Civil and Administrative Tribunal New South Wales Medium Neutral Citation: Reimers v Medical Council of New South Wales [2018] NSWCATOD 180 Hearing dates: 30 & 31 August 2018 Date of orders: 05 November 2018 Decision date: 05 November 2018 Jurisdiction: Occupational Division Before: Haylen QC ADCJ, Principal Member Dr G Dore, Senior Member Dr K Liyanagama, Senior Member Dr C Berglund, General Member Decision: (1) Mr Reimers is found to be a fit and proper person to be registered as a medical practitioner, subject to the conditions specified in Annexure "A" to this decision. (2) Mr Reimers is to pay the costs of the Respondent Medical Council of NSW. Category: Principal judgment Parties: Mr Gerrit Reimers (Applicant) Medical Council of New South Wales (Respondent) Representation: Counsel: T Rickard (Applicant) H El-Hage (Respondent) File Number(s): 2017/00316431 Publication restriction: Nil REASONS FOR DECISION Introduction 1. Mr Reimers has applied to the Tribunal seeking to review orders made by the Medical Tribunal in November 2003. In those proceedings he was found guilty of professional misconduct and his name was removed from the Register of Medical Practitioners. He had been initially suspended from medical practice in April 2000. The Tribunal also ordered that any application for review of its orders could not be filed or dealt with for a period of 10 years. 2. The present application for review is made under s 163A of the Health Practitioner Regulation National Law (NSW) (the National Law). Pursuant to the provisions of s 163B, on such a review this Tribunal may, inter alia, make a reinstatement order and may impose conditions to be met by the practitioner upon obtaining re-registration. By s 163B(3), a reinstatement order is defined as an order that the person may be registered in accordance with Part 7 of the legislation if (a) the person makes an application for registration to the National Board, and (b) the relevant National Board decides to register the person. An inquiry into an application for review is, by s 163C(1), a review to determine the appropriateness, at the time of review, of the order concerned. Background 1. The relevant background to this application travels beyond the matters dealt with in the 2003 decision of the Medical Tribunal and includes applications for registration as a medical practitioner in Victoria in 2009 and in Queensland in 2010, each of which was refused. There were review proceedings taken in relation to these decisions, and proceedings were also commenced in the New South Wales Court of Appeal, in 2012 and 2013, but were unsuccessful. In 2014, Mr Reimers filed an application in this Tribunal seeking a review of the 2003 decision of the Medical Tribunal and that application was dismissed in April 2015. The details of these various proceedings were in evidence before this Tribunal. 2. Mr Reimers graduated in Medicine in 1989 and initially was an intern at Newcastle Hospital. From this time, until mid-1992, he was a Medical Officer for the Royal Australian Air Force, but also worked as a part time Resident Medical Officer at Nepean Hospital. Between 1992 and 1993, he was appointed as a Senior Resident Medical Officer in trauma and anaesthetics at Westmead Hospital. Between 1993 and 1996, he commenced training in anaesthetics and held positions at five public hospitals. In January 1997, he commenced his provisional fellowship year at Liverpool Hospital, at the conclusion of which he was granted a Fellowship of the Royal College of Anaesthetics Australia. In 1998, he commenced practice as Consultant Anaesthetist and obtained appointments at Hawkesbury, Ryde and Hills Private hospitals. 3. From the substantial amount of material before the Tribunal (including the reasons for decision delivered by the Tribunal in 2003 and 2015) it appears that, in 1995, Mr Reimers commenced using opioids. Between 1996 and 2000, he self-administered, and/or appropriated, drugs intended for patient use. In January 1997, he was confronted by a number of colleagues who suggested he was abusing narcotics. Mr Reimers denied the allegations but it was suggested that he should consult Dr Stella Dalton, a Consultant Psychiatrist with expertise in addiction. Later that month he did consult Dr Dalton but did not tell her the truth about his drug abuse. In February 1997, he was again confronted by colleagues about drug abuse at Liverpool Hospital. As a result, he was moved to a position where he had no exposure to drugs but he did not tell his colleagues that he was using narcotics. In March 1997, Mr Reimers was interviewed by the Pharmaceutical Service Branch of the NSW Department of Health due to irregularities in the drugs register at Hornsby Hospital. Dr Reimer denied self-administration of drugs of addiction. He was then referred to the Medical Board and was asked to see and be assessed by Dr Wright, a psychiatrist. He informed Dr Wright that his drug abuse was restricted to only benzodiazepines. He was referred to the Impaired Registrants Panel and, in August 1997, he agreed to a number of conditions being placed on his registration but played down the type and extent of his drug abuse. Approximately 6 weeks later, at his request, those conditions were removed. Liverpool Hospital had been "extremely supportive" of Mr Reimers and his desire to enter specialist practice as soon as he could. 4. In November 1997, as already noted, Mr Reimers became a Fellow of the Royal College of Anaesthetics Australia and obtained appointments as Consultant Anaesthetist at three hospitals. 5. There appears to be no further recorded issues bringing Mr Reimers to attention for his drug use until 2000. In February 2000, he was an anaesthetist for an operation at Ryde Hospital when a patient under his care ultimately died. In the 24 hours before providing anaesthetic services, he had self-administered Pethidine and/or Fentanyl. In April 2000, he misled a Medical Board Inquiry by stating that he had taken certain drugs orally but not by injection. He was then suspended from medical practice. In May 2002, the Health Care Complaints Commission instituted a complaint against Mr Reimers that came for hearing before the Medical Tribunal of New South Wales. In November 2003, the Medical Tribunal found Mr Reimers guilty of professional misconduct and ordered that his name be removed from the Register of Medical Practitioners. The Tribunal further ordered that there be no application for review for 10 years from the date of decision. 6. In the present proceedings, the reasons of the Medical Tribunal in 2003 were closely scrutinised. There were 14 separate complaints particularised: one complaint was found to be not proved, and another complaint was withdrawn. Although a considerable quantity of documents was tendered, and a number of witnesses gave oral testimony, the Tribunal noted that, to a large extent, the factual matters relied upon in support of the charges were not in dispute. Eight of the charges were regarded by the Tribunal as being related, and concerned Mr Reimers taking Pethidine and/or Fentanyl from dosages prescribed for patients, and administering them to himself, and doing so without recording those dosages not used for patients, and/or in the alternative destroying the unused drug, contrary to specific provisions made under the Poisons and Therapeutic Goods Regulation 1994 (NSW) (since repealed). 7. Complaint 1 concerned Mr Reimers role as anaesthetist in an operation conducted at Ryde Hospital on 4 February 2000. The particulars listed seven separate failures in the operating theatre and five failures occurring in recovery, while Mr Reimers was involved in resuscitation of the patient. The patient died a few days after the operation, without regaining consciousness. It is convenient to note, at this point, that Mr Reimers was indicted for manslaughter of the patient but was ultimately acquitted at trial in the Supreme Court. 8. The Tribunal quoted extensively from the evidence given by a Registered Nurse and Clinical Nurse Specialist, who was present with the patient and Mr Reimers in both the operating theatre and in the recovery room. In those 16 pages, the nurse described in detail the steps taken by Mr Reimers to resuscitate the patient. While the two nurses were assisting, Mr Reimers told them to leave the patient alone as they did not know what they were doing. Another doctor entered the room and asked Mr Reimers if he was all right and if he wanted help, to which Mr Reimers replied that he did not need any help and asked why he would need any help. The nurse then told him that she could not find a pulse and again was told that they did not know what they were doing and to leave the patient alone. The nurse then said to him that it had been a long day and could she get the ICU doctor to help, but Mr Reimers said no and that he was all right and that he did not need any help, he just wanted the patient to breathe. Mr Reimers tried a number of ways to resuscitate the patient but was unsuccessful. He asked why the patient was not breathing. The nurse did not think he was under stress although that is what she expected. He did not seem to understand the situation. Later Mr Reimers accepted her suggestion that the Medical Registrar be called in. Mr Reimers had suggested that there was something wrong with the monitors but that was not the case. 9. Dr John Flachs, a Specialist Anaesthetist, examined the records relating to the surgery and provided a report. Dr Flachs stated that the delay in resuscitation was "a serious departure of usual care", while the actual management of the intra-operative part of the anaesthetic was "almost reasonable". However, the documentation on the written anaesthetic chart was "incorrect and inadequate", and was a departure from standards of reasonable care. The usual management of this case was to ensure that spontaneous respiration had been established before the patient was extubated and taken from the operating theatre. In failing to provide conditions for full recovery of neuromuscular function, Mr Reimers had departed from the usual standard of care. It appeared from the nurse's statement that he was not able to accept that the monitoring in recovery was indicative of serious cardiac dysfunction. Mr Reimers seemed to be in denial of the patient's condition, and the refusal of assistance, when it was offered on two occasions, was serious misjudgement and a departure from usual standards of care. It seemed that Mr Reimers' behaviour was irrational and amounted to a failure to provide the expected level of care in that situation. There was a departure from the usual standard of practice in anaesthetics, and this had occurred at the end of the procedure. The time taken to institute artificial respiration was way beyond the usual standard of care, whichever way the events occurred. This was severe criticism and Dr Flachs believed any competent anaesthetist would share that opinion. 10. The Tribunal also received reports from three specialist anaesthetists, Dr Loughman, Dr Warden and Dr Prowse, all of which were critical of Mr Reimers' management of this patient. Dr Loughman categorised his criticisms as "severe", while Dr Warden stated that the identified departures from accepted standards deserved harsh criticism and that his peers would reach a similar view. The Tribunal noted that Mr Reimers did not, in his own evidence or by calling other expert opinions, seek to challenge these specialists. On this basis, the Tribunal held that all the matters particularised in complaint 1 had been established. 11. The Tribunal took the view that complaints 6, 7, 13 and 14 focussed on his professional conduct generally and were to be considered separately from the conduct identified in complaint 1. Complaint 6 alleged that, in January 2000, whilst working as an anaesthetist at Hawkesbury Hospital, he failed to complete the anaesthetic record chart for a patient and failed to make any other record of what drugs or intravenous fluids were given in the operating theatre. Complaint 7 alleged that, in November 1996, at Hornsby Hospital, as a 4th year anaesthetic Registrar, who was providing anaesthetic services to a patient, Mr Reimers failed to pass a central venous catheter into the patient's heart or large vein to measure the pressure and allow circulation supporting drugs to be given effectively. Complaint 13 stated that Mr Reimers suffered from an impairment, within the meaning prescribed in the National Law, in that he suffered from a physical or mental disorder, being addiction to deleterious drugs, Fentanyl and/or Pethidine and/or benzodiazepines, which detrimentally affected and was likely to detrimentally affect his physical or mental capacity to practise medicine. Particular 14 challenged the adequacy of Mr Reimers' anaesthetic records for the patient who died. 12. Prior to the hearing, Mr Reimers admitted complaint 6, while at the hearing his Counsel conceded that the state of the evidence left it open to the Tribunal to find complaints 7,13 and 14 were established. Dr Loughman and Dr Warden found that when Mr Reimers left the operating theatre, when the patient's blood pressure was unacceptably low, that action represented a breach of accepted practice, warranting severe or strong criticism. In relation to complaint 6, Dr Loughman categorized the failures of Mr Reimers as below an accepted standard. 13. In relation to complaint 7, Dr Loughman stated that the patient could, almost certainly, have benefitted from the use of a venous catheter and that he would be critical of Dr Reimers for not making this part of his anaesthesia care. Dr Flachs was "moderately critical" of Mr Reimers in this regard. It appears that the Tribunal accepted that this complaint was established. 14. In April 2000, at a Medical Board inquiry, Mr Reimers admitted that he had taken Fentanyl and Pethidine during the evening prior to the operation where the patient had died. The Tribunal held that it followed that complaint 13 was made out. In relation to complaint 14, Dr Prowse stated that Mr Reimers' anaesthetic record fell well below the Australian and New Zealand College of Anaesthetists (ANZCA) minimum requirements and that his lack of due care for the patient was exemplified in his lack of attention to accurate documentation on the anaesthetic chart. The Tribunal held that this complaint was established. 15. Complaints 2, 3, 4, and 5 concerned different patients but dealt with the failure of Mr Reimers to account for drugs, prescribed for them on 4 February 2000, which were neither recorded as administered nor discarded in accordance with the Regulations. On legal advice, Mr Reimers did not address these matters in his statement or in his oral evidence. His counsel conceded that there was sufficient evidence to make out these complaints. The Tribunal noted that Mr Reimers had failed to explain what had occurred but noted evidence of his drug addiction. On the balance of probabilities, these complaints were found to be established on the evidence. 16. Complaints 9, 10 and 11 dealt with Mr Reimers taking possession of Pethidine, and prescribing it yet retaining amounts for his own use at specified times. Complaint 11 alleged that, on various occasions, between 1996 and 2000, he self-administered drugs of addiction, namely Pethidine, Fentanyl and benzodiazepines, contrary to statutory and regulatory provisions, and had misappropriated drugs from hospital stocks, used drugs intended for patients, and provided anaesthetic services whilst under the influence of narcotic drugs and benzodiazepines. Mr Reimers had no memory of all the specified matters, but admitted that he could have diverted the drugs on some occasions. The Tribunal was satisfied that Mr Reimers had probably retained Pethidine, which was unaccounted for, for his own use, and overall found the complaints established. 17. Complaint 12 alleged that Mr Reimers had deliberately misled the Medical Board on four occasions between May 1997 and April 2000. On these occasions he had: denied the use of narcotics and self-administration of any substance parenterally; failed to disclose that he had been placed in an administrative position pending an investigation by the Pharmaceutical Services Branch; denied he had a substance abuse problem; and had told an inquiry that he had taken Fentanyl and Pethidine orally but denied injecting these substances. These matters were admitted by Mr Reimers in his statement to the Tribunal. 18. In his statement to the Tribunal, in the 2003 case, Mr Reimers dealt with his growing drug addiction and its problems. Looking back, he said he believed that he was in a cycle of behaviour whereby he took Pethidine because of stress and other factors and, in turn, that had an impact upon his relations with others, which, in turn, added to the stress. After consulting Dr Dalton, he continued taking drugs but felt deeply ashamed about his behaviour. Nonetheless, he found he could not admit to, nor confront his problem, and went to extremes to hide the truth. He became extremely defensive. 