MIRAMICHI, N.B. - The head of an inquiry into pathology services at a hospital in northern New Brunswick says Dr. Rajgopal Menon should have lost his licence in 2005, two years before he was suspended from working.
Justice Paul Creaghan says in his report released Wednesday that there has been no program of quality control in the pathology lab at the Miramichi Regional Hospital since 1994.
Menon worked at the Miramichi hospital from 1995 until early 2007, when his licence was suspended following complaints about incomplete diagnoses and delayed lab results.
An audit of Menon's work earlier this year found 18 per cent of 227 breast and prostate cancer reports were incomplete and three per cent were incorrect.
In a lengthy three-volume report, Creaghan says Menon's work at the hospital was flawed.
"Overall, we found that his service was unsatisfactory in terms of both attention to his duties and to the level of his performance," Creaghan wrote.
He also pinpoints a litany of systemic problems within New Brunswick's health-care system and found that the Department of Health had no idea whether pathology labs in the province were operating at acceptable levels of quality.
"The commission found no meaningful peer review of Dr. Menon's work while he was employed at the hospital," Creaghan says in the report.
Among his 52 recommendations, Creaghan says the College of Physicians and Surgeons needs greater resources to deal with discipline matters.
He says the process of suspending Menon's licence took too long, as a result of legal avenues available to the doctor and the cautions approach taken by the college in reacting to potential legal repercussions.
Menon, who is now in his 70s, has maintained his work was not as flawed as the inquiry was told, and he portrayed himself as the victim of a hospital administration that was out to get him.
The report makes no findings of criminal or civil negligence, and none of the findings is binding on the provincial government.
Creaghan also recommends that the Health Department maintain pathology lab services in all regional hospitals in the province, and that it negotiate a deal with the Capital Health Centre in Halifax to provide consultative laboratory services to pathology labs in New Brunswick.
The inquiry heard testimony from 56 witnesses over 42 days of public hearings.
A 2007 peer review, released publicly last March, concluded Menon wasn't fit to work. It stated Menon had medical problems that could have affected the accuracy of his work, including tremors in his hands and cataracts.
An Ottawa lab is reviewing 24,000 cases that were originally examined by Menon during his tenure in Miramichi. About 100 cases from Menon's brief stint at Edmundston Regional Hospital in 2002 are also under review.
Menon has described the inquiry as "unjustified and unfair" and portrayed himself as someone who was being singled out by the hospital administration.
Still, during testimony in May, he apologized for any mistakes that might have been made on his behalf.
"I wish to sincerely apologize to any patient if I made an error in reading their pathology slide," he testified. "I was not aware of any errors in my work."
Menon has filed a civil suit against the regional health authority.
During the public inquiry, Creaghan also heard that the province's health-care system was struggling to deal with an overburdened diagnostic system that lacked proper oversight.
Halifax lawyer Raymond Wagner has filed an application for certification of a class action lawsuit against Miramichi's Regional Hospital Authority on behalf of patients whose test results were reviewed by Menon.
New Brunswick is not the only province that has called an inquiry into problems in its medical labs.
A public inquiry into hundreds of botched breast cancer tests in Newfoundland and Labrador concluded its public hearings on Oct. 31.
The inquiry was asked to determine how an estimated 400 patients under the Eastern Health authority's care were given inaccurate results on their breast cancer tests.
For seven months, the inquiry in Newfoundland and Labrador heard evidence that the St. John's laboratory that processed the tests was marred by staff shortages, improper training and a lack of internal controls.
It has yet to release its final report.
