Health Care Complaints Commission v Salvoza [2025] NSWCATOD 54

1. The Commission relied on a two volume bundle of documents which included statements from Patient A's daughter and son; Dr Atul Gaur; Dr Hardacre; Ms Frexy Prius, the Acting Nurse Unit Manager; Ms Renee Nash, a member of the responding Medical Emergency Team ("MET") and a clinical nurse educator; an expert report of Ms Deen who is an experienced nurse and clinical nurse educator; affidavits from Ms McGuire, the Commission's solicitor; and submissions. The clinical notes were also in evidence as was the transcript of an s 150 interview with Mr Salvoza on 22 August 2022.
2. Mr Salvoza did not file a reply to the Tribunal in response to the Commission's application or provide any evidence. He also did not appear at the hearing or have any representative appear for him.
3. The Commission made an application that the hearing proceed in the absence of Mr Salvoza.
4. The Commission relied on the affidavit evidence of Ms McGuire dated 20 February 2025. We had regard to the fact that Mr Salvoza had left Australia on 31 January 2024 and there was no evidence he had ever returned; the last contact from Mr Salvoza was an email he sent on 11 March 2024; an order was made by the Tribunal for substituted service on 30 August 2024 to the last known email address of Mr Salvoza but despite numerous emails from 2 September 2024 sent by the Commission to Mr Salvoza , he never responded to them. The emails sent to Mr Salvoza included the Complaint, the evidence and several instances of notification of the orders of the Tribunal such as notification of the hearing date. The Commission received automatic notification of delivery of those emails to Mr Salvoza, but did not receive a "read receipt" - which means there is no confirmation that Mr Salvoza read the emails.
5. We were satisfied that the overriding objectives of the Civil and Administrative Tribunal Act 2013 (NSW) were best served in the circumstances by proceeding with the hearing in the absence of Mr Salvoza including for the reasons that the Commission had efficiently prosecuted their case; the witnesses had all made themselves available for the hearing including Patient A's son who had travelled from Dubbo to attend in person; the matter had been listed for many months and numerous attempts had been made to inform Mr Salvoza of the hearing so that he could have an opportunity to be heard (which was delivered to his email address even if not responded to by Mr Salvoza).

1. Mr Salvoza was trained as a registered nurse in the Philippines in 2001 to 2007. He moved to New Zealand in 2011 where he worked as a healthcare assistant while completing a Diploma in Healthcare Studies followed by a Competency Assessment Programme for Overseas Nurses in March 2014.
2. In 2014, Mr Salvoza commenced practising as an RN at North Shore Hospital (Auckland City, New Zealand) in the Short Stay Ward in June 2014. Mr Salvoza worked in a variety of clinical areas in New Zealand hospitals between 2014 and August 2021 when he moved to Australia with his wife and two children.
3. Mr Salvoza was first registered as a nurse in Australia on 15 July 2019 and was registered until 1 July 2023. He has not been registered since 1 July 2023.
4. Mr Salvoza commenced employment at Dubbo Base Hospital ("the hospital") as a registered nurse on 29 November 2021.
5. The complaints against him are in relation to Patient A, an 85-year-old patient at the hospital.

1. Patient A was an 85-year-old patient at the hospital. Patient A had been admitted to the hospital on several occasions between February and April 2022 in relation to a broken left hip from a fall in early 2022.
2. On 7 April 2022, Patient A was admitted to the hospital due to an infection and left hip pain.
3. As part of Patient A's treatment, a Central Venous Catheter (CVC) line was inserted into Patient A's neck. CVCs are a type of Central Venous Access Device or CVAD, commonly used for ongoing administration of intravenous therapies including medication and nutrition.
4. On 13 April 2022, Mr Salvoza removed the CVAD from Patient A's neck while Patient A was sitting upright, leading to rapid desaturation (involving reduced oxygen flow to the blood) and collapse. The MET were called to treat Patient A, however he suffered an air embolism and his condition deteriorated.
5. Patient A died a short time later, on 2 May 2022, as a result of various causes.