19. As recorded earlier, Mr Reimers admitted complaint 13 but an issue arose as to his present state of addiction. This complaint alleged that he "suffers from "a physical or mental disorder, being addiction to deleterious drugs, being Fentanyl and/or Pethidine and/or benzodiazepines that detrimentally affects and is likely to detrimentally affect his physical or mental capacity to practise medicine." At the hearing, it was submitted for Mr Reimers that he had suffered from an impairment, but that he did not currently suffer from that impairment. It was conceded that he was vulnerable to impairment in the future. 20. Dr Murray Wright, a psychiatrist, gave evidence that Mr Reimers still had a substance abuse disorder that was a potentially relapsing condition. Substance abuse was a diagnosis made when someone is using a psychoactive substance to an extent that it is causing problems for them, either in their work or their personal lives, and yet they continue to do it. Dr Dalton also stated that Mr Reimers had a substance abuse disorder and while there was a risk of relapse it varied with people and some could do without substances for the rest of their lives. The Tribunal concluded that Mr Reimers presently had a condition or disorder within the definition of "impairment". 21. The Tribunal noted Mr Reimers' evidence that he had not taken narcotic drugs since April 2000, but regarded him as an unimpressive witness. It was plain that, over a number of years, he had lied about his drug use to anyone who questioned him on that subject, and had engaged in dishonest and deceptive conduct in a number of areas. The Tribunal was not sufficiently confident as to the reliability of his evidence to accept that he had abandoned the use of narcotic substances since April 2000. 22. It was submitted on behalf of Mr Reimers that, despite his professional misconduct, he should be allowed to continue to practise, subject to strict conditions. In the interests of the community, the Tribunal concluded that only an order for removal from the Register would meet what it categorised as a gross departure from appropriate standards of conduct. He had demonstrated extremely significant deficiencies in both character and skill in the practice of medicine. He was shown to be willing on many occasions to put his own interest above those of patients, and in one case to contribute to the tragic death of one patient. It was said to be difficult to conceive that a more serious finding could be made against a medical practitioner. The Tribunal came to the opinion that Mr Reimers had not come even close to proving a reformation of his character to the standard referred to by Walsh JA in Ex parte Tziniolis; re Medical Practitioners Act (1966) 67 SR 448. 23. The Tribunal then turned to the question of fixing a time before which an application for review of its order could be made. The Tribunal felt bound to observe that, on the evidence before it, the deficits of skill and character of Mr Reimers were so great as to cast doubt upon whether he would ever be regarded as a fit and proper person to practise medicine. However, the Tribunal did fix a period of 10 years from the date of its decision before such an application could be made. 24. At this point, it is to be noted that, after his suspension in 2000 and before the decision of the Tribunal to remove him from the Register, Mr Reimers began to study Law at The University of Sydney, in 2001. In 2003, he graduated with a Bachelor of Laws (Hons), but he was not granted a practising certificate in light of his medical deregistration. He did obtain some work in lecturing in health sciences, on a part time basis at a complementary medicine college. A few years later, he commenced a PhD at Sydney University in cardiovascular medicine, and successfully completed his studies in 2010. He was successful in having some of his research published. 25. In 2007, Mr Reimers began to attend a doctors support group named Doctors in Recovery. His attendances were regular and he was made secretary of the group in 2010. In evidence in the present application he said that he was encouraged by members of the group to seek registration. Acting on that encouragement, in February 2009 he applied for registration as a medical practitioner in Victoria, but that application was refused in May 2009. He then applied, in December 2009, for general registration in Queensland. In January 2010, the Medical Board of Queensland refused that application. Mr Reimers stated that, in these applications, he was not challenging the findings of the Medical Tribunal made in 2003, but wanted to be heard in relation to fresh evidence that he was no longer impaired. 26. The May 2009 application for registration in Victoria was made to the Medical Practitioners Board of Victoria. Mr Reimers' application provided a number of documents for consideration, including a copy of the 2003 decision of the Medical Tribunal. He was informed by the Board that it proposed to refuse the application because his character was such that it would not be in the public interest to allow him to practise. In reaching this view, the Board had regard to the findings of the Medical Tribunal in 2003, and the fact that he was prevented from applying again for registration for a period of 10 years. It noted that the Tribunal found that he demonstrated extremely significant deficiencies, both of character and skill, in the practice of medicine. 27. Mr Reimers made written and oral submissions to the Board, and submitted a report prepared by Dr Samuels, together with a report from Dr Dalton and a copy of a hair drug test. In written submissions, he claimed that a false complaint had been made about his truthfulness in a meeting with the Board in April 2000, and that he had been denied natural justice. But for that error, the Tribunal could not have made an adverse finding in relation to complaint 13. 28. Dr Samuels assessed Mr Reimers in late April 2009. Mr Reimers told him his drug use began in 1995, when he was having relationship problems and was finding his training tough. He acknowledged [redacted] the 2001 charge for manslaughter. Dr Samuels could find no evidence of previous psychiatric problems and noted that there was no early history of drug abuse. He found Mr Reimers to be clearly intelligent, completing his schooling and university years without significant problems. 29. It was Dr Samuels' impression that his opioid dependence and abuse problems were in remission but, in the absence of a prolonged period of urine drug screening, he could not be definitive about that view. He recommended that it would be in Mr Reimers' interest to begin with a drug and alcohol specialist and to undertake a regular urine drug screening process, so as to provide confidence to any registration authority. He also recommended a prolonged therapeutic relationship with a drug and alcohol specialist or psychiatrist. In addition, Dr Samuels provided a list of conditions that should be imposed on Mr Reimers should he be registered in Victoria. 30. The Board noted Mr Reimers' apparent limited acceptance of the 2003 decision of the Tribunal, and that those findings were not open to question in the Victorian application. The Board advised him that it would need to be convinced that his character had changed. Mr Reimers acknowledged that there had been a problem with his character and that drug problems could affect an assessment of character. 31. In its conclusion, the Board noted that Mr Reimers had not been attending the support programs for at least a year and that his attendance had been intermittent. He had not consulted Dr Dalton on a regular basis for a number of years. Dr Samuels' report was comprehensive, but there were reservations as to whether he should return to practice and he recommended further treatment. On this basis, the Board was not satisfied that Mr Reimers had addressed the character issues which led to his drug problem. He had limited insight into his drug abuse and its effect on his character. His lack of insight caused the Board to consider that his character was such that it would not be in the public interest to register him in Victoria. 32. In December 2009, Mr Reimers applied to the Medical Board of Queensland for general registration. It appears that the Board refused his application because 10 years had not yet passed since the Tribunal made its decision and imposed that condition. In a covering letter sent to Mr Reimers with a copy of the Board's decision, the Board stated that, when he was eligible to re-apply for registration in New South Wales, the Queensland Medical Board may consider an application from him to practise in Queensland. 33. Also in December 2009, Mr Reimers applied again to the Medical Practitioners Board of Victoria for registration as a medical practitioner. Once again, the Board proposed that the application would be refused and he was given a further opportunity to make representations. In his written response, Mr Reimers unreservedly accepted the 2003 findings of the Tribunal, that he had exhibited deficiencies of character and skill in the practice of medicine because, while actively addicted, he had put his interest above those of his patients. The written submissions contained reports from Dr Dalton and Mr McShane (a treating psychologist) and personal references from 5 people, including 4 Doctors. 34. The Board considered what constituted good character by reference to a Board decision and the well-known passage from Ex Parte Tziniolis; Re Medical Practitioners Act that moral standards, attitudes and qualities of the applicant must be weighed. While the Board accepted that Mr Reimers had changed his behaviour since his last application, evidenced by his involvement with support groups and attendances at a psychologist, it remained unconvinced that he had discharged his onus to demonstrate that he was now of good character. The Board was troubled at his insight in making a new application less than twelve months after the last rejection. 35. The Board concluded by stating that it remained concerned about Mr Reimers' insight into the character defects which resulted in, and may have been a consequence of, his drug use. Evidence that those defects had been addressed satisfactorily had not been provided to the Board such that it could be confident that the public would be protected if Mr Reimers were granted registration. 36. Within a week of this decision being made by the Board, Mr Reimers applied to review it in the Victorian Civil and Administrative Tribunal (VCAT). The application for review was heard over two days, in September 2011, and a decision handed down in late October 2011. Mr Reimers represented himself before the Tribunal and Dr Freckleton SC represented the Respondents. The Tribunal was constituted by a Judge and two doctor members. The decisions noted that, on review, the Tribunal had all the powers and functions of the decision maker. 37. Early in the decision, it was noted that it was the decision of the Medical Tribunal in 2003 that was the ground for rejection by the Victorian Board. The whole of the 2003 decision was before the review Tribunal and it had been "read in full". On review, Mr Reimers accepted that he was guilty of professional misconduct and did not seek to question in any way the facts and findings of the NSW Tribunal, although he did seek to qualify the findings. He submitted that his professional misconduct was a consequence of his drug addiction and that his mind, at the time, was effectively controlled by drugs. He said he had now overcome his drug problems. 38. The Tribunal referred to the report of Dr Samuels, but noted that while there was evidence of urinalysis testing, showing Mr Reimers to be drug free, he had not acted on other aspects of the report. There was a lack of proper evidence of a prolonged therapeutic relationship with a drug and alcohol specialist or psychiatrist. Dr Dalton had provided a report and was satisfied that Mr Reimers was at present in sustained remission. In her opinion, if he remained in remission he could safely practice with conditional registration, involving appropriate restrictions on his practice together with supervision and monitoring. 39. The Tribunal, however, stated that it had not heard from Dr Dalton, that her report was not detailed, and that her treatment of Mr Reimers had not been either regular or prolonged. The Tribunal could not be satisfied that the underlying problem, causing him to become drug dependent, had been resolved, especially in the absence of evidence from an expert of the kind recommended by Dr Samuels in 2009. The Tribunal commended Mr Reimer on his efforts to become drug free and to generally rehabilitate himself, but more evidence was required as suggested by Dr Samuels. 40. In deciding to affirm the decision of the Board, the Tribunal stated that the 2003 decision of the Medical Tribunal in NSW should have full effect, absent extraordinary circumstances. The evidence relied upon by Mr Reimers did not establish such extraordinary circumstances or justify effectively undermining or second guessing the findings and orders of the NSW Tribunal. The Tribunal went on to observe that Mr Reimers required considerable retraining in whatever field of medicine he chose to practice in. 41. Mr Reimers had been extensively cross examined. The Tribunal stated that a number of exchanges showed him to have an appropriate level of insight into his past conduct, and appropriate remorse and empathy with both his patients and the profession, each of whom he had let down by his past conduct. Yet, there were still parts of his evidence that showed that, even now, he still wanted to question or qualify some of the 2003 findings. This was a concern and showed why Mr Reimers would benefit by heeding Dr Samuels' recommendations. 42. In February 2012, Mr Reimers filed a summons in the supervisory jurisdiction of the Supreme Court of NSW alleging that, in 2003, the Medical Tribunal had committed an error of law by finding that his conduct was both the consequence of a mental or physical disorder, and that it was not the consequence of such a disorder. The Court held that relief should be refused on discretionary grounds as the extraordinary lapse in time since the Tribunal decision had not been explained or justified. Granting relief would require the Tribunal, many years later, to rehear the matter when there was no challenge to the validity of the complaints. Further, contrary to Mr Reimers' submission, the Court held that conduct resulting from an impairment could reasonably be held to constitute professional misconduct. 43. Mr Reimers again represented himself in these proceedings. He argued that, if his contentions were correct, the Tribunal would not have to hear the matter again and that its 2003 decision would simply be quashed. The Court rejected that submission and pointed out that success in its jurisdiction, as claimed by Mr Reimers, would render the complaints unresolved. 44. The Court did accept his submission that impairment cannot be professional misconduct, but only in the sense that an impairment was not conduct. An impairment may manifest itself in conduct, or may explain particular conduct in part or in whole. The Court also noted that Mr Reimers could apply for registration again in a little over one year's time, and in the context of the unexplained delay this case might be seen as unnecessary. The terms of the adverse finding of the Tribunal, and its comment that his deficits in skill and character were so great as to cast doubt upon the prospect of him being regarded as a fit and proper person to again practise medicine, did not preclude an application for re-registration being granted. The Court acknowledged that the comment did provide a serious hurdle in the path of re-registration. 45. In March 2013, Mr Reimers filed a further summons in the Court of Appeal and again represented himself at the hearing. He again argued that the Tribunal, in 2003, had erred in law by finding both that his conduct was, and was not, the consequence of a mental or physical disorder. The Court accepted that the matters now raised were differently formulated to those dealt with by the Court in the 2012 proceedings. Those arguments, however, could have been agitated in the earlier proceedings and did not require further evidence. In those circumstances, the Court concluded that the proceedings were properly characterised as an abuse of process of the Court and so should be dismissed. 46. In 2014, Mr Reimers filed an application in this Tribunal, seeking a review of the 2003 decision and re-registration as a medical practitioner. He again represented himself at this hearing. The matter was heard over three days and, in April 2015, the Tribunal dismissed the application. 47. In this decision, the Tribunal set out Mr Reimers' professional history leading to the 2003 proceedings. Twelve of the complaints, as particularised, were set out in full and the final three paragraphs of the decision of the Tribunal were quoted in full. These were the paragraphs where the Tribunal spoke of Mr Reimers' gross departure from appropriate standards of conduct, and voiced the doubt that he may never be regarded in the future as a fit and proper person to practise medicine. 