During the Bundaberg Hospital Commission of Inquiry,
and in its aftermath, I discovered something which – at least to me – seemed very
Now, I accept that my discovery may not be quite so
profound as I have imagined; indeed, it may not be a discovery at all. Perhaps
the phenomenon which I have observed is well-known to all of you. Maybe I have
only just managed to catch up with the rest of society, in becoming aware of
something which, for everyone else, is a commonplace. Quite possibly, the
proposition which I consider to be deep, insightful, even momentous, is, in
fact, perfectly trite, entirely hackneyed.
If that is so – if my supposedly profound discovery is
no more than the received wisdom of the age – let me simply say this, both in
my own defence, and by way of apology in advance for telling you what you
already know: My thesis, whether it be a genuine revelation or just common
orthodoxy, is, I think, still worth discussing.
What, then, is the hypothesis that I am postulating?
In a nutshell, it is that our contemporary society is facing a crisis of
decision-making, quite unlike anything in recorded history.
We live in a peaceful, orderly, liberal, democratic
society; a society which is one of the most affluent in recorded history. The
problems faced by this society are almost trivial, when compared with those
which challenged our parents and grandparents, who lived through two World Wars
and a Great Depression. We certainly have the wealth, the resources and the
technology to address the comparatively minor problems which we face. Our
society can, and should be able to, do so.
Yet nothing happens. Why ? Because those who are
empowered to act decisively can't or won't do so, and those who would act
decisively are not permitted to do so.
I first noticed this trend in my own profession. When
I commenced in practice as a barrister, more than 20 years ago, the majority of
judges – both on the Supreme and District Courts – were men of the war
generation. Most had served in the Army or Air Force, some in the Navy. Most
had been officers, a few held non-commissioned ranks. Even the minority who had
never worn a uniform – whether due to their age or their health, or for other
reasons – had contributed to the war effort in different ways, if only by
taking on the burden of extra work left behind by their absent colleagues.
May I say that this was a greater burden than some may
think. At the height of the War, there were only two barristers remaining in
practice in Queensland;
all the rest were away, serving their country. And there was an arrangement in
place – an arrangement which, so far as I am aware, did not exist in any other
profession or in any other place – that a barrister appearing in court in place
of a colleague who was absent on active service would make over the entire fee
to the absent barrister or his family.
Three features distinguished these judges, who were men
of the war generation, from younger appointees. First, they had (at least in my
perception) a deeper understanding of human nature and human behaviour – a
deeper understanding of what makes people tick. Secondly, I think it is fair to
say that they were generally tougher – harsher – than their successors. And
thirdly, they were, without doubt, more decisive.
A few examples may assist to illustrate these
· One judge of the war generation was hearing submissions from counsel for
a convicted criminal, urging that his client should receive some leniency on
sentencing, on account of his youthfulness – the client was aged 23. The judge exclaimed
that he could not see how this justified any leniency, since he – the judge –
had been fighting in Europe, as an acting
colonel with the AIF, at the same age.
· Another of the war generation judges was hearing submissions on behalf
of a man who had been seriously injured in an industrial accident. Counsel
urged that there should be a substantial award of damages for "pain and suffering"
and "loss of the amenities of life", pointing out that his client could no
longer even tie his own shoe-laces. The judge, who had lost an arm when he was
shot down over North Africa, merely responded:
"He'll get used to it".
· Yet another of the war generation judges asked a self-represented man,
whom the jury had found guilty of armed robbery, whether he had anything to say
in mitigation of penalty. "As God is my Judge", exclaimed the man, "I am not
guilty". His Honour responded in just eight words: "God isn't ... I am ... you
are ... ten years".
I am not saying that these men were better judges than
the current ones. In many cases, their legal education – and their knowledge
and understanding of legal principles – was probably inferior to many of today's
judiciary. There was also an unfortunate tendency to trust authority figures. Whilst
it would be unfair to ascribe to these judges any blame for the corruption in
the pre-Fitzgerald Queensland police force, it may be observed that corruption
was permitted to prosper under a judiciary which was not always astute to
identify instance of perjury, and other misconduct, on the part of police
My point, however, is that these judges were decisive.
They had the self-confidence to reach a conclusion, and to give effect to it,
without wasting any time. Even if they were less learned than present-day
judges, their instincts told them what was right, and they did not hesitate in
giving effect to their instinctive sense of justice.
