The review period for the conditions is seven (7) months.

The education sessions must not be included as part of the Practitioner's normal CPD requirements.

1. Dr John Adams is an obstetrician and gynaecologist. He has been in practice as a doctor since 1975 and during that long period he has not been the subject of any disciplinary proceedings.
2. At the time of the events which gave rise to this disciplinary proceeding, he conducted a main practice in gynaecology and obstetrics at his rooms at Mount Waverley and had two satellite practices. One was at Cranbourne and the other was at Dandenong. He holds both general and specialist registration in obstetrics and gynaecology without restriction.
3. Throughout his recent practice, Dr Adams has been on the elective operating list for obstetrics and gynaecology at the Sandringham Hospital and has participated in the on-call roster at that hospital, conducting both routine and more difficult operations from that hospital. On the 1 October 2013 the Royal Women's Hospital took over the maternity and gynaecology services at Sandringham Hospital. It had previously been managed through Alfred Health.
4. Dr Adams' operating rights remained when the hospital was taken over by the Royal Women's Hospital.
5. A month after this hand over, in November of 2013, registrars at Sandringham dealing with Dr Adams patients reported that some patients had claimed that they had not signed the appropriate consent to operation forms. There was a signature on those documents but the patients said the signature was not theirs.
6. The Royal Women's Hospital investigated the matter further. The matter was handed over to AHPRA and to police when it became apparent that there were at least ten patients of the hospital who were patients of Dr Adams and were in the same position.
7. Following the initial notification both the Women's and the Alfred Hospital files relating to Dr Adams past patient admissions were examined.
8. From this extensive examination it has been ascertained that between the 10 September 2012 and 7 September 2013, a period of 12 months, he caused thirty seven patient consent forms to be signed by a person other than that patient in respect of surgical operations, procedures or medical treatment. He then knowingly provided to the Alfred Health and/or to the Royal Women's Hospital those forged consent forms, knowing that they would form part of the patients' medical record of that hospital.
9. When this behaviour was brought to the attention of the Medical Board of Australia (the Board), the Board considered what course it should take under the Health Practitioner Regulation National Law (Victoria) Act 2009 (the National Law).
10. If the Board is satisfied that a health practitioner's professional conduct or the way he practices his profession is unsatisfactory, the Board has two alternatives under the National Law. For relatively minor breaches it may establish a Panel to consider that issue and if found proven, impose a range of low level sanctions, including the imposition of conditions on registration and a reprimand or caution.
11. If the Board considers the conduct is too grave to be dealt with by a panel, as the Board considers the conduct to amount to professional misconduct, the Board must refer the conduct to this Tribunal.
12. This obligation is contained in section 193 of the National Law.
13. The section says this:
    1. Matters to be referred to responsible tribunal

(1) A National Board must refer a matter about a registered health practitioner or student to a responsible tribunal if -

(a) for a registered health practitioner, the Board reasonably believes, based on a notification or for any other reason -

(i) the practitioner has behaved in a way that constitutes professional misconduct;

1. In this case, the Board considered the gravity of Dr Adams conduct to constitute professional misconduct, and therefore referred his conduct to this Tribunal.
2. Our task is to decide whether Dr Adams has behaved in a way that constitutes professional misconduct, and if so what sanction should be imposed.

1. In the National Law, professional misconduct is defined to include the following:

professional misconduct, of a registered health practitioner,

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

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

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

1. That definition is inclusive. In other words the three categories which are identified above are not the only hallmarks of professional misconduct. A practitioner may commit professional misconduct which does not fit neatly into one or other of those categories.
2. In determining what is and is not professional misconduct this Tribunal is therefore entitled to have regard to the way in which the common law has developed that concept in respect of medical practitioners over a long period of time.
3. In deciding to refer Dr Adams' conduct to this Tribunal, the Board framed the allegations against him in the following way:

That, in the period from on or about 10 September 2012 to 7 September 2013, Dr Adams engaged in professional misconduct within the meaning of the definition of professional misconduct in paragraphs (a) and (b) of section 5 of the National Law;

(b) unprofessional conduct within the meaning of the definition of unprofessional conduct in section 5 of the National Law, meaning professional conduct that is of a lesser standard than that which might reasonably be expected of the health practitioner by the public or the practitioners professional peers;

that Dr Adams caused to be signed multiple patient consent forms in respect of surgical operations, procedures or medical treatment by a person or persons other than the patients whose names were recorded on the forms signing their consent;

that Dr Adams caused such patient consent forms to be provided to Alfred Health and/or the Royal Women's Hospital as evidence of the patients consent to surgery, forming part of the patients medical records, in circumstances where such consent forms had not been signed by the patient.