48. Reference was then made to applications made by Mr Reimers to the Victorian and Queensland Medical Boards for registration and the applications made to the Court of Appeal. These were factual references and no adverse or critical comment was made by the Tribunal concerning these matters. 49. [redacted] 50. Mr Reimers' evidence was that, since 2003, he had never returned to drug taking, despite extremely difficult years since then. He claimed to have total insight into his drug addiction and to ensure he did not succumb to drug use. He had insight and remorse for the adverse impact his drug addiction had had on his ability to practise medicine and the tragic consequences for one of his patients. There was evidence of urine drug analysis in 2009 and 2010 but not after those times. 51. The Tribunal then considered the medical evidence. In 2010, Dr Prior, a consultant psychiatrist, had provided a report for the Queensland Board. He was not satisfied with the level and extent of urine testing undertaken by Mr Reimers, and felt that his level of treatment was inadequate and should have been more intense and over a longer period. There was insufficient evidence to support Mr Reimers' assertion that he had been drug free for ten years. Further treatment was required and an underlying Personality Dysfunction needed to be adequately addressed. For many years, he had not accepted the seriousness of these conditions and his actions. His remorse was belated. He had been motivated by Dr Samuels' guidance and direction but not by his own insight or understanding of his behaviour. Without appropriate treatment, he remained at risk of exhibiting similar behaviour in the future. 52. Dr Dalton, a consultant psychiatrist, had treated Mr Reimers since January 2009, and provided a report in August 2010. He had seen her at six weekly intervals since mid-2009. He was now regarded as having received adequate treatment, and testing had found him to be drug free. Dr Dalton was satisfied that he was in sustained remission and had achieved much with his Law degree, his PhD and his ability to care for two small children on his own. In her opinion, he could be relied up to remain in remission and to practice safely, with conditional registration and appropriate restrictions, supervision and monitoring. 53. Mr Reimers consulted Mr McShane and Eva Wong, clinical psychologists. Mr McShane has provided a report, dated February 2010. Mr Reimers had attended 12 sessions between November 2009 and March 2011. Mr McShane said that he had identified the personal and professional issues behind his previous drug use, which had impaired his medical ability to act appropriately. Mr Reimers was now in a "very different place" to where he was 10 years previously, when impaired. Since then, he had remained drug free, completed a Law degree, and had become a responsible and involved father. Until recently, he was in some way blocked from fully accepting responsibility for his behaviour as a medical practitioner, and had poor acceptance of the 2003 Tribunal decision. Mr Reimers had now gained insight into his previous behaviour and into his developmental, relational and workplace conflict issues that precipitated his initial experimentation and drug dependency. 54. The respondent arranged for Dr Fisher, a consultant psychiatrist, to provide a report, dated July 2014, and he gave oral evidence at the hearing. Dr Fisher was of the opinion that Mr Reimers had insight into his conduct, as described in the 2003 decision of the Tribunal. He accepted expressions of remorse by Mr Reimers for the self-administration of drugs, and for his contribution to the death of the patient. Dr Fisher was asked whether Mr Reimers had overcome the defects of his character that led to his de-registration. In response, Dr Fisher spoke of his experience and that it was often the case that ostensible defects of character were driven by drug seeking behaviour once a pattern of abuse or dependence had been established. He suspected that this was a more likely explanation for Mr Reimers' duplicitous behaviour, which, combined with his abrogation of responsibility to his patients, endangering their lives, led to his de-registration in 2003. 55. Dr Fisher regarded Mr Reimers as a reformed individual who had insight into the inappropriateness of his previous behaviour. There was a chance that he remained at greater risk of drug abuse or dependence in the future but that was not inevitable. Abstinence for a period of 14 years was a credit to his self-discipline and the seriousness with which he had committed himself to abstinence. 56. Dr Fisher concluded that Mr Reimers was now unimpaired and that it would be reasonable for him to apply for registration on condition that he entered the Impaired Registrant's Programme with the Medical Council. He should be fully compliant with all conditions, commencing with thrice-weekly urine drug screening, attendance upon a treating Psychiatrist with expertise in Drug and Alcohol treatment, provision of appropriate supervision and reports, and notifications to his employer of his conditional registration and the reasons for it. 57. In oral evidence, Dr Fisher said that Mr Reimers had a continuing vulnerability but was not currently impaired. The risk of impairment could be mitigated by imposing conditions as suggested. He thought Mr Reimers was insightful and remorseful and not just saying so in order to gain registration from the Tribunal. It was suggested to Dr Fisher that Mr Reimers had undertaken forum shopping only five years after de-registration, and whether this illustrated a lack of insight into the reasons of the Tribunal in 2003. Dr Fisher agreed that this did demonstrate a lack of insight, which had been brought about because he had been to the Doctors Recovery programme and had seen people undertaking that programme and exiting before 10 years of exclusion. 58. At the close of evidence, the Tribunal considered that Mr Reimers faced what it described as an arguably insurmountable problem in gaining registration because he had not practised medicine for 14 years. He accepted that the courses he had undertaken during this period would not qualify him for registration even with conditions and monitoring. The Tribunal considered that he had not given careful thought to what career prospects might be reasonably available. He was not aware of the availability of specific internships or post-internship positions in hospitals, but knew that the demand for these positions exceeded their availability. It seems that, in light of this development, Mr Reimers sought and was granted an adjournment to allow him to commence a regime of drug testing to confirm to the Tribunal that he was, in fact, drug free and to consider precisely what orders he was seeking. The Tribunal noted that there was no evidence from Mr Reimers concerning any continuing drug testing, and none since 2011. His references were not considered up-to-date or from people who knew him over a long period. 59. Mr Reimers' return to work proposal was considered to be framed in the most general of terms. There was no clear indication that it was feasible for him to have any tangible opportunity to seek retraining, and to work in the medical profession under supervision, leading to some form of return to gainful employment as a medical practitioner. Having regard to the nature of the proceedings, the Tribunal was of the view that it needed to consider in detail Mr Reimers' prospects of obtaining and participating in some form of career path, leading to the practice of medicine. It noted that, in any event, market forces would dictate whether he would be successful. The Tribunal then referred to the additional need for Mr Reimers' reinstatement to be subject to registration by the National Board. 60. In coming to a determination of the application, the Tribunal recorded that Mr Reimers accepted that reinstatement should be subject to the conditions nominated by the Medical Council. It then acknowledged that the task of the Tribunal was to consider whether Mr Reimers was now a fit and proper person to be registered as a medical practitioner and that he bore the onus of proving that a reinstatement order should be made. Due to the protective nature of the jurisdiction, the Tribunal had to be comfortably satisfied of the matters so proven. 61. The Tribunal then quoted extensive passages from the decision in Litchfield v Medical Council of New South Wales [2012] NSWMT 8 and other authorities cited therein. The jurisdiction was to be exercised for the protection of the public, who deal with medical practitioners on the basis that they are members of an honourable profession, and who can be expected, without reservation, to conduct the affairs of their patients with honour, and in whom the patients can place unbounded confidence. An applicant for reinstatement bears a heavy onus, and the Tribunal is to assess his or her character, uprightness, honour, and trustworthiness. Where past conduct indicates probably permanent unfitness, the Tribunal will require solid and substantial grounds for concluding that his or her standards have changed, that his or her character is reformed, and that he or she will act honourably. The Tribunal also referred to observations made by Mahoney JA in The Council of the Law Society of New South Wales v Foreman [No 2] [1994] NSWCA 69; 34 NSWLR 408 at [449]: that character involves two things – the acceptance of high standards of conduct, and acting in accordance with those standards under pressure. 62. The Tribunal then examined the details of the Litchfield case. The doctor in question had not practised medicine for 15 years, but had undertaken intensive and extensive treatment from psychiatrists and a psychologist, and had gained continuing professional development points for the previous five triennia. He had undertaken a number of clinical attachments and expressed a preference to take up a position in a medical centre where there would be at least three or four other doctors giving him access to mentoring and advice. He produced evidence that, if reregistered, he would provisionally be offered a position in a regional medical practice, and there was also a possibility of employment in other medical centres. The Tribunal did note that the doctor's misconduct involved inappropriate sexual conduct towards three female patients and was quite different to Mr Reimers' situation. 63. Next, the Tribunal compared the meticulous and detailed preparation, undertaken by Dr Litchfield in support of his application, with that of Mr Reimers. Mr Reimers had been put on notice that he needed to provide evidence of steps taken to reform his character, of the insight he had gained into the matters that led to his deregistration, of his contrition, and of the fact that he was now drug free. When the application had been adjourned, the Tribunal suggested that he undertake a regime of drug testing to demonstrate that he was, in fact, drug free. No such evidence, however, had been produced with the last evidence of drug testing appearing to be in 2010. Mr Reimers had simply asserted that he had been drug free for 12 years, and expected the Tribunal to accept this statement without reservation. Previously he had been told by Dr Samuels that he should take regular urine analysis over a period of time to provide corroborative evidence, but he failed to do so. 64. At the resumed hearing, in 2015, the Tribunal engaged in a prolonged exchange with Mr Reimers, pointing out how he had not discharged the burden of demonstrating that it was appropriate for him to be reinstated. He had repeated that he was drug free but had provided no evidence to support the contention. There had been no concrete attempt to sort out a career path except for one recently flagged proposal. In response, Mr Reimers stated that he did not understand the 2003 decision: he had studied law and knew that he was not struck off for impairment but for character defects. The Tribunal reminded him that he had been struck off for professional misconduct. Mr Reimers replied that, in setting a 10 year period of disqualification, the Tribunal had said that his character defects were such that he could never again practise safely. He did not understand why 10 years had been imposed when other impaired doctors return in two years. He thought he had been treated very much differently to other impaired doctors. The Tribunal then stated that each case was judged on its merits and that, if Mr Reimers had a lawyer representing him, he would have produced some evidence of drug testing together with an appropriate program and a psychiatric opinion. 65. In the view of the Tribunal, these exchanges indicated that Mr Reimers had not come to terms with the conclusions of the 2003 Tribunal and the very serious misconduct in which he had engaged. He had created an unfavourable impression. Lacking insight of the nature and extent of his conduct would create difficulties in addressing and dealing with the responses required to redress the situation. It was observed that Mr Reimers had emphasised his impairment, in order to explain his conduct, yet at no stage had considered what it was in his character or personality structure that caused him to risk his career, and everything else in his life, and to behave knowingly and persistently over a long period of time in the deviant, deceptive and ultimately dangerous manner that he did. He had rejected the strong recommendation of an experienced psychiatrist that he engage in and sincerely embrace what was necessarily a long term and intensive psychotherapy. 66. The Tribunal stated that Mr Reimers had to satisfy it that he was drug free and likely to remain so in stressful circumstances. He had failed to do so. There was limited evidence that he had endeavoured to remain up-to-date with his medical knowledge over 14 years. The Tribunal could not be satisfied that he could safely practice medicine, if reregistered. The evidence concerning a return to work plan created some doubt about whether he would be able to obtain a hospital position attended by close supervision. It had sensibly been suggested by the respondent that he initially undertake a position in an appropriate facility, as an observer, before seeking paid employment. In view of the conclusions already reached, the Tribunal felt it unnecessary to deal further with this discrete issue. The formal order of the Tribunal was that it was not satisfied that the applicant was a fit and proper person to be registered as a medical practitioner. 67. In September 2017, Mr Reimers filed the present application seeking re-registration. In support of that application he filed an extensive statement followed by two further, shorter statements. Annexed to the statements were detailed documents, namely: medical reports from Dr Ricardo Farago, Dr Dalton and Dr Barbero; the results of urine drug screens covering the period from July 2015 to August 2018; documents relating to face-to-face educational activities; observership activities; online educational activities; SMART Recovery documents; results of urine EtG screens between March and August 2018; replies from prospective employers; a Return to Practice Plan; references; a reply from AHPRA; and a reply from ANZCA. 68. Mr Reimers' major statement dealt with his personal history, including joining the Royal Australian Air Force in 1987 with the intention of becoming a medical officer on completion of his degree. He was encouraged by doctors at the base to perform GP locums for extra income, and it was recommended that he obtain a doctor's bag so as to have drugs for emergencies. One of the drugs in the bag was 5 ampoules of pethidine. He decided to specialise in anaesthetics and, in 1992, he sat and passed the Faculty of Anaesthetics Fellowship at his first attempt. In mid-1992, he left the RAAF to become a resident in surgery at Westmead Hospital. 69. Midway through his first year of Anaesthetics training at Westmead, a senior anaesthetist began to constantly pick on him and criticise him in front of other registrars. Mr Reimers regarded this treatment as bullying and he grew to fear the man and dreaded interaction with him. He endured this treatment until 1995, when he left the hospital for another position. The change did not help, and he said that, by this time, the damage to him had been done. He felt worthless and a failure. He no longer felt safe at work and became intensely fearful and anxious about criticism or asking for help, and saw these as signs of failure. He now realised that he needed counselling. He spoke of other general stressors in the workplace, and found many of the cases that arrived at the hospital confronting. His reaction to the bullying had isolated him from his colleagues, his then wife, family and friends. His wife was busy in her practice and he felt that he could not confide in her about anything deeply personal. 