Having found the respondent engaged in five instances of professional misconduct under the Health Practitioner Regulation National Law (Victoria) Act 2009 ('National Law'), the Tribunal orders:

1. Under section 196(2)(a) of the National Law, the respondent is reprimanded.
2. In circumstances where the respondent is not registered, under section 196(4)(a) of the National Law, the respondent is disqualified from applying for registration before 10 February 2029.

1. This proceeding concerns the professional conduct of Ms Koon Hwa Vivian Lee,[1] a dental practitioner qualified to practice as an oral health therapist.
2. The conduct was engaged in at a dental practice Lee opened in September 2018 in North Melbourne (the Clinic).
3. Between January 2019 and April 2020, Lee practiced outside the bounds of her qualifications and training. She performed orthodontic procedures on 44 Patients when she was not qualified to do so and was not under the supervision of an appropriately qualified dentist. Lee billed her Patients for the procedures which she was not entitled to perform.
4. In the period March 2019 to December 2020, Lee made false and misleading clinical records about the orthodontic procedures. The notes appeared on their face to show dentists performed the procedures or that she had consulted about treatment plans and the specific procedures with dentists who worked (or had previously worked) at the Clinic. Some of those false and misleading records were made after Lee was aware the Dental Board of Australia and the Australian Health Practitioner Regulation Agency (Ahpra) were looking into her conduct.
5. During the course of the investigation into her conduct, Lee provided the false clinical records to the Board and Ahpra as if they were correct and made false statements when interviewed.
6. Fortunately, no harm came to any of Lee's Patients as a result of her conduct, however, that conduct carried with it significant risks. Any practitioner performing procedures outside their training and scope is a risk to public safety, a foundation of good practice and one of the primary objectives of the National Law.
7. In June 2024, after a computer expert had analysed the clinical records and after dentists who had worked at the Clinic had made statements, Lee made full admissions to the Board and Ahpra. Thereafter she cooperated with the investigation and the Board's referral of five Allegations to the Tribunal under the Health Practitioner Regulation National Law (Victoria) Act 2009 (National Law).
8. Early in the investigation into Lee's conduct, she gave an undertaking not to practice. That undertaking came into effect in June 2020. By the time of the final hearing in February 2026, Lee had been out of practice for five years and eight months. Lee did not renew her registration in late 2025 and so, by the time of the hearing, she was unregistered.
9. At the hearing, the parties presented a joint proposal to the Tribunal in the form of a Proposed Statement of Agreed Facts, Findings and Determinations (Agreed Statement). The Agreed Statement showed that Lee admitted all facts alleged against her, agreed that her conduct comprised five instances of professional misconduct and she was to be disqualified from applying to be re-registered for three years (added to the five years and eight months she had been out of practice). After considering the material in the parties' joint Tribunal Book (TB), Lee's fulsome admissions and the parties' submissions, we accepted those proposals.
10. Given Lee's admissions, it has not been necessary for us to provide detail about the nature of the procedures the Patients underwent or to identify them.
11. The Allegations and materials refer to five individual Dentists who worked at the Clinic at relevant times. Two of those Dentists alerted the Board and Ahpra to Lee's conduct. To avoid identifying the Patients, in circumstances no criticism was made of the Dentists and none of them were required to attend and give evidence, it is sufficient for us to identify them as Dentists 1, 2, 3, 4 and 5.

1. As stated above, the Board referred five Allegations to the Tribunal. An amended version of the final form of the Notice of Allegations is included in Attachment A to these Reasons. Consistent with the content of these Reasons, the names of the Patients and Dentists have been substituted with descriptors. Particulars which describe procedures and the content of clinical records have been omitted to protect the privacy of the Patients.
2. Each Allegation alleged that the conduct described was:

(a) professional misconduct within the meaning of paragraphs (a) and/or (b) and/or (c) of the definition of professional misconduct in s 5 of the National Law; and/or

(b) unprofessional conduct within the meaning of the definition of unprofessional conduct in s 5 of the National Law; and/or

(c) unsatisfactory professional performance within the meaning of the definition of unsatisfactory professional performance in s 5 of the National Law.

1. We refer to the terms of the relevant definitions later in our Reasons.
2. The alleged conduct in each Allegation was as follows.

1. Allegation 1 is that, between in or around January 2019 and in or around April 2020, Lee practiced outside of the scope of practice of an oral health therapist, as defined by:
   • the Dental Board of Australia: Guidelines for Scope of Practice 2014 (the 2014 Practice Guidelines);[2]
   • the Dental Board of Australia: Scope of practice registration standard 2014;[3] and
   • the Australian Dental Council: Professional Competencies of the Newly Qualified Dental Hygienist, Dental therapist and Oral Health Therapist,[4]

'by performing orthodontic procedures on 44 patients'.

1. Allegation 2 is that, between in or around March 2019 and in or around April 2020, Lee 'knowingly or recklessly made false and/or misleading clinical records'. The clinical records in issue comprised Lee adding the initials of Dentists 2, 3 and 4 on a total of 55 occasions.

1. Allegation 3 is that, between on or about 21 April 2020 and on or about 8 December 2020, Lee 'knowingly or recklessly made false and/or misleading clinical records by creating false clinical records and amending the clinical records after she became aware of the Board/Ahpra investigation'. Allegation 3 concerns:
   • 13 new clinical records Lee created after becoming aware of the investigation into her conduct, in circumstances where none had previously existed; and
   • 35 amendments to existing records made by Lee after becoming aware of the investigation. The amendments were, in broad terms, designed to appear to show one of the Dentists had performed treatment Lee had in fact performed or to reflect discussions about treatment plans or other clinical matters.
2. We note that, when Dentist 3 first became concerned about Lee's misuse of her name and provider number, she downloaded and retained copies of the clinical records she had created. She explained she did so because she realised that Lee's conduct was 'very serious' and that Lee 'had been using my provider number without my consent and had been providing treatment well outside her scope of practice'.[5]

1. Allegation 4 is that, between on or about 8 July 2019 and on or about 9 March 2020, Lee 'engaged in inappropriate billing practices by billing patients for orthodontic procedures when she knew, or ought reasonably to have known, that she was not entitled to perform the procedures'. The alleged conduct involved Lee billing under certain Medicare item numbers for orthodontic procedures when she knew or ought to reasonably have known she was not entitled to perform the procedures or bill them. The billing occurred on 23 occasions for an amount totalling more than $12,000.[6]

1. Allegation 5 is that, between on or about 17 December 2020 and on or about 31 May 2022, Lee 'knowingly or recklessly provided false and/or misleading information to the Board and/or Ahpra during its investigation'. The conduct arose from Lee:
   • Sending Ahpra the falsified patient records referred to in Allegation 2; and
   • Attending an interview on 31 May 2022 (the May 2022 Interview), during which she made statements to the effect that others, including Dentist 3, had added their initials and otherwise made the entries referred to in Allegations 2 and 3;[7] and
   • Attending a second interview on 11 June 2024 (the June 2024 Interview), during which she admitted she added the Dentist's initials and made the entries referred to in Allegations 2 and 3.[8]

1. The following comes from the parties' Agreed Statement, the TB and Lee's Written Submissions.[9]

Lee's personal, qualification and registration history

1. Lee was born in Malaysia in 1990 and migrated to Australia with her family when she was 10 years old. As at the time of the hearing Lee was 37 years' old. She is married and has two young children.
2. After completing secondary school, Lee started working as a dental assistant. And, while doing so, she obtained a Bachelor of Health Sciences at Latrobe University in 2012. She then moved to Queensland and completed a Bachelor of Oral Health Science at Central Queensland University in 2015.
3. On 10 November 2015, Lee was registered as a dental practitioner (oral health therapist).
4. Lee first worked in a Melbourne city clinic as an oral health therapist. She also worked as a dental assistant for Dentist 1 in both Sydney and Melbourne.
5. In September 2018, Lee opened the Clinic. Initially, Dentist 1 and she continued to work together but it appeared that professional relationship broke down and ended in around April 2019.[10]
6. After two Notifications about Lee's professional conduct were received in January 2020, the Board decided to investigate Lee's conduct. In May 2020, the Board gave Lee notice that it intended to take immediate action to suspend her registration.[11] Lee offered an undertaking in place of that form of immediate action.[12] The Board accepted the undertaking which took effect from 4 June 2020.
7. While Lee maintained her registration for a period, notwithstanding she was not practising, on 21 December 2025, she did not renew her registration and so it lapsed with effect from 1 January 2026.
8. Lee still owns the Clinic but is not involved in the day-to day running of the practice. It is run by a principal dentist with the assistance of two employed dentists and a practice manager. As Lee is unable to work in the practice and employs dentists to perform dental work, the practice is not profitable enough for Lee to continue to own it and she hopes to sell the practice this year.

