Medical Tribunal New South Wales Medium Neutral Citation: Health Care Complaints Commission v Dr A Esin Dalat Ozme [2012] NSWMT 15 Hearing dates: 18, 19 June 2012 Decision date: 28 June 2012 Before: Kavanagh J; Dr E Kok, Dr W Jammal, Dr M Gleeson PhD Decision: 1.The doctor is guilty of unsatisfactory professional conduct. 2.The doctor is reprimanded. 3.The doctor is to submit to an audit on her premises of a random selection of her medical records medical records by a person or persons nominated by the Medical Council of New South Wales ("the Council") to assess her compliance with the relevant provisions of the Health Practitioner Regulation (New South Wales) Regulation 2010 (Part 4 and Schedule 2) and the FRACGP's Standards for General Practices (3rd edition), in particular Standard 1.7 'Content of Patient Health Records' with particular attention to her assessment of patients and prescribing of anti-psychotic medication. 4.The audit is to occur within 3 months from the date of this Decision and subsequently at 12 monthly intervals, or as required by the Medical Council. The practitioner is to authorise the Auditor/s to provide the Council with a report on their findings. The practitioner is to meet all costs associated with the audit/s and any subsequent reports. 5.The Tribunal has ordered that there be a suppression order on the name of Patient A to be applied to all documentation including medical reports. 6.That Dr Ozme seek accreditation as a general practitioner and the Council be notified when accredited. 7.Each party shall pay its own costs. Catchwords: UNSATISFACTORY PROFESSIONAL CONDUCT - difficult patient with mental health problems and agoraphobia - failure of doctor over period to examine patient for clinical assessment - doctor prescribed anti-psychotic drugs without clinical examination - failure to keep proper and adequate medical records - doctor guilty of unsatisfactory professional conduct - doctor to ensure accreditation of general practitioner's practice be sought and when obtained, the Medical Council to be notified and the Medical Council to review - each party pay own costs Legislation Cited: Health Care Complaints Act 1993 Health Practitioner Regulation National Law (NSW) No 86a Health Practitioner Regulation (New South Wales) Regulation 2010 Cases Cited: Childs v Walton [1990] NSWCA 41 Director-General, Department of Ageing, Disability and Home Care v Lambert [2009] NSWCA 102 Lee v Health Care Complaints Commission [2012] NSWCA 80 Category: Principal judgment Parties: Health Care Complaints Commission (Complainant) Dr A Esin Dalat Ozme (Respondent) Representation: W Hunt (Complainant) G Furness SC (Respondent) Health Care Complaints Commission (Complainant) Avant Law Pty Ltd (Respondent) File Number(s): MT40008 of 2011 DECISION 1The Health Care Complaints Commission ("the Complainant") brings before the Tribunal a Further Amended Notice of Complaints following consultation with the Medical Council of NSW ("the Council") in accordance with ss 39(2) and 90B(3) of the Health Care Complaints Act 1993 and s 145A of the Health Practitioner Regulation National Law (NSW) No 86a ("the National Law") against Dr A Esin Dalat Osme ("the respondent") being a medical practitioner registered under the Act. 2It is alleged that the respondent: COMPLAINT ONE Has been guilty of unsatisfactory professional conduct within the meaning of section 139B (1)(a)(b) and (l) of the National Law in that she: (i) has demonstrated that the knowledge, skill or judgment possessed, or care exercised, by her in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience. (ii) has contravened the Medical Practice Regulation 1998(repealed) and the Medical Practice Regulation 2003(repealed). (iii) has been guilty of improper or unethical conduct by a medical practitioner in the course of the practice of medicine. PARTICULARS From about 1984 Patient A has been a patient of the practitioner. From about 1991 Patient A consulted with the practitioner in relation to her mental illness, which had been diagnosed as schizophrenia and depression. On 19 April 2003 the medical practitioner attended Patient A at Patient A's home. After this date the medical practitioner continued to prescribe medication to Patient A without seeing her. From approximately 1992 to 2004, Patient A was also being treated by Community Health Services, Marrickville. On 5 November 2004, the practitioner was notified that Patient A was no longer being treated by Community Health Services, Marrickville. From November 2004, the practitioner was the main treating practitioner of Patient A. 1. From 5 November 2004 to 18 March 2008 the practitioner prescribed medication to Patient A without seeing her, in particular the practitioner prescribed anti-psychotic drugs of Solian, Aropax and Seroquel. The practitioner i) failed to attend to Patient A in person and physically examine Patient A; ii) failed to obtain information from Patient A about her condition and to provide advice to Patient A; iii) accepted the information provided by Patient A's mother and/or father and did not undertake an independent assessment of Patient A; iv) did not exercise responsible medical judgment