70. In 1995, Mr Reimers said his life was completely out of balance. He did nothing for the pure enjoyment of it, had no hobbies or social outlets, and was cut off from people at his workplace. He now realised that he blamed himself when things went wrong. His marriage was under strain, and he did things for others but not himself. Early in 1995, he was rotated to Mt Druitt Hospital, where he met other registrars who appeared to have a full and enjoyable social life, which he envied. He learned that drug use was part of their world and, although he had never considered using drugs, at this time, it seemed to equate to success and happiness. 71. By mid-1995, his distress and feelings of worthlessness reached an apex. In desperation, he turned to drugs and first used the pethidine he had in his doctor's bag. He found an immediate sense of attachment, which had been missing in his life, but it quickly wore off and soon the box of drugs was empty. Pethidine was not freely available to him as a registrar so he used readily available substitutes: morphine, fentanyl, propofol and midazolam. Except for fentanyl, he found the drugs unpleasant and did not continue to use them. Since using pethidine, he craved it, but had been unable to find a substitute until mid-1996, when, able to work unsupervised, he gained ready access to it. His drug use escalated, but his health and judgment deteriorated. His first child was born in September 1996, but the pethidine that had taken away the pain of feeling like a failure, also prevented him from feeling the joy of fatherhood. 72. Mr Reimers spoke of his attempts to stay off drugs but how he struggled and failed against the urge to take drugs, especially pethidine. In 1996, colleagues at Hornsby Hospital confronted him about using pethidine, but were trying to help him. He lied to them about his drug taking, but now understood his judgment was impaired. They referred him to Dr Dalton. Despite this, his drug taking continued, following a move to Liverpool Hospital in 1997. During that year, while he was receiving treatment from Dr Dalton, he was taken off clinical duties. He was then referred to the NSW Medical Board Impaired Registrants Panel by Hornsby Hospital and given conditional registration. He protested these conditions, but fully complied with them, and did not use drugs to the end of 1997. He wanted to be clean but was beset by cravings and constant rumination. At this time, he was unable to speak to his wife about his drug problems. Her success as a surgeon left him feeling like a shameful and worthless addicted registrar. 73. At the end of 1997, Mr Reimers asked the Medical Board to remove all conditions from his registration. Liverpool Hospital had been very supportive, and he wanted to enter specialist practice as soon as he could. In October 1997, the conditions were removed, but Mr Reimers now realised that, at that time, he was still very much impaired and should have remained on the programme for at least three to five years. 74. In relation to his anaesthetic practice, between 1998 and 2000, Mr Reimers said that he wanted to make a new start; however, in early 1998 he again gave in to the urge to use drugs. He did not intend to harm his patients but he accepted that he put his need for pethidine ahead of their needs. He had convinced himself that using was harmless and that he could stop at any time, but that showed how aberrant his judgment had become and how far he had fallen into addiction. His attempts to stop his drug use failed, as did his steps to try to reduce his urge for drugs, such as taking regular leave and avoiding lists that were likely to increase his urges. He grew despondent as nothing was working and his marriage was suffering 75. Things came to a head in February 2000 when, with tragic consequences, he failed to properly manage the anaesthetic care of a patient. Mr Reimers stated that he fully accepted that his clinical management of the patient fell well below the required standard. He thought that he now understood why he had refused help from others: it was like a re-run of bullying by supervisors where he felt personally threatened and responded extremely inappropriately. After he had time to process what had happened, he cried, and was shocked and horrified at the death of his patient and at the role he had played in her death. He said that what was left of his world came crashing down and that this was his deepest nadir. Awareness of this made it possible for him to seek professional help. 76. Mr Reimers said that he knew that his life was out of control and that he desperately needed help. Around the end of March 2000, his colleagues asked again if he had a problem with pethidine and this time he fully and candidly admitted his using. He asked them for help and they agreed. He stopped working as an anaesthetist and attended to his health. He fully confessed his drug using with his wife and his lawyers. At the time, his wife was pregnant with twins, and took the news very badly and did not hide her disgust of him. About a week later, his wife lost the twins. Mr Reimers said that he was absolutely devastated at this loss and felt guilty as he considered that he was responsible. In April 2000, he was suspended from practice and was later charged with the manslaughter of his patient. All of the bad elements of his personal and professional life overwhelmed him. He decided not to use drugs again and has never wavered from that resolution, since being suspended. 77. After his suspension, Mr Reimers sought to re-connect with his family and paid more attention to his own health. In 2001, he took a non-clinical position with a medical devices company as a trainer. He then began to study Law at Sydney University with the hope of using his medical and legal qualifications to obtain a place in some other specialty. He re-married, and had two children. Later, he was acquitted of the manslaughter charge. In 2003, he appeared before the Medical Tribunal to answer a number of complaints relating to his drug use. He described himself as being mentally unprepared for the hearing. He had read the decision of the Tribunal many times and could now understand why it found him to be an unimpressive witness. He fully accepted the decision of the Tribunal as being the right one, in all the circumstances. 78. Although he graduated with Honours in Law, at the end of 2003, he was prevented from obtaining a practising certificate, in light of his medical de-registration. For a long period, he was unable to find any full time work, but was able to make a small living by lecturing in health sciences on a part time basis at a complementary medicine college. In 2004, he was sued by the family of the patient who died. He apologised to the family and settled out of court. He knew their loss was his fault and he had no right to defend himself or receive any protection from the law. He described himself as being full of guilt and remorse. 79. In 2005, Family Court proceedings with his former wife came for hearing. The manslaughter case was raised and he felt his relationships were irreparably damaged. He was suffering from symptoms of anxiety, depression and anger. He then enrolled in a PhD in medicine. 80. In mid-2006, his second wife left the marriage with the children. Mr Reimers said he had lost his family for the second time, and hopelessness overwhelmed him – he could see no way out. He had used no kind of illicit drug for six years yet he felt things were going from bad to worse. One evening in August 2006, the man his wife had been seeing came to the house uninvited and unexpectedly and Mr Reimers physically removed him. [redacted] He encountered difficulties with obtaining access to his children and commenced proceedings in the Family Court. That exercise cost him $46,000 in legal fees, and he found that he had squandered half his assets on legal fees and so felt distraught and wondered how he was going to care for his children. 81. In early 2007, Mr Reimers started to attend a doctors group called Doctors in Recovery. He regularly attended meetings and, in 2010, was made secretary, a position he held for a year. He also started to regularly attend meetings of the Narcotics Anonymous movement. He was encouraged by members of the doctors group to apply for registration in Queensland and Victoria, but both applications failed. In both cases he did not challenge the 2003 findings, but sought to bring fresh evidence showing he was no longer impaired. In 2011, he applied to the NSW Court of Appeal to review the decision of the Medical Tribunal, but did not challenge the findings on the complaints, only the consequential orders. This application was out of time and not permitted to proceed. 82. Mr Reimers said he was heavily involved in in the Narcotics Anonymous movement in 2010, attending several meetings a week. He had service positions at each meeting as giving back became an important recovery principle for him. He had no difficulty finding motivation to stay clean and had no urges or cravings to use drugs, but he did need support for dealing with unemployment. In April 2011, he found a contract position with the Australian Taxation Office, and has remained there ever since. He is now a permanent employee. After finding work, he reduced his NA meetings to one regular meeting per week, with ad hoc meetings on the weekends. He has replaced the NA meetings with SMART Recovery, finding it extremely helpful, and now is an accredited SMART Recovery facilitator. 83. When he applied for re-registration in 2014, Mr Reimers said that he still did not know how to prepare a case, so he took the same approach he had taken in 2003 and in the Victorian application. His approach was staying clean and telling the truth, meaning he took responsibility for his actions and was not trying to defend his wrongdoing. He now realised that he did not do what was required and, at the time, did not have the necessary insight and understanding of his drug use. He accepted that he was then not ready to be reinstated. In relation to drug abuse, he asserted that he had not used any sort of illicit substance since 28 March 2000. 84. In relation to his rehabilitation and reformation, Mr Reimers pointed out that he had attended SMART Recovery once a week since December 2015. This was a weekly session of 90 minutes that applied CBT principles to help members with their problems. Although this was a self-help group, facilitators were present to guide the discussion. In July 2017, Mr Reimers became a SMART Recovery facilitator. From November 2015, he became a consumer representative at the Western District Health Service Drug Health Unit. He was required to attend regular meetings to plan initiatives to improve service delivery. 85. Mr Reimers noted that, since 2000, he had been treated by numerous psychiatrists and psychologists, including Dr Dalton, Mr McShane, Dr Farago, Dr Fung, and Mr Barbero. Due to his excellent progress, Dr Dalton, Mr McShane and Mr Barbero had discharged him from their care. He had seen Dr Samuels in 2009, and Dr Fisher in 2014, for the purpose of assessment only. They all diagnosed addiction, with Dr Dalton diagnosing a brief period of depression. None diagnosed a personality disorder. Dr Dalton treated him from 1996 to 2009, when she was satisfied that his addiction was in remission. Following the 2015 Tribunal decision, Mr Reimers consulted Dr Farago as a treating psychiatrist. He had attended over 50 sessions since then and continued to see him on a regular basis. 86. In relation to drug testing, Mr Reimers stated that he had undertaken drug screens many time since 1997. He had never returned a positive test result, nor missed a test. More recently, since 1 July 2015, he had undertaken random urine drug testing in accordance with the Medical Council protocol. As to his present health and lifestyle, Mr Reimers felt his life was now in balance and that he was in good physical health and exercising regularly. He considered himself to be now fitter than ever before. He drank alcohol socially but did not smoke. 87. In relation to return to work plans, his ultimate goal was to become a general practitioner in private practice, focusing on heart issues. He did not want to practise again as an anaesthetist. He understood that, having been out of practice for 18 years, he would need to be highly supervised and have a graduated return to practice. He would have to start in a junior hospital position working under close and regular supervision from a senior practitioner. Obtaining such a position would not be easy, but he had contacted a number of hospitals and believed he had a reasonable chance of engagement. He was prepared to start in an observer capacity and would comply with any conditions imposed on his registration as well as seeking the mentorship of a senior practitioner. 88. In relation to keeping up his medical knowledge, Mr Reimers pointed to his PhD in cardiology and stated that he had an interest in becoming a GP with a special interest in heart health. He had spent time observing a GP work and realised that this work would suit him. He had tried to improve his skills and knowledge of the management of cardiac arrests by undertaking Australian Resuscitation Council accredited training in Basic and Advanced Life Support. He had attended conferences in 2007 and 2008 and gave an oral presentation at one of the conferences. In 2011, he had published a paper relating to cardiovascular research. From 2015 to August 2018, he had completed some 17 courses with face-to-face teaching. He had participated in a clinical observership in Albury, in 2016. Since 2015, he had attended at approximately 10 Grand Rounds at RPAH, and had read numerous articles in the Medical Observer Newsletter, to which he subscribed. He had completed online learning modules, through a number of websites, citing 96 credits (equivalent to 96 hours) on one site since February 2014, 32 programmes since August 2015 on another site, and 54 courses completed since November 2015 on a third site. Mr Reimers stated that the courses completed covered a wide range of topics, including diabetes, asthma, stroke prevention and antibiotic prescribing. Numerous certificates of completion were annexed to his statement. 89. Mr Reimers filed a further statement after attending Dr Glen Smith in February 2018. Dr Smith had been requested by the Medical Council to provide an independent psychiatric assessment. In the course of the assessment, Mr Reimers was asked about his consumption of alcohol. He stated that he never had a problem with drinking but he was aware of many members of NA also having a drinking problem and respected their views of the role of alcohol in their addiction. He was not opposed to attending Doctors in Recovery or NA in the future, although, for personal reasons, he had preferred SMART Recovery. Mr Reimers described his drinking as being social and typically 2 glasses over 5 hours at the weekend. He had never felt compelled to drink, and could stop at any time. He drank to interact with family and friends, but did not need to turn to alcohol in times of stress. After 18 years of not taking drugs, he did not feel his continued mild intake of alcohol would cause a relapse in the future. Since seeing Dr Smith, who recommended complete abstinence from the use of alcohol, he had ceased alcohol consumption entirely and had undertaken twice weekly urine EtG tests. Copies of the results of those tests, indicating a negative result, were before the Tribunal. 90. Mr Reimers had also made further inquiries about his Return to Practice plan. He had come to realise that, given his circumstances, becoming a GP would not be an easy route. He had inquired about internships, including a position advertised at Tweed Hospital. He had also explored the possibility of becoming an Anatomical Pathologist and applied for recent vacancies at Tamworth and Wagga Wagga Hospitals. Both Hospitals indicated that this could be a viable career for him, especially considering his PhD work. He would need to undertake up to 2 years of clinical experience in a hospital, and then 5 years of further training, before being fully qualified. 91. Although he had not contemplated returning to anaesthetics, Mr Reimers had recently become aware that ANZCA had introduced a new scope of practice called non-interventional anaesthetics, which did not involve the administration of anaesthesia or sedation in operating theatres or elsewhere, nor did such anaesthetists work in a hospital or practice environment. They would not be expected to respond to emergency situations. The role was primarily to conduct pre-operative assessments, but they could also be involved in performing research, lecturing or training. He believed this role was most appropriate and practical for him, at this stage, and he had prepared a draft return to practice plan. He did not want to rule out returning to become a GP or taking a position in an emergency-related area of practice, but realised he would be subject to close supervision. In this further statement, he updated the online courses that he continued to take and annexed certificates of completion. He stated that he continued to attend Grand Rounds and included his notes in that regard. 