1. As stated above, three Notifications were sent to Ahpra in early 2020. Dentist 3 first raised concerns about Lee's conduct with Ahpra and Dentist 2. Subsequently, formal Notifications were made by Dentists 2 and 3.
2. The opening paragraphs of Dentist 3's Notification captures the then concerns:[13]

The purpose of this complaint is to notify the [Board] of patients who are currently undergoing orthodontic and general dental treatment at [the Clinic] under what I suspect are treatment plans that have not been approved by a dentist. I am concerned about the possible risk of [permanent] damage to their facial skeletomuscular system by the provision of orthodontic services by a registered oral health therapist as well as other excessive treatment and potential treatment outside her scope of practice.

A secondary purpose is also to bring to light the possible incorrect claiming of treatment using the credentials of dentists who are currently working or have worked at the practice in the past.

1. Dentists 2 and 3 co-operated in the investigation of Lee's conduct and made statements.[14]
2. A third confidential Notification was made in April 2020. After identifying Lee and her Clinic, it said:[15]

we are constantly hearing rumours about her clinic and conduct. [Lee] has Dentists working for her on and off. She uses their provider numbers to run her clinic. She also does treat patients without supervision of a registered dentist since the opening of her clinic according to other practises nearby. Orthodontic treatment is a particular concern to us. Apparently, her main work is related to clear Aligners, particularly a brand named Smile Styler , which she has an account with. A Dental Therapist does not have training to provide orthodontic treatment without supervision. In our view she is putting the general public at risk with her unlawful conduct and needs to be investigated. Most patients from her clinic are not aware of her qualifications and assume she is a dentist

1. We referred above to Interviews conducted with Lee in May 2022 and June 2024. Lee was interviewed by Ahpra officers in the presence of her solicitor. She later confirmed to Ahpra that the transcript of the June 2024 Interview was accurate.[16]
2. As is apparent from the summary of Allegation 5, Lee initially stated that Dentist 3 had made certain entries in the clinical records but soon after she conceded she had made them all. The changing story is reflected in particulars 5.6 to 5.8: after saying she was 'not accusing anybody' and that it seemed from the entries that Dentist 3 had made them, at the June 2024 Interview, Lee said:

I'm going to now say that the clinical records [were] amended after I had become aware of the notification...

1. On 11 December 2024, the Board decided to refer Lee to the Tribunal for the making of findings and determinations.
2. On 31 March 2025, that referral was sent to the Tribunal.

1. The Board had the onus of proving all alleged facts.
2. We were required to make our findings of fact on the balance of probabilities, comfortably satisfied they are open on the evidence, taking into account the seriousness of the allegations and the consequences of findings such as these.[17]
3. It is for the Tribunal to determine the appropriate characterisation of the alleged conduct and the appropriate determinations having regard to the particular facts and circumstances. While no agreement between the relevant board and a practitioner can supplant that duty, any such agreement is highly relevant.

1. At the hearing, we asked Lee's counsel if his client made admissions to every particular of the Allegations as well as the facts contained in the overarching Allegations. He confirmed that was so. In respect of the Allegations which referred to knowing or reckless conduct (Allegations 2, 3 and 5), Lee's counsel confirmed she admitted in each instance that the conduct had been engaged in knowingly.

Summary of relevant facts and the evidence relied on

1. The Board's Written Submissions contained a helpful summary of the matters which were the subject of the Notifications, the information which came to light during Ahpra's investigation and which formed the basis of Allegations 1, 2 and 4 as well as the evidence the Board relied on.[18] We have made use of that summary below.
2. As an oral health therapist, Lee had limitations on her work including that she was only able to provide some types of dental work, was required to only work within a structured professional relationship with a dentist, could only provide orthodontic procedures under direction of a treating dentist or orthodontist and was not able to practise as an independent practitioner.[19]
3. From early August 2019, Dentist 3 commenced working at the Clinic and had a Structured Professional Relationship Agreement with Lee. In late November 2019, Dentist 3 became concerned that Lee may have been providing dental work beyond the scope of her role as an oral health therapist, including using the credentials of dental practitioners who were not working at the Clinic, to complete and claim for orthodontic work.
4. In January 2020, Dentist 3 contacted Dentist 2 to advise her that she believed Lee may have been using Dentist 2's credentials to provide patients with orthodontic work without her knowledge. Dentist 2 had previously worked at the Clinic on a part time basis between around April 2019 and June 2019.
5. The discussions between Dentists 2 and 3 led to them making Notifications in January 2020.
6. Lee was informed that she was under investigation by letter dated 6 April 2020.
7. On 20 April 2020, the third Notification was made.
8. From around 21 April 2020 to around 8 December 2020, Lee knowingly created false and misleading clinical records and amended clinical records in relation to a number of patients for whom she had provided work for outside the scope of her practice (the subject of Allegation 3).
9. During the investigation, the Board uncovered evidence to support Allegation 1 (providing work beyond the scope of practice), Allegation 2 (knowingly creating false and misleading records prior to the Board's investigation) and Allegation 4 (engaging in inappropriate billing practices).
10. Between around 17 December 2020 and around 31 May 2022, Lee provided false and misleading information to Ahpra (and so the Board) during the Board's investigation (Allegation 5). This was in the form of false and misleading documents sent to Ahpra in December 2020 and through her answers to questions during the May 2022 Interview.
11. We pause to note that, not only did Lee provide false and misleading information to the Board and Ahpra as described in Allegation 5, but she was also initially dismissive of the concerns raised by Dentist 3. In April 2020, while seeking information from her former lecturer about her scope of practice, Lee referred to Dentist 3 as a 'disgruntled ex employee' who made a complaint to Ahpra.[20]
12. To properly investigate the matter, Ahpra representatives were required to review a large number of documents, obtain witness statements from Dentists whose credentials had been used by Lee and consult with a computer expert to ascertain whether records provided by Lee had been amended. A statement made by that expert was included in the TB.[21]

1. Having regard to the Agreed Statement, the materials in the TB and Lee's counsel's confirmation that she admitted all facts in all Allegations and particulars, we were comfortably satisfied that the facts alleged in all of the Allegations were proven. In respect of Allegations 2, 3 and 5, we found that the conduct involved making or providing false and misleading information and that the conduct was engaged in knowingly.

1. In light of the parties' agreement that, in respect of each Allegation, the conduct ought to be characterised as 'professional misconduct', our focus is on the meaning of that term in the National Law.
2. Professional misconduct is defined in section 5 of the National Law as including:

(a) unprofessional conduct by the practitioner that amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and

(b) more than one instance of unprofessional conduct that, when considered together, amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and

(c) conduct of the practitioner, whether occurring in connection with the practice of the health practitioner's profession or not, that is inconsistent with the practitioner being a fit and proper person to hold registration in the profession.

1. In relation to a finding under paragraphs (a) or (b) of the definition, the Tribunal must assess the degree of seriousness of the practitioner's conduct having regard to the extent to which the conduct departs from the proper standards of professional conduct of a registered practitioner.
2. In relation to a finding under paragraph (c) of the definition, the term 'fit and proper person' allows for a wide range of matters to be considered. As stated by the Tribunal in Psychology Board of Australia v Griersmith[22] (Griersmith):

It includes not only whether a person has the necessary honesty, knowledge and ability but also whether the person possesses sufficient moral integrity and rectitude of character to permit them to be accredited to the public as a person to be entrusted with the sort of work the relevant registration or licence entails. The decision maker needs to make a value judgment and, in so doing, must make an assessment of the seriousness or otherwise of the particular conduct for evaluation. The same approach is to be applied to weighing matters in favour of the person.