1. A complaint was made about Mr Salvoza by Patient A's daughter in June 2022 to the Australian Health Practitioner Regulation Agency (AHPRA). A mandatory notification was also made by Western NSW LHD to the Nursing and Midwifery Council who subsequently conducted a proceeding under s 150 of the National Law ("s 150 proceeding") and ultimately was referred to the Commission.
2. In his initial response on 8 July 2022 to the HCCC complaint, Mr Salvoza stated:

"1. I had credentials for CVADs in New Zealand that I initially thought would be recognised here in Australia. It was not mentioned at any point of my employment at WNSWLHD, that I needed to be signed off again for this. They allocated me patients with CVADs multiple times which had me thinking I can access and deaccess them and nobody checked or asked me if I needed help since they should have known that I wasn't signed off and will need someone signed off to do them for me. I have always been used to completing all my tasks on my shift and avoid handing over unfinished tasks onto the next shift thus, even though it was not urgent, it was one of the doctors' orders so I did try and carry it out before my shift finished.

2. This has been the first and biggest mistake I have made in my entire nursing career. I became so overwhelmed with how busy my shift was that day. I had another MET call prior to this happening and I was trying to catch up with all my tasks that I mistakenly removed the CVC whilst the patient was sitting. I never intended to inflict harm to my patient and I am deeply saddened that something I did contributed to his deterioration. I tried my hardest best to resuscitate him and have felt remorseful of what happened since then.

3. Being the nurse assigned to the patient, I was the one helping by the bedside. There was someone else transcribing everything that was happening during the rapid response. I assume they have documented the events and interventions done which I would not have been able to do since I was actively doing the interventions to the patient. The incident really affected me that I could not think straight afterwards hence, the lack of clear documentation.

4. I honestly, cannot remember what I have written in my notes that day. I was too affected and my mind has been so clouded with guilt and regret. It was the first time something like this has happened and I didn't know how to react and cope. Since the incident, the hospital decided to put me under supervision on my shifts however, it became all too much for me. I have been notified of some gossiping around the hospital and given the severity of my mistake, I couldn't cope and focus that I thought it was best to resign from my position. This issue has been raised and investigated on by the WNSWLHD themselves. I did not respond and let them do the necessary processes and investigation and patiently waited for their decision. They have decided to put me on the Service Check Registry and they have also submitted a complaint against me for the same issue to the Nursing and Midwifery Council which I have responded to. The Nursing and Midwifery Council is still in the process of reviewing/investigating the said complaint. I am unsure of what the future holds for me but I hope they know how deeply sorry and remorseful I am of what happened and that I had and will never have any intention to harm my patients.

I would like to ask that my response be used for the Commission's assessment purposes only. Thank you."

1. Mr Salvoza also prepared a reflection document (as amended) for the s 150 proceedings as follows:

"Reflection on Issues Raised:

I did not have any intention to harm my patient. I am very sorry for my mistake. I am deeply sorry for the patient and his family. I am saddened to know that he has passed away and that something I did contributed to his early passing. It has immensely impacted my life and I do not wish for it to ever happen to anyone.

I had CVAD and other credentials in New Zealand. The orientation process I had when I started was a little bit tricky as I they had trouble with the logins and access to resources. I was not told at any point that I had to be signed off again to do interventions with the patients. I should have been more careful and asked about these things when I started.

I was used to always try and do all the doctors' orders in the morning on my shift and try my best not to handover tasks.

That day, I was overwhelmed with how busy my shift was going. From one METCALL to the other and only wanted to complete my tasks for the day.

I acted as fast as I can and did all my best to resuscitate him. It was a big mistake for me. I should have known better and should not have let the pressure and chaos get to me.

This incident has deeply affected me. The hospital decided to put me under supervision until they deemed me safe to practice on my own. I tried to come to work and do my duties however, I didn't last long that I had to resign. I have been notified of some gossiping going around the hospital and I guess, also thinking about how big of a mistake I made, it all just affected me in a way that I could not focus on my duties anymore and I lost motivation given the severity of my mistake. This is the first time in my entire career that this has happened, and will make sure to be the last, so I had a hard time coping. I felt that I needed a breather and let everything sink in then eventually face the consequences of my action.

Again, I had no intention to bring any harm to my patients. Going back to everything that had happened, I should have been more careful and mindful. I have been a nurse for more than a decade including my experience in the Philippines, and all I have ever wanted was to care for and serve my patients with the best care possible.