1. Having outlined these allegations, we do not need to dwell at length on whether or not Dr Adams conduct as set out above constituted professional misconduct. This is because he has conceded both that he committed those actions, and that those actions amounted to professional misconduct.
2. This matter has come before us together with an agreed statement of facts and proposed determination which has been signed both by Dr Adams on his own behalf and by a representative of the Board. In that document the notifications to which we have already referred are set out, as are the details of the investigation conducted by the Board into those allegations.
3. That agreed statement of facts and proposed determination contains an admission by Dr Adams that he engaged in the conduct alleged in the notice of allegation and that this conduct constitutes professional misconduct.
4. Even had he not made that admission, we are amply persuaded that Dr Adams' conduct constitutes professional misconduct. It was not just a mere act of oversight or a demonstration of lack of skills. It was a deliberate pattern of fraudulent conduct stretching over 12 months and striking at the heart of the doctor-patient relationship.
5. It therefore remains for this Tribunal to determine the appropriate sentence for Dr Adams in respect of this conduct.
6. Section 192 (2) of the National Law provides that we may decide to do one or more of the following - caution or reprimand Dr Adams, impose conditions on his registration, require him to pay a fine of not more than $30000, suspend his registration, or cancel his registration and disqualify him from applying for registration for a specified time.

1. The document which was presented to us contained an agreed position from both Dr Adams and the Board as to the appropriate sanction to be applied by this Tribunal for the conduct which we have identified above. It was submitted that the appropriate penalty was to reprimand Dr Adams, together with imposing a condition on his registration requiring that he complete specified further education and mentoring.
2. The details of the further education and mentoring were also set out in that document, but we do not need to refer to them at this stage.
3. When this matter was before us on 11 May 2017, we indicated that we were not satisfied at that point that a reprimand was an adequate sanction, given the gravity of the conduct apparent from the evidence before us.
4. We indicated that we wished both parties to have the opportunity to file further material, and if necessary call further evidence or make further oral representations to us, so that we could finally determine whether we should impose the penalty recommended by the parties, or whether Dr Adams should be subject to either suspension of his registration or cancellation of that registration, or some other penalty.
5. We have now received further submissions from both parties. Neither party has sought that any further hearing time be allocated. We are therefore in a position to make a final determination as to the appropriate penalty to be imposed.

1. At the hearing on 11 May 2017, the applicant provided a Tribunal Book containing documents setting out the factual basis surrounding Dr Adams' conduct. We invited Dr Adams to consider whether he wished to give sworn evidence regarding the matters contained in the Tribunal book or in respect of any other matters he wished us to take into account in coming to our determination. We invited him to submit character references or any other mitigatory material in respect of his personal circumstances.
2. He did not take up the offer to give evidence, but instead made a statement from the bar table. There does not appear to us to be any major discrepancy between the way the Board puts his conduct and his description of the conduct itself from the bar table.
3. He said that when he initially dealt with the Sandringham Hospital the booking form for operations was simpler and was easily completed by patients at his Mount Waverley rooms. It was a one page A4 form.
4. He was dismayed when the procedure was changed in 2012, when the Sandringham hospital was still under the control of the Alfred hospital. That one page was replaced by a form containing many pages.
5. He said the vice in having such a complex form and in requiring the consent to operation to be signed at the time of booking the patient into hospital was twofold.
6. Firstly, in his estimation 30 to 40% of the admissions would ultimately have the precise operation changed in character from the time the forms were lodged to the time the operation took place.
7. This was because all of his patients were bulk billed, and therefore they were on a long waiting list to have the operations that they sought. Because of the length of time that expired, the patients' medical condition would often change and so any consent signed at the outset would often be consent to a completely different operation than that which was actually performed.
8. Secondly, he said that many of his patients were not native English speakers and had a great deal of difficulty filling in the forms. He said that to go through such a form with an interpreter is a "pretty lengthy procedure" and was a waste of time if the person did not subsequently undergo the precise operation for which consent was obtained.
9. The forms would invariably not be filled in properly and there would then need to be significant administrative time spent on making sure that the form was returned to the hospital so the operation could be booked in.
10. He put his concerns about this form to what he described as "the powers that be". Initially, the hospital was prepared to make an exception in his case, and admitted his patients on the previous form. Eventually however, he was clearly told that the new form was mandatory, and his patients must sign and submit the eight page form, as all other patients of the hospital were required to do.
11. He said that this created so much work for himself and his staff that in his words "I decided to cut out the middle man and fill in the form myself".
12. He also believed that someone would talk to the patients on admission and if the nature of the operation had changed a new consent form would be executed in the presence of hospital staff. He said he thought the initial consent form was unnecessary as he thought new consents were required to be signed on admission, and so the document his patients were initially required to sign was an unnecessary duplication.
13. He did not provide any information to us in respect of his personal circumstances.

