversial issues has the real potential to bring the courts and judiciary into partisan political debate, and to undermine the fundamental separation between the legislative/executive and judicial branches of government.
Recent history has also shown that judicial experience does not necessarily equip a person to conduct an effective public inquiry. For example, in the three decades between 1960 and 1990, three separate inquiries were conducted in Queensland concerning, broadly, the administration of criminal justice. Two were chaired by serving judges of the Supreme Court; the third by Tony Fitzgerald QC.
Chairman of the first was Sir Harry Gibbs, then a Judge of the Supreme Court of Queensland, later a Justice and ultimately Chief Justice of the High Court of Australia, and one of the most distinguished legal minds ever produced in this country. The Gibbs Inquiry concerned prostitution at the National Hotel in Brisbane. Gibbs was subsequently known as “the only man in Queensland who could not find a tart at the National Hotel”.
In the late 1970s, Justice Lucas of the Supreme Court of Queensland chaired an inquiry into the enforcement of the criminal law. Lucas, himself a very distinguished member of the judiciary, was assisted by Mr. Des Sturgess QC, one of the State’s most respected criminal barristers, and also by a retired superintendent of police. The Lucas Inquiry was marginally more successful than the Gibbs Inquiry in identifying instances of abuse of police powers, and concluded that there must be “more effective control over police activity than there has been up to the present moment”; but recognised that it would be a “task of considerably great difficulty … to lay down how this control should be exercised”. That is where it ended.
Then came the seminal Fitzgerald Inquiry. Gough Whitlam, who has his own reasons for not being a great fan of the late Justice Gibbs, has observed that an extraordinary phenomenon occurred in Queensland in a little over 20 years. The results of the Gibbs Inquiry suggested that police corruption was entirely absent from Queensland. Yet, in just 20 years, the situation had deteriorated to the point that the Fitzgerald Inquiry was able to identify police corruption throughout the State, from the highest ranks of the Police Force down. In another speech, Whitlam was more direct: “police corruption continued to have immunity as a result of the incompetence of Sir Harry Gibbs”.
One therefore cannot cavil with the principle that serving members of the judiciary should not participate in public inquiries. But, whilst judges have withdrawn as participants in public inquiries, they have become more active in controlling public inquiries from the outside.
An inquiry is not a judicial exercise – it is an investigative process. Our justice system, as compared with the justice systems in some other countries, is based on the central notion that (with the exception of coronial inquests) a judge has no role in the investigation of criminal and other matters. It is only once the investigative process is complete, whether in a criminal or a civil matter, that a judge sits in a position of strict neutrality, impartially hearing the evidence which the competing sides – including, in criminal matters, the executive government, through the Police Service and the Office of the Director of Prosecutions – has gathered and presents in the form of admissible evidence.
The process of a public inquiry, whether described as a Commission of Inquiry or a Royal Commission, is totally and fundamentally different. The Inquiry conducts its own investigations. Within its Terms of Reference, it decides what issues to pursue, what investigations to conduct, and what evidence to produce. It is something totally foreign to our Anglo-Australian judicial system: it is closer to the role of an “investigating magistrate” in the legal systems of many countries of Continental Europe. This squarely raises the question whether – and to what extent – the principles regulating the exercise of judicial power should be extended to public inquiries.
As I have said, it would be completely inappropriate for me to question the correctness of Justice Moynihan’s decision. It is regrettable that there was no appeal, if only because the decision of an appellate court might have resolved some apparent inconsistencies between Justice Moynihan’s approach and the approaches which have been taken by other distinguished judges on other occasions, and thus provided guidance for future public inquiries.
Take, for instance, the observations of Justice Jim Thomas in the case of Carruthers v.Connolly, who remarked:
“It is not to be expected that Commissioners who are appointed to examine and make recommendations on matters such as those entrusted to these Commissioners should be devoid of a sense of social, political, moral or economic direction. The main question in the end will be whether a Commissioner is reasonably open to persuasion and seen to be so.”
Elsewhere in the same decision, Justice Thomas added:
“It must be remembered that the cut and thrust of forensic work may produce tensions, and that denigratory comments to counsel, sarcasm and hard words from time to time may not be amiss. It is also to be remembered that although there are the trappings of court procedure, the investigation is essentially inquisitorial, and that the Commissioners are to be expected to play a far more active role in ascertaining the facts than occurs in a court. A wide range of expression and conduct must be permitted for a commissioner, and one should not interpret robust conduct as a badge of bias.”