92. Mr Reimers filed a third statement, in which he provided details of the failure of his care in resuscitating the patient who died. He had previously found the memory of the death too painful to talk about, although he wanted to be held accountable for his actions. He was therefore grateful that his legal team advised that, for the 2003 hearing, he could confine his preparation to his road to recovery from addiction and establishing that he was no longer impaired. In his view, in taking that course, the Tribunal in 2003 was not given the opportunity to fully assess his conduct on that day nor his remorse and contrition. Nevertheless, he accepted that he deserved the severe consequences of losing his right to practise medicine. He stated that, on the day in question, all his thoughts had been conditioned by his addiction and that he was not really in control of himself. His craving to use pethidine, the weekend prior, was intense and he took an opportunity, during the operation, to obtain some excess pethidine. He hid it up his sleeve and was consumed by thoughts as to when he could use it. In order to keep the drug he left the theatre to put it in his sock as that was more secure – he would otherwise never have left the operating theatre. 93. In relation to his conduct in the theatre and in recovery, Mr Reimers repeated that he was absorbed by the prospect of taking the drug to the point that he said he was "in a fairly euphoric mood" and then a further opportunity arose from another operation to secure more of the drug. He was eager to get the patient to recovery and became distracted with some tubing and cables that had fallen away. While his back was turned, the wardsman wheeled the bed out of the theatre without his knowledge. Normally, he would never have taken a patient to recovery if they were not breathing on their own. He accepted that this represented an unacceptable risk and a major departure from his usual standard of care. When he caught up to the wardsman, he saw that the breathing tube was still in the patient and he panicked and did not know what to do. He said he became trapped in a course of action he was deeply unhappy about. In recovery, he did not tell anyone exactly what had happened. Unlike the nurses in recovery, he was unable to be objective. It was many minutes before he realised just how serious the situation was, and by then it was too late. His heart sank, and he knew that he had made an unforgiveable mistake and felt all hope disappear. 94. He stated that his conduct on that day in February 2000 was not characteristic. Mr Reimers said that the number of anaesthetics he had given in his care was in the thousands. He understood that that the HCCC had comprehensively reviewed every anaesthetic procedure he had been involved in since the mid-1990s, but no other issues of sub-standard care or question of skill was raised. He did not suggest that because of this one case, resulting from his addiction and consequent impairment, that other patients were not put at risk. He understood that his addiction and need to obtain and use drugs put his own interests ahead of those of his patients. He said that he was profoundly sorry and ashamed that he practised in such a state over such a long period. 95. Mr Reimers then raised his Return to Practice Plan. He referred to his previously stated desire to be registered as a specialist medical practitioner, and to that end had been in further contact with AHPRA and ANZCA. In particular, he had been in contact with the Director of Professional Affairs for ANZCA who had offered him assistance with tailoring a return to practice plan that would involve, initially, working under supervision for 12 months in a general medical position in a public hospital approved by the Medical Council. During this time, he would re-engage with his anaesthetist colleagues and continue CPD for the College of Anaesthetists. Emails passing between them were annexed. Subject to satisfactory progress, after 12 months he would be able to apply to ANZCA to have his Fellowship re-instated and in consultation with the College, prepare a re-entry to specialist practice plan. He was aware that such a plan would be subject to any conditions on his registration and that he may well be limited in the scope of his practice for the foreseeable future. 96. Mr Reimers concluded this last statement by saying that he continued to abstain from drinking alcohol, and continued to undertake routine testing for drugs and alcohol. Up-to-date test results were supplied to the Tribunal. He stated that he had undertaken further online medical courses and supplied his recent results. 97. In oral evidence, Mr Reimers provided evidence of the type of online courses he had undertaken and the scope of subject matter involved. A number of courses, however, were only available to registered practitioners. He had also undertaken informal discussion with his medical colleagues. He accepted that he needed to get up to speed on his basic knowledge and therefore looked at basic CPD topics. He acknowledged that he had mentioned a number of possibilities in his return to practice plan, that he understood that patient safety was critical, and that he needed to be trained. He therefore proposed to seek a generalist position in a public hospital and, thereby, to rotate through the terms. When he was comfortable with his level of knowledge, and his supervisors agreed, he would consider the next step. After 2 years, he may be able to get back into anaesthetics under level A or B supervision where he would be placed like a junior doctor. He had no problem with level A supervision. He had spoken to a number of hospitals but they were not prepared to consider placing him until he was registered. The Tamworth Hospital was a possibility but he still needed to be registered. He had spoken regularly to two doctors about his return to practice and they were very supportive of him and encouraged his return to anaesthetics. He had kept in touch with them for many years, but accepted that he needed to take advice from a wider field of practitioners. 98. When asked about the risk of relapse and his consumption of alcohol, in the context of new risk factors arising from a return to practice, Mr Reimers said that it was not just stress that led to drug abuse. He referred to his life now being ordered, with a variety of interests, and how different this was to his lifestyle during the period of his drug use. He understood the accountability of practice and that doctors put pressure on themselves and that emotional relapse occurs and therefore mentors were needed to address the issue. 99. In relation to feeling drug urges on return to practice, Mr Reimers said, firstly, that such urges had to be recognised and treated early, as it was insidious. He may have to stop working, and he would need a person to go to where he had a good relationship and could talk to them. If such a person was not immediately available, he would need to delay and distract himself but he did not want to get to this stage. His urges had only lasted for about twenty minutes, so he could get his mind onto something else and control his mind by distraction. He did not see himself being supervised for the rest of his life in practice, and hoped he would progress. 100. Mr Reimers was extensively cross examined on his three statements and the matters that had occurred since February 2000. When was asked if he had discussed the changes in medical science and practice over the last 18 years, Mr Reimers said that he did so with 3 doctors, although such discussion was mainly about their own practice. He was aware of changes in technology and that there were many things a GP could deal with online. There were also regulatory changes, specialised drugs, and more preventive screening, but basic medicine had not changed. He had not discussed practices for the RMO role because he had not got there yet. He realised that he was now at the level of a junior doctor but he was ready, with supervision, to practise safely. He agreed that his Return to Practice Plan was incomplete. 101. Between 1998 and 2000, Mr Reimers agreed that he used pethidine, but not morphine, and that he had used hospital supplies. In 1997, when asked about his drug use by the Medical Board, he lied about self-administration. In August 1997, at a hearing before the Impaired Practitioners Panel, he had lied about not taking opiates in attempting to protect his drug supply and its availability. In 1997, he had lied to Dr Wright and he did not accept then that it was shameful to use drugs. In 1998, conditions were placed on his registration and, six weeks later, he sought to have the conditions removed, and then went back to drugs. In 1998, he did not tell the College of Anaesthetists about his drug use, a decision he now regretted as they were trying to help him. 102. Mr Reimers said that shame about his drug use was significant. He kept his drug use secret, admitting it to nobody, not even his wife. In 2000, he finally admitted he had a drug problem but he was still ashamed and could not speak openly about it. He accepted that there was arrogance as well in play. In the last few years, he was working to be able to call for help and not cover up. At the time, there was another part of him that wanted to keep using. When confronted about his use he was unable to disclose the truth and denied help that was offered. He then made up stories that were accepted. He had come to realise that there was nothing to hide anymore, and his drug history was out in the open. It could not be denied now and it was not good for him to try to do so. 103. On return to practice, Mr Reimers said he would want a colleague with whom he could be open, someone he could talk to, without being judged, especially if he had issues. If a trusted person was not available, he said he could now talk to anyone, and in fact it was good for him. There were therapeutic benefits of speaking about problems and he believed that a person should take responsibility for their faults. 104. In light of his evidence about bullying and his vulnerability to harsh criticism, Mr Reimers was asked how he would cope with such criticism when working, upon re-registration, as a junior doctor with a low level of knowledge. He responded by saying that he was older now, had a better attitude, and could address any faults. He would be fully engaged in his retraining. 105. Mr Reimers' attention was drawn to the 2003 decision of the Tribunal and he accepted the evidence against him. In this case, he was not making excuses for what happened to his patient. In the recovery room, he wanted to look like he was in control. He was then asked if this episode was evidence of a lack of skill or character or was it a matter of being under the influence of drugs. He responded that it was largely evidence of addiction and being put in a position of having to defend his actions. He knew how to detect a cardiac arrest and wanted to be seen as coping. While he was fully trained, this lack of skill was due to drugs and their effect on him. He accepted the finding of the Tribunal in 2003 about his patient and his lack of skill and character on that day, but he did not have that lack of character now. 106. Questions were then directed to the applications made by Mr Reimers for registration in Victoria and Queensland. He said that, while he accepted the 2003 decision, he was providing fresh evidence of being drug free. He made these applications after 9 years rather than the 10 years set by the Tribunal because he thought it was available in those States and the National Law had not yet come into operation. In these applications, he had not ignored Dr Samuels' advice as he had consulted Dr Dalton and Dr McShane. They had discussed his recovery and were happy with his progress and had determined, under the Health Care plan, that he did not need to see them further. 107. In relation to the 2015 decision of the Tribunal, again he was not challenging the findings of the 2003 decision although there were some aspects he could not understand. These were aired in the Supreme Court. He could not understand how, in 2003, it was decided that it was a matter of his character as well as his impairment. He did not believe that the issue went beyond addiction. If he was impaired at the time, how could the Tribunal say that he might be unfit forever? There was no allegation, outside the February 2000 tragedy, that questioned his skill and competency. 108. Mr Reimers said that his return to practice plan was difficult to specify because Hospitals wanted doctors who were already registered although some liked the look of him because of his PhD. It was futile to seek Resident Medical Officer positions because he was not yet eligible. 109. Evidence was also called from Dr Sexton, who was an anaesthetist who had worked with Mr Reimers at Westmead Hospital. He had supervised Mr Reimers at that Hospital in 1989, and regarded him as exceptional and as standing out as unique. Because of his experience in the RAAF he was disciplined. While at Westmead, there was a quality assurance programme but there were no reports of complications involving Mr Reimers. He considered Mr Reimers to be an outstanding person and was shocked at his misconduct. In August 2017, he had caught up with Mr Reimers and they had continued to meet from time to time. He proposed himself as a mentor to Dr Reimers, a role he had been involved in for registrars. He said that he would continue to support Mr Reimers, even if he failed in this application. In addition, he said he knew the supervisor who Mr Reimers said bullied him and that person had a reputation for bullying. In cross examination, he stated that he had never before been a mentor to a de-registered practitioner. 110. Three doctors were called to give evidence at the hearing. Dr Ricardo Farago, consultant psychiatrist, had treated Mr Reimers since February 2015 and had seen him on 51 separate occasions up to September 2017. He provided an extensive report, dated September 2017, and an updated report in March 2018. Dr Glen Smith was a consultant psychiatrist and specialist in Addiction psychiatry. He was asked by the Medical Council to provide an independent psychiatric assessment of Mr Reimers, and that report was dated February 2018. Dr Peter Anderson was a consultant psychiatrist who examined Mr Reimers at the request of the Medical Council and provided a report in July 2018. Dr Michael Amos, a specialist anaesthetist, at the request of the Medical Council, provided an Expert Assessment of the Proposed Return to Practice Plan put forward by Mr Reimers, dated July 2018. Dr Amos was not called to give oral evidence. 111. By order of the Tribunal, Dr Farago, Dr Smith and Dr Anderson met via teleconference, in late July 2018, to enable a joint discussion and the preparation of a joint statement regarding points of agreement and disagreement, relating to Mr Reimers' application to the Tribunal. As a consequence, the doctors prepared a Conclave Statement representing the result of their discussion. 112. The Conclave Report stated that there was agreement that Dr Reimers had a history of severe Opioid Use Disorder and that he presented in Sustained Remission from that condition. The Report then dealt with questions framed in Dr Anderson's report of July 2018, as follows: 1. It was agreed that Dr Reimers had insight into the conduct found by the Tribunal in 2003. Dr Smith considered he had limited insight into the need for abstinence from alcohol and this was a point of difference with the other two Doctors; 2. It was agreed that Dr Reimers had remorse in relation to his prior conduct; 3. It was agreed that he had overcome the defects in his character that led to his de-registration; 4. It was agreed that there were no current character defects impacting on his ability to practice medicine; 5. It was agreed that there was a risk of relapse present in any patient with a history of severe Substance Use Disorder. Dr Smith maintained that the risk of relapse would be higher if he continued to consume alcohol but Dr Farrago and Dr Anderson did not agree with that view. Dr Smith acknowledged his reported abstinence from alcohol and that it was a positive factor reducing his risk of relapse; 6. It was agreed that Dr Reimers presented as not currently impaired, and as fit to practise medicine on the proviso that he was to be monitored in the Health Program with strict conditions if re-registered. Dr Smith maintained the opinion that the use of alcohol would raise a risk of relapse unacceptably in Dr Reimers' case, but that view was not shared by Dr Anderson and Dr Farago; 7. It was agreed that there were no current psychological or behavioural aspects of Dr Reimers which may affect his judgment or ability to act in the best interest of his patients. Dr Smith noted that Dr Reimers had decided to abstain from alcohol and that was agreed to be a positive factor; 8. The only point of difference between the doctors was whether Dr Reimers should abstain from alcohol, and that monitoring should occur to ensure continued abstinence. This was Dr Smith's view, but it was not supported by Dr Anderson and Dr Farago. All doctors considered that there would be a higher risk of relapse with the use of alcohol in people with a history of severe Opioid Use Disorders. Dr Anderson and Dr Farago considered that Dr Reimers had demonstrated that he could consume alcohol without increasing the risk of relapse to opioid consumption or switching to problematic alcohol consumption. Dr Smith did not consider that there was adequate evidence that Dr Reimers had not engaged in problematic alcohol consumption; 9. It was agreed that he had not relapsed despite significant stressors in his life and that was a positive factor. It was also agreed that returning to medical practice would be a substantially stressful period associated with an increased risk of relapse. Dr Smith considered that the use of alcohol, increasing the risk of "cross-reinstatement" to opioid use, would present an unacceptable risk, given the need to protect the safety of the patients. All doctors agreed that there was necessarily a high standard for reduction of risk of relapse given the specific risks to patients associated with relapse in medical practitioners; 10. There was general support for Dr Reimers' application for restoration to the register. Dr Smith qualified that view with the assumption that Dr Reimers would abstain from alcohol and that it would be monitored. 