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They returned home a decade later, while Suresh pursued a medical degree at the University of Sydney. Several of his fellow students remembered him as a very polite student who always greeted them when he passed.

The collators of his graduation class yearbook seemed to have considerable foresight when they suggested Nair was among the most likely to end up in prison, commenting: While never an outstanding student, he was able to pass the appropriate hurdles in medical school before completing residency and embarking on surgical training.

Medical training is a gruelling experience, the easiest part of which is arguably the undergraduate university stage, lasting five or six years. The postgraduate component is arduous, involving very long hours, life and death decision-making, and examinations of heartbreaking intensity — with high failure rates.

Neurosurgery is a specialism with particular glamour and prestige. According to several colleagues who worked closely with him, Nair was widely known as a strange character who always appeared energised and enthusiastic. For the most part, he was a competent doctor, successfully completing the training requirements. The prominent brain surgeon Charles Teo was a supporter and provided Nair with work references.

Yet even Teo, who spoke out in support of Nair last April, also highlighted his personal shortcomings. As Teo told the Sydney Morning Herald: He also began to arrive late to clinics, sometimes missing them altogether.

As a result of unusual behaviour and evidence of drug use, Nair was suspended in , and again in , after which he was forced to undergo regular urine tests and work under supervision. The second suspension related to his clinical practice and the complaint is still under investigation by the Health Care Complaints Commission.

Anthony Eyers, a colorectal surgeon and member of the Medical Council of New South Wales, the body entrusted to oversee doctors who have received complaints from the public or their colleagues, agrees: But, in spite of the concerns, Nair was ultimately allowed to return to work under supervision.

Cregan suspects Nair was cheating the drug tests, admitting that they are not as rigorous as tests for Olympic athletes. However, Peter Procopis, president of the NSW Medical Council, says that, while cheating is possible — strategies include bringing a prepared vial or even having a plastic penis filled with alternate urine to confuse those supervising — it is highly unlikely in this case. Debbie Burns, a mother of two, was operated on by Nair only weeks before he was charged; she required a second operation to fix complications from the first and was told she was not likely to regain feeling in her left hand.

Another patient, Helen Kerner, was already undertaking legal action against Sydney West Area Health Service for an alleged botched operation by Nair in Some patients came out in public support of Nair, however, speaking favourably of his abilities. Lonergan says the process has left many medical administrators asking: Who is ultimately responsible for an impaired doctor?

However, he adds that the hospital and employer also share some of the burden, despite often not being privy to all case details. Managing impaired doctors is a relatively new discipline. Two decades ago, the only way doctors could be held to account for questionable practice was if colleagues confronted them.

A small, dedicated group from within the Australian Medical Association took on the burden of tapping on the shoulders of declining doctors — ageing physicians, for example, or surgeons with faltering physical prowess. But most members of the proud tribe of medicos were reluctant to take on this task.

There has been a steady evolution in the way troubled doctors are dealt with over the past 20 years, with much of the action coming out of NSW. Repeated inquiries and royal commissions have resulted in that state leading the world in this area, according to Procopis.

Regulations initiated in NSW have also been implemented nationally since registration of doctors came under a federal authority two years ago, replacing the old state-based system. Professor Walton says of the particular focus in NSW on how to cope with impaired doctors: The commission resulted in a swathe of recommendations, leading to the formation of the Health Care Complaints Commission, greater transparency of Medical Board decision-making, mandatory reporting guidelines, and a separation of disciplinary and impairment proceedings.

The recommendations of the Chelmsford Royal Commission were refined further after damning investigations emanating from the Inquiry into Campbelltown and Camden Hospitals in Western Sydney, where nurses had spoken out against a culture of bullying and cover-ups.

Then, several years later, came the Garling Report into the public hospital system, precipitated by a waiting patient miscarrying a baby in the public toilets of the Royal North Shore Hospital emergency department. Yet the focus remains on maintaining a doctor in practice where possible, and delaying disciplinary measures.

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