From now on, I will ensure that I know what my scope of practice is. I will ask and seek guidance regarding hospital protocols as I know that each country and each hospital differs regardless of my previous credentials. I will ensure that I will be practicing safely and will put patient safety as my top priority."

1. During the s 150 interview on 22 August 2022, Mr Salvoza said he had certified in New Zealand to access CVCs. He said he had performed hundreds of them. He initially denied knowing that he needed CVC certification in New South Wales but subsequently accepted that he did know about it but thought his experience and training were sufficient.
2. On 21 October 2022, Mr Salvoza was notified that conditions were to be imposed on his registration. On 10 November 2022, Mr Salvoza responded to that notification as follows:

"The conditions given are just too hard for the institutions to cater with.. being short staffed everywhere. I don't think anyone can cater with direct supervision right now."

1. On 14 February 2023, the Commission received confirmation from Mr Salvoza's former employer in New Zealand that he did not have certification, education or training in CVC while working there.
2. On 31 January 2024, Department of Immigration records before the Tribunal show that Mr Salvoza departed Australia. There is no evidence that he has returned.
3. Ultimately the Commission sent a communication to Mr Salvoza's email address, notifying him of the referral of the complaint and inviting him to provide submissions. Mr Salvoza responded from his email on 11 March 2024:

"I know this is not an excuse but 2 weeks prior someone pulled out a cvv on the same ward with the same results and had no complaints done.. As I remember so well I came from an emergency next door.. was a busy morning and had no breaks and lunch done.. I was really thinking hard of getting that lunch that time. I've owned to my mistake and has not received any support from nwsma. I am very sorry for what have happened and would like to get back to nursing. I have to do supervisions on my practice until deemed okay to practice on my own. I really badly need to be back to the work I loved for half my life.. My life can't be any more than crap.. im broke, no family, no job.. This is the only things that gives me hope."

1. This was the last communication from Mr Salvoza before the Tribunal.

1. The Commission's Complaint (as amended on 10 December 2024) alleges that Mr Salvoza is guilty of unsatisfactory professional conduct under s 139B(1)(a) of the National Law and professional misconduct under s 139E of the National Law.
2. The particulars of each Complaint are set out below:

"Mr Von Karla Almero Salvoza ('the practitioner') of Dubbo being a nurse formerly registered under the National Law,

AMENDED COMPLAINT ONE

is guilty of unsatisfactory professional conduct under section 139B(1)(a) of the National Law in that the practitioner has engaged in conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of nursing is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience.

...

AMENDED PARTICULARS OF COMPLAINT ONE

Procedure- Removal of CVAD

1. On 13 April 2022, in the Surgical Inpatient Unit at DBH, the practitioner inappropriately removed a CVAD from Patient A's neck in circumstances where:

(a) Patient A was sitting upright in a chair instead of lying supine or in the Trendelenburg position; and/or

(b) he applied a non-occlusive dressing (gauze and Hypafix) to the CVAD removal site rather than an airtight/occlusive dressing; and/or

(c) he was not appropriately credentialled to perform this procedure at DBH; and/or

(d) he was acting outside the scope of his qualifications and expertise.

Post-Procedure Conduct

7. On 13 April 2022, at DBH, following his removal of the CVAD from Patient A's neck the practitioner failed to respond appropriately to Patient A's deteriorating condition when he:

a. did not make any efforts to resuscitate Patient A; and/or

b. did not assist Patient A while waiting for the MET to arrive.

Record Keeping

11. The practitioner failed to record adequate and accurate clinical notes for Patient A on 13 April 2022 when he:

a. recorded inaccurate information that Patient A was nil by mouth for theatre in circumstances where another nurse had noted earlier that Patient A was able to eat and drink as theatre had been cancelled;

b. did not document the integrity of the CVAD tip;

c. did not document a post-procedure patient assessment including observations following removal of the CVAD;

d. did not document a timestamped observation data reflecting Patient A's subsequent deterioration; and

e. did not complete a sufficiently detailed incident report following the MET call.

COMPLAINT TWO

The practitioner is guilty of professional misconduct under section 139E of the National Law in that the practitioner has:

i. engaged in unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration, and/or

ii. engaged in more than one instance of unsatisfactory professional conduct that, when the instances are considered together, amount to conduct of a sufficiently serious nature to justify the suspension or cancellation of the practitioner's registration.

