An experienced obstetrician has surrendered his right to practice medicine after his failure to diagnose a serious medical condition in a pregnant woman resulted in the death of a newborn baby and lifelong disabilities to a surviving twin.
But a tribunal has found systemic issues within the health system contributed to the tragic event as the experienced obstetrician felt he was unable to step down from on-call duties despite suffering the effects of cancer treatment.
Dr Philip Paris-Browne failed to diagnose pre-eclampsia in a pregnant woman at Shoalhaven District Memorial Hospital in Nowra in the days before the twins were born via caesarean section on January 2, 2015.
The baby boy was stillborn while the second baby, a girl, survived and was flown to neonatal intensive care at Sydney's Royal Prince Alfred Hospital. She has permanent hearing loss in her right ear and speech difficulties.
The mother, known for legal reasons as Patient A, was flown to the same hospital and placed in intensive care.
The Health Care Complaints Commission prosecuted Dr Paris-Browne in the NSW Civil and Administrative Tribunal last month.
At the time of the incident, the 35-year veteran was the on-call obstetrician at the hospital. He had been diagnosed with cancer and part of his liver was surgically removed in 2011.
After undergoing a gastrectomy - where part of the stomach is surgically removed - in 2014, he asked hospital management to take him off on-call obstetric duties because he was not coping with the physical demands.
But he said he was "rebuffed" by hospital management and as the only other choice provided was resignation from all work, he felt "compelled" to continue working on-call obstetric shifts.
"At the time of this incident I had indicated I could not cope physically with on-call work," he told the tribunal.
The commission alleged he failed identify Patient A's pre-eclampsia and the resultant risk to the babies during the time between her admission to hospital about midday on New Year's Eve 2014 and 8pm on New Year's Day.
At that time, Patient A's usual obstetrician took over and a few hours later an emergency caesarean section was carried out.
Dr Paris-Brown told the tribunal his own ill health contributed to his failure to recognise how sick Patient A was when she was admitted to hospital.
In a statement to the tribunal he said: "I would like to say first how sorry I am about the loss of [the baby boy]. I am sorry that I failed to recognise how ill Patient A was when she was admitted to hospital under my care, and I am sorry I failed to recognise the risk to the twins. I am sorry about the ongoing consequences for [Patient A] and [the baby girl], and the grief it has caused her family."
Following the incident he had a meeting with hospital management where he agreed to stand down from all on-call duties. He was allowed to continue performing elective gynaecology.
He retired from medical practice last month and said he will not seek re-registration.
The tribunal found Dr Paris-Brown found guilty of unsatisfactory professional conduct.
The commission said it would have sought a finding of professional misconduct and Dr Paris-Browne's deregistration had he not surrendered it effective April 1. It said given his age, serious health problems and genuine remorse, it was satisfied he would not seek to practice again.
On Wednesday Dr Paris-Browne was reprimanded and ordered to pay costs.