Civil and Administrative Tribunal New South Wales Medium Neutral Citation: Danaei v Medical Council of New South Wales [2024] NSWCATOD 116 Hearing dates: 8 – 9 July 2024 Date of orders: 01 August 2024 Decision date: 01 August 2024 Jurisdiction: Occupational Division Before: Acting Judge Levy SC, Principal Member Dr J Fogarty, Senior Member Dr H Haikal-Muhktar, Senior Member M Christenssen, General Member Decision: (1) Pursuant to s 163(1)(c) of the Health Practitioner Regulation National Law (NSW) 2009, the applicant Dr Aliyar Danaei, may apply to the Medical Board of Australia for registration to reinstate him as a medical practitioner subject to the practice and health conditions listed in the Appendix to these reasons. (2) The Medical Council of NSW is the appropriate review body for the purposes of Part 8, Division 8 of the Health Practitioner Regulation National Law (NSW) 2009. (3) Pursuant to clause 13 of Schedule 5D of the Health Practitioner Regulation National Law (NSW) 2009, the applicant is to pay the respondent's costs of these proceedings on the ordinary basis as agreed or assessed. Catchwords: OCCUPATIONS — registration of medical practitioners — application for re-registration after expiry of disqualification period — male general practitioner disqualified from registration following findings of unsatisfactory professional conduct and professional misconduct — violation of professional boundary between doctor and patient — sexual relationship with a vulnerable female patient — whether previous Tribunal findings on 24 December 2021 expressing concern over former registrant's insight into past misconduct and his mental health issues have been clearly and sufficiently addressed and displaced by appropriate remedial steps — assessment of likelihood of reoffending — whether public health and safety would be adequately protected if the practitioner were to be reinstated at this time notwithstanding the previous Tribunal findings on 24 December 2021 — reinstatement subject to practice and health conditions Legislation Cited: Civil and Administrative Tribunal Act 2013 (NSW), s 64(1) Health Practitioner Regulation National Law (NSW) 2009, s 3, s 3A, s 3B, s 139B, s 139E, s 149C, s 149E, s 163A, s 163B, s 163C NCAT Procedural Direction 3, clauses 19(c) and (d) Cases Cited: Ameisen v Medical Council of NSW [2013] NSWCATOD 49 Briginshaw v Briginshaw (1938) 60 CLR 336; [1938] HCA 34 Coe v Health Care Complaints Commission [2013] NSWMT 12 Dasreef Pty Ltd v Hawchar [2011] HCA 21; (2011) 243 CLR 588 Davie v The Lord Provost, Magistrates and Councillors of the City of Edinburgh (1953) SC 34 Dawson v Law Society of NSW [1989] NSWCA 58 Evatt v New South Wales Bar Association (NSW Court of Appeal unreported, 12 April 1972) Evatt v New South Wales Bar Association (NSW Court of Appeal unreported, 15 December 1981) Ex Parte Lenehan (1948) 77 CLR 403; [1948] HCA 5 Haber v Health Care Complaint Commission [2018] NSWCATOD 16 Health Care Complaints Commission v Danaei (No 2) [2021] NSWCATOD 216 Health Care Complaints Commission v Danaei [2021] NSWCATOD 188 HG v The Queen (1999) 197 CLR 414; [1999] HCA 2 Jan v Health Care Complaints Commission [2021] NSWCA 350 Makita (Australia) Pty Ltd v Sprowles (2001) 52 NSWLR 705; [2001] NSWCA 305 Ng v Health Care Complaints Commission [2018] NSWCATOD 105 Paric v John Holland Constructions Pty Ltd [1985] HCA 58 Qasim v Medical Council of New South Wales [2021] NSWCA 173 Re Mansoor Haider Zaidi [2006] NSWMT 6 South Eastern Sydney Area Health Service v Edmonds [2007] NSWCA 16 Zepinic v Health Care Complaints Commission (No 2) [2018] NSWCATOD 92 Zepinic v Health Care Complaints Commission [2020] NSWSC 13 Texts Cited: E Brooks, M H Gendel, S R Early, D C Gundersen & J H Shore, "Physician Boundary Violations in a Physician's Health Program: A 19-Year Review" (2012) J Am Acad Psychiatry Law 40(1), 59-66. Category: Principal judgment Parties: Dr Aliyar Danaei (Applicant) Medical Council of New South Wales (Respondent) Representation: Applicant (self-represented) Counsel: A Petrie (Respondent) Solicitors: Medical Council of New South Wales (Respondent) File Number(s): 2023/00461308 Publication restriction: Publication restrictions apply to these proceedings. See paragraph [1] of these reasons. REASONS FOR DECISION Table of Contents Non-publication order [1] Introduction – Application for reinstatement to medical register [2] – [22] Grounds of the application [23] – [29] Jurisdiction and legislative focus [30] – [34] Baseline considerations [35] – [40] Legal principles for reinstatement [41] – [53] Issues [54] – [55] Evidence overview [56] – [61] Applicant's background [62] – [70] Development of applicant's relationship with Patient A [71] – [106] Mandatory report of boundary violation with Patient A [107] Termination of applicant's employment [108] - [109] Applicants' certification documents [110] - [126] Approach to assessment of expert medical and allied evidence [127] - [134] Review of medical and allied evidence [135] – [174] Applicant's submissions [175] – [182] Respondent's submissions [183] – [185] Consideration and determination [186] – [218] - Baseline findings, factual acknowledgments, relevant insights [187] – [194] - Applicant's credit as a witness [195] – [198] - Assessment of guidance value of expert medical and allied evidence [199] – [203] - Reformation of prior professional failings [204] – [213] - Displacement of previous adverse findings in favour of reinstatement [214] – [218] - Conditions for practice [219] Disposition [220] Costs [221] – [222] Orders [223] Non-publication order 1. At the outset of the hearing, the Tribunal made an order pursuant to s 64(1) of the Civil and Administrative Tribunal Act 2013 (NSW) to the effect that the disclosure or publication of the name of any patient referred to in the evidence, or the name of any person referred to in the evidence who has made a complaint in respect of the applicant, is prohibited. For the avoidance of doubt this order does not preclude the disclosure or publication of the name of the applicant. Introduction 1. By application made to this Tribunal pursuant to s 163B(1)(c) and s 163B(4) of the Health Practitioner Regulation National Law 2009 (NSW) ("the National Law"), Dr Aliyar Danaei ("the applicant") who presently works as a general medical practitioner in Iran whilst he remains deregistered in this jurisdiction, seeks reinstatement onto the Register of Medical Practitioners in this State. 2. The applicant, who had legal representation in the underlying proceedings which led to his de-registration, is self-represented in these proceedings. He appeared without language difficulties and gave his evidence by means of an AVL connection from Tehran, in Iran. 3. The applicant became deregistered because he crossed and then violated the professional boundary between doctor and patient by engaging in a personal and then an intimate sexual relationship with a vulnerable female patient with mental health issues which included a severe form of borderline personality disorder, depression, and other health issues ("Patient A"). The relationship resulted in pregnancy and the birth of a child now aged 6 years, who lives with her mother. 4. The applicant's offending conduct evolved incrementally over the course of a six-month period between November 2017 and May 2018. In that period, as an international medical graduate who had relatively recently arrived in Australia to work under supervision in an area of need, he was experiencing loneliness, social and cultural isolation, and he had his own mental health issues, including major depression. In that time, it appears that his practice supervisor was unaware of those mental health problems. 5. The applicant claims that since his deregistration, with the passage of time, with treatment and further medical education, he has remediated his prior professional failings and he now seeks reinstatement. He accepts that if he is to be reinstated, in light of earlier adverse Tribunal findings, for the protection of the health and safety of the public, his registration would be required to be subject to a series of practice and health conditions. 6. Following two earlier decisions in the Occupational Division of the New South Wales Civil and Administrative Tribunal ("the Tribunal") by two differently constituted Tribunals, on 19 November 2021 and 24 December 2021, in a two staged process, adverse findings were made declaring the applicant had engaged in unsatisfactory professional conduct and professional misconduct on account of his boundary crossing behaviour which led to boundary violations involving an intimate sexual relationship with Patient A, and related matters: Health Care Complaints Commission v Danaei [2021] NSWCATOD 188; Health Care Complaints Commission v Danaei (No 2) [2021] NSWCATOD 216. 7. The Medical Council of New South Wales ("the respondent") neither consented to nor opposed the application for re-registration but properly, in the public interest, took an active part in the proceedings by testing the evidence and making submissions on relevant matters requiring consideration by this Tribunal. 8. These reasons assume familiarity with the prior Tribunal decisions identified in paragraph [7] above. Those decisions were preceded by some earlier administrative inquiries initiated by the respondent pursuant to s 150 and s 150A of the National Law. These reasons should be read in conjunction with those earlier decisions. 9. The circumstances in which the applicant's relationship with Patient A developed were complicated. Nonetheless, what occurred was plainly unethical according to accepted standards of practice and applicable codes of professional conduct. It is plain that the applicant knew that to be so, based on his understanding of basic professional ethical standards that applied both in Australia, and in Iran, where he obtained his primary medical qualifications. The circumstances in which the applicant's personal relationship with Patient A developed to the point of boundary violation are identified below with greater particularity at a later point in these reasons at paragraphs [71] to [106]. 10. The applicant concedes that before he commenced his intimate sexual relationship with Patient A, without a clinically documented indication other than the fact that she was a new patient, he ordered a series of tests to screen her for possible sexually transmitted diseases. He ordered those tests on three separate occasions over the course of a period of three months. The applicant also admitted keeping inadequate medical records in relation to his consultations with Patient A. 11. The prior Tribunal determined that there was insufficient evidence to conclude that those tests were carried out as part of a pre-meditated plan by the applicant to pursue an intimate sexual relationship with Patient A, although that was plainly suspected. In these proceedings that finding by the previous Tribunal is not open to be re-litigated. The child of that relationship, a daughter now aged 6 years, lives with her mother, Patient A. 12. The applicant remained a registered medical practitioner subject to conditions of practice at the time the Stage One Tribunal hearing took place, however, his registration had expired by the time of the Stage Two Tribunal hearing. 13. On 24 December 2021, the Stage Two Tribunal recorded findings made pursuant to s 149C(1) and s 149C(4)(a) of the National Law to the effect that if the applicant had been registered at the time of that hearing, his registration would have been cancelled. 14. In those circumstances, orders were made disqualifying the applicant from registration for one year from 24 December 2021. At that time, he was also precluded from making an application for reinstatement for a year. That preclusion period commenced to run from 24 December 2021. In fact the applicant filed his application for registration almost two and a half years after those orders were made, notwithstanding that he could have done so much earlier. 15. Since the applicant became disqualified from registration he has lived and worked in Iran as a general medical practitioner, where he has been deriving a very modest income compared to the potential earnings of general practitioners in this country. 16. On 30 November 2023, from Iran, the applicant completed his application for reinstatement as best he could, nominating his postal address as the place where he had formerly practiced, in West Gosford, New South Wales. Whilst he believed the usual filing fee for his reinstatement application was waived in light of his disclosed financial circumstances, it appears he was mistaken in that regard, as such applications are fee exempt. 17. Throughout the previous Tribunal proceedings, and in these proceedings, the applicant has unreservedly acknowledged his misconduct as a big mistake on his part, and he did not seek to downplay or avoid answering difficult questions on the detail of the matters that led to him being deregistered. 18. The applicant has not only unreservedly accepted personal responsibility for that misconduct, but without seeking to make excuses or justify his wrongdoing, he has expressed his deep regret, deep shame and deep remorse at being in breach of his obligations to Patient A, whose vulnerability he has acknowledged. He has also expressed his sorrow to Patient A for having breached his professional responsibilities. He is plainly regretful and remorseful that his actions have caused harm and have had a negative impact on Patient A's mental health and well-being. 19. The applicant has also expressed his deep regret at bringing the medical profession into disrepute as a result of having placed his own emotional needs ahead of his professional obligations towards Patient A as her medical practitioner. He has acknowledged this constituted a breach of trust on his part. 20. The applicant claims that now, with greater insight, maturity, and the benefits of medical treatment and psychological therapy, and with the benefit of the educational programs he has attended and completed, he is more mature, better informed, better able, and is now equipped with suitable strategies for avoiding a future recurrence of the boundary violations for which he was deregistered. 21. The applicant stated that if he is permitted to do so, he intends to return to Australia as soon as possible so he can continue working as a medical practitioner. If that occurs, he also hopes to spend more time with his daughter and provide her with financial and emotional support. Grounds of the application 1. The applicant initiated these proceedings by filing his application form on 14 December 2023. The stated grounds of his application for reinstatement were identified as follows: "As the 12-month period has expired I would like to apply for reinstatement of my Registration. I have insight and have reflected on my prior misconduct. I have gained a clear understanding of boudaries (sic) in the doctor/patient relationship as outlined in the Medical Board's Code of Conduct. I understand the importance of being vigilant with patient's mental health conditions and their vulnerability. I have significantly improved my mental health as a result of continuous Psychotherapy and Cognitive Behaviour Therapy (CBT), work/life balance and having clear strategies in managing my mental health well-being. I have matured and grown immensly (sic)." 1. In summary, the applicant claims that at this time, the Tribunal would be comfortably satisfied that by the remedial steps he has undertaken, he has addressed the previous issues of concern which led to his disqualification and his current de-registration. 2. The applicant concedes that his own mental health issues, his loneliness and isolation, his long working hours, and his use of prescribed psycho-stimulant medication, his inexperience in dealing with the challenges of managing patients with borderline personality disorder presentations such as those of Patient A, in combination, were influential factors which led to his offending conduct. It also appears from the expert medical evidence that there may well have been an iatrogenic component which influenced the applicant's offending conduct consequent upon him taking the psycho-stimulant drug Vyvanse or lisdexamfetamine, which was prescribed by his treating psychiatrist to treat a diagnosis of inattentive attention deficit hyperactivity disorder ("ADHD"). 