Legislation cited: ACT Civil and Administrative Tribunal Act 2008 s 55

Health Practitioner Regulation National Law (ACT) ss 5, 156, 193, 196

Therapeutic Goods Act 1989 s 32BD

Legislation cited: Dental Board of Australia - Code of Conduct

Cases cited: Ha v Pharmacy Board of Victoria [2002] VSC 322

Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630

Health Care Complaints Commission v Lu [2023] NSWCATOD 51

Health Care Complaints Commission v Meneghetti [2020] NSWCATOD 39

Nursing and Midwifery Board of Australia v Lakicevic [2020] VCAT 2

Medical Board of Australia v Bradford [2023] QCAT 29

Medical Board of Australia v Jansz [2011] VCAT 1026

Medical Board of Australia v Tunbridge [2020] SACAT 34

1. The respondent engaged in conduct that constitutes professional misconduct, namely conduct that was substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience.
2. The respondent is reprimanded.
3. The respondent's registration as a dental practitioner is conditioned by requiring the respondent:

(a) to undertake and successfully complete a program of education approved by the applicant, including a reflective practice report, in relation to the maintenance of adequate patient health records; and

(b) to facilitate and submit to an audit of his practice with a focus on his use of therapeutic goods, products and materials in the treatment and management of patients and the adequacy of his clinical records.

1. The respondent pay the applicant's costs of this proceeding, to be taxed in default of agreement.

1. The Practitioner must undertake and successfully complete a program of education, approved by the Dental Board of Australia (the Board) and including a reflective practice report, in relation to the maintenance of adequate patient health records.
2. Within 4 weeks of the notice of the imposition of these conditions, the Practitioner must, on the approved form (HPN24), nominate for approval by the Board an education course, assessment or program (the education) addressing the topics required.
3. The Practitioner must ensure:
   1. the nomination includes a copy of the curriculum of the education.
   2. the education consists of a minimum 4 hours and contains a formal assessment component.
4. Within 8 weeks of the notice of the Board's approval of the education, the Practitioner is to provide:
   1. Evidence of successful completion of the education.
   2. A reflective practice report demonstrating, to the satisfaction of the Board, that the Practitioner has reflected on the issues that gave rise to this condition and how the Practitioner has incorporated the lessons learnt in the education into the Practitioner's practice.
   3. Evidence of having undertaken and successfully completed the formal assessment component of the education.

1. The Practitioner must submit to an audit of their practice (the audit), including any supporting records, within 1 month of the notice of the imposition of these conditions and thereafter on a two monthly basis, by permitting an auditor (the auditor) approved by the Board to attend any and all places of practice (public and private) for the purpose of the audit and by permitting the auditor to provide a report in relation to the findings of the audit.
2. The audit and the audit report are to focus on:

- the Practitioner's use of therapeutic goods, products and materials in the treatment and management of patients;

- adequacy of the Practitioner's clinical records;

and must include, at a minimum, 25 patients per audit, to include all implant patients (if any) and otherwise as randomly selected by the auditor from patients records and/or practice management records provided by the Practitioner.

1. Within 14 days of the notice of the imposition of these conditions, the Practitioner must provide to the Australian Health Practitioner Regulation Agency (Ahpra):
   1. nomination, on the approved form (HPN12), of an auditor(s) to be approved by the Board and Ahpra
   2. acknowledgement, on the approved form (HPN12), that Ahpra will seek reports from the approved auditor at the conclusion of each audit, and
   3. acknowledgement, on the approved form (HPNA12), from the nominated auditor.
2. Within 14 days of the notice of the approval of the nominated auditor, the Practitioner is to provide a written audit plan, from the approved auditor, outlining the form the audit(s) will take and how the area of concerns for the Board will be addressed. The audit(s) will take the form determined by the auditor.
3. In the event an approved auditor is no longer willing or able to provide the audit required, the Practitioner must notify Ahpra within fourteen days of becoming aware of this and provide a new nomination of a proposed auditor(s) to the Board and Ahpra in the same terms as the previous nomination of auditor(s).
4. Within 7 days of the notice of the imposition of these conditions the Practitioner must provide to Ahpra, on the approved form (HPC), the contact details of a senior person, such as the Senior Practice Manager/Senior Manager/Senior Partner/proprietor/owner/other as appropriate or equivalent (the senior person) at each current place of practice. In providing this form, the Practitioner acknowledges that Ahpra will contact the senior person and provide them with a copy of the conditions on the Practitioner's registration or confirm that the senior person has received a copy of the conditions from the Practitioner. The Practitioner will be required to provide the same form:
   1. within seven days of the commencement of practice at each subsequent place of practice, and
   2. within seven days of each and every notice of any subsequent alteration of these conditions.