1. When this matter first came before us we were very concerned that the imposition of a reprimand may not be adequate to reflect the seriousness of Dr Adams' conduct as we have described it above.
2. We were told that there had in fact been no harm done to any of those thirty seven patients, as each operation had a satisfactory outcome. We accept that this is true. As far as we understand it, none of Dr Adams' patients have made a complaint to the Board or elsewhere regarding the events we have described.
3. However, we remain concerned that the forging of a patient's signature is an extremely serious act for a practitioner to undertake.
4. Firstly, it is a clear breach of the criminal law. Dr Adams was dealt with in the Magistrates Court on charges of falsifying a document, a charge which carries a maximum level of imprisonment of 10 years. He was placed on a diversion. This means that there was no finding by the Magistrates Court of guilt. Even so, he has admitted that fraudulent conduct. Any member of the community who forges another person's signature on a document commits a very serious offence. When that person is in a doctor-patient relationship, it is our view that the offence is magnified in seriousness.
5. Secondly, in forging the signature of the patient, he has effectively taken away the patients ability to exercise an informed consent to the operation. This is no small matter. Indeed it may be said that the recent history of the medical profession is one of encouraging openness between doctor and patient, and encouraging patients to take responsibility for their own medical decision making.
6. Dr Adams response when we put that concern to him was to indicate that he was confident that he had discussed the matters on the form with all of his patients, including the potential complications of any operation.
7. He provided us with his notes in respect of patient consultations with eight of those patients. His note on each occasion was cursory; - the words "operation discussed" were most frequently used. There seems to us to have been very little in his notes to rely on had there been a subsequent dispute as to what he had told his patients about the forthcoming operation.
8. We accept that his recollection was that he would discuss the advantages and risks of the proposed operation with each patient. But even assuming that he had done so, it is nevertheless an extremely paternalistic approach to patient care for the doctor to have taken it upon himself to complete these detailed documents on his patients' behalf, and apparently without their knowledge.
9. It has meant that patients have not had the opportunity to discuss their treatment options and the benefits and risks of the operation in a considered manner with their family or other persons before opting to go ahead with treatment.
10. Further, in forging the patients' signatures Dr Adams has placed other professionals including his colleagues at great risk. For instance, the forged consent form includes consent to anaesthesia. An anaesthetist may well have relied upon such a consent and would have been entitled to do so, not knowing that the consent was forged.
11. We illustrate this danger by reference to the form itself.
12. The form details the name of the patient and the operation to be performed. It then goes on;

- blood transfusions including blood and blood products required in association with this operation procedure or medical treatment;

- medicines, or other forms of treatment normally associated with this procedure;

- other and unexpected procedures/ treatments that are found to be necessary;

- the removal of tissue during the procedure to assist doctors for diagnostic treatment purposes and for the tissue to be kept for pathological examination, quality procedures, training and ethically proven research;

• if required, careful and appropriate disposal of remained tissue.

We (meaning the doctor and the patient) have discussed appropriate treatment options and the nature, effects, possible risks and benefits of the chosen procedure/treatment, including those of blood transfusion if relevant. I consent to the proposed procedures/ treatment.

