A NSW tribunal has apologised to four women pelvic mesh patients after breaching its own non-publication order by naming them in a judgment, while denying media access to files about the mesh cases to protect the women's privacy. "I just feel like I've been screwed all over again," said one of the women, known as Patient A, who cannot work, uses a catheter to urinate and relies on a wheelchair after four pelvic mesh surgeries at Sydney Private Hospital in 2013 and 2014. "There's no justice. We can't see what happened at the hospital because the tribunal says our names can't be disclosed and then they name us anyway," said Patient A, after her name appeared in a NSW Civil and Administrative Tribunal judgment of pelvic mesh surgeon Peter Petros on May 23. This was despite a tribunal non-publication order making it an offence to disclose her name, and after the tribunal registry rejected previous Newcastle Herald attempts to access the files of Dr Petros's colleague, Dr Richard Reid, because of a non-publication order over patients' names in that case. Both men have been found guilty of professional misconduct following pelvic mesh surgery on more than 100 women at Sydney Private Hospital in 2013 and 2014, where Dr Petros failed to disclose his financial interest in the Tissue Fixation System (TFS) pelvic mesh device invented by him. Patient A, two other women known as Patients B and L, and the late Alison Blake were implanted with the TFS device by Dr Reid after the hospital allowed him to continue operating, despite two near-fatal incidents involving women patients in April and June, 2013. The second incident occurred one week after Dr Reid resumed surgery following a suspension after the first incident, and on condition he adopt the TFS technique under Dr Petros's supervision. In a "surprisingly brief" report to the hospital medical advisory committee after the second woman nearly died, Dr Petros did not mention the TFS device, the Civil and Administrative Tribunal found. The tribunal was told Dr Reid was allowed to continue operating at Sydney Private Hospital following the second incident after a two-hour meeting between Dr Petros and a senior hospital representative. A tribunal panel in September, 2018 found Dr Reid guilty of professional misconduct after serious injuries to 17 patients, and after finding he lacked honesty, "effectively abandoned" a woman patient, misrepresented himself as a University of Newcastle professor and associate professor, "flagrantly ignored" conditions over his practice, failed to gain patient consent before implanting pelvic mesh and exhibited "zeal" for Dr Petros's non-mainstream mesh theories. Patient A said there was no justice in a system that took more than four years to find the doctors guilty of professional misconduct, but could not impose any sanctions because both men retired before the decisions. There was also no justice in a system that closed the door on public examination of how the hospital, other hospitals and the health system responded to concerns raised about the two men, Patients A, B and L said. A number of women returned to the hospital multiple times after mesh complications, including Patient B who had surgery four times between July and December, 2013, but was not advised she was implanted with the TFS device until after her third surgery. Patient A had four surgeries between October, 2013 and July, 2014 after she was implanted with the TFS device. "I can't see how the hospital didn't know what the hell was going on. I was in there four times and there were other women there each time who'd been back two or three times. Didn't it occur to anyone at the hospital to ask 'Why are all these women coming back?'," Patient A said. Patient L said women wanted a further investigation of the hospital and the health system's oversight of the hospital. She also supported media access to files in the Petros and Reid cases because of the large volume of material discovered during investigations of the two men that has not been made public. "The way that it is at the moment it just feels like the system is supporting the doctors. There were two near-fatal incidents at that hospital and it didn't seem to make the hospital stop, re-evaluate and slow down. Instead they just ramped it up and more women were injured," Patient L said. In 2017 NSW Health Minister Brad Hazzard ordered a review of the hospital after Patient L's hospital records showed she was under anaesthetic for 90 minutes more than she needed to be because her TFS surgery was photographed without her knowledge or consent. "I did not find out until I got my hospital notes and came across it. It made me gasp. It was another violation to know someone has been positioning you to take photographs while you're powerless to do anything about it, and don't know about it," Patient L said. "It makes me feel violated. I have no idea where those photos have gone. No-one's been able to tell me." A NSW Health spokesperson said the Sydney Private Hospital review found no breaches of legislation but recommended a number of improvements to policies about patient consent. NSW Health also undertook "extensive regulatory investigation and action" at the hospital after events in 2013 and 2014, including a review of all Dr Reid's patient medical records. It found "a number of areas for improvement". Hospital audits in November, 2017 and July, 2018 showed recommendations were implemented, the health spokesperson said. Teacher Alison Blake had three mesh surgeries over 17 days in February, 2014, after she was implanted with TFS. She took her own life in June, 2015 after a doctor said there was nothing more that could be done for her mesh complications. In a letter to her daughter Leesa Tolhurst she wrote: "I simply cannot bear to be lying on a couch for months on end and to have to rely on catheters, enemas, Temazepam, pain killers and be a burden to my family and friends." In March Mrs Tolhurst succeeded in an application to the Civil and Administrative Tribunal to have the non-publication order over her mother's name lifted, after Dr Reid tried to stop being "named and shamed" as Ms Blake's doctor. Mrs Tolhurst called for a full inquiry into the pelvic mesh scandal, with power to subpoena documents and compel evidence. "No-one responsible for this has really been held accountable and women like my mother have just been abandoned. She went in for surgery trusting the doctor, the hospital and the health system and she was failed at every point," Mrs Tolhurst said. Patient A said she was devastaed after she was named in the NCAT decision. The tribunal withdrew the decision, after it was alerted to the women's names by the Newcastle Herald, and re-released it this week with the names redacted. "I don't trust the health system. I don't trust doctors. I don't trust any of them after what's happened to me. I trusted the system that said my name wouldn't appear, then it does. Having that happen has just compounded the lack of trust I have for everything, 1000 times," Patient A said. Sydney Private Hospital, part of the Macquarie Health Corporation, declined to respond to Herald questions about oversight of Dr Reid and Dr Petros and the hospital's assessment of the TFS device, which was one of the first pelvic mesh devices in the world to be cancelled in November, 2014, and which continued to be implanted in women at the hospital after the cancellation. A Macquarie Health Corporation spokesperson said the hospital had a rigorous credentialing process which was managed through a medical advisory committee. "The hospital relies on the Therapeutic Goods Administration to approve medical devices for use in the hospital. The safety, care and wellbeing of our patients is the highest priority of the hospital, which has processes and systems in place to ensure this priority is met," the spokesperson said.