Health Ombudsman v Hoddle [2022] QCAT 142

Brigginshaw v Brigginshaw [1938] HCA 34; (1938) 60 CLR 336

Health Care Complaints Commission v NG [2015] NSWCATOD 139

Health Ombudsman v Arora [2019] QCAT 200

Health Ombudsman v Asinas [2021] QCAT 306

Health Ombudsman v Chang [2022] QCAT 58

Health Ombudsman v DKM [2021] QCAT 50

Health Ombudsman v Duggirala [2021] QCAT 326

Medical Board of Australia v Griffiths (Review and Regulation) [2017] VCAT 822

Medical Board v Thomas [2021] VCAT 229

Pharmacy Board of Australia v Tan [2016] VCAT 1653

C Templeton, instructed by the Office of the Health Ombudsman

• [1] These disciplinary proceedings were referred to the Tribunal by the applicant Director on 28 June 2021. There is a statement of agreed and disputed facts signed by the legal representatives for both parties and dated 30 September 2021.
• [2] The respondent was, at all times material to the allegation the subject of the referral, a registered osteopath.
• [3] The respondent's registration is currently suspended.[1] The respondent did not attend the hearing in person but was legally represented. He had given written notice to the tribunal that health concerns prevented him from attending.

• [4] The respondent, by his response to the referral:

(a) Admits the allegations contained in the application for the referral that[2]:

(i) on 9 January 2019 and 11 April 2019 the respondent engaged in criminal conduct which resulted in convictions for two counts of sexual assault and two counts of rape;

(ii) that on 19 January 2021 he was convicted after a trial in the District Court of Queensland at Maroochydore of the criminal offences of 2 counts of sexual assault and two counts of rape;

(iii) on 19 January 2021 he was sentenced to 3 years imprisonment suspended after serving 9 months for an operational period of three years;

(b) Denies[3] certain factual allegations being:

(i) that he removed the patient's underwear or sexually assaulted the patient on 9 January 2019;

(ii) that he raped or sexually assaulted the patient during an appointment on 11 April 2019; and

(iii) specific conversations about which evidence was given at the criminal trial, which, as the tribunal reads the transcript, was effectively evidence led to support preliminary complaint concerning the alleged offences.

(a) the respondent does not deny that he was convicted of the offences; and

(b) the respondent continues to deny that he committed the acts which were the subject of the jury verdicts of guilty.

• [6] The conduct giving rise to the referral occurred on 9 January 2019 and 11 April 2019.
• [7] There are some agreed facts which are relevant:

(a) at the time of the alleged conduct the respondent owned and operated a private practice offering metaphysical therapy, counselling, personal development workshops and teaching in a small building close to his home[4];

(b) on 15 January 2020 the Office of the Health Ombudsman received a complaint and notification from the Queensland Police Serve that the respondent had been charged on 2 January 2020 with the counts of which he was ultimately convicted and it commenced an investigation that day[5];

(c) on 21 January the Health Ombudsman issued an interim prohibition order prohibiting the respondent from providing any health services pursuant to s 68(1) of the HO Act and on 22 January 2020 took immediate action to suspend the respondent's registration[6];

(d) the alleged offending relates to a female patient identified as BA. This patient was 34 years old at the time of the conduct, had been receiving treatment and counselling from the respondent since 2013 and had attended approximately 24 appointments lasting between 30 minutes and one hour[7];

(e) on 9 January 2019, BA had attended for treatment which involved undressing to her underwear and laying face down on the examination couch while the respondent talked BA through a guided meditation, massaged the patients buttocks and thighs and told her 'there was still energy stuck in her pelvis[8]';

(f) at the conclusion of the appointment the patient informed the respondent that she was moving interstate with her husband and son and would not be back until April[9];

(g) BA returned for treatment on 11 April 2019 commenting that she had neck and lower back pain as well as a sore right knee. BA again undressed to her underwear and laid face down on the examination couch. The respondent massaged her back;

(h) after the appointment BA returned to Perth where she attended counselling. Ultimately, in June 2019, she reported the offences to the Western Australian Police Service[10];

(i) the respondent, in interview on 2 January 2020, as part of the investigation, denied each of the allegations of sexual assault and rape[11]; and

(j) the allegations were subject of a jury trial in the Maroochydore District Court commencing on 18 January 2021. On 19 January 2021 the respondent was convicted on all four counts and sentenced to three years imprisonment, suspended after 9 months for an operational period of three years[12].