as to whether it was appropriate to issue such prescriptions; v) failed to adequately monitor the continued drug use of Patient A during the course of her treatment; vi) failed to make any adequate assessment as to whether the treatment being provided by the medical practitioner was causing any harm to Patient A; vii) failed to make any adequate assessment as to the effectiveness of the treatment being provided to Patient A; viii) failed to refer Patient A to mental health specialists and/or counsellors or obtain assistance from these practitioners; ix) failed to make any adequate assessment of alternative treatment options for Patient A including referring Patient A to other practitioners including a dietician; and x) failed to ensure that a care plan or treatment plan was in place. 2. The medical practitioner failed to keep proper and adequate records of her treatment of Patient A in accordance with clause 13 and 14 of, and Schedule 2 of the Medical Practice Regulation 1998(repealed) and clause 5 and 6 of, and Schedule 2 of the Medical Practice Regulation 2003(repealed). The medical practitioner i) failed to note that she prescribed medication to Patient A without seeing, speaking with, or examining Patient A; ii) failed to adequately note, any information known to the medical practitioner that was relevant to Patient A's diagnosis or treatment, including information concerning the patient's medical history, the results of any physical examination of the patient, information obtained concerning the patient's mental state, the results of any tests performed on the patient or other factors that may require special consideration when treating the patient; iii) failed to note particulars of any clinical opinion reached by the medical practitioner, iv) failed to note any plan of treatment for Patient A; v) failed to note the treatment recommended by treating psychiatrists or to keep copies of all letters from treating psychiatrists; vi) failed to adequately note, particulars of all medication prescribed to Patient A on each occasion medication was prescribed; and vii) failed to note information or advice given to Patient A in relation to any medical treatment proposed. COMPLAINT TWO Has been guilty of professional misconduct within the meaning of section 139E of the National Law (NSW) in that she has: (i) Engaged in unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of her registration and/or (ii) Has Engaged in unsatisfactory professional conduct on a number of occasions which, when considered together, amount to conduct of a sufficiently serious nature to justify suspension or cancellation of her registration. PARTICULARS OF COMPLAINT TWO Each of the particulars to Complaint One set out above is relied upon in respect of Complaint Two. Background 3Dr Ozme is 63 years old and is married with an adult daughter. She attended Hacettepe Medical School in Turkey and gained her Medical Degree in 1972. After graduating, she travelled to England to undertake a three month internship at the Newcastle Upon Tyne Hospital after which she returned to Turkey. Between 1972 and 1977, she underwent further training in pediatrics at the Hacettepe Children's Hospital and spent the final year working as a pediatric hematology trainee. She went on to work as a pediatrician at the Istanbul Community Health Centre from 1979 to August 1980. 4Dr Ozme migrated to Australia in August 1980 and passed the AMEC exams in 1982. Since that time she has been working as a general practitioner in Sydney. Currently she works as a general practitioner at both Enmore in the mornings and Auburn in the afternoons. 5The doctor first saw Patient A in 1984. The patient was diagnosed in 1993 with schizophrenia. The patient was unresponsive, withdrawn and non-communicative. The Evidence: Complaint One 6As to Complaint One, it has two aspects: the doctor failed to examine the patient yet continued to prescribe anti-psychotic drugs in the relevant period and secondly, the doctor failed to keep adequate records of her treatment of Patient A. 7The doctor admitted that after Patient A's discharge from Marrickville Community Mental Health Service's care, she prescribed her with medication for her mental illness without performing a clinical examination. 8However, the doctor was provided with a medical report which recommended treatment, medication and dosage from a psychiatrist in Turkey. Dr Ozme relied on this specialist advice when she was re-prescribing medication and dosage. 