3. The expert evidence in these proceedings indicates the use of that medication was likely to have been accompanied by symptoms similar to acute mania and impaired judgment, which was thought to have contributed to the appellant initiating a sexual relationship with Patient A. That evidence raises the question of whether the applicant's use of that medication, which was prescribed by his treating psychiatrist, could be seen as being a mitigating factor in the applicant's offending conduct. That evidence was not available for the consideration at the previous Tribunal hearings. 4. The applicant claims that over the course of time, following his participation in psychiatric and psychological treatment, with prescribed medication, his mental health issues of previous concern, particularly his major depression, have been in remission. The applicant also claims his personal circumstances have now materially changed in that he has had a stable 2-year relationship in Iran with his fiancée whom he plans to marry. His wish is for them to travel to Australia as a couple, and for him to practice in Australia. 5. The applicant also claims his prior deficiencies of insight, behaviour and character failings which based the adverse findings in the previous Tribunal hearings have now been satisfactorily addressed by treatment, further education, and mature reflection on his part. He states that if he is reinstated to practice in this country, his aspiration is to have a relationship with and his 6-year-old daughter, and he intends to take personal and financial responsibility for her as a parent, although she would continue to live with Patient A. 6. In that regard, the applicant stated that on past visits to Australia following his deregistration he has met with Patient A and with their daughter and he has had mature and constructive contact with them. On that basis, he believes that his aspirations for having a supportive parental relationship with his daughter are feasible. At present, he is only able to visit here on tourist visas because without reinstatement and registration, he is unable to work here in his profession. He is conscious of the child's need for stable non-disruptive parental contact, which is the basis for his explanation as to why he has not sought to have contact with the child since late 2023, given the uncertainties over the outcome of these proceedings. Jurisdiction and legislative focus 1. The objective focus and overriding principle guiding the exercise of jurisdiction in this case must be the paramount consideration of the safety and the protection of the public. As such, the focus is not on the particular needs, wishes and circumstances of the practitioner: s 3, s 3A, and s 3B of the National Law. 2. Section 3(2)(d) of the National Law identifies as a relevant objective of the legislation the facilitation of the rigorous and responsive assessment of overseas-trained health practitioners. 3. Section 3A(1) of the National Law identifies the paramount guiding principle of the administration of that legislation as being the protection of the health and safety of the public. 4. Section 3B of the National Law requires that in the exercise of jurisdiction and functions under that legislation the health and safety of the public must be the paramount consideration. 5. This Tribunal has jurisdiction to hear and determine an application for reinstatement. That jurisdiction consists of a non-discretionary power to make an order in favour of reinstatement if such a course is determined to be appropriate at the time the application is heard, having due regard to the overriding paramount principles identified in the legislation: s 3, s 3A, s 3B, s 163A, s 163B and s 163C of the National Law. Baseline considerations 1. The baseline requirement for considering the present application for reinstatement is that this Tribunal must have regard to the full force of the previous findings of the Tribunal's Stage Two reasons published on 24 December 2021 in order to determine whether those findings which were adverse to the applicant should still be regarded as being applicable at this time: Health Care Complaints Commission v Danaei (No 2) [2021] NSWCATOD 216, at [42] to [64]. 2. The determination by the Stage Two Tribunal gave detailed consideration to a series of factors. These included not only the seriousness of the impugned conduct and the need for the public to have confidence in the medical profession, but questions concerning the applicant's insight, his emotional and mental health, his competence and knowledge, his relationship with his daughter, his financial situation, and his preparedness to work in an area of unmet need. 3. In that regard, the Stage Two findings concluded that the applicant was a competent practitioner who has shown insight into the events, and despite doubts about his emotional and mental well-being, that Tribunal was satisfied that the risk of the applicant again violating sexual boundaries in the future was low. 4. Notwithstanding that conclusion, and in conformity with accepted principles, the previous Tribunal considered the applicant's impugned conduct to be sufficiently serious to require deregistration for general deterrence as well as for the maintenance of confidence in the medical profession: Health Care Complaints Commission v Danaei (No 2), supra, at [64]. 5. As the applicant became disqualified due to the expiry of his registration, as distinct from suspension, he was required to apply to this Tribunal for reinstatement after the expiry of the disqualification period. 6. Recognising those baseline factors, in this application for reinstatement, the essential questions to be determined are whether the applicant has now demonstrated his fitness to practice, and whether, if he is to be reinstated, what would be the likely impact on the health and safety of the public in terms of the risk of a recurrence of the behaviour which led to his disqualification. Legal principles for considering reinstatement 1. The applicant bears the heavy onus of proof to satisfy the Tribunal by clear, solid and substantial evidence, that he has undergone a reformation of his past character flaws which led to his deregistration thereby justifying an order for his reinstatement onto the register of medical practitioners in this jurisdiction. 2. The discharge of that onus of proof cannot be achieved by simply making unsupported assumptions based on flimsy aspirational and platitudinal evidence where the paramount consideration is the safety and protection of the public: s 3A and s 3B of the National Law. The decided cases, which authoritatively explain those requirements are uncontroversial, and are summarised below. 3. The starting point for the Tribunal's consideration of a reinstatement application by a former medical practitioner against whom adverse findings have been made in respect of ethical breaches is to recognise the well-established principle that there is no public interest in forever denying a former practitioner the chance of redemption through reformation of character, if that can be satisfactorily established. 4. On the contrary, the decided cases indicate that the public interest is better served where practitioners who have offended against the accepted standards of practice but are otherwise suitably qualified are afforded a second chance provided reformation has been affirmatively established. 5. The test to be applied in an application for reinstatement is the provision of clear and demonstrative proof of persistence in habits of integrity, uprightness and responsibility: Dawson v Law Society of NSW [1989] NSWCA 58, (at 15.10), following Evatt v New South Wales Bar Association (NSW Court of Appeal unreported, 12 April 1972), which was cited with approval in Evatt v New South Wales Bar Association (NSW Court of Appeal unreported, 15 December 1981); Coe v Health Care Complaints Commission [2013] NSWMT 12, at [23]; Ameisen v Medical Council of NSW [2015] NSWCATOD 49, at [24]. 6. The paramount consideration in an application for reinstatement must be that the privileged status of registration as a medical practitioner should only be afforded to those practitioners who are suitably trained, qualified, and who can be trusted to practice in a competent and ethical manner according to expected standards of practice that are protective of the health and safety of the public. Of relevance to this case, where prior findings of unfitness to practice have been recorded, there is a heavy onus is on the applicant to displace the earlier adverse findings of unfitness and to clearly show that he is no longer unfit: Qasim v Medical Council of New South Wales [2021] NSWCA 173, at [17]-[19]; Jan v Health Care Complaints Commission [2021] NSWCA 250, at [21]. 7. The jurisdictional power to recommend reinstatement is conferred on the Tribunal by the force of the enabling legislation within the National Law. That power does not involve the exercise of a discretion. Instead, it is a power that must "be exercised with the greatest of caution and only upon solid and substantial grounds": Jan v Health Care Complaints Commission [2021] NSWCA 350, at [67], following Ex Parte Lenehan (1948) 77 CLR 403, 422; [1948] HCA 5, as was applied in Ng v Health Care Complaints Commission [2018] NSWCATOD 105, at [27]-[29], and in many other cases. 8. Central to the exercise of that conferred power, when considering an application for reinstatement, the Tribunal must assess the potential for risk to the health and the safety of the public: s 3A and s 3B of the National Law. 9. That assessment is required because studies show that practitioners with a history of prior sexual boundary violations are more likely to commit further sexual boundary violations. Those studies acknowledge the known phenomenon that further violations by such practitioners tend to go underreported for fear of legal retribution: E Brooks, M H Gendel, S R Early, D C Gundersen & J H Shore, "Physician Boundary Violations in a Physician's Health Program: A 19-Year Review" (2012) J Am Acad Psychiatry Law 40(1), 59-66. Accordingly, in this instance, a considered risk assessment is required. 10. The Tribunal's jurisdiction for undertaking those assessments is not punitive in nature. In Re Mansoor Haider Zaidi [2006] NSWMT 6, at [42], the former Medical Tribunal of New South Wales set out a conveniently digested form, a summary of the principles to be applied in applications for reinstatements, as follows: "1. The purpose of the jurisdiction which is exercised by the Tribunal is not for punishment or further punishment of the former practitioner. Instead the Tribunal's jurisdiction is for the protection of the public which deals with medical practitioners on the basis that they are members of an honourable profession who can be expected without reservation to conduct the affairs of their patients with honour and in whom the patients can place unbounded confidence. What is in question in an application for reinstatement to the Medical Register is whether an applicant is fit and proper to be held out to the rest of the profession, to patients and to the whole of the community as a person worthy of their confidence. 2. An applicant who seeks to establish fitness to have his name restored to the Register having been earlier removed from it bears the onus of proving the case. It is a heavy onus and the question whether the applicant is a fit and proper person, is one to be trusted to exercise the high responsibilities of the profession is one to be determined on solid and substantial grounds and as an applicant for reinstatement to the Medical Register he is in a more disadvantageous position than an original applicant. He must in effect displace the decision for deregistration which has been made. That decision involves the judgment that the applicant is probably permanently unfit to have his name on the Register. As a consequence, presumptions of fitness which might arise otherwise than from an absence of contrary suggestions can no longer advantage him, precisely because of the removal of his name from the Register on the basis of unfitness. 3. The ultimate issue is whether the Tribunal can conclude on the basis of all the evidence that an applicant is now a fit and proper person to join other members of an honourable profession in the responsible and trusted activities which are involved in the work of the medical profession, what is at stake is not so much the reputation of the applicant but the Tribunal's assessment of his character, uprightness, honour and trustworthiness. In the case of some offences committed over an extended period with deliberate intent and resulting in serious distress to patients it will be very difficult to contemplate any circumstances in which the name of the offender will be restored to the Register. 4. It is not a question of what an applicant has suffered in the past. It is a question of his worthiness and his reliability for the future. What in this respect the Tribunal must determine is whether it is satisfied that for the future the applicant will act in accordance with the high standards and responsibilities of the profession. It is difficult to decide what a man will do in the future and the decision in a particular case is to a greater or lesser extent dependant upon the Tribunal's assessment of the applicant. In making that assessment, it may draw inferences from what he has done in the past, and in particular, what led to his being removed from the Register. An understanding of that may assist the Tribunal to determine what are his standards and his understanding of a practitioner's responsibility, and from this, what he is apt to do in the future. Where what has been done in the past has been sufficient to indicate his probably permanent unfitness the Tribunal will require solid and substantial grounds for the conclusion that his standards have changed, his character has been reformed and that he will act honourably." 1. More recently, those guiding principles have been affirmed, echoed and applied without controversy in other cases: Zepinic v Health Care Complaints Commission [2020] NSWSC 13, at [85], citing the first instance decision of Zepinic v Health Care Complaints Commission (No 2) [2018] NSWCATOD 92, at [7]-[8], also citing Haber v Health Care Complaint Commission [2018] NSWCATOD 16, at [12]. 2. In Re Mansoor Haider Zaidi [2006] NSWMT 6, at [42], the ultimate question to be determined was identified as being whether an applicant has established worthiness and reliability for the future practice of medicine, that is, whether the Tribunal can be comfortably satisfied on the balance of probabilities that in the future the applicant will act in conformity with the high standards and privileged responsibilities expected of the medical profession when dealing with the health needs of patients. 3. The latter considerations were unquestioningly applied in reinstatement cases determined by the former Medical Tribunal of NSW. They also apply unquestionably in this Tribunal, which is the successor to that Tribunal. Issues 1. In light of those principles, the fundamental issues calling for determination in these proceedings centre around the applicant's credit as a witness; his acknowledgment and level of insight with regard to his past sexual misconduct concerning Patient A; whether the expert evidence provides reliable guidance on those matters; whether the previous adverse findings against the appellant have been satisfactorily displaced by clear, solid and reliable proof on the balance of probabilities such that those findings should be seen to be no longer appropriate with reference to efforts at reformation and remediation of his prior professional failings which have led to his deregistration. 