At least to my way of thinking, that is what our
community expects of its judiciary. Perhaps you will forgive me for quoting one
greatest-ever judges, Sir Owen Dixon, speaking about a previous Chief Justice
of Australia, Sir Samuel Griffith. Griffith, I might say, is one of my own
heroes – a man so industrious, so decisive, that he could hold the offices of
Premier and Attorney-General, whilst continuing to conduct a flourishing
practice as a barrister, and finding time to draft Australia's Constitution; a
man who, whilst discharging the duties of Chief Justice of Queensland to a
standard of efficiency seldom equalled and never bettered, also found the time
to prepare the first (and still, in my humble opinion, the best) codification
of our criminal law, whilst occupying his leisure hours in publishing a
translation, from the original Renaissance Italian, of Dante's Divine Comedy. Dixonsaid of Griffith that he was "dominant and decisive", that "he did not hesitate, he just felt
that he knew; and that what he knew was right". Is that not how a judge should
In recent weeks, Queensland's "tabloid of record" – the Courier-Mail – has focussed extensively
on a certain Federal Magistrate who, in two cases, allegedly plagiarised the
work of another magistrate. The same Federal Magistrate is accused to
extraordinary delays – delays of over 3½ years – in handing down her decisions.
One report stated that "there had been more complaints about [this
Magistrate's] handling of cases than any other state or federal judicial
officer". I have also been told, by more than one lawyer, that it is common
practice, when a case is listed before this Magistrate, either to settle the
case or to get it adjourned, due to both the standard of her judgments, and the
delay in receiving them.
commenting on the truth of these allegations, let me simply adopt the remarks
of Peter Lyons QC, President of the Queensland Bar, as quoted in the Courier-Mail:
"... the federal attorney-general makes appointments to the courts
without adequate consultation about the suitability of potential appointees.
Nor is there anything like sufficient recognition of the obvious requirement
that a person appointed to judicial office must have extensive experience in
the conduct of litigation."
legislation to establish the Federal Magistrates Court, the then Federal Attorney-General,
Darryl Williams QC MP, said in his second reading speech: "The Federal
Magistrates Service is intended to provide a quicker, cheaper option for
litigants ... ". At a later point, Mr Williams added: "there will be more
emphasis on delivering decisions orally in appropriate cases, rather than
parties having to wait for reserved judgments". He concluded: "the Federal Magistrates Service
will be able to deal with matters before it with a less formal and more
streamlined manner, to ensure that matters are dealt with as expeditiously and
cheaply as possible." [emphasis added]
were all very noble objectives. But, if the allegations against this particular
Federal Magistrate are true, those ambitions seem to have foundered through a
single and simple mistake: the failure to appoint, as a member of the Court, a
person who has not only the intellectual capacity, but also the
self-confidence, necessary to make prompt decisions. Earlier, I summed up the
problem facing our community by saying that "those who are empowered to act
decisively can't or won't do so, and those who would act decisively are not
permitted to do so". It would seem that at least one Federal Magistrate falls
into the former category.
you may ask, is the connection between all of this and my experience as Chairman
of the Bundaberg Hospital Commission of Inquiry?
commenced that Inquiry with the (perhaps naive) belief that this phenomenon,
which I have detected in some aspects of our judicial system – this crisis of
decision-making – is confined to the judicial branch of government. What I
discovered, both during and after that Inquiry, is that the same phenomenon
infects decision-making processes at virtually every level of public
administration. Indeed, our courts are models of efficiency and decisiveness,
as compared with other branches of government.
us begin, where the Commission of Inquiry began, with Dr Jayant Patel. On all
of the evidence now available, there can be no doubt that he was, quite simply,
a menace to life and limb for patients in Bundaberg. But to focus on Patel is
to treat the symptom, and to ignore the disease. Without in any way detracting
from the seriousness of Patel's malpractice, it has to be said that what
happened in Bundaberg was not just tolerated, but actively encouraged, by bureaucratic
have previously pointed out that, for Patel even to obtain the position of
Director of Surgery in Bundaberg – let alone for him to retain that position
for two years whilst killing and maiming dozens, perhaps hundreds, of patients
– required the medical bureaucracy to fail at every turn. Let me sum up what
was needed to produce this result:
· First, it required a Medical Board which was content, without adequate
enquiry, merely to take Patel's word that he was duly qualified and fit to
practise surgery in Queensland – a Medical Board which made no serious attempt
to check his credentials, despite their having documentation, provided by Patel
himself, which, on close scrutiny, would have alerted any careful enquirer to
unresolved problems in Patel's professional background – a Medical Board
willing to assume that a private employment agency, a firm which expected to
earn about $13,000 for placing Patel in Bundaberg, had conducted all the
necessary checks with Patel's previous employers and professional referees.
