Civil and Administrative Tribunal New South Wales Medium Neutral Citation: Health Care Complaints Commission v Osborne [2014] NSWCATOD 118 Hearing dates: 8, 9, 10 September 2014 Decision date: 20 October 2014 Jurisdiction: Occupational Division Before: Sidis AJ, Deputy President Dr P Anderson, Professional Member Dr M Cox, Professional Member Ms J Houen General Member Decision: 1. The practitioner's registration is suspended for a period of six months commencing on the date that is 14 days from the date of publication of these Reasons. 2. Upon resumption of her practice following the period of suspension, the conditions listed in these Reasons are imposed on the practitioner's registration. 3. The Conditions may be altered, varied or removed at the discretion of the Medical Council of New South Wales and, pursuant to s 163 of the Health Practitioner Regulation National Law (NSW) 2009, the Medical Council is the appropriate review body. 4. The practitioner is to pay the Commission's costs of the proceedings. Legislation Cited: Health Practitioner Regulation National Law (NSW) 2009 Health Practitioner Regulation (New South Wales) Regulation 2010 Cases Cited: Health Care Complaints Commission v Do [2014] NSWCA 307 Law Society of NSW v Foreman (1994) 34 NSWLR 408 In re Dr Peter Keith [2000] NSWMT 12 Law Society of NSW v Walsh CA 40589/96, 15 December 1997 In re A Practitioner (1984) 36 SASR 590 Category: Principal judgment Parties: Health Care Complaints Commission (Complainant) Dr Lamorna Osborne (Respondent) Representation: Health Care Complaints Commission (Complainant) Avant Law Pty Ltd (Respondent) File Number(s): 1420091 Publication restriction: Order pursuant to Schedule 5D, clause 7 of the Health Practitioner Regulation National Law (NSW) that the names of the patients, whose treatment was the subject of the complaints, not be disclosed or published. reasons for decision 1The Tribunal conducted an inquiry into four of the five complaints brought by the Health Care Complaints Commission, concerning the professional conduct of Dr Lamorna Osborne, a practitioner registered under the Health Practitioner Regulation National Law (NSW) 2009. 2The complaints concerned the way in which the practitioner treated two elderly patients who were in the final stages of their lives. The Commission complained that the standard of treatment was such that the practitioner was guilty of unsatisfactory professional conduct and professional misconduct within the meaning of ss 139B and 139E of the National Law. 3The Tribunal orders, pursuant to Schedule 5D, clause 7 of the Health Practitioner Regulation National Law (NSW), that the names of the patients, whose treatment was the subject of the complaints, not be disclosed or published. 4The complaints asserted that the practitioner: COMPLAINT ONE Is guilty of unsatisfactory professional conduct under section 139B of the National Law in that the practitioner has: (i) engaged in conduct that demonstrates that the knowledge, skill or judgement possessed, or care exercised, by the practitioner in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience, and/or (ii) engaged in improper or unethical conduct relating to the practice or purported practice of medicine. BACKGROUND FOR COMPLAINT ONE At all relevant times the practitioner was a general practitioner and the treating doctor for Patients A and B who were residents of Pacific Heights Nursing Home (PHNH) in Sylvania. Patient A was admitted to PHNH in 2000 after suffering a stroke which left her in a permanent vegetative state. Patient A was 53 years old. In early December 2011 Patient A developed gangrene on one of her toes and a chest infection. On 7 December 2011 an End of Life Care Pathway was commenced. Patient A died on 11 December 2011 at approximately 1650 hours. Her Death Extract Certificate records cause of death "(I)(a) pneumonia, 1 week (b) cardiovascular accident, 11 years (II) gangrene of toe, 10 days." Patient B was admitted to PHNH in 2011 with Alzheimer's disease with aggression and behavioural difficulties and osteoporosis. She was 81 years old. Patient B died on 6 May 2012 at approximately 1220 hours. Her Extract Death Certificate records cause of death: "(I) peripheral vascular disease, 1 year (II) renal failure, 3 years (III) Alzheimer's disease, 12 years." PARTICULARS OF COMPLAINT ONE 1. On or around 6 or 7 December 2011 at approximately 1330 or 1430 hours the practitioner administered 5mg morphine intravenously and 15mg morphine intramuscularly to Patient A: (a) contrary to clinical guidelines that morphine should not be administered intravenously in a Residential Aged Care Facility; (b) failing to use the subcutaneous route of administration; (c) in a quantity in excess of the recognised therapeutic standards for: (i) palliative care; and/or (ii) a patient naive to opiates. 2. On or around 6 or 7 December 2011 at approximately 1330 or 1430 hours the practitioner ordered that 10mg of morphine be administered subcutaneously or intramuscularly to Patient A fourth hourly: (a) failing to limit the route of administration to subcutaneous; (b) in a quantity in excess of the recognised therapeutic standards for palliative care. 3. On or around 6 or 7 December 2011 at approximately 1330 or 1430 hours the practitioner ordered that 30mg of morphine be administered subcutaneously or intramuscularly to Patient A "PRN" ("as needed"): (a) failing to limit the route of administration to subcutaneous; (b) in a quantity in excess of the recognised therapeutic standards for palliative care. 4. On 11 December 2011 at approximately 1630 hours the practitioner increased Patient A's dose of morphine to 60mg morphine to be administered subcutaneously every two hours: (a) in a quantity in excess of the recognised therapeutic standards for palliative care; (b) without adequate or sufficient evidence that the increase in dosage was necessary or appropriate in the circumstances; (c) contrary to recognised therapeutic standards for increasing doses of morphine; (d) when this dose could have lead to opioid toxicity. 5. On 11 December 2011 at approximately 1630 hours the practitioner administered 60mg of morphine to Patient A intravenously: (a) contrary to clinical guidelines that morphine should not be administered intravenously in a Residential Aged Care Facility; (b) without adequate or sufficient evidence that the increase in dosage was necessary or appropriate in the circumstances; (c) in a quantity in excess of the recognised therapeutic standards for palliative care; (d) when this dose could have lead to or hastened the death of Patient A; (e) when the practitioner ought to have known that this dose could have lead to the death of Patient A. 6. On 3 May 2012 at approximately 1900 hours, the practitioner administered 30mg of morphine to Patient B intramuscularly: (a) in a quantity in excess of the recognised therapeutic standards for palliative care; (b) failing to use the subcutaneous route of administration. 7. On 3 May 2012 at approximately 1900 hours, the practitioner ordered 10mg of morphine be administrated to Patient B subcutaneously or intramuscularly every four hours: (a) when 4 hourly morphine administration was not indicated given Patient B's: (i) age; and/or (ii) renal failure. (b) in a quantity in excess of the recognised therapeutic standards for palliative care; (c) failing to limit the route of administration to subcutaneous. 8. On 4 May 2012 at approximately 0330 hours the practitioner increased Patient B's dose to 30 mg of morphine to be administered subcutaneously or intramuscularly every four hours: (a) in a quantity in excess of the recognised therapeutic standards for palliative care; (b) contrary to recognised therapeutic standards for increasing doses of morphine; (c) without adequate or sufficient evidence that the increase in dosage was necessary or appropriate in the circumstances; (d) without ordering appropriate "breakthrough" or "PRN" doses of morphine; (e) when 4 hourly morphine administration was not indicated given Patient B's: (i) age; and/or (ii) renal failure. 