1. Within 21 days' notice of the imposition of these conditions the Practitioner must provide to Ahpra, on the approved form (HPC), the contact details of a senior person, such as the Director of Medical Services, Director of Nursing, Senior Practice Manager, Senior Manager, Senior Partner, Proprietor, Owner, or equivalent (the senior person) at each current place of practice. In providing this form, the Practitioner acknowledges that Ahpra will contact the senior person and provide them with a copy of the conditions on the Practitioner's registration or confirm that the senior person has received a copy of the conditions from the Practitioner. The Practitioner will be required to provide the same form:
   1. within seven days of the commencement of practice at each subsequent place of practice, and
   2. within seven days of each and every notice of any subsequent alteration of these conditions.
2. All costs associated with compliance with the conditions on their registration are at the Practitioner's own expense.

1. On 29 June 2023, the Dental Board of Australia (the Board) filed an application for disciplinary action pursuant to section 193 of the Health Practitioner Regulation National Law (ACT) (the National Law) particularising four allegations with respect to the respondent, a registered dental practitioner (the practitioner or respondent). The practitioner holds a Bachelor of Dental Science from the University of Queensland. He has been registered as a Dental Practitioner (General) since 28 May 2004.
2. The parties reached a proposed settlement of the proceeding. In particular, they reached agreement on the relevant facts, characterisation of the practitioner's admitted conduct, and determinations on penalty. The proposed settlement was reduced to writing in the form of joint submissions as to findings and determinations and an agreed statement of facts, characterisation, and determinations.
3. Arising from the settlement, the Tribunal had power under section 55 of the ACT Civil and Administrative Tribunal Act 2008 (the ACAT Act) to make orders by consent without holding a hearing if the Tribunal was satisfied the proposed orders would be consistent with the agreed terms of settlement, within the powers of the Tribunal, and appropriate to make.
4. On 3 April 2024, with reliance on the agreed terms of settlement, the Tribunal provided the parties with draft orders to be made by consent. The parties advised their consent to the orders. On 4 April 2024, the Tribunal made orders accordingly. What follows are reasons for those orders, drawing heavily from the parties' joint submissions as to findings and determinations and their agreed statement of facts.

1. Under the Therapeutic Goods Act 1989 (Cth) (the TG Act), therapeutic goods must be entered into the Australian Register of Therapeutic Goods (the Register) before they can be lawfully imported, exported, manufactured, and supplied in Australia, unless a specific exemption, approval, or authority applies. The inclusion of therapeutic goods in the Register, through a regulatory approval process, is an important safeguard to ensure the safety, quality, and performance of products. Medical devices and biologicals go through strict approval assessments before they are entered in the Register and made available for supply in Australia.
2. Between mid-2018 and August 2021, the practitioner imported and supplied therapeutic goods to patients which were not included in the Register and not subject to an exemption, approval, or authority.
3. On 30 March 2021, the Australian Health Practitioner Regulation Agency (AHPRA) received a notification alleging the practitioner was using dental products on patients that were not approved for use in Australia by the Therapeutic Goods Administration (the TGA) and not exempt from approval.
4. As a result of the notification, on 13 May 2021 the Board imposed conditions on the practitioner's registration under section 156(1) of the National Law. In summary, the conditions required the practitioner not to undertake procedures, treatment, or management of patients using unapproved therapeutic goods; not to apply to the TGA for access to unapproved therapeutic goods; and to submit to an audit of his practice.
5. On 8 March 2023, the Board formed a reasonable belief the practitioner had behaved in a way that constitutes professional misconduct. On 29 June 2023, the Board filed its application for disciplinary action (the Application) which set out four allegations:

(a) the practitioner breached ss 32BD(4A) and 32BD(4A) of the TG Act by importing and supplying biologicals and medical devices (namely Renovix Plus, LifeNetHealth Oragraft products, Hahn tapered implants, and Hahn implant abutments (the Products)) to patients particularised in the Application in circumstances where those therapeutic goods were not included in the Register nor subject to an exemption, authority, or approval under the TG Act;

(b) the practitioner failed to obtain informed consent for the use of the Products on the particularised patients prior to or during treatments;

(c) the practitioner failed to make and keep accurate, current and complete records of the services provided, with sufficient detail to permit planning for continuity in the delivery of dental services, in respect of the particularised patients; and

(d) the practitioner, between 17 May 2021 and 2 August 2021, failed to comply with an immediate action condition on his registration when he undertook procedures, treatments and/or management of patients, by using Hahn implant abutments in respect of particularised patients.

1. The Board relied on an expert opinion report from Professor John Abbott dated 6 April 2022. In his report, Professor Abbott acknowledged the practitioner failed to comply with the TG Act by using the Products. However, he states the Products have a -

good evidence base and substantial research to give confidence in their efficacy. Additionally, they have been CE and or FDA approved and I would suggest that the actual risk to [the practitioner's] patients would be negligible.

1. Professor Abbott stated he believes the practitioner was carrying out what he thought was best practice for his patients and notes the practitioner has "undertaken advanced CPD in the USA in order to develop his implant skills to a very high level".
2. Regarding informed consent and record keeping, Professor Abbott reviewed patient notes made by the practitioner and observed that actual written or verbal consent for the use of the Products was not present in the notes, and that the patients may not have consented to the implant or graft procedures if they had been aware the practitioner was using illegally imported products. Professor Abbott described the practitioner's record keeping as "undeniably a weakness" that fell below the standard that would be expected of a practitioner of similar qualification or experience.
3. Professor Abbott concluded his report by stating that although the practitioner -

desired the best outcomes, his understanding of the law and professional care for his patient was derelict and below what would be expected of similarly qualified practitioners.

1. The Board relied on the Dental Board of Australia - Code of Conduct (17 March 2014 - 28 June 2022) (the Code) which the practitioner was subject to at the time of the conduct. The Code highlighted the importance of compliance with the law and set out what good practice involved with respect to informed consent and record keeping.
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;

(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. The parties agreed the practitioner's conduct amounted to professional misconduct within the meaning of the definition in section 5(a).
2. In their joint submission, the parties agreed that in relation to a finding under section 5(a), the gravity of professional misconduct is not measured by reference to the worst cases, but by the extent to which it departs from the proper standards.[1] In this regard, the parties agreed that Professor Abbott's description of the practitioner's understanding of the law and professional care for his patients as "derelict" supports characterisation of the practitioner's conduct as professional misconduct.
3. On the evidence, I was satisfied a finding that the practitioner's conduct amounted to professional misconduct is appropriate.

1. Upon finding the practitioner behaved in a way that constituted professional misconduct, the Tribunal was able to make one or more of the following determinations pursuant to section 196(2) of the National Law: the practitioner be cautioned or reprimanded;[2] condition(s) be imposed on the practitioner's registration;[3] the practitioner be fined not more than $30,000 made payable to the Board;[4] and/or the practitioner's registration be cancelled.[5]
2. If it imposed a condition on the practitioner's registration, it needed also to decide a review period for the condition.[6]
3. In their joint submissions, the parties noted the principles which guide the making of determinations in disciplinary proceedings are well established. The purpose of the imposition of determinations in disciplinary matters (with reference to cases cited by the parties) is to maintain proper ethical and professional standards so as to: protect the public;[7] and protect the professio[n],88 Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630 at 637 in the sense of maintaining its stature and integrity in the eyes of the public.9
4. The parties appropriately noted that in determining whether a particular form of regulatory action properly protects the public and the profession, consideration must be given to the following principles: general deterrence; specific deterrence; maintenance of professional standards; and protection of the reputation of the profession.
5. The parties noted the law relating to the making of determinations was extensively considered in Medical Board of Australia v Jansz[10] (Jansz) and can be summarised as follows:

(a) the purpose of the imposition of determinations is to protect the public;

(b) determinations are intended to maintain proper ethical and professional standards for the protection of the public and also for the protection of the profession in the sense of maintaining stature and integrity in the eyes of the public;

(c) determinations should in no way be punitive;

(d) the objectives of determinations can be achieved by specific deterrence, that is, the deterrence of the person concerned from further inappropriate conduct; by general deterrence, that is, the deterrence of other practitioners minded to conduct themselves similarly; and by facilitation of rehabilitation on the part of the practitioner;

(e) personal matters such as shame, personal ordeal, and financial difficulty are of little relevance save insofar as they contribute to the specific deterrence of the practitioner;

(f) the likelihood of recidivism, or, put another way, an assessment of the ongoing risk posed by the practitioner, should be central to the imposition of a determination;

(g) 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;

(h) insight can include as 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;

(i) empathy with the consequences, and/or a willingness to take measures to identify risk factors and to do what is necessary to avoid further transgressions; and

(j) any form of official censure is of consequence. It has been observed by the Courts that a reprimand is a serious matter for a professional person and should not be considered a "slap over the wrist".

1. As the parties noted, the factors in Jansz are not intended to be exhaustive nor determinative of how a penalty determination should be made.

1. In their joint submissions, the parties submitted the practitioner failed to comply with the law in his practice as a registered health professional by using unapproved therapeutic goods, including after intervention by the TGA, by failing to ensure all products he used in his practice were approved or otherwise lawfully supplied. In doing so, he also breached an immediate action condition for several months. He also failed to obtain informed consent from patients and his recordkeeping was inadequate. On the evidence, I am satisfied findings to that effect are appropriate.
2. In terms of seriousness, the parties submitted the underlying conduct of importing and using therapeutic goods that have not been approved by the TGA is a serious matter. I agree. It explains the swift action the TGA took by executing a warrant at the practitioner's practice on 20 May 2021 and seizing certain items, and by issuing 20 infringement notices totalling $266,400.
3. The public have an expectation that health professionals will undertake procedures, treatments, and generally manage patients using approved therapeutic products. Accordingly, the practitioner should have checked the status of the Products with the TGA before supplying them to patients. In addition, a patient's informed consent and adequate records detailing that consent are particularly important when health practitioners are supplying or prescribing products not approved or made in Australia. The failure by the practitioner to obtain informed consent is a serious matter.
4. Whilst the practitioner contended his breaches of the TG Act were inadvertent, he should have checked with the TGA before importing and using the Products rather than relying on information provided by manufacturers.

1. As the Board acknowledged, the practitioner has admitted his errors and has expressed remorse and insight into the seriousness of his actions. In particular, he acknowledged he failed in his professional responsibility to ensure the Products were approved by the TGA or otherwise lawfully exempt.
2. The practitioner maintains he was unaware the Products were not approved for use in Australia until APRHA notified him of that fact in April 2021. He maintains he relied on international approvals of the Products, in particular approvals by authorities in the USA. Importantly, there is no evidence he knowingly breached the TG Act.
3. The practitioner co-operated with APRHA and the TGA in their investigation of the practitioner's conduct.
4. The practitioner has already incurred a significant financial penalty, namely payment of infringement notices totalling $266,400 arising from his importation and supply of dental implants and bone grafts that were not approved for use in Australia in breach of the TG Act.[11] The practitioner has paid the notices.
5. The practitioner maintains he continued to use Hahn implant abutments between 17 May 2021 and 31 August 2021, after APRHA notified him about his use of Products unapproved for use in Australia, because he believed the implants did not require approval and their use was therefore lawful. He ceased using the implants upon being told they did require approval. There is no evidence the practitioner has used non-TGA approved products since 31 August 2021.
6. In Professor Abbott's opinion, the risk to patients posed by the practitioner's use of the Products was negligible. There is no evidence any patient was harmed by the practitioner's conduct.
7. The practitioner sent letters to 87 patients notifying each of them that the Products he used were unapproved. No patient has expressed concern about the practitioner's use of the Products.
8. The practitioner has no history of notifications and no history of disciplinary action.