• [8] The respondent maintains by his response to the referral, the agreed facts and an unsigned letter to the Tribunal dated 12 March 2022, which was sent by email and referred to at the hearing today although not formally tendered, that the alleged conduct did not occur.

• [9] The applicant contends that there is authority for the proposition that a respondent is unable to assert factual matters inconsistent with his conviction for the offences[13].
• [10] In Health Ombudsman v Asinas[14], at [20], Judge Allen QC stated that the authorities he had been referred to supported the proposition that the practitioner would be unable to assert factual matters inconsistent with his conviction of the offences the subject of the referral in that case. I agree with those observations as to the import of the authorities. The applicant submits this relates to the facts which to go the conduct the subject of the convictions and that it is not necessary for the Tribunal to resolve any disputes about factual matters which were peripheral to those matters (going to evidence of preliminary complaint given by witnesses at the criminal trial), which is disputed in paragraphs [28] and [29] of the statement of agreed and disputed fact.
• [11] At the criminal trial BA gave evidence and was cross examined about what occurred in the appointments on 9 January 2019 and 11 April 2019. She gave evidence that she was sexually assaulted and raped. The respondent, as was his right, did not give or call evidence at the trial. Inherent in the jury's determination to convict the respondent on each of the counts must be their acceptance of BA's evidence that the conduct occurred as she gave evidence about. As such, consistent with the authorities the respondent cannot now assert that the conduct did not occur.
• [12] For the purposes of understanding the sanction, the subject matter of the offences, in short summary taken from the transcripts is:

(a) as to the sexual assault on 9 January 2019;

(i) it involved the respondent working down from BA's lower back into her buttocks and the back of her thighs and, ultimately, her sliding off the examination couch. She stood in what she described as a labour position and the respondent came around behind her, got his hand out and was stroking her on the outside of her vagina, stroking her labia majora, like the outside lips of her vagina, and dragging his hand down[15]; and

(b) as to the two counts of rape and the sexual assault on 11 April 2019;

(i) the respondent removed the patient's underwear and was touching her buttocks. He then separated her legs with his hands. He started to put fingers inside her vagina, firstly one, and then moved it in, around and in and out and then a second finger and a third finger in. She said that it was too intense, and he mumbled something and stopped. She then went on to say that it lasted for in the order of 30 seconds to a minute, it was unexpected, that the respondent said nothing to her about the conduct before it occurred and that she did not give any permission and he did not seek any permission to do what he did. After that incident, which constituted one of the rape counts, the patient rolled over onto her back, and at that point her evidence was that the respondent spread her legs and put his tongue inside her vagina repetitively and was licking her inside and out. Again, she did not consent to that. Her evidence was that the respondent's tongue was inside her vagina, touching the walls of her vagina and her clitoris and the lips of her vagina. At that point, the respondent came around to the top of the bed and he kissed her and licked her mouth and licked her teeth and then he lifted her hands up and put them over his waist, and he then leant over and touched her breasts, first her left breast and then her right breast. She gave evidence that he pinched her right nipple, saying this one has less energy in it. She estimated that that conduct went for in the order of 10 seconds whilst he was touching her breasts.[16]

• [13] The Tribunal proceeds on the basis that those are the factual findings of the conduct that gives rise to the criminal convictions.

The respondent's professional and disciplinary history

• [14] The respondent obtained the qualifications of Bachelor of Applied Science (Osteotherapy) in 1988. He was aged between 68 and 69 at the time of the events the subject of the referral. He will turn 72 years of age shortly.
• [15] He had no criminal or disciplinary history prior to the conduct the subject of the referrals.
• [16] He has served the custodial element of the sentence which was imposed upon him for the criminal convictions. A balance of approximately 11 months of the suspended sentence remains operational at the time of the hearing of this referral.

• [17] The applicant has filed written submissions dated 29 November 2021. The applicant submits the conduct constitutes professional misconduct within the meaning of each of sections 5(a) and 5(c) of the National Law. In oral submissions the respondent's solicitor did not resist that characterisation.
• [18] It is, according to statute, a matter for the Tribunal to ultimately determine the characterisation of the conduct.
• [19] The Tribunal is comfortably satisfied that the respondent's conduct is properly characterised as professional misconduct which both:

(a) is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and

(b) is inconsistent with the practitioner being a fit and proper person to hold registration in the profession.