9. On 5 May 2012 at some time between 0330 hours and 1130 hours, the practitioner increased Patient B's dose to 60mg of morphine to be administered subcutaneously every four hours: (a) when it was likely that Patient B was suffering from opioid toxicity; (b) without adequate or sufficient evidence of increased pain; (c) in a quantity in excess of the recognised therapeutic standards for palliative care; (d) contrary to recognised therapeutic standards for increasing doses of morphine; (e) without ordering appropriate "breakthrough" or "PRN" doses of morphine; (f) when 4 hourly morphine administration was not indicated given Patient B's: (i) age; and/or (ii) renal failure. (g) When this dose could lead to or hasten the death of Patient B; (h) when the practitioner ought to have known that the dose could have lead to the death of Patient B. COMPLAINT TWO Is guilty of unsatisfactory professional conduct under section 139B of the National Law in that the practitioner has: (i) contravened a provision of the Health Practitioner Regulation (New South Wales) Regulation 2010 ("the Regulation"). BACKGROUND FOR COMPLAINT TWO See background for Complaint One. PARTICULARS OF COMPLAINT TWO 1.The practitioner failed to keep records of consultations with Patient A in accordance with clause 7 and Schedule 2 of the Regulation on: (a) 6 December 2011; (b) 7 December 2011; (c) 8 December 2011; (d) 11 December 2011. 2. The practitioner failed to keep records of consultations for Patient B in accordance with clause 7 and Schedule 2 of the Regulation on: (a) 3 May 2012; (b) 5 May 2012. 3. On 2 May and 6 May 2012 the practitioner consulted with Patient B and contravened clause 7 and Schedule 2 clause 1 of the Regulation in that the records for the consultations failed to adequately document: (a) the medical problems arising at each consult; (b) an appropriate management plan; (c) a rationale for medications prescribed; (d) a comprehensive diagnosis. COMPLAINT THREE is guilty of professional misconduct under section 139E of the National Law in that the practitioner has: (i) engaged in unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration, or (ii) engaged in 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. BACKGROUND FOR COMPLAINT THREE See background for Complaint One. PARTICULARS OF COMPLAINT THREE Complaints One and Two, including the particulars thereof, are repeated and relied on both individually and cumulatively. COMPLAINT FOUR Has an impairment within the meaning of section 5 of the National Law, being a physical or mental impairment, disability, condition or disorder (including substance abuse or dependence) that detrimentally affects or is likely to detrimentally affect the doctor's capacity to practice the profession of medicine. PARTICULARS OF COMPLAINT FOUR 1. The practitioner suffers from a depressive disorder. COMPLAINT FIVE Is not competent to practice medicine within the meaning of section 139(a) of the National Law. PARTICULARS OF COMPLAINT FIVE The particular of Complaint Four is repeated and relied upon. 5Complaint 5 was not pressed. 6The National Law provides in s 3A: In the exercise of functions under a NSW provision, the protection of the health and safety of the public must be the paramount consideration. 7This principle has guided the Tribunal in its consideration of the issues arising out of the complaints made against the practitioner in this matter. Unsatisfactory Professional Conduct 8The complaint required consideration of the following provisions of s 139B of the National Law: (1) Unsatisfactory professional conduct of a registered health practitioner includes each of the following: (a) Conduct significantly below reasonable standard Conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of the practitioner's profession is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience. ... (l) Any other improper or unethical conduct Any other improper or unethical conduct relating to the practice or purported practice of the practitioner's discretion or skill. Professional Misconduct 9S 139E of the Law provides: For the purposes of this Law, professional misconduct of a registered health practitioner means- (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. 10The practitioner admitted all of the particulars of Complaints 1 and 2. The inquiry before the Tribunal was therefore limited to the circumstances and seriousness of the admitted conduct and the determination of appropriate protective orders. BACKGROUND TO THE COMPLAINTS 11The practitioner was born in Scotland in 1957. She studied medicine at Glasgow University and in 1979 was awarded bachelor degrees in medicine and surgery. During a period when she lived in Zimbabwe she undertook further studies and gained qualifications in anaesthetics, practising in that field for a period, and then practising in paediatrics and accident and emergency in London and Edinburgh. 12The practitioner settled in Australia in 1988, working as a general practitioner on the Gold Coast until 2003. After moving to Sydney, she practised as a general practitioner in the southern suburbs of Sydney until she joined the Kirrawee Family Medical Practice in 2008. She remained in that practice to the date of the hearing. 13The practitioner's evidence that she undertook continuing education at an adequate and appropriate level was not challenged by the Commission. 14In the course of practice in Australia the practitioner's conduct in respect of two prior incidents was the subject of complaints. The first was dealt with by the Medical Board of Queensland and was substantially dismissed. The circumstances relating to this complaint were not relevant to the proceedings. 15The second complaint concerned an error made by the practitioner while changing a patient's medication from tablet to liquid form and involved the over prescription of Epilim. Notwithstanding the practitioner's assertion to the contrary, the Tribunal considered the practitioner's response to the complaint concerning this error to be relevant to the issues involved in the current complaints. 16The Kirrawee Family Medical Practice was operated by nine general practitioners who worked in variable shifts. The majority of the patients of the practice were elderly and some required home visits while others were inpatients of nursing homes. One of the nursing homes attended by the practitioners was the Pacific Heights Nursing Home where patients were offered high care, respite care and palliative care. 17It was the practitioner's treatment of two patients at the Pacific Heights Nursing Home that was the subject of the complaints. The major concern in each case was the quantity and method of administration of morphine given, on the practitioner's orders, to those patients both of whom were in the end stages of their lives and receiving palliative care. COMPLAINT ONE Patient A 18Patient A was admitted to the nursing home in 2000 after suffering a stroke that left her in a vegetative state. She had a tracheostomy and was fed through a PEG tube. Her limbs were severely contracted and she suffered recurrent chest infections that were treated with antibiotics and suctioning. Until 6 December 2011 the pain associated with patient A's contractures was treated with paracetamol. 