Health Care Complaints Commission v Luque

Findings on the Complaints

1. The HCCC submitted that the Tribunal was entitled, but not obliged, to draw adverse inferences from the silence of the practitioner on the complaints and her lack of participation in the proceedings: HCCC v Wingate (2007) 70 NSWLR 323 [42-50]; Lucire v HCCC [2011] NSWCA 99.
2. Given what appear to be very difficult recent personal circumstances for the practitioner, her history of dysfunction over the past several years and the many indications in the evidentiary material of possible unresolved mental health and /or substance abuse issues, we decline to draw any adverse inferences from the practitioner's nonparticipation. The lack of any evidence from the practitioner about the subject of the complaints is, however, relevant in the determination of appropriate protective orders.
3. Complaints 1 and 2 are of unsatisfactory professional conduct, comprising both conduct significantly below the reasonably expected level (s 139B(1)(a) and improper or unethical conduct relating to the practice or purported practice of nursing (s139B(1)(l)).
4. Complaint 3 is that complaints 1 and 2, individually and cumulatively, are of such seriousness or repetition as to amount to professional misconduct.
5. Complaints 4, 5 and 7 are that the practitioner has been convicted of criminal offences.

Complaint 1

1. Complaint 1 comprises 10 particulars, concerning alleged mishandling of medications by the practitioner at Netherby (1-7), Scalabrini (8) and Chesalon (9-10).
2. On 17 July 2013 the practitioner completed a medication incident form, backdated to 27 June 2013, regarding 18 Oxynorm 20 mg capsules. In this form the practitioner stated that she had been informed, through a note from an unnamed 'agency RN' left under her office door on the morning of 28 June 2013, that the box of Oxynorm had fallen from the medication trolley and been crushed, spilling the drugs on the floor, and that that the agency nurse had destroyed all of the drugs.
3. Particular 1 is that the above incident form was deliberately false and misleading, particular 2 is that the practitioner's related entry in the Sch 8 register was also false and misleading (in that it stated that the drugs had been returned to the pharmacy for destruction), particular 3 concerns the failure to promptly report the loss or destruction of the drugs to a supervisor or employer, and particular four is that the practitioner misappropriated the drugs or in the alternative failed to arrange for them to be appropriately disposed of by a pharmacist.
4. The internal investigation documents from Netherby in evidence document that:

• no agency nurse was registered on 27 June 2013;
• the relevant signatures of both entrant and witness on the Sch 8 register could not be identified;
• the drug register entry by Ms Luque stated that the drugs had been returned to the pharmacy;
• the pharmacist in charge gave a statement that they did not attend the site to destroy the medication; and
• Ms Luque was unable to produce the note which she claimed to be from the agency RN.

1. In light of the above factors, and the inconsistent and implausible contemporaneous account given by the practitioner, we find that on the balance of probabilities particulars 1 to 3 are proved. The inescapable inference that flows from our findings on 1-3 is that the drugs were misappropriated by the practitioner, and so particular 4 is also proved to the required standard.
2. On 15 July 2013 there were two bottles of Ordine held in the Sch 8 cupboard; an unopened bottle containing 200 ml and an open bottle with 22 ml remaining. The practitioner administered 1 ml of Ordine to a resident and recorded 'new bottle started' on the Sch 8 register, with no record of the balance from the open bottle. Particular 5 is that the practitioner failed to accurately record Ordine in the Sch 8 register, particular 7 is that she failed to complete a medication incident form or take any other steps to promptly report the loss of the open bottle of Ordine, and particular 6 is that the practitioner misappropriated or in the alternative failed to arrange for appropriate destruction of the missing 21 ml of Ordine from the open bottle.
3. The internal investigation documents from Netherby in evidence document that:

• Two nurses stated that the open Ordine bottle had been returned by them to the Sch 8 cupboard with liquid still in it earlier on the relevant night;
• Ms Luque at first claimed she had been handed an empty bottle of Ordine by a staff member who was not an RN, but at a later point claimed that this was a different person, who was an RN but whom she never identified;
• Ms Luque claimed that she then threw away the empty bottle rather than putting in the pharmacy return box.