1. In considering the appropriate determinations, the parties noted the following cases, all of which involved conduct that was found to be professional misconduct. That said, as the parties noted, no two cases are the same and each case must be decided upon its own unique set of facts and circumstances.
2. In Medical Board of Australia v Bradford,[12] the Queensland Civil and Administrative Tribunal (the QCAT) considered the circumstances of a doctor who inappropriately prescribed compounded peptide substances, human growth hormone and similar medications to four patients; failed to obtain properly informed consent; failed to maintain adequate clinical records; provided inadequate or inappropriate assessment, treatment, management or follow up; and inappropriately self-prescribed a number of medications. By way of disciplinary action, the Medical Board sought a 12-month suspension period whilst the doctor argued a fine was appropriate. In the result, the QCAT reprimanded the doctor, suspended their registration for 3 months, and placed conditions on their registration following the expiry of the suspension. In considering sanction, the Tribunal considered similar decisions involving improper or inappropriate prescribing and observed that -

some suspension of registration is imposed in most cases ... of inappropriate prescribing, although in bad cases there are examples of preclusion periods being imposed on registration, and in some cases, suspensions are not imposed, usually because of particular circumstances.[13]

1. In imposing the 3-month suspension, the QCAT stated that its decision "must show that the maintenance of professional standards is important, and is taken seriously",[14] and there was "really no alternative to a period of suspension to give proper effect to the considerations of general deterrence and maintenance of professional standards".[15]
2. In Health Care Complaints Commission v Lu,[16] the NSW Civil and Administrative Tribunal (the NCAT) considered the circumstances of a nurse who injected a patient in a home setting with a mixture of substances which were not registered or approved by the TGA. The nurse admitted her wrongdoing. The Health Care Complaints Commission sought suspension of the nurse's registration for 6 months, along with the imposition of supervision and mentoring conditions following the expiry period. The NCAT found the nurse had demonstrated insight as to the nature and extent of her departure from the applicable standards, was genuinely remorseful for her actions, and there was no risk she would repeat her conduct. The NCAT formally reprimanded the nurse and ordered her to pay costs of $18,000.
3. In Health Care Complaints Commission v Meneghetti,[17] the NCAT considered the circumstances of a medical practitioner who prescribed medications (including human growth hormones) without a proper therapeutic purpose and in excessive quantities and combinations, and other medications which were not registered on the Register. The unregistered medications were prescribed without reliable evidence of the quality, safety, or efficacy of the drugs for use in humans and there were no valid medical indications for use of the drugs. The NCAT was not convinced by the medical practitioner's evidence that she continued to prescribe the medications because she felt intimidated and threatened by the patient. It also found the practitioner was not completely candid with investigating bodies. The NCAT found the practitioner knew from the start that what she was doing was wrong. The NCAT cancelled her registration, prohibited her from applying for review for 18 months, and ordered her to pay the applicant's costs.[18]
4. In Medical Board of Australia v Moschou,[19] the South Australian Civil and Administrative Tribunal (the SACAT) considered the circumstances of a medical practitioner who inappropriately prescribed peptide medications, steroids, and benzodiazepine medications to 10 patients and himself, some of which were not approved for use in Australia. The misconduct occurred for more than 7 years. The medical practitioner also admitted he failed to adequately monitor the patients and that his record keeping setting out the patients' informed consent was deficient and not in accordance with the relevant Code of Conduct. The SACAT took into account that the practitioner co-operated with the Medical Board's investigation and voluntarily disclosed affected parties not revealed by the applicant's investigations. It also took into account that the practitioner had no prior disciplinary history in his 40-year medical career but was a senior practitioner when he engaged in the professional misconduct. The SACAT reprimanded the practitioner reprimanded, suspended him from practice for nine months, and imposed conditions on his registration to exclude such prescribing, and for supervision and auditing.
5. In Medical Board of Australia v Tunbridge,[20] the SACAT considered the circumstances of a medical practitioner who inappropriately prescribed medications to 20 patients, including growth hormone releasing peptide (which is not approved by the TGA for use in Australia and is regarded an experimental drug), and other medications which can have adverse effects. He also failed to adequately monitor or treat patients and failed to maintain adequate records. The practitioner had also let his registration lapse. The practitioner had been admitted for more than nine years, By the time of the hearing he was no longer registered. The SACAT noted that other than admitting his wrongdoing, the practitioner made no attempt to convince the SACAT he had gained insight into his behaviour or that he could be trusted to practise in a safe manner. The SACAT reprimanded the practitioner, disqualified him from registration for two years, and ordered him to pay the Board's costs.[21]
6. The authorities indicate that cases involving inappropriate prescribing are likely to warrant a suspension of registration.[22]
7. The parties submitted that, viewed objectively, there are factual circumstances of this case that are less serious than those featured in the above cases. The parties also noted the evidence of mitigating factors in this case set out above, which indicate there is lesser need for specific deterrence in this case. I agree.
8. Nonetheless, the parties agreed the importance of general deterrence, maintenance of professional standards, and protection of the reputation of the profession mean the Tribunal should deliver a clear message that conduct of the kind committed by the practitioner undermines the public confidence in the dental profession. But for the existence of the mitigating factors, conduct of the present kind would ordinarily warrant a period of suspension. I agree.
9. The parties submitted general deterrence, maintenance of professional standards, and protection of the reputation of the public would be achieved by reprimanding the practitioner and imposing conditions on his registration. I agree.
10. With respect to public safety, the practitioner has ceased using the Products, has written to all affected patients to inform them the Products were unapproved, and has admitted his wrongdoing. There is no evidence the practitioner poses an ongoing risk to the safety of the public. There is, therefore, a lesser need for specific deterrence in this case and general deterrence will be sufficiently achieved by the protective orders that were proposed by the parties. I considered the orders were appropriate.

