1. By consent, the applicant has leave to further amend the Amended Notice of Allegations consistent with the matters agreed between the parties at today's hearing.

Having found the respondent engaged in professional misconduct under the Health Practitioner Regulation National Law (Victoria) Act 2009 (National Law), the Tribunal orders:

1. Under section 196(2)(a) of the National Law, the respondent is reprimanded.

1. This proceeding concerns a disciplinary referral the Medical Board of Australia[2] made to the Tribunal in respect of anaesthetist, Dr David Canty.
2. The sole Allegation before us was that, on 24 September 2020, Dr Canty engaged in professional misconduct and/or unprofessional conduct in that he failed to provide safe and appropriate anaesthetic care to a paediatric Patient,[3] by leaving the operating Theatre for a period of no less than 30 minutes, so that the Patient was unattended by an anaesthetist while under general anaesthetic.
3. Dr Canty provided care to his Patient, who was undergoing a dental procedure at the standalone dental Theatre, during the second COVID-19 related lockdown which was in place in Melbourne. The dental procedure was permitted under then applicable health restrictions. After administering the anaesthetic and observing the Patient for a period, Dr Canty left the Patient in the care of the treating Dentist and an experienced Anaesthetic Nurse to move to an adjoining room to attend a Zoom conference call related to a time-sensitive commitment in his role as an academic supervisor. After around 30 minutes, Dr Canty returned to his Patient in Theatre and was present for the final part of the dental procedure.
4. We record that, while Dr Canty's absence from Theatre for around 30 minutes presented a risk of harm to the Patient, that risk did not materialise.
5. The Anaesthetic Nurse was present and monitoring the Patient at all times while the Dentist undertook the procedure. There was no dispute that Dr Canty was in an adjoining room from which he stated that he could see and largely hear what was occurring. The Anaesthetic Nurse was aware Dr Canty was only seconds away from his Patient.
6. We were told that Dr Canty unsuccessfully tried to re-schedule the Zoom call. It was apparent from materials before us that, at that time, Dr Canty wrongly considered it acceptable for an anaesthetist to leave a patient in certain circumstances and we had no doubt that influenced his conduct.
7. As discussed below, guidelines then in place, which were known to Dr Canty, stated that an anaesthetist ought not to leave a patient under anaesthetic other than in 'exceptional circumstances' and then for 'brief' periods of time. Those requirements apply whether the anaesthetist is in a hospital setting or providing mobile services at a Theatre of the kind in issue before us.
8. After Dr Canty was put on notice of concerns about his conduct in respect of the Patient (in July 2022) he accepted that he had acted inappropriately. In September 2022, Dr Canty wrote a response to the Board (September 2022 Response) in which said he 'did not appropriately monitor' the Patient and that his conduct represented 'a severe lapse in judgement'.
9. He accepted that he ought to have chosen whether to undertake his professional responsibilities to his Patient by remaining with them or attend the Zoom call and further that there was no justification for him electing to do both.
10. We were informed by Dr Canty's counsel that, prior to this matter, there had been no complaints of any kind about Dr Canty's conduct during his around then 15 year career as an anaesthetist. That was not disputed by the Board. Accordingly, we proceeded on the basis that the September 2020 incident was a once off very serious lapse in judgment and failure to meet the standards to be expected of a practitioner with training and his experience.
11. The lesson to be learned by Dr Canty and other anaesthetists is that there are always risks associated with any time they are away from their patient and so their physical presence and vigilance is always required except in exceptional circumstances.
12. The broader lesson is that a medical practitioner's duties to a Patient come before other responsibilities.
13. By the time of the hearing, the parties had agreed on all necessary facts to establish that the facts in the Allegation were proven as set out in their Amended Agreed Statement of Facts.
14. The parties had also agreed that Dr Canty's proven conduct was appropriately characterised as professional misconduct as defined in paragraph (a) of the definition of that term as contained in the Health Practitioner Regulation National Law (Victoria) Act 2009 (National Law): that is, his conduct was unprofessional conduct which was substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience.
15. The parties agreed that the appropriate determination was that Dr Canty was to be reprimanded. That position had regard to all of the circumstances surrounding the Allegation including Dr Canty's immediate admissions of wrongdoing, his careful and fulsome reflections on his conduct and the steps he had taken to build his knowledge and understanding since he was notified of the Allegation in July 2022.
16. After having careful regard to the contents of the parties' joint Tribunal Book (TB), which included Dr Canty's September 2022 Response and the parties' written and oral submissions, we were comfortably satisfied that the necessary facts were proven, that it was appropriate to characterise the proven conduct as professional misconduct under paragraph (a) of the definition and that it was appropriate in all of the circumstances to impose a reprimand.