In quoting those passages, I should not, for a moment, be taken as suggesting that Justice Moynihan’s decision was wrong. What is surprising, in light of Justice Moynihan’s decision, is how deeply flawed must have been the reasoning of Justice Thomas – who was subsequently appointed to the Queensland Court of Appeal.
Similarly, one may have regard to the decision by Mr.Davies QC to accept in evidence at his Inquiry the totality of the evidence received at the Bundaberg Hospital Commission of Inquiry, apart from the oral testimony of Mr.Leck and Dr.Keating. As I understand the situation, Justice Moynihan ruled, not only that I was disqualified, but also that my Deputies Sir Llew Edwards and Margaret Vider were disqualified, on the footing that most or all of the evidence received by us was, as he put it, “tainted”. By my calculations, Mr.Davies has excluded a half-day’s evidence out of 50 days of evidence – that is to say, about 1%.
Again, I should not be misunderstood as criticising Justice Moynihan’s decision. But, once again, in light of Justice Moynihan’s decision, it is surprising that Mr.Davies – also a former Appeal Court Judge – has reached a conclusion which is so demonstrably erroneous. Indeed, what makes all of this even more surprising is that Mr Davies’ decision, so obviously in conflict with Justice Moynihan’s judgment, has not even been challenged.
No; I am not saying that Justice Moynihan’s decision was wrong. Rather, on the assumption that it correctly reflects the present state of the law in Queensland, I would urge that the law must be changed, and changed urgently – before there is another public inquiry.
In saying that the law must be changed, I know that I risk being accused of “sour grapes”. Let me make it clear, however, that I bear no animosity. I was, and I remain, deeply grateful to the Premier, Mr. Beattie, for doing me the honour of entrusting to me this extraordinarily important task. I would not be totally honest if I denied that, following Justice Moynihan’s decision, I felt some brief resentment. After all, nobody likes to be sacked. But any ill-feeling quickly evaporated, under the torrent of letters, cards and emails which I received from so many members of the public – most of them complete strangers – expressing their support for me, and their thanks for what I had done to date.
For that overwhelming public reaction, I can only be grateful to Justice Moynihan. It is no mean feat to turn a lawyer – a member of the most distrusted and reviled profession in our community – into a popular and even heroic figure. Like Sir John Kerr’s dismissal of the Whitlam Government, Justice Moynihan’s decision to sack me has apparently struck a chord with the public’s sense of fair play, and the instinctive Australian stance of supporting the under-dog.
Any lingering disappointment is not for myself, but for the people who had made real sacrifices, and who were disappointed and distressed that the Inquiry would not run its full course. I include in this the patients, and members of patients’ families, who suffered the distress of speaking publicly about their own medical problems, and the deaths of their loved ones. I also include the clinicians – the doctors and nurses – who risked their own professional careers to come forward and speak frankly about problems in Queensland Health. And, perhaps more than anyone else, I include the handful of health administrators who broke ranks with their colleagues in the bureaucracy, to spill the beans on the issues which confront our public hospital system.
In any event, I am determined not to be seen as the victim in this situation. The real victims are people like Mrs. Kemps and Mrs. Bramich, who lost their husbands; people like the 15-year-old boy, who lost his leg; people like Toni Hoffman and Peter Miach, who placed their own careers on the line to come forward with the truth; people like the numerous nurses and doctors, and the occasional bureaucrats, whose consciences would not allow them to miss what they saw as a once-in-a-lifetime opportunity to blow the whistle on systemic problems which would not otherwise have come to light. For me to claim the status of a victim, as compared with such people, would be the height of arrogance – and it would make me no better than those who ultimately brought me down.
No; when I say that the law as expounded by Justice Moynihan must be changed, it is not “sour grapes”. My simple proposition is that, on the assumption that Justice Moynihan has correctly stated the law as it applies to public inquiries in Queensland, it will be near impossible to successfully conduct any public inquiry in this State in the future. I say that, essentially, for four reasons.
First and foremost, the success of a public inquiry depends on attracting and maintaining the support and goodwill of the public. In a nutshell, the public need to know that the inquiry is “fair dinkum”. Unless the public is convinced that the inquiry is “fair dinkum”, the inquiry will inevitably face a series of impediments.