1. The doctors were sworn together to give oral evidence at the same time, and each doctor was provided with an opportunity to deal with or answer every question asked in examination or cross examination. The doctors were closely questioned by both counsel over an extended period. 2. In oral evidence, Dr Anderson said that it was difficult to assess personality when a person was in the grip of drug addiction – personality and character were best assessed when a patient was free from drugs. Dr Smith agreed with that view and stressed that he had seen Mr Reimers only once for assessment and that his treating doctor was better placed to comment on this aspect. He also said that he did not find Mr Reimers to be anti-social or narcissistic. 3. The doctors were asked to comment on the fact that, at the time that Mr Reimers was trying to resuscitate the patient, he had refused assistance and whether that was a sign of arrogance or a lack of insight. Dr Farago said that, at the time, Mr Reimers was impaired and it was impossible to determine whether his conduct was arrogant or lacking in insight. Dr Anderson said that his actions were poor because of his addiction, whether under the influence of the drug or not. Dr Smith said that he was either under addiction or impaired. Dr Farago said his opinion would not change if Mr Reimers was not under the effects of drugs at the time of the incident. 4. In relation to Mr Reimers lying while drug addicted, Dr Farago said that a person would say anything while under the influence of drugs. Dr Anderson thought Mr Reimers had been slow to stop lying and that people with drug impairment usually got the message quicker than Mr Reimers had, but some others do not hit rock bottom until later. 5. It was put to the doctors that Mr Reimers did not have full insight even now. Dr Anderson said that he had gained insight later, and had no reason to question it. Dr Farago said he needed to talk to Mr Reimers about the 2003 case but he certainly had insight now and it was full insight into his addiction and problems. Dr Anderson was of the opinion that he had full insight into the failures of his conduct and the harm done to patients. Dr Smith disagreed about the use of the past to assess insight. Mr Reimers had admitted no insight at the time but later said he had insight. Dr Farago added that it was difficult to say when he gained insight, whether in 2005, 2008 or 2010, but that between 1995 and 2000 he had no insight. In any event, from 2015 he had clearly accepted the need for change. He had discussed relapse prevention and all types of scenarios with Mr Reimers. Dr Anderson also noted that he had engaged in self-help as a recovering addict and continued to do so. Dr Smith said the biggest risk was of relapse and Mr Reimers had no real insight into what would happen when he engaged in full time practice. This was difficult and so he needed to engage in a recovery programme. 6. The doctors were then asked how to manage and prevent relapse, especially if Mr Reimers was working where drugs were available. Dr Smith said that strong supervision and monitoring was required, including extensive testing. Mr Reimers would need support from someone really important, and could get that in a recovery programme. He would need extremely close supervision, such as Category A supervision. Dr Anderson agreed with these supervision proposals. Dr Farago said that it depended on what practice Mr Reimers took up. He should not have access to schedule 8 drugs, and if there was such access then close supervision was necessary. Random drug testing was also required. 7. A question arose as to whether the various applications and legal review applications were evidence of a lack of insight. Dr Farago had asked about these steps and concluded that they were not the result of arrogance or a lack of acceptance of the decision in 2003, but rather that Mr Reimers did not seem to understand the process. He was ashamed and guilty and seemed half hearted. He did accept the criticisms, and that they were valid, but had seen others readmitted in a much shorter time and did not know why he could not resume because he regarded himself as drug free. Dr Anderson said that Mr Reimers understood he was deregistered because he was a pethidine addict but he was later no longer addicted so asked why he could not go back to practice. Mr Reimers did not see character as a separate matter nor did he see that he needed other proof of his drug free state. Dr Smith was of the view that the appeals were not properly prepared, and that they showed a lack of insight. By 2015, Mr Reimers had taken positive steps to see Dr Farago and to be involved in programmes and the like. 8. Dr Farago was asked about the application in the Court of Appeal, in 2012, where Mr Reimers argued that the Medical Tribunal had acted unreasonably. Dr Farago said that character was not an issue before the Tribunal, yet it seemed to find against him on that issue. That was Mr Reimers' complaint about unfairness, and he claimed there was no basis for such a finding. There was no evidence about character and so the question was raised how could there be such a finding. 9. The issue of alcohol consumption was again raised, in the context that, after 18 years, there had been no evidence of relapse, although Mr Reimers did drink. Dr Smith said that the length of time did not change his view that there was a risk if he drank and returned to practice. Dr Farago pointed to research papers that said that the longer a person was in remission the less likely they were to relapse due to alcohol. He noted that, in the last three years, Mr Reimers had experienced many stressors, and was drug tested, but found to suffer no relapse into drugs. 10. The doctors were asked if addiction impaired clinical skills greatly. Dr Smith said that withdrawal itself was especially harmful and could go for days or weeks. A person could be significantly affected the day after taking a drug dose. Dr Farago said that addicted patients think that they are perfectly fine and are not addicted. 11. Dr Farago was directed to his first report where he advised against Mr Reimers returning to specialist practice because of the risk of psychological stressors and the availability of drugs. Dr Farago said that he had now changed his view after he had spoken to drug and alcohol experts, but Mr Reimers would need category B supervision. Dr Smith thought Mr Reimers could go back to anaestethics but if would be difficult with the risk of relapse being no different to anybody else. As long as he had support he would do as well as anybody else. 12. Dr Farago was also asked about his second report, where he spoke of Mr Reimers' fluency in medical knowledge. He said that they had spoken of medical matters and this was the basis of his opinion. He was not aware of Mr Reimers undertaking a medical competency test. Mr Reimers told him that he had tried to undertake certain online programmes but it was a requirement that he be registered as a medical practitioner. Therefore he did whatever other courses were available. 13. In submissions for Mr Reimers, it was put that he fully accepted the 2003 findings of the Tribunal, regarding his wrongdoing and guilt, but did not necessarily accept other interpretations of that decision. Mr Reimers had undergone testing for drugs from 2000 to 2010. Since 2015, the evidence was that he had been continually tested, without missing an appointment, with a nil detection result. That testing was carried out in accordance with the Medical Council's Urine Drug Testing (UDT) Protocol. The evidence was that Mr Reimers was in remission and has been since 2000. Dr Farago's evidence was that he had been seen on 56 occasions, and was accepted as truthful, and had been honest about his long term abstinence from drugs. His dishonest behaviour up to 2000 was a function of his illness of opioid addiction, rather than any inherent character defect, a view that was shared by Dr Fisher. Further, he noted that Mr Reimers had accepted the faults found by the Tribunal in 2003. 14. Since late 2015, Mr Reimers had been dedicated to building up his medical knowledge, having undertaken over 130 online courses in general medicine topics. In addition, he had undertaken a number of face to face teaching programmes and attended grand rounds at RPAH on a semi-regular basis. He gave evidence of discussions with relevant authorities, concerning the development of a Return to Practice Plan, initially with general registration. 15. Since his de-registration, Mr Reimers had been assessed by three psychiatrists appointed by the Medical Council, namely Dr Fisher in respect of the 2014 application for review, and by Dr Smith and Dr Anderson in respect of this application. In 2014, Dr Fisher concluded that Mr Reimers was fit to return to practice with conditions, having gained the necessary insight into his misconduct, and was most likely a reformed man. Dr Anderson and Dr Farago also came to the view that he was fit to resume practice with appropriate conditions. 16. Dr Smith was of the view that, if Mr Reimers abstained from alcohol and attended support groups, he was a fit and proper person to resume registered practice. Dr Smith was concerned, however, that someone with a previous drug habit, who continues to consume alcohol, represented an increased risk of relapse. It was submitted that, as shown by the evidence given by Dr Anderson and Dr Farago, this view was not universally accepted. Other psychiatrists who had provided reports, including Dr Fisher, had not identified alcohol consumption as having any impact on the likelihood of relapse. It appeared that Dr Smith had ignored the fact that Mr Reimers had been consuming alcohol in moderate quantities for the entire time he had been in remission but had not cracked. 17. It was accepted that Mr Reimers had experienced some difficulty in formulating a strategy for his return to practice, and had changed his mind several times. While this might appear to be unsatisfactory, it reflected an evolution in his thinking as the matter progressed. In his circumstances, developing a return to practice plan was always going to be a problematic exercise and with an absence of 18 years from practice he was at a considerable disadvantage in demonstrating his worth to prospective hospital employers. It should be no surprise that he had been unable to obtain any firm commitments to date. 18. Mr Reimers accepted that he will have to serve a substantial "apprenticeship" in the hospital system, whatever his final path may be. He also accepted that any position would come under close scrutiny from the Medical Council, in terms of appropriate supervision and continuing education. A detailed list of appropriate conditions was provided to the Tribunal and the respondent for consideration. He agreed that those conditions would provide for ongoing drug testing and he was prepared to join the Medical Council's Health Programme. It was further submitted that Mr Reimers understood that he would need to be reintegrated into the profession through an extended period of hospital service, and that there were no guarantees in this regard. Those matters, however, should not preclude him from the chance to restore his reputation and to return to his profession. 19. Submissions for the Respondent were detailed, and addressed the relevant principles applicable on a review where re-instatement was sought by a medical practitioner. Those principles were not in contest, and the parties agreed that Mr Reimers bore a heavy onus in demonstrating that he was now a reformed person and a fit and proper person to be registered as a medical practitioner. Protecting the interests of the public was an integral part of the Tribunal's role (Mukherjee v Medical Council of NSW [2018] NSWCATOD 124). Further, it was submitted that, in accordance with s 163C(1) of the National Law, the Tribunal was to determine the appropriateness of the order concerned, as at the date of hearing. 20. Briefly stated, the Medical Council opposed the application on the following grounds: 1. Mr Reimers had not discharged the heavy onus of proving he was a fit and proper person to be re-registered. He had limited insight into the requirements of practice as a Resident Medical Officer; 2. He had not provided sufficient evidence of his up-to-date medical knowledge, such that the Tribunal could comfortably conclude that he can now undertake practice as a Resident Medical Officer; 3. He had not prepared a proper return to work plan for the position of Resident Medical Officer. His evidence was that he had not had a specific conversation with anyone regarding the skills and scientific knowledge required to undertake practice as a Resident Medical Officer in current times. There was very little evidence that he had a realistic prospect of retraining and of obtaining work in the medical profession under supervision. 1. In support of these grounds it was submitted that Mr Reimers did not present as an impressive witness with genuine insight. On many occasions, he gave longwinded answers that were not directly responsive or helpful to the Tribunal. At times, he appeared defensive and to recite pre-rehearsed answers. 2. An important consideration for this Tribunal was the view expressed, in 2003, by the Tribunal that there was doubt as to whether Mr Reimers would ever be fit to practise. This was said to be a serious indictment of his skill and character. In 2012, the Court of Appeal said that the findings in the 2003 decision were a serious hurdle in the path of his re-registration. It was submitted that the 2003 decision was not limited to Mr Reimers' character or drug taking, and the Tribunal was also critical of his competence and found that he had a deficit of skill and character, a point recognized in the 2015 decision. 3. In relation to Mr Reimers' drug abuse, it was submitted that, while he continued to assert that he was drug free from 2000, there was no evidence to support that proposition except for 2009 and 2010 and the period 2015 to 2018. His assertion might be treated with caution given his prior dishonesty – in dealings with the Impairment Panel, Dr Dalton and Dr Wright, and the College of Anaesthetists – when he failed to disclose his use of drugs. In the period since 2015, Mr Reimers had asserted compliance with the Medical Council protocol, but did not specify the relevant protocol. In those circumstances, the Tribunal should exercise care and caution in deciding whether to accept that he has been drug free. 4. In the 2015 decision, the Tribunal found that Mr Reimers had still not come to terms with the 2003 decision. He had repeatedly ignored advice to undertake drug testing and regular therapy. Instead, he pursued legal avenues to quash or by-pass the 2003 decision. These actions showed a lack of insight into the 2003 decision, especially in relation to the order that he not seek a review for 10 years. In giving his evidence in this case, Mr Reimers still did not fully accept the 2003 decision that his character and skill were significantly deficient. 5. In the present case, evidence had been received from Dr Anderson, Dr Smith and Dr Farago. They generally agreed that Mr Reimers had demonstrated insight into the conduct underlying the 2003 decision, that he was remorseful, and that currently he was not impaired. It was submitted, however, that there were obvious limitations to that expert evidence. Dr Anderson and Dr Smith had seen Mr Reimers only once, for the purposes of these proceedings, and did not have a prolonged therapeutic relationship with him. There was no explanation of his character flaws, as evident in [redacted] his belligerent behaviour towards medical regulators. There was no evidence that these matters were explored with Dr Farago or any other doctor, and it was not clear that Mr Reimers has any insight into aspects of his character that triggered or might have triggered such behaviour. The expert opinions about insight appeared to be limited to insight into impairment occasioned by the use of opioids. All experts agreed that there was a risk of relapse. 