1. And in the last paragraph of the form the patient declares that she has been advised and understands that the medical practitioner who originally saw the patient, or who placed the patient on the waiting list may not be the person who ultimately performs the operation.
2. The patient then declares that she has been advised of and understands the hospitals elective surgery access policy and how to obtain information about the health privacy principles regarding the collection, use and disclosure of her health information.
3. We also note that the form provides for alternative persons to provide consent if the patient is not capable of consenting to his or her own treatment, and outlines an exhaustive set of categories of persons who may do so on behalf of a patient in that situation.
4. Thus it is obvious from the contents of the form itself that each professional working with those thirty seven patients has been put at potential and unnecessary risk - from the anaesthetist, to the pathologists, to those using tissue from the patient for research purposes, and to the hospital pharmacists, not to mention the hospital authority and its staff. To conduct any medical procedure on a patient without their consent potentially exposes that practitioner to civil litigation. This is a very significant matter to take into account in assessing the seriousness of the doctor's conduct.
5. In the written documents initially presented to us, Dr Adams conceded only that he had "caused" the consent forms to be filled out.
6. The reason for that wording seems to have been that at the outset when contacted by the hospital and the police, he had not admitted undertaking the forgery himself. Instead he appears to have suggested to both the Board's investigators and the police that the consent forms had been filled out by members of his staff under his direction. We had understood at the hearing that he had maintained that position for a significant period of time.
7. His staff were therefore interviewed by the police and the allegation that they had forged the signatures was put to them. Each one of them denied doing so.
8. On the day of the hearing we asked him to clarify whether or not his staff were involved in the forgery. In a statement made from the bar table, he admitted that it was he who forged the signatures and that his staff were not involved at all in this criminal conduct.
9. He later addressed this issue in his written submissions as follows:

Early in the investigation when I was unsure of the direction of the police activities I made a statement which was non-specific re-the signing of the documents. Later on, in court and via AHPRA investigation I readily admitted that I was the only perpetrator of the fake signatures.

1. From the material before us, we are unable to make a finding as to exactly when he first admitted that it was him who undertook the forgery, not his staff. Whether he maintained that position for a significant period of time or not, we are horrified by the doctor's actions in initially blaming his staff for placing the forged signatures on the consents.
2. For some time at least, he deliberately placed the reputations of all of his staff under a cloud. Dr Adams displayed no discomfiture at all at the hearing about having placed his staff in this position.
3. We are further not completely persuaded that Dr Adams motivation in forging these consents was altruistic. He said that he did so simply to facilitate the booking process and not bother the patient with unnecessary work. He said that he did so "naively". The Board also emphasised in its submission that the forgeries were not made for financial gain.
4. However, clearly the completion of this extra work would have added to the administrative burden both to himself and to his staff. In effect, he was saving time by bypassing the correct admission procedures. He said he did not have staff at the satellite practices who could monitor the completion and return of these documents. The employment of extra staff seems to us to have been a simple way to avoid the administrative difficulties Dr Adams faced. We put this point of view to him when he was before us, and were not satisfied with his response.
5. He has not provided any evidence that any other practitioner faced with these requirements has seen the need to deliberately bypass them in the way that he did.
6. Lastly, we are very concerned about the effect of our decision upon the reputation of the medical profession. Patients need to be able to completely trust their doctor to look out for their interests. In our view the forging of a patient's signature is a complete antithesis to the requirement for complete candour between doctor and patient.

1. The Board provided an outline of submissions at the time this matter was heard, and supplemented that outline with a sample of the hospital consent form, together with some further written submissions.
2. Each of those submissions concedes that this is serious conduct.
3. The first submission notes that it is conduct which transgresses the Guide to Good Medical Practice, a code of conduct for medical practitioners. It does so with respect to the obligation of trustworthiness of a doctor, and the need to obtain a valid authority before undertaking any examination, investigation or treatment and the keeping of accurate medical records. The Guide also notes that the requirement for consent forms to be signed at the time the patients decide to undergo elective surgery was designed to ensure the integrity and accuracy of the elective surgery waiting lists by ensuring that patients placed on the list really wanted and required the surgery.
4. The Board also noted that the forging of the consent forms took place over a long period - a period of over 12 months, and that each forging was deliberate, and was also a deliberate breach of the policy of the Department of Health, as represented in the forms.
5. We note also the submissions made by the Board reminding us that the purpose of the imposition of a penalty is to protect the public and to maintain proper ethical and professional standards for the protection of the public and the protection of the professions.
6. We acknowledge also that our determination should be in no way punitive. It is a protective determination and not a punitive one. Punishment is within the jurisdiction of the criminal law. It plays no role in this proceeding.
7. It was urged on us by the Board that an assessment of the ongoing risk posed by Dr Adams should be central to the imposition of a determination, as should also the degree to which he has acquired insight into his conduct.
8. The Board submitted that the imposition of a reprimand should be seen as a serious matter, particularly given that it is to be imposed upon a practitioner when an otherwise blameless record, and with no history of medical malpractice. It was suggested that it should not be considered merely a "slap over the wrist."
9. In support of the submission that a reprimand was not to be seen as a slap on the wrist, the Board referred to the remarks of Justice Marks in Peeke and the Medical Board of Victoria[1], which is itself referred to in the VCAT case of Medical Board of Australia v Fox[2].
10. It emphasised that this Tribunal had in the past accepted that a reprimand was a serious form of censure. It particularly referred us to paragraph 63 of Fox , where the Tribunal observed:

A reprimand certainly does not trivialise a serious lapse of professional standards, and has the potential for serious adverse implications for the medical practitioner. A finding of unprofessional conduct and/or professional misconduct, combined with the reprimand, is in itself a serious form of censure and condemnation for Dr Fox' conduct.

1. In submitting to us that a reprimand was the appropriate penalty, the Board noted that there was no actual compromise of patient care. It also underscored Dr Adams cooperation with the Board's investigation, his admissions that he had engaged in conduct which constituted professional misconduct, and the fact that he had been dealt with in the criminal justice system.
2. It urged that we should place conditions on his registration in order to facilitate his rehabilitation and also satisfy the need for protection of the community.
3. It was further submitted by the Board that the agreed statement of facts was a highly relevant matter for this Tribunal to take into account in making a determination. Although agreeing that the Tribunal is not bound by that document, the Board submitted that the Tribunal should not depart from that agreed position without clear or exceptional reason to do so. The Board referred to the case of the Medical Board of Australia v Lai[3] for the proposition that the Tribunal should not depart from an agreed sanction where a negotiated settlement and proposed penalty are broadly speaking within the permissible range having regard to all the circumstances.
4. Further, the Board relied upon the authority of the Commonwealth v Director of Fair Work Building Industry Inspectorate[4], where the High Court confirmed that there was an important public policy benefit in receiving and accepting appropriate agreed penalty submissions, and that if the Tribunal is persuaded of the accuracy of the agreement as to facts and consequences and that the penalty is an appropriate one, it is a highly desirable practice for the court to accept the parties proposal.
5. In its further submissions, the Board effectively repeated those matters which we have referred to above. The Board also noted Dr Adams intention in filling out the forms to be misguided but that there was no suggestion of any significant personal benefit from the misconduct.
6. The Board put forward the view that Dr Adams intention was to facilitate the elective surgery booking process for his patients and to overcome confusion or complexity for his patients that he believed had been created by a new elective surgery consent form and booking process.
7. It submitted that the criminal proceedings and disciplinary consequences were likely to have had a significant deterrent effect on him and that he had not been the subject of any prior notifications or disciplinary proceedings, and that he has continued to practice without any further incident or notification since this conduct.
8. Although the Board referred to Dr Adams insight as "not being fully developed", the Boards second submission set out some of the statements made by Dr Adams to us when the matter was before us on 11 May 2017 and suggested that these statements contained such a comprehensive expression of remorse that there was no need for a penalty removing him from practice.
9. We had asked the Board to provide us with any factually similar cases in respect of a doctor forging documents on behalf of a client. The Board was unable to point us to any such cases. It submitted that Dr Adams case turns on its own facts and that other cases provide little assistance.
10. As we have set out above, Dr Adams made a statement to us from the bar table when the matter was before us on 11 May 2017.
11. He also provided us with further submissions dated 26 May 2017 and two character references.
12. In that material he accepted that his actions were unprofessional and that he "had disregarded hospital protocol".
13. He outlined the negative outcomes to himself personally and to his practice which had flowed as a result of being investigated by the Board. In particular he indicated that he has lost his public hospital appointment which was the "backbone" of his practice. He said that he had thereby suffered significant financial loss as well as loss of professional standing and damage to his personal and professional reputation.
14. He also said that his medical registration was very important to him as he still enjoyed practice.
15. He reiterated that he has had 44 years of medical practice without any previous problems and that since the onset of this process he had become much more aware of "the legal - bureaucratic aspects" and the importance of those concepts in medical practice.
16. He also attached two personal references.
17. The first was from Peter Trowbridge, an obstetrician and gynaecologist. Dr Trowbridge described Dr Adams as a very seasoned practitioner whose main interest is the welfare of his patients. He described him having been actively involved in the teaching of other staff and students, being a willing mentor to himself and other colleagues wherever required.
18. Dr Anthony Lawrence is also an obstetrician and gynaecologist. He describes Dr Adams as being honest, competent and extremely caring of his patients.
19. We accept that those references establish that Dr Adams is a caring practitioner and a man of otherwise good character. We take them into account in assessing the appropriate penalty to be imposed.
20. However, we observe that neither of those referees indicated whether or not they knew of the nature of the charges which we are dealing with today. Even though both work in the same speciality as Dr Adams, neither of them suggested that they had any difficulty with patients completing hospital consent forms before admission, and neither expressed any view on the seriousness of Dr Adams conduct.
21. Dr Adams provided us with a further submission dated 2 June 2017. Although it was out of time, the Board indicated that it had no objection to the submission being taken into account by us. Indeed, from the wording of the document, it appeared that the solicitors for the Board may have invited him to make this further submission.
22. We think it is appropriate to set out this submission in full. It reads as follows:

I have been ruminating on the reasons for my actions. During my many years working in the public sector my operating work load capacity reduced by over 50%. This was not due to my attitude but to changes in work practices, union activities and new bureaucratic and legal requirements.

As a result I became frustrated and I suppose contemptuous with the hospital functioning.

I have never had much faith in the consent form as a legal document. In the event of serious problems leading to litigation patients seem to say they didn't understand what they were signing or certain aspects weren't explained.

At the time of the introduction of the new admission forms I was under some personal stress and perhaps not thinking my best.

As a result of the above and also because I saw it simplifying the process and avoiding not occasional problems for the patients, I took it upon myself to complete the forms. I realise the person I put at most risk was myself because in the event of complications neither the hospital nor my indemnity company would have supported me.

1. We accept that a reprimand is a significant penalty to impose, and that this is particularly so where it is imposed upon a practitioner with an otherwise blameless record. We do note that the decision in Fox may not be entirely on point, as in that case a period of cancellation was imposed on the practitioner as well as a reprimand, but we do agree that in an appropriate case the issue of a reprimand can fulfil all of the sentencing objectives under the Act.
2. In coming to our decision we do take into account that Dr Adams has previously been of good character. He has been in practice for a very significant length of time. Over that long period he has had no disciplinary proceedings brought against him, and as far as we know, he has had no medical negligence claims.
3. That is a significant achievement in what is a challenging speciality.
4. That is really all that we know about his personal circumstances. One of his referees mentioned that he had brought up four children. We do not know anything about the circumstances in which he did this. We know nothing of his professional history apart from the brief description of his practice in the two references which he provided. In the second submission set out above, he refers to feeling under some personal stress at the time of the introduction of the new admission forms. Regrettably we do not have any further information about this.
5. We are also prepared to accept that he has shown some remorse for his actions. This is apparent from his plea of guilty, and he also at our invitation confirmed his remorse at the hearing. We are persuaded that Dr Adams will not commit this offence again. The fact that he has been discovered and has faced disciplinary proceedings will be sufficient to prevent him offending in this way in the future. There is thus little need for specific deterrence.
6. We are not however completely satisfied that Dr Adams has taken these proceedings seriously, or that he has any real insight into the damage which he has caused or potentially caused either to his patients or the profession.
7. At the hearing before us he said that he agreed that he had been "flippant about bureaucracy" and that he needed to give "bureaucracy" more regard.
8. Dr Adams described the operations performed by him at the Sandringham Hospital as being operations of a routine nature. He said he thought it was reasonable at the time in his patients' interest to circumvent the hospital's requirement for consent.
9. This attitude towards the hospital authority is also borne out in the submission sent by Dr Adams dated 2 June 2017, where he refers to his contempt with the "hospital functioning".
10. In reading the 2 June submission we particularly note that even though the consideration of the reputation of the profession, the potential for harm to the doctor-patient relationship, the position in which his colleagues were placed, and the position in which he placed his own staff were issues raised squarely at the hearing and in the Board's submissions, he did not even refer to these issues in that submission. He focussed on the effect on him of hospital policies, rather than the effect of his actions on his patients and the community.
11. In our view his responses in both of his submissions display a misunderstanding of the reasons for need for documentation of consent. The documentation is not required because of bureaucracy. It is required in order to fulfil the doctor's obligation to involve patients fully in decisions of a critical nature concerning their care.
12. His responses also indicate that he is still lacking in insight as to the seriousness of his behaviour, even after having had the chance to reflect on his behaviour for the last three years while this investigation has been continuing, and even after having been dealt with in the Magistrates Court.
13. The Board has strenuously argued against suspension or cancellation of Dr Adams' registration. We take the view that in adopting this position the Board has not taken properly into account the way in which Dr Adams actions placed his colleagues and these thirty seven patients at risk, the length of time over which this offending occurred, and the harm to the reputation of the profession involved. Luckily there was no complication with any of the operations performed. If there had been, the ramifications for Dr Adam' patients and colleagues and the hospital itself would have been grave.