2. Those issues must be satisfied according to a high bar for proof on the balance of probabilities having due regard to the seriousness of the issues and the risks involved: Briginshaw v Briginshaw (1938) 60 CLR 336; [1938] HCA 34, at 358 – 363. They must be determined by the Tribunal with primary focus on the paramount consideration of the protection of the health and safety of the public. That paramount consideration must override any considerations of sympathy arising from hardship and economic disadvantage experienced by the applicant following his deregistration as those matters are neither relevant nor determinative on the question of fitness to practice. Evidence Overview 1. In addition to the applicant's evidentiary statements, he gave oral evidence and made his submissions by means of an AVL connection from Tehran. In combination, the time zone difference and a fluctuating internet connectivity unfortunately meant that his treating psychologist and psychiatrist in Iran could not be called to give oral evidence to explain aspects of their clinical letters which formed part of the applicant's evidence in the proceedings. 2. Oral evidence was given by the practice manager of the medical practice where the applicant had worked in Wyong until his employment there was terminated due to the disclosure of the boundary violation which led to his deregistration. The substance of her evidence was that following the passage of time and in light of her knowledge of the applicant's remedial efforts to address the issues his deregistration, that former practice is now prepared to re-employ him in Gosford if he is reinstated. 3. In support of his application for reinstatement, the applicant produced a bundle of documents, correspondence and reports: Exhibit "A", pp 1-53, together with a further 14 pages of annexures. The respondent Medical Council also produced a bundle of documents; Exhibit "1", Tabs 1-24, pp 1-240. Some of those materials had been considered at the previous Stage Two hearing. 4. The respondent's bundle of documents contained copies of historical disciplinary documentation and comprising the materials and the decisions which preceded the present application. Those materials were supplemented with further uncontroversial documents comprising professional guidelines tendered during the course of the proceedings. The applicant's documentary evidence, which included his statements and certificates, was marked in the series Exhibits "A" to "B". The respondent's documentary evidence was marked in the series Exhibits "1" to "16". 5. The deliberations of the Tribunal were assisted by expert evidence both in the form of a written report and further explanatory oral evidence from Associate Professor Chanaka Wijeratne, a consultant psychiatrist who examined the applicant at the request of the Health Professionals Councils Authority for the purpose of these proceedings. 6. Relevant aspects of that array of evidence will be considered and referred to in the appropriate context and detail in these reasons. Applicant's background 1. The applicant is presently aged 41 years. He is living and working as a general medical practitioner in Iran. 2. In 2010, at age 27 years, he obtained the degrees variously described as Doctor of Medicine or Bachelor of Medical Sciences from the University of Guilan in Iran. Between 2011 and 2013 he worked as a medical practitioner in general practice in a number of remote rural areas in Iran, ultimately working in Tehran. 3. In 2013, when aged 30 years, the applicant passed his AMC MCQ examinations on his first attempt. On 19 October 2015, as an international medical graduate, he was registered as a medical practitioner in New South Wales subject to supervision conditions. Shortly afterwards he returned to Iran. 4. In March 2016, the applicant returned to Australia and began working at the Reliance Medical Practice on the Central Coast of NSW, in Wyong as a general practitioner in accordance with the supervision conditions of his registration. 5. Whilst working as a general practitioner on the Central Coast, the applicant experienced feelings of loneliness, homesickness and isolation from his family, and he became depressed. Those personal problems did not seem to have come to the attention of his practice supervisor although they did come to the concerned attention of the practice manager as she explained in her oral evidence. She was the one who noticed he was not doing well psychologically and suggested he seek psychological assistance. 6. In July 2017, he referred himself to a psychiatrist, Dr Sian Ong, who diagnosed and treated him with medication for the diagnosed conditions of depression and ADHD. He disclosed to Dr Ong that he was feeling stressed about his forthcoming FRACGP examinations. Dr Ong prescribed antidepressant medication for the applicant to treat his depression as well as Ritalin for his ADHD. 7. As the applicant experienced an adverse reaction to Ritalin, that drug was substituted with another dextamphetamine psycho-stimulant lisdexamfetamine or Vyvanse, which was later recognised to have some significant side effects which were apparently not initially understood, either by the applicant, or by Dr Ong who had prescribed that medication to him. 8. Of relevance to these proceedings, those side effects included a feeling of increased energy and work capacity. This resulted in the applicant taking on large numbers of patients over extended working hours each week as a response to his depression, loneliness and isolation. Although unrecognised at the time, apart from mania like symptoms and impairment of judgment, another side effect of that ADHD medication Vyvanse was increased libido, which was a factor identified in the evidence of Associate Professor Wijeratne. 9. Between 1 July 2017 and 25 September 2019, the applicant continued to consult Dr Ong for periodic psychiatric review, treatment, and for prescriptions for his medications for his conditions of depression and inattentive ADHD. In that period, in March 2018, the applicant made a short trip to Iran, and on his return, he resumed working at the Wyong practice. Development of applicant's relationship with Patient A 1. It is necessary to identify and summarise the events which led to the applicant's offending conduct in order to form the baseline from which to evaluate whether the applicant has truly implemented the required changes in his outlook and understanding of the requirements for the ethical practice of his profession. 2. The following summary has been reconstructed from the source referenced chronology comprising MFI "1", the findings recorded in the previous Tribunal decisions and s 150 and s 150A proceedings, and from relevant evidentiary concessions and admissions made by the applicant. 3. It is beyond dispute that at all relevant times, the applicant knew from his medical education in Iran, and from his knowledge of applicable medical ethics guidelines in Australia, that a professional ethical boundary must at all times be observed and maintained between doctor and patient, and that in particular, sexual relations with a patient were totally unacceptable and amounted to professional misconduct, especially in the case of a vulnerable patient who had significant mental health issues. 4. The evolution of the personal boundary crossing relationship between the applicant and Patient A developed according to the following chronological summary. 5. On 19 November 2017, following the applicant's return to Australia from Iran, whilst working at the Wyong practice, Patient A, a 33-year-old female patient, first consulted him for treatment of what was noted to be a sore finger. She also told him she had a history of a work related back injury which was the subject of a workers' compensation insurance claim, for which she was consulting another medical practitioner. 6. At that time, like Patient A, the applicant was also aged 33 years. He was experiencing loneliness, cultural and social isolation, and he was also feeling homesick. Over the course of a series of ensuing consultations with Patient A, a good personal rapport developed between them. 7. Hindsight analysis shows that between 19 November 2017 and 30 May 2018, the applicant had some 28 consultations with Patient A. Some of those consultations were very close together in timing. The applicant's clinical notes for some of those consultations were at times either sparse, absent, or did not record adequate detail of what had been discussed or concluded. The content of those notes of his consultations with Patient A attracted peer professional criticisms which the applicant accepts. 8. When the applicant commenced treating Patient A, he did not have access to the medical records kept by her former general practitioner. Therefore, initially, he did not realise there were aspects of her past history that indicated she was a vulnerable patient who had a history of addiction to marijuana, issues over her alcohol use, a series of miscarriages, post-natal depression, depression generally, and most significantly, a severe borderline personality disorder. 9. It appears that initially, either Patient A did not fully disclose those matters to the applicant, or he did not have the clinical acumen to discern that Patient A had emotional issues which indicated she ought to have been regarded as being a vulnerable patient who should be treated with due caution. 10. Subsequently, the applicant eventually obtained access to Patient A's medical records from her former general practitioner. Consequently, he became aware of aspects of her medical history which ought to have caused him to take pause and reflect on the fundamental inappropriateness of the social relationship which was developing between them. 11. Along that timeline, in the professional setting the applicant came to know many personal things about Patient A. Those matters included details of her sexual history, her past history of testing for sexually transmissible diseases, her multiple past miscarriages, her history of depression, her history of post-natal depression after the birth of her son, and significantly, her diagnosis of borderline personality disorder. In combination, those matters ought to have signalled to him that his patient was psychologically and emotionally vulnerable. 12. Whilst the applicant ought to have had a professional awareness of the inappropriateness of a personal relationship with Patient A, and he ought to have had an awareness of the potentially adverse professional consequences for him if he engaged in a personal relationship with her, instead he became distracted by the circumstances, and he basked in and enjoyed the personal attention that Patient A was directing his way. 13. In those circumstances the applicant was somewhat blindsided to some key red flag characteristics within Patient A's presentation which ought to have suggested to him that she had some serious emotional issues well before he became aware that she had a diagnosis of borderline personality disorder. Those aspects of her presentation were, amongst other things, her over familiar and friendly attitude towards him, her felicitous and flirtatious manner, and her choice of late in the day appointments with him. 14. In those circumstances, the applicant felt flattered by Patient A's attentions and sociability. In that context, in December 2017, Patient A began suggesting they have meetings outside the practice. Initially, the applicant resisted those suggestions and he declined. That initial stance of resistance indicated that he plainly understood the need to maintain professional boundaries. 15. Although inexcusable, over the course of time, despite his initial instinctive resistance which led him to decline Patient A's invitations to meet privately, eventually he succumbed and accepted an invitation for them to meet socially away from the practice setting. He said this occurred due to his failure to recognise the warning signs that should have flagged to him the need for his cautious attention. He explained that his failures on that account occurred because he lacked assertiveness in securing the required boundaries. 16. The applicant either remained unaware or was oblivious to the signals he was giving Patient A which encouraged her to engage in personal communications outside the context of the medical practice. Ill-advisedly, at an early stage, he provided Patient A with his mobile telephone number as a means by which he could be contacted. The applicant only came to fully realise the implications of this in hindsight, with the assistance of psychological therapy. However, at the time, the evolving circumstances ought to have alerted him to the dynamics at play and this should have caused him to reflect upon and supress any inclinations he entertained for having a personal and sexual relationship with Patient A. 17. In hindsight, in broad terms, without seeking to ascribe moral blame to Patient A for the way in which the relationship developed, the applicant acknowledged that he was attracted to her. He was flattered by the attention she was directing towards him, and eventually, on a social outing, he did not flinch from a kiss and an embrace which Patient A had initiated, and he did not appear to resist or strategize against further personal contact with her. Instead, ultimately a sexual relationship developed between them after they ended up at his home on one of those social meetings. An intimate sexual relationship continued thereafter, intermittently, on a number of occasions over the course of some months. It is not necessary to catalogue all of those occasions in these reasons. 18. In those events, it is plain that the applicant did not initially or fully appreciate the psychological processes which were operating in the dynamics of those circumstances, namely the well understood mechanisms of transference and countertransference that foreseeably led him into the realm of crossing the professional doctor and patient boundary. 19. In that time, it remains a curiosity as to why the applicant arranged STI testing of Patient A on three separate occasions over the course of as many months, apparently without telling her why he ordered those tests. The first tests were carried out on 28 November 2017 (at the fifth consultation), the second tests were carried out on 17 December 2017 (at the twelfth consultation) and the third tests were carried out on 2 January 2018 (in between the seventeenth and eighteenth consultations). 20. Whilst the applicant was seeing Patient A in the Wyong practice, ill-advisedly, he was also having social meetings with her away from the practice in a cafe. From his training both in Iran and in Australia, he must have known that those circumstances were leading him towards an ill-advised boundary crossing and potential breaches of the ethical requirements of his profession. 21. Over the course of time, that realisation ought to have become increasingly more evident to the applicant as he became incrementally aware of Patient A's mental health issues, as follows: 1. On 11 December 2017, at the ninth consultation, he prepared a Mental Health Treatment plan for her; 2. On 17 December 2017, at the twelfth consultation, he wrote a referral letter for her to attend a psychologist; 3. On 27 December 2017, at the sixteenth consultation, he noted symptoms comprising high levels of tension and anxiety; 4. On 30 December 2017, at the seventeenth consultation, he prescribed Zoloft, an antidepressant, and Targin, for pain relief; 5. On 31 January 2018, at the twentieth consultation, he wrote a letter to Patient A's treating psychologist seeking an opinion on the management status of her borderline personality disorder; 6. On 6 February 2018, at the twenty first consultation, he changed Patient A's antidepressant medication from Zoloft to Cymbalta on account of her experiencing confusion whilst she was taking the former antidepressant medication; 7. On 14 March 2018, whist the applicant was on holidays in Iran, he spoke to Patient A from there. He stated that whilst there, in that conversation, they had agreed to end their relationship; 8. On 10 April 2018, at the twenty fourth consultation, the applicant became aware that in the week before, on 4 April 2018, Patient A had threatened suicide, which had led to an overnight admission to St George Hospital for "reaction to severe stress and adjustment disorders": Exhibit "6". He also became aware that following that overnight admission, she was then transferred to the Wyong Acute Care Team at the Central Coast Community Health Centre, where she stayed for 4 nights between 5 and 9 April 2018; 9. At that twenty fourth consultation, Patient A disclosed to the applicant that she had been hospitalised (as outlined above) for an apparent mental health breakdown. Consequently, at that consultation, the applicant provided Patient A with a referral to a psychiatrist, but in doing so he did not make a record as to what was discussed or disclosed by Patient A, including with regard to the reasons for her recent hospitalisation for mental health issues. 