1. In light of the unchallenged evidence, and the inconsistent and implausible contemporaneous account given by the practitioner, we find that on the balance of probabilities particulars 5 and 7 are proved. The inescapable inference that flows from those findings is that drugs were misappropriated by the practitioner, and so particular 6 is also proved to the required standard.
2. Particular 8 is that on 5 June 2014 the practitioner inappropriately kept 2 boxes of the Sch 4D drug diazepam labelled 'Ward stock' (comprising an unstated number of 10mg ampoules) in the cupboard next to her desk at Scalabrini, instead of in the Sch 4 cupboard.
3. The letter of termination sent by Scalabrini to the practitioner on 16 June 2014 records that management held two meetings with the practitioner to discuss the allegations, on 11 June and 12 June 2014 and that in these meetings the practitioner admitted to keeping the drugs in breach of the relevant mediation handling policy.
4. There is limited evidence concerning the Scalabrini incident but it does include a witness statement from the then manager of that facility which outlines the circumstances in which the medication was found in Ms Luque's desk and his recollection of her contemporaneous response.
5. We are satisfied on the available evidence that Ms Luque was aware of, and responsible for, the storage of Sch 4 mediation in her office instead of in the Sch 4 cupboard. This particular is proved on the balance of probabilities.
6. On 21 February 2015 the practitioner accessed the Sch 4 cupboard at Chesalon unaccompanied. Complaint 9 is that this access was inappropriate and Complaint 10 is that the practitioner thereby misappropriated 5 tablets of Temazepam 10 mg.
7. Witness statements were provided by a RN who was present at the time, and by the Executive Manager of the facility. The RN witness statement appends her detailed contemporaneous notes, which formed the basis of the 2015 notification.
8. The RN account is that she witnessed the practitioner accessing the Sch 4 cupboard and heard her remove medication from a Webster pack. Ms Luque first stated that she was obtaining medication for a named patient, but when the RN told her that the patient did not regularly use that medication, Ms Luque said to the RN that she was checking to see if any Sch 4 needed to be ordered and added that she thought there was medication missing as 'we have had casuals and agencies on'.
9. The RN was aware that a Sch 4 count had been undertaken and recorded that morning. She requested another staff member to undertake a Sch 4 count with her, and in that process identified that there were 5 missing Temazepam relating to two different patients which had occurred between the two counts.
10. The Executive Manager noted in her statement that: it was not part of Ms Luque's role to check the balance of the Sch 4 cupboard and order medication; policy was that the Sch 4 cupboard was not to be accessed by a single staff member alone; Ms Luque's 'master key' opened the Sch 4 cupboard; when she spoke to Ms Luque on 21 February 2015 Ms Luque's response was that she was accessing the Sch 4 cupboard to put a resident's jewellery in there for safe keeping; and the cupboard was not used for the latter purpose to the Executive Manager's knowledge.