19In early December 2011 patient A developed gangrene in one of her toes and a chest infection. In consultation with the patient's next of kin a decision was taken to cease active treatment. An End of Life Care Pathway form was completed on 7 December 2011 that noted that patient A was being palliated and that she was in severe pain associated with the gangrenous toe. 20Patient A was commenced on morphine on 7 December 2011. The first dose of morphine was 30 mg administered by the practitioner as 5 mg intravenously (iv) stat and 15 mg intramuscularly (im). Thereafter and until 11 December 2012, in accordance with the practitioner's directions, patient A was given morphine at the rate of 10 mg subcutaneously (sc)/im at four hourly intervals, three doses of 30 mg sc prn (or breakthrough) in lieu of the regular dose and one dose of 30 mg sc prn in addition to the regular 10 mg dose. 21On 11 December 2011 the practitioner increased the dose to 60 mg sc at two hourly intervals. At 4.30 pm on that date the practitioner ordered a stat dose of 60 mg of morphine which she administered by injection iv. Patient A was attended by a nurse for 10 minutes after this injection. At some time between 4.40 pm and 4.50 pm patient A died. 22Between 7 December 2011 and 11 December 2011, patient A received not less than 370 mg of morphine. Patient B 23Patient B was admitted to the nursing home in 2001 at the age of 80 years. She suffered from Alzheimer's disease with problems of aggression and from osteoporosis. In early May 2012 her condition deteriorated significantly with nursing notes recording that she was lethargic, sleepy and unable to swallow. Until this time patient B was provided with pain relief by means of a Norspan Transdermal Patch that delivered Buprenorphine at the rate of 15 g weekly and she received daily paracetamol. 24On 3 May 2012 the practitioner ordered that these medications cease and that morphine be commenced. The practitioner administered a stat dose of 30 mg of morphine im to patient B at 7 pm on 3 May 2012 and ordered 10 mg sc/im at four hourly intervals. The practitioner ordered two further increases in dosage: on 4 May 2012 the dose was increased to 30 mg at four hourly intervals and on 5 May 2012 to 60 mg at four hourly intervals. 25Five of the 60 mg doses were administered. The registered nurse who attended to patient B early on 6 May 2012 was concerned that her condition was such that a dose of 60 mg was not required. She spoke with the practitioner who authorised her to reduce the dose to 30 mg. 26Patient B died at 12.20 pm on 6 May 2012. 27The medication chart recorded that patient B received 600 mg of morphine between 3 May 2012 and 6 May 2012, of which 420 mgs were administered between 03:30 on 5 May 2012 and 11:30 on 6 May 2012. Peer Review 28Dr Lake provided comprehensive and thorough reports that were supported by a multitude of references. 29She accepted that morphine was clinically indicated for patient A on 7 December 2011 and she set out the considerations to be taken into account. Dr Lake noted that the End of Life Pathway Plan that formed part of her patient notes indicated that commencing doses of 2.5 mg at four hourly intervals were appropriate for a patient who, like patient A, was opioid naïve. 30Dr Lake was strongly critical of the practitioner's use of large doses morphine when treating patient A and of her failure to follow recommended guidelines when increasing dosages and when setting prn doses. She considered that it was inappropriate and unnecessary to increase the dose to 60 mg two hourly on 11 December 2011 and inappropriate and unnecessary to administer 60 mg iv on 11 December 2011, when the need for a dose in excess of that recommended by the guidelines was not indicated. 31In Dr Lake's opinion, this injection could have hastened patient A's death. 32Dr Lake was strongly critical of the means of administration of the initial dose of 5 mg iv and 15 mg im and of the administration of the final dose of 60 mg iv. She noted that the guidelines indicated the sc method of administration that, according to Dr Lake, was less painful than im administration and provided relief only a matter of minutes later than iv administration. 33Dr Lake's opinion was that, in respect of each particular concerning the treatment of patient A, the conduct complained of fell significantly below the standard that might reasonably be expected of a practitioner of the practitioner's level of training and experience. 34Dr Lake accepted that morphine was clinically indicated for patient B on 3 May 2012. She was concerned that the medical records indicated that patient B suffered from increasing renal failure and noted that the death certificate listed a three year history of renal failure as a cause of death. The records indicated that the practitioner was aware of this condition. In such circumstances, in her opinion, morphine should have been used in patient B's case less frequently or replaced with Hydromorphone. 35Dr Lake was strongly critical of the starting dose of 30 mg and of the four hourly dose of 10 mg because they were, in her opinion, excessive and contra-indicated in a patient with renal failure. She also considered the prn doses to be inappropriate. 36Dr Lake was also strongly critical of the administration of the initial dose im when the sc method was less painful. 37She was strongly critical of the increases in doses to 30 mg four hourly on 4 May 2012 and to 60 mg four hourly on 5 May 2012, stating that the increases were contrary to those recommended in the guidelines and there was insufficient evidence of severe pain to a level where doses in those quantities were warranted. 38In Dr Lake's opinion, the morphine administered to patient B between 3 and 6 May 2012 could have hastened her death. In the course of her cross examination, Dr Lake made it clear that, while doses of 60 mg were given on the practitioner's orders on 5 May 2012, the two doses administered by registered nurse Smith on 6 May 2012 were of 30 mg each. 39Dr Lake's opinion was that, in respect of each particular concerning the treatment of patient B, the conduct complained of fell significantly below the standard that might reasonably be expected of a practitioner of the practitioner's level of training and experience. 40In the course of cross examination Dr Lake agreed that there was no documented tool to assist the practitioner in determining the pain levels that patients A and B were experiencing and that each patient was unable to speak and therefore report the extent of her pain. She noted, however, that the practitioner had available, for assistance in this regard, the medical records and the reports of nurses and family members. The Practitioner's Response 41The practitioner admitted without qualification all of the particulars of the complaints relating to patient A and patient B. In the light of these admissions, it was unnecessary to canvas all of the evidence provided through the statements of the families of patients A and B and of the staff of the nursing home. 42The practitioner acknowledged that, as stated in the peer review, the doses of morphine prescribed and the methods of administration did not accord with recognised guidelines. She acknowledged that the guidelines indicated that the sc method of administration was preferred over im or iv methods when oral administration was not possible. 43The practitioner conceded that she did not consult the guidelines and that she made significant and serious errors that were critical to her practice involving, as it did, predominance in the treatment of the elderly. She said that at 7 December 2011 she was familiar with the doses appropriate to the care of the elderly and of the recommended doses and methods of administration appropriate to opioid naïve patients. She said that at the time she commenced patient A on morphine she ought to have known better. 44The practitioner's explanation for her conduct was that she made serious errors in the treatment of patients A and B at a time when she suffered from an unrecognised and undiagnosed Major Depressive Disorder that affected her judgment in exercising her functions as a general practitioner. COMPLAINT TWO 45Clause 7 of the Health Practitioner Regulation (New South Wales) Regulation 2010 requires a practitioner to make and keep a record or ensure that a record is made and kept for each patient. 46Schedule 2, clauses 1 and 2 of the Regulation specify the information to be provided in the record and the general requirements as to content. 