Civil and Administrative Tribunal New South Wales Medium Neutral Citation: Health Care Complaints Commission v Nguyen-Phuoc [2015] NSWCATOD 81 Hearing dates: 25, 26, 27, 28, and 29 May 20158, 9,10 and 29 July 2015 Decision date: 07 August 2015 Jurisdiction: Occupational Division Before: F Marks ADCJ Dr L King (Professional Member) Dr S Howle (Professional Member) M Kelly (Lay Member) Decision: 1. We find the respondent guilty of professional misconduct under complaint four by reason of the findings made against the respondent in each of complaints one, one A, two, two A and three. 2. The proceedings are stood over for stage 2 hearing on 20 August, 2015. Catchwords: Medical practitioner practising complementary medicine - requirement to practice in conformity with orthodox medicine - held if practice of complementary medicine exposes patients to risk of harm or adverse consequences constitutes professional misconduct. Medical practitioner issuing prescriptions for medications while suspended constitutes professional misconduct Medical practitioner failing to maintain proper clinical records constitutes unsatisfactory professional conduct Legislation Cited: Health Practitioner Regulation National Law (NSW), ss 139B, 139E Health Practitioner Regulation (NSW) Regulation 2010, Schedule 2 Category: Principal judgment Parties: Health Care Complaints Commission (Complainant) Dr Bao-Quy Nguyen- Phuoc (Respondent) Representation: Counsel: W Hunt (Complainant) Solicitors: Health Care Complaints Commission (Complainant) B Nguyen-Phuoc (Respondent in person) File Number(s): 1420316 Publication restriction: Pursuant to Schedule 5D Clause 7 of the Health Practitioner Regulation National Law publication of the name of or any information which would identify the original complainant and another patient cared for by the Respondent is prohibited. Reasons for decision 1. These proceedings are constituted by a Further Amended Complaint. The complainant is the Health Care Complaints Commission which seeks findings of unsatisfactory professional conduct and professional misconduct against the respondent, a former registered medical practitioner, Bao-Quy Nguyen-Phuoc. 2. The complaint is in the following terms: FURTHER AMENDED COMPLAINT The Health Care Complaints Commission of Level 13, 323 Castlereagh Street, Sydney NSW, having consulted with the Medical Council of New South Wales in accordance with sections 39(2) and 90B(3) of the Health Care Complaints Act 1993 and section 145A of the Health Practitioner Regulation National Law (NSW) ("the National Law") HEREBY COMPLAINS THAT Dr Bao-Quy NGUYEN-PHUOC ("the practitioner") of Shop 71, Level 4 Ashfield Mall, 260 Liverpool Road, Ashfield NSW 2131 ("the Practitioner") being a medical practitioner registered under the National Law, COMPLAINT ONE Is guilty of unsatisfactory professional conduct under sections 139B of the National Law in that the practitioner has engaged in: (i) 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) any other improper or unethical conduct relating to the practice of medicine. BACKGROUND TO COMPLAINT At all relevant times, the Practitioner was working as a sole general practitioner in Greystanes until December 2010 when a Medical Tribunal ordered that the Practitioner work only in a group practice. From February 2011 the Practitioner was working at a medical centre called the Ashfield General Practice. On 16 March 2011, a Council appointed auditor conducted a review of twenty of the Practitioner's patient records and prepared a report dated 1 April 2011. PARTICULARS OF COMPLAINT ONE 1. Patient A consulted with the Practitioner on 1 September 2010, 1 December 2010, and 16 March 2011. 2. At the 1 September 2010 consultation with Patient A, the Practitioner: a) failed to conduct a comprehensive physical, cognitive and mental examination of the patient; b) failed to ensure that Patient A understood any medical information provided to him and/or proposed treatment alterations by the Practitioner; c) failed to obtain clinical information from the patient's treating specialists and his usual treating general practitioner; d) obtained from Patient A a signed consent form authorising no communication between the Practitioner and the patient's other treating specialists and general practitioner; e) failed to ensure that: (i) Patient A sufficiently understood the consent form before signing it; (ii) the patient's cognitive impairment did not compromise his ability to consent to the Practitioner's proposed treatment. 3. In managing, treating and caring for Patient A between 1 September 2010 and 16 March 2011, the Practitioner: a) failed to appropriately treat the patient's level of cortisol, referred to in a pathology report dated 1 February 2011, which was inadequate; b) ordered pathology tests including Candida serology and coeliac genetic testing, without reference to any evidence-based medical assessment or treatment protocol relevant to the patient's health conditions; c) proposed inappropriate treatment not founded on established medical principles and in the absence of sufficient clinical information. 4. Between May 2008 and March 2011, the Practitioner consulted with Patient B and during the course of care and treatment provided to the patient the Practitioner failed to include accurate patient information in a referral to Dr Julian dated 8 June 2010. 5. Between May 2010 and February 2011, the Practitioner consulted with Patient C and during the course of care and treatment provided to the patient the Practitioner: a) ordered Candida serology testing, without reference to any evidence-based medical assessment or treatment protocol relevant to the patient's health conditions; b) administered to the patient vitamin C and multivitamin B injections in the absence of an appropriate management plan and/or evidence of vitamin deficiency. 6. Between November 2010 and December 2010, the Practitioner consulted with Patient D and during the course of care and treatment provided to the patient , the Practitioner: a) ordered Candida serology testing without reference to any evidence-based medical assessment or treatment protocol relevant to the patient's health conditions; b) administered to the patient five parenteral vitamin C and multivitamin B injections in the absence of any vitamin deficiency; c) failed to adequately manage the patient's persistently elevated cholesterol levels. 7. Between November and December 2010, the Practitioner consulted with Patient E and during the course of care and treatment provided to the patient, the Practitioner: a) ordered Candida serology testing without reference to any evidence-based medical assessment or treatment protocol relevant to the patient's health conditions; b) treated the patient with thyroid extract despite the absence of clinical indicators; c) administered to the patient repeated parenteral vitamin C and multivitamin B injections without clinical indicators and/or vitamin deficiency. 8. Between September 2010 and February 2011, the Practitioner consulted with Patient F and during the course of care and treatment he ordered Candida serology testing without reference to any evidence-based medical assessment or treatment protocol relevant to the patient's health conditions. 9. Between January 2011 and February 2011, the Practitioner consulted with Patient G and during the course of care and treatment provided to the patient the Practitioner: a) diagnosed B12 deficiency in the absence of supporting biochemical evidence; b) ordered insulin pathology testing unsupported by peer-reviewed evidence; c) administered to the patient parenteral vitamin C and multivitamin B injections without a clear management plan and/or evidence of vitamin deficiency in the patient. 10. Between September 2010 and April 2011, the Practitioner consulted with Patient H and during the course of care and treatment provided to the patient, the Practitioner: a) ordered serology testing without reference to any evidence-based medical assessment or treatment protocol relevant to the patient's health conditions; b) failed to support a diagnosis of "low thyroid clinically" with any evidence-based laboratory reference; c) failed to obtain informed patient consent to the treatment using thyroid extract. 11. Between November 2003 and February 2011, the Practitioner consulted with Patient I and during the course of care and treatment provided to the patient the Practitioner ordered Candida serology testing without reference to any evidence-based medical assessment or treatment protocol relevant to the patient's health conditions. 12. Between January 2011 and March 2011, the Practitioner consulted with Patient J and during the course of care and treatment provided to the patient the Practitioner ordered for the patient: a) Candida serology testing without reference to any evidence-based medical assessment or treatment protocol relevant to the patient's health conditions; b) insulin pathology testing which is unsupported by peer-reviewed evidence. 13. Between April 2001 and January 2011, the Practitioner consulted with Patient K and during the course of care and treatment provided to the patient, the Practitioner: a) administered to the patient parenteral multivitamin B injections without evidence of patient consent; b) conducted an inadequate physical examination. COMPLAINT ONE A is guilty of unsatisfactory professional conduct under section 139B of the National Law in that the practitioner has: (i) whether by act or omission, contravened a provision of the National Law, or the regulations under the National Law or under the NSW regulations; (ii) engaged in any other improper or unethical conduct relating to the practice of medicine. PARTICULARS OF COMPLAINT ONE A 1. Between 1 September 2010 and 16 March 2011 the Practitioner consulted with Patient A and contravened Part 4 clause 7 and Schedule 2 of the Health Practitioner Regulation (New South Wales) Regulation 2010 ("the 2010 Regulation") in that he failed to record: a) a physical assessment for chronic liver disease in relation to hepatitis C; b) an assessment of the adequacy of treatment for Hypogonadism; c) his management of the patient's imbalanced adrenal function by noting the patient's weight, body mass index, body fat distribution, waist circumference, postural blood pressure measurement; d) a visual assessment or neurological assessment; e) a notation of an original head injury; f) adequate evidence of the patient's psychological and psychosocial history; g) an assessment of signs or lack of signs of thyroid disease or adequacy of current management; and/or, h) any clinical opinion reached by him. 2. The Practitioner contravened: Part 3 clause 5 and Schedule 2 of the Medical Practice Regulation 2003 (repealed) ("the 2003 Regulation") between May 2008 and 31 August 2008; Part 2 clause 4 and Schedule 1 of the Medical Practice Regulation 2008 (repealed) ("the 2008 Regulation") between 29 August 2008 and 30 June 2010; and Part 4 clause 7 and Schedule 2 of the 2010 Regulation between 1 July 2010 to March 2011 in that the Practitioner consulted with Patient B and failed to record: a) sufficient information concerning the patient's case to allow another registered medical practitioner to continue management of the patient's case; b) a clearly accessible summary of current medications, allergies, and medical problems; c) an accurate history for the patient; and/or, d) any evidence of advice about preventative healthcare. 3. The Practitioner contravened: Part 2 clause 4 and Schedule 1 of the Medical Practice Regulation 2008 between May 2010 and 30 June 2010; Part 4 clause 7 and Schedule 2 of the 2010 Regulation between 1 July 2010 and February 2011 in that he consulted with Patient C and failed to record: a) a management plan with respect to vitamin C and multivitamin B injections; b) an allergy assessment; c) notes as to information or advice given to the patient in relation to use by the practitioner of complementary therapies; d) written consent given by the patient to any treatment proposed by the practitioner; e) a satisfactory summary sheet; and/or, f) advice given to the patient in relation to preventative healthcare. 4. Between November 2010 and December 2010 the practitioner consulted with Patient D and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) sufficient evidence supporting the use of Candida serology testing; b) clinical indications in relation to five (5) parenteral vitamin C and multivitamin B injections; c) a satisfactory summary sheet; and/or, d) advice regarding preventative healthcare. 5. The Practitioner contravened: clause 13 and Schedule 2 of the Medical Practice Regulation 1998 (repealed) ("the 1998 Regulation") between 1 September 1998 and 31 August 2003; Part 3 clause 5 and Schedule 2 of the 2003 Regulation between 29 August 2003 and 31 August 2008; Part 2 clause 4 and Schedule 1 of the 2008 Regulation between 29 August 2008 and 30 June 2010; Part 4 clause 7 and Schedule 2 of the 2010 Regulation between 1 July 2010 and March 2011 in that he consulted with Patient E and failed to record: a) any informed patient consent in connection with the use of the unorthodox thyroid extract therapy; b) any clear clinical indication for repeated parenteral vitamin C and multivitamin B injections; c) a satisfactory summary sheet; d) regularly updated clinical summaries and/or, e) advice given to the patient in relation to preventative healthcare. 6. The Practitioner contravened: Part 2 clause 4 and Schedule 1 of the Medical Practice Regulation 2008 between May 2010 and 30 June 2010; Part 4 clause 7 and Schedule 2 of the 2010 Regulation between 1 July 2010 and March 2011 in that he consulted with Patient F and failed to record: a) adequate clinical notes related to the need for vitamin injections; b) the clinical reasons for using Tertroxin; c) the clinical reasons for recommending the use of Hysone; d) a satisfactory summary sheet; and/or, e) advice regarding preventative healthcare. 7. Between January 2011 and February 2011 the Practitioner consulted with Patient G and contravened Part 2 clause 4 and Schedule 1 of the 2008 Regulation in that he failed to record: a) information or advice given to the patient in relation to use by the practitioner of complementary therapies; b) written consent given by the patient to any treatment proposed by the practitioner confirming explanation of the need for use, risks, side effects and comparative costs; c) a satisfactory summary sheet; and/or, d) advice given to the patient in relation to preventative healthcare. 8. Between September 2010 and April 2011 the Practitioner consulted with Patient H and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) informed patient consent to treatment using thyroid extract; b) a satisfactory summary sheet; and/or, c) advice regarding preventative healthcare. 9. The Practitioner contravened: Part 3 clause 5 and Schedule 2 of the 2003 Regulation between November 2003 and 31 August 2008; Part 2 clause 4 and Schedule 1 of the 2008 Regulation between 29 August 2008 and 30 June 2010; Part 4 clause 7 and Schedule 2 of the 2010 Regulation between 1 July 2010 and February 2011 in that he consulted with Patient I and failed to record: a) necessary information such as allergies, ongoing medication, and past medical history; b) necessary and sufficient information concerning the patient's case to allow another medical practitioner to continue management of the patient's case; c) notes as to information or advice given to the patient in relation to use by the practitioner of complementary therapies; d) written consent given by the patient to any treatment proposed by the practitioner confirming explanation of the need for use, risks, side effects and comparative costs; e) a satisfactory summary sheet; and/or, f) advice given to the patient in relation to preventative healthcare. 10. The Practitioner contravened: Part 3 clauses 5 and Schedule 2 of the 2003 Regulation between April 2001 and 31 August 2008; Part 2 clause 4 and Schedule 1 of the 2008 Regulation between 29 August 2008 and 30 June 2010; Part 4 clause 7 and Schedule 2 of the 2010 Regulation between 1 July 2010 and February 2011 in that he consulted with patient K and failed to record: a) information in relation to this patient, including particulars of any medication prescribed and dosages and reasons for prescriptions for this patient; b) a satisfactory summary sheet; c) advice given to the patient in relation to preventative healthcare; d) patient consent for the administration of multivitamin B injections; and/or, e)particulars of a physical examination. 11. Between May 2010 and 30 June 2010 the Practitioner contravened Part 2 clause 4 and Schedule 1 of the 2008 Regulation and between 1 July 2010 and March 2011 the Practitioner contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he consulted with Patient L and failed to record: a) a satisfactory summary sheet; and/or, b) evidence of advice in relation to preventative healthcare. 12. The Practitioner contravened: clause 13 and Schedule 2 of the 1998 Regulation between May 1998 and 31 August 2003; Part 3 clause 5 and Schedule 2 of the Medical Practice Regulation 2003 between 29 August 2003 and 31 August 2008; Part 2 clause 4 and schedule 1 of the 2008 Regulation between 29 August 2008 and 30 June 2010; and Part 4 clause 7 and Schedule 2 of the 2010 Regulation between 1 July 2010 and March 2011 in that he consulted with Patient M and failed to record: a) sufficient information concerning the patient's case to allow another registered medical practitioner to continue management of the patient's case; b) a clearly accessible summary of current medications, allergies, and medical problems; c) any plan of treatment for the patient; and/or, d) any evidence of advice as regards preventable healthcare. 13. The Practitioner contravened: clause 13 and Schedule 2 of the 1998 Regulation between 1 September 1998 and 31 August 2003; Part 3 clause 5 and Schedule 2 of the 2003 Regulation between 29 August 2003 and 31 August 2008; Part 2, clause 4 and Schedule 1 of the 2008 Regulation between 29 August 2008 and 30 June 2010; and, Part 4 clause 7 and Schedule 2 of the 2010 Regulation between 1 July 2010 and March 2011 in that the Practitioner consulted with Patient N and failed to record: a) an updated medical summary within the clinical file; b) sufficient information concerning the patient's case to allow another registered medical practitioner to continue management of the patient's case; c) a clearly accessible summary of current medications, allergies, and medical problems; and/or, d) advice in relation to preventable healthcare. 14. Between August 2010 and October 2010 the Practitioner contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation by consulting with Patient O and failing to record: a) any discussion with the patient about the risks associated with his treatment, including osteoporosis and atrial fibrillation; b) the patient's consent to unorthodox treatment; c) a satisfactory summary sheet; and/or, d) advice regarding preventative healthcare. 15. Between September 2010 and February 2011 the Practitioner consulted with Patient Q and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) information or advice given to the patient in relation to any medical treatment proposed by him; b) any written consent given by the patient to the treatment proposed by the practitioner confirming explanation of the need for use, risks, side effects and comparative costs; c) a satisfactory summary sheet; and/or, d) advice given to the patient in relation to preventative healthcare. 16. Between October 2010 and May 2011 the Practitioner consulted with Patient R and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) sufficient information concerning the patient's case to allow another registered medical practitioner to continue management of the patient's case; b) a clearly accessible summary of allergies, immunisation, and ongoing management information; and/or, c) advice given to the patient in relation to preventative healthcare. 17. The Practitioner contravened: clause 13 and Schedule 2 of the 1998 Regulation between 1 September 1998 and 31 August 2003; Part 3 clause 5 and Schedule 2 of the 2003 Regulation between 29 August 2003 and 31 August 2008; Part 2 clause 4 and Schedule 1 of the 2008 Regulation between 29 August 2008 and 30 June 2010; Part 4 clause 7 and Schedule 2 of the 2010 Regulation between 1 July 2010 and March 2011 in that he consulted with Patient S and failed to record: a) adequate examination; b) clinical management plans; c) the patient's waist measurement, weight, BMI or waist/hip ratios in relation to a discussion of possible metabolic syndrome; d) any examination in connection with the administration of frequent parenteral multivitamin B injections; e) patient consent in connection with the administration of frequent parenteral multivitamin B injections; f) a satisfactory summary sheet; and/or, g) advice regarding preventative healthcare. 18. The Practitioner contravened: Part 3 clause 5 and Schedule 2 of the 2003 Regulation between November 2003 and 31 August 2008; Part 2 clause 4 and Schedule 1 of the 2008 Regulation between 29 August and 30 June 2010; Part 4 clause 7 and Schedule 2 of the 2010 Regulation between 1 July 2010 and February 2011 in that he consulted with Patient T and failed to record: a) sufficient information concerning the patient's case to allow another registered medical practitioner to continue management of the patient's case; b) particulars of any medication prescribed to the patient; and/or, c) advice regarding preventative healthcare. 