‘Flawed judgment, lack of remorse’: Charlie Teo guilty of unsatisfactory professional conduct

The career of controversial neurosurgeon Charlie Teo is effectively over due to the conditions placed on his practising certificate following a formal reprimand and a finding that he was guilty of unsatisfactory professional conduct.

The damning findings were handed down on Wednesday by a professional standards committee, which was investigating the once-feted surgeon over futile surgeries that left two patients in a vegetative state. They never regained consciousness and subsequently died.

Charlie Teo at his Pagewood home on Wednesday.Credit: Nick Moir

“We have found the practitioner guilty of unsatisfactory professional conduct. We have determined that the practitioner should be reprimanded and that some conditions should be placed on his registration,” the committee found.

The findings against him include that he lacked insight and judgment and failed to properly explain the risks of the operations.

The Health Care Complaints Commission had alleged that Teo’s decision to operate on Patient A, a Perth woman with a brain stem glioma, was unethical and improper. The committee found that “there can be no doubt that the operation undertaken was not one which the majority of neurosurgeons in Australia would have supported”.

The committee also “ultimately concluded that the practitioner’s judgment in deciding to operate on Patient A was inappropriate for the following reasons. First, it was high-risk and inappropriate surgery by reason of the nature and location of the tumour, its genetic type, and that it was diffuse [over a wide area].”

The committee concluded that Teo did “not exercise appropriate judgment in proceeding to surgical resection” of Patient A and that “there is no directly relevant statistical data, medical literature and/or clinical guidelines to support the type of surgery proposed to Patient A”.

After her operation in October 2018, Patient A did not regain consciousness and died in April 2019.

An eight-day hearing earlier this year came after a joint investigation by this masthead and 60 Minutes revealed shocking outcomes of other futile surgeries performed by Teo for which vulnerable patients had been pressured into paying exorbitant fees.

The Health Care Complaints Commission raised extraordinary allegations against Teo after complaints were received following two disastrous brain surgeries. The outcomes for both female patients were catastrophic.

Patient B, was a 61-year-old married woman from Geelong who had two children and five grandchildren. She was diagnosed with a diffuse stage 2 astrocytoma, IDH wild-type.

In the case of Patient B, “the practitioner carried out surgery which was different to that proposed to the patient, and the surgical strategy led to unwarranted and excessive removal of normal functional brain”.

It was inappropriate that Teo demanded an upfront fee of $35,000 from a vulnerable woman before he operated on her for the removal of her tumour in February 2019, the committee found.

The operation was a disaster and Teo removed an excessive portion of normal brain.

The neurosurgeon also used inappropriate language to Patient B’s daughter in March 2019 during a phone conversation about her mother’s vegetative state. “You’re asking the wrong f---ing question,” Teo told her. He also said, “Would I do it all over again? F---ing oath I would. You should be grateful. I’ve given the family extra f---ing time.”

Charlie Teo arrives at a disciplinary hearing in Sydney in March.Credit: Nick Moir

While Teo’s slapping the face of the unconscious woman was found to be inappropriate, it did not constitute a finding of unsatisfactory conduct.

Patient B’s family paid more than $10,000 for her to be flown back to Geelong, where she died on March 30, 2019. The following month her husband lodged a complaint with the HCCC.

A further complaint was lodged by the chief medical officer of Epworth Hospital in Geelong following a Mortality and Morbidity review into Patient B’s treatment.

Neurosurgeon Elizabeth Lewis, who chaired the review of Patient B’s care, told the committee that it was wrong for Teo to offer futile surgery “and then just send the patient back to a local hospital when things do not go well. It shows a complete lack of compassion and responsibility for appropriate care of people.”

Lewis also reported that this was not an isolated incident. “There have been a number of complaints re this doctor’s management of patients, his lack of communication with the original treating doctor and his ‘I am the best attitude’.”

‘It shows a complete lack of compassion and responsibility for appropriate care of people.’

Neurosurgeon Elizabeth Lewis

Teo was also criticised for conducting “experimental” surgery that was not done in a clinical trial setting.

“Of greater significance is his lack of reflection on his judgment in offering surgery without supporting statistical data or peer support which, in his own experience, may or may not be proved to have been in error in 10 years’ time.

“While the practitioner expresses sorrow and takes responsibility for bad surgical outcomes, he does not express any remorse for offering surgery to Patient A or Patient B. This lack of insight into his judgment causes us concern.”

In August 2021, the NSW Medical Council deemed that the initial complaints against Teo were so serious that his surgeries could place the health and safety of the public at risk. After an urgent hearing, conditions were placed on Teo’s ability to operate.

Teo’s restrictions included that he was not allowed to perform any “recurrent malignant intracranial tumour and brain stem tumour surgical procedures” unless he obtained written approval from an independent neurosurgeon of 20 years’ standing who had to be approved by the Medical Council.

However, Teo could not find a neurosurgeon to approve his surgeries.

In the decision handed down on Wednesday, the committee said it had “endeavoured to appropriately balance the health and safety of the public while ensuring that the practitioner can continue to provide his surgical services to patients”.

In doing so, the committee reduced the level of professional experience from an approved neurosurgeon to 15 years’ experience rather than 20.

Teo had submitted that the requirement of written approval from another neurosurgeon before surgery was a de facto “suspension” of his medical licence.

He also submitted that as a “pioneer in the field” he should not be restricted from performing surgery “which may not yet be recognised by peer-supported literature as being beneficial.”

He also claimed that because he practices and teaches around the world and that “his skills and supervision are in demand” there was no benefit in having a supervisor.

The HCCC rejected Teo’s suggestions, instead submitting the conditions were necessary to “protect the public having regard to the practitioner’s failure to properly weigh the risks and benefits of surgery, his understanding of obtaining informed consent, his understanding of patients’ right to privacy, bodily integrity and his use of inappropriate language”.

The committee also found that “the practitioner has, for the most part, become isolated from the majority of his peers, and does not conform to a number of relevant accepted professional standards”.

Teo continued to complain this week that jealous colleagues who were envious of his superior talents had been out to destroy him for years.

In a podcast, he said the two complaints had been lodged by “my enemies” and that “the accuser, the plaintiff, the judge, the jury, and the executioner, are all the same person or the same institution, you got no chance”.

The professional standards committee was chaired by former Family Court judge Jennifer Boland. Also on the panel were two Victorian neurosurgeons and one layperson.

Comment was sought from Teo.

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