It is, I am sure, no secret to say that much of the evidence which emerged at the Bundaberg Hospital Commission of Inquiry would not have come to our attention, unless people were convinced that we were “fair dinkum”. Why would a clinician – let alone a bureaucrat – risk his or her career to blow the whistle, unless they were convinced that some good would come of it ? Why would people trust us with intelligence, such as where to find the smoking gun in relation to hospital waiting lists, unless we had already won their trust ? Why would senior bureaucrats within Queensland Health break ranks with the then Director-General and Deputy Director-General, unless it was in the clear expectation that we would make appropriate use of the evidence which they provided ?
I am, for example, criticised for shaking hands with Toni Hoffman. Some apologists have suggested that it was a spontaneous gesture, to which no significance should be attached. It was not. It was deliberate and pre-meditated. It was intended to convey, and I think succeeded in conveying, a simple message – although the message was, ostensibly, too subtle for some.
In shaking hands with Toni Hoffman, I was certainly not suggesting or implying that every word of her evidence was accepted without reservation. Indeed, as I noted at the time, and as she herself conceded, much of her evidence was based on second-hand reports, and some of it may have been mistaken. Of course, I had an open mind about those things, and, even to this day, I still have an open mind.
What made Toni Hoffman a hero is the fact that she stood up for what she believed to be right. For that, and for that alone, I am proud to have shaken her hand, and I would be pleased to do so again. The message which this was intended to convey, and which I think was successfully conveyed to all but a handful of people who chose to read something more sinister into it, was simply this: that I, as Commissioner, respected the fact that Toni Hoffman had risked her entire career to blow the whistle on a situation which she regarded as unacceptable.
Needless to say, subsequent evidence has proved Toni Hoffman to have been right, at least as regards most of the matters canvassed in her testimony. But that is not, and never was, the point. The point is that a public inquiry depends upon people with the courage and confidence to speak frankly. If a simple hand-shake with Toni Hoffman encouraged just one other witness to emulate her example of courage and confidence, then that hand-shake was definitely worth all of the trouble which it has since caused me. In fact, I believe that many more witnesses were encouraged to come forward as a result of Toni Hoffman’s example, and the courtesy and respect with which her evidence was received.
Encouraging members of the public to come forward with relevant information is just one of the benefits which flow from gaining the public’s confidence. Another, and equally important consequence is simply a matter of practical politics.
Public inquiries depend, almost entirely, on the continued support of the government of the day. The government appoints the inquiry, nominates its members, and sets its terms of reference. The government decides how long the inquiry has to receive evidence and prepare its report, and what funding is available. If the inquiry needs more time or more money – or if it becomes necessary to expand or fine-tune the terms of reference – the inquiry must go, cap in hand, to seek the government’s indulgence.
The difficulty, of course, is that public inquiries often wander down paths which are uncomfortable for the government of the day. This may not be what the government originally intended. Governments, of all political persuasions, are well known for following Sir Humphrey Appleby’s maxim that one should “Never hold an Inquiry unless you know the outcome before you call it”. But mistakes sometimes happen. What started out, for example, as an examination of clinical issues at one hospital, may somehow evolve into an exposé regarding contentious issues like hospital waiting lists. One never can tell.
Unless there is deep public and media support, it would be an easy matter for a government to restrict, or even terminate, any public inquiry – to turn off the funding tap, and to refuse requests, however reasonable, for extensions of time or changes to the terms of reference. Public confidence is the one protection which public inquiries have against interference from the government of the day.
And public confidence is equally important, not only in ensuring that an inquiry has the necessary time and resources to properly explore all of the issues within its remit, but also to ensure that its ultimate recommendations are acted upon. We all remember the famous commitment to implement the Fitzgerald Inquiry recommendations, “lock, stock and barrel”. Would there have been such a commitment – let alone the political will to make that commitment a reality – unless the Fitzgerald Inquiry had already achieved widespread community confidence ?
So that is the first reason why the members of a public inquiry – any public inquiry – must be free to behave in a way which, in the context of judicial proceedings, may be regarded as demonstrating an appearance of bias. They must be free to act in a way calculated to attract and maintain public trust; to demonstrate that they are “fair dinkum”.