19. The Practitioner contravened: Part 3 clause 5 and Schedule 2 of the 2003 Regulation between 1 September 1998 and 31 August 2008; Part 2 clause 4 and Schedule 1 of the 2008 Regulation between 29 August 2008 and 30 June 2010; Part 4 clause 7 and Schedule 2 of the 2010 Regulation between 1 July 2010 and February 2011 in that the Practitioner consulted with Patient U and failed to record: a) summaries in an easily accessible form; b) particulars of any medication prescribed for the patient; and/or, c) advice regarding preventative healthcare. COMPLAINT TWO Is guilty of unsatisfactory professional conduct under sections 139B of the National Law in that the practitioner has engaged in: (i) 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; (i) any other improper or unethical conduct relating to the practice of medicine. BACKGROUND TO COMPLAINT TWO At all relevant times, the Practitioner was working at the Ashfield General Practice, Ashfield NSW. On 10 April 2013 a Medical Council appointed auditor, as a required condition imposed on the Practitioner following proceedings under Section 150 of the National Law on 17 May 2011, conducted a review of eighteen patients seen by the Practitioner on four randomly selected dates from 25 July 2012. PARTICULARS OF COMPLAINT TWO 1. The Practitioner consulted with Patient V on two occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) ordered blood zinc level tests despite an absence of clinical indicators; b) failed to exercise appropriate clinical judgment by prescribing the drug hydrocortisone when the patient's cortisol blood test results were within the reference range; c) failed to exercise appropriate clinical judgment by prescribing the drug hydrocortisone in the absence of an appropriate management plan; d) failed to give appropriate information or advice in relation to the potential side effects of hydrocortisone; e) failed to appropriately monitor the effects of hydrocortisone therapy by ordering blood tests; f) failed to exercise appropriate clinical judgment by recommending intramuscular Vitamin D3 Forte injections in the absence of an appropriate management plan and/or clinical evidence of vitamin deficiency; g) prescribed progesterone cream in the absence of an appropriate management plan; h) failed to provide appropriate preventative health information or advice to adequately manage the patient's elevated cholesterol levels. i) failed to provide appropriate information or advice concerning the need for regular cervical cytology [pap smear]. 2. The Practitioner consulted with Patient W on four occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) failed to order investigative tests of the patient's immune function despite noting a diagnosis of "post viral auto-immune arthropathy" ; b) failed to adequately manage the patient's abnormal 'iron studies'; c) diagnosed "post viral auto-immune arthropathy" in the absence of any laboratory-based clinical evidence; d) failed to exercise appropriate clinical judgment by administering to the patient intravenous 'Myers cocktail' infusions in the absence of an appropriate management plan and / or clinical evidence of vitamin deficiency or compromised immune function; 3. The Practitioner consulted with Patient X on four occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) Diagnosed " hypothyroidism" in the absence of any laboratory-based clinical evidence; b) diagnosed an "iron deficiency" in the absence of any laboratory-based clinical evidence; c) failed to give appropriate preventative health information or advice to adequately manage the patient's elevated cholesterol levels; d) failed to exercise appropriate clinical judgment by recommending intravenous 'Myers cocktail' infusions in the absence of an appropriate management plan and/or clinical evidence of vitamin deficiency; e) ordered blood serum lipids and serum/glucose tests despite an absence of clinical indicators; f) failed to order analysis and culture of a specimen of sputum in investigating possible lower respiratory tract infection; g) diagnosed a pneumococcal infection without appropriate clinical indicators on examination; h) administered 1g of the drug Rocephin by intramuscular injection on one occasion contrary to the recommended dosage of 1 to 2g daily for between four to fourteen days. 4. The Practitioner consulted with Patient Y on six occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) failed to exercise appropriate clinical judgment by recommending intramuscular Ferrum H [iron] injections in the absence an appropriate management plan and/or clinical evidence of an iron deficiency; b) administered the drug Rocephin by intravenous injection on one occasion contrary to the recommended dosage of 1 to 2g daily for between four to fourteen days and / or in the absence of clinical indicators; c) failed to exercise appropriate clinical judgment by recommending intravenous 'Myers cocktail' infusions in the absence of an appropriate management plan and/or clinical evidence of a vitamin deficiency; d) failed to provide appropriate preventative health information or advice including annual immunisation against influenza and/or immunisation against pneumococcal pneumonia given the clinical history and age of the patient. 5. The Practitioner consulted with Patient Z on sixteen (16) Occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) diagnosed "borderline hypothyroidism" in the absence of any laboratory-based clinical evidence; b) failed to exercise appropriate clinical judgment by prescribing the drug Armour Thyroid despite the patient's thyroid function blood test results being within the reference range; c) failed to exercise appropriate clinical judgment by prescribing the drug hydrocortisone despite the patient's cortisol blood test results being within the reference range; d) failed to exercise appropriate clinical judgment by prescribing the drug hydrocortisone in the absence of an appropriate management plan; e) failed to exercise appropriate clinical judgment by prescribing intramuscular Vitamin B Forte injections in the absence an appropriate management plan and/or clinical evidence of vitamin deficiency; f) failed to exercise appropriate clinical judgment by recommending intravenous 'Myers cocktail' infusions in the absence of an appropriate management plan and/or clinical evidence of a vitamin deficiency; g) failed to manage the patient's elevated fasting glucose levels; h) failed to provide appropriate preventative health information or advice including an annual prostate examination given the clinical history and age of the patient's. 6. The Practitioner consulted with Patient AA on two occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) ordered plasma, zinc and red cell magnesium blood level tests despite an absence of clinical indicators; b) diagnosed "subclinical hypothyroidism" in the absence of any laboratory-based clinical evidence and/or any documented physical examination; c) failed to exercise appropriate clinical judgment by prescribing the drug Armour Thyroid despite the patient's thyroid blood test results being within the reference range; d) failed to support a diagnosis of "adrenal fatigue/exhaustion" in the absence of any laboratory-based clinical evidence; e) failed to exercise appropriate clinical judgment by prescribing the drug hydrocortisone when the patient's cotisol blood test results were within the reference range; f) failed to exercise appropriate clinical judgment by prescribing the drug hydrocortisone having regard to the patient's presenting clinical complaints including hypertension and hyperlipidaemia; g) failed to adequately manage or provide treatment for the patient's fasting insulin levels which the pathologist noted as consistent with insulin resistance; h) failed to provide appropriate preventative health information and advice including undertaking a dietary review given the clinical history of the patient; i) failed to implement an appropriate management plan for the patient. 7. The Practitioner consulted with Patient AB on three occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) diagnosed "subclinical hypothyroidism" in the absence of any laboratory-based clinical evidence and/or any documented physical examination; b) failed to exercise appropriate clinical judgment by prescribing the drug Armour Thyroid despite the patient's thyroid function blood test results being within the reference range; c) diagnosed "gluten syndrome HLA-DQ-2,2" in the absence of any laboratory-based clinical evidence. 8. The Practitioner consulted with Patient AC on nine occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) failed to conduct an adequate physical examination of the patient; b) diagnosed "subclinical hypothyroidism" in the absence of any laboratory-based clinical evidence and/or any documented physical examination; c) provisionally diagnosed "gluten syndrome" in the absence of any laboratory-based clinical evidence and/or any documented physical examination; d) failed to provide appropriate health information and advice to adequately manage the patient's elevated cholesterol levels; e) failed to provide appropriate preventative health information and advice including the need for a regular cervical cytology [pap smear]; f) failed to implement an appropriate management plan for the patient. 9. The Practitioner consulted with Patient AD on two occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) failed to exercise appropriate clinical judgment by prescribing the drug hydrocortisone having regard to the patient's diabetic status; b) failed to exercise appropriate clinical judgment by prescribing the drug hydrocortisone in the absence of an appropriate management plan; c) failed to provide appropriate preventative health information or advice including annual immunisation against influenza and/or immunisation against pneumococcal pneumonia given the clinical history and age of the patient. d) failed to implement an appropriate management plan for the patient. 10. The Practitioner consulted with Patient AE on fifteen occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) diagnosed "hypothyroidism" in the absence of any laboratory-based clinical evidence and/or any documented physical examination; b) failed to exercise appropriate clinical judgment by prescribing the drug Armour Thyroid despite the patient's thyroid blood test results being within the reference range; c) failed to exercise appropriate clinical judgment by recommending intramuscular Ferrum H [iron] injections in the absence of an appropriate management plan and/or clinical evidence of vitamin deficiency; d) failed to exercise appropriate clinical judgment by recommending intravenous 'Myers cocktail' infusions in the absence of an appropriate management plan and/or clinical evidence of a vitamin deficiency; e) failed to provide appropriate preventative health information and advice including the need for regular cervical cytology [pap smear]; f) failed to implement preventative health measures to adequately manage the patient's elevated blood lipid and cholesterol levels; g) failed to diagnose, manage or treat the patients elevated fasting glucose levels; h) failed to exercise appropriate clinical judgment by prescribing the drugs hydrocortisone, cortate, oroxine, armour thyroid, tertroxin and nilstat in the absence of an appropriate management plan; i) failed to implement an appropriate management plan for the patient. 11. The Practitioner consulted with Patient AF on three occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) failed to exercise appropriate clinical judgment by ordering blood zinc level tests despite an absence of clinical indicators; b)failed to exercise appropriate clinical judgment by ordering blood cortisol tests despite an absence of clinical indicators; c) failed to exercise appropriate clinical judgment by prescribing the drug hydrocortisone despite the patient's cortisol blood test results being within the reference range; d) failed to exercise appropriate clinical judgment by prescribing the drug hydrocortisone having regard to the patient's hyperlipidaemia; e) failed to give appropriate information or advice in relation to the potential side effects of hydrocortisone; f) diagnosed the patient with asthma without evidence of abnormalities on clinical examination of the respiratory system; g) failed to exercise appropriate clinical judgment by prescribing both the drugs seritide and symbicort concurrently for asthma; h) failed to exercise appropriate clinical judgment by recommending intravenous 'Myers cocktail' infusions in the absence of an appropriate management plan; i) failed to provide appropriate preventative health information or advice to adequately manage the patient's elevated cholesterol and triglyceride levels; j) failed to provide appropriate information or advice concerning the need for regular cervical cytology [pap smear]. 12. The Practitioner consulted with Patient AG on two occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) failed to exercise appropriate clinical judgment by ordering zinc, red cell magnesium, cortisol, insulin, androgens and CRP blood test levels without reference to any laboratory-based clinical evidence; b) diagnosed "hypothyroidism" in the absence of any laboratory-based clinical evidence and/or any documented physical examination; c) failed to exercise appropriate clinical judgment by prescribing the drug Armour Thyroid when the patient's thyroid function blood test results were within the reference range; d) failed to exercise appropriate clinical judgment by increasing the patient's current thyroid drug dosage by 50%; e) failed to provide appropriate information or advice concerning the need for regular cervical cytology [pap smear]. f) failed to implement an appropriate management plan for the patient. 13. The Practitioner consulted with Patient AH on two occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) diagnosed "hypothyroidism" in the absence of any laboratory-based clinical evidence and/or any documented physical examination; b) failed to exercise appropriate clinical judgment by prescribing the drug Armour Thyroid when the patient's thyroid function blood test results were within the reference range; c) failed to exercise appropriate clinical judgment by prescribing the drug hydrocortisone on the noted basis that it can "help augment thyroid function"; d) failed to exercise appropriate clinical judgment by prescribing the drug hydrocortisone in the absence of an appropriate management plan and / or any laboratory-based clinical evidence; e) failed to consider or recognise potential side effects and / or contraindications of therapy including the prescribing of hydrocortisone given the patient's diagnosis and treatment of superficial venous thrombosis; f) failed to implement an appropriate management plan for the patient. 14. The Practitioner consulted with Patient AI on two occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) diagnosed "hypothyroidism" in the absence of any laboratory-based clinical evidence and/or any documented physical examination; b) failed to exercise appropriate clinical judgment by prescribing the drug Armour Thyroid when the patient's thyroid function blood test results were within the reference range; c) failed to exercise appropriate clinical judgment by recommending intravenous 'Myers cocktail' infusions in the absence of an appropriate management plan and/or clinical evidence of vitamin deficiency; d) failed to provide appropriate preventative health information and advice including the need for regular cervical cytology [pap smear]; e) failed to implement an appropriate management plan for the patient. 15. The Practitioner consulted with Patient AJ on twelve occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) Failed to exercise appropriate clinical judgment in the prescribing of higher dosages of hydrocortisone despite the diminishing levels of the patient's natural cortisol blood levels; b) failed to exercise appropriate clinical judgment by prescribing the drug hydrocortisone and in the absence of an appropriate management plan; c) failed to exercise appropriate clinical judgment by over prescribing thyroid hormone supplements and in the absence of an appropriate management plan; c) failed to recognise, manage and treat the patient's thyrotoxic status; d) failed to exercise appropriate clinical judgment by administering intravenous 'Myers cocktail' infusions in the absence of an appropriate management plan and/or clinical evidence of a vitamin deficiency; e) failed to exercise appropriate clinical judgment by administering intramuscular Ferrum H [iron] injections in the absence an appropriate management plan and/or clinical evidence of an iron deficiency; f) failed to provide appropriate preventative health information and advice including: i. the need for a regular cervical cytology [pap smear]; ii. blood glucose monitoring; Iii. dietary and physical exercise advice given the clinical history and presenting clinical indicia of the patient; g) failed to consider or recognise possible side effects and / or contraindications of therapy given the patient's presenting symptoms and diagnosis; h) failed to implement an appropriate management plan for the patient. 16. The Practitioner consulted with Patient AK on two occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) failed to exercise appropriate clinical judgment by prescribing intramuscular Ferrum H [iron] injections in the absence an appropriate management plan and/or clinical evidence of a significant iron deficiency; b) failed to exercise appropriate clinical judgment by prescribing intramuscular Vitamin D3 Forte injections in the absence of an appropriate management plan and/or clinical evidence of vitamin deficiency; c) failed to provide appropriate preventative health information and advice including immunisation against HPV given the age of the patient; d) failed to implement an appropriate management plan for the patient. 17. The Practitioner consulted with Patient AL on one occasion between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) failed to exercise appropriate clinical judgment by ordering plasma, zinc, insulin, red cell magnesium, vitamin c and coeliac genetic blood level tests despite an absence of clinical indicators; b) failed to exercise appropriate clinical judgment by prescribing melatonin in the absence of an appropriate management plan; c) failed to implement an appropriate management plan for the patient. 18. The Practitioner consulted with Patient AM on two occasions between 25 July 2012 and 10 April 2013. During the course of care and treatment provided to the patient the Practitioner: a) failed to conduct an adequate physical examination of the patient including height, weight and lung function; b) failed to exercise appropriate clinical judgment by prescribing Vitamin B Forte injections in the absence of an appropriate management plan and/or clinical evidence of vitamin deficiency; c) failed to implement an appropriate management plan for the patient. COMPLAINT TWO A is guilty of unsatisfactory professional conduct under section 139B (b) and (i) of the National Law in that the practitioner has: (i) by act or omission, contravened a provision of the National Law, or the regulations under the National Law or under the NSW regulations; (ii) engaged in any other improper or unethical conduct relating to the practice of medicine. PARTICULARS OF COMPLAINT TWO A 1. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient V and contravened Part 4 clause 7 and Schedule 2 of the Health Practitioner Regulation (New South Wales) Regulation 2010 ("the 2010 Regulation") in that he failed to record: a) an accurate history for the patient including any physical and /or clinical examinations conducted; b) all relevant clinical diagnoses and findings; c) a clearly accessible summary of current medications, allergies, and medical problems; d) clinical reasons for prescribing vitamin D3 Forte injections; e) clinical reasons for recommending the use of hydrocortisone and the potential side effects of hydrocortisone treatment; f) a management plan in respect to the prescribing of hydrocortisone; g) a management plan in respect to the prescribing of progesterone; h) written consent given by the patient to any treatment proposed by the Practitioner; i) advice given to the patient in relation to preventative healthcare; j) information and advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; k) sufficient information concerning the patient's case to allow another registered medical practitioner to continue management of the patient's case; l) communication with the patient's other treating practitioners. 2. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient W and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) the patient's presenting symptoms; b) an accurate history for the patient including any physical and /or clinical examinations conducted; c) all relevant clinical diagnoses and findings; d) a clearly accessible summary of current medications, allergies, and medical problems; e) a management plan in respect to the prescribing of hydrocortisone; f) written consent given by the patient to any treatment proposed by the Practitioner; g) information and advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; h) sufficient information concerning the patient's case to allow another registered medical practitioner to continue management of the patient's case; i) communication with the patient's other treating practitioners. 3. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient X contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) the patient's presenting symptoms; b) an accurate history for the patient including any physical and /or clinical examinations conducted; c) all relevant clinical diagnoses and findings; d) a clearly accessible summary of current medications, allergies, and medical problems; e) clinical reasons for prescribing Ferrum - H injections and/or vitamin injections; f) information and advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; g) information or advice given to the patient in relation to the potential side effects of treatment; h) advice given to the patient concerning appropriate dosage of the drug Rocephin; i) information or advice given to the patient in relation to preventative healthcare; j) sufficient information concerning the patient's case to allow another registered medical practitioner to continue management of the patient's case; k) communication with the patient's other treating practitioners including specialist referrals. 4. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient Y contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) the patient's presenting symptoms; b) an accurate history for the patient including any physical and /or clinical examinations conducted; c) a clearly accessible summary of current medications, allergies, and medical problems; d) all relevant clinical diagnoses and findings; e) clinical reasons for prescribing vitamin injections; f) information and advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; g) written consent given by the patient to any treatment proposed by the Practitioner; h) information or advice given to the patient in relation to preventative healthcare; i) sufficient information concerning the patient's case to allow another registered medical practitioner to continue management of the patient's case; j) communication with the patient's other treating practitioners. 5. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient Z and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) the patient's presenting symptoms; b) an accurate history for the patient including any physical and /or clinical examinations conducted; c) a clearly accessible summary of current medications, allergies, and medical problems; d) all relevant clinical diagnoses and findings; e) a management plan in respect to the prescribing of hydrocortisone; f) clinical reasons for recommending the use of hydrocortisone; g) clinical reasons for prescribing vitamin injections and /or 'Myers cocktail' infusions; h) information and advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; i) particulars of any medication prescribed and dosages and reasons for prescriptions for this patient; j) information or advice given to the patient in relation to preventative healthcare; k) sufficient information concerning the patient's case to allow another medical practitioner to continue management of the patient's case; l) communication with the patient's other treating practitioners including specialist referrals; m) symptoms or signs of the patient's presentation despite noting a diagnosis of 'unstable angina'. 6. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient AA and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation by failing to record: a) the patient's presenting symptoms; b) an accurate history for the patient including any physical and /or clinical examinations conducted; c) a clearly accessible summary of current medications, allergies, and medical problems; d) all relevant clinical diagnoses and findings; e) the clinical reasons for recommending the use of hydrocortisone; f) a management plan in respect to the prescribing of hydrocortisone; g) informed patient consent to treatment using thyroid extract; i) information and advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; j) information or advice given to the patient in relation to preventative healthcare; k) sufficient information concerning the patient's case to allow another medical practitioner to continue management of the patient's case; l) communication with the patient's other treating practitioners. 7. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient AB and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) an accurate history for the patient including any physical and /or clinical examinations conducted; b) a clearly accessible summary of current medications, allergies, and medical problems; c) all relevant clinical diagnoses and findings; d) all investigative tests ordered and the results of same; e) information or advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; f) particulars of any medication prescribed and dosages and reasons for prescriptions for this patient; g) information or advice given to the patient in relation to preventative healthcare; h) sufficient information concerning the patient's case to allow another medical practitioner to continue management of the patient's case; i) communication with the patient's other treating practitioners. 8. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient AC and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) the patient's presenting symptoms; b) an accurate history for the patient including any physical and /or clinical examinations conducted; c) a clearly accessible summary of current medications, allergies, and medical problems; d) all relevant clinical diagnoses and findings; e) clinical reasons for prescribing vitamin injections and /or 'Myers cocktail' infusions; f) information or advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; g) written consent given by the patient to any treatment proposed by the Practitioner confirming explanation of the need for use, risks, side effects and comparative costs; h) clinical reasons for recommending the use of complementary therapies with the associated potential side effects of the treatment in light of the patient's history; i) information or advice given to the patient in relation to preventative healthcare; j) sufficient information concerning the patient's case to allow another medical practitioner to continue management of the patient's case; k) communication with the patient's other treating practitioners. 9. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient AI and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) the patient's presenting symptoms; b) an accurate history for the patient including any physical and /or clinical examinations conducted; c) a clearly accessible summary of current medications, allergies, and medical problems; d) all relevant clinical diagnoses and findings; e) clinical reasons for recommending the use of hydrocortisone; f) clinical reasons for prescribing vitamin injections and /or 'Myers cocktail' infusions; g) information or advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; h) information or advice given to the patient in relation to preventative healthcare; i) sufficient information concerning the patient's case to allow another registered medical practitioner to continue management of the patient's case; j) communication with the patient's other treating practitioners. 10. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient AE and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) an accurate history for the patient including any physical and /or clinical examinations conducted; b) a clearly accessible summary of current medications, allergies, and medical problems; c) all relevant clinical diagnoses and findings; d) clinical reasons for recommending Ferrum – H injections; e) clinical reasons for recommending the use of hydrocortisone; f) information or advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; g) information or advice given to the patient in relation to preventative healthcare; h) sufficient information concerning the patient's case to allow another registered medical practitioner to continue management of the patient's case; i) communication with the patient's other treating practitioners. 11. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient AF and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) the patient's presenting symptoms; b) an accurate history for the patient including any physical and /or clinical examinations conducted; c) a clearly accessible summary of current medications, allergies, and medical problems; d) all relevant clinical diagnoses and findings; e) clinical reasons for recommending the use of hydrocortisone; f) a management plan in respect to the prescribing of hydrocortisone; g) clinical reasons for recommending vitamin injections and /or 'Myers cocktail' infusions; i) information or advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; j) particulars of any medication prescribed and dosages and reasons for prescriptions for this patient; k) information or advice given to the patient in relation to preventative healthcare; l) sufficient information concerning the patient's case to allow another registered medical practitioner to continue management of the patient's case; m) communication with the patient's other treating practitioners. 12. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient AG and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) results of any physical and /or clinical examinations conducted; b) a clearly accessible summary of current medications, allergies, and medical problems; c) all relevant clinical diagnoses and findings; d) information in relation to this patient, including particulars of any medication prescribed and dosages and reasons for prescriptions for this patient; e) clinical reasons for recommending the use of thyroid extract; f) information or advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; g) information or advice given to the patient in relation to preventative healthcare; h) sufficient information concerning the patient's case to allow another registered medical practitioner to continue management of the patient's case; i) communication with the patient's other treating practitioners. 13. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient AH and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) an accurate history for the patient including any physical and /or clinical examination conducted; b) a clearly accessible summary of current medications, allergies, and medical problems; c) all relevant clinical diagnoses and findings; d) particulars of any medication prescribed and dosages and reasons for prescribing for this patient; e) clinical reasons for recommending the use of hydrocortisone; f) a management plan in respect of the prescribing of hydrocortisone; g) clinical reasons for recommending the use of thyroid extract; h) information or advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; i) reasons for investigative tests ordered; j) information or advice given to the patient in relation to preventative healthcare; k) sufficient information concerning the patient's case to allow another medical practitioner to continue management of the patient's case; l) communication with the patient's other treating practitioners. 14. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient AI and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) the patient's presenting symptoms; b) an accurate history for the patient including any physical and /or clinical examination conducted; c) a clearly accessible summary of current medications, allergies, and medical problems; d) all relevant clinical diagnoses and findings; e) clinical reasons for recommending the use of thyroid extract; f) information or advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; g) information or advice given to the patient in relation to preventative healthcare; h) sufficient information concerning the patient's case to allow another medical practitioner to continue management of the patient's case; i) communication with the patient's other treating practitioners. 15. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient AJ and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) the patient's presenting symptoms; b) an accurate history for the patient including any physical and /or clinical examination conducted; c) a clearly accessible summary of current medications, allergies, and medical problems; d) all relevant clinical diagnoses and findings; e) clinical reasons for recommending the use of hydrocortisone; f) a management plan in respect to the prescribing of hydrocortisone; g) informed patient consent to treatment using thyroid extract; h) clinical reasons for recommending the use of thyroid extract; i) clinical reasons for prescribing vitamin injections and /or 'Myers cocktail' infusions; j) particulars of any medication prescribed and dosages and reasons for prescribing for this patient; k) information or advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; l) information or advice given to the patient in relation to use by the Practitioner of complementary therapies; m) information or advice given to the patient in relation to preventative healthcare; n) sufficient information concerning the patient's case to allow another medical practitioner to continue management of the patient's case; o) communication with the patient's other treating practitioners. 16. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient AK and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) the patient's presenting symptoms; b) an accurate history for the patient including any physical and /or clinical examination conducted; c) a clearly accessible summary of current medications, allergies, and medical problems; d) all relevant clinical diagnoses and findings; e) clinical reasons for recommending Ferrum –H injections; f) information or advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; g) information or advice given to the patient in relation to preventative healthcare; h) sufficient information concerning the patient's case to allow another medical practitioner to continue management of the patient's case; i) communication with the patient's other treating practitioners. 17. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient AL and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) an accurate history for the patient including any physical and /or clinical examination conducted; b) a clearly accessible summary of current medications, allergies, and medical problems; c) all relevant clinical diagnoses and findings; d) particulars of any medication prescribed and dosages and reasons for prescribing for this patient; e) clinical reasons for recommending vitamin injections and /or 'Myers cocktail' infusions; f) clinical reasons for recommending the use of high dose intravenous vitamins; g) information or advice provided to the patient to enable an informed decision regarding conventional and complementary treatments; h) information or advice given to the patient in relation to preventative healthcare; i) sufficient information concerning the patient's case to allow another medical practitioner to continue management of the patient's case; j) communication with the patient's other treating practitioners. 18. Between 25 July 2012 and 10 April 2013 the Practitioner consulted with Patient AM and contravened Part 4 clause 7 and Schedule 2 of the 2010 Regulation in that he failed to record: a) an accurate history for the patient including any physical and /or clinical examination conducted; b) a clearly accessible summary of current medications, allergies, and medical problems and immunisations; c) all relevant clinical diagnoses and findings; d) clinical reasons for recommending high doses of vitamin C; e) sufficient information concerning the patient's case to allow another medical practitioner to continue management of the patient's case; f)communication with the patient's other treating practitioners. COMPLAINT THREE Is guilty of unsatisfactory professional conduct under sections 139B(1)(l) of the National Law in that the practitioner has engaged in improper or unethical conduct relating to the practice of medicine. BACKGROUND TO COMPLAINT THREE On 10 July 2013 the Practitioner's registration was suspended following proceedings under section 150 of the National Law. COMPLAINT THREE 1. Between 27 August 2013 and 30 April 2014 the Practitioner issued prescriptions for medications whilst his registration was suspended, as detailed in the attached Schedule A, to: a) Patient AN on 27.8.13 b) Patient AO on 30.7.13 c) Patient AP on 16.9.13 d) Patient AQ on 17.9.13 e) Patient AR on 21.9.13 f) Patient AS on 30.9.13 g) Patient AT on 30.9.13 on two occasions h) Patient AU on 3.10.13 i) Patient AV on 3.10.13 j) Patient AW on 3.10.13 k) Patient AX on 10.10.13 l) Patient AY on 10.4.14 m) Patient AZ on 30.3.14. COMPLAINT FOUR Is guilty of professional misconduct within the meaning of section 139E of the National Law in that he 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 his registration. BACKGROUND TO COMPLAINT FOUR As for Complaints One and Two and Three. PARTICULARS OF COMPLAINT FOUR Complaints One. One A, Two, Two A, and Three of this Complaint and the particulars thereof are repeated and relied upon, both individually and cumulatively. 1. The proceedings were contested, and the respondent was self-represented. Suppression Orders 1. An order was made under clause 7 of Schedule 5 D of the Health Practitioner Regulation National Law (the National Law) suppressing the names and any other information which would or which would tend to identify any patient of the respondent. A Two-Stage Hearing 1. With the consent of the parties the proceedings were conducted on a two-stage basis. These reasons for decision deal with the first stage, namely whether any of the complaints and particulars thereof brought against the respondent have been made out to the requisite standard, namely that we have been comfortably satisfied on the balance of probabilities that they have been so made out, based on the nature and extent of the evidentiary material. The Evidentiary Background 1. A great deal of documentary evidence was tended by the complainant and the respondent, exceeding 5000 pages. In addition a number of witnesses gave oral evidence on behalf of the complainant and the respondent gave oral evidence and was cross-examined. Some general background material which is included within the narration which follows is based on that evidence. 2. The respondent was first registered as a medical practitioner on 6 November 1989. His registration was ultimately suspended on 10 July 2013. On 6 February 2015 he voluntarily surrendered his registration, and is accordingly no longer registered as a medical practitioner. 3. The respondent's conduct first came to the attention of the relevant authorities on 6 January 2004 when a complaint about his prescribing practices was received by the then NSW Medical Board. A performance assessment was conducted later that year and his performance was found to be below the standard reasonably expected of a practitioner of an equivalent level of training or experience in a number of areas. A performance review panel enquiry was convened and an adverse finding was made against him on 24 June 2005. Following this conditions were imposed on the respondent's registration on 18 August 2005. A further performance reassessment conducted in March 2006 again found his performance to be below the relevant standard. Following a complaint about the respondent the Medical Board convened enquiries in September 2006 and further conditions were imposed on the registration of the respondent effective from 3 October 2006. A further performance review panel conducted in 2008 again found that the respondent's conduct was below the relevant standard. Following a complaint made to the Health Care Complaints Commission in March 2010 a reference was made to the Medical Tribunal which handed down a decision on 7 December 2010. The respondent was found guilty of professional misconduct and further conditions were placed on his registration. An examination of the decision of the Tribunal and other previous proceedings taken against the respondent will only be relevant in any stage 2 proceedings. 4. In essence, the respondent practices complementary medicine. This is said to be "a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine." (As defined by the National Centre for Complementary and Alternative Medicine"). Relevantly for the purpose of these proceedings complementary medicine will include the use of herbs, foods, vitamin C, minerals, and dietary supplements. The respondent said that he practised integrative medicine, which we understand to involve the blending of conventional and natural/complementary medicines and/or therapies "with the aim of using the most appropriate of either or both modalities to care for the patient as a whole. 