1. The particulars of Complaint 1 are repeated and relied upon both individually and cumulatively for the purposes of Complaint 2.

1. The Commission submits that Mr Salvoza is guilty of unsatisfactory professional conduct under s 139B(1)(a) of the National Law, which can be determined by whether the conduct particularised in the complaint is established, and if so, whether the conduct constitutes unsatisfactory professional conduct.
2. In establishing Complaint One, the Commission relies on three categories of conduct as set out in the Amended Complaint above:

(1) Mr Salvoza's conduct in the removal of the CVAD;

(2) his failure to respond after its removal; and

(3) his inadequate and inaccurate record-keeping of the event.

1. The Commission relies on evidence which demonstrates that Mr Salvoza had not completed the CVAD learning module, therefore he did not possess the hospital's required certification to remove Patient A's CVAD. This was not a mandatory module at the hospital, but without it a nurse could not perform this procedure. In addition, he removed the CVAD while Patient A was sitting in a chair, which is not the correct position; and he did not apply the correct dressing following its removal.
2. It is submitted that Mr Salvoza did not attempt to resuscitate Patient A, nor did he put anything in his notes to suggest that he did.
3. The Commission relies on the evidence of Ms Renae Nash, who provided a statement which described that on arrival at the scene, Patient A was in the chair and completely unresponsive, and Mr Salvoza was "just standing there and not intervening at all".
4. Patient A's son (who was present during the procedure) also provided a statement which described what occurred after the CVAD was removed. He stated that his father was quickly in respiratory distress. When Patient A did not respond to Mr Salvoza's inquiries as to whether he was "all right", Mr Salvoza hit the emergency button. Patient A's son does not recollect Mr Salvoza attempting to resuscitate his father while waiting for the MET to arrive.
5. The inaccuracies and omissions in Mr Salvoza's record-keeping also relied on by the Commission, are set out in the above Amended Complaint. Mr Salvoza's recorded notes were as follows:

"Received pt awake, alert and oriented

Obs stable BTFs

On NBM as per team with IVFs ngoing. VIP=0

CVC was insitu with dx peeling off

IVC on R arm VIP=0

family was present during mane handover.

meds were with held as per NBM going to OT order.

IVABS given by RN Jessica

Routine Obs checks were done around lunchtime

family in attendance

pt. was sitting on bed side chair. with IDC insitu

CVC line was removed; firm pressure dressing with combine and hypafix dressing

?loosen with facial hair on obstruction of it sticking. reinforced with nearest surgical tape.

pt. went pale and metcall was called. transferred to ICU"

1. As to the question of whether the conduct the subject of the complaints constitutes unsatisfactory professional conduct under s 139B of the National Law, the Commission submits that it was "significantly below the standard reasonably expected of a practitioner with an equivalent level of training or experience".
2. The Commission relied on an expert report of Ms Deen, an experienced nurse and Clinical Nurse Educator, and a procedure document published by NSW Health entitled "lntravascular Access Devices (IVAD) - Infection Prevention and Contro" (August 2019). Both documents were consistent in what was required for safe removal of CVADs.
3. Ms Deen's report detailed standard practice for CVAD removal as follows:

"The expected standard of practice for performing a CVAD removal is that it is to be indicated by the medical team for removal, the procedure is performed by aseptic technique and the patient is placed flat on their back or ideally with their head tilted downward slightly, this is to ensure that there is suitable pressure in the veins to decrease risk of introducing air during the removal of the catheter. This process is explained to the patient whilst setting up for the procedure. Following the removal an airtight dressing is to be applied for a period of at least 24hrs and the patient should remain flat for 30-60mins post removal before being sat upright again.... If a patient were sitting out of bed, it would be expected practice that the patient would be returned to their bed for the procedure or at the very minimum laid supine in an appropriate piece of equipment (ie reclining 'fall out' chairs)."

1. The explanation provided by Mr Salvoza was that the ward was busy and that he would have needed a hoist to get Patient A back into bed. In Ms Deen's opinion, unless there was some urgent need, the procedure should have been delayed until Patient A returned to bed in the afternoon so that it could have been performed safely and according to policy.
2. Ms Deen opined that Mr Salvoza's actions were significantly below the expected practice of a practitioner in his position, in that:

(1) He removed the CVAD while Patient A was sitting upright.