1. The following comes from the materials in the TB and the parties Agreed Statement. The terms of the Allegation are contained in Attachment A with amendments to use the same definitions as in these Reasons and to remove detail about the dental procedure performed on the Patient.

1. Dr Canty graduated from University of Tasmania in 1996.
2. He was first registered as a medical practitioner in Tasmania on 20 December 1996.
3. He obtained fellowship of the Australian and New Zealand College of Anaesthetists (ANZCA) in 2005.
4. Dr Canty obtained a Diploma in Perioperative and Critical Care Echocardiography in 2005 and his PhD in 2012.[4]
5. Dr Canty's 11 page curriculum vitae,[5] contains details of his training and extensive experience as an anaesthetist. Dr Canty has published numerous academic articles in his field and spoken at many conferences here and overseas.
6. Dr Canty is involved in teaching, holding academic appointments at University of Melbourne, Monash University (honorary) and the Menzies Institute for Medical Research.
7. Dr Canty states that he developed and leads the 'Focused Ultrasound Simulation Education Program and the Simulation Centre, a new research stream in educational research specialising in new ultrasound teaching method utilising eLearning and self-directed simulation for an increased scalability'. Dr Canty describes that Program as the 'most successful ultrasound teaching program in Australia' which teaches knowledge and practical skills in 'diagnostic (heart, lung, abdomen, DVT, peri-arrest) and procedural (vascular, drainage of effusions) ultrasound'.

The notification, the Board's investigation and referral to the Tribunal

1. On 9 December 2021, the Australian Health Practitioner Regulation Agency (AHPRA) received an anonymous Notification about Dr Canty's conduct in respect of the Patient on 24 September 2020.
2. In due course, the Board decided to investigate the Notification. As indicated above, it was first sent to Dr Canty on 28 July 2022, around seven months after the Notification was received.[6] Dr Canty send the Board his September 2022 Response[7] and further responses were sent to the Board later that month and in November 2022.[8] The latter attached details of Dr Canty's continuing professional development obligations (CPD) compliance documents.
3. On 21 December 2022, the Board determined to refer Dr Canty to the Tribunal and did so on 28 March 2023.

1. Dr Canty's September 2022 Response included the following:[9]

Prior to outlining the specific details of what took place, I wish to state to AHPRA and the Board that the incident which is the subject of this [Notification] is not representative of my usual practice and the events that transpired represented a severe lapse in judgement. I have reflected on this in more detail in my reflective report that also speaks to the education undertaken by me in response, however I wanted to make my position clear from the outset and emphasise that I am determined to demonstrate a genuine commitment to self-improvement.

. . .

I contacted [the Anaesthetic Nurse], the day before the dental procedure and explained that the procedure to be performed by [the Dentist] which was estimated to take 1.5 to 2 hours and asked him whether he would feel comfortable observing the patient for a short time whilst I attended a Zoom call in close proximity to [the Patient]. [The Anaesthetic Nurse] agreed to this and was aware that if he wanted me to return to the [Theatre] for whatever reason, that I would do so immediately.

On the day of the procedure, I performed my usual preoperative assessment of the child, by taking a history from the parent and examination of the child. I deemed that [the Patient] was healthy, and I did not have any concerns for the anaesthetic and have performed many anaesthetics on paediatric patients before . . .