9The doctor opined as to her treatment of Patient A in the following way: I admit that I did not attend Patient A in person and physically examine her after 19 April 2003. However I was not consulted after 6 May 2003 until 8 November 2003, a period of 6 months. After 5 November 2004 the patient's parents refused to bring Patient A to see me and refused to let me see her at home. Patient A had been my patient since 1984. I did not want her condition to deteriorate as a result of not receiving medication. I felt that I was the only link between Patient A and her family in terms of her health and did not want them to also shut me out and for Patient A to be without medication and without medical care. I believed her parents would never have taken her or have easily taken her to any other medical practitioner in Australia. They came to me because, as a doctor of Turkish background, we had a linguistic and cultural connection and trust that had been built up over the many years they had been consulting me. In the circumstances I chose to continue prescribing the patient's anti-psychotic medication that had been commenced by psychiatrists and other medication. I state this in order to put into context my predicament in continuing to prescribe without seeing the patient, not in order to advance any excuse in doing so. 10Further background was obtained through evidence from the doctor as well as documentary records. 11The doctor after initially treating Patient A before the relevant period of the complaint became concerned as to the patient's mental condition and it was Dr Ozme who referred her to Marrickville Community Mental Health some years before. The Marrickville Service between May and 8 November 2003 treated the patient. However, after 8 November 2003 the patient was discharged from the Service given she refused to have the Service examine her at home. She also refused to attend at the Service. There was a diagnosis of agoraphobia. 12It was in this circumstance the patient's parents returned to see Dr Ozme. The mother was a patient of the doctor's. The mother communicated to the doctor that her daughter would not have her visit at home nor would the patient attend at the surgery but requested Dr Ozme be her daughter's treating general practitioner. 13The doctor in this circumstance agreed to continue to prescribe for Patient A. The family had the daughter examined by the Turkish psychiatrist in Turkey. She revealed she relied upon the Turkish psychiatrist's report during the relevant period to assure herself that the patient had been advised to take particular medications. It appears Patient A was taken to Turkey by her parents in 2007. She was medicated to take the trip. Dr Ozme did not provide or prescribe any other medication to Patient A than that recommended by the psychiatrist. 14In relation to the doctor's alleged failure to monitor or adequately monitor the continued drug use of Patient A, Dr Ozme stated: I deny that I failed at all to monitor the patient's continued drug use. When the patient's mother consulted me I questioned her to find out how the patient was and if there were any drug related symptoms, such as extra-pyramidal signs, dysarthria, wide-based gait etc. I also organised regular blood tests to assess metabolic complications of the treatment. The mother would also check the patient's blood pressure and report this to me when we met. The doctor requested and organised blood tests. The patient's mother took her blood pressure. All results were checked by Dr Ozme before she re-prescribed medication. She unfortunately recorded the dates these tests were performed in the patient's mother's treatment notes. However the doctor also stated: I admit...that in the absence of personally reviewing the patient I did not adequately monitor the patient's continued drug use during the course of the treatment. 15The doctor further admitted to failing to obtain information from and providing advice to Patient A about her condition. However, the doctor opined: She was non-communicative and monosyllabic. I believe that the Marrickville Mental Health Service also encountered this difficulty in assessing the patient. As such the doctor stated that any information regarding Patient A invariably came from her family over the many years of Dr Ozme treating her, and not directly from Patient A herself. 16Further, the doctor opined: The patient's mental health illness, even with Marrickville Mental Health Service's treatment and management over almost twelve years and subsequently up until her death was chronic and resistant to treatment. 17Dr Linda Mann, as a peer doctor general practitioner, was relied upon by HCCC and gave evidence. She provided two reports, one of 30 May 2011, the other 18 November 2011. In cross examination she conceded that she had misunderstood and accepted the doctor did do home visits. She conceded, it was established from the evidence, that Dr Ozme was not permitted to do home visits by Patient A. Dr Mann opined: I note the difficulty of managing such patients. I note that the parents had declined care from Marrickville Community Centre. I also note the absence of any comprehensive assessment at any time as reflected in these notes. Even if there had been, it is possible that the outcome may have been the same. Patients like (Patient A) are vulnerable and have an increased incidence of self-harm and suicide. This makes it even more important for GPs to undertake standard care, and confront the difficulties that they face in doing this with even more vigour, to improve the life of such patients. 18The doctor, when told how Dr Ozme had organised blood tests and blood pressure readings before reissuing medication prescriptions, conceded this was an example of the doctor being involved in the treatment of Patient A. Having made those factual concessions Dr Mann, however, reiterated the conduct was, in her view given the two aspects of the complaint, significantly below the standard and invited her strong criticism. 