Complaint 2

1. Complaint 2 comprises nine particulars, concerning the practitioner's possession of apparently falsified professional qualifications, false or misleading statements made about her employment history to regulators, and providing false or misleading records of employment and role in her Curriculum Vitae (CV).
2. On 21 February 2015 Chesalon stood the practitioner down from duties pending an investigation. On the Executive Manager's account, on 23 or 24 February 2015 she met the practitioner outside the facility for the return of the practitioner's keys. The Executive Manager states that only she and the practitioner had keys which opened the practitioner's office.
3. On 24 or 25 February 2015 the Executive Manager unlocked Ms Luque's office so that a senior staff member could search for resident documentation which was urgently needed. That staff member found several documents in the office in the name of Person A which were certificates of participation in various CPD events and three documents in the name of Person B, which were academic records, a testamur for a Master of Nursing and a testamur for a Graduate Diploma in Clinical Practice. In addition to the original documents there were photocopied and laminated copies of the same documents in which the practitioner's name had been placed over the correct recipients' name. In one instance a small piece of paper with the practitioner's name was paper clipped to the original. The staff member's evidence, corroborated by the Executive Manager, was that she immediately went into the Executive Manager's office, which was next door, and presented these documents to her.
4. In the response made by the practitioner through her legal representative to the HCCC on 13 July 2015, the practitioner stated that: The certificates I had were caught up with my things when I packed up at my prior job. I had taken them to work to give to a friend who worked at [that site] and lived close by, she was going to pick them up and take them to work, but she didn't come and I left them in my office and I had forgotten about them...I had not photocopied them to pass them off as mine…
5. Copies of both the original and altered documents were in evidence, as was a statement by Person A in which he provides an account of how the original documents came to be in an unsecured but individually allocated storage space in an open plan workspace that he shared with the practitioner at a previous workplace. Person B is related to Person A.
6. Person A is adamant that he did not provide any of the original documents to the practitioner and was unaware that she had possession of them. Person A further notes that he and two other staff members were present when the practitioner left that employment and packed up her desk.
7. The allegations are that the practitioner wrongly held in her possession the documents belonging to Person A (particular 1) and Person B (particular 2) and that she attempted to prepare a forged version of those documents (particular 3 concerning Person A, being forged professional training certificates, and 4 and 5 concerning Person B, being forged professional qualifications).
8. We find that there is no basis to doubt the account given by the Executive Manager and staff member, and Person A: which is that no other person than the Executive Manager had access to the practitioner's office, the office was unoccupied by the practitioner for a very short time before the documents were discovered, and the original documents came from a previous workplace where the practitioner was able to access to the documents but was not authorised to do so.
9. The only reasonable explanation is that the practitioner herself had improper possession of these documents and altered them to manufacture forged training certificates and professional qualifications. Particulars 1- 5 are proved on the balance of probabilities.
10. In the course of the 2015 investigation the practitioner made a written submission, and then oral statement to the s 150 proceedings held by the Council on 9 March 2015 to the effect that she had left her employment at Scalabrini because of the cost of travel. On 30 July 2015 the practitioner repeated that claim in writing through her legal representative in correspondence to the HCCC.
11. Particulars 6 and 7 are that these statements were false and misleading, as the practitioner in fact lived in on-site accommodation at the facility.
12. The statements that the practitioner had left Scalabrini because of the cost of travel were false and are of significance because they carry the inherent implication that her departure was voluntary, and conceal the fact that she was dismissed because of a breach of medication handling policy. Given that the 2015 investigation was concerned with allegations concerning medication handling, this was clearly relevant information. A practitioner in such circumstances has clear ethical and professional duties of candour, and moreover, the practitioner in this instance was asked the direct question in the s 150 hearing whether she had left Scalabrini because of 'any problems?' In this context we do not hesitate to find that the statements were intended to mislead investigators and regulators and the particulars are proven.
13. Particulars 8 and 9 concern the curriculum vitae provided by the practitioner to the HCCC on 30 July 2015, and allege that some details were deliberately false or misleading.
14. Particular 8 concerns the dates provided by the practitioner for her employment in three jobs, all of which overstate the amount of time she worked there. The entries for Scalabrini and Netherby which form the basis of sub-particulars (a) and (b) are inaccurate by only a few weeks. We find that such minor inaccuracies are a common incident of professional life, and moreover are of such brief duration that they would not seriously mislead a reader. These two sub-particulars are therefore not found proved.
15. The final two sub-particulars of particular 8 relate to the practitioner's earlier employment elsewhere, in which she overstated the first period by 6 months and in the second instance claimed a period of employment that did not exist at all. These latter two claims are not the kinds of error that could be inadvertent, and are of such a serious nature as to mislead a recipient as to the substantive duration of the practitioner's employment with that particular employer by a period of some two years. The latter two sub-particulars are therefore found proved.
16. Particular 9 alleges that the practitioner provided a false or misleading account of her employment in the terms above when she described herself in her CV as, variously, a 'Care Manager', 'Clinical Nurse Consultant', 'Clinical Facilitator' and 'Clinical Nurse' when she was at all times a registered nurse. In essence this was a claim that the practitioner had inflated the seniority or responsibility of her roles.
17. The HCCC presented no evidence to demonstrate that the various roles which the practitioner undertook were described in job advertisements, or in key employment documentation, as anything other than the terms claimed by the practitioner. This particular is therefore not made out.
18. The peer expert witness for the HCCC, Ms Miller, provided a report and supplementary report. Ms Miller opined that all of the alleged particulars, if proved, constituted conduct significantly below the expected standard reasonably expected of a practitioner of similar training and experience and invited her strong criticism.
19. In relation to the improper handling, documentation and misappropriation of Sch 4 and Sch 8 medications, Ms Miller noted that, Medication management is an essential and high risk area for all aged care facilities. This is why it has such strong governance structure through legislation and policies that are in place to not only protect residents but also staff. This is why it must be adhered to at all times.
20. We have no hesitation in finding that the proved conduct falls so significantly below the expected standard that complaints 1 and 2 of unsatisfactory professional conduct are clearly made out.
21. Further, as a consequence of our findings that the proved conduct in the particulars under complaints 1 and 2 involved misappropriation of Sch 4 and Sch 8 medications, the creation of falsified professional documentation, and the provision of false and misleading information to regulatory authorities, we also find that complaints 1 and 2 are also proved on the alternative basis of improper or unethical conduct in the practise of nursing within the meaning of s 139(1)(l).