1. In assessing whether conduct is inconsistent with being a fit and proper person under paragraph (c) of the definition of professional misconduct, the focus is on whether the conduct of the practitioner is inconsistent with the practitioner being a fit and proper person to hold registration, as opposed to the practitioner's current suitability to hold registration.
2. It involves an objective assessment which looks towards the conduct in light of the applicable standards and relevant definitions, rather than matters arising later in time, such as remorse, insight and rehabilitation.

1. The parties agreed the Tribunal should make findings about Lee's proven conduct as follows:

(i) A finding that, in relation to Allegation 1, Lee engaged in professional misconduct within the meaning of paragraph (a) of the definition of professional misconduct in section 5 of the National Law.

(ii) A finding that, in relation to Allegation 2, Lee engaged in professional misconduct within the meaning of paragraphs (a) and (c) of the definition of professional misconduct in section 5 of the National Law.

(iii) A finding that, in relation to Allegation 3, Lee engaged in professional misconduct within the meaning of paragraphs (a) and (c) of the definition of professional misconduct in section 5 of the National Law.

(iv) A finding that, in relation to Allegation 4, Lee engaged in professional misconduct within the meaning of paragraphs (a) and (c) of the definition of professional misconduct in section 5 of the National Law.

(v) A finding that, in relation to Allegation 5, Lee engaged in professional misconduct within the meaning of paragraphs (a) and (c) of the definition of professional misconduct in section 5 of the National Law.

1. The copy of the Notice of Allegations includes guidelines and codes relied on by the Board (set out in Attachment B to these Reasons). Lee agreed that they all applied to her at relevant times and that her conduct amounted to breaches of the kind alleged in respect of each Allegation.
2. It is sufficient for us to refer to the following parts of those guidelines and codes.
3. The Dental Board of Australia Code of Conduct,[23] says:
   • Practitioners have a duty to make the care of patients or clients their first concern and to practice safely and effectively. They must be ethical and trustworthy. Patients or clients trust practitioners because they believe that, in addition to being competent, practitioners will not take advantage of them and will display qualities such as integrity, truthfulness, dependability and compassion. Practitioners have a responsibility to recognise and work within the limits of their competence and scope of practice. Scopes of practice vary according to different roles (Principle 1.2);
   • Care of the patient or client is the primary concern for health professionals in clinical practice. Providing good care includes recognising the limits to a practitioner's own skills and competence and referring a patient or client to another practitioner when this is in the best interests of the patients or clients (Principle 2.1(d));
   • Maintaining a high level of professional competence and conduct is essential for good care. Good practice involves:
     • recognising and working within the limits of a practitioner's competence and scope of practice, which may change over time (Principle 2.2(a));
     • maintaining adequate records (Principle 2.2(e)); and
     • consulting and taking advice from colleagues when appropriate (Principle 2.2(j));
   • An important part of the practitioner-patient/client relationship is effective communication. This involves communicating appropriately with and providing relevant information to other treating practitioners, in accordance with applicable privacy requirements (Principle 3.3(m));
   • Good care is enhanced when there is mutual respect and clear communication between all health professionals involved in the care of the patient or client. Good practice involves communicating clearly, effectively, respectfully and promptly with colleagues and other practitioners caring for the patient or client (Principle 4.2(a));
   • Maintaining clear and accurate health records is essential for the continuing good care of patients or clients. Good practice involves keeping accurate, up-to-date, factual, objective and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients or clients, medication and other management in a form that can be understood by other health practitioners (Principle 8.4(a)); and
4. The 2014 Practice Guidelines state:[24]

Oral health therapists are dual qualified as a dental therapist and dental hygienist. They provide oral health assessment, diagnosis, treatment, management and preventive services for children and adolescents and, if educated and trained in a program of study approved by the National Board, for adults of all ages. Their scope may include restorative/fillings treatment, tooth removal, oral health promotion, periodontal/gum treatment, and other oral care to promote healthy oral behaviours. Oral health therapists may only work within a structured professional relationship with a dentist. The education requirement for a graduate oral health therapist to be registered is a minimum three-year full time bachelor degree education program approved by the National Board. Oral health therapists may only work within a structured professional relationship with a dentist.

1. Lee's Written Submissions took no issue with the following matters relied on by the Board in respect of characterisation. .

Allegation 1 - practicing outside scope of practice

1. The Board's Written Submissions[25] submitted that the following factors supported a finding that the conduct in Allegation 1 fell within paragraph (a) of the definition of professional misconduct:[26]
   • Repetitious and extended conduct - the conduct occurred frequently over a period of approximately 16 months. The conduct involved the use of four different practitioner's credentials without their knowledge or permission and involved 44 patients, treated on 100 occasions. The conduct therefore cannot be described as a single lapse in judgment;
   • Multi-faceted and organised conduct - Lee engaged in a range of inappropriate and organised behaviour which involved several steps being taken on each occasion. Her conduct involved providing orthodontic procedures without being under the direction of a dentist and acting outside the scope of a structured professional relationship;
   • Risk to patients - conduct of this nature has the potential to cause harm to the patients involved. Although no harm eventuated, there was a genuine risk that Lee could have caused harm to her patients, given she was not appropriately qualified or experienced to provide the types of treatments that she did. Lee's training was limited to being an oral health therapist and by working beyond the scope of her practice, there was real potential of her making errors and providing treatment that was not to standard; and
   • Disregard for colleagues - the conduct involved Lee inappropriately using the credentials of four of her colleagues, within the profession. As a result, it exposed each practitioner to risk of scrutiny as Lee applied their names to work and events, that they had no awareness of. The conduct represents a complete disregard by Lee of her colleagues.
2. We agreed with and adopted the above factors.
3. We regarded it as a serious breach of standards for a health practitioner to, instead of clarifying their scope of practice if they were uncertain, proceed to perform the procedures. The fact that Lee performed so many procedures outside scope adds to the seriousness of her failure to enquire.
4. We considered the failure to enquire particularly serious given Lee (personally or through her business) prepared and entered into an agreement with Dentist 3 for structured professional supervision.[27] The relevant agreement was on Lee's business letterhead and contained a framework which included specified procedures which were, and importantly, were not within Lee's scope of practice.
5. If, as was suggested by Lee's counsel, that agreement was standard form and may not have been understood by his client, there was a further failure by Lee to take the opportunity to clarify her scope and to understand a legal document she then signed.
6. While fortunately no harm came to any of the Patients, we agreed that Lee's conduct represented a significant risk of harm as described by the Board. As stated earlier, any practitioner performing procedures outside their training and scope is a risk to public safety, a foundation of good practice and one of the primary objectives of the National Law.
7. We add that the risk extended to Patients receiving potentially inappropriate and ineffective treatments (that they paid for) which might have necessitated different or repeat treatment at a later date.
8. Lee's conduct also put her colleagues at risk of possible future legal claims and scrutiny. Her conduct had the potential to tarnish their professional reputations.
9. We agreed that the appropriate characterisation of Lee's proven conduct as contained in Allegation 1 was professional misconduct under paragraph (a) of the definition.