1. On 12 April 2018, which was just three days following Patient A's discharge from mental health treatment by the Wyong Acute Care Team, she and the applicant engaged in unprotected sexual intercourse at his home, which resulted in the conception of their child. 2. By 17 April 2018, if not beforehand, the applicant was aware of the recent hospital admission because on that date he referred Patient A to a psychiatrist in Gosford for an opinion and management of multiple issues including chronic pain, borderline personality disorder, recent suicidal thoughts and an assumed risk of suicide where, according to the referral letter, the only medication Patient A was taking was one 60mg capsule of Cymbalta capsule each morning: Exhibit "5". Cymbalta is an antidepressive used to treat major depressive disorders. 3. On 17 April 2018, at the twenty fifth consultation, the applicant made a second referral for Patient A to see a psychiatrist and a pain specialist for assessment of her chronic pain. By that time it was plain that the applicant had already received Patient A's hospital discharge summary. 4. On 9 May 2018, in conversation that took place away from the practice, the applicant and Patient A discussed the positive result from her urine pregnancy testing. Those discussions were followed by a discussion at the applicant's home, where they discussed the subject of Patient A either continuing with or terminating the pregnancy. 5. On 15 May 2018, at the twenty seventh consultation, after reviewing the positive urine pregnancy test carried out on 9 May 2018, the applicant referred Patient A for obstetric ultrasound imaging tests. 6. On 30 May 2018, at the twenty eighth and last consultation, the applicant noted Patient A's "high level of anxiety" which he ascribed as being "due to her psychological problems and suicidal thought[s]", and he noted "it might be prudent to continue with her psychologist and exercise physiologist". At that time Patient A was provided with a new Workcover certificate. The basis for referring her to an exercise physiologist was obscure. 7. In either late May or early June of 2018, in a non-clinical personal setting the applicant advised Patient A to have a termination of her pregnancy. Patient A did not accept that recommendation. 8. On 3 June 2018, Patient A disclosed to another doctor in the practice that she was pregnant as a result of her sexual relationship with the applicant, and that she had been advised to terminate the pregnancy because of the medications she was taking, and because she had not been taking folic acid supplements. 9. On 3 June 2018, Patient A consulted an obstetrician at the Royal Hospital for Women about her pain, her depression, and her medication intake, following which she ceased taking some of her medications and she decided not to terminate her pregnancy. 10. The events described above raised questions as to the adequacy of applicant's professional acumen and insight regarding the obligation of medical practitioners to recognise and appropriately maintain personal and professional boundaries between doctor and patient and how this should be achieved and maintained in challenging circumstances. 11. Those questions arose because the applicant had either ignored or had failed to recognise an incremental series of warning signs and professional implications of the boundary crossing that was occurring and which ultimately led to him into violating that boundary, notwithstanding that in their sexual relationship, both he and Patient A were consenting adults. 12. His explanation for not seeking out professional advice and assistance at an early stage of the relationship when he realised the professional implications of his misconduct was that he felt shame, guilt, fear, and felt trapped by the circumstances. He also said he thought he would cause damage to Patient A irrespective of whether he kept seeing her or not. 13. That latter explanation demonstrates that the applicant had placed his own emotional needs above those of Patient A. 14. Now, reflecting back on those events, without glossing over them, the applicant has unreservedly accepted that those events occurred due to professional and personal failings on his part, and he has apologised for those failings. He also unreservedly accepts the previous Tribunal findings of unsatisfactory professional conduct and professional misconduct which properly required that his registration be cancelled. 15. The applicant also unreservedly accepts that as a result of his misconduct, Patient A has suffered emotional and other harms. He said that if he is able to take up employment in Australia, and when he has the financial capacity to do so, he intends to take practical steps in terms of his personal responsibility for their child. In that regard, he is also sensitive to the fact that the child is entitled to financial and emotional support, for which he intends to take personal responsibility. Mandatory report of boundary violation with Patient A 1. On 25 July 2018, when another general practitioner became aware of the intimate sexual relationship between the applicant and Patient A, that general practitioner made a mandatory report of that disclosure to the regulator. On 23 August 2028, Patient A made a second disclosure to another doctor in the practice regarding her pregnancy which followed from her intimate sexual relationship with the applicant. Termination of applicant's employment 1. On 31 August 2018, following the management of the practice becoming formally aware of the applicant's intimate sexual relationship with Patient A, the applicant's employment with that practice was terminated by the practice manager. 2. The disciplinary proceedings involving the s 150 hearings, and the Stage One and Stage Two Tribunal hearings then followed. Appropriately, the applicant admitted the relationship with Patient A. This ultimately resulted in his disqualification from practice on account of his violation of the professional boundary between doctor and patient. Applicant's certification documents 1. On the issue of fitness to practice, the applicant relied upon a series of certificates of attainment including various CPD courses he has attended. Some of those certificates had already been considered in the previous Tribunal hearings. In the paragraphs that now follow, those documents are reviewed in the order in which they bear dates of issue. Where the documents were in the Farsi language they were accompanied by certified translations. Certification from the Medical Council of Iran 1. On 23 January 2010, the applicant obtained formal certification as the holder of a degree in medicine (translated as a doctor's degree) issued under the Medical Council of Iran's national code for medical licensing, as certified by Dr Reza Laripour, the Vice-President for Technical Affairs and Supervision for that Medical Council. The certificate was issued on 6 March 2024. Avant Mutual Group: Managing Boundary Issues for patients with mental health issues 1. The Avant Mutual Group Limited provided a confirmatory certificate to the effect that on 15 May 2019, the applicant completed a CPD learning centre course on managing boundary issues for patients with mental health issues for which he earned 2 activity points according to the requirements of the Royal Australian College of General Practitioners. Avant Mutual Group: CPD Course: Ethics obligations knowledge and skills: Professionalism in Medicine 1. The Avant Mutual Group Limited provided a confirmatory certificate to the effect that on 16 May 2019, the applicant completed a CPD learning centre course on ethical obligations knowledge and skills entitled Professionalism in Medicine, for which he earned 2 activity points according to the requirements of the Royal Australian College of General Practitioners. Central Queensland University course on Professional Boundaries - a Health Professionals Guide 1. The Centre for Professional Development within the Central Queensland University provided a certificate to the applicant certifying that on 17 May 2019, he completed a one-hour course of professional boundaries entitled "A Health Professional's Guide". Certificate from Black Dog Institute – Online Mental Health Self Care for Doctors 1. The Black Dog Institute certified that on 18 May 2019, the applicant completed an online training Webinar for Online Mental Self-Care for Doctors, for which he earned 2 activity points according to the requirements of the Royal Australian College of General Practitioners. Avant Mutual Group: CPD Course: Medical records: Chapter One – Documentation 1. The Avant Mutual Group Limited provided a confirmatory certificate to the effect that on 12 September 2021, the applicant completed a CPD learning centre course on documentation in medical records, for which he earned 3 activity points according to the requirements of the Royal Australian College of General Practitioners. Avant Mutual Group: CPD Course: Medical records: Chapter Two – Legal Requirements 1. The Avant Mutual Group Limited provided a confirmatory certificate to the effect that on 12 September 2021, the applicant completed a CPD learning centre course on the legal requirements of medical records, for which he earned 3 activity points according to the requirements of the Royal Australian College of General Practitioners. Iran University of Medical Sciences – Certificate 1. Dr Ali Moski, the Vice-President for Therapy at the Iran University of Medical Sciences provided a certificate dated 13 January 2024 confirming the applicant's activity or status as a general practitioner between 17 December 2014 to 19 March 2015, and between 20 March 2022 and 11 December 2023. Certificate of attendance: 10th Annual Conference of Medical Ethics in Iran 1. On 6 March 2024, Dr Babak Shekarchi, the Vice-President for Education and Research for the Medical Council of Iran, certified that between 14 and 16 February 2024, the applicant had attended at the 10th Annual Conference of Medical Ethics conducted by that Council. 2. That certificate of attendance gave no indication of the programme of the conference. It did not specify whether the ethical question of boundary violation, which is the subject of a medical ethics code of conduct in this country, was on the agenda of that conference. Certificate of Good Standing issued on 6 March 2024 by Medical Council of Iran 1. On 6 March 2024, Dr Mohammadreza Kheradmand, the Vice-President of Disciplinary Affairs of the Medical Council of Iran, certified that as at that date, there was "no record of final disciplinary sanction" relating to the applicant held by that organisation. That certificate was issued by the Medical Council of Iran in the absence of any knowledge of the applicant's history of boundary violation with Patient A and the subsequent disciplinary proceedings that followed as the applicant did not make such disclosures to that Medical Council. Reliance Medical Practice – Reference 1. On 26 March 2024, Ms Julie Abdilla, the CEO of Reliance Health, provided the applicant with a reference based on her professional workplace acquaintance with him in the period between April 2016 and August 2018. The reference was in the following terms: "I worked with Dr Aliyar Danaei for about 21⁄2years between April 2016 and August 2018. In my opinion, and the opinion of one of our senior supervising GP's, Dr Danaei was an excellent GP, always following up his patients, dedicated to all his patient's wellness and was professional in his attendance. He understood the Australian Healthcare industry, and this was reflected in his practice. He has generous heart; he was always generous with his time and very supportive towards the practice. He was very instrumental in building our Wyong practice. After Dr Danaei had been practicing for 12-18 months, I noticed that he was not doing too well personally. I believe he struggled with self-doubt and I tried my best to ensure him of our respect towards him, and I also tried to encourage him to seek the help of a Psychologist, and I believe if he did, he would still be working with us. Dr Danaei, like a few of our overseas trained single doctors would have found it very difficult not only to adjust to living alone in Australia, but also living away from their friends and family. I would be very happy to discuss further if needed." [Emphasis added] 1. Ms Abdilla's reference made no mention of whether she was aware of the Applicant's professional wrongdoings whilst working at the practice. The emphasised reference in that letter to the applicant's dedication "to all his patient's wellness and was professional in his attendance" requires comment. 2. The correctness of that statement is questionable because Patient A was one of the patients of the practice and that statement could not possibly have applied to the applicant's care of her as patient. 3. In her oral evidence, Ms Abdilla acknowledged that she was aware of the applicant's professional and ethical transgressions towards Patient A when she wrote that letter. She also acknowledged the misleading content of that letter, as it made no reference to the applicant's dismissal from his previous employment from that practice. 4. That said, Ms Abdilla has maintained contact with the applicant since his dismissal. She obviously thought highly of him, and she stated that the practice would be prepared to re-engage the applicant if he were to be reinstated. Approach to the assessment of expert medical and allied evidence 1. As the array of evidence requiring consideration in these proceedings includes correspondence and reports from medical and allied treating practitioners and experts, it is appropriate at this point to identify some key principles which govern the assessment of the guidance value of expert evidence as it applies to the facts of the case. 2. The general law requirements governing the acceptability of opinion evidence from experts and the persuasive weight to be given to such opinions are well understood across all Tribunals exercising judicial functions: Paric v John Holland Constructions Pty Ltd [1985] HCA 58, at [9]; Makita (Australia) Pty Ltd v Sprowles (2001) 52 NSWLR 705; [2001] NSWCA 305, at [59], [87], pp 743-744; Dasreef Pty Ltd v Hawchar (2011) 243 CLR 588; [2011] HCA 21, at [83]. 3. When evaluating expert evidence, it is important to distinguish between matters of fact that are assumed to be correct, and the consequential formation of opinions based on those found facts: HG v The Queen [1999] HCA 2; (1999) 197 CLR 414, at p 427; [39]. In that case, at page 429, Gleeson CJ pointed out: "… Experts who venture 'opinions' (sometimes merely their own inference of fact), … may invest those opinions with a spurious appearance of authority, and legitimate processes of fact-finding may be subverted. …" 1. For reliability, expert opinions must be based on the factual accuracy of its foundations. The factual evidence must have a sufficient similarity with the underlying assumptions that form the basis for the opinions expressed by experts: Paric v John Holland (Constructions) Pty Ltd, supra, at [9]. 