The commission was established by the Queensland Governor-In-Council in 2005 to investigate, among other things, the conduct of Dr Jayant Patel, a former surgeon of Bundaberg Base Hospital.
Bundaberg Hospital administrators Darren Keating and Peter Leck undertook a court case against Morris.
The commission found gross negligence in Patel's conduct, as well as systematic failures of management to deal with the problem.
Davies recommended that Patel be referred to the public prosecutor for consideration of manslaughter, fraud, and assault charges.
[4] The state chief health officer at the time, Dr Gerry FitzGerald was criticised for his own investigation into Patel, describing it as too positive.