Allegation 2 - knowingly make false and misleading clinical records (before the Notifications)

1. The Board submitted that the following factors supported a finding that the conduct in Allegation 2 fell within paragraphs (a) and (c) of the definition of professional misconduct:[28]
   • Repetitious and extended conduct - the conduct occurred over a period of approximately 13 months. The conduct is therefore elevated in seriousness, when compared to a single creation of false and misleading records;
   • Dishonesty - the conduct was knowingly carried out by Lee in an attempt to conceal the fact that she was practising outside the scope of her practice; and
   • Disregard for colleagues - as described above in the context of Allegation 1.
2. It is obvious that knowingly making false and misleading clinical records represents a substantial departure from standards such that it falls within paragraph (a) of the definition of professional misconduct. Accordingly, we made that finding.
3. Leaving aside the dishonesty aspect for the moment, false and misleading clinical records means that other clinicians do not have accurate and up to date information about diagnosis, past treatment and treatment plans. That can lead to inappropriate decision making about subsequent treatment. In addition, clinical records are relied on in respect of billing and related matters. If complaints or possible claims are made, clinical notes are an essential source of information.
4. We agree that the conduct in Allegation 2 was dishonest and the fact it was engaged in repeatedly over such a long period showed that Lee was well aware she was creating false records as to the treatment provided to the Patients. The only purpose Lee could have had for making the false clinical records was to cover up the fact she was acting outside her scope of practise.
5. By making the entries using the relevant Dentist's names and initials Lee exposed them to the risk described above and she dishonestly represented that they were aware of and actively involved in the treatment.
6. We had no difficulty agreeing that the proven conduct in Allegation 2 also constituted professional misconduct under paragraph (c) of the definition.

Allegation 3 - knowingly make false and misleading clinical records (after the Notifications)

1. The Board submitted that the conduct in Allegation 3 fell within paragraphs (a) and (c) of the definition of professional misconduct.[29]
2. The Board relied on the matters discussed in the context of Allegation 2 and submitted that the seriousness of the conduct was 'heightened' in circumstances where the clinical records were amended after Lee became aware that she was under investigation by the Board.
3. We agreed that the elements referred to above in respect of Allegation 2 were relevant to Allegation 3: the conduct was repeated over a period of eight months and showed the same kind of disregard for Lee's colleagues.
4. We rely on the comments above as to why the conduct in Allegation 3 falls within paragraph (a) of the definition of professional misconduct.
5. We agree with the Board's concern about Lee engaging in the dishonest conduct after becoming aware the Board was investigating her use of Dentist 3's name and the other matters raised in Dentist 3's Notification.
6. The National Law imposes obligations on people, including registered health practitioners, to cooperate and act honestly during investigations.[30] It is particularly important for health practitioners to be open and honest with the regulator where the purpose of investigations is to determine whether there is a risk (or potential risk) to public safety or a need for disciplinary or related action. Those expectations apply to health practitioners who are the focus of the investigation. A failure to act honestly and openly with the regulator is a very serious matter which is relevant to whether the practitioner is a fit and proper person as described in Griersmith (see [59] above).
7. We found that the conduct in Allegation 3 also constituted professional misconduct under paragraph (c) of the definition.

Allegation 4 - engaging in inappropriate billing practices

1. The Board submitted that the following factors supported a finding that the conduct in Allegation 4 fell within paragraphs (a) and (c) of the definition of professional misconduct:[31]
   • Repetitious and extended conduct - the conduct occurred over a period of approximately 8 months. The total quantum of the billing was $12,395.80. The conduct was therefore elevated in seriousness, when compared to a single incident of inappropriate billing;
   • Dishonesty - the conduct was carried out in circumstances where Lee was aware that she had provided the services outside of her scope of practice and therefore was not entitled to bill for them; and
   • Disregard for colleagues - as described above in the context of Allegation 1.
2. We agreed that repeated inappropriate billing was a substantial departure from standards. There was nothing one off about the conduct and the regularity with which Lee inappropriately billed her patients was a further consequence of her performing procedures outside her scope, using her colleague's credentials to do so.
3. Allegation 4 does not contain an express allegation of dishonesty but Lee agreed that, at the time the billings were made, she knew she was not entitled to perform the relevant procedures. It follows that she knew she was not entitled to claim payment for such procedures.
4. The particular lack of integrity involved in the inappropriate billing fell squarely within both paragraphs (a) and (c) of the definition of professional misconduct.
5. We note that Allegation 4 did not contain a claim that the billing was done to provide a financial benefit to Lee. We had no information as to whether refunds were given to the Patients or whether any health funds took action against her.

Allegation 5 - providing false and misleading information to the Board

1. The Board submitted that the following factors supported a finding that the conduct in Allegation 4 fell within paragraphs (a) and (c) of the definition of professional misconduct:[32]
   • Repetitious - Lee's attempts to frustrate the Board's investigation processes were not limited to a single incident. Lee provided false and misleading information through the false records and then in an interview with the investigator; and
   • Dishonest - Lee's conduct is inherently serious. The conduct was done knowingly and involved considerable effort. The behaviour is indicative of a complete disregard for the regulator.
2. There can be no question that, at the time Lee engaged in each form of conduct described in Allegation 5, she knew she was providing false information to the Board. The number of occasions she did so means the conduct falls within paragraph (a) of the definition of professional misconduct.
3. Lee knew she had created false records and falsified others when she sent them to Ahpra. She knew full well that, when she suggested entries in issue had been made by Dentist 3, that was completely false as she had made them herself. The dishonesty displayed in the May 2022 Interview was particularly disgraceful. The conduct was that of someone who lacked the honesty and integrity expected of a registered health practitioner and so fell within paragraph (c) of the definition.

1. The Board also made submissions as to the overall conduct in which Lee engaged.[33]
2. First, the Board submitted that we could have regard to community expectations and the reputational risk created by the conduct. It submitted that Lee's conduct underpinning each allegation carried the potential to seriously undermine the profession's good standing and the inherent trust that the public has in it. The Board asserted that patients have the right to 'attend for dental services with the understanding that the person providing their treatment is suitably qualified and supervised'. The community expects that members of the profession will act within the regulations and be honest about their training and experience prior to providing and billing for services.
3. The Board submitted that the 'community would be shocked to learn the nature and extent of the conduct engaged in' by Lee and that Lee's conduct was 'fundamentally contrary to these community expectations'.
4. Second, the Board referred to the professional standards of the profession, referring to those contained in Attachment B to these Reasons. The Board asserted that those 'professional standards make plain that members of the profession must recognise the limits of their own skill and competence and sets out clear boundaries for the practice of oral health therapists'.
5. The Board submitted that Lee failed to adhere to those standards 'in a variety of ways and her conduct represents a stark departure from professional expectations'.
6. As we have made individual characterisation findings, it is not necessary to do more than agree in broad terms that the totality of Lee's conduct had the potential to undermine community confidence in the profession. That conduct may raise concerns in community member's minds about whether a practitioner providing services has the training and experience to do so, and further, whether they will be billed appropriately.
7. Conduct by a practitioner which involves dishonesty and knowing breaches of obligations and standards risks public safety. It also has the capacity to damage the reputation of other practitioners.
8. As is apparent from our findings, Lee's conduct represented a wholesale departure from the standards contained in the Code of Conduct.

1. Section 196(2) of the National Law sets out the determinations the Tribunal may make where professional misconduct or unprofessional conduct has been proven. They include imposing a reprimand, cancellation of registration, suspension of registration and the imposition of conditions and the imposition of a prohibition order.
2. The well-established principles for consideration when making determinations under the National Law are as follows.[34]
3. The Tribunal's primary role is to protect the public rather than to punish health practitioners who engage in professional misconduct or unprofessional conduct. Determinations also assist to maintain proper ethical and professional standards to protect the public and the profession in the sense of maintaining stature and integrity in the eyes of the public. The Tribunal is also required to, in appropriate cases, make determinations which will deter the individual health practitioner from engaging in the same or like conduct again and/or which serve as a warning to other health practitioners that engaging in the conduct will bring serious consequences - the latter is known as general deterrence.
4. In some cases, specific deterrence is of lesser importance because a practitioner has been rehabilitated, is retired or has otherwise agreed not to practice again. Despite that, general deterrence may call for the imposition of a determination which acts as a warning to other members of the profession that like conduct may lead to significant consequences.
5. It is understood that, although determinations are not intended to be punitive, they can have that effect on individual practitioners.
6. Personal matters such as shame, personal ordeal, and financial difficulty are of little relevance except insofar as they contribute to the specific deterrence of the practitioner.
7. The assessment of the ongoing risk posed by the practitioner is central to the imposition of a determination. The degree to which the practitioner has acquired insight into his or her conduct is relevant to the assessment of the continuing risk posed by the practitioner. Insight can include an understanding of the nature of the conduct, an acceptance that the conduct was wrong, an appreciation of why the practitioner engaged in that conduct, empathy with the consequences, and/or a willingness to take measures to identify risk factors and to do that which is necessary to avoid further transgressions.
8. Any form of official censure is of consequence. A reprimand should not be considered a 'slap over the wrist'; it puts the public and the relevant profession on notice that the practitioner has failed to meet the standards of the profession and is a means by which the Tribunal admonishes the practitioner for their proven conduct.