· Secondly, it required a public hospital system, willing to employ Patel
as a surgeon, without making even the most rudimentary inquiries or
investigations regarding his previous employment or professional standing. If
Patel had applied to Woolworths for a job stacking shelves, he should have
expected to face more rigorous integrity checks.
· Thirdly, it required a health system which was driven by budgets,
statistics, and other bureaucratic falderal – a health system which was totally
oblivious to the welfare of patients. The primary object in appointing Patel to
the vacant surgical position was to find somebody – anybody – who could be
relied upon to work long hours for a modest salary, without making waves with
his bureaucratic masters. The standard of his surgical skills was an
· Fourthly, it required an administration at Bundaberg Base Hospital willing to
ignore the fact – for it is the fact – that Patel's employment at Bundaberg had
been approved by the Medical Board on the condition that he be supervised by the Director of Surgery. Instead,
without permission from the Medical Board, Patel was employed as the Director of Surgery, not
supervised by anyone. From his first day in that position, Patel was acting
illegally – with the active connivance of Queensland Health's bureaucrats.
· Fifthly, it required bureaucrats who were willing to ignore – without
even paying lip-service to – credentialing and privileging procedures, which are
supposed to ascertain a specialist's level of competence, and to set limits for
the procedures which he or she is permitted to undertake. In Patel's case,
there was not even an interview panel set up to consider his suitability to
fill the vacancy.
· Sixthly, it required an administration which ignored all of the usual
safeguards which are standard in public and private hospitals – peer review
systems, such as Mortality and Morbidity Committees – systems by which the
performance of one surgeon is supposed to be reviewed by his or her professional
colleagues. Such systems ought to have picked up problems with Patel's surgical
practice; but Patel himself, as Director of Surgery, was put in charge of those
systems for the Surgical Department at Bundaberg: not surprisingly, the systems
over which he was appointed to preside failed to detect his own incompetence.
· Seventhly, when the alarum bells did start to ring – perhaps faintly at
first, but with increasing volume as the body-count mounted – it required
hospital administrators willing to turn a deaf ear to all of the warnings which
were filtering through from the clinical areas of the hospital: warnings from
the doctors and nurses who attempted to draw attention to the Patel problem,
and warnings even from the patients who had suffered at Patel's hands, or
members of their families.
· The eighth requirement was an administration, not only willing to turn a
deaf ear to the increasing stream of complaints about Patel, but also willing to
turn a blind eye to the legal processes which should have stopped the Patel
juggernaut after just one fatality: the strict legal requirements of the Coroners Act. Under that legislation, it
is mandatory to report any death which (and I quote) "was not reasonably
expected to be the outcome of a health procedure". Yet, of the 13 deaths which
have been identified as connected with sub-optimal care by Patel, only one was
reported to the coroner. The Bundaberg Hospital administration
knew that every one of these operations was "elective", in the sense in which
that term is used by Queensland Health – in other words, they were operations
where the patient's survival did not depend upon urgent surgery. But 12 out of
13 death were allowed to go unreported.
· However, even to have such incompetents supposedly running the hospital depended
on a ninth requirement, involving an
administrative failure at a much higher level. The hospital executive in
Bundaberg would not even have made the short-list with a private sector
employer, seeking a manager for a far less complex business, with fewer staff
and a much smaller turnover, performing a much less significant role. Private
sector employers look for managerial staff who are resourceful – who have
judgment and discretion, presence of mind, initiative – who are innovative,
progressive and proactive. Those same criteria in fact disqualify a person from
appointment or promotion within the Queensland Health bureaucracy. District
Managers, Directors of Medical Services, and the like, are not expected to
think for themselves; in fact, they are not even allowed to. The reality is
that the executives in Bundaberg did exactly what was expected of them – no
more and no less – and the ultimate blame lies with the architects of a system
which set them up to fail.