5. On 1 July 2005 a Joint Position Statement was issued by the RACGP and AIMA. That Statement noted that a significant number of general practitioners in Australia either accessed or referred to alternative medical systems and complementary medicine for patients including acupuncture, chiropractic, hypnosis and meditation, and herbal remedies. It noted that there was "a growing interest in complementary medicine among medical specialties such as those of oncology, paediatrics, obstetrics and gynaecology, and rheumatology." 6. The Statement emphasised that there was concern "that patient outcomes should be critically evaluated and that medical practitioners and consumers should have information about potential benefits, potential adverse effects, and pharmaceutical/herb interactions." Furthermore, there was a need to become aware of the results of research designed to assess the effectiveness of complementary medicine and access to peer-reviewed medical journals and the like. It was said to be essential "that scientific research is carried out in such a way as to permit complementary medicine to be assessed on an evidence basis." Such a basis required the particular use of "current best evidence" in making decisions about the care of patients based upon scientifically established external clinical evidence as well as a practitioner's own clinical experience and clinical practice. 7. As will be seen, evidence was given in the proceedings by Dr Gary Deed, who practices complementary medicine as part of a general practice which he conducts in Queensland. He is a past president of the Australasian College of Nutritional and Environmental Medicine, a past member of the Advisory Committee of Complementary Medicine established through the TGA, a past president of Diabetes Australia and other similar organisations. It was the evidence of Dr Deed that a medical practitioner in general practice who practised complementary medicine was first and foremost a medical practitioner, and that his or her practice of complementary medicine must always be conducted in accordance with orthodox medical practice. 8. In his evidence, the respondent emphasised that he was an integrative and complementary doctor and that this was the focus of his practice in dealing with his patients. He said that his patients were always complex, and required a great deal of time to manage them. He contrasted his practice with a general practitioner who undertook a short consultation to fill a repeat prescription or to note briefly signs of a common illness. He said that most of his patients were usually tertiary educated, and professional or business people. They had usually seen "umpteen other doctors, GPs and specialists alike and now turned to us as a last resort. If it wasn't for us, these patients may have been lost to the medical profession altogether as they seek out naturopaths or homeopaths etc." 9. In evidence the respondent said that it was fundamental to his practice of medicine that he would not accept a patient as being "normal" and not requiring treatment merely because blood levels were within a normal range. In certain conditions, based on population studies there would be a wide range selected by pathologists as to what might be "normal." It was the approach of the respondent that he would endeavour to maximise the condition of the patient by striving to attain a result which was at the upper normal level, rather than being at the lower end of the normal range. As will be seen, this approach is not consistent in general terms with the practice of orthodox medicine and has led, in the particular circumstances of the complaints being considered in these proceedings, to the allegations made against the respondent. 10. In his defence, the respondent maintained that there were outcomes which he had achieved with particular patients which were in the "miraculous" category. He cited the circumstances of Patient O in the proceedings who had recurrent illnesses over a 15 year period and was said to have presented with problems with liver function, high cholesterol levels, headaches, dizziness, nausea, lack of concentration, chronic fatigue and the like necessitating constant attendance on a stream of specialist medical practitioners. She became bedridden every time she caught a cold. When he first saw this patient she was age 61. He commenced her on a regime of a Myers' cocktail infusions to boost her immune function and commenced a trial on Armour Thyroid Extract. The respondent noticed a dramatic improvement in her cholesterol levels and in the patient's hypothyroidism which he had diagnosed as subclinical. This was a condition which he said would be ignored by conventional medicine because the patient had shown a normal range of TSH. 11. In an extract of a letter forwarded by this patient to the respondent she said that she was now "over my illness thanks to this doctor and I highly recommend his treatment. All I have now is vitamin C powder, Zinc tablets and super Multi-vitamin C tablets. I am now very happy with my life as I can carry on normally with my daily functions at home and I am enjoying family life once again." 12. It was experiences of this kind that motivated the respondent to continue to practice medicine in this way. In support of his approach to his practice of medicine, the respondent relied upon a series of articles contained within a number of publications. Some of the authors clearly have postgraduate qualifications in medicine, and some have none. We have no information to assist us in assessing the provenance of the articles, the expertise and qualifications of the authors and whether and to what extent the expressions of opinion are appropriately scientifically based. The articles do, however, assist in understanding the approach of the respondent to the practice of medicine, particularly in the area of controversy which is at the heart of these proceedings. 13. Some of the articles deal with subclinical and sub laboratory hypothyroidism, their diagnosis and treatment with Armour Thyroid, a hormone replacement therapy which contains both T4 and T3. The orthodox practice of medicine advocates treatment by T4 only because T4 creates a reservoir from which the body can create T3. It appears that the use of thyroid hormone, as advocated by the respondent has its genesis in the work of a Dr Broda Barnes MD in the USA. Orthodox medicine recommends thyroid replacement therapy for patients with persistently elevated TSH levels. However, the alternative view followed by the respondent is that even where TSH levels are essentially normal, any ongoing symptoms such as tiredness can be assisted by administering thyroid replacement medication. In these circumstances a patient is said to be suffering from "subclinical hypothyroidism", a condition where the thyroid gland is only just keeping up with the needs of the body. To the extent that this condition is not capable of being revealed by standard pathology tests, it is also called "sub-laboratory hypothyroidism." The approach contended for by the respondent indicates that there are a number of conditions commonly associated with hypothyroidism including chronic fatigue, depression, dermatological conditions, asthma, hypertension and cardiovascular disease. The respondent acknowledged that his approach to the diagnosis and treatment of hypothyroidism was inconsistent with that of orthodox medical practitioners, but insisted that he was right, and they are wrong. 14. In general terms, the respondent asserted that he was a specialist in the area of gluten intolerance and coeliac disease. Furthermore, he firmly supports the use of an intravenous vitamin C and mineral formula for the treatment of a wide range of clinical conditions, known as a "Myers' cocktail." We have previously referred to a number of papers published in a variety of publications, primarily in the area of alternative or complementary medicine, in support of the approach to diagnosis and treatment in these areas as pursued by the respondent. 15. We should add that we do not regard these proceedings as being a forum for the determination of whether and to what extent the approach to treatment contended for by the respondent as he applied it to his patients is scientifically sound. In other words, we should not be taken to be making any general observations or pronouncements about the practice of complementary medicine outside the practice of the respondent as undertaken by the respondent. Our task is to determine whether, on the evidence before us, we can be comfortably satisfied that the complaints brought against the respondent are made out, and if so, what consequential protective orders are appropriate to be made. 16. The nature and extent of the controversy will become clearer as we discuss the circumstances of particular patients whose details are the subject of the complaints which we are considering in these proceedings. 17. Prior to the hearing commencing, the respondent had been directed to file such evidence that he wished to adduce in answer to the evidence filed by the complainant. Whilst the respondent did file some evidence directed to some specific issues by way of written narration, that material did not address in any detail most of the complaints which dealt with the circumstances of particular patients. We may have been entitled in the circumstances to allow the proceedings to continue on the basis that the respondent would be denied an opportunity of adducing any evidence in reply concerning the bulk of the allegations brought against him, but to do so would arguably deny him an opportunity to defend himself in circumstances where his future ability to be registered as a medical practitioner could be compromised. Another possibility was to grant an adjournment to allow the evidence to be adduced, but as the respondent had failed in this regard over a period of some months, there could be little confidence that he would attend to this matter in a timely manner. Perhaps, because the respondent had surrendered his registration, any delay would be to his detriment only. On balance, we took the view that overall it was more important to determine the proceedings as quickly as possible. To this end, much of the evidence of the respondent was given orally, with a less than desirable efficient use of resources, but, as acknowledged by the respondent, he has had an adequate opportunity to present his case. The respondent acknowledged also that all of the documentary material filed by him in the proceedings, and propositions put by him to expert witnesses by way of cross examination constituted either evidence or submissions made in support of his case. 18. Until 2010 the respondent practised principally alone as a sole practitioner. For most of this period he operated out of a surgery at Greystanes, where, over a period of about 11 years he treated some 5000 patients. He said that he saw 20 to 25 patients a day working Monday to Saturday. Practice conditions imposed by the Medical Council from 7 December 2010 required him to cease working as a solo General Practitioner within six months of that date and to practice only in an approved group practice. He then commenced working in a group practice at the Ashfield from March 2011 for about two years. Afterwards he commenced work at a group practice at 1A, The Strand, Croydon for about two weeks until his registration was suspended on 10 July 2013. As we have previously stated, the respondent voluntarily surrendered his registration on 6 February 2015. 19. Before commencing a detailed examination of the complaints, we note that in general terms they fall into a number of categories as follows: 1. Inappropriate conduct as a medical practitioner 2. This is the subject of complaints one and two 3. Failure to record necessary information 4. This is the subject of complaints one A and two A 5. Improper or unethical conduct in issuing prescriptions for medications while registration was suspended 6. This is the subject of complaint three 1. For completeness we note that the complainant asserts that the respondent is guilty of both unsatisfactory professional conduct and professional misconduct. If the latter allegation is found proven, the Tribunal is empowered to either suspend or cancel the registration of the respondent as a medical practitioner. The Circumstances of Patient A 1. This is a convenient starting point for an examination of the medical practice of the respondent, in the context of the allegations made against him. The circumstances of Patient A are included in particulars 1 to 3 of complaint one and particular 1 of complaint one A. 2. The complaint concerning Patient A was initiated by Dr Kathleen McCarthy, a rehabilitation physician in the Brain Injury Rehabilitation Service at Westmead Hospital. Dr McCarthy had been the treating rehabilitation physician of this patient since 1991 after he suffered a traumatic brain injury in 1989. He was left with significant physical disabilities, required a powered wheelchair for mobility, required significant support to manage living in his own home and "lacks insight into the extent of his cognitive impairment and underestimates the level of support he receives." He was under the care of an endocrinologist because he was suffering from traumatic panhypopituitrism. Dr McCarthy noted that he had remained on hormone replacement treatment for many years and was otherwise stable. In her letter of complaint dated 23 March 2011 Dr McCarthy said that this patient had attended the respondent in late 2010 and again in February 2011 having been convinced to do so by a female friend who was a patient of the respondent. She said that the respondent had initially told the patient to stop all his hormonal replacement therapy including cortisone and to take extracts of veal and pig thyroid. The respondent had done this without telling the patient's family practitioner or herself. 3. Dr McCarthy had no difficulty with the patient consulting another practitioner. However she said that "the issue is that, for a patient with a complex chronic medical condition with several specialists involved, (the respondent) made no attempt to find out (the patient's) status, nor contact any of his treating physicians and on the available pathology reports, clearly is unaware of several of (the patient's) disorders……. I consider that his health is at risk and that should he continue his treatment he will be at risk of death due to the overwhelming effects of panhypopituitary failure." 4. As part of its investigations into the conduct of the respondent the complainant had available to it his clinical and other records relating to Patient A. These records were also made available to Dr Gary Deed, who was asked to provide an opinion concerning the treatment by the respondent of a number of patients, including Patient A. For the purpose of providing his opinion Dr Deed was asked to comment on a number of aspects which he did in a report dated 28 December 2011, followed by a further report of 12 February 2012. 5. Dr Deed first commented about whether a thorough physical, cognitive and mental examination had been conducted on this patient before the respondent had changed his treatment or medication. Of course, Dr Deed only had available to him the respondent's medical records. From those records he was unable to conclude that a thorough physical cognitive and mental examination had been conducted. He commented that "there appears to be no awareness of clinical linkages between the history and examination. For instance there is no record of physical assessment for chronic liver disease in relation to the hepatitis C, no record of assessment of adequacy of treatment for hypogonadism, no record of adequacy of management of imbalanced adrenal function such as weight, body mass index, body fat distribution, waist circumference, postural BP measurement. There is no record of visual assessment or neurological assessment in view of the history of pituitary dysfunction. There is no documentation of the original head injury…. And I find no adequate evidence of a psychological and minimal psychosocial history. Finally there is no evidence of assessment of signs or lack of signs regarding thyroid disease or adequacy of current management." He thought that the respondent fell significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience. 6. Dr Deed was asked to comment on whether the patient would have been able to understand the proposed treatment to be given by the respondent. Before discussing his evidence, we need to refer to a consent form signed by this patient on the first occasion that he consulted the respondent. The form purports to authorise the respondent "not to contact any of my other treating doctors except in each instance directed by me specifically. I have been advised by (the respondent) that even if I elect not to have my treating doctors informed of the care and treatment being provided my decision may have to be overridden. This decision will be made by (the respondent) and is made on the basis that (the respondent) has a statutory duty to ensure that my health and safety is maintained." In oral evidence Dr Deed was asked to comment on the value of such a direction, and whether the respondent should have agreed to treat this patient on the basis of such a direction. Dr Deed was firmly of the opinion that with a patient with such a complex medical history and condition, it was essential to make contact with existing and former treating medical practitioners before embarking upon any form of treatment. If he had not be permitted to make contact with treating medical practitioners, Dr Deed would inform such a patient that he was unable to treat him. 7. Dr Deed had access to the report of Dr McCarthy. He relied on the opinion expressed in that report to conclude that the capacity of this patient to understand technical and complex medical information was reduced. He thought the patient would not have been able to understand fully the proposed treatment alterations. He regarded the form authorising non-communication as not constituting informed consent and as not obviating the need of the respondent to communicate with other doctors. He said "the existence of this form is not standard clinical practice and could easily be misinterpreted." He was of the opinion that the conduct of the respondent fell below the standard reasonably expected of a practitioner of an equivalent level of training or experience in failing to ascertain the level of understanding of this patient. 8. Subsequently, Dr Deed was given access to a report of Pauline Langeluddecke, a clinical psychologist who had carried out a neuropsychological assessment on the patient on 2 February 1996. 9. She concluded, on the basis of psychometric testing conducted about six years after the patient sustained a head injury that he was suffering from significant cognitive impairment "which is consistent with an acquired organic brain syndrome. His intellectual functioning is significantly diminished, from an (at least) low average level premorbidly to a borderline – mentally retarded level at the present time. Both his verbal and visuospatial abilities are impaired. He demonstrates mild-to-moderate impairment in immediate/short-term memory and marked impairment in his capacity for new learning. His attentional capacity is poor. Executive intellectual functions related to self-monitoring, adaptability, higher-level reasoning, and abstraction, and planning, and generativity are diminished." On the basis of the additional information furnished within this report Dr Deed modified his previous response. In failing to ascertain the level of understanding exhibited by this patient, the conduct of the respondent was significantly below that standard and he was strongly critical of the respondent. 10. Dr Deed was asked to give an opinion about whether the respondent should have consulted with the patient's treating specialist or next of kin before changing his treatment. Having regard to the notation in the respondent's clinical notes that this patient had complex and chronic clinical problems, Dr Deed was of the opinion that in making clinical changes in his management it was essential that the respondent obtained collateral clinical information from the treating specialists and the usual GP. The respondent's own notes indicated that he should have obtained greater clarity in history and examination to continue to provide medical services to this patient. This departure was significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience and invited the strong criticism of Dr Deed. 11. Dr Deed was of the opinion that the proposed treatment given by the respondent to this patient was not appropriate because of the lack of clinical history and the failure to carry out an appropriate examination. This failure invited his strong criticism. 12. When asked to comment on the success of the treatment regime afforded to Patient A by the respondent after reviewing pathology results Dr Deed made a number of observations: 1. The pathology results did not indicate any deterioration in thyroid function and he questioned the prescription of thyroid extract replacement 2. There was no criticism of increase in vitamin D supplementation 3. There was no criticism of the use of vitamin B 12 supplementation 4. A serum cortisol result indicated an inadequate level of this supplemented hormone. This should have been reassessed by the treating endocrinologists and the respondent's management in this area fell below the standard reasonably expected of a practitioner of an equivalent level of training or experience. 