2. Expert opinions must be analysed for reliability according to the reasoning which underpins the opinions, and for the validity of the underlying assumptions upon which such opinions are based. Where there is disconformity between the facts assumed by the expert and the facts ultimately accepted, expert evidence that is otherwise admissible, must be assessed as to its persuasive weight: Dasreef Pty Ltd v Hawchar, supra, at [83]. 3. Statements by experts that simply invoke sweeping statements in the form of unsupported ipse dixit reasoning or oracular pronouncements do not provide a proper basis for acceptance of expert evidence because such opinions are untestable, and therefore should carry little weight: Makita (Australia) Pty Ltd v Sprowles, supra, at [59], [83] - [87], [93]; South Eastern Sydney Area Health Service v Edmonds [2007] NSWCA 16, at [130] – [131], following Davie v The Lord Provost, Magistrates and Councillors of the City of Edinburgh (1953) SC 34, at 39 – 40. 4. In addition to those general law considerations, in this Tribunal, the assessment of the reliability of expert opinions must also be guided by the degree to which those opinions are compliant with the well-understood procedural requirement of being appropriately reasoned, including by adequate identification of the basal assumptions for such opinions: NCAT Procedural Direction 3, clauses 19(c) and (d). 5. In combination, those principles operate as a guide to the evaluation of the expert medical and allied opinions tendered in evidence in these proceedings. Review and assessment of medical and allied evidence 1. The applicant relied upon historical correspondence from his initial treating psychiatrist and his initial treating psychologist, Dr Ong and Mr Kearney. That correspondence was previously considered by the Stage Two Tribunal. In addition, he relied upon correspondence from his treating psychiatrist and psychologist in Iran. The report and oral evidence of Associate Professor Wijeratne were also considered by the Tribunal. That array of correspondence, reports, historical medical and allied correspondence is identified and summarised in the following sequence. Correspondence from Dr Sian Ong, Consultant Psychiatrist 1. On 21 July 2017, the applicant first sought psychiatric assistance from Dr Sian Ong for treatment of his mental health issues which at that time were described as being major depression with inattentive ADHD. 2. It is noteworthy that the applicant first consulted Dr Ong some 5 months before he commenced his intimate sexual relationship with Patient A. That relationship commenced in January 2018. Whilst Dr Ong's correspondence covers the periods both before and after the commencement of that relationship, the descriptive content of his correspondence is somewhat oblique, and makes no direct reference to the fact of and the details of the applicant's unethical relationship with Patient A. 3. Between 21 July 2017 and 25 September 2019, the applicant consulted Dr Ong on a total of 12 identified occasions for review and treatment. 4. In that period, Dr Ong issued three letters variously addressed to the solicitor for the applicant's professional indemnity insurer, the Medical Council of NSW, and Mr Brian Kearney, a treating psychologist to whom Dr Ong had referred the applicant for treatment. 5. An overall view of Dr Ong's correspondence shows that in those sessions, the applicant was primarily focussed on his own needs. Dr Ong's letters make no mention of any contemporaneous feelings of remorse and empathy that might have been expressed by the applicant over the effects his unethical conduct has had on Patient A. 6. It is also noteworthy that the specific issue of boundaries only arose within Dr Ong's correspondence some 2 years after the first consultation, namely, on 29 September 2019. By that time, the applicant had already appeared before a s 150 hearing convened on 23 October 2018, by which time his boundary violation with Patient A had already come under investigatory scrutiny by the regulator: Exhibit "1", Tab, 8, pp 102-11. 7. On 15 November 2018, Dr Ong wrote to the Medical Council in relatively oblique and minimalist terms, noting that the applicant had self-referred when he presented on 21 July 2017 with a mixture of mood and inattention difficulties that had adversely impacted on his functioning and his interpersonal relationships. At that time Dr Ong wrote: "He had been troubled by depressed mood for a number of reasons, particularly in relation to his social isolation, cultural adaptation issues and loneliness. He has struggled with feeling isolated from his friends and family and as a recent single unmarried immigrant living alone here, his struggles with loneliness are particularly heightened and contributory to his emotional vulnerabilities and sense of judgement in interpersonal relationships." [Exhibit "1", Tab 10, p 128] 1. In the context of the applicant's offending behaviour, the vague oblique reference to his sense of judgment concerning "interpersonal relationships" was obscure and relatively uninformative. 2. On 29 September 2019, Dr Ong wrote to the applicant's treating psychologist Mr Brian Kearney, also in relatively vague and non-specific terms, as follows: "Thank you for assisting Dr Danaei who presented for review on 25 September. I note that he has benefitted from your input and that he has a good understanding of appropriate management of boundaries within his professional life. I understand that the role plays in a number of challenging complex settings that a medical general practitioner may encounter, as well as healthy assertiveness interpersonal skills are crucial skills that he has been practising within your sessions. He has also been reflecting and consolidating such skills in a number of ways. I note that he has also participated in online courses to enhance and consolidate his interpersonal skills within general medical practice settings. As you know, he is applying to the Medica! Council for review of his registration conditions. This is appropriate as he has significantly learned from the past mistake and he has been now aware with a good understanding of the professional boundaries within medical practice settings as well as having benefitted from assertiveness skills when dealing with difficult complex patient circumstances." [Exhibit "1", Tab 10, p 127] 1. The absence in that letter of any specific reference to the appellant's boundary violation with Patient A is remarkable, even when making due allowance for the fact that his correspondence was clinical, and not medico-legal in nature. 2. On 10 October 2019, Dr Ong wrote to the applicant's former solicitor to provide some contextual background assistance for the applicant's registration issues: Exhibit "1", Tab 10, pp 125-126. 3. That letter noted the stresses the applicant was experiencing associated with his medical examinations and in relation to the social isolation where he was living and working. That letter also noted that the applicant had a longstanding history of sub-optimal attention and associated difficulties. The letter recorded that before the applicant had consulted Dr Ong, he had trialled a number of antidepressants including citalopram and duloxetine. 4. Dr Ong's letter to the applicant's former solicitor stated that the applicant had a strong family history in Iran of mood disorder. It noted that the applicant's father suffered bipolar disorder and one sister suffered significant major depression requiring treatment. Dr Ong's letter went on to identify the historical dates of the applicant's consultations with Dr Ong, and the prescribed medication regime, being Citalopram 20mg and Vyvanse 50 mg, with significant benefit, "without unwanted effects". That comment by Dr Ong must be viewed and read down in light of the evidence of Associate Professor Wijeratne who identified known side effects which included mania like symptoms, impairment of judgment, and increased libido. 5. In vague and non-specific terms, Dr Ong's letter to the applicant's former solicitor stated that the applicant had engaged well with all aspects of his treatment regime and had also benefitted from the psychological assistance provided by Mr Kearney. That treatment involved role playing, interpersonal assertiveness skills, managing complex cases, and boundary issues. The reference to boundary issues was oblique in that context. 6. Dr Ong's letter to the applicant's former solicitor concluded with the opinion that the applicant was considered fit for medical practice. He did so in the following terms: "I consider him fit to practice as a medical practitioner. He has learned from his life lesson, with a significantly enhanced awareness and insight of clinical interpersonal boundary issues as well as interpersonal skills to manage potential complex situations in the future." [Exhibit "1", Tab 10, p 126] 1. The Dr Ong's reasoning for his opinion on the applicant's fitness to practice was sparse and lacked any specific reference to the relevant factual details that formed the basis the "life lesson" to which he made oblique reference. That lack of explanatory detail undermines the reliability of that expressed opinion. On its own, that opinion does not carry persuasive weight. Correspondence from Mr Brian Kearney, Clinical Psychologist 1. On 20 October 2019, Mr Brian Kearney, the clinical psychologist whom the applicant consulted, wrote to the applicant's former solicitors confirming he had been consulted by the applicant at the referral of Dr Ong in order to assist him "to improve interpersonal boundaries and interpersonal skills, with a special focus on workplace interactions": Exhibit "1", Tab 11, pp 129-131. 2. The inherently vague and euphemistic description within the above cited extract does not specifically identify the egregiously serious sexual nature of the applicant's "interpersonal boundaries" issues with specific reference to a mentally ill and vulnerable patient in the context of boundary violations, which Mr Kearney was presumably addressing in his treatment of the applicant. 3. Without precise identification of the factual details of those matters, the evidentiary utility and persuasive value of Mr Kearney's report relative to the issues with which this Tribunal is concerned on this application must necessarily be significantly limited: Paric v John Holland (Constructions) Pty Ltd, Ibid, at [9]. 4. Mr Kearney noted the applicant's presenting history of depression which followed his suspension for boundary violation, and he recounted the applicant's presenting symptoms as "feeling miserable" and being "really depressed". 5. It appears from the terms and the content of Mr Kearney's report that the focus of the applicant's depression was not an underlying mental health issue, but was instead, his personal subjective discomfiture over the disciplinary predicament in which he found himself as a result of his ethical transgression being exposed in the complaint process. 6. Mr Kearney noted the applicant's test scores on the Depression Anxiety Stress Scale to be severe for the element of depression, normal for the element of anxiety, and moderate for the element of stress on that test. Mr Kearney recorded the applicant's expectations from his psychological treatment to be as follows: "Dr Danaei reported he would like to be reinstated to the training programme and had undertaken a number of courses (including RACGP and University of Queensland) on medical and professional boundaries. He described difficulties with boundaries arising from: cultural differences, fears of complaints or negative reactions from patients; difficulties saying 'no'; and, trying to care for patients. He reported understanding that this had sometimes went wrong 'signals'. He reported he wanted to help to 'define boundaries' very clearly, for example when patients ask for unreasonable things. … He stated he wanted to help interpersonal skills and communication skills in order to be able to apply professional boundaries, especially with challenging and difficult patients. Dr Danaei appears to have good insight into the impact of his anxiety including fears of rejection and catastrophising about outcomes (e.g. patient complaints) on his difficulty in voicing boundaries directly to patients, as well as trans-cultural issues and the impact of being in a small community where he was very visible. He appeared to be open and non-defensive in describing complaints and findings against him. He presented as motivated to address the fundamental issues described above." [Exhibit "1", Tab 11, p 130]. 1. The fundamental issues Mr Kearney was referring to in the above description consisted of the admixture of the applicant's depressed mood, which remained symptomatic despite treatment, his anxiety and constant worry and stress over his situation, his pre-existing social anxiety concerns which were occurring in the context of the outstanding disciplinary proceedings, and some background stresses which included migration, relocation, and isolation due to separation from his family, as well the "registration / training process" and "financial distress". 2. Mr Kearney's description of his treatment interventions with the applicant seemed to cover a range of complex situations and techniques. These were described as including feedback, goal clarification for psychological input, education about professional boundaries and the skills required to enable action to be taken and apply those skills in interpersonal situations with patients. This treatment was provided in the context of cognitive behavioural therapy, relaxation training, breathing techniques, education and application of skills concerning interpersonal boundaries and assertive communication strategies with practice using role play techniques to handle specific patient interactions, provision of reading materials, identification of management of problem situations that presented as obstacles in applying the requisite skills. 3. Mr Kearney indicated that he had gained the impression that the applicant was an active and engaged participant in the described treatment interventions, and appeared motivated to improve his skills in applying professional boundaries citing as evidence, compliance with set homework tasks, producing notes taken in relation to assigned research tasks, demonstrating an understanding of relevant concepts from readings, asking appropriate questions, active participation in role playing sessions which practiced assertive communications and voicing boundaries, as well as voicing unhelpful thoughts and beliefs that could operate as potential barriers or obstacles to communication and maintaining boundaries. 4. Mr Kearney's letter concluded with the following statement' "At treatment completion, Dr Danaei reported he felt confident that he could engage with work as a GP and interact with patients using the skills to be able to apply the appropriate ethical and professional practice guidelines and principles. He reported his mood as improved with a low level of symptoms. This was reflected in his scores on the DASS at session 5 as shown in the table. I recommended he continue to see Dr Orig for ongoing care as he navigated the Medical Council process. No foreseeable harm to self or others was detected throughout the contact." [Exhibit "1", Tab 11, p 131] 1. The reliability of Mr Kearney's opinions and concluding remarks must necessarily be seen to be limited by the absence of relevant details to reliably ground those remarks in specifically identifiable facts concerning the applicant's offending conduct in the professional setting. Therefore, on its own, and in combination with Dr Ong's correspondence, Mr Kearney's opinion must be seen to carry little persuasive weight on the questions of the applicant's insight and his fitness to practice. 