(2) He used a non-occlusive dressing, contrary to requirements for an airtight/occlusive dressing.

(3) As Mr Salvoza did not possess the required certification for the procedure, he should have referred it on to a certified staff member or obtained supervision. (This is consistent with the Nursing and Midwifery Board of Australia - Code of Conduct for Nurses which states that nurses must work within their scope of practice.)

(4) He did not reposition the patient following the removal of the CVAD; "follow the DRSABC algorithm of basic life support"; or even apply oxygen while waiting for the emergency staff to respond.

(5) Mr Salvoza's records were inadequate in that:

(a) Following removal of the CVAD he did not record the integrity of the tip or a post-procedure patient assessment:

(b) There was no time-stamped observation data of the change in Patient A's condition;

(c) He did not record observations on the time he activated the MET call; and

(d) There was an overall lack of detail and imprecision regarding the patient and Mr Salvoza's conduct in carrying out the procedure.

1. In addition, the Code of Conduct for Nurses provides that in the event of a problem, nurses must act immediately to rectify the situation and to escalate concerns when needed to protect the safety of the patient.
2. The evidence recorded above was not challenged by Mr Salvoza as he did not appear. We note that in his s 150 proceedings and in his written communications, Mr Salvoza said he did everything he could to resuscitate Patient A. This is contrary to the evidence of Ms Nash and Patient A's son (who was present in the room) and, as noted above, observed that Mr Salvoza took no steps to resuscitate Patient A and did not provide any assistance when the MET team attended. We accept the evidence of Patient A's son and Ms Nash that was before the Tribunal.
3. We also note that in his written response, Mr Salvoza said another person was transcribing notes onto the record and that he assumed they would include more details about what had occurred. There is no such evidence of another person performing this role. We also observe that the notes that are recorded are those of Mr Salvoza.

1. The same particulars set out above for Complaint One are relied on for Complaint Two, which is that Mr Salvoza's conduct constituted professional misconduct under the National Law, s 139E.
2. The Commission submits that while Mr Salvoza was not deliberately trying to harm Patient A, his conduct was objectively serious as he exposed the patient to significant risk while performing a task for which he was not certified and thus outside his permitted scope of practice.

1. The principles relevant to disciplinary proceedings under the National Law are uncontroversial. The overarching principles are found in s 3 and s 3A of the National Law. Section 3A mandates that in determining proceedings the Tribunal has the protection of the health and safety of the public as its paramount consideration.
2. The Tribunal may exercise the disciplinary powers conferred by Subdiv 6 of Div 3 of Pt 8 of the National Law if (a) it finds the subject matter of the complaint to have been proven or (b) the practitioner admits to it in writing to the Tribunal: National Law, s 149.
3. The Commission bears the onus of proving the complaints against Mr Salvoza on the balance of probabilities. The Tribunal is not bound by the rules of evidence in these proceedings: National Law, cl 2 of Sch 5D.

1. Section 139B of the National Law provides a detailed list of behaviours that are covered by the term "unsatisfactory professional conduct" in relation to registered health practitioners in NSW.
2. Section 139B(1)(a), the relevant paragraph regarding the complaint against Mr Salvoza, provides:

139B Meaning of "unsatisfactory professional conduct" of registered health practitioner generally [NSW]

(1) Unsatisfactory professional conduct of a registered health practitioner includes each of the following -

(a) Conduct significantly below reasonable standard

Conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of the practitioner's profession is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience.

...

1. The Tribunal discussed the process of a determination of whether the conduct was significantly below the reasonable standard in Health Care Complaints Commission v Amalakumar [2019] NSWCATOD 173 at [25] as follows:

"Determining whether the 'knowledge, skill or judgment' possessed by a practitioner, or the 'care exercised' by a practitioner is significantly below the standard reasonably expected, in order for the elements of s 139B(1)(a) to be established, requires the undertaking of an evaluative process. A benchmark standard which is expected of practitioners in the relevant field must be ascertained, and then the conduct which has been proven against the practitioner the subject of the disciplinary action, must be assessed against that standard. If the conduct is considered to be below the standard arrived at, then a further evaluation must be made as to whether the conduct is significantly below that standard. If that conduct is assessed to be significantly below the standard reasonably expected, then there is no discretion as to whether that conduct is characterised as unsatisfactory professional conduct. The section designates it as such."