6. The evidence showed that Mr Reimers had not taken steps to maintain the currency of his medical knowledge. Between 2001 and 2003, he studied Law. Between 2004 and 2006, he lectured in basic chemistry, medicine, anatomy, and physiology at an alternative medicine college. Between 2006 and 2009, he completed his PhD in Cardiovascular Medicine. He had undertaken limited reading of medical textbooks and subscriptions. His limitations in this area were highlighted by the Tribunal in the 2015 decision. In the present case, there was no evidence from an appropriate person as to his current medical knowledge and his understanding of professional practices. 7. In his three statements, Mr Reimers changed his mind about a suitable future medical role he might pursue. These shifts were troubling and showed a lack of a clear path to return to practice and understanding of what was involved in these roles. There was little evidence of him having taken serious steps to undertake appropriate observerships, nor did he provide evidence of establishing and maintaining networks with other medical practitioners working in a hospital setting. Consideration 1. In view of the number of applications made over time by Mr Reimers, it is appropriate to state at the outset that this review concerns the decision made by the Medical Tribunal in 2003, as was acknowledged by both parties. The applications for registration made in Victoria and Queensland, the applications for judicial review made in the NSW Court of Appeal, and the 2014/15 application to this Tribunal, serve as significant background to assist the Tribunal to determine whether or not Mr Reimers has successfully addressed his previous drug taking habit and whether or not, to put it briefly, he can now be regarded as a fit and proper person to be registered as a medical practitioner. 2. In the 2003 decision, the Tribunal noted that, largely, the facts were not in dispute. While the mismanagement of the patient who died was properly the focus of detailed examination, there were other complaints concerning Mr Reimers' personal use of drugs from hospital stocks, his misleading of the Medical Board on a number of occasions, and significant deficiencies in his record keeping during a specified period. Three specialist anaesthetists voiced severe criticism of his competence, in relation to the matters particularised, although one specialist thought his failure to use a venous catheter on one occasion deserved only moderately critical comment. Mr Reimers' use of drugs since 1995, and the circumstances in which he obtained those drugs, were clearly important considerations. 3. Expert psychiatric evidence, at that time, was that Mr Reimers still suffered from a substance abuse disorder that was potentially a relapsing condition. Without independent verification by way of testing, the Tribunal was unable to accept his assertion that he had been drug free since 2000. It was found that he demonstrated extremely significant deficiencies in both character and skill in the practice of medicine and noted that it was difficult to conceive that a more serious finding could be made against a medical practitioner. His deficit of skill and character was so great as to cast doubt upon whether he would ever be regarded as a fit and proper person to practise medicine. He would not be able to apply for registration again for a period of ten years from the date of decision. By any standard, these were damning findings. 4. It is convenient, at this point, to deal with an issue that was given some prominence in the present proceedings, being what was contemplated by the Tribunal in 2003 when it referred to Mr Reimers' deficit of skill and character. Mr Reimers stated in this case that he could not understand the reference to character when the whole issue was the extent of his impairment brought about by drug use. It is to be noted that there is no reference in the 2003 decision to [redacted]. No other issues of general character were mentioned. These Court matters were raised in the 2015 decision but the Tribunal did not regard them as having any significance for the determination of the application then under consideration. It therefore appears that the reference to a deficit of skill and character, in the 2003 decision, encompassed Mr Reimers' considerable failures in relation to the patient who died and his failure to meet medical standards whilst impaired, and to his long history of dishonesty and deceit in dealings with colleagues, administrators and regulatory bodies about the extent and nature of his drug abuse. Mr Reimers gave uncontested evidence in these proceedings that he had been informed that his entire medical career had been examined by the HCCC, but that no other issues of sub-standard care or skill had been raised. 5. In 2009, the Victorian Board accepted that drug problems could affect character. In the present proceedings, Dr Anderson said that it was difficult to assess personality when a person was in the grip of drug addiction and that personality and character were best assessed when a patient was free from drugs. Dr Smith agreed and thought that Mr Reimers' treating doctor was better placed to address this issue. Asked if addiction impaired clinical skills greatly, Dr Smith said that withdrawal itself was especially harmful and could go on for days or weeks. Dr Farago expressed the view that a drug addicted person would think that they were perfectly fine and not addicted. The Tribunal accepts that this was the context in which Mr Reimers' character was addressed in the 2003 decision. 6. A further matter agitated in the present hearing was the high onus of proof required of Mr Reimers in order to obtain re-instatement. That description of the onus borne by Mr Reimers was accepted by the parties. The Tribunal considers that it is a statement of principle long recognised in this type of application. In this context, the Respondent drew attention to the conclusion of the Tribunal in 2003 that the deficits of skill and character of Mr Reimers were so great as to cast doubt upon whether he would ever be regarded as a fit and proper person to practise medicine. It is to be noted that, in the 2012 judgment of the Court of Appeal, it was pointed out that the statement of the Tribunal did not preclude an application for re-registration, nor did it prevent such an application being granted. Nevertheless, that judgment provided, whilst it stood, a serious hurdle in the path of re-registration. 7. It is necessary for the Tribunal in this case to examine what has changed in Mr Reimers' conduct and circumstances, such that he may comfortably be assessed as a changed person, who can be held out to the public as a fit and proper person to be registered as a medical practitioner. It is accepted that in this exercise Mr Reimers bears a heavy onus and that the terms of the 2003 decision represent a significant hurdle he must overcome. 8. It is clear that, in the 2003 decision, the then present state of Mr Reimers' addiction was a significant consideration. He had not contested the core of the detailed complaints, but had asserted that he had been drug free since 2000. In the absence of detailed and independent evidence that established that he had fully participated in a screening programme, the Tribunal was not prepared to accept his unsupported evidence on this matter. Indeed, the Tribunal concluded that he was still impaired. 9. While the Tribunal, in the 2003 case, had expert evidence from four Specialist Anaethetists, who dealt with Mr Reimers' conduct as an aneathetist, there is no mention or detailed record of specialist evidence supporting his case for the continuation of his registration with conditions. The Tribunal does briefly mention evidence given by Dr Dalton, who had been consulted from time to time by Mr Reimers since 1997. That reference was limited to recording her opinion that Mr Reimers had, and still had at the time, a substance abuse disorder. It is therefore unknown what evidence, if any, was given by her as to the possibility that he could return to practice. It may well be the case that the Tribunal considered the lack of evidence regarding his abstinence from drugs since 2000 as so significant that no further inquiry was necessary. That course was entirely open to the Tribunal. 10. The applications for registration made in 2009 to the Victorian and Queensland authorities faced what clearly became an insurmountable barrier, namely, the NSW Tribunal's decision that no new application for registration could be made in that State until 2013. Although, apparently, not bound at that time by any National Law to recognise and give effect to the 2003 decision, the Tribunals were not prepared to undermine those orders. The task was aided by the fact that, again, Mr Reimers did not present independent evidence of long term abstinence from drugs, as demonstrated by continuous screening and adherence to a therapy plan established by a specialist consultant. While some wider observations were made, these matters appeared to be central to the conclusion to reject the applications. 11. It is of some significance that the Victorian tribunal had evidence from Dr Samuels that it was likely that Mr Reimers' opioid dependence and abuse problems were in remission but that needed to be confirmed by prolonged urine drug screening. It appeared that, subject to such screening and engagement in a prolonged therapeutic relationship with a drug and alcohol specialist or psychiatrist, Mr Reimers may be registered again with conditions. 12. Mr Reimers' appeal to VCAT against the decision in his second application also failed, although the Tribunal made a number of interesting findings. Again, comment was made about giving full force to the 2003 decision. Reference was also made to a number of exchanges during the evidence that showed him to have an appropriate level of insight into his past conduct and appropriate remorse and empathy with both his patients and the profession. It was noted that there was still not full compliance with Dr Samuels' recommendations. Dr Dalton provided a report stating that Mr Reimers was in sustained remission, but she was not called as a witness at the hearing. 13. These applications, followed by applications in the NSW Supreme Court, were identified by the Medical Council as evidence of Mr Reimers' lack of acceptance of the 2003 findings and as indicative of his continuing lack of insight. In cross examination, Mr Reimers responded to these propositions. Having had the opportunity of considering the totality of the evidence, this Tribunal is not persuaded that the propositions are soundly based. Firstly, probably relying on his recently acquired legal qualifications, Mr Reimers decided to appear for himself in all these proceedings, and thereby denied himself the benefit of an independent advocate. Before the State authorities, he attempted to argue that he was now drug free and had been for some time, and so should be treated like others in the profession who were impaired but whom he understood were able to return to practice after a few years rather than the 13 years he was given. He had presented evidence that he was in remission, but failed to understand that what was required was independent evidence of being drug free. Before the Tribunal in 2003 he had accepted the vast majority of allegations and accepted his guilt. In the cases before the Supreme Court, he attempted to argue legal points as to why the 2003 decision was invalid; not because he was not guilty of the conduct alleged, and refused to acknowledge his past as an addict, but because he wished to demonstrate that he was now capable of returning to the profession as a drug free person and thereby could sidestep the 13 year sentence. He may well have been driven to bring these ill-advised cases because he believed that he was drug free and in remission, but the authorities would not accept his word. In each of these cases, at no point did he call into question findings about his guilty conduct. Unfortunately, this course of action only led to conjecture about his motives. It is also to be remembered, as was recently noted, that he could not understand how the 2003 Tribunal had made an apparent finding as to his character, separate from the effects of his drug addiction. 14. Whilst these various applications, pursued by Mr Reimers, may appear to be ill-advised or even ham-fisted, properly understood they did not amount to an attempt to renege on the wide ranging admissions he made in the 2003 proceedings. There is more cogent evidence now before this Tribunal of his current state of mind, insight and remorse and that will be considered later in this decision. 15. The 2015 decision of this Tribunal investigated a number of issues but made no adverse findings flowing from prior conduct that brought Mr Reimers before the Courts and the various applications to other tribunals and Courts pursued between 2009 and 2012. At one point, the Tribunal expressed its concern at the ability of Mr Reimers to obtain a hospital position, given his long absence from practice, but ultimately the crucial issue became, again, the absence of independent evidence of being drug free while undertaking an appropriate programme with a specialist. This issue had been raised with Mr Reimers during the course of the case and he had been given an adjournment to provide recent evidence of drug screening. Upon resumption, no such evidence was presented. The Tribunal observed that his case deserved the attention and presentation of a professional advocate. 16. Having regard to the manner in which the case was resolved, the Tribunal in 2015 probably concluded that it was unnecessary to consider the expert medical reports that were provided by the parties. Mr Reimers provided a report from Dr Dalton, dated August 2010, stating that he was regarded now as adequately treated and that testing had found him drug free. He was in sustained remission and should remain in remission and practice safely with conditional registration. Mr Reimers had also consulted Mr McShane and Eva Wong, clinical psychologists, and Mr McShane's report of February 2010 was before the Tribunal. Mr Reimers had attended twelve sessions and was found to be "in a very different place" to where he was 10 years previously: he had completed high level academic degrees and had become a responsible and involved father. He had now gained insight into his previous behaviour and into his developmental, relational and workplace conflict issues, which had precipitated his initial experimentation and drug dependency. It may well have been that these reports were not sufficiently current to warrant further consideration 17. The Respondent Medical Council did provide a more up-to-date report from Dr Fisher, a consultant psychiatrist, dated July 2014. This report, and the reports relied upon by Mr Reimers, have been summarised earlier in this decision, but it is sufficient to note that Dr Fisher concluded that he had insight into the conduct dealt with in the 2003 decision, that he was remorseful, and that he presented as a reformed individual. He was no longer impaired and it was reasonable for him to apply for registration with conditions attached. 18. In the present case, the Tribunal has the added assistance of three medical experts, who provided separate reports and who gave oral evidence. That evidence has been extensively summarised earlier in this decision. In short, Mr Reimers was found to have insight into the conduct that brought him before the Tribunal in 2003 and had demonstrated remorse in relation to that conduct. He had overcome the defects in his character that led to de-registration and there were no current defects of character affecting his ability to practise medicine. The defects in his character, which had led to his de-registration, were seen to be a consequence of his active drug dependence at that time. He was not currently impaired and was fit to practise medicine with strict conditions to be observed. Mr Reimers displayed no current psychological or behavioural aspects that may affect his judgment or ability to act in the best interests of his patients. It was accepted that there was a risk of relapse where there was a history of severe Substance Use Disorder, but only Dr Smith thought that risk was raised by his consumption of alcohol. As earlier noted, the three specialists were extensively cross examined but their evidence remained as frank and forceful as initially given. 19. Only Dr Farago was cross examined as to the basis of his belief that Mr Reimers had sufficient medical knowledge to resume practise, given his long absence from the profession. Dr Farago's satisfaction that Mr Reimers had fluency in medical matters arose from discussions they had over time and he was also aware that he had undertaken a number of online courses. Mr Reimers provided evidence of numerous courses he had completed, but explained that there were courses that were only available to registered practitioners and this restricted the scope of matters he could study. 