19The Tribunal has sighted the Doctor's clinical records of Patient A. The Tribunal accepts the notes are best and accurately described by Doctor Mann as follows:: The notes are scanty, often with single words, legible, and generally have no history, examination, formulation, or follow up. Diagnoses are listed, and sometimes medication. Some notes are written on results, with no reference in the body of the notes to refer a reader to that note. On one occasion, two different visits are noted on a result which is itself a different date. Critical letters are absent (the letters that detail the medication that Dr Ozme represcribed). If no such communication exists, then the reason that Dr Ozme commenced and continued to prescribe medication should be detailed (eg. came with medication prescribed in Turkey by Dr ...) There is no health or medication summary in the bundle I have been provided with. 20The doctor then opined: I consider that Dr Ozme's medical records of her assessment, care and treatment of (Patient A) fall below the standard expected of a practitioner of an equivalent level of training and experience. 21Doctor Marcela Cox opined to the medical insurance company on 20 August 2011: While it is acknowledged that (Patient A) would have been a challenging patient to manage and it does appear Dr Ozme was trying to be of assistance to the family I have several concerns regarding Dr Ozme's assessment, care and treatment: ... Dr Ozme was acting as the general practitioner for (Patient A). After November 2004 Dr Ozme would have been aware that she was the only medical practitioner regularly involved in (Patient A)'s care as she had been discharged from the MCMHS. Dr Ozme did arrange blood tests to monitor (Patient A)'s general health and was aware that (Patient A)'s family checked her blood pressure. Other aspects of (Patient A)'s health, however, should also have been monitored, such as her weight, chest examination and breathing tests in regard to her smoking and chronic cough, her mental state, social functioning, immunisations etc. To make such assessments a patient requires a clinical review in person. ... Despite the difficulties posed for Dr Ozme in reviewing (Patient A), it is my opinion that as Dr Ozme was acting as (Patient A)'s general practitioner, providing ongoing prescriptions for anti-psychotic medication and pathology tests, she ought to have organised periodic clinical reviews, either by home visits or arranging for (Patient A) to be brought to the surgery. If neither of these options were possible, Dr Ozme should have discussed with the family the transfer of care of (Patient A) to another doctor who could provide home visits. 22Dr Cox further opined: While Dr Ozme should have arranged to review (Patient A) personally, based on her mother's reports that her condition was stable and the fact that she had been reviewed by psychiatrists overseas, it is my opinion that Dr Ozme was not required to arrange a specific psychiatric review for (Patient A) between 2004 and March 2008. ... It is my opinion that, given the circumstances, the minimum standard of care reasonably expected would have been for Dr Ozme to arrange to review (Patient A) at least every 6-12 months to assess both her physical and mental health status. At these visits an appropriate history should have been taken from (Patient A) and her family and any relevant physical examination performed, such as weight, blood pressure, heart and chest examination, blood sugar level testing etc. (Patient A)'s management plan should have been discussed with the family and then any prescriptions provided. All of this information should have been recorded in patient's medical record in an appropriate manner. 23In Dr Cox's evidence, when asked what the doctor should have done, she stated: I think it would have been extremely difficult. I think that one option would be to talk to a mental health colleague, ring up the Marrickville Health Team, talk to a psychiatrist, ask them what they would advise. One option would be when the mother came in for a prescription to have some form of negotiation and try to be a little firmer with the mother and say: Look, maybe we will just have a month and then, you know, then I have to see this patient. But I think it was complicated, difficult. 24On being asked whether Dr Cox considered that Dr Ozme departed from the standard reasonably expected of a practitioner of an equivalent level of training or experience, and whether any such departure was significantly below this standard, Dr Cox stated: Due to the mitigating factors mentioned..., Dr Ozme's departure from the standard in regard to her clinical care does not attract my strong criticism. 