1. Section 139E of the National Law provides as follows:

139E Meaning of "professional misconduct" [NSW]

For the purposes of this Law, professional misconduct of a registered health practitioner means -

(a) unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration; or

(b) more than one instance of unsatisfactory professional conduct that, when the instances are considered together, amount to conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration.

1. The term "professional misconduct" does not have a specific meaning, and it is merely a category of "unsatisfactory professional conduct" which is sufficiently serious to justify suspension or cancellation: Chen v Health Care Complaints Commission (2017) 95 NSWLR 334; [2017] NSWCA 186 at [19] (Basten JA) ("Chen"). The exercise involves an evaluative judgment to be made by the Tribunal as to the nature and seriousness of the conduct: Chen at [20].
2. In Health Care Complaints Commission v Robinson [2022] NSWCA 164 at [35], the Court noted that the "seriousness of the conduct" concerns not just acts or omissions but also the circumstances of their occurring. Justice Kirk at [36]-[37] agreed that there was force in the Commission's submissions that the sorts of issues arising in characterising the nature of the conduct include:

"(1) the practitioner's state of mind at the time of the impugned conduct (eg whether conduct was deliberate or inadvertent);

(2) any knowledge the practitioner had of particular vulnerabilities in a patient;

(3) the risks of harm that the conduct was apt to create;

(4) the practitioner's knowledge, skill and training;

(5) the disciplinary history of the practitioner, as repeated inappropriate conduct may be treated as being of a more serious nature than isolated inappropriate conduct..."

1. The question for the Tribunal then, is whether the conduct in question is of a sufficiently serious nature to justify suspension or cancellation. As held in Health Care Complaints Commission v Karalasingham [2007] NSWCA 267 at [67], the conduct "must have the capacity to justify such an order, whether or not such an order should be made in particular circumstances".

1. While the conduct the subject of the complaint regarding Mr Salvoza relates to a single incident, rather than "repeated inappropriate conduct", the circumstances here were of a particularly serious nature. This was due to the significant risk to the patient of an air embolism and cardiovascular collapse. We find that the procedure was outside the permitted scope of Mr Salvoza's practice, as he did not have the hospital's required credentials.
2. The risk of harm that the conduct was apt to create was serious, even being a single occurrence of such conduct, particularly when Mr Salvoza knew that he did not possess the required certification, and that the patient was extremely vulnerable.
3. We regard his conduct of being a most serious matter. This is only compounded by his ineffective response once the patient was clearly in distress. On the evidence before us, he did nothing to resuscitate the patient or take any steps to assist Patient A. He also did not make any attempts to help the nurse who came rushing to Patient A's aid. This is not just contrary to accepted practice but is inexplicable.
4. In addition, we find that Mr Salvoza made inaccurate records and insufficiently detailed records of what occurred, both before and post treatment. He also subsequently sought to minimise his conduct by asserting there would have been someone else present making the records. We find such an assertion improbable.
5. We are comfortably satisfied on the evidence that Mr Salvoza is guilty of unsatisfactory professional conduct. Complaint 1 is established on the evidence.
6. Whether Mr Salvoza's conduct is considered separately or cumulatively, we find his conduct was of such a serious nature, that it justifies suspension or cancellation. We find Mr Salvoza's conduct so serious that had he been registered we would have cancelled his registration.
7. Consequently, we are also satisfied that Mr Salvoza is guilty of professional misconduct. Complaint 2 is established.

What if any disciplinary orders should be made?