47The aspects in which these requirements of the Regulation were not complied with were set out in detail in the particulars of Complaint Two. They related both to the absence of records and the quality of such records as were made. The practitioner's response 48The practitioner's statement contained admissions that she made no record of consultations on the dates specified in the complaint. She acknowledged that her records of consultations with patient B on 2 and 6 May 2012 were inadequate and that in respect of both patients A and B her record keeping was deficient. 49The practitioner said that it was her usual practice to make her records in the medical progress notes contained in patient files. She did not remember whether she made notes on the dates referred to in the particulars and relied on the state of her mental health to explain this absence of memory. 50At the hearing before the Tribunal the practitioner referred to the statement of the Executive Director of Nursing at the nursing home dated 14 December 2012 where the nursing home's systems for keeping records were described. The Executive Director stated that it was usual for general practitioners to record their visits in the medical progress notes, either by handwriting the notes or entering them in the Medical Director computer program. On occasions the general practitioner made no note. In such cases, the nurse noted the visit in the nursing notes. 51The statement explained that: We did have a glitch with the Medical Director system in around September this year, when we were installing infrastructure for a new computer system, and some information that had previously been entered on Medical Director was lost. I'm not sure whether (patient A or patient B's) records were affected, but I notice that there is no record of prescriptions issued for (patient A) after April 2011, and none for (patient B) after May 2011 - so this suggests to me that some of their records were lost. 52The practitioner relied on the explanation for the absence of records provided by the Executive Director of Nursing and said, further, that it was often difficult at weekends to access patient files because they were locked away and the registered nurse who held the key to the room that housed the notes was not always readily available. 53The medical progress notes produced in respect of patient A provided an apparently continuous record up to 6 December 2011. The note made on 6 December 2011 was reasonably comprehensive. There were no medical progress notes for the practitioner's visits to patient A on 7, 8 and 11 December 2011. 54The Tribunal accepted that, having regard to the evidence that some records were missing, it was not possible to conclude that the practitioner failed to make any record concerning those visits or to determine the adequacy of any record made. 55The medical progress notes produced in respect of patient B were continuous to 6 May 2012. The entry on that date followed immediately after entries for 4 April 2012 and 2 April 2012. There were no records for the consultations on 3 and 5 May 2012. Peer Review 56On the basis of the material with which she was provided, Dr Lake formed the opinion that the practitioner failed to document all visits to patients A and B and to document medical problems that occurred, her diagnosis and plan of management. In both cases, she considered the conduct complained of to be significantly below the standard reasonably expected of a practitioner of the partitioner's level of training and experience. 57The paucity of the practitioner's records of consultations at the nursing home prompted the Medical Council to direct that an audit be undertaken of the medical records that she maintained at her practice. The audit was undertaken on 16 August 2013. 58The auditor reported on 29 August 2013: Dr Osborne's medical records would enable another practitioner to take over the care of Dr Osborne's patients with relative ease and as such are consistent with the relevant provisions of the Health Practitioner Regulation (NSW) regulation 2010. 59The Medical Council accepted that no further review was required. COMPLAINT FOUR 60The practitioner said that she suffered from a depressive disorder in the period when she treated patients A and B. 61There was a history of mental illness in her family that affected her mother and father. Her brother suffered from schizophrenia and her sister from alcohol dependence. The practitioner's history was of episodes of depression in 1983 and 1998, at the time of relationship breakdowns, and of anxiety for which she was treated in 2008. 62The practitioner attributed the development of her depression in late 2011 to: (1)An unusually heavy workload in the second half of 2011. (2)The criminal conduct and attempted suicide of her brother in Scotland that caused her great distress and required that she travel urgently to Scotland to provide him with support and assistance. (3)The unsatisfactory nature of the relationship in which she was involved at the time. 63She said that, on her return from Scotland in November 2011, she experienced feelings of apathy, absence of enjoyment of life, irritability, low energy and loss of self esteem and social detachment and sadness. 64The practitioner reported these features to Dr Murray Wright, to whom she was referred for treatment in January 2013. He diagnosed a Major Affective Disorder with an episode of Major Depression that was likely to have been present at the time of the conduct that was the subject of the complaints. Dr Jonathan Phillips assumed treatment of the practitioner in April 2014 when Dr Wright took an extended period of leave. He agreed with Dr Wright's diagnosis, adding that there were co-morbid symptoms of fatigue, anxiety and panic. In Dr Phillips' opinion the practitioner's abnormal pattern of prescribing was likely to be the result of significant impairment in the emotional and cognitive domains. 65Dr Bruce Westmore examined the practitioner at the request of the Medical Council. He also agreed with the diagnosis. In the course of his evidence to the Tribunal Dr Westmore said that depression affected attention, concentration and judgment and therefore could lead to error. He thought these features might suggest a link between the practitioner's mental health and her over prescription of morphine. FINDINGS Complaints One and Two 66The Tribunal was not satisfied that the practitioner's conduct was solely attributable to the state of her mental health. There were two reasons for this conclusion. 67The first reason related to the practitioner's initial apparent confidence in her judgment concerning the doses of morphine prescribed to patient B. 68On 6 May 2012 a registered nurse at the nursing home questioned the prescription of 60 mg of morphine for patient B. Her concern was that she had never before been directed to administer 60 mg of morphine. She was particularly concerned because patient B appeared to be close to death and not in need of morphine at the level prescribed. The registered nurse provided a statement in which she said that in response to her query: Dr Osborne sort of started to tell me why it was okay. I think she said something about not letting the levels drop down and she said something about it was all right to double the dose every 24 hours. 69The practitioner agreed that she might have said this to the registered nurse. She confirmed that she agreed that the nurse should administer a dose of 30 mg. She said the nurse was experienced and she accepted her judgment as to what she thought was appropriate. 70The practitioner then spoke to the Director of Nursing at the nursing home. The Director of Nursing stated that the practitioner spoke to her about one of the staff who refused to give the increased dose of morphine and of the need for education of the staff. The practitioner said she intended that this education be provided both to nursing staff and to medical practitioners. 