1. The parties agreed that the following determinations ought to be imposed on Lee:
   • Under section 196(2)(a) of the National Law, Lee was to be reprimanded; and
   • In circumstances where the respondent is not registered, under section 196(4)(a) of the National Law, Lee was to be disqualified from applying for registration for three years from the date of our orders.

1. As she was entitled to, Lee elected not to give evidence before us in relation to determinations. She instead relied on the written and oral submissions made by her counsel.[35]
2. First, reference was made to Lee's comprehensive admissions to the conduct in the Allegations and their characterisation as professional misconduct. She was said to have 'reflected on her conduct' and 'feels embarrassed, shame and regret'.
3. Second, it was submitted that Lee's feeling of shame, embarrassment and regret and her 'complete acceptance of the matters in the Agreed Statement, support the fact that she is unlikely to engage in further inappropriate conduct'.
4. Third, in respect of Allegation 1, Lee 'conceded at an early stage that she had practised outside of the scope of her practice and accepted the serious nature of the [A]llegations'.
5. Reference was made to the May 2022 Interview when Lee stated:[36]

I do understand everything that was mentioned is extremely serious. Um, and I do understand why it was brought to AHPRA's attention. Um, and consequently I've had two years to reflect on everything. I honestly have done my research now to understand my actual scope of practice, um, and, um, the need to have that paper, you know, structured professional relationship agreement done . . . I understand there is a chance that, you know, there will [be] conditions or cancellations of my registration and I'm willing and happy to oblige by that. You know, the, the other thing I wanted to say is I've also had an open discussion with the principal dentist at the practice, um, so she's well aware of everything that's happening. Um, and she's happy to continue to supervise and guide me and mentor me if needed, um, so then I have a structured and supported environment to - if I'm allowed to get back to work eventually.

1. In the July 2022 Interview and a written response dated 14 August 2024,[37] Lee was said to have shown 'insight into the conduct the subject of [A]llegations 2, 3, 4 and 5' that included 'understanding of the nature of the conduct, an acceptance that the conduct was seriously wrong, an appreciation of why the practitioner engaged in that conduct, empathy with the consequences, and the willingness to take measures to identify risk factors and to avoid similar behaviour'.
2. During the July 2022 Interview, Lee provided the following statement as to why she engaged in the conduct ('ui' indicates unintelligible):[38]

Okay, yeah, so when the notifications first came through I obviously found myself really overwhelmed because it wasn't just one notification it was multiple notifications. Overwhelmed with fear and anxiety and at (ui) pregnant (ui) potentially losing my registration and livelihood this (ui) because I do understand...

I have committed to addressing the root causes of my actions and have acknowledged and reflected on my actions, and am very well aware of and prepared for the consequences that I am now face. Over the last 4.5 years while this investigation has been ongoing, I have been actively trying to engage in ongoing CPD education and training to strengthen my ethical decision-making skills, clinical notes taking, and to be certain about my understanding of my scope of practice.

I fully understand the seriousness of the allegations and that my professional dental career is now jeopardised, based on concerns for the safety of the public. That realisation has been quite devastating to me. Regardless of the outcome of this investigation, I have the deepest regret for what I have done, and commit to learning from this experience to become a better person.

When the notifications first came through, I found myself overwhelmed with fear and anxiety, particularly the fear of potentially losing my registration and livelihood.

This fear clouded my judgement by amending the clinical records. In no way do I seek to excuse or justify my actions now; rather, I want to convey the depth of my remorse and the sense of desperation I felt at the time.

Of course I now understand that succumbing to fear was not only ethically wrong but also detrimental to the integrity of patient care and the profession as a whole. I failed to uphold the standards of honesty and transparency that are paramount in healthcare, and for that I am truly apologetic and remorseful.

1. Lee's counsel submitted that the comments reflected his client's acquisition of insight into her conduct and her commitment to abide by her obligations in the future.
2. Lee's Written Submissions stated that Lee accepted the Board's submissions to the effect that the proposed penalties, including the disqualification, were appropriate and met the need for specific deterrence in making the determinations.
3. Lee's counsel noted that Lee had made significant admissions of the facts alleged, 'which is itself indicative of her contrition and remorse'. He stated that, from 14 August 2024, she cooperated fully with the Board and her admissions and co-operation meant that the matter has been progressed promptly to a hearing and have avoided the necessity for a prolonged hearing and for the notifiers to give evidence.
4. As to the time since Lee gave an undertaking not to practice (on 27 May 2020) and the fact she had not practised since, Lee accepted that her conduct has contributed to the delay. Notwithstanding the matters raised by the Board as to the complexity of the investigation (including as a result of the false and misleading information Lee provided), Lee's counsel submitted that the investigation had been on foot for 'a very significant period of time and that the delay had added to the uncertainty and personal burden' carried by his client. He submitted that it was appropriate for the Tribunal to consider 'the totality of the time that has passe[d] when making the determinations'.
5. We were provided with information about Lee's completion of continuing professional development activities (CPD) including courses described in Lee's Written Submissions as having 'a particular focus on ethical decision-making skills and clinical note-taking'. It was submitted that the completion of the CPD was evidence of Lee's rehabilitation and an appropriate matter for us to take into account when making determinations.
6. On a personal note, the submissions referred to the regulatory consequences Lee's conduct had caused and will continue to cause her; namely personal hardship in respect of her own practice and business, her professional reputation and her family's financial position.
7. While Lee acknowledged that those 'personal ordeals' were consequences of her own wrongdoing, it was submitted that those and the proposed determinations were 'a strong reason why the Tribunal can be confident' that Lee was 'most unlikely to engage in transgressions in the future'. The submissions stated that, after 'working so hard to return to establish her own practice at such a young age, she understands the personal cost of her wrongdoing'.
8. Lee's personal hardship, arising from her conduct, was said to be a strong deterrent to other health practitioners.

1. The Board submitted it was appropriate that the Tribunal express its condemnation of the nature and extent of Lee's misconduct by reprimanding her, noting that a reprimand is a serious matter for a professional person. The Board further noted it has been observed that a reprimand will almost always follow a finding of professional misconduct.

1. The Board submitted[39] that a period of disqualification of three years, in addition to the five years and eight months Lee had been out of practice, was necessary to meet the need for general and specific deterrence, maintain proper ethical and professional standards and to protect the profession in the sense of maintaining its stature and integrity in the eyes of the public. That period of disqualification was said to represent a period of time that fairly gives weight to the seriousness of Lee's conduct, particularly her repeated dishonesty.
2. The Board reiterated that Lee's conduct was of a very serious nature, which occurred over a lengthy period of time and involved dozens of incidents.
3. The Board submitted that it was 'imperative' that the Tribunal make clear to practitioners that this type of conduct undermines the reputation of the profession and the public's trust in it.

1. The Board submitted that the Tribunal should have regard to protection of the public by deterrence of other practitioners and the maintenance of the reputation and standards of the profession.

1. The Board submitted that the proposed determinations met the need for general deterrence. It submitted that a period of disqualification would send a message to other members of the profession that this type of conduct will not be tolerated. It added that, given that the matter involved a combination of conduct of a serious nature, the need for general deterrence was said to be 'heightened'.

1. The Board referred again to the need for the standards of the profession to be respected and maintained. It noted that Lee had breached a number of standards, across different areas including dishonesty towards the regulator. The imposition of a period of disqualification was said to be required to reinforce the significance of the professional standards that apply to all members of the profession.