25As to the second element to the complaint - the failure of the doctor to keep proper records, Dr Cox opined: In regard to record-keeping, however, the departure does attract my strong criticism. Anti-psychotic medications have the potential for serious adverse effects. When prescribing such medications Dr Ozme should have kept a record of the history given by the family regarding (Patient A)'s mental state, any side effects noted and any change in her treatment regimen after having psychiatric review. A medication summary sheet and correspondence from psychiatrists should also have been kept up to date. While the expected standard of record keeping has changed since 1984, the records kept by Dr Ozme for the period of care of (Patient A) are significantly lacking in my opinion. Most entires are only a few words at most, usually just a diagnosis and medication prescribed. There are notes from two different dates written on a mobile chest x-ray report, which itself has another date. The doctor therefore concluded: [I]t is my opinion that Dr Ozme's standard of care fell significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience, both in regards to clinical care and record-keeping. 26Dr Paul Friend, clinical psychiatrist, also provided a report of 24 August 2011 in which he opined: I would have expected that Dr Ozme would have undertaken face-to-face assessments of (Patient A) and where appropriate to have undertaken a physical examination and recorded her findings. If this were not possible because (Patient A) was not cooperating with such assessments, I would have expected that Dr Ozme would have discussed alternative approaches with (Patient A) and/or her parents. 27On being asked what level of criticism he would attach to Dr Ozme's treatment of Patient A, Dr Friend opined: It would appear to be difficult for Dr Ozme to balance all of these requirements. She seems to have fulfilled the requirement of maintaining treatment as she understood it. It appears that Dr Ozme's concern to continue to treat (Patient A) overrode other requirements of medical care including assessment and examination and careful recording of these findings. ... However considering matters overall, I believe that Dr Ozme's standard of care was below that expected of a practitioner of an equivalent level of training or experience. Dr Ozme allowed this situation to continue on for over four years. There is no documentation that she tried to implement alternative treatment/management strategies. I believe that it is significantly below the standard of a general practitioner of equivalent training or experience. 28On being asked what factors may have assisted in the management of Patient A, Dr Friend stated: In the end the only avenue open to Dr Ozme may have been to decline to prescribe medication unless (Patient A) accepted a face-to-face assessment and that could have caused (Patient A)'s mental state to deteriorate. 29In relation to the complaint as to her failure to adequately assess the effectiveness of the treatment being provided to Patient A, Dr Ozme stated: I admit however that an appropriate assessment also required my reviewing the patient personally and if necessary seeking advice from the Marrickville Mental Health Service as to my assessment and treatment options, if any. However because of the stance of the patient and her parents' this was not possible. 30As regards to her failure to refer Patient A to or to seek assistance from a mental health specialist or counsellor, the doctor stated: The parents' however did organise for the patient to consult with Turkish psychiatrists, who because they were Turkish like them, they trusted. I admit however that it was not optimal for specialist in-put to be provided from doctors in Turkey and specialist in-put from a doctor in Australia was really required. Complaint Two 31The doctor repeated her responses to the particulars of Complaint One in relation to Complaint Two but contends such conduct does not establish that she is guilty of, as the complaint alleges, professional misconduct. 32Since the complaint, the doctor has undertaken the following courses: (1)A two day "Managing Mental Health" course on 14 and 28 November 2009, organised by Central Sydney GP Network (2)A "Mental Health Seminar" on 21 November 2010 organised by the Macarthur Division of General Practice. (3)A four hour placement on 12 May 2011 with Royal Prince Alfred Hospital's Drug & Alcohol Liaison Service, covering drug health organised by the Central Sydney GP Network. (4)A four hour placement on 16 June 2011 at the Camperdown Community Health Service, Adult Mental Health Team covering mental health organised by the Central Sydney GP Network. (5)A Monash University Short Certificate Course entitled "Issues in General Practice Prescribing" completed in November 2011. Consideration 33Unsatisfactory professional conduct is defined in s 139B of the National Law. Professional misconduct is defined in s 139E of the National Law. Both terms define the conduct as including "any other improper or unethical conduct relating to the practice or purported practice of the practitioner's profession". 34The practitioner admitted each of the Particulars in Complaint 1 and, as a consequence, she is guilty of unsatisfactory professional conduct. The Tribunal is comfortably satisfied the factual matters particularised in Complaint 1 and the admissions were proper and appropriate in the circumstance. 