5. There was no indication or proper basis to carry out other pathology tests including Candida serology and coeliac genetic testing. The former is controversial. In oral evidence Dr Deed described the tests carried out by the respondent as "controversial, scientifically un-validated testing." 1. Dr Deed was asked to comment on whether the treatment afforded by the respondent was appropriate. He said that there was a recently published Statement from the Endocrine Society of Australia indicating that the use of thyroid replacement therapy was inappropriate. That Statement was attached to Dr Deed's report. However that publication post dated the treatment given by the respondent to this patient, and Dr Deed declined to criticise him accordingly. The Statement is issued under the name of Professor Peter Ebeling MD FRACP Chair on behalf of ESA Medical Affairs Sub- committee. Its contents are useful in understanding one of the controversies which is part of the substantive issues in these proceedings. It compares thyroid extract which was almost always used by the respondent to thyroxine, the product commonly prescribed by "most doctors." It notes that thyroid extract is commonly associated with alternative and complementary medicine practitioners. It is said to have been not pure, not approved by the TGA, not available on the PBS, not produced by a pharmaceutical company, not subject to existing TGA regulations, has limited quality control, and is marketed as a "bioidentical hormone", a marketing term. The statement describes a number of competing claims made with respect to both products. It is said that there have been no published controlled clinical trials, concerning thyroid extract "and most endocrinologists are concerned the superiority is due to a placebo effect or an effect of overtreatment." The statement calls for the exercise of caution when prescribing thyroid extract, and refers to concerns "because of the process by which many of them are made and the lack of quality controls. In particular, purity and dose equivalents with thyroxine and between different preparations are not regulated." The position of the ESA is that thyroid extract should not be used until appropriate testing has been published, quality assurance is adopted in its production and mandatory reporting of adverse events etc has been introduced. That Statement was published on 27 October 2011. 2. In cross-examination by the respondent Dr Deed was asked several times why he was so critical of the respondent for using thyroid extract rather than thyroxine. It was put to him that all the respondent had done was to change the medication from one form of medicine to another. Dr Deed gave an answer which it is worth quoting in full because it summarises what we perceive to be an appropriate and proper approach to the orthodox practice of medicine in contradistinction to the position constantly and continually maintained by the respondent throughout the course of these proceedings. Dr Deed said: "I think the pointy end of the argument dismisses the blunt stick attached to it. That this man had a complex chronic endocrine cognitive physical disorder and that as I go back over my previous statement that it behoves you, in a patient who's had specialist endocrine involvement over a period of time, pre-existing prior to your assessment and involvement with the patient, it behoves you to understand the context of his current therapy and to incorporate that in your thinking and communication with that specialist team before you change therapy. As (a) principle of quality general practice according to the standards of general practice, that's the operating model for which you should base your process on. So of the pointy end of the stick, changing thyroid (medication) as an element in a complex algorithm of interacting endocrine pathology, social, physical pathology, is contextually inappropriate." 1. Dr Deed was highly critical of the management by the respondent of inadequate cortisol levels reported on Patient A. He thought that there was a potential for significant harm to the patient and that there had been inadequate management of this circumstance by the respondent. This matter was the subject of amplification in oral evidence given by Dr Deed. The pathology result in early February 2011 indicated a cortisol level of 44, with the "normal" level being within a range of 138 to 650. Given the extremely low level in the context of this patient's brain injury and his long-standing adrenal support, this result should have spurred the respondent into taking urgent action. He should also have immediately made contact with the patient's treating endocrinologists. 2. Dr Deed pointed out that the respondent had diagnosed Patient A as suffering only from hypothyroidism and said that this was a cause of his cognitive impairment. Dr Deed rejected this assertion, particularly as no pathology result was suggestive that the patient was suffering from this condition. He did not think that it was clinically possible that the patient was suffering from hypothyroidism and he thought that the greatest possibility was that the patient had an acquired brain injury with pre-existing cognitive impairment before seeing the respondent. 3. It was suggested to Dr Deed by the respondent that a medical practitioner practising complementary medicine might seem to diagnose and treat conditions which were not necessarily accepted within orthodox medicine as being legitimate diagnoses. Dr Deed strongly rejected this proposition on the basis that a medical practitioner in general practice was first and foremost a general practitioner and that if he or she strayed from orthodox medicine such a person would be practising as a naturopath or a herbalist. 4. In evidence, the respondent said that he saw no need to undertake a cognitive examination of this patient because he was reviewing the current regime of treatment with his treating medical practitioners. The respondent said he was able to assess the patient's cognitive ability himself and the only change he made to the existing treatment regime was to prescribe Armour Thyroid in lieu of thyroxine. His other medication was outside his control. The respondent said in cross-examination that he now accepted that this patient was cognitively impaired on the basis of the specialist evidence but he then commented that the patient "changes from time to time." The respondent noted that the patient took himself off the medication which he had prescribed and blamed the patient solely for this but acknowledged the cognitive impairment factor. 5. The respondent referred to criticism by Dr Deed about his treatment of Patient A in failing to address the inadequate cortisol level of 44. The respondent noted that the patient had coped with this level for many years, and that Professor Carter had disagreed that this required urgent intervention. 6. The respondent conceded that he had not made a note of any head injury suffered by this patient. He further conceded that he had failed to record any clinical opinion about this patient. Patients B to T 1. There are common themes which apply to these patients and about which evidence was given by Dr Deed both in his written report and orally. In dealing with this evidence we shall also refer to the evidence of the respondent concerning each of these patients, to assist in evaluating whether and to what extent the complaints concerning these patients have been made out. 2. Dr Deed made the following general points in oral evidence: 1. The respondent said that he conducted testing for candida to see if there was a clear cut problem in the nature of "gut dysbiosis". Dr Deed said that there were more astute ways of looking for, and much more scientifically validated ways of assessing digestive symptoms. 2. There is no scientific validation to conducting coeliac gene testing which the respondent said he undertook as an exclusion test rather than a diagnostic test in order to exclude coeliac disease. Dr Deed thought that the appropriate diagnostic testing for coeliac disease should only be carried out where there were symptoms and a positive antibody test and elevation of certain antibodies. 3. The respondent put to Dr Deed that the patients who came to see him had complex and difficult problems. Dr Deed said that in those circumstances good general practitioners would be aware of the complexity and difficulty, and would "construct around them a system of chemical clinical care modelling, a process of well-documented clear clinical history taking, physical examination and clear management plan in and within areas of uncertainty and controversy it elevates one's responsibility to have even more careful processes such as recommended in the Medical Board guidelines to have consent forms, and full patient information in practising this form of medicine." 4. From his review of the records relating to these patients he found that "there was a degree of disorganisation without clear, necessary information that behoves a GP engaging in good quality general practice to maintain quality care…… and then the appropriation of the complementary medicine was not associated with a risk-benefit presentation to the patients documented as consents and then on occasions not associated with adequate diagnostic information or clinical examination and review. Any process, even in medicine, requires a management plan but when you're using therapies which, you know, if we're going to find the definition of complementary medicine, it raises the bar in a risk process that you are saying this is maybe controversial, it is not done by my peers, therefore I will apply a standard to be clearly transparent, articulate, wise, in my appropriation of that care which includes the documentation of consents, etc, as I've just outlined and the principles of general practice, examination, documentation of history and management planning and I don't see that as it runs through these patients." He pointed to the circumstances of Patient O as an example. Repeated testing showed normal thyroid function, yet the respondent prescribed thyroid extract replacement hormonal therapy. This was not only not orthodox medicine, but not even scientifically valid. This was not the practice of complementary medicine but a form of medicine which did not accord with the scientific principles of general practice. Furthermore, additional thyroid extract may have a potential for harm by increasing the risk of osteoporosis and atrial fibrillation. Patient O was aged 61, post menopausal, and therefore at some risk of developing or accelerating osteoporosis. 5. The level of use of parenteral, namely injectable, therapies is part of a risk framework. This is especially so as the administration of any substance from an injection carries a risk, even though small. The administration of injections of vitamins may cause complications. This requires evidence of informed consent. 6. The prescription of a thyroid extract in lieu of prescribing thyroxine should be the subject of informed consent because of concerns about manufacturing and standards of quality that exist outside of the regulatory framework for prescription medication. This is consistent with the Statement of the Endocrine Society of Australia. 7. A number of documents relied upon by the respondent to support his approach to the practice of medicine are in reality opinion pieces, some are old and not updated and in the expression of opinion are closer to philosophy rather than science. Dr Deed was asked to comment on an article relied upon by the respondent dated January 2003 published by the American Association of Clinical Endocrinologists. That article commenced by stating that over 13 million Americans with thyroid disease remained undiagnosed. Dr Deed pointed out that firstly the document itself was a newsroom press release and contained no clinical references. Furthermore, it is now out of date and inappropriate to rely upon it in terms of scientific evaluation. 1. In his response, the respondent said that he conceded all of the criticisms of Dr Deed regarding his record-keeping and in the area of controversy "like Candida or Insulin or Coeliac genetic testing for all my patients except for patient A as he is a special case." 2. In his report, Dr Deed made the following comments with respect to the remaining patients whose records were given to him for review. In dealing with each one, we have set out the respondent's response when made specifically for that patient. Patient B 1. The medical records were deficient in that an independent medical practitioner would not be able to provide medical services to this patient having read them. A referral letter wrongly showed current medications as nil and other significant history.as nil. The clinical records and clinical management were significantly below the relevant standard. 2. The respondent said this was a repeat referral for Medicare claim purposes . Patient C 1. There is no record of notation of allergy assessment. No reason was noted to order candida serology testing. There were repeated vitamin injections but no record of informed consent. Patient D 1. Candida serology testing is ordered without appropriate evidence in support. There was no clinical indication recorded for multiple vitamin C and multivitamin B injections. There was an absence of basic medical prevention associated with the persistent elevated cholesterol levels of this patient. 2. The respondent said that he was only a consultant and not the regular GP. Patient E 1. There was no appropriate evidence to support candida testing, there was use of thyroid extract without evidence of need on testing, there was no informed consent recorded for this unorthodox therapy, there were repeated injections of vitamin C and multivitamin B without a clear recorded clinical indication or deficiency. Patient F 1. There were repeated injections of intravenous vitamin C and intramuscular multi vitamin B without adequate clinical notes related to the clinical need (other than vitamin B12 deficiency recorded on one date). There is a notation of other treatments without clinical notation as to why they were being administered. Patient G 1. There is a notification of a diagnosis of B12 deficiency without any biochemical evidence in support. There was no evidence of informed consent for vitamin injections. Patient H 1. There was no evidence to support candida testing and no evidence of informed consent for the use of thyroid extract. Patient I 1. There was no evidence to support candida testing. Patient J 1. There was no comment. Patient K 1. A complex history was not adequately summarised. There was no evidence of informed consent for vitamin injections, and minimal records of physical examination. Patient L 1. There was a recorded diagnosis of alopecia and fatigue. The pathology results showed adequate levels of vitamin B12 and elevated RBC folate. Despite this the respondent gave vitamin B injections on seven occasions, and this treatment is controversial. Patient M 1. This patient had complex and chronic medical conditions. The patient required careful ongoing assessment. The records were poor especially with gaps in any clear medical summary of current medical conditions and medications or allergies. Patient N 1. There was no evidence of an updated medical summary within the file Patient O 1. There was no documentation of informed consent concerning the administration of thyroid extract replacement hormonal therapy, and such therapy is not usual in practice. Furthermore it increases the risk of osteoporosis and atrial fibrillation. Patient P 1. Records for this patient dated back to 1997. There was no clear regularly updated clinical summary. Patient Q 1. The same issues arose with respect to candida testing as applied to other patients. Patient R 1. The clinical records were disorganised with no clear presentation of necessary summary information. Patient S 1. Very poor documentation of examination and clinical management planning. There is frequent use of multi vitamin B injections without recorded consent or examination. Patient T 1. A complex history is not adequately summarised in an easily accessible form. There is poor documentation of medications and dosages and reasons for prescriptions plus possible adverse reactions. Patient U 1. A complex history is not adequately summarised in an easily accessible form, including medications and dosages and reasons for prescriptions. 2. We should say for completeness that during the course of his giving evidence it became clear that when furnishing his report, Dr Deed did not have available to him all of the relevant patients' records. Those records were later furnished to Dr Deed who subsequently reported that their contents did not cause him to alter the opinions which he had expressed. Dr A D W Patterson 1. Dr Andrew Donald William Patterson was retained by the HCCC to provide an opinion with respect to a number of patients of the respondent who were the subject of the complaints upon which these proceedings are based. Dr Patterson qualified in medicine in 1974. Between January 1978 and January 1991 he practised as a general practitioner in the Sydney area. Between January 1991 and November 2003 he undertook a variety of tasks for the Australian Defence Force and for the Navy. This work involved, inter alia, working as a medical practitioner. Since that time Dr Patterson has worked in a variety of areas, all associated with the practice of medicine. In 1997 he obtained Vocational Registration by the Royal Australian College of General Practitioners. 2. Two reports of Dr Patterson became evidence in the proceedings, and he gave oral evidence. 3. At the commencement of his oral evidence, Dr Patterson was asked to make some general observations about the conduct of the respondent. He first commented on the clinical records which he had examined. He said that there were "frequently gaps in the record, or indeed illegible records that made it difficult to understand how a particular diagnosis or form of treatment had been decided on." In making this comment Dr Patterson was conscious of the integrity of patient records in circumstances where another medical practitioner might be required to take over medical care. 4. Dr Patterson noted that there were frequent diagnoses of a sub-clinical hypothyroidism.. He used the term "subclinical" to indicate a lack of symptoms. Accordingly, if the pathology or other testing did not indicate the presence of a condition for which there were no symptoms, it is possible that the patient did not suffer from that condition. As an example, if a patient presented with complaints of tiredness and fatigue, this would not be subclinical. 5. There was, in the course of cross examination, an exchange between Dr Patterson and the respondent concerning the ability to diagnose hypothyroidism where TSH levels were within the normal range. It was the position of Dr Patterson that if blood test results were within normal range, then this would not assist in confirming any diagnosis. The respondent proceeded on the basis that he would endeavour to change the patient's blood levels to match the most favourable level within the range. Accordingly, he would continue to attempt to treat a patient even though blood test levels were within a normal range. 6. The respondent described a situation where the patient was receiving static treatment and had a total cholesterol level of 3 which was in the normal range. He administered hypothyroidism medication, took the patient off statins and although the cholesterol level increased by 50% it was still within normal range. The respondent asserted that this demonstrated that the medication which he administered for hypothyroidism was capable of lowering cholesterol levels. Dr Patterson said there was no scientific basis for such an assertion, and there may be other factors in play to explain the change in cholesterol levels. However, when referred to the particular clinical records of the patient concerned, Dr Patterson noted that the triglycerides level had moved from 1.3, within the acceptable range, to 2.4 which was above that range. He said that he would be concerned that the triglyceride level had almost doubled and that this would cause the patient to be at an increased risk of cardiovascular disease and an increased risk of pancreatitis. Furthermore, he said that the patient would need to retest in three months' time to check his LDL cholesterol level. 7. Dr Patterson included within his report a number of references which we consider are of assistance in understanding the essential controversy in these proceedings which centres around certain aspects of the manner in which the respondent practised medicine, and in particular by reference to his practice of complementary medicine. 