The second reason is equally important. A judge, hearing a case in a court of law, has no part in formulating or implementing the tactics and strategies which will ensure that the truth emerges. After all, judges are not concerned with absolute truth, merely with relative truth. A judge’s function is not to discover what actually happened – it is merely to decide which of two versions of history, presented by the opposing parties, represents the closer approximation to the truth. If neither party is able to secure, or if neither chooses to adduce, evidence from a particular witness who might be able to assist the judge in discovering the truth, then the judge has to do the best that he or she can without the benefit of such evidence.
Public inquiries are not like that – nor should they be. Just think of the Fitzgerald Inquiry, which would have been finished in a matter of weeks if it were not for the evidence of one, Jack Reginald Herbert. Fitzgerald’s counsel assisting travelled to London to interview Herbert, and did a deal with him which involved his receiving immunity from prosecution in return for lifting the lid on the Pandora’s Box of police corruption in this State. No judge, sitting in any court of law, could have done that. Yet the course of Queensland history would have been very different if it had not happened.
The Herbert example is, of course, an extreme one. He was a vile creature, who confessed to his own perjury and corruption in order to bring down his partners in crime. Yet Fitzgerald was able to do a deal with him which acknowledged that, for the greater public good, the judicial system could turn a blind eye to Herbert’s own criminality, in return for evidence which exposed more wide-ranging problems.
I would hesitate in even mentioning, in the same context as a grub like Herbert, people as decent and honourable as Toni Hoffman or Peter Miach. Yet I am criticised for treating some witnesses differently from others. To the extent that I did so, it was (again) a calculated and deliberate attempt, on my part, to encourage potential witnesses to come forward with the truth. Two decades down the track, I am sure that there are plenty of people who are pleased to discover, even at this late stage, that Fitzgerald broke the rules by treating some witnesses differently from others – people like ex-Police Commissioner Terry Lewis, like former Ministers of the Crown Don Lane, Brian Austin, Geoff Muntz, and Leisha Harvey, and many of the other 200 plus individuals who faced criminal charges in the aftermath to the Fitzgerald Inquiry.
There are other tactical decisions for which I have been criticized, such as calling Dr Keating and Mr Leck to give evidence at short notice. Let me say, at once, that I had no inkling of Mr Leck’s psychiatric problems when I made that decision – his learned counsel, and instructing solicitors, did not raise that matter. Justice Moynihan remarks, in his Reasons for Judgment, that “each applicant was given short notice which, in practical terms, they had little option but to accede to the proposal”; I can only infer that, like myself, Justice Moynihan was not informed by Leck’s solicitors and counsel that he had another option which he did not chose to exercise – that of asking to be excused on account of the state of his mental health.
In the result, the testimony which I was able to secure from Mr Leck will, it seems, forever be his final word on the subject. Be that as it may, I remain fervently of the view that any Inquiry Commissioner must have a sufficient scope of discretion to decide which witnesses are called, and when, even if that involves treating some witnesses differently from others.
In the final analysis, it is the Commissioner’s function to discover the truth. Part of the professional skill-set of a barrister is to know how to use a range of forensic approaches in the interests of eliciting the truth. At one extreme, this may involve the “softly softly” approach – asking easy and apparently sympathetic questions in order to have the witness let down his or her guard. At the other extreme, it may involve asking questions which are apparently aggressive or even extravagant, with the object of inducing the witness to argue that a less extreme view should be taken – in effect, giving the witness the opportunity, in denying a more serious allegation, to admit to a less serious one.
Regardless of whether such tactics are successful or not, they form part of any competent barrister’s armoury of techniques which – as experience has shown over many centuries – comprise the most effective system ever devised by human ingenuity, short of physical torture, for drawing out the truth from a recalcitrant witness.
But Justice Moynihan felt that my questions, directed to Mr Leck and Dr Keating, went beyond “exploratory or tentative statement of issues with a view to testing their correctness or to give the witnesses an opportunity to respond to a provisional view”. It is, in my view, a singular inhibition on a public inquiry to say that a commissioner is confined to an “exploratory or tentative statement of issues” – and is prohibited from expressing those issues otherwise than in a way which is limited to “testing their correctness or giv[ing] the witnesses an opportunity to respond to a provisional view” – if the commissioner believes that a different forensic approach is more likely to bring out the truth.