35We accept from the evidence the doctor's failings regarding her clinical care and her failure to properly keep treatment records regarding Patient A demonstrated her practice of medicine was significantly below the standard reasonably expected of a general practitioner of equivalent training. She also breached the relevant regulations regarding proper prescribing practices in this circumstance. 36We find such departures from the standard should be viewed as unsatisfactory professional conduct. 37However, the HCCC presses for a finding, on the same particulars under Complaint 2, that the conduct was professional misconduct, in accordance with the definitions under the National Law, that is: a)unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration; or b)more than one instance of unsatisfactory professional conduct that, when the instances are considered together, amount to conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration. 38Neither Dr Cox nor Dr Friend held the same critical view of the conduct as held by Dr Mann. We prefer the view held by Drs Cox and Friend. 39Dr Mann while she conceded that she mistakenly believed it was not the doctor's practice to do home visits and also did not understand that the doctor ordered blood tests and blood pressure readings before re-prescribing nonetheless she reiterated her opinion as to the conduct. While Dr Mann's opinions, as a general practitioner with many vulnerable patients, were relied upon, Dr Cox described a similar type of general practice. Dr Cox's judgement of the circumstance Dr Ozme found herself in was more thoughtful as to the dilemma faced by the doctor. Dr Cox balanced her understanding of the circumstance but emphasised there must be a professional recognition from Dr Ozme of the need for responsible clinical practice and proper patient record keeping. 40Mr Hunt, counsel for the HCCC further relied upon Dr Mann's severe criticism of the conduct to propose that a patient with a mental disorder requires protection through the rigor of proper practice. It would, he contended, be against the public interest for the Tribunal to find that a doctor who did not examine a patient over a three year period but continued to prescribe medication for that patient meet little consequence for such conduct. 41Dr Ozme gave evidence that she had not considered the gravity of her conduct until after she received the notification from the HCCC as to a complaint. The HCCC submitted that the doctor's failure to realise the significance of her proven failures over the relevant three year period revealed in the doctor no awareness of the ethical standards required of a medical practitioner and in that context, the conduct should be viewed as professional misconduct. Further, the HCCC submitted for over three years the doctor's practice in her treatment of Patient A, while not incompetent, was unsatisfactory professionally and should be viewed by the Tribunal when the conduct is repetitive as aggregated over the three years as professional misconduct. 42Reliance was placed upon Dr Friend's expressed view: Dr Ozme was neglectful of the requirements for managing (Patient A) rather than doing anything that was intrinsically harmful. As such I believe that Dr Ozme would be likely to improve her medical practice in similar circumstances with further training and/or mentoring. 43We have considered the submission of the HCCC but do not accept the conduct was professional misconduct nor do we accept that, given the period of complaint was over three years, the conduct should be viewed as a number of events which aggregated should persuade there was professional misconduct. 44We found the doctor to be honest, candid and remorseful. She accepted the conduct was unsatisfactory professionally. We find the complaint does not reveal a pattern of conduct but rather reveals the doctor failed to have clinical examinations in a particular circumstance where she was focused upon maintaining the patient's medication. Dr Friend noted she concentrated her efforts on maintaining her treatment regime for the patient. 45Of significance to the Tribunal is the fact that there is no other example of such conduct over the last four years notwithstanding the doctor treats other vulnerable patients. The doctor has practiced medicine for over 39 years and over 29 years in Australia without complaint. 46One of the concerns of the Tribunal was to question whether the doctor had access to her professional peers and whether she could have sought advice given she recognised the vulnerability of her patient and the difficulties in treating her. 47In pressing for protective orders which required the doctor to be placed under supervision of the Medical Council at Level 3 of the Council's guidelines, Mr Hunt proposed that although the doctor was an active member in her region of the AMA and thereby in contact with her peers, she failed to use that network to support her in her treatment difficulties. This is a difficult proposition. At the time the doctor did not recognise her treatment was lacking. However, the personal references provided to the Tribunal allay the Tribunal's expressed concern that the doctor may have been labouring in isolation. She appears to have a fine, locally based, support structure. As to the fact that peer support was not used by the doctor because the doctor failed, at the time, to recognise, while her treatment is not challenged as incompetent, it was revealing as to her failure to understand the need for a clinical examination and the rigor needed in recordkeeping more particularly so for the most vulnerable of patients. As all the doctors recognised, if in some unfortunate circumstance someone had to take over the patients care, the records would have been of no assistance. 