"The hospital was so concerned about repeated deaths likely due to punctures (of the pulmonary artery) during the insertion by an anaesthetist of central lines that a new programme, VAMP (Vascular Access Management Program) was implemented.

"Relevant doctors were retrained and the policy now requires that two doctors (either two anaesthetists or an anaesthetist and a surgeon) must be present in the Operating Room to do this procedure (one to attend to the anaesthesia and the other to put in the catheters).

"The doctor alleged to have the original problems was never investigated. He left Bermuda but was allowed by the Privileges Review Committee to return as a four-month locum in 2006.

"In that short period, another (white) doctor filed a complaint that required the Chief of Anaesthesia to remind this doctor of the standard for responsiveness."

Ms Brock set the above example alongside this: "During gall bladder surgery, a staple became loose leading to leakage from the common bile duct as well as to collapsed lungs and malfunctioning kidneys.

"Surgeon misdiagnosed the site of the leak but did not respond appropriately by sending patient by air ambulance abroad.

"Patient later heard him acknowledge that the staple must have fallen off, but his written explanation to the Office of Quality and Risk Management did not mention this.

"The hospital did not probe any further to learn how the staple became dislodged. There is no indication that the doctor's response was egregious. It is mentioned here simply to ask the question: if this were a black doctor, would there have been more scrutiny?"

She concluded by asking: "On the face of the clinical problems, which doctors are black; which are white? Based on who got the benefit of the doubt, which doctors are black; which are white?"