8. The first reference is contained in a publication issued by Alphapharm, a pharmaceutical company concerning the product Hysone, which was regularly prescribed by the respondent. The document is entitled "product information" and was approved by the Therapeutic Goods Administration on 30 October 2007. It noted that the active ingredient of this substance is hydrocortisone, also known as cortisol. The publication, in common with publications of this kind lists a large number of precautions which should be exercised in the use of this product. Importantly, the publication states "adverse effects to corticosteroids may be produced by too rapid withdrawal or by continued use of large doses". In the list of adverse effects there is reference to fluid retention, congestive heart failure, muscle weakness, osteoporosis, adverse effect on the bowel, and many more. There are detailed instructions concerning dosage and the manner of administration. 9. The second publication is issued by Coeliac Australia in a "fact sheet" which we assume is intended to be read by the general public and by those interested in coeliac disease. Importantly, for the purpose of these proceedings, the document refers to the manner of diagnosis of coeliac disease. It says; "A diagnosis of coeliac disease should be confirmed by small bowel biopsy. Screening tests, including antibody blood tests and genetic tests, are not sufficient to diagnose coeliac disease. Blood tests are prone to error and the presence or absence of coeliac disease should never be based solely on a blood test result. Likewise a positive gene test result is not diagnostic; the genes for coeliac disease only indicate susceptibility and many people carry these genes without ever developing coeliac disease…." The publication lists other coexisting gastrointestinal disorders such as inflammatory bowel disease, large bowel cancer and infection. 10. A further publication entitled "diagnosing coeliac disease" issued by the Coeliac Society also refers to persons carrying a coeliac gene. The publication says in part; "Only one in 30 people who carry a coeliac gene will develop coeliac disease. Hence the gene test alone cannot diagnose coeliac disease. A gluten-free diet should never be commenced based on a positive gene test. A gluten-free diet should only be started after confirmation of coeliac disease by small bowel biopsy. The gene test is useful for excluding coeliac disease – a negative gene test effectively rules out coeliac disease….." 11. Dr Patterson was often critical of the respondent's clinical notes and records. The respondent pointed to the fact that Dr Patterson had been retained to examine his records for the period 25 July 2012 to 10 April 2013. Some of the patients had seen the respondent prior to 25 July 2012, and therefore Dr Patterson had not examined such detailed clinical records as existed at the time of the first consultation with these patients. Furthermore, the respondent had two sets of records, one consisting of his handwritten notes, and the other computerised records. He said that Dr Patterson had not looked at both sets of records and treated them together when analysing his records. On examination of some of the records, it became clear that there was some validity in these assertions of the respondent. Furthermore, the respondent pointed out that some of the matters referred to in the reports of Dr Patterson were facually incorrect, and upon examining the records, we agreed. We have concluded that it is unsafe to rely on the reports of Dr Patterson with respect to individual patients, save for 3, about whom the respondent was unable to demonstrate any relevant inaccuracy. They are Patients V, AA and AC. We shall deal with Dr Patterson's consideration of these patients' records and the respondent's response in turn. Patient V 1. There was no indication in the clinical records suggesting a need to order tests for zinc levels. The respondent said that he habitually did this for patients as a general screening exercise, and without there necessarily being any referable symptoms. 2. The respondent's clinical judgement in the interpretation of test results was incorrect. He prescribed hydrocortisone even though the early-morning cortisol level was within the normal range. In addition he recommended an intramuscular injection of vitamin D despite a normal level. There was no clinical indication for these treatments especially in view of well-known potential side effects. 3. The respondent relied on his general approach of treating cortisol levels even though within a "normal" range. The respondent said that because of either lower thyroid dysfunction or her body being "under stress" the patient needed a physiological dose of cortisol to improve the conversion of T4 to T3 and hopefully improve her complaints ranging from "the insomnia to the agitation to the fatigue, to the cholesterol elevation." He said it would also assist her borderline uric acid levels which were at the upper limit. As to the vitamin D, the respondent said that the patient's levels were at the lower end of the normal range. He wanted to increase them to the "optimal level", for "many reasons". Included in these reasons were diabetes and osteoporosis. He conceded that there were side-effects associated with excessive amounts of vitamin D but said that the intramuscular injections which he had given the patient were safe because only 1% or 2% of the population would start to get some cramps and milder toxicity symptoms. He said that he was "well versed" in this area, and that many of his patients chose intramuscular injections rather than taking a tablet every day. 4. It was put to the respondent during questioning from members of the Tribunal that the clinical notes showed a diagnosis of adrenal insufficiency even though this was based on a slight drop in blood pressure from a sitting to standing position. He conceded that he inserted this diagnosis on the computer records because upon prescribing Hysone he was only given a choice of diagnosing adrenal insufficiency and not improvement of thyroid function. He acknowledged that the computer program did not recognise the prescription of Hysone for thyroid function. 5. There was no evidence in the records that the respondent acknowledged or discussed with the patient the potential serious side effects of hydrocortisone treatment. Nor, on the records, did the respondent arrange for progress blood tests to monitor the effects of hydrocortisone. There was no reference in the records to an appropriate management plan for the prescription of Progesterone cream. 6. The respondent conceded that there was no written management plan in his records, but did state that there was mention in his records of Progesterone cream and that he was continuing treatment which had been commenced by the patient's GP. He agreed that there was no mention of arranging follow up blood tests, but said that it was his habit to do so. He said, in part, "her script was for 100 tablets ie would last for only 2 month (sic) and if she were to come back for more/for review, then would need to follow up blood test then." Even though the patient had elevated levels of LDL cholesterol there was no mention in the records of any recommended treatment. The respondent said that he was not the regular treating GP of this patient and she only came to him for a review "of her whole health". This required him to undertake a full set of testing. but she had already had had certain testing carried out by her treating GP, and this explained why there was no mention in the records of treatment for cholesterol or the need for regular Pap smear testing. 7. Overall, Dr Patterson assessed the conduct of the respondent as falling below the standard expected of a practitioner of an equivalent level of training and experience, including a complementary medicine practitioner, and this conduct invited his strong criticism. Patient AA 1. The respondent diagnosed subclinical hypothyroidism and adrenal fatigue in circumstances where thyroid function test and cortisol levels were within the normal range. A pathologist had noted a fasting insulin level consistent with insulin resistance and recommended a follow-up but there is no note of any such follow-up in the records. There is a record of the patient being offered thyroid supplements and hydrocortisone tablets, but there was no clinical indication for this treatment. The respondent offered the use of an inhaler, presumably to prevent asthma but there is no record of him having performed any lung function tests to assist in evaluating this treatment. There is no record of any appropriate preventative health care having been offered to this patient who suffered from gout, hypertension and hyperlipidaemia. 2. The respondent asserted that his diagnosis and treatment were justified in keeping with his practise of complementary medicine, and that he achieved a good outcome for this patient . His insulin had fallen and his "FBG went from 5.1 to 4.9." Patient AC 1. The clinical records note a number of complaints made by the patient but there is no mention of any presenting symptoms or diagnosis. The respondent made a provisional diagnosis of subclinical hypothyroidism and gluten syndrome. There is no indication of any clinical examination of the neck to check for the thyroid disorder or of the abdomen in the case of a gluten associated disorder. Some of the pathology tests were not relevant to these conditions. Furthermore these tests were ordered three weeks after similar tests had been conducted by another medical practitioner. The clinical notes failed to record some consultations, failed to record certain treatment and there is no evidence for the use of complementary medicine. There was no evidence in the clinical records of preventative healthcare including Pap smears and reviewing high cholesterol levels. Professor John Carter AO 1. During the course of the proceedings, and especially whilst receiving the oral evidence of Drs Deed and Patterson, it became clear that there was a fundamentally different learning, understanding and approach to the diagnosis, testing and treatment of conditions such as hypothyroidism and adrenal insufficiency between the respondent, on the one hand, and Drs Deed and Patterson on the other. The respondent emphasised that his understanding of the endocrinological basis for his approach and for the manner in which he practised complementary medicine came from the teachings of William McCormack Jefferies whom the respondent said was a well-known endocrinologist in the USA and had developed particular theories in these areas. Drs Deed and Patterson, in their evidence reflected their understanding of orthodox endocrinological medicine as they understood it to be practised in Australia. However, neither of them professed to have expertise in the area of endocrinology, whilst the respondent asserted that he did have the expertise, or at least, sufficient learning to rebut the opinions expressed by Drs Deed and Patterson. We were concerned that it was necessary to have recourse to expert endocrinological opinion and we asked the HCCC to retain an expert in this field. It was in these circumstances that Professor John Carter was asked to provide assistance to the Tribunal by way of a written report supplemented by oral evidence. 2. Professor Carter is a clinical professor in endocrinology at Sydney University and has been practising as an endocrinologist for 43 years. We proceed on the basis that he is eminently qualified and an expert in his field, and the respondent did not contend to the contrary. The Order of Australia was awarded to Professor Carter for his services to medicine. Professor Carter's report dated 22 June 2015 dealt with a number of issues which the Tribunal had asked to be considered. We shall deal with each of these issues, as set out in the report in summary form. 3. Professor Carter was first asked to consider in general terms the indications for prescribing oral hydrocortisone. Essentially he said that it is used for adrenal insufficiency, either complete or partial. It is also used as an anti-inflammatory agent and for other purposes which we need not consider. 4. Professor Carter was then asked whether a diagnosis of adrenal insufficiency could be precluded if blood levels were within the normal range for early morning cortisol. He said that an early morning cortisol level within the normal range did not preclude adrenal insufficiency but it could be excluded if there was a value in excess of 550nmol/L. If there was total adrenal insufficiency the early morning cortisol level would be below the lower limit of the normal range. Within the normal range, the higher the cortisol level, the less the chances of partial adrenal insufficiency being present. Professor Carter added that a single test for cortisol levels was insufficient to demonstrate a possible adrenal insufficiency, as practised by the respondent. Normal practice would involve serial testing. 5. Professor Carter said that a diagnosis of adrenal insufficiency was a recognised one and indicated that the adrenal glands were not capable of producing normal amounts of cortisol, either basally or when stimulated due to stress. He said that the definitive test to diagnose adrenal insufficiency was to perform a Short Synacthen Test. Cortisol should not be administered unless the results of this test indicated adrenal insufficiency. 6. Professor Carter thought that the addition of oral hydrocortisone to a patient with normal morning cortisol levels may have deleterious effects, particularly if higher doses are taken for longer periods of time. Oral hydrocortisone would cause suppression of pituitary ACTH production which could in turn have an impact on the production of adrenal androgens which play a role with respect to the integrity of collagen tissues and maintaining normal tissue fragility. Doses in excess of replacement dose of hydrocortisone can lead to Cushing's syndrome involving weight gain, high blood pressure, bruising, myopathy and osteoporosis. Furthermore, hydrocortisone can cause insulin resistance, can interfere with glucose metabolism and may precipitate diabetes in genetically predisposed individuals. There is no safe dose but side effects are less likely with lower doses than high doses. We note that this evidence, which we accept, is contrary to the approach taken by the respondent in practice in that he habitually prescribed hydrocortisone to patients with normal morning cortisol levels. The respondent debated, however, the level of hydrocortisone which he prescribed. Nevertheless, his general approach is inconsistent with the opinion expressed by Professor Carter. 7. Professor Carter said that generally speaking, in the case of doses of hydrocortisone including pharmacological doses that are high, doses can be ceased suddenly without deleterious effects if the length of administration is no more than four weeks. The longer a person has been taking 30 – 40 mg of hydrocortisone daily, the more likely it is that there will be adrenal insufficiency if the administration is stopped suddenly. He said this could manifest as low blood pressure, altered consciousness, vomiting and abdominal pain and could be fatal if untreated. There would be milder symptoms with lower levels of hydrocortisone such as marked lethargy and altered consciousness. He thought there should be a staged reduction of any dose of hydrocortisone. 8. Professor Carter was then asked to comment on the administration of hydrocortisone to some of the patients the subject of these proceedings. For this purpose Professor Carter was given a copy of some of the respondent's clinical notes. Despite having normal cortisol levels, patient Z was prescribed hydrocortisone by the respondent. Professor Carter said that he could see no reason to prescribe cortisone to this patient and there was no evidence biochemically of a diagnosis of adrenal insufficiency. Professor Carter could see no basis for diagnosing adrenal fatigue or exhaustion in the case of patient AA, and came to a similar conclusion in the case of patient AD. 9. Professor Carter was then asked to give an opinion about the use of thyroid extract rather than thyroxine. He said that it was not appropriate to use the extract and it would not be recommended because "the amount of active thyroid hormone is not as well standardised in the extract as they are in the thyroxine preparations." Despite this he said that the extract could be used as an alternative treatment for hypothyroidism. However, when TSH levels were normal it was not appropriate to prescribe thyroid extract unless the patient had a goitre or in other extremely rare situations. Any variation of TSH levels within the normal range did not generally indicate any need for adjustment by way of a dose of thyroid extract. Professor Carter did not think it appropriate to prescribe thyroid extract to a patient complaining of tiredness who had normal thyroid function studies. He said "one of the potential problems with prescribing thyroid extract in people with normal thyroid tests is that the TSH level could become suppressed and this can lead to a reduced bone density and thus increased risk of osteoporotic fractures in addition to increasing the chance of arrhythmias, particularly atrial fibrillation, developing." We note that these opinions support those expressed by Drs Deed and Patterson, and are contrary to the opinions and the practice of the respondent. 10. Professor Carter also commented on the administration of thyroid extract to patients who were the subject of these proceedings. Based on the records of the respondent he was of the opinion that there was no basis to administer thyroid hormone therapy to Patients Z or AA. In the case of patient AB Professor Carter noted that the clinical records contained no comment as to why a diagnosis of hypothyroidism was considered and there was no biochemical evidence of abnormally raised TSH level. 11. The respondent engaged in a great deal of cross-examination of Professor Carter in which the respondent endeavoured to explore his approach to the treatment of his patients. In that Professor Carter did not express any views contrary to those set out above, it is not profitable to examine this material in any detail. 12. However, we note that Professor Carter said that in the case of a normal person being prescribed 25 µg of thyroxine in a day no real damage would be done, provided the TSH level remained in the normal range, and even so there would probably be no real benefit to the patient. 13. Professor Carter was adamant that thyroxine had not been proven to improve subclinical hypothyroidism in a large number of double-blind placebo controlled trials. Accordingly if the thyroid levels were within normal range a medical practitioner should look for some other cause for complaints of tiredness and the like. Professor Carter said that he had treated some patients who had complained of tiredness with thyroxine, but solely because of a possible placebo effect. He did not disagree that those patients might feel better but not because of the thyroxine administered. However, Professor Carter was unable to say that any harm would have been suffered by any of the patients whose records he had reviewed. 14. In the course of reiterating that high levels of hydrocortisone could cause harm if used for more than four weeks, the respondent put to Professor Carter that he had prescribed 40 mg of hydrocortisone per day to "a lot of patients" none of whom had reported any problems, at least to him. Professor Carter thought that those patients were lucky not to have come under a stressful situation whilst under such a regime. Furthermore, suddenly stopping that treatment would be potentially very harmful to them. He said that putting patients on 40 mg a day for one year is potentially dangerous, would affect their immune response and make them susceptible to infections, protein breakdown and muscle wasting. Furthermore, if there was a genetic disposition there would be an increased risk of developing diabetes and if they were diabetic then this could make their condition worse. The respondent said that he had 100 patients that he was treating on 20 mg twice a day, making a total of 40 mg a day, who were abruptly taken off this medication when he was suspended from practice. He had other patients on the same regime who stopped suddenly. He was not aware of any patients suffering harm under these circumstances. 15. Professor Carter said that no endocrinological society of specialists anywhere in the world had recommended the use of thyroid extract, as utilised by the respondent, instead of thyroxine. Professor Carter also said that he had never heard of the "guru" upon whom the respondent so heavily relies, William McCormack Jefferies, but he had the impression that his teachings would not stand up to scrutiny. The understanding of endocrinology had moved on from the 1980s. 16. Professor Carter thought that the respondent did have an understanding of the control mechanism impacting upon the thyroid but his persistence in prescribing thyroid extract took him out of mainstream medicine and in doing so he was not following guidelines established by national bodies in Australia. He found it difficult to understand why the respondent persisted in prescribing thyroid extract rather than thyroxine. 