48In consideration of the appropriate protective order in the circumstance the Tribunal accepts there has been a proper expression of contrition. Ms Furness SC for Dr Ozme submits when the Tribunal accepts the honest contrition of the doctor and is persuaded that the doctor has now a clear insight into her failures, there is no necessity for a protective order (Childs v Walton [1990] NSWCA 41). We accept this proposition. In Director-General, Department of Ageing, Disability and Home Care v Lambert [2009] NSWCA 102, Basten JA stated at [83]: [I]n a particular case, there may be a factual finding that the harrowing experience of disciplinary proceedings, together with the real threat of loss of a livelihood may have opened the eyes of the individual concerned to the seriousness of his or her conduct, so as to diminish significantly the likelihood of its repetition. Often such a finding will be accompanied by a finding that the person concerned has achieved a level of insight into his or her own character or misconduct, which did not previously exist. 49This reasoning was adopted in Lee v Health Care Complaints Commission [2012] NSWCA 80 by Barrett JA (Macfarlan JA and Tobias AJA agreeing) at [20]: 1. The specific purpose for which orders are made is protective in the public interest and is not punitive with respect to the individual. 2. That is not to deny that such orders may be punitive in effect and that punitive effects may be relevant in formulating a protective order. 3. The punitive effects may be directly relevant to the need for protection so that, in a particular case, there may be a factual finding that the harrowing experience of disciplinary proceedings, together with the real threat of loss of a livelihood, may have opened the eyes of the individual concerned to the seriousness of his or her conduct so as to diminish significantly the likelihood of its repetition and to produce a level of insight into his or her own character or misconduct which did not previously exist. 50Having regard to Dr Ozme's years of practise without complaint, her admissions and her insight into how unsatisfactory was her impugned conduct we accept the doctor should not receive a formal Medical Council supervision order. However, the Tribunal recommends that Dr Ozme obtain her accreditation of her general practice and the Medical Council be notified when that accreditation is obtained within a reasonable period of time. 51We encourage the doctor to make use of the clear network of peer advisors and professional colleagues she has built up through her practice and through both her medical college membership and attending divisional meetings and to use those peer contacts when she recognises a difficult patient to test her judgement as to the appropriate care and to discuss the possible range of clinical options. 52The Tribunal, however, while accepting the doctor has attended and finished all the appropriate retraining and updating, directed to the best practice and manner of clinical record keeping, is of the view the doctor should undergo an audit of her records now that she has had the opportunity to review her past unsatisfactory record keeping practices. 53Accordingly we do not order any practice conditions be placed upon the doctor. ORDERS 54We make the following orders: 1.The doctor is guilty of unsatisfactory professional conduct. 2.The doctor is reprimanded. 3.The doctor is to submit to an audit on her premises of a random selection of her medical records by a person or persons nominated by the Medical Council of New South Wales ("the Council") to assess her compliance with the relevant provisions of the Health Practitioner Regulation (New South Wales) Regulation 2010 (Part 4 and Schedule 2) and the RACGP's Standards for General Practices (3rd edition), in particular Standard 1.7 'Content of Patient Health Records' with particular attention to her assessment of patients and prescribing of anti-psychotic medication. 4.The audit is to occur within three months from the date of this Decision and subsequently at 12 monthly intervals, or as required by the Medical Council. The practitioner is to authorise the Auditor/s to provide the Council with a report on their findings. The practitioner is to meet all costs associated with the audit/s and any subsequent reports. 5.The Tribunal has ordered that there be a suppression order on the name of Patient A to be applied to all documentation including medical reports. 6.That Dr Ozme seek Accreditation of her Practice and the Council be notified when accredited. 7.Each party shall pay its own costs. 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: 13 July 2012