High-profile neurosurgeon Charlie Teo has been found guilty of unsatisfactory professional conduct, marring a career plagued with controversy. NSW HEALTH CARE COMPLAINTS COMMISSION * The health watchdog investigated complaints relating to two of Dr Teo's patients with terminal brain tumours * Neither patient regained consciousness after surgery undertaken in 2018 and 2019 at Sydney's Prince of Wales Private Hospital * During hearings in March 2023 Dr Teo admitted his actions were responsible for the women's poor outcomes, but rejected any suggestion he was negligent PATIENT A * A 41-year-old Perth woman saw Dr Teo a week after being diagnosed with diffuse stage four tectal midbrain glioma on October 12, 2018 * The mother-of-three and her husband flew to Sydney to attend a consultation 11 days later * Dr Teo said he would attempt a radical resection of the tumour after two surgeons refused to operate * The proposed operation was attempted on October 24 for a fee of $35,000 * Patient A did not regain full consciousness after the operation and died on April 5, 2019 PATIENT B * A 66-year-old mother-of-two saw Dr Teo after being diagnosed with a diffuse stage two astrocytoma, IDH wild-type in August 2018 * Dr Teo said he would attempt a radical resection of the tumour, with the aim of prolonging her life * The proposed operation was attempted on February 25, 2019 for a fee of $35,000 * Patient B did not regain full consciousness following the surgery and died on March 30, 2019 COMMISSION FINDINGS * Dr Teo did not properly communicate the risks involved and failed to give Patient A enough time to make an informed decision * The decision to operate on Patient A was "high-risk and inappropriate" * The risk of neurological morbidity, including vegetative state, "outweighed any potential benefits from the surgery" * Dr Teo's attitude to and rationale for conducting the surgery was "substantially experimental" * Dr Teo failed to exercise proper skill in operating on Patient B * Patient B was told the proposed operation would be a resection of the tumour * The operation that was carried out was a right frontal lobectomy, much of the tumour was left behind and a large amount of non-tumour brain tissue was removed * Dr Teo inappropriately slapped Patient B across her face in front of her family while she was unconscious * The $35,000 fee was inappropriate OUTCOME * Dr Teo was found guilty of unsatisfactory professional conduct by the commission in a judgement on July 12, 2023 * Conditions will be imposed on his registration and he will need to obtain a written statement from a Medical Council-approved neurosurgeon to perform certain surgical procedures * An appeal can be lodged with the NSW Civil and Administrative Tribunal within 28 days KEY QUOTES * "Surgery in this situation is not recommended or carried out by a majority of the practitioner's peers, nor a responsible minority of surgeons" * "The procedure was not supported by the literature (and) the practitioner in his professional capacity had an overriding ethical duty to refuse surgery" * "The practitioner's attitude to and rationale for conducting this type of surgery is substantially experimental" * "I haven't been able to save lives that I know I can save" - Dr Teo Australian Associated Press