• [20] The applicant seeks, and the respondent in oral submissions did not oppose a making of a reprimand.
• [21] The applicant seeks and the respondent agreed in oral submissions that, given the nature of the conduct, cancellation of the respondent's registration is an appropriate order. Taken overall and given the seriousness of the charges of which the respondent was convicted, the Tribunal accepts the applicant's submission that the conduct was clearly inconsistent with him being a fit and proper person to hold registration in the profession of osteopathy.
• [22] There will be an order for cancellation of the respondent's registration.
• [23] The real issue for the Tribunal is whether any period of disqualification should be indefinite or for a finite period.
• [24] The considerations relevant to indefinite disqualification have been set out in Duggirala_[17]_ and DKM_[18]_. The Tribunal may only make an order for indefinite disqualification if it is satisfied that upon the cessation of any finite period, there is no grounds to believe the respondent may become fit to practice again.[19]
• [25] Consistent with the standard of proof required[20] and that the consequences of such a finding to a practitioner are catastrophic, such a finding should not be lightly made[21].
• [26] It is apparent from a review of the authorities that orders for lengthy periods of definite suspension have been made in cases involving serious sexual misconduct leading to criminal convictions on some occasions.
• [27] The applicant contends firstly for an indefinite disqualification, but accepts, on the authorities, that it is a matter on which reasonable minds may differ, particularly given the test for the imposition of an indefinite disqualification period.
• [28] In the absence of an indefinite disqualification period, the applicant contends for a disqualification period of in the order of 10 years before the respondent can apply for re registration as an osteopath. The applicant also seeks an order that the respondent be prohibited from providing any health service until he obtains registration as a health practitioner.
• [29] The respondent contended for a period of disqualification of in the order of 5 years.
• [30] The applicant's submissions were that:

(a) the respondent's conduct was particularly serious because:

(i) the patient was particularly vulnerable due to not only the inherent power imbalance in the osteopath/patient relationship but also due to the respondent being a long time and trusted family friend;

(ii) the patient had disclosed confidential and private information about a difficult labour with her first child;

(iii) the conduct on 11 April 2019 in particular, involved protracted conduct by the practitioner, including:

1. a digital rape which went for in the order of 30 seconds;
2. a further oral rape; and
   1. sexual assault;

thus involving multiple parts of the patient's body. This conduct should be regarded as particularly serious, even egregious, although I use that word, the applicant's counsel did not;

(iv) the applicant points to the fact that the respondent as a registered Osteopath is required to comply with the Osteopathy Board Code of Conduct and the Sexual and professional boundaries: Guidelines for Osteopaths;

(v) the conduct, being sexual misconduct, is in breach of sections 1.2 and 8.2 of the Code of Conduct and paragraph 3 of the guidelines;

(b) the purpose of disciplinary proceedings is to maintain professional standards and public confidence in the profession and to protect the public. The sanction in a particular case must be considered based on the peculiar facts and to be crafted to something which best achieves those purposes;

(c) the applicant points to the patient's particular vulnerability, the serious criminal conduct that occurred over two treatment sessions and then continuing denial of the conduct as significant considerations.

[31] In oral submissions the respondent's solicitor informed the Tribunal that the respondent was frail consequent upon surgery to replace some valves in his heart, which had occurred between the conduct being charged and conviction, but that he would like to keep open the prospect of some work in counselling if his age and health permitted. In his written submission the respondent advised, amongst other things that he had paid money in accordance with the Victims of Crime Compensation Act 2009 (Qld) and he resisted any order for a fine. The Tribunal observes that no fine is presently sought and no fine will be ordered.

• [32] When turning to consider the issue of sanction, it is important to recall that the purpose of these proceedings is protective in nature and not punitive. The Tribunal must regard the health and safety of the public as paramount[22].
• [33] Factors the Tribunal must consider include [23]:

(a) the nature and seriousness of the conduct;

(b) whether the practitioner acknowledges culpability and whether there is evidence of contrition or remorse;

(c) what needs for specific or general deterrence;

(d) whether there have been other disciplinary findings before or after the conduct in question;

(e) evidence of character;

(f) evidence of rehabilitation;

(g) whether there has been delay from the time the investigation started to the conclusion of the matter in the Tribunal; and

(h) any other mitigating factors.

