A man is facing a $AU30,000 fine after allegedly masquerading as a doctor at Australian hospitals for more than a decade.
Shyam Acharya is accused of stealing a doctor's name and medical qualifications while in India before moving to Australia and becoming a citizen.
To find work in Australia, he allegedly used fraudulent documents to gain registration with the Medical Council of New South Wales in 2003.
Mr Acharya worked in New South Wales at Manly, Hornsby, Wyong and Gosford hospitals under the name Sarang Chitale up until 2014.
As a junior doctor, he was under the supervision of other clinicians and NSW Health, said one clinical incident involving a team Mr Acharya worked in was reported.
The patient involved in the incident has been notified.
Mr Acharya's current whereabouts are unknown, but the Australian Health Practitioner Regulation Agency (AHPRA) has confirmed it has laid charges against him for a breach of the Health Practitioner Regulation National Law.
The charge carries a maximum penalty of $AU30,000.
Medical Council did not receive complaints
Medical Error Action Group founder Lorraine Long said it was unclear what work Mr Acharya had been carrying out.
"If he's working in a hospital, what was he actually doing in the hospital?" she said.
"I mean he had to have been conducting medical procedures of some sort.
"You couldn't work in a hospital for that long and... not do any procedure. I find that hard to believe."
However, NSW Health's deputy secretary Karen Crawshaw said no complaints were received by the Medical Council of NSW or the Health Care Complaints Commission.
"The root cause of this was false identity to get into the country in the first place," she said.
"The documentation that got him registered was in fact legitimate documentation of a doctor.
"We now require written references and contact directly referees of doctors seeking employment."
Ms Crawshaw had defended the department's recruitment practices and said the blame does not rest with the state.
Health Department to crack down on fake passports
NSW Health Minister Brad Hazzard said the situation was shocking and that he would raise it at a national level.
"It is quite disturbing that a foreign national could get through our border protection with a false passport and ID based on an Indian citizen who had trained as a doctor," he said.
"I will raise it at this month's COAG Health Minister's meeting to see whether the checks and balances are in place at a national level so that this can't occur again."
Mr Hazzard said he has also directed NSW Health to make sure it did whatever it could to look beyond fake passports.
"The Ministry of Health has advised me there have been substantial changes since 2003 in the checks that are made, but I want health to revisit the issue," he said.
Opposition health spokesman Walt Secord has called on the State Government to reveal if it has contacted all patients who may have been affected between 2003 and 2014.
"It is incredible that this man could practice for 11 years and come into contact with hundreds of patients and go unnoticed," he said.
The ABC has sought comment from the Australian Federal Police and the Department of Immigration and Border Protection.