1. A reprimand is an appropriate mechanism for the Tribunal to express its condemnation of the nature and extent of the practitioner's misconduct, noting a reprimand is a serious matter for a professional person. It indicates to the public, patients, and other practitioners that the standards expected of a practitioner have not been met and that the practitioner has been censured.[23]
2. An ordered reprimand will also serve a general deterrent function and thereby promote the health and safety of the public by reinforcing the message that practitioners must adhere to the legislative requirements and professional standards that apply to them in their profession.

1. The parties submitted the conditions set out at Annexure A to the orders made on 4 April 2024 should be imposed on the practitioner's registration, with a review period set of 6 months. In summary, the conditions require the practitioner to:

(a) undertake and successfully complete a program of education, approved by the Board, including a reflective practice report in relation to the maintenance of adequate patient health records; and

(b) submit to an audit of his practice with a focus on the practitioner's use of therapeutic goods, products, and materials in the treatment and management of patients, and the adequacy of his clinical records.

1. I found those conditions are appropriate. They mitigate future risk and enhance confidence in the practitioner's practise of dentistry. They will help address the identified deficiencies in the practitioner's practice and monitor the implementation of his learnings from education, through the receipt and consideration of independent assessment of the practitioner's records and implant practice.

1. The parties submitted the practitioner should be ordered to pay the Board's costs in this proceeding, to be taxed in default of agreement. That order is appropriate.

[1] Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630 at 638

[7] Ha v Pharmacy Board of Victoria [2002] VSC 322 at [91]; Medical Board of Australia v Jansz [2011] VCAT 1026 at [358]- [373][n]

[9] Ha v Pharmacy Board of Victoria [2002] VSC 322 at [97]; Medical Board of Australia v Jansz [2011] VCAT 1026 at [358]- [373]

[10] [2011] VCAT 1026 at [358]- [373]

[12] [2023] QCAT 29

[13] [2023] QCAT 29 at [34]

[14] [2023] QCAT 29 at [36]

[15] [2023] QCAT 29 at [37]

[16] [2023] NSWCATOD 51

[17] [2020] NSWCATOD 39 at [35], [36]-[38], and [110]

[18] [2020] NSWCATOD 39

[19] [2020] SACAT 110

[20] [2020] SACAT 34

[21] [2020] SACAT 34 at [35]- [37]

[22] Medical Board of Australia v Bradford [2023] QCAT 29 at [34]

[23] Nursing and Midwifery Board of Australia v Lakicevic [2020] VCAT 2 at [42]