SA Health on Wednesday released the results of two reports into what CEO Robyn Lawrence on May 4 called a “completely unacceptable” situation, after it was found the the man treated at least 15 patients at Port Augusta Hospital from April 24 to May 2.

The first report, by Henderson Horrocks Risk Services, examined how the unregistered doctor gained access to the hospital, while a second by Professor Alan Sandford focused on policies and processes which led to the man “being considered as a suitable prospective employee”.

The Henderson Horrocks report delved into SA Health’s recruitment process, during which the man failed to provide information, “prevaricated and lied”.

The report said the man – identified only as PI (Prospective Intern) – was an Australian citizen with an international medical degree who applied for an intern position with the Flinders and Upper North Local Health Network (FUNLHN) in late 2022, despite not being registered as a doctor in Australia.

He applied for registration in early 2023, and the report said he deliberately withheld information from FUNLHN while it waited for approval before employing him.

“It is clear from PI’s failure to disclose his registration history in (redacted) that PI was cognisant that this history would have negatively impacted any regulatory agency or hospital’s decision to register him,” the report said.

“From 28 November 2022, when PI lodged his internship application until 3 May 2023, PI wilfully and deliberately failed to disclose his criminal and disciplinary history to FUNLHN. He did so, suspecting that if they had known about his criminal and disciplinary history, they would not have employed him.”

The report said that the “critical shortage of junior doctors in FUNLHN” and an inability to find interns “were driving factors in the acceptance of a late application from a far-from-ideal applicant”.

“Flaws in the recruitment and selection process allowed PI, an individual with a professional disciplinary history and a criminal history of deception and dishonesty around registration, to proceed through the recruitment and selection process without serious scrutiny,” it said, citing a lack of questioning the man’s CV and referees as well as background checks.

The report said that FUNLHN Medical Education Unit officials who were unaware of his background invited him to an Intern Orientation Program, and that due to a a “misguided expectation based on experience that an intern would be registered and credentialled shortly after orientation”, he was given accommodation and a Whyalla Hospital access card. He was also named as a new intern in a staff newsletter and on social media and included on an internal junior doctor timetable.

This “created the illusion to anybody outside of the recruitment and onboarding processes that PI was an employee and therefore registered”, the report said.

By April 24, 2023, Port Augusta Hospital staff believed PI “was a registered, employed intern starting his second rotation” at their hospital and he was given an access card after he “misrepresented himself starting his rotation in ED that day”.

The report said that the Medical Education Unit had “understandable but unacceptable trust” that a medical graduate awaiting registration would not lie about being registered or treat patients without being registered, and should have told Patient Services that PI was not allowed to start work until they authorised it.

PI then lied to Port Augusta Hospital emergency department staff that he was a new intern and worked there on six days, the report said. On at least four occasions after, the report said, the MEU told him he could not work in the ED as he was not registered or credentialled, and he failed to tell them he was.

The report made a number of recommendations, with the first being that a Google search be made on all applicants, along with criminal and international history checks, that new and clearer guidelines for assessing and selecting junior doctors be developed and that prospective interns not be given access cards, be listed on internal rosters or staff communications.

The Australian Health Practitioner Regulation Authority is holding a separate investigation into the incident.

SA Health CEO Robyn Lawrence said that the report findings were accepted and recommendations would be worked through to “make sure our hiring processes are as thorough and robust as the public expects them to be”.