2. There was no further evidentiary correspondence concerning the applicant's treatment from either Dr Ong or Mr Kearney, or from any other practitioner in Australia. The most likely explanation for this is that the applicant was required to return to Iran when his work visa expired following his disqualification from practice. As a result, the applicant's mental health treatment then continued with specialists in Iran. In November 2019, the applicant returned to Iran, where he obtained further treatment from Dr Nazemi, a psychiatrist, and Dr Mohemadi, a psychologist. Dr Farzad Nazemi, Consultant Psychiatrist in Iran 1. On 12 March 2024, Dr Farzad Nazemi, a consultant psychiatrist in Iran wrote a letter to the Medical Council of NSW concerning the applicant in the following terms: "12/03/2024 Re: Dr. Aliyar Danaei Medical Council of NSW I first saw Dr Danaei on 6 December 2022 with symptoms of depressed mood, hopelessness, helplessness, sleep problem, lack of concentration, and feeling guilty. He had not been on any medications including Antidepressants for the prior 2 years. Dr Danaei was a 41-year old doctor living alone. He was working part-time 2 days a week as a GP in a clinic in Baharestan. Dr Danaei told me he had lost his career in Australia due to breaching boundaries with a vulnerable patient. Now, He has a daughter in Australia whom he misses a lot. He told me he had been feeling guilty for his mistake, he was remorseful for what he had done and had an insight for his mistake. He had high scores for Depression in K10 and DASS21. A few years earlier in Australia Dr Danaei saw a Psychiatrist and he was diagnosed with Major Depressive Disorder (MDD) due to loneliness and social isolation, and inattentive ADHD. He was prescribed citalopram 20 mg daily plus Vyvanse (long-acting Dexamphetamine) 30 mg then increased to 50 mg daily for symptoms of inattentive ADHD. After starting the medications, Dr Danaei reported that he started to feel better, his symptoms improved and he had a better concentration and energy. After 2 consecutive consultations in a week with Dr Danaei, I realized symptoms of Dr Danaei were more likely due to a spectrum of mood disorders namely Major Depressive Disorder. I believe his symptom of lack of concentration was as a result of his mood disorder not inattentive ADHD. Dr Danaei had passed important examinations in his medical science university, qualifying exams to be a GP in Australia and English tests with high scores. Thus, I believe, his temporary symptom of lack of concentration was due to his Depression and situational rather than something in nature and permanent. I started a trial of Asentra 50 mg twice a day, and I referred Dr Danaei to a Psychologist specialized in cognitive behavioural therapy. In follow up consultations on 9 February 2023 and 6 June 2023, after 2and 6months, Dr Danaei started to feel better. His mood improved gradually. He had better thought-processing, more energetic and better sleeping and eating habits. His pessimistic attitude started to fade away. Dr Danaei was happy with the treatment plan, medications and his Psychotherapy sessions with his Psychologist. My latest consultation with Dr Danaei was on 29 February 2024. Hsi mood has significantly improved. He is working full-time as a GP in a clinic and has more confidence, good quality sleep, normal thought-processing and is well-focused. He now has a fiancé and plans to marry her in the near future. I tapered down his medication dosage to 75 mg per day and have a plan to gradually cease it in about 3months, if everything goes well. I believe, Dr Danaei went through a difficult time. A male losing his job, in his mid-age, living alone unemployed with symptoms of Depression. In risk analysis, he was considered high risk, However, Dr Danaei managed to take himself out of the situation and deal with his obstacles. His intelligence, self- awareness, as a result of CBT, and his knowledge from reading books, helped him in his way to maturity. Dr Danaei is now more confident, resilient and stronger to deal with challenges in future. He is aware of keeping his mental health well by recognizing early alarm signs. Dr Danaei has learnt a lot from his mistake of breaching professional boundaries with a patient. He has a clear strategy for the future to keep professional boundaries with patients and monitor his mental health. I confirm that Dr Danaei is, currently, fit to work as a General Practitioner and deserves to be given a second chance. Please don't hesitate to contact me if you need more information." 1. The persuasive power of Dr Nazemi's cited opinion as to the applicant's fitness to practice as recorded in the final paragraph of that quotation requires evaluation according to the requirements for reliability of expert testimony that apply in this jurisdiction as outlined at paragraphs [127] – [134] above. It is not apparent as to whether Dr Nazemi was made aware of those requirements, particularly NCAT Procedural Direction 3, clauses 19(c) and (d), when he was asked to prepare his report. 2. Without intending any disrespect to Dr Nazemi, whilst there is no issue with his factual summary of the treatment he gave the applicant, his final opinion as to the applicant's fitness for resuming work as a general practitioner must be seen to be of limited forensic and probative value in this jurisdiction because of an issue over the sufficiency of his reasons for that opinion and because the correspondence does not permit a reasoned comparison to be made between the expected standards of practice in Australia and in Iran. Associate Professor Zadeh Mohamedi, treating psychotherapist in Iran 1. On an unspecified date, Associate Professor Zadeh Mohamadi (PhD), a psychologist, wrote a letter in the following terms, addressed to whom it may concern, in relation to his treatment of the applicant: "I would like to take the opportunity to offer a formal confirmation letter for Dr Aliyar Danaei, who was referred to me by the psychiatrist. He participated in my psychotherapy sessions with symptoms of depression and feelings of loneliness and helplessness from August 2021 to June 2022. The sessions were held one hour, once a week. In the first stage, cognitive-behavioural techniques (CBT) were applied, focusing recognition of negative thoughts and feelings, cognitive restructuring, stress management techniques and problem solving were practiced and taught, in 24 sessions and after six months follow-up was done. In this intervention, he gained sufficient insight into the internal sources of traumatic emotions and self-efficacy. Due to Mr Danai's (sic) chief complaint, I became aware of his neglect of professional medical ethics, we discussed the psychological aspects of this issue. During the meetings, the issue of self-awareness and responsibility was taken into consideration. My evaluation of whether he is mentally and psychologically ready to work as a doctor or not, I got, his motivati167on to get involve in the treatment and recovery process was high and his awareness of individual boundaries, behavioural control and emotion regulation were significantly improved and strengthened. In my opinion, his ability in professional relationships is trusted. Please kindly, if you have any questions regarding this letter, please do not hesitate to contact me." 1. Again, without intending any disrespect to Professor Mohamedi, the remarks made at paragraph [166] above also apply to the persuasive weight of his expressed opinions on the applicant's trustworthiness and fitness to practice as cited above, but with the caveat that he did not have the opportunity of clarifying his views by oral evidence as his availability to give evidence did not coincide with the Tribunal's timing. In those circumstances, the applicant decided not to delay the proceedings by seeking a further date on which to call that evidence. Dr Chanaka Wijeratne, Consultant Psychiatrist 1. On 15 May 2024, at the request of the Health Professionals Councils Authority, the applicant was examined for the purpose of these proceedings by Associate Professor Chanaka Wijeratne, a consultant psychiatrist. The examination took place by means of a telehealth consultation, where Associate Professor Wijeratne was situated in Sydney and the applicant was located in his home in Tehran. Associate Professor Wijeratne's report which followed that consultation was tendered as part of the respondent's materials in these proceedings: Exhibit "1", Tab 1, pp 3-14. Associate Professor Wijeratne also gave oral evidence in the proceedings. The summary which now follows incorporates a combination of the views expressed in his report together with clarifications provided in his oral evidence. 2. After identifying the briefing materials and the instructions for the preparation of his report, Associate Professor Wijeratne provided an overview summary of the applicant's background circumstances, his health and psychiatric history, his mental state, his medication intake, and a review of relevant documents concerning the details of the circumstances leading to the complaint which resulted in the cancellation of the applicant's medical registration. That report included a consideration of the Stage Two Tribunal and the s 150A inquiry reasons for decision. 3. Associate Professor Wijeratne's report addressed a series of six questions that he was asked to consider in relation to the applicant's psychiatric state, and his level of insight, based on the history he obtained, and on the basis of the identified documents he had read. His opinion covered the following six elements with additional annotations in his oral evidence: 1. Diagnosis of Major Depressive Disorder, recurrent, in remission – The applicant's reported onset of depression, and his diagnosis of a depressive disorder in the context of his long working hours in mid-2017, and his diagnosis of ADHD for which he took the prescribed psycho-stimulant drug lisdexamfetamine until September 2018, were noted to have also been accompanied by symptoms similar to acute mania and impaired judgment. Associate Professor Wijeratne inferred, in retrospect, that the applicant should be ascribed a diagnosis of Major Depressive Disorder, recurrent but in remission. He added the following conclusion in that context: "In my opinion, at the time Dr Danaei engaged in an inappropriate sexual relationship with Patient A, he was vulnerable as a result of his loneliness, social isolation and the fact he was living in another country, far removed from his own culture and family. The prescription of lisdexamfetamine further contributed to the initiation of his sexual relationship with Patient A." [Exhibit "A", Tab 1, p 12] It follows from that opinion that an iatrogenic cause may well have been a mitigating factor in the applicant's boundary violation with Patient A due to possible impairment of judgment. That opinion was not available for the consideration of the earlier Stage One and Stage Two Tribunal. In light of the contributing factor of the effects of lisdexamfetamine, Associate Professor Wijeratne considered that the applicant should not be prescribed stimulants because of the risk of a recurrence of drug induced mania, as occurred when the applicant was taking that prescribed drug which resulted in him experiencing increased energy which led him to work 12 to 14 hours per day, along with experiencing the associated side effects of reduced appetite, increased libido and impaired judgment, all of which was suggested consistency with a diagnosis of hypermania or drug induced mania. 1. Diagnosis of an Impairment – On the question of whether the applicant is suffering a relevant impairment as defined by the Health Practitioner Regulation National Law (NSW), Associate Professor Wiijeratne answered that question in the affirmative: Exhibit "A", Tab 1, p 12. He considered that the applicant's recurrent depressive disorder, albeit in remission at present, should be seen to be an impairment issue because inherent in that condition is the risk of recurrence or relapse of depression which could have an adverse effect on the ability of the applicant to practice safely. In his oral evidence he said this justified the imposition of structured conditions centred around practice and health issues. Given the applicant needed ongoing anti-depressant medication he added that treatment conditions and conditions for supervision and mentoring were necessary in the long term subject to periodic reassessment. 2. Consequences from a possible relapse of depressive disorder – On the question of the applicant's impairment, Associate Professor Wijeratne considered that whilst the applicant's major depressive disorder was presently in remission, thus giving him an opportunity to reflect on his past behaviour, he also noted the possibility of a relapse following a period of remission, where the onset of depression or mania would hinder his capacity to self-reflect, which emphasised the need for the applicant's health to be monitored on an ongoing basis: Exhibit "A", Tab 1, p 12. In his oral evidence he added that the applicant was at risk of relapse of depression if he were to encounter psychosocial triggers or emotionally triggering situations such as, for example, difficulty negotiating childcare and access issues with Patient A, especially if she were to become manipulative, which was identified as a characteristic of borderline personality disorder as described in the evidence. 3. Qualified opinion on the insight question – On the question of whether the applicant has in fact developed insight into appropriate strategies to manage the stated concerns such that there would be no risk to patient health and safety and if he were to be restored to the Register, Associate Professor Wijeratne gave a qualified answer by stating that the applicant "does appear to have developed some level of insight with the passage of time and long term consultations with his psychologist and treating psychiatrist". That qualified view was also tempered by the fact that the applicant, whilst expressing remorse and self-reflection, and accepting "full responsibility for his boundary violation", did not discuss the consideration of the potential harm to Patient A from his actions: Exhibit "A", Tab 1, pp 12-13. The critical focus of that comment was ameliorated to a significant degree in Associate Professor Wijeratne's oral evidence where he fairly acknowledged there were some time constraints associated with the interview with the applicant which may have had an impact on the comprehensiveness of that interview of the applicant where there may not have been an opportunity to cover those elements of concern. He considered it likely that the applicant's prior difficulties with factors such as loneliness, and isolation would tend to be ameliorated by his stated plans for marriage, and the proposal for multiple structured health and practice conditions concerning treatment, mentoring and supervision. He added that those factors would also tend to militate against the occurrence of a further boundary violation, which he acknowledged should now be assessed as being of a relatively low risk in light of the remedial efforts the applicant has undertaken to date. 4. Range of onerous conditions – On the question of whether conditions should be imposed if the applicant were to be reregistered, Associate Professor Wijeratne suggested the need for a series of structured health and practice conditions which addressed the regular need for treatment and review, and restricted practice conditions, including working conditions, working hours, Level C supervision, mentorship, CPD activities to include management of patients with borderline personality disorder and other particular presentations, and restriction on the ability to prescribe S4D and S8 drugs: Exhibit "A", Tab 1, p 13-14. In his oral evidence, those prescribing recommendations were modified to a degree on considering a factual clarification the applicant made to an aspect of the evidence as to his administration of opioid drugs to another patient as was considered at the s 150A hearing. Associate Professor Wijeratne considered that any practice conditions should be structured in a form which recognised that as an international medical graduate in need of appropriate mentoring and support, in order to guard against problems relating to adequacy of acculturation and orientation to local practice conditions, the applicant should not be set up for failure. 