The third reason why it is necessary to judge public inquiries by standards different from those applicable to courts of law is that public inquiries must be informed by what Justice Thomas called “a sense of social, political, moral or economic direction”. For a judge in a court of law, there is a roadmap – it may sometimes be imperfect, sometimes ambiguous, sometimes incomplete – but a roadmap nonetheless. That roadmap is the law, comprising Acts of Parliament, regulations and other subordinate legislation, and previous judicial decisions. If the judge strays off the road, there are appeal courts to set him or her back on the right track. But public inquiries do not have any such roadmap: they must navigate by dead reckoning, informed by what Justice Thomas calls their “sense of social, political, moral or economic direction” – what I would call, more succinctly, their “moral compass”.
The celebrated Washington Post journalists, Bob Woodward and Scott Armstrong, attribute to Justice William O. Douglas – the leading judicial activist on the US Supreme Court in the second half of the Twentieth Century – the proposition that he was for “Government over big business; the individual over government; and the environment over all else”.
If the Queensland equivalents of Woodward and Armstrong – say, Mr Hedley Thomas and Mr Sean Parnell – were to summarise my approach at the Bundaberg Hospital Commission of Inquiry, they might conclude that I am for the clinician over the hospital administrator, for the hospital administrator over the Charlotte Street bureaucrat, and for the quality of patient care over all else. That would be, at any rate, a reasonable set of inferences regarding my own moral compass.
Frankly, it is not clear to me from Justice Moynihan’s Reasons for Judgment whether my mistake was to have a moral compass at all; or whether the Judge accepted that I was entitled to have a moral compass, but thought that my moral compass was misdirected. Thus, I was criticised for the view that, in the hospital context, practising clinicians – that is to say, doctors and nurses who actually participate in treating and caring for patients – fulfil a more useful function than bean-counters, pen-pushers, and other bureaucrats.
That I held such a view – that I still hold such a view – is beyond doubt. I made no attempt to conceal it. Justice Moynihan is perfectly entitled to take a different view. He may believe, for instance, that balancing the budget is a more socially desirable outcome than healing the sick. But I do not understand that it was His Honour’s function to substitute his own views for mine. Justice Moynihan’s sole function was to determine whether my Inquiry had miscarried, by creating an apprehension or appearance of bias. If (contrary to the views of Justice Thomas) a commissioner is not entitled to have a moral compass – a “sense of social, political, moral or economic direction” – it would seem to me that there is little point in having public inquiries at all.
Of course, a commissioner’s moral compass may be so misguided, so unreasonable, that a court of law would be entitled to conclude that the proceedings amount to an abuse of process. But nothing of that nature was suggested in the case before Justice Moynihan – not against me, and certainly not against my Deputy Commissioners, Sir Llew Edwards and Margaret Vider. Short of such a situation, surely it is a matter for the individuals chosen to constitute the public inquiry – rather than a Supreme Court Judge – to identify the social, political, moral and economic factors which guide the inquiry’s proceedings and deliberations.
One of the many features which distinguish a public inquiry from a court of law is the fact that the inquiry’s report – its findings and recommendations – are not binding on anyone. If, for instance, the inquiry concludes that a specific person has a case to answer for criminal or official misconduct, those issues are decided by the appropriate court or tribunal. Implementation of the inquiry’s recommendations is a matter for the government of the day, and whilst the inquiry’s conclusions may carry some political weight, the government is free to decide which recommendations to adopt, and when and how to do so.
What is important, to my mind, is this: to the extent that the inquiry’s report reflects the moral compass of its members, that should be apparent to all concerned. In selecting the person or persons to constitute a public inquiry, the government will presumably choose people in whom it has confidence – even if their moral compass is somewhat different from the government’s own political agenda. When the Beattie Government appointed me, along with Llew Edwards and Margaret Vider, I assumed it was because the Beattie Government wanted our honest and sincere views regarding the issues comprised in our Terms of Reference. What I did not anticipate – and do not accept, even now – is the proposition that we should have discarded our moral compasses because a Supreme Court Judge may not agree with them.
The fourth and final reason why public inquiries ought not be subject to the same constraints as a court of law is, however, the most important. As the word “inquiry” implies, the process is an investigative one. It is, frankly, bizarre that the most formal type of investigative process known in our system of constitutional government should be hamstrung by constraints which do not apply to less formal inquiries, such as those conducted by the police and other law enforcement agencies.
Consider the case of a police detective, investigating a series of suspicious deaths – which, after all, is exactly what I was doing. If the principal suspect were found to have fled, it is absurd to imagine that the police should be restrained in asking hard questions of the person who arranged payment of the principal suspect’s airfares. Yet that, in substance, seems to be something which I – as a commissioner – was not permitted to do.