14. In this case we are confronted with an extremely serious set of circumstances. Dr Adams has deliberately forged the signatures of 37 patients over a period of 12 months. The document in question is of vital importance, both as to the conduct of the operation itself, and as to the patient's interaction with the doctor and other medical staff involved.
15. We are very concerned about the effect of our decision upon the reputation of the medical profession. Patients need to be able to completely trust their doctor to look out for their interests. In our view the forging of a patient's signature is a complete contradiction to this need for complete candour between doctor and patient.
16. The offending has been most serious and has spanned a period of 12 months. It is not spur of the moment offending. At the time it was committed, Dr Adams was not a young and inexperienced practitioner. He was very experienced practitioner, running three practices. Further he had been in contact with the hospital about the need to sign the forms, and the importance of those forms to the admission of patients must have been impressed upon him, as the hospital had ultimately refused to admit his patients unless the forms were signed. It is offending deliberately undertaken in order to bypass systems which he knew were in place at the hospital to properly deal with patient consents.
17. The question of general deterrence is of fundamental importance to our determination. We consider that the public's faith in the medical profession would be severely undermined if a doctor who forged their signatures on important medical documents was not severely dealt with. Trust is fundamental to the doctor-patient relationship, and that trust would evaporate if it were thought that doctors who engaged in this conduct were permitted to remain in practice. We have a duty to protect the stature and integrity of the medical profession in the eyes of the public.
18. We also have a duty to encourage the maintenance of proper ethical and professional standards within the profession. It is indisputable that falsifying patient documents is unethical and flies in the face of the standards of the profession
19. As we said at the beginning of these reasons, the recent history of the medical profession is a history of encouraging openness between doctors and patients, and fully encouraging patients to take control of their own medical decision-making. This is an impossible goal to achieve if doctors behave as Dr Adams behaved in this case.
20. We have considered carefully whether we should follow the penalty set out in the agreed determination. We accept that the fact that this determination has been agreed both by Dr Adams and by the Board is a significant matter to take into account. We accept also that it is desirable for agreed determinations of this nature to be encouraged. Such an agreement significantly reduces the cost of disciplinary proceedings. It may also, as has happened in this case, prompt admissions from the doctor as part of the overall settlement proposed.
21. We accept that if the negotiated settlement and proposed penalty are within the permissible range and are appropriate, it is highly desirable for the Tribunal to accept the proposal.
22. We also accept that the entering into of this agreement by Dr Adams is a reflection of his remorse, and his effective plea of guilty has saved the Board and the potential witnesses the expense of contested hearing and the trauma and inconvenience of having to give evidence at a contested hearing.
23. We are also satisfied that his acceptance of the proposed conditions for education and training is a positive step. One of our tasks is to consider the question of rehabilitation. Dr Adams acceptance that he needs this education and trading is positive evidence that his rehabilitation has commenced.
24. However we are unable to be satisfied that the proposed agreed penalty is within the permissible or appropriate range, for all the reasons set out so far in this judgment.
25. We have considered whether we should cancel Dr Adams registration. Although we regard this sanction as being within range, we have ultimately decided that taking into account Dr Adams previous flawless record and the other matters of mitigation to which we have already referred, the appropriate disposition in this case is a period of suspension of his registration.
26. We have decided to suspend his registration for a period of 6 months. This suspension will commence on 1 August 2017, to give Dr Adams the opportunity to rearrange his practice affairs before the commencement of the suspension.
27. We have further determined that he should undertake courses designed to educate him as to his responsibilities as a medical practitioner, both towards his patients and also towards those other medical professionals with whom he works. We therefore propose to impose conditions identical to those sought by both parties in the agreed determination, with those conditions effective from the end of the suspension period.

[1] Unreported - 19 January 1993 at page 6

[2] [2016] VCAT 408

[3] [2011] VCAT 1754 at paragraph 14

[4] [2015] HCA 46; (2015) 326 ALR 476