· Tenthly, and finally, what occurred in Bundaberg required an over-arching
administrative system designed to silence the final line of defence in our
medical system against the likes of Jayant Patel: the loyal, hard-working,
competent and conscientious clinical staff – the Toni Hoffmans and the Peter
Miachs of this world – who attempted to blow the whistle on Patel. Within the
Queensland Health bureaucracy, such whistleblowers face threats at every turn: the
threat of being sent to Coventry; the threat of facing trumped-up disciplinary
complaints; the threat of having their work hours re-scheduled to less
convenient times; threats to their prospects of career advancement; indeed, threats
to their entire careers.
tenth point is possibly the most critical. It explains why I have said that this
crisis in decision-making has two aspects: first, that those who are empowered
to act decisively can't or won't do so; and secondly, that those who would act
decisively are not permitted to do so. It is not enough that the ship is
without a captain – that the bridge has been taken over by the purser's clerks,
the cabin boys and the stokers. In addition, the deck officers have to be thrown
in the brig, cast adrift in lifeboats, or simply flung overboard, so they
cannot even warn the passengers that the ship is sinking.
has this problem come about? It is easy to say that it is the result of an
over-inflated bureaucracy. The statistics speak for themselves: within Queensland
Health, there are some 9,250 employees whose duties are exclusively bureaucratic.
That is more than double the number of hospital beds provided by Queensland
Health – more than 2½ times the number of medical practitioners employed by
is a truism to say that decision-making, unlike almost every other form of human
endeavour, is retarded rather than accelerated by the number of people
involved. A hole may be dug more quickly if there are 10 workers involved
rather than one; but the decision where to dig the hole will be made much more
quickly if it is left to one person rather than a committee of 10.
C. Northcote Parkinson, the author of Parkinson's
Law – a book almost unique for the fact that it is often quoted (or perhaps
I should say misquoted) by people who do not even know that there is a book of that
name – offers statistical proof for what he terms "Parkinson's First Law": the
proposition that "a Civil Service expands at an inexorable rate of growth,
irrespective of the work (if any) which has to be done".
· One example he gives is the Royal Navy. As early as the 1930s, Parkinson
had successfully predicted that the Royal Navy would eventually have more
admirals than ships – an interesting contrast with a health service which has
more administrators than the total number of hospital beds and doctors
combined. Parkinson notes that, in 1914, "4,366 officials could administer what
was then the largest navy in the world" – a navy comprising 542 capital ships
and about 125,000 officers and men. By 1967, when the number of ships had
fallen from 512 to 114, and the number of officers and men had declined to
under 84,000, the number of public servants had risen from 4,366 to some 33,000
– a number, Parkinson concludes, "barely sufficient to administer the navy we
no longer possess".
· Another example was the British Army, which – according to Parkinson –
"need never shirk comparison with the Admiralty":
1935 a civilian staff of 9,442 sufficed to administer an Army reduced to
203,361 officers and men; the low-water mark of unpreparedness for a conflict
which was by then obviously inevitable. By 1966 a civilian staff of 48,032 was
giving encouragement to some 187,100 men in uniform, a 7.9% reduction in
fighting strength being accompanied by a 408% increase in paperwork."
· Parkinson's third example was the British Colonial Office. In 1935, a
mere 173 bureaucrats were sufficient to administer an empire which encompassed
about a quarter of the world's population, and a similar proportion of its land
mass. By 1960, the bureaucracy had grown from 173 to 2,827 – a sixteen-fold
increase – despite the fact that the empire had virtually ceased to exist.
Parkinson stops short of offering any cure for this
malaise. In his words: "It is not the business of the botanist to eradicate
weeds. Enough for him if he can tell us just how fast they grow."
In my observation, the size of the Queensland Health bureaucracy
is a significant factor; but it does not, alone, explain the Department's
inefficiency. The problem is not simply that there are too many people; the
problem is also that they are the wrong people. They are the people who,
whether or not they possess the intellectual capacity to make good decisions,
lack the self-confidence to do so.
One clear manifestation of this is the committee
system which exists within Queensland Health. No issue of any significance can
be, or is, decided, unless it has been considered by a committee – or, as is
more often the case, a myriad of different committees, examining the same issue
from different viewpoints.
A cogent example of this emerged during the Inquiry. It
involved a minor set of legislative amendments which the higher echelons of the
bureaucracy regarded as essential. The evidence revealed that these amendments
had been under consideration by the so-called "legislative projects unit" for
some eight months. As I commented at the time (and I stand by my comment) "that
project would take anyone – any competent lawyer – about half a day to finalise".