• [34] General deterrence is always an important aspect of disciplinary proceedings such as these because of the need to send a message to other professionals that to behave in this way is apt to bring the profession into disrepute. The applicant submits that general deterrence is very important in this matter to denounce the respondent's transgressions. The Tribunal accepts that submission.
• [35] The applicant also submits that specific deterrence is crucial due to the respondent's continual denial of the conduct which demonstrates a lack of insight into the gravity of what has occurred. Where the respondent has continued to deny his conduct, he has plainly demonstrated no remorse, no insight and no rehabilitation. The Tribunal accepts a measure of specific deterrence is called for in these circumstances.
• [36] The respondent in his unsigned letter of 12 March 2022, makes reference to suffering mental health conditions as a result of the trauma from the past two years. Although a mental health condition that a practitioner has may be a relevant factor for the Tribunal to consider in any given matter, where the respondent's assertions are unsubstantiated by any evidence as to the nature of any condition, or how it has been derived and its symptoms, the Tribunal places little weight on this factor.

• [37] The applicant has directed the Tribunal to consider Health Ombudsman v Arora_[24],_ Health Care Complaints Commission v NG_[25],_ Medical Board v Thomas_[26]__, Health Ombudsman v_ Duggirala[27], Health Ombudsman v DKM_[28]_ and Pharmacy Board of Australia v Tan_[29]. The applicant also sent through the decision of Health Ombudsman v Chang[30]_ (Chang) shortly prior to the hearing.
• [38] The respondent has not put before the Tribunal any authorities in relation to sanction. In oral submissions the respondent's legal representatives referred to Chang.
• [39] Arora resulted in a nurse being disqualified from registration for six years from the date of the order. The nurse was charged with sexual offences in relation to three patients on three separate night shifts in hospitals. The conduct was of a serious nature and involved, amongst other conduct, digital penetration of two of the patients. The respondent faced three jury trials and was acquitted on each. In the referral the applicant proffered, as separate allegations of misconduct, the same sets of circumstances as were prosecuted in the criminal trials. Noting the Tribunal could consider all the evidence together, the Tribunal, having reviewed the evidence from each trial, in circumstances where the respondent, who was represented before the Tribunal, put no material before it and took no issues as to cross admissibility, found the applicant had proved the allegations. At the time of the Tribunal hearing the nurse had not practiced for a period of 5 years, rendering the overall disqualification period 11 years.
• [40] The applicant properly conceded in oral argument that Arora may be regarded as more serious than the present because it involved equivalent conduct but multiple patients.
• [41] Thomas involved a psychiatrist who sexually assaulted a patient after a prolonged period of grooming behaviour. The respondent was convicted at a criminal trial and served time in custody. Before the Tribunal, he was disqualified from applying for registration for five years from the date of the order, because of the serious nature of the conduct. The respondent had indicated a clear intention that he would not return to practice and the Tribunal observed that given his age (at 71) and his ill health, a return to practice was unlikely. The time the Tribunal ordered out for further disqualification was on top of the three years and nine months for which the respondent had already been suspended. There was thus an effective sanction period of almost 9 years.
• [42] NG concerned an osteopath who was found by the Tribunal to have inserted his finger into a patient's vagina for 30 seconds. The respondent was not criminally charged. NG's registration was cancelled and he was disqualified from applying for registration for 18 months. (The applicant in that case had contended for disqualification for at least two years). The respondent there did not accept the conduct had occurred, but he was considered by the Tribunal to have shown some understanding of the ramifications of such conduct and had not challenged the truthfulness of the patient, submitting instead that the patient was mistaken. He tendered a significant number of references and had no previous disciplinary history. The Tribunal is satisfied objectively that the current allegations are objectively more serious than that of NG. There is no analysis of the considerations which led to the disqualification period and the Tribunal places no reliance otherwise on this authority.
• [43] Tan involved a pharmacist working as a pharmacist intern, who was convicted of raping a 22-year-old patient. Tan's registration was cancelled, and he was disqualified from applying for registration for four years. Tan denied the allegations and made comments to police along the lines that his professional role allowed for examination of patient's breasts, buttocks and genitalia. It was not until later in the proceedings he showed remorse for the conduct. The applicant distinguishes Tan on the basis that he was a young practitioner suffering from a diagnosed mental health condition. Those matters are appropriate points of distinction.