1. As each of the complaints are made out, we are required to consider what if any protective orders should be made.
2. Part 8, Div 3, Subdiv 6 of the National Law which is headed "Disciplinary Powers of Tribunals" sets out the disciplinary powers available to the Tribunal where a complaint is found proven: see ss 149A, 149B and 149C of the National Law. They include the power to caution, reprimand and counsel a practitioner and impose conditions on the practitioner's registration. Where, as in this case, the Tribunal is satisfied the practitioner is guilty of professional misconduct, the Tribunal may suspend the practitioner's registration for a specified period or cancel their registration: s 149C(1) of the National Law.
3. In determining the appropriate orders, the paramount consideration is the protection of the health and safety of the public: see s 3A of the National Law. As the Tribunal's paramount consideration is the protection of the health and safety of the public, an imposition of restrictions on the practice of a health professional is only to be made in pursuit of according with this higher objective. Such restrictions are only to be imposed where necessary to ensure health services are provided safely, at an appropriate quality: see s 3A(2)(c) National Law.
4. This determination may only be made by reference to the facts of the particular case before the Tribunal and by considering what measures are needed to ensure future behaviour of the practitioner is shaped in such a way that is consistent with these protective goals: Lee v Health Care Complaints Commission [2012] NSWCA 80 at [34].
5. In addition to the protection of the public being the paramount consideration, it has also been held that other relevant purposes of such proceedings include the need to maintain the standards of the relevant profession, and to deter others from engaging in like conduct: see for example, Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630 at 637.
6. As such, the purpose of the disciplinary powers of the Tribunal is not to punish a practitioner but rather to protect the public and maintain proper professional standards.

1. We note that Mr Salvoza is not currently registered.
2. In the present case, as we are satisfied on the evidence that Mr Salvoza's conduct is of a sufficiently serious nature that if he had been, we would have cancelled his registration. We therefore consider an order under s 149C(4)(a) of the National Law is appropriate.
3. The Commission sought an order that Mr Salvoza be disqualified from registration for a period of 12 months from the date of this decision. We agree this is an appropriate period for the protection of the community. We have taken into account the fact that he has not been registered since July 2023.
4. The fact that he has not engaged in this Tribunal process at all, gives us no confidence that he has meaningful insight into the consequences of his behaviour which fell well short of what is expected of a registered nurse. We acknowledge his reflection and what he said during the s 150 interview that he was deeply sorry and that his conduct had effectively ruined his life. However, on each occasion, he sought to minimise his conduct and blame the hospital for insufficient resources and support. Further, the more contemporaneous correspondence he sent on 11 March 2024, when he learned of the outcome of the Commission's investigation, shows that Mr Salvoza, while expressing sorrow for what happened, again focused on minimising his conduct by suggesting other nurses also engage in this behaviour with similar results but do not get reported. The defensive nature of his communication and his non-responsiveness to further communications from the Commission including for these proceedings, demonstrates a lack of insight into his conduct and we find it demonstrates a level of flippancy about what has occurred.
5. Similarly, he said he tried everything he could to resuscitate but the evidence we have accepted is to the contrary. It appears to us he was trying to cover up the true state of affairs and again minimise his part.
6. The same is true of the insufficient recording keeping, he tried to blame someone else who he "assumed" would take notes - that person was not identified and, on the evidence, there was no such person. Again, this demonstrates Mr Salvoza attempting to deflect blame to someone else.
7. Consequently, we are unable to be satisfied that Mr Salvoza demonstrated genuine insight into his conduct. We have no confidence in him practising as a registered nurse and consider the community should be protected.
8. If Mr Salvoza returns to Australia and seeks re-registration, by imposing a period of 12 months disqualification it will indicate the seriousness of the circumstances and the extent of our concerns about Mr Salvoza's ability to provide the community competent nursing services. It should also indicate to those considering any application on re-registration, that a cautious approach should be adopted to his application. This, in our view, will give further protection to the community.

1. The Commission seeks its costs. In exercising the power to award costs conferred by cl 13, Sch 5D of the National Law, the general rule is that costs follow the event unless there has been some disentitling conduct of the successful party.
2. We have not identified any conduct of the Commission which would disentitle them to costs and costs should be awarded in the Commission's favour.

(1) If Mr Salvoza had been registered as at the date of these orders the Tribunal would have made an order cancelling his registration pursuant to s 149C(4)(a) of the Health Practitioner Regulation National Law (NSW).

(2) Pursuant to s 149C(4)(b) of the Health Practitioner Regulation National Law Mr Salvoza is disqualified from being registered for twelve months from the date of these orders.

(3) The Registrar is to notify the National Board that pursuant to s 149C(4)(c) it is to record on the National Register kept by the Board the fact the Tribunal would have cancelled Mr Salvoza's registration if he had been registered.

(4) Mr Salvoza is to pay the applicant's costs under cl 13 of Sch 5D of the Health Practitioner Regulation National Law as agreed or assessed.

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.