When Winston Churchill became Prime Minister in the
darkest days of 1940, one of his first steps was to commission a supply of
stickers, which he would subsequently affix to ministerial directions and
memoranda, bearing the words "ACTION THIS DAY". Any contemporary politician who
sought to emulate Churchill's attempt to overcome bureaucratic inertia would
need rather larger stickers, reading something like this:
ACTION THIS DAY
or as soon as possible hereafter, once:
(1) a business case study has been prepared;
(2) a detailed feasibility report has been obtained;
(3) an environmental impact statement has been
(4) indigenous welfare issues have been fully addressed;
(5) approval has been given by the legislative standards
(6) compliance with equal opportunity guidelines has
(7) workplace health and safety implications have been reviewed;
(8) there has been compliance with the "Smart Directions
Statement for Information Technology Conditions within the Queensland
(9) appropriate consultation with community interest
groups has been undertaken;
(10) the proposal has been submitted to the relevant
inter-departmental review committee;
(11) all relevant ethical and integrity considerations
have been satisfied in conformity with "whole of government" policy;
(12) detailed costings have been prepared and approved by
(13) tenders have been let in accordance with the Financial Accounting and Audit Act,
the whole-of-Government buying policy, and the Auditor-General's Guidelines;
(14) media releases have been prepared by the
Department's media office in consultation with the Minister's press
(15) the launch date has been confirmed with the Cabinet
Office and all relevant Ministers and Heads of Departments.
Unlike Professor Parkinson, I am willing to offer a
suggestion as to how we can address this problem. Appropriately, I think, my
suggestion is drawn from an analogy in medical science.
Some years ago, Toowoomba General Hospital experienced a problem with antibiotic-resistant bacteria infecting one of the
wards. The solution adopted by the Medical Superintendent was practical, if
somewhat unorthodox. He acquired a number of mirrors, and had them set up
throughout the ward to shine sunlight into every nook and cranny. He reasoned –
correctly, as it turned out – that the infectious bacilli could only survive in
Today, new and much more virulent pathogens are
threatening the health of this State's public hospital system – the 9,250
bureaucrats whom I have mentioned. These parasitic organisms also thrive in an
environment of Cimmerian gloom, and have evolved an immunity to even the most
Any attempt to control these infections by
conventional means is worse than useless. Even if you succeed in getting rid of
significant numbers, you eliminate only the weakest and least harmful. Those
remaining are hardier, even more resistant to control – they reproduce and
multiply at an even greater rate.
The only treatment which has any chance of success is
the antimicrobial ministration pioneered at Toowoomba General Hospital.
These organisms, inhabiting the crepuscular recesses and crevices of the public
hospital system, are susceptible only when exposed to direct light.
Experimentation which I conducted at the Bundaberg Hospital Commission of
Inquiry shows that even the threat of exposure sends them into frenzied
paroxysms – like Dracula, they crumble to dust when the spotlight is turned on
In his evidence, the distinguished cardiologist,
Professor Con Aroney, described the conduct of such organisms as "sociopathic".
In an attempt to understand what Professor Aroney means by that, I have done a
little research of my own. According to one source, a sociopath appears normal,
and is therefore not easily recognisable as deviant or disturbed. The clinical
indicators associated with this personality type include: glibness or superficial
charm; a grandiose sense of self; a lack of any remorse, shame or guilt;
callousness or a lack of empathy; and a failure to perceive that anything is
wrong with them. Sociopaths are described as authoritarian, secretive,
manipulative, paranoid, and pathological liars.
Those who think that Professor Aroney was guilty of
exaggeration when he adopted the expression "sociopath" might care to look at a
particular document generated out of Queensland Health's headquarters in Charlotte Street –
a so-called "risk rating matrix". This document, we were told, is designed to
assist staff in categorising the seriousness of adverse events. A death –
whether resulting from medical malpractice, or resulting from a workplace
health and safety incident – is regarded as a "major" issue. On the other hand,
significant damage to Queensland Health's own reputation is an "extreme" issue.
Who, but a sociopath, could have designed an official document which rates the
death of a human being – any human being, whether a patient in one of the
Department's hospitals, or even an employee of the Department – as a less
serious matter than an injury to the Department's own enviable reputation?