Complaint 3

1. Complaint 3 is that the first and second complaints, both individually and cumulatively, are of such seriousness as to constitute professional misconduct.
2. The HCCC noted that the provision of false and misleading information alone may constitute such a serious and deliberate departure from accepted professional standards as to constitute professional misconduct: Wanigaratne v HCCC [2011] NSWCA 204 [62]; HCCC v Abad [2009] NSWNMT 23.
3. As this Tribunal has repeatedly noted, our system of health regulation exists with the paramount objective of protecting the health and safety of the public and it cannot achieve that protection without the co-operative and candid involvement of health practitioners. Health practitioners must uphold the highest standards of honesty and integrity in dealing with health regulators: HCCC v Kesserwani [2017] NSWCATOD 149; HCCC v Chowdhury [2015] NSWCATOD 65.
4. The proved conduct entails a number of findings of dishonest conduct, and our express conclusion concerning both complaint 1 and 2 is that the practitioner has behaved improperly and unethically in the course of her professional practice.
5. Both the seriousness of the proved conduct and its repetition lead to the conclusion that the conduct is of such gravity as to meet the threshold of professional misconduct.

Complaints 4, 5 and 7

1. These complaints are that the practitioner has been convicted of criminal offences on three occasions in NSW, in 2016, 2017 and 2019 in the circumstances outlined in the background above: paras 10 to 14.
2. The National Law provides under s 149C that the Tribunal may suspend or cancel a practitioner's registration if: (c) the practitioner has been convicted of or made the subject of a criminal finding for an offence, either in or outside this jurisdiction, and the circumstances of the offence render the practitioner unfit in the public interest to practise the practitioner's profession; or (d) the practitioner is not a suitable person for registration in the practitioner's profession.
3. The HCCC relied only upon subsection (c).
4. The issue to be determined is whether the circumstances of these offences render the practitioner unfit in the public interest to practise as a nurse.
5. The HCCC submitted that the evidence as a whole demonstrated that the practitioner was unfit in the public interest to practise; stressing that the offending conduct was not an isolated incident, with various criminal charges over time which escalated in seriousness; and the criminal conduct involved premeditation and deception. Nurses are held in a position of trust in the community and the offences, particularly the 2017 offence, involved a grave violation of that trust.
6. The HCCC further submitted that there was no evidence of insight or reformation on the part of the practitioner, particularly given the most recent criminal proceedings occurred only weeks before the hearing, and that the lack of the practitioner's participation in these proceedings could only serve to heighten those concerns.
7. We accept all of the HCCC submissions on this point.
8. None of the criminal offences took place in the course of Ms Luque's professional practice as a nurse. It is not a requirement of the National Law that there be a direct nexus between the occurrence of the offence and the professional role, but where there is no nexus a more careful inquiry into the public interest factors may be required. There may be instances in which 'public interest' is taken to encompass the goal of broader protection of the reputation of the profession, such as in cases in which it is determined that the relevant professional's practice poses no discernible risk to the health and safety of the public. In this case we find that the public interest encapsulates both a risk to the profession and a direct and demonstrable risk to the health and safety of the public.
9. First, we note that the circumstances of the 2016 and 2017 offences have a direct bearing on the question of professional responsibility, even though they did not occur in the practise of nursing.
10. The 2016 offence reflects directly, and extremely poorly, upon Ms Luque's attitude to her responsibility to her employers, and to her clients/patients. The offence took place in the course of Ms Luque's employment, in which she was providing a health service, being first aid/paramedicine to rail users, and it involved an abuse of her professional position for personal gain. The person whose credit card Ms Luque stole and fraudulently misused was a customer of her employer, and her employer had safekeeping of that credit card.
11. The 2017 offence involved the grievous misuse of public health resources, including ambulance, emergency room and hospital services; all of which treated the practitioner on an urgent basis as a victim of trauma. This latter offence was thus an abuse of other health professionals, and of health resources on a systemic level. In addition this conduct was an abuse of the public trust placed in all health professionals in that the practitioner made a false report which gave rise to a police response, subjecting numerous people to investigation, subjecting an innocent person to accusation, and diverting substantial police resources from the protection of the public.
12. While little is known of the third offence, it, like the others, involved dishonesty.
13. The circumstances of all three offences, but most particularly the 2017 offence, indicate that the practitioner is not fit to practise in the public interest as a health professional. Ms Luque has demonstrated that she cannot be trusted in her practise of her given health profession, in undertaking the provision of other health services, or indeed even as a patient of emergency health services.
14. The four Queensland criminal proceedings noted above at para 3 did not lead to the recording of a conviction. Section 149C(1)(c) is framed to address both criminal convictions and being 'the subject of a criminal finding for an offence'. However the Queensland findings were not particularised as part of the complaint before this Tribunal.
15. The HCCC submitted that the Queensland findings were relevant to the overall assessment of all the circumstances in considering the risk which the practitioner posed to the health and safety of the public in formulating appropriate orders. In essence the HCCC submitted that the fact that the practitioner has been subject to multiple criminal proceedings for largely similar offences of dishonesty, including theft in the workplace, over such a considerable period of time, must be considered as exacerbating the risk she poses. In all, Ms Luque has faced criminal courts on 7 occasions over a period of 16 years.
16. Nothing is known about the circumstances of the Queensland criminal findings. In the absence of participation by the practitioner in these proceedings, and in the absence of specific notice to her concerning that issue, we determine that it is appropriate to have regard to the Queensland proceedings only inasmuch as they are part of the 'circumstances' of the three later NSW offences that were particularised in the complaint. That is, we have regard to the fact that the particularised NSW offences occurred after the practitioner had already been subject to criminal proceedings and been granted more than one 'second chance'.