Every investigative process – whether criminal, civil, scientific, or of any other nature – consists of essentially the same process. On begins by looking at the evidence which is most readily available. One then forms an hypothesis as to what might have happened, drawing inferences – and maybe forming suspicions – based on the available evidence. As the evidence accumulates, you test your hypothesis, your inferences, your suspicions. Of course, you keep an open mind. As more evidence emerges, your suspicions may be answered; inferences may be negatived; initial hypotheses may be contra-indicated. You may have to modify the existing hypothesis; or you may reject it entirely, and attempt to formulate a new one. Once all of the evidence is complete, you reach your conclusions. If you are lucky (or prescient), your conclusions may bear some resemblance to your initial hypothesis; more often, you will have considered and rejected a series of hypotheses during the course of the investigation.
The idea that one can conduct any kind of investigation, with a mind that is a blank canvass, is simply farcical. One might as well say that Howard Florey’s investigation of the clinical uses of penicillin was misconceived, because Florey began with an hypothesis (or a suspicion, if you like) that penicillin could be adapted as a chemotherapeutic agent. This may be contrasted with Alexander Fleming’s initial discovery of the antibiotic properties of penicillin, which occurred entirely by chance. Are future public inquiries to be entitled, like Florey, to develop and explore hypotheses – or are they obliged, like Fleming, to leave everything to chance ?
Let us turn the clock back to the afternoon of the fateful day – day 4 of the Bundaberg Hospital Commission of Inquiry, Thursday 26 May 2005 – when Dr Keating entered the witness box for the first time; and Mr Leck did so for the first – and apparently the last – time. At that time, did I have suspicions? Of course! Had I begun to draw tentative inferences? Undoubtedly! Was I in the process of developing a preliminary hypothesis? Naturally! Had I therefore prejudged the issues? Certainly not!
Consider the fact that, on 26 May, Mr Leck claimed to be unable to recall approving Jayant Patel’s airfares back to the United States – something which occurred just 8 weeks earlier, and which had been the subject of a great deal of media discussion and speculation in the meantime. I would call that suspicious. I would say that the proposition is so inconsistent with ordinary human experience that it called for explanation. Perhaps there was a good explanation – maybe the explanation lies in Mr Leck’s psychiatric condition. But I would contend that I was entitled to ask for an explanation, and the record will show that I never got one.
Consider, likewise, the fact that – four days after Patel fled the country – a letter went out from Mr Leck’s office, albeit signed by someone else, but inviting inquiries to Mr Leck, which warmly thanked Patel for his contributions at Bundaberg Base Hospital. Mr Leck claimed to recall having taken no part in the writing or sending of that letter. Perhaps that was true, but I thought it suspicious; I thought that it called for explanation. Was I wrong to think that way?
Certainly, with the benefit of subsequent evidence, it is plain that my suspicions were well-founded. If one believes the testimony of the man whose signature appeared on the letter – Mr Viv Chase, Chairman of the Bundaberg District Health Council – the letter was drafted by Mr Leck, and he (Mr Chase) knew nothing about it until it was presented to him for signature. Indeed, Mr Chase’s evidence is corroborated by the fact that, according to his usual practice, correspondence which he personally drafted was prepared on his own computer in his own home: only correspondence drafted by Mr Leck was generated from Mr Leck’s office. Likewise, the person who typed the letter – Ms Joan Dooley, Mr Leck’s personal assistant – swore that she was in no doubt that Mr Leck drafted it.
Based on the subsequent testimony of Mr Chase and Ms Dooley, one may think that Mr Leck has a case to answer for committing wilful and corrupt perjury – unless, perhaps, the inconsistencies between his testimony and that of Mr Chase and Ms Dooley can, once again, be explained on the basis of Mr Leck’s psychiatric condition. But the issue is not whether the suspicions which I entertained, at the time when Mr Leck gave evidence, were borne out by subsequent evidence. The real question is whether I was entitled to entertain such suspicions at all, or to ask questions calling for answers to such suspicions.
Consider, again, the fact that, on 24 December 2004 – Christmas Eve – Dr Keating wrote to Jayant Patel, offering him a further term of employment of four years, commencing on 1 April 2005 – or April Fool’s Day, as I have been criticised for calling it. As matters appeared at the time when Dr Keating entered the witness box, I thought that was a surprising thing to have done, in a context where:
Dr Miach had already communicated to Dr Keating at least some of his concerns about Patel, including the fact that peritoneal catheters inserted by Patel had a 100% complication rate.