The palpable dishonesty of Queensland Health with
respect to waiting list figures is another example. To borrow Andrew Lang's
aphorism, Queensland Health uses statistics as a drunken man uses lampposts –
for support, rather than for illumination.
was intrigued to learn, recently, that the Office of the Coordinator-General –
an office which, to my knowledge, is unique to Queensland – was first created
in 1938 by the Forgan Smith Labor Government, following an international
fact-finding mission aimed at finding ways to restore the State's economy in
the wake of the Great Depression. After reviewing the situation in a number of
countries, Forgan Smith came upon a striking example of an economy which had
been devastated by the Depression, but which had recovered more rapidly than
most, due principally, as the mission concluded, to the efficiencies which
resulted from having a single decision-maker empowered to make things happen.
That economy was, of course, the economy of Nazi Germany. The role of
Queensland's Coordinator-General was modelled – not, as you may be guessing, on
Adolf Hitler – but on Dr Fritz Todt, founder and head of what was called
"Organisation Todt", the German government's construction and engineering group
responsible for such projects as the Autobahn network. Incidentally, after Todt's
death in an air crash, he was succeeded by Reichsminister Albert Speer.
about the same time, the Forgan Smith Labor Government was embarked on another
revolutionary agenda. It set out to create the first public universal free
hospital system in the world – an initiative which predated the National Health
Scheme in the UK by some 15 years, and Australia's first national free health
scheme, Medibank, by close to 40 years.
fulfil that truly momentous platform, the relevant minister – Ned Hanlon –
deliberately "head-hunted" a man who was both an outstanding medical
practitioner, with a specific expertise in tropical medicine, and an
experienced public health administrator. Thus came Dr Sir Raphael Cilento to
the role of Director-General of Health and Medical Services. Described by Ross
Patrick in his History of Health and
Medicine in Queensland as "brilliant, energetic, eloquent and ambitious" –
and by Hanlon, quite simply, as "the best man in Australia for the position" –
Cilento was to become, for all intents and purposes, the Coordinator-General's
equivalent in the Health Department; if you like, the Fritz Todt, or the Albert
Speer, of health administration in the State.
is probably irrelevant to mention that Sir Raphael was also the father of noted
Queensland actress, Diane Cilento, and therefore, at one time, the
father-in-law of the original James Bond, Sean Connery – also the grandfather
of actor Jason Connery, who, at the time of his birth, the press liked to call
"008". However, a better indication of Sir Raphael's calibre can perhaps be
drawn from the fact that, after the Second World War, he was given one of the
most difficult and demanding jobs imaginable, when he was appointed as the
United Nations Director for Refugees and Displaced Persons.
Queensland succeeded in its attempt to establish the first public universal free hospital
system in the world is a testament to the efficiency of having, as the mandarin
in charge of the scheme, a person both qualified and willing to make decisions,
and to get things done. I have no doubt that Cilento made mistakes, as everyone
makes mistakes who has the courage to actually do something. But even bad
decisions are better than no decisions at all – and, on the whole, it would
seem that the decisions made by Cilento were mainly the right ones.
recently, the Beattie Government has apparently learnt that one intelligent,
self-confident and courageous decision-maker is far more effective, in a
situation of crisis, than a team of mediocrities. I refer, of course, to the
appointment of General Peter Cosgrove to take charge of the emergency aid
effort in North Queensland following Cyclone
Larry. The crisis in Queensland Health is perhaps not so acute, but it is
certainly more wide-spread, and poses a greater threat to the lives and health
of a greater number of Queenslanders. What Queensland Health needs, right now,
is a medical equivalent of Peter Cosgrove – another Raphael Cilento – an
intelligent, experienced, vigorous, and decisive leader – so that Queensland
Health, like Innisfail, can be put on the road to recovery.
that happen? I doubt it. Some 9,250 bureaucrats have too much to lose – for if
there is even one person who would act decisively and is permitted to do so,
what is to become of those who are presently empowered to act decisively, but
can't or won't do so?
my own experience, as the Chairman of a Commission of Inquiry, serve as a
warning to others. Any attempt to act decisively inevitably stirs up powerful
bureaucratic opposition. I have spoken of bureaucratic inertia: basic physics
tells us that a body's inertia is directly proportionate to its mass. To
overcome the inertia of the Queensland Health's massive bureaucracy will
require an irresistible force to meet an (almost) immovable object – otherwise,
the weaker element will be destroyed.
should know. I tried, and I failed.