71This incident did not, however, prompt the practitioner to check any reference or guideline to confirm the correctness of the doses prescribed to patient B. 72Further, in response to the investigations undertaken by the Commission, the practitioner: (1)Acknowledged from the outset that she should not have administered morphine to patient A intravenously but maintained in the course of interviews on behalf of the Commission and at the hearing before the Medical Council that the doses of morphine given, while high, were not unacceptable in a palliative care setting; (2)Claimed that the doses given, both initially and their rate of increase, were based upon guidelines that were contained in patient notes at the nursing home but acknowledged that she did not consult those notes before adopting the doses administered to patients A and B; (3)Denied that the doses prescribed for patient B were erroneous. She said the rapid increases in doses were needed because patient B continued to suffer from pain; (4)Said that her rule of thumb was that, if the morphine was not effective, the dose could be increased by 25% to 50% in a 24 hour period; (5)In retrospect, conceded that the increase from 10 mg to 30 mg, or by 200%, was wrong. 73These aspects of the evidence indicated to the Tribunal that the practitioner thought the doses she prescribed were appropriate and it was therefore not necessary to consult the guidelines that she knew were available in patient A's file or through publications, written and on line. 74Further, it appeared that the practitioner failed to consult medical records when those notes would have informed the practitioner that patient A was opioid naïve and that patient B suffered from impairment of renal function, both factors to be taken into account in determining appropriate levels at which to administer morphine. 75The second reason for rejecting the claim that the conduct was solely attributable to the mental illness from which she suffered at that time was that it did not appear to have the extreme effect on upon the practitioner's functioning that Dr Phillips suggested was likely to have been the result of the illness. 76Dr Phillips said that, to commit such serious and significant errors in the prescription of morphine, the practitioner would have been seriously affected by illness. He said she would have suffered from cognitive disturbance leading to impairment of concentration, attention and memory; the capacity to marshal facts and make proper and balanced judgments and temporary impairment of executive function involving the prefrontal and frontal areas of the brain. 77The evidence suggested that the practitioner suffered from this illness from at least November 2011 until, with treatment from Dr Wright commencing in January 2013, her condition improved. 78The Tribunal did not accept that an illness, extending over such a lengthy period and resulting in the severity of impairment suggested by Dr Phillips, would have failed to exhibit features of aberrant behaviour in addition to that of over prescription in two isolated instances. The Tribunal expected that, in course of the Commission's investigation, evidence at least of some form of uncharacteristic irritability or impatience on the part of the practitioner might have been reported. 79The practitioner's statement that she was irritable and impatient was not supported by any of the substantial number of statements of the nursing staff of the nursing home and references provided by the practitioner's patients and colleagues, some of them working in her practice. 80Some of the references contained comments that acknowledged the referees' awareness of the stress, arising out of her personal and professional circumstances, under which the practitioner was working towards the end of 2011. One referee said: She showed visible signs of distress and loss of weight. Another referred to the extreme duress placed on the practitioner by her brother's circumstances and her handling of the under staffed medical practice in the winter months of 2011 and another to her comment upon her return from Scotland in November 2011 that: I have never been so stressed in all my life. 81None of the material before the Tribunal indicated that these stresses affected the practitioner's behaviour or the performance of her role as a medical practitioner. 82The Executive Director of Nursing at the nursing home stated: 20.... I spoke to all of the RNs and asked them if they had any concerns or problems working with Dr Osborne and if they felt uncomfortable. None of the RNs felt that they had any problems with Dr Osborne and the overwhelming feedback was that if they did have any problems, they felt that they would have been able to ring Dr Osborne. and 47... I have great respect for Dr Osborne as a GP as far as her compassion towards family and residents and her management. She's a very hands on GP and contactable and will make time to meet the families of residents. She will discuss with the family the resident's needs and expectations. 83Patient B's daughter, in her statement to the Commission's investigators, said: 14. I have no complaint about Dr Osborne's treatment of my mother and wish to thank her for her care of Mum over the years. I consider Dr Osborne to be a very kind, dedicated and caring doctor, who always took the time to answer my questions over the years regarding Mum's deteriorating health. 84In her reference patient B's daughter said: I knew Dr Osborne always had a very heavy workload because she was a popular, hardworking, dedicated and caring doctor greatly respected by patients, patient's families and medical colleagues. I read in the complaint that Dr Osborne has an impairment and suffers from a depressive disorder. In the five years that I have dealt with Dr Osborne closely, I have never seen any such disorders. 85The registered nurse who raised concern about the 60 mg dose of morphine prescribed for patient B said: 32. I've always thought Dr Osborne was a pretty good doctor. She's good to work with and she's approachable and she'll come in. They don't all do that. It was just that one day with (patient B) when I didn't feel that 60 mg of morphine was appropriate for her condition, and I talked to Dr Osborne about it. 86These examples were typical of the positive terms in which many of the witnesses and referees spoke of the practitioner's approach to her practice of medicine. While the comments describe a skilled, conscientious and caring medical practitioner, they did not describe one affected in the manner described by Dr Phillips. 87The Tribunal's findings are: (1)The Tribunal did not accept that the Major Depressive Disorder was the sole cause of the serious errors made by the practitioner in her prescription of excessive doses of morphine to patients A and B. It was the Tribunal's conclusion that, while the practitioner's mental health was a contributing factor, the evidence established that the practitioner lacked knowledge and skill concerning the prescription and administration of morphine in a palliative care setting and that she failed to consult readily available guidelines to determine recognised therapeutic standards. (2)The Tribunal finds the practitioner guilty of unsatisfactory professional conduct under s 139B of the National Law in that, in her treatment of patient A and patient B, the practitioner engaged in conduct that demonstrated that the knowledge, skill or judgement possessed, or care exercised, by the practitioner in the practice of medicine was significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience. (3)There was no evidence of improper or unethical conduct on the practitioner's part arising out of the circumstances giving rise to Complaint One. The Tribunal therefore made no finding in this regard. Complaint Two 88In the light of the evidence concerning the misplacement of medical records at the nursing home, the Tribunal made no finding in respect of the records relating to patient A. 89The Tribunal finds Complaint Two proved in respect of the records of patient B. The Tribunal finds the practitioner guilty of unsatisfactory professional conduct under s 139B of the National Law in that the practitioner contravened clause 7 and Schedule 2 of the Regulation in respect of the consultations with patient B on 3 and 5 May 2012 and clause 7 and Schedule 2, clause 1 of the Regulation in respect of consultations with patient B on 2 and 6 May 2012. COMPLAINT THREE 90The errors made by the practitioner were serious and significant to the extent that the Tribunal accepted that they could have hastened the deaths of patients A and B. Of particular concern was the practitioner's failure to check against accepted therapeutic guidelines that she was prescribing morphine in quantities that were appropriate to palliative care and to the particular needs of patients A and B. Her failure to do so was the result of her failure to exercise skill and judgment in checking her understanding of appropriate therapeutic doses against the guidelines. 