1. The Board stated that, in reaching its position as to determinations, it had taken into account Lee's 'recent admissions' and the period of time she had already spent away from practice. Notwithstanding those factors, it submitted there continued to be a need for specific deterrence. It described Lee's insight as 'relatively recent'. The Board noted that, in the May 2022 Interview, Lee denied the conduct completely and attempted to suggest that Dentist 3 may have amended the clinical records. Following further investigation, Lee made admissions in the June 2024 Interview.
2. The Board submitted that Lee's 'persistent dishonesty and brazen conduct' provided reason to give weight to specific deterrence. The proposed determinations would have the effect of 'bringing home' to Lee the seriousness of her failings and deter her from any further departure from professional standards into the future.

1. Like Lee's counsel, the Board referred to the delay in the matter reaching the Tribunal given the extended investigation.
2. It referred to the Tribunal's approach in other cases,[40] including the acceptance that it is usual for the Tribunal to have regard to all relevant matters, including periods out of practice, when exercising its discretion to impose determinations.
3. It submitted that, given the complexity and scope of the conduct, including the need to consult with a computer expert to ascertain whether records provided by Lee had been amended and having hundreds of pages of false and misleading clinical records provided by her, the investigation into these matters was significant. It noted that, since the referral had been made to the Tribunal in March 2025, the parties had progressed the matter promptly to hearing.

1. We were referred to four other cases on the basis they were of a similar nature in that they involved some like conduct.[41]
2. While we had regard to the Board's summaries of the cases, it is not necessary to describe them given the totality of the facts and circumstances were different to those before us.

1. We gave weight to the parties' submissions as to the appropriate determinations.
2. We agreed a reprimand was necessary to put the public and the profession on notice that Lee failed to meet the standards of the profession and she has been admonished for her proven conduct.
3. We accepted that the events of the last five years and eight months would have taken a considerable toll on Lee and that the hardships that have followed are significant. We accepted she showed remorse for her conduct which persisted from January 2019 until the June 2024 interview.
4. However, we did not have a clear explanation about why Lee failed to act diligently to clarify her scope of practice in and after 2019. The responses referred to above suggested that Lee misunderstood her scope of practice despite the fact those matters would have been covered in her studies and were clearly set out in the readily available 2014 Practice Guidelines. Although it was somewhat heartening to hear that, by May 2022, she had done her 'research' and knew she had to have 'that paper' (i.e. a structured professional relationship agreement), she did not explain how the fact she had such an agreement in place with Dentist 3 in July 2019 did not stop her engaging in the conduct.
5. While Lee said she had taken time to address 'the root causes' of her actions, it was not apparent to us what those were, other than her fear reaction when she found the Board was investigating her in 2020. We had no detailed explanation for why she misused multiple Dentist's credentials over such a long period.
6. We noted Lee's CPD activities many of which, on the document provided, focussed on record keeping. There was no reference to any specific ethics-focussed CPD.
7. In those circumstances, we agreed with the Board's submission that specific deterrence had a role to play when making determinations. While we very much doubt Lee would engage in like conduct again given the consequences it brought her and her family, she did not demonstrate to us deep insight.
8. We agreed that the disqualification for three years (on top of five years and eight months out of practice) was an appropriate means to inform the public that its safety and the standards of the profession were uppermost in our minds.
9. We were also satisfied that total period would put other practitioners on notice that conduct of the kind engaged in by Lee would not be tolerated and would lead to very significant consequences.

The following allegations are referred to the Victorian Civil and Administrative Tribunal pursuant to s 193(1) of the Health Practitioner Regulation National Law (Victoria) Act 2009.

In the allegations, the following defined terms are used:

• Ahpra - Australian Health Practitioner Regulation Agency.
• Board - Dental Board of Australia.
• Clinic - Luxe Dental Care, Level 1, 33 Flemington Road, North Melbourne VIC.
• Code of Conduct - Dental Board of Australia Code of Conduct for registered health practitioners, 2014 (in effect from 17 March 2014 to 28 June 2022).
• Dental Council Professional Competencies - Australian Dental Council: Professional Competencies of the Newly Qualified Dental Hygienist, Dental therapist and Oral Health Therapist (February 2016).
• National Law - Health Practitioner Regulation National Law (Victoria) Act 2009.[42]
• 2014 Registration Standard - The Dental Board of Australia: Scope of practice registration standard 2014 (29 June 2014 to 30 June 2020).
• 2014 Practice Guidelines - The Dental Board of Australia: Guidelines for Scope of Practice 2014 (30 June 2014 to 30 June 2020).

1. Between in or around January 2019 and in or around April 2020, [Lee] engaged in:

(a) professional misconduct within the meaning of paragraphs (a) and/or (b) and/or (c) of the definition of professional misconduct in s 5 of the National Law; and/or

(b) unprofessional conduct within the meaning of the definition of unprofessional conduct in s 5 of the National Law; and/or

(c) unsatisfactory professional performance within the meaning of the definition of unsatisfactory professional performance in s 5 of the National Law,

in that she practiced outside of the scope of practice of an oral health therapist, as defined by the 2014 Practice Guidelines, the 2014 Registration Standard and the Dental Council Professional Competencies, by performing orthodontic procedures on 44 patients.

• 1.1 On 10 November 2015, Ms Lee was registered as a dental practitioner (oral health therapist) with the Board (registration number DEN0001989273).
• 1.2 At all relevant times, Ms Lee:

(a) held general registration as a dental practitioner;

(b) was a registered health practitioner within the meaning of the National Law; and

(c) was practising at the Clinic, a dental clinic which Ms Lee owns.

• 1.3 In or around September 2018, Ms Lee opened the Clinic and was practising at the Clinic as an oral health therapist.
• 1.4 Between in or around September 2018 and in or around April 2019, [Dentist 1] worked at the Clinic as a dentist.
• 1.5 Between on or about 29 April 2019 and on or about 24 June 2019, [Dentist 2] worked at the Clinic as a dentist. During this time, providing clear aligner treatment was not within [Dentist 2's] scope of practice.
• 1.6 Between on or about 6 August 2019 and on or about 21 January 2020, [Dentist 3] worked at the Clinic as a dentist. [Dentist 3] and Ms Lee had a Structured Professional Relationship Agreement dated 15 July 2019. During this period, it was not within [Dentist 3's] scope of practice to provide any orthodontic work, such as clear aligner treatment.
• 1.7 Between on or about 18 March 2020 and on or about 26 August 2020, [Dentist 4] worked at the Clinic as a dentist.
• 1.8 Between in or around June 2018 and in or around June August 2019, [Dentist 5] worked at the Clinic as a dentist.
• 1.9 The scope of practice of an oral health therapist includes:

(a) providing restorative/fillings treatment, tooth removal, oral health promotion, periodontal/gum treatment, and other oral care to promote healthy oral behaviours[43];

(b) only working within a structured professional relationship with a dentist[44];

(c) providing orthodontic procedures only under the direction of a treating dentist or orthodontist[45]; and

(d) not practising as an independent practitioner[46].

• 1.10 Orthodontic aligner treatment, occlusal splint treatment and orthodontic retainers are orthodontic procedures.
• 1.11 Between in or around January 2019 and in or around April 2020, Ms Lee performed orthodontic procedures on 44 patients on 100 occasions, as set out in Annexure A.
• 1.12 When Ms Lee performed the orthodontic procedures at particular 1.11, she was not practising within her scope of practice as an oral health therapist in that she was not practising:

(a) under the direction of any dentist, including [Dentists 1, 2, 3, 4 or 5]; and/or

(b) within the scope of a structured professional relationship.

• 1.13 Ms Lee's conduct at 1.11 was in breach of the registration requirements of an oral health therapist as identified in the 2014 Registration Standard.
• 1.14 The Board refers to, as set out in Annexure B, principles 1.2, 2.1, 2.2(a), 2.2(j), 2.2(o), 3.3, 4.2 and 4.5 of the Code of Conduct.
• 1.15 Ms Lee's conduct was inconsistent with:

(a) the principles of the Code of Conduct set out at particular 1.14;

(b) the 2014 Practice Guidelines;

(c) Dental Council Professional Competencies and/or

(d) 2014 Registration Standard.