Appropriate Protective Orders

1. In light of the above findings, the unavoidable conclusion is that the practitioner poses a very substantial risk to the health and safety of the public and that the only appropriate outcome is that her registration as a nurse be cancelled. The conduct was extremely serious, calculated and dishonest, and sustained over a prolonged period.
2. It is a matter of public record that nursing home and aged care residents are extremely vulnerable populations, by reason of their age, related health conditions, and possible difficulties in communicating to authorities if the care they receive is substandard or otherwise improper. A Royal Commission into Aged Care Quality and Safety was established on 8 October 2018 because of such concerns. In this case we have found that the practitioner moved through three aged care facilities, improperly accessing restricted drugs at each.
3. There is no basis upon which the Tribunal can conclude that the practitioner has any insight, or has taken any steps towards remediation or 'reformation'.
4. The HCCC submitted that an order of cancellation be accompanied by an order under s 149C(7) that the respondent be prevented from applying for a review of such cancellation for a period not less than 3 years.
5. The setting of a non-review period is not to punish the practitioner but to protect the public. NSW Court of Appeal jurisprudence has indicated that the fixing of a period of non-review has a 'twofold operation' in that it firstly indicates a minimum period within which the Tribunal considers the person should not be able to practise their profession, thus serving both an individual and general deterrence purpose by sending a message to the practitioner, the public and the profession about professional standards and the seriousness of the breach; and secondly it holds open to the practitioner the possibility of return to the profession at a later time: Chen v HCCC [2017] NSWCA 186; HCCC v Do [2014] NSWCA 307.
6. In this case we determine that the setting of a non-review purpose is not appropriate. Firstly, it is unclear that a message of individual deterrence would impact upon the practitioner at this juncture. Secondly, we find that the conduct is so serious and so sustained that the setting of a period of 3 years before review may be artificial if it were taken to suggest that remediation could occur within such a time. This is particularly so given the additional finding that Ms Luque is not fit to practise in the public interest.
7. In our view, a later Tribunal considering a review application would need to be satisfied that the practitioner had taken very major steps to demonstrate in a sustained way a substantial period of functional behaviour necessitating, at the very least, a lengthy period of non-offending, and realistically entailing much more active steps towards personal development and professional remediation and reintegration.
8. General denunciation of the practitioner's conduct is made clear by these reasons, through the order of cancellation, and through the orders made in the NSW criminal proceedings. The nursing profession can be taken to be clearly on notice from this, and many other such cases, that conduct involving misappropriation of restricted medications, and misleading regulators is regarded as of the utmost seriousness, and that it will very likely lead to cancellation of registration.
9. The HCCC also sought an order prohibiting the practitioner from providing other health services, including as an assistant in nursing and aged care, until such time as she is re-registered as a nurse. The HCCC submitted that the misappropriation of drugs of addiction, coupled with criminal conduct and unethical behaviour, and the failure of the respondent to demonstrate any insight or remediation, must lead to the conclusion that the risk she poses to public health and safety is substantial. We accept these submissions.
10. The evidence as a whole paints a bleak picture of the practitioner as someone with a complete lack of regard for the role of health regulators and other authorities.
11. In addition to the findings on the particularised complaints, we note that, for example, Ms Luque claimed through her legal representative in correspondence to the HCCC on 13 July 2015 that she was not 'currently employed in the health sector but holds a casual retail position'. Further correspondence through Ms Luque's legal representative on 30 July 2015 stated that Ms Luque was 'currently unemployed' and attached a CV which stated that from 26 February 2015 to 'current' she was 'not working'.