91The Tribunal finds Complaint Three proved and finds the practitioner guilty of professional misconduct under s 139E of the National Law in that the practitioner: (i) Engaged in unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration. (ii) Engaged in 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. COMPLAINT FOUR 92The medical evidence clearly established that the practitioner suffered from a Major Depressive Disorder at the time of the conduct that was the subject of the Complaint. While the Tribunal did not accept that the disorder resulted in the serious symptoms described by Dr Phillips, the Tribunal was satisfied that, at that time, it detrimentally affected the practitioner's capacity to practise. 93The section of these Reasons that deals with protective orders explains the basis for the Tribunal's finding that the practitioner continued to the date of the hearing to suffer from this Disorder and that it was likely to detrimentally affect her capacity to practise. 94The Tribunal therefore finds Complaint Four proved and finds that the practitioner has an impairment within the meaning of s 5 of the National Law, in the nature of a mental disorder that detrimentally affected and is likely to detrimentally affect the practitioner's capacity to practise the profession of medicine. PROTECTIVE ORDERS 95The determination of the appropriate protective orders in the circumstances of these proceedings involved consideration of both the seriousness of the conduct that is the subject of the complaints and the extent to which the practitioner's mental health was likely to interfere with her capacity to practise in the future. 96On the issue of the practitioner's mental health, the Tribunal noted the agreement between the treating practitioners and Dr Westmore that the practitioner was fit to continue to practise provided that she did so on certain conditions. On 26 February 2013, following a hearing under s 150 of the National Law, the Medical Council imposed conditions that, with one minor amendment concerning the practitioner's hours of practice, continued to apply. The practitioner has complied with all of them. 97The practitioner urged the Tribunal to continue certain of those conditions while ameliorating their effect in some respects. The basis for this request was Dr Phillips' opinion that the practitioner was in full remission from the Major Depressive Disorder to the point where she no longer suffered from impairment as defined by the National Law. 98Dr Westmore, Mr Fox, the practitioner's treating psychologist, and Dr Dunn, her treating general practitioner, agreed with Dr Phillips that the practitioner's condition had improved significantly with the benefit of psychotherapy and anti-depressant medication. She had also withdrawn from her previously unsatisfactory relationship. 99Dr Westmore and Dr Phillips also agreed that the practitioner, having suffered from three episodes of depression at times of stress, remained vulnerable to further occurrences of her illness. The issue on which Dr Westmore and Dr Phillips disagreed was whether the practitioner's illness was in full or partial remission. Dr Westmore's opinion was that the practitioner had reached the stage of partial remission only. Dr Phillips' thought remission was total. Notwithstanding this difference of opinion, both Dr Westmore and Dr Phillips recommended the imposition of conditions that required that the practitioner's treatment continue indefinitely. 100Dr Phillips explained the apparent contradiction between his opinion and his recommendation that the practitioner continue to have ongoing treatment by reference to the need to monitor her condition to guard against recurrence. With respect to Dr Phillips, the Tribunal took the view that term remission could be distinguished from the term recovery. The Tribunal considered that the vulnerability of the practitioner to further episodes of depression when placed in situations of stress and the requirement that she be treated on an indefinite basis established that she continued to suffer from an impairment within the definition of the National Law. 101Dr Langeluddecke was also of the opinion that an element of ongoing monitoring was required to ensure that the practitioner remained fit to practise. 102The Medical Council referred the practitioner to Dr Langeluddecke for neuropsychological assessment. She reported on 18 November 2013 that the practitioner's cognitive functioning was reasonably well preserved for age and that she had sufficient cognitive resources to perform the duties expected of a general practitioner in a safe and efficient manner. Dr Langeluddecke noted, however, that tests demonstrated some weaknesses in the performance of higher order tasks and recommended that the limits on the practitioner's working hours and patient load be continued and that monitoring of her mood and stress levels continue in order to ensure that she remained emotionally stable and able to function cognitively at optimal levels. 103The major area of contention between the parties on the question of protective orders arose out of the Tribunal's finding of professional misconduct. The Commission contended that the circumstances that resulted in this finding warranted an order that the practitioner's registration be cancelled for a minimum period of two years or, in the alternative, registration be suspended for an appropriate period. The practitioner contended that, in the light of the successful treatment of her depression, it would be more appropriate to allow her to remain in practice on the conditions, with some modifications, imposed by the Medical Council. 104In support of its submissions the Commission pointed to those aspects of the practitioner's conduct that were very serious indeed. They included the administration of morphine intravenously in a nursing home facility; the significant extent to which morphine was overprescribed; the series of gross over prescriptions, particularly in the case of patient B, with no attempt to check the prescriptions against recognised and readily available guidelines; the contraindication of morphine in doses prescribed to patient A when she was opioid naïve and to patient B who suffered from renal failure; and the significant extent to which increases in doses failed to heed the principles relating to the titration of morphine. 105The Tribunal considered that there were two aspects of the evidence that were particularly troubling. The first was the practitioner's evidence that she did not relate her intravenous injection of 60 mg of morphine as a potential cause, 20 minutes later, of the death of patient A and that she did not reflect on the circumstances of patient A's death when prescribing morphine for patient B. The second was that these high doses of morphine could have hastened the deaths of both patients. 106The Tribunal was also concerned that the practitioner was unable to provide an acceptable explanation for her conduct. Her reliance on the state of her mental health as the sole cause of her mistakes was not supported by the evidence. To the contrary, the evidence indicated that, at the time of the prescription of morphine to patients A and B, the practitioner was confident that the doses prescribed were acceptable and she considered it unnecessary to consult readily available guidelines. 