"March 03: Anaesthetist out of room for 12 minutes leaving patient unmonitored. There is no policy in place for OR nurses to monitor patients re anaesthesia.

"KEMH response: Will be discussed at next Anaesthesia Department meeting.

"November 03: (The same) doctor left one patient unmonitored on table in OR to commence anaesthesia in induction room. Could not get the epidural properly sited before having to return to other patient.

"KEMH response: Will be discussed at the next Anaesthesia Department meeting. Meeting with chief of staff — new policies to be written and implemented. Guidelines re monitoring were not adhered to. Doctor agreed to follow guidelines.

"December 03: All anaesthetists aware that there was no monitoring equipment in Anaesthetic Room. Patient left unattended — went pale and complained of chest pain. 'The problem is arising because some anaesthetists are not following safety precautions and protocol of anaesthetising only one patient at a time.'

"KEMH response: Discussed at Anaesthesia Department meeting. Doctor agreed to follow monitoring guidelines.

"January 04, 10.10 a.m.: anaesthesia commenced on first patient. 10.20 a.m.: doctor left patient unattended to place epidural in second patient.

"KEMH response: New policies to be written; verbal warning given."

Ms Brock pointed out that a number of good practice guidelines had been broken and asked: "If this doctor were black, would he have gotten the benefit of the doubt once — much less four times?"

She added: "This doctor was never disciplined. Interviewees tried to explain this away by noting that these incidents occurred at a time when (black) leadership was reluctant to discipline colleagues.

"That does not explain why a subsequent chief of staff did not even know about these incidents — and therefore did not have a history to compare with when later reports were again filed about this doctor."