• [44] In Health Ombudsman v Chang a registered health practitioner, working as a massage therapist, during a massage of a female patient made momentary contact with her clitoris, then later, made further contact, rubbing it for a few seconds. He then inserted a finger into her vagina and moved it in and out for about 10 seconds. The patient told him to stop as soon as he inserted his finger and, after she told him to stop a second time, he did. She reported the matter to the police shortly thereafter. A jury found the respondent not guilty of a charge of rape. The Tribunal was, however, satisfied on the material before it that the conduct had occurred.
• [45] The Tribunal found this was a very significant breach of the respondent's duties and responsibilities, where he had taken advantage of the patient's vulnerable position. There was no evidence of any insight into the wrongfulness of his conduct or any remorse (at [24]).
• [46] The Tribunal found that having been away from the profession for about 4 and a quarter years, an additional preclusion period of a further 5 years was reasonable and consistent with the outcome in _Aror_a, allowing for factual differences (at [30]).
• [47] Whilst the applicant did not rely on the following two authorities in terms of comparable facts, it is important to review them briefly in light of consideration as to the issue of an indefinite period of disqualification and circumstances in which one has been imposed.
• [48] Duggirala was a medical practitioner convicted of sexually assaulting a female patient. The conduct involved him squeezing both her breasts and prodding around her pelvic bone. At the time of the conduct the practitioner was aged 59. The then Deputy President of the Tribunal Judge Allen QC noted that the conduct occurred in breach of chaperone conditions imposed in an earlier disciplinary proceeding and in a greater context of various incidents of conduct the subject of disciplinary proceedings. The Tribunal was satisfied that in the context of his prior disciplinary history, which showed a continued propensity to breach professional boundaries and a failure to adhere to conditions, that he was not a fit and proper person to hold registration, nor would he be in the future.
• [49] The Tribunal considers that in this case the respondent's objective conduct is more serious than that of Duggirala but it must be considered against the backdrop, unlike in Duggirala, of him having no prior disciplinary history, a factor that was given significant weight and consideration in Duggirala where the practitioner could only be considered a recidivist type offender_._ In particular, the Tribunal notes that Judge Allen QC referred specifically to an observation of the Tribunal in an earlier disciplinary proceeding against the doctor that " ... if he were to again conduct himself in a manner which was in breach or further breach of the conditions which are imposed upon his registration, that would be a very serious matter which must necessarily put in peril, one would think, his continued capacity to practice in the profession."[31]
• [50] Thus, the doctor should have been on notice of the importance of complying with his imposed conditions.
• [51] DKM involved a medical practitioner convicted of maintaining a sexual relationship with a child under 16 years, who was his biological daughter. The relationship commenced when she was 9 years old and went for seven years. Whilst noting that the sexual misconduct was unrelated to his practice as a medical practitioner, the Tribunal was satisfied that the actions could only be described as "showing a gross defect of character." Before the Tribunal the respondent had sought to demonstrate remorse by giving evidence that he had wanted to plead guilty but was persuaded not to by his then solicitors. That evidence was inconsistent with written instructions he had given to those solicitors and evidence he gave at trial that he was innocent of the charges alleged against him. The Tribunal observed that the respondent's lack of frankness reflected poorly on his personal character and adversely affected the credibility of his evidence on the other charges which the applicant proffered (relating to failure to notify of being charged and making a false statement on a declaration). Overall, this lack of frankness was found to reflect poorly on his present character and fitness to practice.
• [52] The Tribunal found there were no grounds to believe the respondent would, after addressing recency of practice issues, present any risk of any time to patients[32] and that further preclusion from practice was not required to meet deterrent aspects of sanction[33]. The main consideration on sanction was the health and safety of the public, the purpose being to protect the public and the profession[34]. Ultimately the Tribunal determined that the heinous conduct of the respondent in his sexual exploitation of his daughter so indelibly marked the respondent's character as to compel a conclusion that he could not properly be regarded now or in the future as a fit and proper person to hold registration as a medical practitioner[35]. The Tribunal reached this conclusion having regard to the extent of the professional misconduct reflected by the offending; the unprofessional conduct (reflected in the other two allegations) and the lack of frankness in the conduct of the proceeding before the Tribunal, which served to reinforce that conclusion[36].
• [53] The protracted nature of the offending in DKM, together with the practitioner's lack of frankness before the Tribunal on the disciplinary proceedings makes, to this Tribunal's view, DKM a more serious example of the conduct for that specific offence, than in the present case.
• [54] Ultimately the applicant submitted in the Tribunal, that, on the issue of indefinite disqualification, the focus of the inquiry for the Tribunal should be whether the conduct was so serious it represented an indelible stain on the respondent's character, picking up the language in Duggirala at [72].
• [55] The Tribunal considers the following factors:

(a) the conduct occurred over two occasions, separated by about a 3 month period. The sentencing judge found the conduct couldn't be considered a single aberration;

(b) it occurred against one patient;

(c) the conduct, particularly on the occasion of 11 April 2019 was protracted and extremely serious. By contrast, however, with the conduct in DKM, the conduct occurred over the course of a day and doesn't bear the levels of heinousness which can be identified in DKM;

(d) the respondent had practiced as an osteopath for fifty years without any complaints and had no criminal history;

(e) even after conviction the respondent maintains his innocence of the offending. As such, he has not demonstrated any remorse, insight or rehabilitation;

(f) the respondent has only been relatively recently released from serving the custodial term of his sentence; and

(g) the respondent is almost 72, and has some health conditions. He has expressed that he will not return to clinical practice, but there is some prospect, he may wish to resume counselling type activities if his age and health allows.

• [56] Balancing all those factors, and considering the guideposts set in Arora, Thomas and Chang (where there were no orders for permanent disqualification), the Tribunal is ultimately unpersuaded that there are no grounds to believe that the respondent may become fit to practice as a practitioner again. As such it finds that an order for indefinite disqualification should not be made. That is not to downplay the seriousness of the conduct.
• [57] Consistent with the cases in Arora, Thomas and Chang, the conduct the subject of the referral deserves a lengthy disqualification period, by reason both of its seriousness and the lack of any present indication of rehabilitation, remorse or insight. The Tribunal notes that the respondent has been suspended already for a period in the order of 2 years and 2 months. Balancing all of these factors, the Tribunal has determined that a further disqualification period of 8 years from the date of this order is an appropriate period of disqualification. It is a little longer than that imposed in Chang, to reflect that the circumstances of the underlying conduct giving rise to the offences in this case as being more serious.
• [58] Given the nature of the respondent's practice and particularly the services which were being performed at the time that the conduct occurred which was the subject of the criminal offences, which appears on the evidence before the Tribunal to include massaging and counselling, in the interests of protection of the public, an equivalent disqualification period is applied for the provision of health practitioner services. Consequently, the Tribunal has also determined that it is appropriate to make an order that the respondent should not provide any health service until he obtains registration as a health practitioner.
• [59] The Tribunal has derived significant assistance from the assessors on questions of fact and thanks the assessors for their thoughtful engagement and assistance.

• [60] The Tribunal makes the following order(s):

(a) Pursuant to s 107(2)(b)(iii) of the Health Ombudsman Act 2013, the respondent has behaved in a way that constitutes professional misconduct.

(b) Pursuant to section 107(3)(a) of the Health Ombudsman Act 2013, the respondent is reprimanded.

(c) Pursuant to section 107(3)(e) of the Health Ombudsman Act 2013, the respondent's registration is cancelled

(d) Pursuant to s 107(4)(a) of the Health Ombudsman Act 2013, the respondent is disqualified from applying for registration as a health practitioner for 8 years from the date of this order.

(e) The respondent is prohibited from providing any health service until he obtains registration as a health practitioner.

(f) Each party is to bear its own costs of the proceeding.

[1] Statement of Agreed and Disputed Facts (SOAF) [4].

[14] [2021] QCAT 306.

[17] Health Ombudsman v Duggirala [2021] QCAT 326.

[18] Health Ombudsman v DKM [2021] QCAT 50.

[19] Health Ombudsman v Duggirala [2021] QCAT 326 at [71].

[20] Brigginshaw v Brigginshaw [1938] HCA 34; (1938) 60 CLR 336.

[21] Health Ombudsman v DKM [2021] QCAT 50 at [60] and the authorities cited therein; Health Ombudsman v Duggirala [2021] QCAT 326 at [72].

[22] Health Ombudsman Act 2013 s 4(2)(c).

[23] Medical Board of Australia v Griffiths (Review and Regulation) [2017] VCAT 822 at [43].

[24] [2019] QCAT 200.

[25] [2015] NSWCATOD 139.

[26] [2021] VCAT 229.

[27] [2021 QCAT 326.

[28] [2021] QCAT 50.

[29] [2016] VCAT 1653.

[30] [2022] QCAT 58.