107The practitioner's failure to check her prescriptions against guidelines was of greater concern in the light of evidence that in June 2010 the practitioner, by mistake, prescribed Epilim in liquid form in twice the appropriate quantity. This error was the subject of a complaint that was dealt with by the Medical Council. In response to the complaint the practitioner admitted the error and wrote to the Medical Council on 30 March 2011: I subsequently reviewed my prescribing practices and prescribing guidelines. I carry out an NPS Quality Use of Medicines Audit every year. ... As a result of this error, I cross check the dose against any established guidelines after the prescription has been printed. 108The Medical Council responded on 2 August 2011 with the following advice: You would be wise to reflect on the reasons that this occurred and take steps to ensure that no such error occurs in the future. In accordance with your professional responsibilities, you are required to familiarise yourself with any medications prior to prescribing them. Prior to prescribing, particularly when changing the formulation of an existing medication, it is prudent to check that you are prescribing the correct medication at the appropriate dose. ... Please note that any future complaint will be considered in the context of your previous dealing with the Council, although individual, concluded complaints will not be reopened. 109Senior Counsel representing the practitioner pointed out that the commitment given in her letter of March 2011 related to prescriptions that were printed and that therefore were issued in the environment of the practitioner's surgery where guidelines could be accessed with relative ease. The Tribunal did not accept that a lower standard of cross checking could be expected of any practitioner in a nursing home environment, and particularly this practitioner in the light of the advice she received from the Medical Council a matter of months before the errors committed in prescribing for patient A. Legal Principles 110In addition to s 3A of the National Law, to which reference has already been made, s 3(2) of the National Law deals with the objectives of the national registration and accreditation scheme which include: (a) to provide for the protection of the public by ensuring that only health practitioners who are suitably trained and qualified to practise in a competent and ethical manner are registered; 111The paramount principle of protection of public health and safety has been the subject of much judicial consideration. In its argument in support of deregistration or suspension the Commission relied on the decision of the Court of Appeal of New South Wales in Health Care Complaints Commission v Do [2014] NSWCA 307 that dealt with the principles concerning the means by which the public is to be protected from professionals who are guilty of professional misconduct. Meagher JA, with whom Basten and Emmett JJA agreed, said: 35 The objective of protecting the health and safety of the public is not confined to protecting the patients or potential patients of a particular practitioner from the continuing risk of his or her malpractice or incompetence. It includes protecting the public from the similar conduct or incompetence of other practitioners and upholding public confidence in the standards of the profession. That objective is achieved by setting and maintaining those standards and, where appropriate, by cancelling the registration of practitioners who are not competent or otherwise not fit to practise, including those who have been guilty of serious misconduct. Denouncing such misconduct operates both as a deterrent to the individual concerned, as well as to the general body of practitioners. It also maintains public confidence by signalling that those whose conduct does not meet the required standards will not be permitted to practise. 112Justice Meagher, in support of this principle, cited the concern of Mahoney JA in Law Society of NSW v Foreman (1994) 34 NSWLR 408 at 441 that the protection of the public: ...extends also to the protection of the public against similar defaults by other solicitors and has, in this sense, the purpose of publicly marking the seriousness of what the instant solicitor has done. 113The emphasis in these decisions on factors or deterrence and public denunciation in the determination of appropriate protective orders did not, in the Tribunal's opinion, overrule the equally important principle that it is not imperative that the registration of a practitioner found guilty of professional misconduct be cancelled or suspended. In re Dr Peter Keith [2000] NSWMT 12 was a decision in which the Tribunal summarised the principles at [52] as follows: (a) The fact that the conduct in question is by definition sufficiently serious as to justify suspension or removal does not mean that the practitioner must be removed: HCCC v Karalasingham [2007] NSWCA [67] (b) The question of fitness to practise is to be determined as at the date of the hearing not as at the date of the conduct: A Solicitor v Council of the NSW Law Society (2004) 216 CLR 253 [21]; Prothonotary of the Supreme Court of NSW v P [2003] NSWCA 320. Although of course the nature and extent of the conduct in question is a significant aspect of the fitness to practise. 114Justice Beazley in The Law Society of NSW v Walsh CA 40589/96, 15 December 1997, cited the following from In re A Practitioner (1984) 36 SASR 590 where King CJ said: The proper use of suspension is, in my opinion, for those cases in which a legal practitioner has fallen below the high standards to be expected of such a practitioner, but not in such a way as to indicate that he lacks the qualities of character and trustworthiness which are necessary attributes of a person entrusted with the responsibilities of a legal practitioner. 115In this case, the evidence provided by the practitioner concerning her current fitness to practise was impressive and included: (1)expert evidence of the successful treatment of the Major Depressive Disorder to the point where the practitioner's treating practitioners and Dr Westmore agreed that, with appropriate conditions, her mental illness at the time of the hearing did not affect her capacity to practise and did not pose a threat to the safety of the public; (2)the practitioner's total compliance with the requirements of her treating medical practitioners and with the conditions of practice imposed by the Medical Council on 26 February 2013; (3)the very evident remorse and contrition displayed by the practitioner; (4)the admissions made from the outset in relation to patient A and in relation to patient B when the provisions of the guidelines were pointed out to the practitioner; (5)the reports of nursing home staff concerning the practitioner's above average levels of care and skill; (6)the references of patients and colleagues attesting in positive, even glowing, terms to her care and skill as a general practitioner; (7)the absence of evidence of unethical conduct or conduct that was improper in the sense that it was undertaken with malicious intent; (8)the practitioner's action in taking leave from her practice between December 2012 and June 2013, a period during which she conscientiously attended to her treatment and dealt with unsatisfactory aspects of her personal life; (9)the guarding against the recurrence of circumstances that might place the practitioner under extreme stress by limiting her hours of practice, ongoing treatment and monitoring of her mental health and the termination of the unsatisfactory personal relationship. 116The Tribunal also accepted that it was appropriate to address the paramount considerations of the health and safety of the practitioner's patients by imposing conditions upon the practitioner's continuing registration in order to guard against her vulnerability to the recurrence of episodes of Major Depression. 117The remaining question was whether her registration should be cancelled or suspended for a period as a mark of denunciation of the very serious aspects of her misconduct. 