17. Professor Carter thought that the respondent did not have a reasonable understanding of partial adrenal insufficiency and the need to clearly establish a diagnosis. No such diagnosis had been established in any of the patient records of the respondent that he had considered, notwithstanding that the respondent had so concluded. If in doubt the respondent should have administered a Short Synacthen Test. Furthermore, the respondent did not understand the issues involved in the process of conversion of T4 to T3. His knowledge in this area was incorrect in the context of the use of hydrocortisone. 18. Professor Carter said that the respondent should warn patients of the adverse effects of administering hydrocortisone and what to do if symptoms developed. He would make a note of this warning in his clinical records. If the respondent were to prescribe hydrocortisone for a long period, it would be mandatory to arrange a medical alert bracelet to be worn or for the patient to carry a card saying that she or he was taking hydrocortisone so that an injection should be given in the case of loss of consciousness. The respondent agreed that he should have arranged for a bracelet or card in appropriate cases, and that he had not done so. We note that this is not a matter the subject of any complaint in these proceedings. Matters Emerging From the Cross Examination of the Respondent 1. There are some matters of a general nature given in the evidence of the respondent to which we wish to make reference as they impact upon the matters referred to in the evidence of Drs Deed, Patterson and McCarthy and Professor Carter. 2. The respondent did not challenge the expertise of Dr Deed in his ability to comment on his conduct, although he did not accept the knowledge of Dr Deed about the practice of complementary medicine. He did not make any challenge to the expertise of Dr McCarthy as a rehabilitation physician or the undoubted expertise of Professor Carter. Notwithstanding the professed views of Professor Carter which he accepted as reflecting a conventional orthodox approach, the respondent nevertheless said that there were certain cases where thyroid extract was appropriate to be used and to this extent the approach of Professor Carter was incorrect. He regarded Professor Carter as having particular expertise in patients suffering from Addison's disease, rather than patients who had the mild symptoms which he usually saw. 3. The respondent said that he preferred literature which supported the practice of alternative medicine over orthodox medicine in the area of hypothyroidism and adrenal insufficiency. He asked this Tribunal to prefer his opinions to that expressed by other medical practitioners in the proceedings. He agreed that in not practising orthodox medicine, and in endeavouring to treat patients who had not been assisted by orthodox medical practice, he was embarking sometimes on a dangerous course, but said: "I have to help my patients". 4. The respondent agreed in cross-examination that he tended to ascribe similar problems to all of his patients because this is the type of patient who was attracted to his practice. 5. The respondent agreed that the use of a Short Synacthen test was the best way to assess whether a patient was suffering from adrenal insufficiency. He did not at any stage have such a test administered to any patient, although he accepted that he should have done so in some cases. He regarded the test as involved and difficult and it was usually administered in a hospital setting. 6. The respondent prescribed on average hydrocortisone of between 20 to 40 mgms per day. However these patients were continuing to produce normal levels of about 25 mgms per day. The respondent said that a dose of between 10 and 40 mgms will not suppress the adrenal gland. But, on the basis of the evidence of Professor Carter, this is incorrect. Even a small dose of 10 mgms per day could suppress normal adrenal function including adrenal androgen and mineralocorticoid production which may lead to adverse effects including dehydration, bruising of the forearms and osteoporosis. 7. Despite having surrendered his registration, and having previously been suspended, the respondent said that he had continued to treat his family members for common conditions such as the flu and for colds, and by giving them enemas and vitamin injections. He said that he would so continue, despite being given a warning by the Tribunal that in doing so he would arguably be in breach of the law, and the Tribunal could not be seen to be condoning conduct of this kind. Complaint 3 1. It is convenient to deal with the evidence concerning this complaint discretely. The complaint relates to prescriptions for medication furnished to 13 patients between 27 August 2013 and 30 April 2014 following suspension of the respondent's registration on 10 July 2013. The evidence is that the items dispensed consisted of predominantly thyroid extract capsules and to a lesser extent hydrocortisone and melatonin. There are a number of computer-generated scripts issued by the respondent which are in evidence. We do not understand the respondent to have argued that they were not issued by him on the dates shown. One of the scripts was issued on 27 August 2013, bearing the address of the Croydon medical practice at which the respondent had previously practised, namely 1A the Strand, Croydon. There are nine scripts issued between the period 16 September 2013 to 30 April 2014. These show an address of 6 Queen Street Croydon, the residential address of the respondent. 2. In written evidence, the respondent admitted having issued all of the scripts except three of them. With respect to one of them, patient AO, the HCCC withdrew any evidence, and we do not find this particular of the complaint proven. With respect to patients AY and AZ, the HCCC did not produce copies of the scripts, but relied on Medicare generated records providing details of dates of the scripts, the names of the patients and the substance prescribed. The respondent said that he did not issue these scripts, but had kept no records of any scripts issued while he had been suspended, so had no records to support his belief. We accept these business records as establishing the issue of these scripts by the respondent on the dates shown to persons who had clearly been his patients, for the supply of hydrocortisone. 3. In explanation, the respondent said that he had been suspended abruptly, that he had some 5000 patients on his books at that time and "they were all terrified that they cannot find another doctor to replace me who cannot at least provide the same prescription for their conditions." He said that he patiently explained to them over the phone that he was suspended, could not prescribe drugs, they should find a local doctor, and that any prescriptions issued would be "useless" because a chemist would be able to ascertain that his license to prescribe had been revoked. He said he endeavoured to find other practitioners for them who were trained complementary doctors. The respondent said that some of the patients had asked for him to write out a "sample script" so they could give it to their doctor, and others said they needed their "life-saving medication right now" and needed time to find a replacement doctor who would prescribe the same medication. The respondent admitted that he was wrong to issue the scripts and that he should have indicated that they were samples. By way of mitigation the respondent said that there were 5000 patients who were "desperate to have access to their life-saving medication continue uninterrupted" and "I did this to help my patients, first and foremost." 4. Of course, the respondent did not have anything like 5000 active patients at the time that he was suspended, as he conceded in evidence. 5. At first the respondent used prescription pads which he had obtained at the Croydon practice. He had the computer program used to generate the scripts installed on a home computer. At the time that he issued the scripts he did not have the original patient records because he was no longer practising at Croydon but he did have some notes on his computer and he kept patient records on a program which he had at home. He said that at the time of the issue of these scripts he was not treating these patients. The respondent said that after he left Croydon a former patient would call him and ask for a prescription. He acted only on the telephone request and did not take any clinical information from the patient, nor did he give any advice. The computer program on his home computer was changed by his wife so that the address shown on the scripts which were issued later showed as his home address. The respondent said that he should not have done this but he did it because it was important to give his patients the scripts. Changing the address was "the lesser of two evils" because otherwise he would have had to show the address at the Croydon practice. 6. In cross-examination the respondent was taken to one of the scripts which he had issued which showed a repeat. It was put to him that prescribing a repeat would not be compatible with issuing a script on an urgent basis to tide a patient over while finding another complementary practitioner. The respondent said in evidence that he had telephoned the pharmacist and asked that the repeat not be filled. This obvious fabrication presupposes that the respondent knew somehow the identity of the pharmacist where the repeat was going to be filled, and we regard the respondent as deliberately seeking to mislead the Tribunal in making this assertion. It was also put to the respondent that issuing scripts more than a month after his suspension was not indicative of an emergency situation. 7. In cross-examination the respondent was taken to an extract of accounts from a medical supply business for the period 24 July 2013 to 31 December 2013. He said that some of the items consisted of magnesium sulphate and sodium chloride. These items were for his own personal use and for his children and for his treatment of his family members. He thought that there were at least 20 family members including his children, parents, wife's parents and family. He gave treatment for simple colds and flu, and gave intravenous injections. He also used some of the bags which were attached to cannulas for the purpose of giving enemas. Between 24 July 2013 and 19 August 2013 he was either using or had used 100 sets for himself and his family members. On 19 August 2013 he reordered a further 100 sets. He said that his wife did the ordering, all for personal use, and that she was probably worried that she may not be able to order any more. He acknowledged that about 100 sets had been used in less than one month. The total cost of all these blood solutions sets was of the order of $900. In all he had ordered some 700 sets in the period of 12 months after he had been suspended. He said that in addition to his family some patients had wanted a caffeine enema and his wife may have sold some sets to patients wanting to use them for this purpose. Some General Observations Based on the Evidence 1. Counsel for the complainant submitted that there were a number of themes which could be applied to the conduct of the respondent as described in the evidence of Dr Patterson and we reproduce them verbatim from these submissions because they apply also to the evidence of Dr Deed; 1. There is a pattern of conduct in the diagnoses and treatment of hypothyroidism, unsupported by any clinical indications, including where relevant blood tests results were normal and within the reference range. 2. There is a pattern of conduct in the administration of Myers' cocktail infusions, unsupported by a clinical indication, including an absence of evidence of vitamin D deficiency. 3. There is a pattern of conduct in failing to provide appropriate preventative health care, including risk indicators such as age, sex and medical history. 4. There is a pattern of conduct in the diagnoses and treatment of iron deficiency, absent any clinical indicators, including where relevant blood tests were normal and within the reference range. 5. There is a pattern of conduct of poor record keeping, which was common to all patient records. 1. Each of the patterns of conduct described above needs to be qualified, based on the evidence given in the proceedings. The reference to clinical indications and an indicator referred to in (a), (b) and (d) is based upon the principles of orthodox medicine as advocated by Drs Patterson and Deed and by Professor Carter. For reasons which we shall shortly explore, we consider that it is appropriate for a medical practitioner professing to apply complementary medicine to first and foremost ensure that he or she is not exposing any patient to any risk of undue harm in the practice of complementary medicine where such practice differs from orthodox medical practice. 2. The asserted failure to provide appropriate preventative health care needs to be assessed in the context of the practice which the respondent undertook. Primarily he said that patients consulted him for specific advice and treatment in the realm of complementary medicine. For many of those patients the respondent did not become the primary health carer, and his practice was more in the nature of a specialist practitioner being consulted by patients about a particular problem or a particular treatment regime. The nature and extent of any obligation to provide preventative healthcare would depend upon the nature and extent of the relationship established between the respondent and the patient. The clearer the mutual understanding between them, the more likely that any appropriate boundaries could be fixed. Of course, the delineation of those boundaries would depend upon the dialogue between the respondent and the patient. One might arguably expect to see such a delineation reduced to writing. Unfortunately, many of the records lack the clear definition of the boundaries in the manner asserted by the respondent in evidence as representing his understanding of his relationship with a particular patient. Absent any indicia of informed consent as reflected in the patient records, the critical pattern of conduct identified in c above is more likely to have been established. 3. The evidentiary material which we have set out above has clearly exposed the differential approach to the practice of medicine in the areas which are the subject of these proceedings as exhibited by the respondent on the one hand, and orthodox principles of medicine on the other. As we have previously pointed out, if a medical practitioner practices medicine in a way which orthodox medicine says may be harmful to a patient then the practitioner will need to consider carefully all of the scientific evidence upon which his or her practice of medicine is based. It must be evidence which is scientifically evaluated and appropriately assessed. Of course, the greater the degree of scientific evidence, the more likely it is that the practitioner will, in reality, be practising orthodox medicine. The respondent has not demonstrated to us, applying the "ordinary standard", that is on the balance of probabilities, that there is an adequate scientific basis for the manner in which he practises complementary medicine where this is inconsistent with the orthodox approach which we have earlier described. 4. It is clear to us from the whole of the evidence that essentially the respondent is an intelligent, passionate man who cares deeply about his patients. He has developed a strong, but narrow, belief system which directs his clinical practice in a way that is inconsistent with orthodox Australian general practice. So much can be gleaned from the evidence of the expert witnesses given in the proceedings. 5. The respondent has used his knowledge of human physiology to create a belief in his interpretation of symptoms, signs and pathology reports that is out of step with his peers in general practice. He uses references which are often not peer-reviewed, but are opinion pieces, whilst ignoring more rigourous references which dispute his beliefs. He is able to interpret facts in such a way as to fit his own paradigm of illness. This has resulted in him developing a narrow range of diagnostic possibilities for many of his patients. It has enabled him to interpret symptoms, signs and especially pathology reports in a way that fits his diagnoses rather than in a more orthodox manner. For instance, he interprets, to suit his belief, blood levels that are within the normal range as being abnormal if the results are either towards the low or high end of the normal range. He also interprets the small changes in normal laboratory levels, which are due to the inherent variability of the testing mechanism, as being highly significant. He then uses these diagnostic paradigms to construct a management plan using medications that are therapeutically powerful, and so are potentially dangerous when used in an unorthodox manner. When we say "unorthodox", we mean used in a manner that is inconsistent with published therapeutic information. For instance, the use of doses of hydrocortisone equivalent to the body's endogenous production of cortisol (which the respondent says are "physiological doses") from the adrenal gland, when blood results show that the adrenal gland is producing a normal amount of cortisol itself. This has the potential to cause adrenal suppression which, if it becomes permanent, would lead to iatrogenic Addison's disease. 6. The respondent appears to have a powerful and unshakeable belief in his interpretation of the physiology of the human body, and is unable to consider that he may be wrong. As such he is practising medicine, not as a complementary practitioner in the sense that we have earlier described it, but in a manner inconsistent with that of his general practitioner peers, and in a manner which is potentially dangerous, as described in the expert evidence of Professor Carter. The respondent's medical records are, on the evidence, often confusing in understanding the respondent's diagnosis and management plans. They appear to us to assume a great deal of knowledge and application on the part of the respondent without there being any need to reduce it to writing. They seem to confirm an impression of the respondent's inability to think broadly, and laterally, about possible diagnoses and treatments. The shortcomings in the respondent's records as identified in the expert evidence which we have previously set out would not permit, in many cases, another medical practitioner, perhaps even one practising complementary medicine, to readily understand and deal with a patient without reverting to a basic examination and investigation of the patient's circumstances. 7. Significantly, for the outcome of these proceedings, based on the expert opinion of Professor Carter, the respondent in having exposed his patients to a pharmacologically active agent in the absence of any accepted clinical or biochemical evidence of a disease recognised in orthodox medical practice, has created a potential for harm. In the case of thyroid extract, possible increased risk of osteoporosis, and in the case of hydrocortisone iatrogenic adrenal suppression after 4 weeks. To fail to make an accurate diagnosis of adrenal insufficiency with a short synacthen test compounds the potential for harm. 8. However, we have not been provided with any expert opinion or other evidence that candida testing, coeliac genetic testing, injections of iron and vitamins and the administration of Myers' cocktails have a potential to cause harm, or might otherwise constitute conduct which differs from an acceptable standard, and we do not intend taking these matters into account adverse to the interests of the respondent for the purpose of these proceedings. Unsatisfactory Professional Conduct and Professional Misconduct 1. Complaints one, one A, two, two A and three allege that the respondent is guilty of unsatisfactory professional conduct and complaint four alleges that the respondent is guilty of professional misconduct. These expressions are defined in the legislation which governs these proceedings, namely the Health Practitioner Regulation National Law (NSW) ("the Act"). The relevant portions of these provisions are in the following terms: 139B Meaning of "unsatisfactory professional conduct" of registered health practitioner generally [NSW] (1) "Unsatisfactory professional conduct" of a registered health practitioner includes each of the following- (a) 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. (b) A contravention by the practitioner (whether by act or omission) of a provision of this Law, or the regulations under this Law or under the NSW regulations, whether or not the practitioner has been prosecuted for or convicted of an offence in respect of the contravention. . 139E Meaning of "professional misconduct" [NSW] 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. 