12. Employment records from Safety Australia indicate that the Ms Luque was employed by them in the rail position noted above at para 10 from 12 September 2014 to 5 November 2015, and payroll records show her working 224 hours between 11 March 2015 and 30 June 2015, such that all of the statements in the above paragraph were false. The role was advertised as 'Paramedic' and the first selection criterion listed as 'Degree qualified as a Paramedic or Registered Nurse'. The job description of the role was as a 'Paramedic/Registered Nurse'. We note that while paramedicine is now one of the professionals regulated under the National Law, it was not at that time. However this was very clearly not a retail position, or 'not working', but rather was employment providing a health service in the nature of paramedicine.
13. The overall pattern of the practitioner's employment history is one in which she has moved from location to location, and from hospital to community care, to a series of aged care facilities in turn, to allied health service provision, staying in each for a relatively short period until (on at least the four occasions documented in these proceedings) 'caught out' and terminated. This history gives very grave cause for concern should the practitioner return to the aged care residential sector in any caregiving role, or should she obtain employment providing any form of unregulated health service, such as the provision of personal or health care services in the community sector. Personal care and home care services take place in the homes of patients with no on-site supervision and in a setting in which there are no controls over the storage, recordings and disposal of restricted medications.
14. In light of our findings of the very substantial risk posed by the practitioner, a prohibition order is required, and we are determined to cast it in the broadest possible terms to cover all health services as defined under s 4 of the Health Care Complaints Act 1993 (NSW).
15. For clarity, we emphasise that this prohibition includes, but is not limited to, the provision of assistant in nursing, personal care assistant and home care services, and that it operates from the date of these orders until such time as the Tribunal reviews the cancellation of the practitioner's registration as a nurse.
16. The HCCC sought costs of the proceedings on the basis that it had acted properly in the prosecution of the complaint and in the proceedings: Qasim v HCCC [2015] NSWCA 282; Lucire v HCCC (No 2) [2011] NSWCA 182.
17. Although the HCCC did not succeed in the entirety of complaint 2 (in that particular 9 and half of particular 8 were not proved), the balance of the complaint was proved, as was the gravamen of the overall case. This was not a case in which it could be said that the applicant had failed to succeed in proving a significant element of the case. There was no disentitling conduct and the HCCC is entitled to their costs.

Orders 1. Pursuant to a finding of professional misconduct, and a finding that the circumstances of the criminal offences which she has been convicted of render the practitioner unfit in the public interest to practise the profession of nursing, the practitioner's registration as a nurse is cancelled under s 149C(1)(b) and (c); 2. Pursuant to s 149C(5) of the National Law, the practitioner is prohibited from providing any health service as defined by s 4 of the Health Care Complaints Act 1993 (NSW), until such time as she is permitted to re-register as a nurse; 3. The respondent to pay the applicant's costs of these proceedings as agreed or as assessed under the Legal Profession Uniform Law Application Act 2014 (NSW); 4. Pursuant to s 64 of the Civil and Administrative Tribunal Act 2013 (NSW) a prohibition on the disclosure or publication of the names of the patients and persons listed in the schedule to the complaint, and of all other patients identified in the evidence.

I hereby certify that this is a true and accurate record of the reasons for decision of the Civil and Administrative Tribunal of New South Wales. Registrar DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment or decision. The onus remains on any person using material in the judgment or decision to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court or Tribunal in which it was generated. Decision last updated: 23 August 2019