5. Impact on ability to adhere to conditions if relapse occurs – On the question of whether the applicant may have issues that might adversely impact on his ability to adhere to conditions placed on his registration if reinstated, Associate Professor Wijeratne stated that the most likely reason for the applicant not adhering to any conditions would be if he would have a relapse of a mood episode: Exhibit "A", Tab 1, p 14. 1. Associate Professor Wijeratne considered that on an overall view, the applicant's statements of deep shame, embarrassment and remorse seemed genuine, and as such, those expressed feelings, taken together with the applicant's scarifying experience of the disciplinary process, were strong factors that militated against the likelihood of him committing further boundary violations. 2. Associate Professor Wijeratne identified a qualifying issue, namely that the historical treatment reports which he reviewed, and which have been summarised in these reasons, failed to deal with any diagnostic formulation of the applicant's personality. This was a point of some significance as such factors could be of relevance to the risk of re-offending. That said, his review of the applicant's history did not suggest any adverse personality or attachment issues had been causative of the applicant's prior boundary violating behaviour. 3. The respondent noted Associate Professor Wijeratne's comments and recommendations and took them into account in proposing appropriate health and practice conditions for registration. We have incorporated the substantive effect of those opinions as to the appropriate conditions in the Appendix to these reasons. Applicant's submissions 1. The applicant commenced his submissions by restating his abject apologies to Patient A and her family for the psychological harm his conduct has caused her. He expressed hope that she could forgive him for compromising her medical care by his breaches of ethical standards of practice. He accepted that he had acted against his obligations as a doctor and that he had acted against his own personal ethics. He also expressed his apologies and his regret that his conduct had brought the medical profession into disrepute. 2. The applicant acknowledged that his professional misconduct was due to his inexperience and his lack of an effective ability to establish and maintain professional boundaries. He also acknowledged that in combination, his inexperience in dealing with a vulnerable patient with mental health issues, and the effect of his own mental health issues had contributed to his professional misconduct whereby he had placed his own emotional needs above his obligations to his patient. 3. In making those acknowledgments the applicant did not seek to diminish his own responsibility by reference to the iatrogenic factor identified by Associate Professor Wijeratne, namely the effects of the prescribed psycho-stimulant ADHD medication Vyvanse that he was taking, which was known to impair the exercise of judgment, amongst other things. The applicant submitted that after reflection and receiving psychological and psychiatric treatment for his own mental health issues, including over 30 sessions of cognitive behavioural therapy, and his completion of the educational and training courses described in the evidence, he considers that he has grown immensely as a person, having learned from his mistakes. He submitted that he is now a different and more confident, mature, less anxious and insightful person than was the case six years earlier when his offending conduct occurred. 4. The applicant submitted that now, he is equipped to utilise appropriate strategies and management plans to prevent such mistakes from recurring in the future. He also submitted that he has learned to be more vigilant with patients suffering mental health problems, and is now able to be appropriately assertive and active in establishing and maintaining professional boundaries 5. The applicant spoke convincingly of his passion for the ethical practice of medicine and of his desire to help people to suffer less. He described those concepts as being the essence of the way in which he intended to practice. He referred to the fact that following treatment, his own mental health issues have been in stable remission. He stated that as a result of the disciplinary processes he has been through he has learned how to effectively deal with life's challenges. 6. The applicant made an earnest plea to be afforded a second chance through reinstatement as a medical practitioner in order to contribute to society in a positive, ethical and meaningful way. He hopes to be able to return to practice in Australia and to be in a position to support his daughter both financially and emotionally, and in that way, he hoped to provide Patient A with at least a partial measure of compensation for her predicament that was caused by his misconduct, which he unreservedly acknowledged as being a significant departure from the expected standard of practice. 7. The applicant described the disqualification process he has been through as the darkest experience of his life. He described the experience as being a heavy price which he has paid for his significant misconduct. He submitted, with humility, that he has learned the lesson of his life from that experience. 8. In making those submissions the applicant did not seek to justify his offending conduct in any way. He accepted full responsibility for his actions and acknowledged the required disciplinary process as being necessary in the interest of the protection of public health and safety, Respondent's submissions 1. The respondent maintained the position of neither consenting to nor opposing the application for reinstatement. Instead, the respondent addressed a series of protective practice and health conditions which have to be assessed as to reasonableness in the context of risk. Those matters will be addressed in the course of our consideration on conditions of practice and the result of that consideration is embodied in the Appendix to these reasons. 2. The respondent's written submissions raised concerns as to the genuineness and the adequacy of the applicants' evidence as to his insight into his past professional wrongdoings with regard to Patient A. The respondent's written submissions also questioned the applicant's apparent lack of expressed concern or empathy over how his actions had caused harm to Patient A. In light of our findings as to the applicant's credit and in light of the comments made by Associate Professor Wijeratne on that topic as cited at sub-paragraph (d) of paragraph [171] above on that latter point, we consider that those submissions should be discounted and not accepted. 3. In oral submissions the respondent pointed to a number of concerns about the applicant's evidence which dissipated in importance during exchanges during addresses in light of the absence of any suggestion put to the applicant that he was disingenuous in any aspect of his evidence. Consideration and determination 1. We now turn to address the issues identified at paragraphs [55] – [56] above, applying the principles as identified at paragraphs [41] – [53] above. Baseline findings: applicant's factual acknowledgments and insight 1. The baseline for the consideration of this application is to recognise the full force of the adverse Stage One and Stage Two Tribunal findings of unsatisfactory professional conduct and professional misconduct. 2. The applicant did not contest those findings. He has fully accepted the factual basis for them without reservation, and he did not seek to deflect or make exculpatory excuses for the findings concerning his conduct and professional failing, including with regard to the deficiencies in his clinical records relating to Patient A. Those findings identified serious personal and professional failings in the applicant. 3. Notwithstanding the Tribunal's collateral findings that the applicant had practiced in an otherwise competent and ethical manner, consequential protective orders were determined to be necessary. In making those orders the previous Tribunal placed emphasis on the need for a preclusion period before re-registration could occur, emphasising the need to maintain public confidence and trust in the medical profession as well as the need for a statement of general deterrence against the occurrence of such conduct. 4. In summary, in abject terms, the applicant described his boundary crossing and boundary violations as a big mistake and a breach of his obligation of trust which Patient A was entitled to expect of him. He expressed his deep remorse, shame, guilt and regret over those matters, including regret at having brought the medical profession into disrepute. He also expressed shame and sorrow at having caused harm to Patient A's mental health and well-being. In making those acknowledgments with considerable humility the applicant has shown appropriate insight into the consequences of his misconduct. 5. Although Associate Professor Wijeratne's report initially referred to the applicant's apparent lack of empathy for Patient A, those remarks were later qualified in his oral evidence in which he fairly acknowledged there might have been some time constraints which could have affected the depth of discussion on that point at interview with the applicant. Accordingly, that former criticism of him must be read down in his favour. 6. We are comfortably satisfied that at all times the applicant had insight into the unethical nature of his personal and intimate relationship with Patient A, but he found himself ill-quipped to assertively set appropriate boundaries, which allowed his misconduct to escalate in circumstances where he was too fearful to terminate the relationship and implement appropriate measures for the benefit of Patient A. The circumstances were compounded by his own depression, loneliness and social isolation, which led to escalation into boundary violations. 7. The applicant's submissions summarised at paragraphs [175] to [182] above and his evidence which underpins those submissions, together with the effects of his reflections, the therapies and the remedial educational courses he has undertaken, comfortably persuade us that he is now equipped with the required insight into the causes and the consequences of his offending professional conduct. 8. In our assessment, the relevant difference between the circumstances of the applicant's past offending conduct and his present situation is that now, with appropriate insight and vigilance, he is better able to recognise the scope for such offending professional conduct to occur, and to take appropriate steps to avoid a recurrence. Applicant's credit as a witness 1. We accept the genuineness of the applicant's evidence as summarised in in the preceding paragraphs. 2. The applicant was not challenged by cross-examination as to his credit. It was not suggested to him that his explanatory evidence was either disingenuous, insincere, or conveniently couched in formulaic terms in order to seek a favourable outcome in these proceedings. 3. Whilst the applicant did refer to and emphasise his own mental health issues at the time of the offending events, namely his depression and his feelings of loneliness, cultural and social isolation as historical background facts, he did not put those matters forward as excuses or justifications for his misconduct. Nor did he seek to take the opportunity of sheltering himself from criticisms over his personal misjudgments by reference to the iatrogenic side effects from his use of the prescribed drug dexamphetamine or Vyvanse, which Associate Professor Wijeratne identified as a relevant contributing factor. 4. We find the applicant gave credible and reliable evidence concerning his offending conduct, the circumstances in which it developed, his insight and remorse concerning those events, the remedial mental health therapy and further medical education he has undertaken, and his expressions of sorrow and empathy towards Patient A for the harm she has encountered as a consequence of his actions. We accept the genuineness and the sincerity of the applicant's evidence on those matters, and generally. Assessment of guidance value of expert medical and allied evidence 1. Before addressing the question of whether the applicant has adequately addressed and remediated the personal flaws and mental health issues which led him to cross and violate the professional boundary with Patient A it is necessary to consider the content and the implications of the medical and allied evidence on those matters. That evidence is reviewed and summarised at paragraphs [135] to [174] above. 2. In summary, as identified in those paragraphs, whilst the clinical correspondence from Dr Ong, Mr Kearney, Dr Nazemi, and Professor Mohamedi contain relevant historical and factual descriptions of their respective assessments following their interviews with the applicant and their treatment of him, on the important question of whether the applicant is now fit to be reinstated to the medical register, that correspondence cannot be given the persuasive weight sought by the applicant. 3. Without intending any disrespect to those practitioners, the reason for that conclusion is that the content of that correspondence from those practitioners does not adequately meet the necessary criteria for the reliability and acceptance of expert evidence, as explained at paragraphs [124] – [134] above. 4. The ipse dixit sweeping statements inherent in that correspondence, absent required supporting reasons, do not meet the assessment standard for reliability of expert evidence. That is not a criticism of the authors. The deficiency lies with the self-represented applicant who apparently did not appreciate the need for expert evidence to be compliant with applicable standards for acceptance. 5. In contrast, the expert report and evidence of Associate Professor Wijeratne plainly meets the required standard for acceptance. We find the opinions he has expressed in his report and in his explanatory oral evidence represent a reliable guide to the determination of the issues requiring consideration in these proceedings. Reformation of prior professional failings 1. In our assessment, the applicant has satisfactorily discharged the heavy onus he carries in that regard by presenting persuasively clear, cogent and substantial evidence of the reformation of his personal vulnerabilities and flaws that led to his deregistration. 2. In our assessment the applicant has demonstrated the characteristics of integrity, maturity and personal responsibility in acknowledging his boundary transgressions, and by not seeking to deflect or avoid blame. 3. Those acknowledgments included admitting his initial reluctance to seek professional assistance whilst the boundary violating behaviour was still current because he was fearful of the professional consequences if he did so. That candid admission against his interests shows that he can now face up to his earlier shortcomings with appropriate insight into them. 4. The applicant has shown consistent commitment, both in Australia and in Iran, to the task of reforming himself by acknowledging his mental health issues and obtaining appropriate treatment for his depression which is now in remission. That remission has given him the opportunity to reflect on his past offending actions. In addition he has sought out proper assistance to ensure that he is equipped with strategies to avoid future recurrences. 5. The applicant has also used the extended opportunity whilst deregistered to pursue suitable courses in further medical education to better equip himself against the risk of recurrence of the offending conduct. In that period of his deregistration, he has also matured and gained appropriate insight into the causes for his lapse in standards, and how to strategise to avoid recurrences. 