A WOMAN was bleeding to death after pelvic mesh surgery at a private hospital in 2013 but two surgeons, including one who invented the mesh device implanted in her, sent her to a hospital twice the distance from a major public hospital emergency department.
It was a "most concerning" decision, said the NSW Civil and Administrative Tribunal on Thursday after finding gynaecologist Peter Petros guilty of professional misconduct.
But the tribunal could impose no disciplinary sanction against Dr Petros, 78, because he retired before the guilty finding. This is despite Dr Petros failing to disclose a financial interest in his pelvic mesh device to women implanted with it after the device was cancelled in November, 2014 on safety grounds.
Dr Petros's colleague and former University of Newcastle associate professor Richard Reid also retired before professional misconduct findings against him in September.
Dr Petros, who invented the Tissue Fixation System (TFS) pelvic mesh device, admitted the decision in June, 2013 to send the woman by ambulance from Sydney Private Hospital to another hospital was "about damage control" after her condition deteriorated dramatically about four hours after surgery.
It was one of the first times Dr Reid had used TFS; Dr Reid was under surgical restrictions imposed by Sydney Private Hospital and the NSW Medical Council after serious surgical incidents involving other women, and he damaged the woman's pelvic artery, causing the life-threatening bleeding.
The woman was injured while Dr Petros supervised Dr Reid and after Sydney Private Hospital's medical advisory committee directed Dr Reid to use the TFS device and procedure. The tribunal was told 108 women were implanted with the TFS device at the hospital, including after it was cancelled.
A tribunal decision handed down on Thursday found Dr Petros initially wanted to send the woman injured during the June, 2013 surgery to St George Private Hospital.
But a St George doctor "recommended she be taken to Royal Prince Alfred Hospital as it was closer to the Sydney Private Hospital and there was an emergency department".
The ambulance instead was directed to St George Public Hospital where the woman patient's uncontrolled bleeding eventually required 12 units of blood and "significant resuscitation".
Dr Petros "did not describe how he and Dr Reid decided to transport the patient to St George Hospital, at twice the distance from Royal Prince Alfred Hospital, which is most concerning," the tribunal said.
In a report about the incident to Sydney Private Hospital's medical advisory committee one month later Dr Petros said the woman had "recovered well and should be discharged soon", without making a direct inquiry about her condition.
"In fact the patient was not discharged for a further period of four weeks," the tribunal found.
Dr Petros also failed to tell the medical advisory committee the woman nearly died after she was implanted with his TFS device.
The "surprisingly brief" report sought to minimise the severity of the complications and the direct link between the damaged artery and the mesh device, and that attempts to stop the bleeding at Sydney Private Hospital failed.
Dr Petros "downplayed any potential role" of the pelvic mesh surgery in his report to the medical committee which allowed Dr Reid to continue operating on women who were subsequently seriously injured during TFS surgery.
Dr Petros's professional misconduct included that he misled the NSW Health Care Complaints Commission while it investigated complaints against him, deliberately tried to hide his continuing financial interest in the TFS device and his handover of the critically-injured woman patient failed to include significant information, including that she had been implanted with a mesh device.
It is the third time Dr Petros has been investigated for professional misconduct, but the first time he has been found guilty.
Dr Petros, whose prototype pelvic mesh device was tested on 13 large female dogs in Western Australia in the late 1980s and later marketed by the Australian Medical Association as a surgical "breakthrough", failed to disclose he retained a financial interest in the TFS device for years as he promoted its use to other doctors and Sydney Private Hospital.
The tribunal found Dr Petros failed to give sufficient information to Sydney Private Hospital in March, 2013 about his family trust ownership of the device patent, where the hospital could only purchase the TFS device from Adelaide-based TFS Manufacturing, owned by former Newcastle basketballer Paul Zadow.
When he was questioned by the HCCC in 2015 about his financial interests in the device he failed to mention the family trust, and provided a copy of his agreement with Mr Zadow with a crucial page missing.
"The tribunal is satisfied (Dr Petros) deliberately set out to mislead the HCCC and to hamper it in its investigation," the tribunal said.
An earlier pelvic mesh invention by Dr Petros, the Intra Vaginal Sling (IVS) device, which was developed in Western Australia, was sold to American firm Tyco in 2001.
The IVS was approved by American regulators to treat prolapse, a complication after childbirth, only months after Australian reviewers in February, 2001 found no "good quality evidence to determine the safety and efficacy" of the device procedure.
The American IVS approval allowed multiple prolapse device kits on the global market without clinical trials over the following decade under America's controversial device approval system, including at least one Johnson & Johnson device cited in a class action by 1000 Australian women against the company.
In early April Dr Petros gave evidence to the tribunal about receiving two "lucrative" offers by American companies in 2008 to purchase his TFS device, which was invented in the period after the IVS sale.
In late April American regulators banned all prolapse mesh devices because of safety and efficacy concerns more than 18 months after a similar move in Australia.