"Why didn't they check?" That was the front-page headline in a Bundaberg, Australia newspaper about Dr. Jayant Patel, asking why the local hospital had hired Dr. Patel when he had already been the subject of medical discipline for patient deaths and injuries in Portland, Oregon.

But tragically, the question wasn't asked until Dr. Patel had been working in the Australian city for three years and until he had been the subject of several confidential complaints to the licensing authorities from nurses who saw frequent complications with his surgical patients.