20. It is of some significance that a number of specialists over the years, who had treated or provided a report on Mr Reimers' present suitability for re-registration, did not raise his lack of current knowledge as a barrier. Mostly, it was understood that he would need to commence in a very junior position in a public hospital and be subject to comprehensive conditions. Whether he is again allowed to practise in a specialty, such as anaesthesia, can only be answered well into the future and in the light of his achievements during that period. These matters were canvassed by Dr Amos, who was critical of Mr Reimers' speculation about returning to anaesthesia practice, and it is clear that there would be very substantial barriers to that occurring in the near future. However, in his evidence, Mr Reimers stated that he was aware and understood that he could only hope for a very junior medical position if re-registered. He was prepared to spend time as an observer to increase his knowledge. Finally, it seems highly unlikely that the three specialists who gave oral evidence in this case, and others in the past, who supported re-registration, would have done so if they held any doubts about his capacity to practise. Indeed, Mr Reimers' high level of academic achievement obtained since the 2003 decision supports the conclusion that he has the capacity to acquire all the skills necessary to safely practise medicine in the future. The conditions under which he resumes practice will be central to this objective. 21. Another argument put forward for the Respondent was that Mr Reimers had not presented a well thought out return to work plan and, during the course of his evidence, had changed his mind about which particular area of the profession he wished to practise. It is understandable that, after an absence of 18 years, he has been unable to secure a possible or firm offer of employment. Much will turn on the terms of his re-admission. Mr Reimers believed that he had real interest due to his PhD but he understood he faced stiff competition for junior positions. His past work history, and the areas where he has made enquiries recently, suggests that he is prepared to work outside of the city or in regional or rural areas. 22. Ultimately, this aspect of the case must be determined on the basis that the jurisdiction being exercised concerns satisfaction that the applicant is a fit and proper person to be re-registered as a medical practitioner. As observed in the 2015 decision of the Tribunal, whether or not he finds general employment or employment in his preferred field will be subject to the requirements of the market and the requirements of the Medical Council. 23. In summary, it can be concluded that much has changed since Mr Reimers was dealt with in 2003. There are two most significant changes. In this case, the Tribunal has independent evidence of continuous drug screening from July 2015 up to and including the time of hearing in September 2018. On no occasion did he fail a test. This stands in stark contrast with the absence of such evidence in the 2015 hearing. This recent history is supported by much earlier evidence of drug screening over a number of broken periods although this fact merely acknowledges that, at various times in the past, he has been able to maintain a clear drug record. The second significant change is that Mr Reimers has committed to a long term, ongoing programme with a consultant psychiatrist, Dr Farago. Between July 2015 and September 2018, he has seen Dr Farago on 51 occasions. These were the markers laid down by Dr Samuels, and Mr Reimers' failure in the past to follow those requirements has been cited by various Tribunals as the key reason for his application for re-registration being denied. Dr Farago has indicated that if re-registered he will continue to treat and monitor Mr Reimers and ensure that there is no relapse. He noted that Mr Reimers had in place measures to prevent relapse. 24. The Tribunal fully accepts the joint opinions of Dr Anderson, Dr Smith and Dr Farago, particularly as to Mr Reimers' insight, remorse, the fact that he is in sustained remission from the opioid use disorder, and that he is not currently impaired. In the 2015 case, Dr Fisher found that he was a changed man and that view appears to be consistent with the joint view expressed now by Dr Armstrong, Dr Smith and Dr Farago. It is also important to note that it was not until he saw Dr Samuels that Mr Reimers began to open up about his inner demons that led him into his use of drugs. In the present case, over the three statements of evidence he filed, apparently for the first time before a Tribunal, he spoke frankly and in detail about the circumstances leading to his addiction and his state of mind at the time his patient died. In this period, he described his life as completely out of balance. The evidence suggests that, over 18 years, he has faced many stressful situations without relapsing. Over these years, he has also participated in therapy groups including Doctors in Recovery, Narcotics Anonymous and SMART Recovery (where he has held an important position). All of this evidence speaks of a person who has, over time, come to grips with his personal problems and his drug addiction. In the view of the Tribunal, he is now a fit and proper person to be registered as a medical practitioner. 25. The Tribunal also accepts that the evidence clearly requires that, on return to the profession, Mr Reimers must be bound by strict and comprehensive conditions. This possibility was raised with the parties during the hearing and both have responded with a list of suggested conditions. Having regard also to the expert evidence, the Tribunal has formulated conditions designed to meet many of the challenges Mr Reimers will face on his return to the profession, and they are attached to the decision as annexure "A". Having regard to his particular circumstances, it is expected that the Medical Council may wish to impose other conditions deemed appropriate. Orders 1. Mr Reimers is found to be a fit and proper person to be registered as a medical practitioner, subject to the conditions specified in Annexure "A" to this decision. 2. Mr Reimers is to pay the costs of the Respondent Medical Council of NSW. ********** annexure a Public Conditions (Practice) 1. Not to undertake any practice in anaesthetics or intensive care medicine. 2. Not to possess, supply, administer or prescribe any "drug of addiction" (Schedule 8 drug) as defined by the Poisons and Therapeutic Goods Act 1966 (NSW). 1. To provide written evidence to the Medical Council of NSW that he has attended the offices of the Pharmaceutical Regulatory Unit and consented to an Order being made under the Poisons and Therapeutic Goods Act to prohibit him from possessing, supplying, administering or prescribing any Schedule 8 drug within a month of the release of the NCAT decision, made on 5 November 2018. 1. Not to possess, supply, administer or prescribe any substance listed in Schedule 4, Appendix D of the Poisons and Therapeutic Goods Regulation 2008 (NSW). 1. To provide written evidence to the Medical Council of NSW that he has attended the offices of the Pharmaceutical Regulatory Unit and consented to an Order being made under the Poisons and Therapeutic Goods Act 1966 to prohibit him from possessing, supplying, administering or prescribing any Schedule 4, Appendix D drug within a month of the release of the NCAT decision, made on 5 November 2018. 1. Prior to recommencing clinical practice, the practitioner is to complete a period of observership in a Medical Council of NSW approved accredited teaching hospital under the supervision of an experienced medical practitioner. Observership is defined as acting in the capacity of an observer, in a role equivalent to that of a final year medical student. The practitioner is: 1. To nominate, for approval by the Council, an accredited teaching hospital and an experienced medical practitioner willing to act as the observership supervisor. An "experienced medical practitioner" is defined as having current specialist registration in Australia; clinical privileges at the nominated hospital; and experience supervising medical students. 1. To ensure that he is at all times under the on-site supervision of his observership supervisor or, with the approval of the observership supervisor, a practitioner working at the level of a registrar or above. 2. To complete a minimum of 200 working days, or 400 sessions as an observer. A session is a period of at least 4 hours. 3. To complete the observership within 24 months of the Council's approval of the observership arrangements. 4. To ensure that: 1. He completes a report of his observership; 2. Yhe report includes a log of his attendance, dates and hours, the clinical practice observed, what he learnt and how this may impact on his future practice; 3. The report includes, but is not necessarily limited to, some or all of the following topics: basic clinical skills; diagnostic/problem solving skills; patient management skills; prescribing skills; medical records; infection control; management of psychosocial aspects of illness; managing workload and stress; professional ethics; the doctor-patient relationship; recent developments in medical practice; 4. At the completion of each quarter of the observership, the report is signed, with written comments on its content and its authenticity provided, by the observership supervisor; 5. The report is submitted to the Council within 14 days of the completion of each quarter of his observership; 6. The observership supervisor provides the Council with a quarterly report of his progress during the period of observation. The report should address the practitioner's progress and highlight any areas in need of development and any matters of concern. 1. Responsible for any costs incurred in relation to the period of observation and any subsequent reports. 2. Only able to seek the Council's approval to recommence clinical practice after the satisfactory completion of the observership including the receipt of all observership reports by the Council. 1. Not to recommence clinical practice prior to the Medical Council of NSW verifying his compliance with Condition 4. 2. To practise only in a Medical Council of New South Wales approved position at Post Graduate Year 1 or Year 2 level, in a hospital accredited for Prevocational Training and/or its secondment network. 3. Not to supervise any medical practitioner or student. 4. To practise under Category A supervision in accordance with the Medical Council of NSW's Compliance Policy – Supervision (as varied from time to time) and as subsequently determined by the appropriate review body. To be subject to Category A supervision for a minimum period of 12 months. 5. To obtain Medical Council of NSW approval prior to changing the nature or place of his practice, including within the approved secondment network. 6. To forward evidence to the Medical Council of NSW within 14 days of commencing practice, that he has provided a copy of this decision and a copy of his practice and health conditions, current at that time, to the Director of Medical Services and the Director of Prevocational Education and Training or equivalent and to authorise those persons to inform the Council if there are any issues of concern to them regarding his performance or health. 7. Within 14 days of a change in the nature or place of his practice, he is to forward evidence to the Medical Council of NSW that he has provided a copy of this decision and a copy of his practice and health conditions, current at that time, to the Director of Medical Services and the Director of Prevocational Education and Training or equivalent and to authorise those persons to inform the Council if there any issues of concern to them regarding his performance or health. 8. Prior to commencing his observership, the applicant is to nominate an experienced registered medical practitioner to act as his professional mentor for approval by the Medical Council of NSW in accordance with the Medical Council of NSW's Compliance Policy – Mentoring (as varied from time to time) and as subsequently determined by the appropriate review body. 1. To meet with his Council-approved mentor on a monthly basis, for at least one hour. At each mentoring meeting, the practitioner is to include discussion of the following: personal and professional development; personal and/or medical practice issues, initially issues highlighted in the NCAT decision. 2. To authorise the mentor to report, in an approved format, to the Council every three months, and to inform the Council if there is any concern about his/her professional conduct, health or personal wellbeing. 3. To authorise the Medical Council of NSW to provide proposed and approved mentors with a copy of this decision and a copy of the Medical Tribunal decision, dated 4 November 2003. 4. To be mentored for a minimum period of 2 years from the date of the first mentor meeting. 1. To authorise the Medical Council of NSW to notify current and future persons or organisations at places where he undertakes a clinical observership or works as a medical practitioner in Australia, of any issues arising in relation to compliance with these conditions. 2. To authorise and consent to any exchange of information between the Medical Council of NSW and Medicare Australia and Pharmaceutical Services for the purpose of monitoring compliance with these conditions. Private Conditions (Health) 1. Not to prescribe for self-medication. 2. Not to self-administer: 1. any Schedule 4D or Schedule 8 Drug; or 2. any narcotic derivative, non-prescription compound analgesic or cold medication. Such medications must only be prescribed and taken at the direction of his treating practitioner. 1. That, should he be prescribed or directed to take a: 1. Schedule 4D or Schedule 8 Drug, 2. Narcotic derivative, or 3. non-prescription compound analgesic or cold medication, he must notify the Council Appointed Psychiatrist and the Medical Council of NSW (the Council). In addition, within seven days, he must provide the Council with written confirmation of such treatment from the treating practitioner. 1. To continue taking any medication prescribed by his treating practitioner/s. 2. To comply with the Medical Council's Drug Screening Policy and Participant Procedure: drug screening (as varied from time to time) and attend for: 1. urine drug screening 3 times a week, and 2. quarterly hair drug screening. 1. To attend for treatment by a psychiatrist of his choice who has expertise in drug and alcohol dependence. The frequency of treatment is to be determined by the treating practitioner. The practitioner is to authorise the treating practitioner to inform the Medical Council of NSW of any of the following: failure to attend for treatment; termination of treatment; or a significant change in health status (including a significant temporary change). 2. To attend for treatment by a general practitioner of his choice. The frequency of treatment is to be determined by the treating practitioner. The practitioner is to authorise the treating practitioner to inform the Medical Council of NSW of any of the following: failure to attend for treatment; termination of treatment; or a significant change in health status (including a significant temporary change). 3. To attend a drug and alcohol recovery group (such as Doctors in Recovery, SMART Recovery, Narcotics Anonymous or equivalent) on a weekly basis. 4. That the extent of his professional medical duties is to be guided by his health status and the advice of his treating and Council-Appointed Practitioners. 5. To attend for review by the Council-Appointed Psychiatrist on a three-monthly basis or as otherwise directed by the Council, at the Council's expense. 6. To attend a Review Interview at the Council in three months or as otherwise directed by the Council. 7. To authorise the Council to forward copies of this Decision and any subsequent Council Review Interview or other reports and any other information relevant to his health and treatment, to the Council-Appointed Practitioners and to his treating practitioners. Additional Orders 1. The Medical Council is the appropriate review body for the purposes of Part 8, Division 8 of the Health Practitioner Regulation National Law (NSW). 2. Sections 125 to 127 of the Health Practitioner Regulation National Law are to apply whilst the practitioner's principal place of practice is anywhere in Australia other than in New South Wales, so that a review of these conditions can be conducted by the Medical Board of Australia. 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 Amendments 20 November 2018 - Annexure A numbering corrected. 21 November 2018 - Private Conditions in Annexure A removed, not for publication. 16 January 2019 - Private Conditions in Annexure A published by order of Presiding Member. 27 October 2021 - Redactions have been made pursuant to an order made under s 64(1)(c) of the Civil and Administrative Tribunal Act 2013 (NSW) on 27 October 2021 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: 27 October 2021