1. Between in or around March 2019 and in or around April 2020, Ms Lee engaged in:

(a) professional misconduct within the meaning of paragraphs (a) and/or (b) and/or (c) of the definition of professional misconduct in s 5 of the National Law; and/or

(b) unprofessional conduct within the meaning of the definition of unprofessional conduct in s 5 of the National Law; and/or

(c) unsatisfactory professional performance within the meaning of the definition of unsatisfactory professional performance in s 5 of the National Law,

(d) in that she knowingly or recklessly made false and/or misleading clinical records.

• 2.1 The Board refers to and repeats particulars 1.1 to 1.13.
• 2.2 Between in or around March 2019 and in or around April 2020, Ms Lee knowingly or recklessly made false and/or misleading records in that when she performed the orthodontic procedures at 1.12, Ms Lee recorded in the clinical records the initials of the following dentists at the Clinic as the dentist who had directed Ms Lee to perform the orthodontic procedures:

(a) initials [AA], for [Dentist 2], on 10 occasions . . .

(b) initials [BB], for [Dentist 3], on 14 occasions . . . and

(c) initials [CC], for [Dentist 2], on 31 occasions . . .

• 2.3 The clinical records at 2.2 were false and/or misleading as [Dentists 2, 3 and 4] had not directed Ms Lee to perform the orthodontic procedures.
• 2.4 Between in or around March 2019 and in or around April 2020, Ms Lee knowingly or recklessly made false and/or misleading records in that she recorded in the clinical records the names of the following dentists at the Clinic as the dentist that had approved the SmileStyler orthodontic treatment:

(a) [Dentist 2], for 9 patients . . .

(b) [Dentist 5], for 1 patient . . . and

(c) [Dentist 3], for 2 patients.

• 2.5 The clinical records at 2.4 were false and/or misleading as [Dentists2, 3 and 5] had not approved the SmileStyler orthodontic treatment.
• 2.6 The Board refers to, as set out in Annexure B, principles 2.2(e), 4.5(b), 8.4(a), 8.4(b) and 8.4(e) of the Code of Conduct.
• 2.7 Ms Lee's conduct was inconsistent with the principles of the Code of Conduct set out at particular 2.6.

Make false clinical records (post notification)

1. Between on or about 21 April 2020 and on or about 8 December 2020 Ms Lee engaged in:

(a) professional misconduct within the meaning of paragraphs (a) and/or (b) and/or (c) of the definition of professional misconduct in s 5 of the National Law; and/or

(b) unprofessional conduct within the meaning of the definition of unprofessional conduct in s 5 of the National Law; and/or

(c) unsatisfactory professional performance within the meaning of the definition of unsatisfactory professional performance in s 5 of the National Law,

in that she knowingly or recklessly made false and/or misleading clinical records by creating false clinical records and amending the clinical records after she became aware of the Board/Ahpra's investigation.

• 3.2 The Board refers to and repeats particulars 1.1 to 1.13 and 2.2 to 2.55.
• 3.3 On 6 April 2020, Ms Lee was made aware of the Board's investigation by a letter sent by Ahpra.
• 3.4 Between in or around 21 April 2020 and in or around 8 December 2020, after Ms Lee became aware of the Board's investigation, Ms Lee knowingly or recklessly created clinical records for the following patients [details for 10 Patients redacted]:

• 3.5 The clinical records at 3.4 were false and/or misleading as they did not exist prior to 6 April 2020.

3.6 Between in or around 21 April 2020 and in or around 8 December 2020, after Ms Lee became aware of the Board's investigation, Ms Lee knowingly or recklessly created false and/or misleading clinical records by amending the [35] existing clinical records [to suggest clinical discussions were held with a specified Dentist]:

• 3.7 The clinical records amended at 3.6 were false and/or misleading in that they were amended after Ms Lee was aware or ought to have been aware of the Board's investigation and the information recorded by Ms Lee at 3.6(a) - (ii) did not occur.
• 3.8 The Board refers to, as set out in Annexure B, principles 1.2, 8.4(a), 8.4(b) and 8.4(e) of the Code of Conduct.
• 3.9 Ms Lee's conduct was inconsistent with the principles of the Code of Conduct set out at particular 3.8.

1. Between on or about 8 July 2019 and on or about 9 March 2020 Ms Lee engaged in:

(a) professional misconduct within the meaning of paragraphs (a) and/or (b) and/or (c) of the definition of professional misconduct in s 5 of the National Law; and/or

(b) unprofessional conduct within the meaning of the definition of unprofessional conduct in s 5 of the National Law; and/or

(c) unsatisfactory professional performance within the meaning of the definition of unsatisfactory professional performance in s 5 of the National Law,

in that she engaged in inappropriate billing practices by billing patients for orthodontic procedures when she knew or ought reasonably to have known that she was not entitled to perform the procedures.

• 4.2 The Board refers to and repeats particulars 1.1 to 1.13.
• 4.3 Medicare item numbers 825, 811, 833, 873 and 965 are item numbers relating to orthodontic procedures.
• 4.4 Ms Lee engaged in inappropriate billing practices by billing patients for the orthodontic procedures set out in . . . when Ms lee knew or ought reasonably to have known that she was not entitled to perform the procedures nor bill for them.
• 4.5 The Board refers to, as set out in Annexure B, principles 1.2 and 2.2(a) of the Code of Conduct.
• 4.6 Ms Lee's conduct was inconsistent with the principles of the Code of Conduct set out at particular 4.5.

Provide false and/or misleading information to the Board

1. Between on or about 17 December 2020 and on or about 31 May 2022, Ms Lee engaged in:

(a) professional misconduct within the meaning of paragraphs (a) and/or (b) and/or (c) of the definition of professional misconduct in s 5 of the National Law; and/or

(b) unprofessional conduct within the meaning of the definition of unprofessional conduct in s 5 of the National Law; and/or

(c) unsatisfactory professional performance within the meaning of the definition of unsatisfactory professional performance in s 5 of the National Law,

in that she knowingly or recklessly provided false and/or misleading information to the Board and/or Ahpra during its investigation.

• 5.1 The Board refers to and repeats particulars 1.1 to 1.13 and 3.3 to 3.7.
• 5.2 On 2 November 2020, a Schedule 5 Notice was issued to Ms Lee by Ahpra requiring the production of all clinical records, results, documents, reports, correspondence and notes of patients for the period of 1 January 2019 to 4 June 2020.
• 5.3 On 17 December 2020, Ms Lee provided the patient records to Ahpra and/or the Board that had been created and/or amended by Ms Lee as set out at 2.2 to 2.5 and 3.2 to 3.7.
• 5.4 Ms Lee knowingly or recklessly provided the false and/or misleading information at 5.3 to the Board.
• 5.5 On 13 May 2022, a Schedule 5 Notice to appear before an investigator was issued to Ms Lee.
• 5.6 On 31 May 2022, Ms Lee attended an interview with Ahpra investigators. During the interview, Ms Lee made the following statements:

(a) Q 205: Yeah. So, what you're saying to me is that you didn't change the original records, is that right?

Ms Lee: That's right... So, um, I would say my clinical notes are usually pretty consistent. Um, in terms of what I write.

(b) Q 251: Have you gone back and looked at who has made the changes, if you didn't?

Ms Lee: Ah, yes, so um, most of it ah, would be [Dentist 3]. Um, we - I'm - I'm not accusing anybody, but the initials - it shows up the initials, um, and it was [Dentist 3] ah, so I - I presume it's her. Um, like I said, you know, when - when she was still with us, um, she would come early hours of the day, and then she would leave um, you - you know well and truly after everyone has left. So, that's the only - that's the only way I can think of it being done, but ah, other than that, you know, unless I've - I've made certain mistakes in my notes or anything like that, but I - I definitely haven't changed anything.

(c) Q 260: Yeah, so when we've sent it to you. You've - you've looked at both of the - what [Dentist 3's] saying is the original ones and then the ones that you've provided as subsequently. And you can see the difference, when lines have been added, so you acknowledge that, but from what I'm understanding is that you're submitting that you didn't change those, is that correct?

Ms Lee: That's correct.

(d) Q 262: Okay. But you're submitting that from your interpretation of the audit log that you believe [Dentist 3] has made those changes?