Toni Hoffman had provided to Mr Leck – who had, in turn, informed Dr Keating about – a letter detailing a litany of concerns regarding Patel’s clinical competence.
Just a week earlier, on 17th December, Mr Leck had received advice from Queensland Health’s Audit and Operational Review Unit, that the issues raised by Toni Hoffman were “issues of clinical practice and competence”, and that it was “appropriate for a suitably qualified team of medical practitioners to review the practices of Dr Patel”.
The evidence of Mr Leck suggested – and this was not contradicted by Dr Keating – that Dr Keating did not even consult Mr Leck, as the District Manager and his immediate superior, before making this offer of a 4-year contract to Patel.
There was no immediately apparent explanation for the urgency in offering a new contract to Jayant Patel on Christmas Eve, when his current contract would not expire for another 3 months – let alone to offer him a 4-year contract – let alone to do so, whilst an investigation into “issues of clinical practice and competence” was pending.
However, it seems to follow from Justice Moynihan’s decision that I was not entitled to find these things suspicious, even disturbing – that I was not entitled to call upon Mr Leck and Dr Keating to explain themselves or their conduct – that I was not permitted to express my surprise, my concern, indeed my alarm, so as to let both men know, very clearly, why I considered that an explanation was called for, and what they needed to explain.
Why should this be so? Why should I, as commissioner, be the only person in Queensland who did not find it suspicious that Mr Leck, just 8 weeks later, claimed to be unable to recall authorising payment for Patel’s return flight to the United States? Why, as commissioner, should I, alone amongst the citizens of this State, not be permitted the luxury of expecting Mr Leck to explain the letter to Patel which issued from his office 4 days later? Why should I be expected, as commissioner, to have thought processes so very different from every other Queenslander, that I was could not feel anxiety at the circumstances in which Dr Keating offered to renew Patel’s contract until March of the year 2009?
It was a great personal honour and privilege to be asked by the Premier to head the Bundaberg Hospital Commission of Inquiry. But, like most honours and privileges, I sensed that it carried with it certain duties. To my mind, my foremost duty – and I make no apology for this – was to ask the questions and pursue the issues which I imagined that the people of this State would want answered, if they had the opportunity to confront the likes of Peter Leck and Darren Keating.
If the person chairing a public inquiry is prohibited by law from forming and voicing suspicions, drawing inferences, and developing hypotheses, then we might as well give up. There is simply no point in having Commissions of Inquiry, or Royal Commissions, whilst the law in Queensland remains as stated by Justice Moynihan.
If the Bundaberg Hospital Commission of Inquiry has any lasting influence on the conduct of public inquiries generally, I hope it will flow from the successful experiment of allowing the proceedings to be televised. My fear, however, is that Justice Moynihan’s decision will lead future public inquiries in a very different direction: away from the ideals of openness and transparency which were my touchstones, and towards a recognition that any attempt at openness and transparency increases the risk of a successful judicial challenge. If that were to happen, I think that the public would be the losers.
That is why I say to you, on the assumption that Justice Moynihan’s decision is correct in law, that the law must be changed. Fortunately, our constitutional system of government already embodies a procedure which permits public inquiries to be conducted without fear that they will transgress Justice Moynihan’s ruling. Parliamentary inquiries – including inquiries conducted by Parliamentary commissioners – are exempt from judicial scrutiny. They are not subject to judge-made rules of the kind applied by Justice Moynihan. They are accountable only to the Parliament and, through the Parliament, to the electorate.
I see a future in which there are no more Royal Commissions or Commissions of Inquiry in this State – a future in which public inquiries, like the Bundaberg Hospital Commission of Inquiry, will be conducted by Parliamentary Commissioners, free of judicial oversight, but subject to the ultimate control of the legislature and the electorate.
And that is how it should be. Serving judges have withdrawn from participating in public inquiries, for the very reason that such inquiries are properly viewed as part of the political process – part of the legislative/executive branch of government – rather than an exercise of judicial power. The next logical step is to recognise that, as part of the democratic processes connected with the legislative and executive branches of government, public inquiries should be exempt from oversight by unelected judges, and brought under the direct control of the State’s foremost democratic institution, the Parliament.