118The Tribunal decided that the positive features of the practitioner's response to the complaints did not sufficiently outweigh the consideration that the practitioner's misconduct demonstrated a level of incompetence, the consequence of which was that it could have hastened the deaths of two patients. This represented a serious departure from the standard of medical practice reasonably expected of a practitioner of her level of training and experience. For this reason, the Tribunal decided that, in order to serve the objective of maintaining public confidence in medical practice, a period of suspension of six months was warranted and that, on resumption of practice, the practitioner should be required to comply with the conditions set out in these Reasons. 119In order to allow for the orderly transfer of the practitioner's patients to the care of another practitioner, the period of suspension is to commence from a date which is 14 days after the date of publication of these Reasons. CONDITIONS 120There were relatively minor differences between the parties concerning the terms of the conditions that were appropriate. They accepted that the practitioner's weekly hours of work should continue to be restricted. The practitioner asked that she be allowed to practise for 35 rather than the current 32 hours per week. The Tribunal regarded this to be a reasonable request in the light of the agreement between the psychiatric experts concerning the extent to which the practitioner had recovered from her illness. 121Having regard to the considerable constraints imposed by the conditions overall, the Tribunal did not consider it necessary to require that the practitioner be placed on additional conditions requiring her supervision. 122The parties substantially agreed concerning health conditions. The Tribunal was satisfied that it was appropriate to continue to provide for three monthly reviews for the purposes of health conditions 6 and 7 and to allow for the Medical Council to vary periods between reviews when and if this became appropriate. COSTS 123The practitioner submitted that no adverse order for costs should be made against her in circumstances where there was unanimous agreement that she was fit to practise, she admitted the particulars of the complaints from the outset and she complied at all times with the requirements of treatment and with the conditions imposed by the Medical Council. 124The practitioner claimed that these were circumstance in which referral of the complaints to the Tribunal was not warranted. 125The Tribunal noted that s 145D(1) of the National Law imposes a duty on the Commission to refer a complaint to the Tribunal if it: ... forms the opinion that it may, if substantiated, provide grounds for the suspension or cancellation of a registered health practitioner's or student's registration. 126The Tribunal's finding that the practitioner's mental health was not the sole cause of her misconduct confirmed that the Commission's election not to exercise the discretion allowed for in s 145D(2) was well founded. 127In the circumstances, the referral of the complaints to the Tribunal was considered to be not only appropriate but a matter of legal obligation. 128The Tribunal also noted that, while the practitioner admitted the particulars of Complaints One and Two, she did not admit to unsatisfactory professional conduct or professional misconduct in circumstances where her departure from reasonably expected medical standards was significant and the potential consequences of her conduct were serious. 129The Tribunal concluded, therefore, that there was no basis upon which to depart from the general principle that, having succeeded in proving all of the complaints, the Commission was entitled to an order that the practitioner pay its costs of the proceedings. ORDERS 130The practitioner's registration is suspended for a period of six months commencing on the date that is 14 days from the date of publication of these Reasons. 131Upon resumption of her practice following the period of suspension, the following conditions are imposed on the practitioner's registration: Practice Conditions (1)Not to prescribe, possess, supply, administer, handle or dispense any drug of addiction (Schedule 8 drugs). (2)To practise no more than a total of 35 hours in any week. (3)Not to conduct any nursing home consultations. (4)Not to conduct any home visit consultations. (5)Not to undertake any after hours or on-call work. (6)Not work in or provide any palliative care. (7)To provide within 7 days of receipt of this Decision, a copy of her health and practice conditions signed by or on behalf of her current employer/s or practice principal or partners in the practice and authorise the employer, practice principal or partners to notify the NSW Medical Council of any issues arising in relation to compliance with these Conditions. In the case of any future employer, this must be provided to the NSW Medical Council within 7 days of commencing employment. (8)If employed in any capacity by a hospital, the practitioner must notify these health and practice conditions to the Director of Clinical Training (or equivalent) or Medical Director and Nursing Unit Manager of the Department/s in which she is practising and must forward to the NSW Medical Council, within 7 days of receiving the Tribunal's decision or within 7 days of commencing employment, a copy of these Conditions signed by each of these persons. (9)To inform her employer, Practice principal or partners of these health and practice conditions. (10)To advise the Council prior to changing the nature or place of her practice. (11)To authorise and consent to any exchange of information between the Council, Medicare Australia and the Pharmaceutical Services, Legal and Regulatory Services Branch (NSW Ministry of Health) where such exchange is necessary to facilitate the monitoring of compliance with these Conditions. Health Conditions (1)To attend for treatment by a general practitioner of her choice, at a frequency to be determined by the treating practitioner. To authorise the treating practitioner to inform the Council 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)To attend for treatment by a psychiatrist of her choice, at a frequency to be determined by the treating psychiatrist. To authorise the treating psychiatrist to inform the Council of failure to attend for treatment, termination of treatment or if there is a significant change in health status (including a significant temporary change). (3)To attend for treatment by a psychologist of her choice, at a frequency to be determined by the treating psychologist. To authorise the treating psychologist to inform the Council of failure to attend for treatment, termination of treatment or if there is a significant change in health status (including a significant temporary change). (4)To comply with all treatment recommendations from her treating practitioners, including any prescribed medication. (5)The extent of her professional medical duties is to be guided by her health status and the advice of her treating and Council approved practitioners. (6)To attend for review by a Council appointed psychiatrist on three monthly basis or as otherwise directed by the Council, at the Council's expense. (7)To attend a Review Interview with the Council within three months of the date of this Decision and then at a frequency to be determined by the Council. (8)To authorise the Council to forward copies of this Decision and any subsequent Council Review Interview or other reports and any other information relevant to her health and treatment to Council appointed practitioners and to her treating practitioners. 132These Conditions may be altered, varied or removed at the discretion of the Medical Council of New South Wales and, pursuant to s 163 of the National Law, the Medical Council is the appropriate review body. 133The practitioner is to pay the Commission's costs of the proceedings. ********** 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: 20 October 2014