6. The applicant is now very much aware of the need to continue to maintain treatment for his mental health in order to properly manage his depression, which is now in remission. He is insightful of the risk and the adverse consequences of a relapse in his mood disorder. He is aware of the need for that risk to be the subject of monitoring and for his mental health to be properly maintained. 7. The applicant has shown he is appropriately conscious of the fact his misconduct has caused harm to Patient A. Our impression from his evidence is that now, after pursuing appropriate psychological and psychiatric treatment, and by attending appropriate educational courses, he is properly equipped with better medical knowledge and education to know how to avoid a repetition of his past mistakes. In that regard, we note and accept the evidence of Ms Abdilla in which she said the applicant is now "a different person". 8. On the evidence before this Tribunal, we are comfortably satisfied that the applicant is now acutely mindful of the need to adhere to applicable ethical codes to ensure he does not repeat his past offending conduct. 9. We are fortified in that view by the assessment of Associate Professor Wijeratne who satisfied himself that the applicant has appropriate insight and commitment to avoid similar difficulties in the future, as explained at sub-paragraph (e) of paragraph [171] above. 10. Those views are supported by the cited literature concerning lowered risks of reoffending based on expressions of remorse and self-reflection and an understanding of vulnerabilities that led to the offending behaviour, together with the development of an appropriate self-management plan in conjunction with treatment, supervision, and mentoring. Displacement of prior finding of unfitness in favour of reinstatement 1. The regulatory scope within the National Law as explained in decided cases provides a pathway for reinstatement in appropriate cases. That pathway is established and available where there has been acknowledgment of past error and convincingly clear and reliable proof, based on satisfactory evidence, of reformation of the personal flaws which led to deregistration in the first instance. 2. The Tribunal notes that throughout all levels of his engagement with the disciplinary proceedings the applicant has consistently acknowledged his professional mistakes without reservation concerning his violation of the professional boundary by his unethical sexual relationship with Patient A. He has not sought to deflect or shirk from taking full responsibility for his professional and personal mistakes, nor has he sought to take refuge from criticism by making exculpatory excuses. 3. The Tribunal's task of determining the issue of whether the applicant has at this time satisfactorily proven that his quest for reinstatement is justified must be guided by the paramount consideration of the health and safety of the public: s 3, s 3A and s 3B of the National Law. He must show that he is now worthy of trust in the professional setting, and that he is now fit to practice his profession. 4. The applicant's sincere acknowledgments of past wrongdoing, his remedial efforts through the pursuit of psychological and psychiatric treatment to manage his depression, his pursuit of further educational courses, his unchallenged competence as a practitioner, the willingness of the former practice where he worked to re-engage him, and the opinion of Associate Professor Wijeratne as to the risk of him reoffending being relatively low, in combination comfortably persuade us that the applicant is unlikely to reoffend, and therefore if reinstated, he would not pose an unacceptable risk to the health and safety of the public. 5. For the foregoing reasons, on the basis of the evidence we have identified and accepted, we find that the applicant has discharged the onus of establishing that the earlier Tribunal findings of unfitness to practice no longer apply to him. Conditions 1. On reinstatement of the applicant the public are entitled to expect that he would be required to comply with a series of structured conditions to ensure public health and safety. Those conditions have been the subject of expert evidence, submissions, and debate. In our view, the appropriate practice, health, mentoring and supervision conditions for applicant, subject to review by the Medical Council, are incorporated in the Appendix to these reasons. Disposition 1. We consider that according to the legal tests and criteria identified earlier in these reasons, having due regard to the paramount consideration of the health and safety of the public, subject to the applicant's adherence to proposed conditions of practice set out in the Appendix, the applicant has justified his request for reinstatement. Costs 1. The respondent was required to actively participate in these proceedings and was entitled to test the applicant's evidence and make submissions in the public interest. It follows that the respondent's costs incurred in that regard should be paid by the applicant on the ordinary basis, as agreed or assessed. 2. The applicant raised no objection to having to pay the costs of the proceedings but sought to pay any such costs by way of instalments on account of his impecuniosity. That is a matter for negotiation between the parties. That issue ought not represent a barrier for reinstalment. Orders 1. The Tribunal makes the following orders: 1. Pursuant to s 163(1)(c) of the Health Practitioner Regulation National Law (NSW) 2009, the applicant Dr Aliyar Danaei, may apply to the Medical Board of Australia for registration to reinstate him as a medical practitioner subject to the practice and health conditions listed in the Appendix to these reasons. 2. The Medical Council of NSW is the appropriate review body for the purposes of Part 8, Division 8 of the Health Practitioner Regulation National Law (NSW) 2009. 3. Pursuant to clause 13 of Schedule 5D of the Health Practitioner Regulation National Law (NSW) 2009, the applicant is to pay the respondent's costs of these proceedings on the ordinary basis as agreed or assessed. ********** APPENDIX – Conditions Practice conditions 1 To obtain Medical Council of NSW approval prior to re-commencing or changing the nature or place of practice. 2 To practice in a group practice approved by the Medical Council of NSW where there are at least 2 registered medical practitioners (excluding the subject practitioner) and: 1. Where the patients and patient records are shared between medical practitioners 2. Where there is always one other registered medical practitioner on site 3. Which is an accredited practice. 3 To treat no more than 35 patients in any day, and no more than 5 patients per hour. 4 The practitioner is to provide the Medical Council of NSW with copies of records confirming the number of patients treated, their consultation times and hours worked on any dates as specified by the Council. 5 To practice no more than 40 hours per week. 6 To complete within 6 months of recommencement of practice The National Prescribing Curriculum organised by the University of Tasmania. 1. Within 1 month of recommencement of practice they must provide evidence to the Medical Council of NSW of their enrolment in the abovementioned course. 2. Within 1 month of completing the abovementioned course, they are to provide evidence to the Council from the training provider that they have satisfactorily completed the course. 3. To bear responsibility for any costs incurred in meeting this condition. If the National Prescribing Curriculum organised by the University of Tasmania is unavailable, he must propose to the Council for approval a similar course to be undertaken in accordance with the requirements of this condition and provide a written explanation, within 2 months of recommencement of practice. 7 To complete within 6 months of recommencement of practice Complete Better Pain Management Program (12 modules) organised by Faculty of Pain Medicine Australian and New Zealand College of Anaesthetists (ANZCA). 1. Within 1 month of recommencement of practice they must provide evidence to the Medical Council of NSW of their enrolment in the abovementioned course. 2. Within 1 month of completing the abovementioned course, they are to provide evidence to the Council from the training provider that they have satisfactorily completed the course. 3. To bear responsibility for any costs incurred in meeting this condition. If the Complete Better Pain Management Program (12 modules) organised by Faculty of Pain Medicine Australian and New Zealand College of Anaesthetists (ANZCA) is unavailable, he must propose to the Council for approval a similar course to be undertaken in accordance with the requirements of this condition and provide a written explanation, within 2 months of recommencement of practice. 8 To practice under category C supervision in accordance with the Medical Council of NSW's Compliance Policy – Supervision (as varied from time to time) and as subsequently determined by the appropriate review body. 1. The terms of the Council's Compliance Policy are varied to require the practitioner to: 1. Have monthly face-to-face supervision meetings with the Council-approved supervisor for a minimum period of 1 hour. 2. Authorise the Council-approved supervisor to forward reports to the Council (in a Council-approved format) every month. 1. At each supervision meeting the practitioner is to review and discuss his practice with his approved supervisor with particular focus on: 1. Professionalism and professional ethics, including but not limited to: 1. Maintaining appropriate professional boundaries with patients 2. The Medical Board of Australia's 'Good Medical Practice: A Code of Conduct for Doctors in Australia' and 'Guidelines: Sexual Boundaries in the Doctor-Patient Relationship'. 1. Compliance conditions. 2. Workload management. 3. Clinical performance, including assessment, management of patients, surgical procedure technique and appropriate investigations, including the assessment and management of patients with mental health issues. 4. Medical records, including a review with the supervisor of a minimum of 5 randomly selected medical records from the preceding month. 5. Appropriate prescribing practices concerning the assessment and management of patients with chronic pain, including appropriate prescribing of Schedule 8 drugs of addiction and Schedule 4 Appendix D drugs. 1. Within the first 6 months of supervision and in addition to the supervision meetings, the practitioner is to undertake monthly observations with the Council approved supervisor. These observations will alternate between: 1. The practitioner observing the approved supervisor conduct at least 3 patient consultations with patients. 2. The practitioner having at least 3 patient consultations observed by the approved supervisor. 3. Details and feedback about the observed consultations are to be discussed during the supervision meetings and recorded in the supervision reports. 4. Each observation session is to be a minimum 1 hours in duration. 5. On completion of the minimum required observation sessions, the practitioner is required to submit for Council consideration a reflective report outlining and demonstrating: 1. Lessons learned from the observation sessions, and 2. How the practitioner will implement his learnings into his future medical practice 1. To authorise the Medical Council of NSW to provide the approved supervisor(s) with a copy of the decision which imposed this condition and any other decision or report as determined by the Council. 2. Not to practice until a supervisor has been approved by the Medical Council of NSW. 9 To nominate an experienced General Practitioner to act as his professional mentor for approval by Medical Council of NSW in accordance with the Medical Council of NSW's Compliance Policy – Mentoring (as varied from time to time) and as subsequently determined by the appropriate review body: 1. The terms of the Medical Council of NSW's Compliance Policy – Mentoring are varied so that the Council-approved mentor must not be co-located or practice at any location where the practitioner works. 2. At each mentoring meeting the practitioner is to include discussion of the following: 1. initially the issues highlighted in this decision and then any personal and medical practice issues that may arise 2. Maintaining boundaries and Professional ethics 3. Work life balance and workload 4. His personal and professional development 1. To authorise the mentor to report, in an approved format, to the Council every 3 months about the fact of contact, and to inform the Council if there is any concern about his professional conduct or personal wellbeing. 2. To authorise the Medical Council of NSW to provide approved mentors with a copy of the decision/s which led to the imposition of this condition. 10 To authorise and consent to any exchange of information between the Medical Council of NSW and Medicare Australia for the purpose of monitoring compliance with these conditions. Health Conditions: 11 Not to prescribe for self-medication. 12 To attend for treatment by a General Practitioner of their choice but not working at their place of practice, at a frequency to be determined by the treating practitioner. The practitioner is to: 1. authorise the treating practitioner to inform the Medical Council of NSW of failure to attend for treatment, termination of treatment or if there is a significant change in health status (including a significant temporary change) 2. provide the Council with the professional details of the treating practitioner. 13 To attend for treatment by a psychologist of their choice, at a frequency to be determined by the treating practitioner. The practitioner is to: 1. authorise the treating practitioner to inform the Medical Council of NSW of failure to attend for treatment, termination of treatment or if there is a significant change in health status (including a significant temporary change) 2. provide the Council with the professional details of the treating practitioner. 14 To attend for treatment by a psychiatrist of their choice, at a frequency to be determined by the treating practitioner. The practitioner is to: 1. authorise the treating practitioner to inform the Medical Council of NSW of failure to attend for treatment, termination of treatment or if there is a significant change in health status (including a significant temporary change) 2. provide the Council with the professional details of the treating practitioner. 15 To attend for review by a Council Directed Health Assessor (Psychiatrist) on a 3 monthly basis or as otherwise directed by the Medical Council of NSW. 16 To attend a Medical Council of NSW Review Interview on a 3 monthly basis or as otherwise directed by the Council. 17 To authorise the Medical Council of NSW to forward copies of the decision which imposed this condition and any reports and any other information relevant to their health and treatment to the Council Directed Health Assessors, supervisors and to their treating practitioners. 18 These conditions may be altered, varied or removed by the Medical Council of New South Wales and the Medical Council is the appropriate review body for the purposes of Part 8 Division 8 of the Health Practitioner Regulation National Law (NSW). 19 Sections 125 to 127 of the Health Practitioner Regulation National Law are to apply whilst the practitioner's principal place of practice is anywhere in Australia other than New South Wales. I hereby certify that this is a true and accurate record of the reasons for decision of the Civil and Administrative Tribunal of New South Wales. Registrar DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment or decision. The onus remains on any person using material in the judgment or decision to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court or Tribunal in which it was generated. Decision last updated: 01 August 2024