1. In determining whether the respondent is guilty of unsatisfactory professional conduct in the manner asserted in the complaints with which we are dealing we first take into account that it is his conduct as a medical practitioner that is in question. The practice of complementary medicine by the respondent was undertaken in the course of his practice as a medical practitioner. It is by the standards appropriate to a medical practitioner that his conduct must be considered. The thrust of the National Law is to provide protection for the public in the way in which medicine is practised. In considering whether the practice of medicine by the respondent in terms of his knowledge, skill, judgement and care is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience we have regard to the circumstances of the respondent's patients, including especially any potential for harm or adverse consequences caused by the conduct of the respondent. In addition, Sec 139B (1)(b) directs attention to "other improper or unethical conduct relating to the respondent's practice of medicine." We shall return to this latter aspect when considering complaint three. 2. We have already observed that in continuing to prescribe thyroid extract and hydrocortisone to patients with normal blood levels the respondent was not practising orthodox medicine, and in doing so he has exposed patients to a risk of potential harm. In stating this we are conscious that there is no specific evidence of any patient actually suffering harm, but this is beside the point. It is sufficient that there is a risk of harm which is not fanciful or remote to attract the protection that the National Law is intended to provide. Certainly, on the evidence, there was a real risk of harm to Patient A by reason of the conduct of the respondent. Furthermore, the failure of the respondent in the circumstances described relating to individual patients to communicate with other treating practitioners, and in failing to record the matters of significance which are the subject of complaints one A and two A, are further indications of unsatisfactory professional conduct as described in the Section. All of this is clear from the evidence of the three medical practitioners adduced by the complainant. 3. The blatant issue of prescriptions by the respondent in the circumstances which we have found clearly constitutes a course of conduct which is both improper and unethical. It is only sufficient to refer to those circumstances as we have set them out to justify the conduct of the respondent being described in this way. 4. Whether unsatisfactory professional conduct constitutes professional misconduct is often determined by reference to characterisation of conduct as either dishonourable or disgraceful. Whether unsatisfactory professional conduct is sufficiently serious to justify suspension or cancellation of registration involves the exercise of a value judgement involving in turn an objective assessment of the conduct of the respondent against the relevant standard. We shall discuss this aspect further when considering complaint four. Complaint Three - Including Findings 1. We propose shortly to examine the evidence in some detail by reference to all of the complaints brought against the respondent, save for complaint Three which we are able to deal with discretely. As is clear from the concessions made by the respondent in the course of his evidence, he has issued prescriptions to a number of patients after his suspension from registration on 10 July 2013. These cover a period up to 10 April 2014, many months after the suspension took effect. In the course of issuing these prescriptions the respondent asserted that he was firstly continuing to practice at the Croydon practice when he was no longer doing so, and secondly that he was practising from his home address. At all times he was aware that he was not permitted by law to prescribe those medicines which were the subject of each prescription. We do not believe the excuse which he proffered that he was merely writing sample scripts to enable other practitioners to know what he had been prescribing for his former patients. If this was his intention he could have merely written out the medication on a plain piece of paper, or ensure that the script was appropriately marked as a sample. Furthermore, we do not accept the respondent's assertion that he was writing the scripts on some form of emergency basis to tide his patients over until they could attend on another practitioner practising complementary medicine. The scripts continued to be issued by him for many months after he was suspended, when all urgency would have evaporated and in one case he issued a repeat. We regard the respondent as having attempted to fabricate excuses in the face of the clear evidence that he was in contumelious breach of the legislative regime which prohibited him from writing scripts and purporting to practice medicine. The evidence which he willingly gave by way of concession that he had continued to treat his family, including extended family, notwithstanding that he was no longer registered and would continue to do so notwithstanding the warning which we had firmly given him during the course of the proceedings is indicative that the respondent is not prepared to submit to any lawful regime if he feels that it is not in his interests to do so. In making these observations we are conscious that the treatment of his family is not a subject of any complaint brought against the respondent in these proceedings, but it is important, in our opinion, because it corroborates the conclusion which we have otherwise come to concerning the unlawful and inexcusable issue of scripts as alleged in complaint three. 2. We formally find that we are comfortably satisfied that the allegations in complaint Three have been made out and that in all the circumstances they constitute professional misconduct. We would hope that our discussion of the circumstances in which the respondent unlawfully and without excuse issued the scripts whilst suspended from practice, as we have described them, is sufficient to justify the characterisation of the conduct of the respondent as constituting professional misconduct. His actions were both disgraceful and dishonourable and inconsistent with the standards of conduct which are expected by the community of medical practitioners registered to practice as such within New South Wales. We are unable to detect the presence of any circumstances which would mitigate in any way the conduct of the respondent which we have so found. Conclusions and Findings for Complaint One 1. This complaint focuses firstly on conduct as described in the practice of medicine and secondly on improper or unethical conduct. 2. Particulars 2 and 3 are directed to the treatment of Patient A. We find, on the evidence set out above that we are comfortably satisfied that the following particulars are proven namely 2 (a),(b) (c),(d),and (e), and 3 (a). In the first consultation with this patient, the respondent should either have conducted the comprehensive examination referred to or obtained such detailed and comprehensive information from the treating medical practitioners to obviate the need for that examination. In the course of his evidence the respondent conceded that the patient had a cognitive impairment, and in the circumstances he should not have relied on the purported signed consent form authorising no communication with other practitioners. If the patient had insisted, the respondent should have refused to treat him in accordance with the opinion of Dr Deed. Even allowing for the low cortisol level, and accepting the opinion of Professor Carter, the respondent should have alerted the patient's treating practitioners to the need to assess this level. 3. We accept that carrying out Candida serology and coeliac genetic testing on this patient does not accord with orthodox medical practice. There is no evidence that apart from the procedure itself involved in the taking of a blood sample, there was a potential risk or harm to the patient, as we have earlier described. We propose to adopt the same approach in considering the circumstances of the other patients whose treatment is the subject of these proceedings. 4. Particular 4 concerns Patient B. The respondent said the referral was a repeat and for Medicare purposes only. Nevertheless, the records failed to disclose current medications and other significant history which may have been useful to the specialist concerned, even allowing for the fact that this specialist may have already seen the patient. We find this particular proven. 5. Particular 5 concerns Patient C. It relates to Candida serology testing and the administration of vitamin D injections in the absence of an appropriate management plan and/or evidence of vitamin D deficiency. As with other similar matters, we find this particular proven in the manner asserted in this Complaint. 6. Particular 6 concerns Patient D. We find it proven with respect to paragraphs (a) and (b), consistent with the approach which we intend to adopt. The respondent said that he was monitoring the patient and trying non-pharmacological interventions like diet and losing weight first. In these circumstances we do not find (c) proven. 7. Particular 7 concerns Patient E. In that it refers to Candida serology testing and the administration of vitamin injections, we do not find it proven. We find the allegation concerning the treatment of thyroid extract proven. 8. Particular 8 concerns Patient F. In that it refers to Candida serology testing, it is not proven. 9. Particular 9 concerns Patient G. In that it refers to vitamin deficiency and iron injections we do not find the particular proven. We do find paragraph (b) proven as conceded by the respondent. 10. Particular 10 concerns Patient H. The respondent conceded paragraph (b) and we find this particular proven to this extent. 11. Particular 11 concerns Patient I and Candida serology testing and we do not find this proven. 12. Particular 12 concerns Patient J. Paragraph (b) is conceded and we find this particular proven to this extent. 13. Particular 13 concerns Patient K. In that the evidence relates to the administration of vitamins, we do not find this particular proven. 14. In those cases where the level of thyroid extract is potentially sufficient to cause harm as identified by Professor Carter, we conclude that the conduct of the respondent constitutes professional misconduct. In all other cases where findings have been made in connection with complaint one we conclude that the conduct constitutes unsatisfactory professional conduct. Conclusions and findings for Complaint One A 1. This complaint focuses attention on the respondent's record keeping (as does complaint Two A, and the general comments which follow apply also to that Complaint). There are statutory requirements dealing with the nature and extent of those records which a medical practitioner is required to keep. Relevantly, the records are described in Schedule 2 to the Health Practitioner Regulation (NSW) Regulation 2010 which is in the following terms: SCHEDULE 2 – Records kept by medical practitioners and medical corporations in relation to patients 1 Information to be included in record (1) A record must contain sufficient information to identify the patient to whom it relates. (2) A record must include the following: (a) any information known to the medical practitioner who provides the medical treatment or other medical services to the patient that is relevant to the patient's diagnosis or treatment (for example, 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 and information concerning allergies or other factors that may require special consideration when treating the patient), (b) particulars of any clinical opinion reached by the medical practitioner, (c) any plan of treatment for the patient, (d) particulars of any medication prescribed for the patient. (3) The record must include notes as to information or advice given to the patient in relation to any medical treatment proposed by the medical practitioner who is treating the patient. (4) A record must include the following particulars of any medical treatment (including any medical or surgical procedure) that is given to or performed on the patient by the medical practitioner who is treating the patient: (a) the date of the treatment, (b) the nature of the treatment, (c) the name of any person who gave or performed the treatment, (d) the type of anaesthetic, if any, given to the patient, (e) the tissues, if any, sent to pathology, (f) the results or findings made in relation to the treatment. (5) Any written consent given by a patient to medical treatment (including any medical or surgical procedure) proposed by the medical practitioner who treats the patient must be kept as part of the record relating to that patient. 2 General requirements as to content (1) In general, the level of detail contained in a record must be appropriate to the patient's case and to the medical practice concerned. (2) A record must include sufficient information concerning the patient's case to allow another medical practitioner to continue management of the patient's case. (3) All entries in the record must be accurate statements of fact or statements of clinical judgment. 3 Form of records (1) An abbreviation or shorthand expression may be used in a record only if the abbreviation or expression is generally understood in the medical profession in the context of the patient's case or generally understood in the broader medical community. (2) Each entry in a record must be dated and must identify clearly the person who made the entry. (3) A record may be made and kept in the form of a computer database or other electronic form, but only if it is capable of being printed on paper. 4 Alteration and correction of records A medical practitioner or medical corporation must not alter a record, or cause or permit another person to alter a record, in a way that obliterates, obscures or renders illegible information that is already contained in the record. 5 Delegation If a person is provided with medical treatment or other medical services by a medical practitioner in a hospital, the function of making and keeping a record in respect of the patient may be delegated to a person other than the medical practitioner, but only if: (a) the record is made and kept in accordance with the rules and protocols of the hospital, and (b) the medical practitioner ensures the record is made and kept in accordance with this Schedule. 1. It is a trite observation that comprehensive record-keeping is essential to assist a medical practitioner in affording proper and appropriate treatment to patients. A history of reported symptoms, diagnoses, tests and procedures, medication, and referrals amongst other matters are necessary tools in the practice of medicine. It is important also that another medical practitioner who may be required to afford treatment to the patient be able to become informed about the patient as quickly as possible by reference to existing medical records. A failure to keep and maintain necessary and appropriate records may not only constitute a breach of the statutory requirements set out above, but may, in appropriate cases be characterised as constituting unsatisfactory professional conduct or even professional misconduct, 2. We now proceed to deal with the particulars of Complaint One A brought against the respondent. 3. Particular 1 concerns Patient A. Despite the protestations of the respondent that some of the matters referred to in the particulars were noted in the records of this patient, the preponderance of the allegations are made out on the evidence of Dr Deed. In a patient exhibiting such complex problems, it was essential that the respondent's records be as comprehensive as possible. We find that this particular is proven save for (e). 4. Particular 2 concerns Patient B. We find this particular proven, based on the evidence of Dr Deed. 5. Particular 3 concerns Patient C. The respondent resisted some aspects of this particular, for example by stating that there was a copy of a Pap Smear in the record. He said that he had given advice about the matters referred to in the particular but we accept that overall, on the evidence of Dr Deed, this particular is proven. 6. Particular 4 concerns Patient D. In essence, the respondent concedes that this particular is proven, and we so find. 7. Particular 5 concerns Patient E. The respondent conceded some of the particulars. We find paragraphs (a) and (b) proven. 8. Particular 6 concerns Patient F. The respondent conceded paragraphs (a) and (c) and we find these paragraphs proven. 9. Particular 7 concerns Patient G. The respondent conceded paragraphs (a) and (b) and we find these proven. 10. Particular 8 concerns Patient H, was conceded by the respondent, and we find it proven. 11. Particular 9 concerns Patient I. The respondent conceded paragraph (d) and to this extent we find the particular proven. 12. Particular 10 concerns Patient K. The respondent asserted that the matters referred to in paragraphs (a), (b) and (c) were referred to in his computer generated records. The respondent conceded paragraph (d) and refuted paragraph (e) without explanation and we find the particular proven with respect to paragraph (d) only. 13. Particular 11 concerns Patient L. On the basis of the available evidence we do not find this particular proven. 14. Particular 12 concerns Patient M. The respondent said that this was a patient whom he had not seen since 2009 and who consulted him twice in February and March 2011 for a vitamin injection. On this basis he rejected the allegations. Nevertheless, it was still important that the respondent made some basic notations concerning the circumstances of the consultations and some material observations about the patient's condition. In that he failed to do so we find this particular proven. 15. Particular 13 concerns Patient N. On the basis of the evidence in the proceedings, including that of Dr Deed, we do not find this particular proven. 16. Particular 14 concerns patient O. Paragraph (a) asserts that there was a failure to record a discussion about the risks associated with the treatment administered including osteoporosis and atrial fibrillation. Whilst this only creates a potential for harm if given in high doses, nevertheless there is a requirement to record informed consent to the administration of this treatment. We find this particular proven, 17. Particular 15 concerns Patient Q. The respondent conceded that he obtained oral consent only to paragraph (a), and otherwise disputed the particular. We find the particular proven only with respect to (a). 18. Particular 16 concerns Patient R. The evidence was of poor record keeping. We find this particular proven. 19. Particular 17 concerns Patient S. Based on the evidence of Dr Deed we find this particular proven. 20. Particular 18 concerns Patient T. Based on the evidence of Dr Deed we find this particular proven. 21. Particular 19 concerns Patient U. Based on the evidence of Dr Deed we find this particular proven. 22. In all cases where we have found the particulars proven, we conclude that the conduct of the respondent constitutes unsatisfactory professional conduct. Conclusions and Findings for Complaint Two 1. Particular 1 concerns Patient V. The provisions of this particular essentially go to the respondent's administration of hydrocortisone therapy and the use of progesterone cream. We find the particular proven with respect to paragraphs (d),(e),(f),(g) and (h). We note the evidence of the respondent that the patient consulted him for a review of her "whole health". In this regard, the respondent should have ensured that he covered preventative healthcare, unless there was a clear understanding with the patient otherwise. To this extent we find paragraphs (k) and (l) proven. 2. Particular 6 concerns Patient AA. Based on the evidence of Dr Patterson, but consistent with the approach we have earlier taken, we find paragraphs (b) to (g) and (h) proven. 3. Particular 8 concerns patient AC. It is concerned with the approach to the practice of complementary medicine by the respondent and consistent with the approach that we have previously taken, we find particulars (b), (c), (d) and (f) proven. Conclusions and Findings for Complaint Two A 1. Particular 1 concerns Patient V. On the basis of the evidence of Dr Patterson we find this particular proven. 2. Particular 6 concerns Patient AA. Based on the evidence of Dr Patterson we find this particular proven. 3. Particular 8 concerns Patient AC. Based on the evidence of Dr Patterson, we find this particular proven. 4. In all cases where we have made findings that the particulars are proven we conclude that the conduct of the respondent constitutes unsatisfactory professional conduct. Complaint 4 1. The complainant relies on the findings made in connection with Complaints one, one A, two, two A and three both individually and in the aggregate as justifying a conclusion that the conduct of the respondent complained of constitutes professional misconduct. In that we have already found that the subject matter of Complaint three constitutes professional misconduct, and given the serious nature of the other particulars of complaint that we have found proven, we have no hesitation in finding that in the aggregate all of the conduct of the respondent described in the particulars which we have found proven constitutes professional misconduct. Further Proceedings We confirm the proceedings are adjourned for further hearing on 20 August 2015, on which date the stage 2 hearing will be conducted. 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: 07 August 2015