Abdalla Khalafalla performed almost 30 operations beyond his skill level, according to a report tabled in the state parliament.
He had worked at Mackay Base Hospital from 2004 to 2006.
It was in August 2006 former Nationals MP De-Anne Kelly charged in federal parliament that four cases Queenslanders were injured in operations conducted by the unsupervised doctor.
Subsequently the Health Quality and Complaints Commission (HQCC) began its investigation.
Its report tabled in the state parliament Tuesday said the Egyptian-trained surgeon worked outside his level of competency, posing as a specialist.
Surgeon Dr Jon Cohen, who reviewed Dr Khalafalla's surgical technique and postoperative management in 26 cases, found he used "potentially dangerous techniques" on six occasions.
Two patients would have died had corrective action not been taken by other medical professionals at the hospital, Dr Cohen said.
Dr Cohen found Dr Khalafalla's inability to manage surgical complications, including haemorrhaging, was a result of inadequate training in major abdominal surgery.
"Training in major abdominal surgery has been deficient as evidenced by the results of the surgical cases under his care," Dr Cohen said.
The Commission's chief Professor Michael Ward said Dr Khalafalla had worked in Townsville and country Victoria, prior to his appointment in Mackay, but concerns about his competence and conduct were not shared with Mackay Base Hospital upon his recruitment there.
"There was substantial information about his clinical performance dating back to 2002," Professor Ward said.
"Had this information been shared it is fair to assume this situation could have been minimised or prevented altogether."
An audit will be conducted of all cases of major surgery performed by him at Mackay Base Hospital without direct supervision.
Dr Khalafalla is living in Victoria but is no longer registered to practise.
The commission report has been passed on to Victorian and other authorities around Australia.
Prof.Ward could not guarantee Dr Khalafalla was not currently working in Queensland.
"We don't know where he is," Professor Ward said.
"He may be working somewhere in Australia, although it is unlikely he would still be in Queensland."
Health Minister Stephen Robertson said the Khalafalla case highlighted problems with credentialling, which involves working out the range of procedures a doctor can perform according to their qualifications.
"What has happened in this case is that over a two-year period between 2004 and 2006 ... this individual has been allowed on occasion to operate without appropriate supervision,'' Robertson said.
"That was a result of a breakdown of communication between the College of Surgeons, the medical board and indeed Queensland Health.''
Robertson said the government had since taken steps to improve the credentialling system, but the best solution would be to put in place a national scheme.
The HQCC has recommended an Australia-wide reporting system for tracking the performance of medical practitioners be established to ensure international medical graduates are better placed based on their qualifications and competence.
Queensland Health has supported the HQCC's recommendation to introduce legislation which allows information about doctors to be shared among regulatory boards and specialist colleges.
The Queensland opposition slammed the HQCC over seemingly unreasonable delays during the two-year investigation.
Shadow Health Minister John-Paul Langbroek said he was perplexed as to why it had taken so long to complete a report on the international medical graduate.
"Two years is far too long to wait for answers," Langbroek said.
"Reports of this nature should be completed with priority."
Langbroek said that during 2006 and 2007 the HQCC conducted 38 investigations but only seven were finalised.
He also said the report raised serious questions as to whether the government had learned anything from the Bundaberg Hospital tragedy involving Dr.Jayant Patel.
"What this report suggests is that a critical lack of communication between industry and government agencies is putting patients' lives at risk,'' Langbroek said in a statement.
"The fact that a doctor with serious question-marks over his head as to his clinical capability was allowed to operate without any supervision is beyond belief in this post-Patel era.''
The commission said there also should be guidance for all medical staff working with deemed specialists to ensure they are aware of any restrictions on the specialist, and a review of monitoring and oversight processes to ensure internal witnesses could blow the whistle on problems without fear of reprisal.
Health minister Robertson said he had taken to state cabinet a proposal to introduce new laws mandating the reporting of harm to patients.
"Doctors are duty bound, if they see one of their colleagues doing something untoward, to report it,'' Robertson said.
Any professionals who do not report harm could face a range of penalties.
Robertson said a discussion paper would be released soon and he hoped to have the laws in place by the end of the year.
Barrister Tony Morris, QC, who headed the initial inquiry into Dr Patel, the former director of surgery at Bundaberg Base Hospital now on manslaughter charges, said on Tuesday he had read the HQCC report and found it "absolutely terrifying".
"It's like reliving a bad nightmare," Morris told ABC radio.
"You read the report and it's almost a complete replication of what happened in Bundaberg.
"And the really terrifying part is it's still the same attempt by the bureaucracy to say `It's not our fault - let's blame the doctors.'
"But Queensland Health are to blame and the only change I've seen is that the bureaucrats are now smarter about how they get back at whistleblowers."
He said the health department needed to be rebuilt from scratch.