Ms Lee: That's correct.

• 5.7 On 20 May 2024, a Schedule 5 Notice to attend before an investigator was issued to Ms Lee.
• 5.8 On 11 June 2024, Ms Lee attended an interview with Ahpra investigators. During the interview, Ms Lee stated:

I'm going to now say that the clinical records was amended after I had become aware of the notification...

So I asked [the practice manager] who had all the access, I think [the practice manager] is pretty much the only one that had access to every username, password and full access to Dental4Windows server, to help me make sure that all the notes you know were aligned with what I had said because not all the notes I had done were aligned with what I said...

So, I guess the, in terms of dealing with the software is what [the practice manager] did. But in terms of what to put in the clinical notes was what I had given her. So, yeah ultimately I was the one that I guess gave the okay to what's, what's written in the clinical notes.

• 5.9 In a written response dated 14 August 2024, Ms Lee wrote:

When the notifications first came through, I found myself overwhelmed with fear and anxiety, particularly the fear of potentially losing my registration and livelihood. This fear clouded my judgement by amending the clinical records.

• 5.10 The information provided by Ms Lee to Ahpra at 5.6 was false or misleading in that the patient records had been created and/or amended by Ms Lee to include false and/or misleading information as set out at 2.2 to 2.5 and 3.23 to 3.7.
• 5.11 Ms Lee knowingly or recklessly provided the false and/or misleading information at 5.6 to the Board.
• 5.12 It is an offence pursuant to clause 21 of schedule 5 of the National Law for a person to give an investigator a document containing information the person knows is false or misleading in a material particular.
• 5.13 It is an offence pursuant to clause 20 of schedule 5 of the National Law for a person to state anything to an investigator that the person knows is false or misleading in a material particular.
• 5.14 The Board refers to, as set out in Annexure B, principles 1.2 and 8.4(a) of the Code of Conduct.
• 5.15 Ms Lee's conduct was inconsistent with:

(a) the principles of the Code of Conduct set out at particular 5.14; and/or

(b) Clause 20 and 21 of Schedule 5 of the National Law.

1. Dental Board of Australia Code of Conduct for registered health practitioners, 2014 (in effect from 17 March 2014 to 28 June 2022) (Code of Conduct) relevantly provides that:

• 1.1 While individual practitioners have their own personal beliefs and values, there are certain professional values on which all practitioners are expected to base their practice. Practitioners have a duty to make the care of patients or clients their first concern and to practise safely and effectively. They must be ethical and trustworthy. Patients or clients trust practitioners because they believe that, in addition to being competent, practitioners will not take advantage of them and will display qualities such as integrity, truthfulness, dependability and compassion. Practitioners have a responsibility to recognise and work within the limits of their competence and scope of practice. Scopes of practice vary according to different roles (Principle 1.2);
  • 1.2 Care of the patient or client is the primary concern for health professionals in clinical practice. Providing good care includes:

(a) recognising the limits to a practitioner's own skills and competence and referring a patient or client to another practitioner when this is in the best interests of the patients or clients (Principle 2.1(d);

• 1.3 Maintaining a high level of professional competence and conduct is essential for good care. Good practice involves:

(a) recognising and working within the limits of a practitioner's competence and scope of practice, which may change over time (Principle 2.2(a); > > (b) maintaining adequate records (Principle 2.2(e); > > (c) providing treatment options based on the best available information and not influenced by financial gain or incentives (Principle 2.2(h)) > > (d) consulting and taking advice from colleagues when appropriate (Principle 2.2(j)); > > (e) evaluating practice and the decisions and actions in providing good care (Principle 2.2(o));

• 1.4 An important part of the practitioner-patient/client relationship is effective communication. This involves:

(a) communicating appropriately with and providing relevant information to other stakeholders, including other treating practitioners, in accordance with applicable privacy requirements (Principle 3.3(m));

• 1.5 Good care is enhanced when there is mutual respect and clear communication between all health professionals involved in the care of the patient or client. Good practice involves:

(a) communicating clearly, effectively, respectfully and promptly with colleagues and other practitioners caring for the patient or client (Principle 4.2(a));

• 1.6 Good patient care requires coordination between all treating practitioners. Good practice involves:

(a) ensuring that it is clear to the patient or client, the family and colleagues who has ultimate responsibility for coordinating the care of the patient or client (Principle 4.5(b));

• 1.7 Maintaining clear and accurate health records is essential for the continuing good care of patients or clients. Practitioners should be aware that some National Boards have specific guidelines in relation to records. Good practice involves:

(a) keeping accurate, up-to-date, factual, objective and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients or clients, medication and other management in a form that can be understood by other health practitioners (Principle 8.4(a)); > > (b) ensuring that records are held securely and are not subject to unauthorised access, regardless of whether they are held electronically and/or in hard copy (Principle 8.4(b)); and > > (c) making records at a time of events or as soon as possible afterwards (Principle 8.4(e)).

• 1.8 The Dental Board of Australia: Guidelines for Scope of Practice 2014 (30 June 2014 to 30 June 2020) (2014 Guidelines) relevantly provides that:
  • 1.9 Oral health therapists are dual qualified as a dental therapist and dental hygienist. They provide oral health assessment, diagnosis, treatment, management and preventive services for children and adolescents and, if educated and trained in a program of study approved by the National Board, for adults of all ages. Their scope may include restorative/fillings treatment, tooth removal, oral health promotion, periodontal/gum treatment, and other oral care to promote healthy oral behaviours. Oral health therapists may only work within a structured professional relationship with a dentist. The education requirement for a graduate oral health therapist to be registered is a minimum three-year full time bachelor degree education program approved by the National Board. An oral health therapist could only work within a structured professional relationship with a dentist.
  • 1.10 The registration standard does not allow dental hygienists, dental therapists and oral health therapists to practise as independent practitioners.

[1] In these Reasons, the use of bold type indicates a defined term or name of an organisation or person. Cases are defined by use of bold and italics.

[2] In effect from 30 June 2014 to 30 June 2020.

[3] In effect from 30 June 2014 to 30 June 2020.

[5] Dentist 3's Statement dated 20 January 2025, TB 70-237 [74].

[6] Column G of Annexure A to the Notice of Allegations.

[11] Exercising powers under section 156 of the National Law.

[14] Dentist 2's Statement (dated 10 January 2022, TB 238-283) and Dentist 3's Statement.

[17] Briginshaw v Briginshaw [1938] HCA 34.

[18] Board's Written Submissions dated 17 December 2025, [7.1]-[7.19].

[19] See further below from [63] and TB 3035, 3029 and 3038.

[22] [2019] VCAT 52 [67].

[23] In effect from 17 March 2014 to 28 June 2022.

[26] Board's Written Submissions [9.4].

[28] Board's Written Submissions [9.5].

[29] Board's Written Submissions [9.6].

[30] See for example sections 20, 21 and 22 of the National Law.

[31] Board's Written Submissions [9.7].

[32] Board's Written Submissions [9.8].

[33] Board's Written Submissions [12]-[13].

[34] See Medical Board of Australia v Jansz [2011] VCAT 1026 [358]-[373]; and Medical Practitioners Board of Victoria v Naik [2009] VCAT 755 [60]-[61].

[35] Lee's Written Submissions [17]-[28].

[39] Board's Written Submissions [13.8]-[13.11].

[40] Medical Board of Australia v Nguyen [2024] 233 [106] and Dental Board of Australia v Nairn [2022] WASAT 86 [180]-[182]

[41] Dental Board of Australia v Hussain (No. 2) [2022] VCAT 980; Dental Board of Australia v Trijo [2020] VCAT 558; Dental Board of Australia v Creighton [2019] VCAT 782 and Dental Board of Australia v Masters [2024] VCAT 249 and [2024] VCAT 523.

[42] The National Law as applicable in Victoria is the Schedule to the Health Practitioner Regulation National Law Act 2009 of Queensland adopted pursuant to s 4 of the Health Practitioner Regulation National Law (Victoria) Act 2009.

[45] Dental Council Professional Competencies.