[After the anaesthetic commenced], I remained with [the Patient] for a further 30-40 minutes and did not leave [them] immediately as is alleged. I spoke with [the Anaesthetic Nurse], and we both agreed that [the Patient] was stable. I asked [the Anaesthetic Nurse] whether it would be okay for me to attend the Zoom meeting whilst he monitored the patient (initially hoping to do this in the theatre with headphones on as to not distract others). He agreed that I could attend the Zoom meeting in the tearoom adjacent to the operating room, knowing that I would respond immediately as I was in earshot of the operating room and I had my mobile phone with me. Prior to leaving the operating room, I informed [the Dentist] that I would be just outside the theatre observing, and [the Anaesthetic Nurse] would be monitoring the patient temporarily.

In the tearoom, which is immediately next door, I was able to hear the beeping of the pulse oximeter, enabling monitoring of [the Patient's] oxygenation; however, I felt that I would be more comfortable if I could watch [them], observe [the Dentist and the Anaesthetic Nurse] and hear the ventilator. Accordingly, I spent most of the time whilst on the Zoom call standing outside the operating room observing the patient, anaesthetic machine, monitors, [the Dentist and the Anaesthetic Nurse], through the window of the operating room door. I would not have been visible to them. [The Anaesthetic Nurse] was seated close [the Patient and facing them], away from the operating room door. I do understand that these are not mitigating factors and that I should have remained directly with [the Patient] for the entirety of the procedure as is expected of me, as is my usual practice.

[The Patient] remained stable and I was not contacted by [the Anaesthetic Nurse] whilst I was outside of the room for around 30 minutes. When I returned to the operating room, the patient remained in a stable condition . . .

Following the event, I felt guilty about my actions, with these feelings being more prominent of late.

. . .

I did not appropriately monitor [the Patient] after administering anaesthetic in accordance with the ANZCA's expectations. I feel it important that I am frank and transparent with AHPRA and the Board.

. . . Regardless of who made the [Notification], it does not change the way I feel about my actions which I alone are accountable for.

I am hopeful that the Board will recognise that I understand the gravity of my own actions and that this mistake will not be repeated. I remain committed to providing high-level, patient-centred care and ensuring that others that work in my field also learn from my mistake. I am very thankful that there was no adverse outcome here on account of my actions.

1. The essential facts as contained in the Allegation were not in dispute and have been summarised above.
2. There was only one factual matter which was partly in dispute. While the Board alleged that Dr Canty failed to inform the Dentist that he was leaving the operating theatre, Dr Canty said he did. The parties agreed that the Dentists had stated that she had not been informed by Dr Canty that he was leaving. They further agreed to amend the particulars of the Allegation to that effect.

1. The Board had the onus of proving all alleged facts.
2. We were required to make our findings of fact on the balance of probabilities, comfortably satisfied they are open on the evidence, taking into account the seriousness of the allegations and the consequences of findings such as these.[10]
3. Having regard to the Agreed Statement and the materials in the TB, which included Dr Canty's admissions, we were comfortably satisfied that the relevant facts alleged in the Allegation were proven.

1. Characterising proven conduct is an objective assessment which looks towards the conduct in light of the applicable standards and relevant definitions, rather than matters arising later in time, such as remorse, insight and rehabilitation.
2. In relation to a finding under paragraphs (a) or (b) of the definition of professional misconduct, the Tribunal must assess the degree of seriousness of the practitioner's conduct having regard to the extent to which the conduct departs from the standards of professional conduct reasonably expected of a medical practitioner with an equivalent level of training and experience. The gravity of professional misconduct is not measured by reference to the worst cases, but by the extent to which it departs from the proper standards.

1. There was no dispute that, at all relevant times, Dr Canty's conduct as a medical practitioner, specialising in anaesthesia, was governed by a number of guidelines, codes and standards.
2. The Australia and New Zealand College of Anaesthetists (ANZCA) published two sets of relevant guidelines. First, in 1988, ANZCA Guideline PS18 and second, in 2017, ANZCA Guideline PG18(A), which replaced PS18. The relevant obligations were essentially in the same terms in each version as follows:

5.1 Clinical observation and assessment by a vigilant anaesthetist is essential for safe patient care during anaesthesia . . .

5.2 A medical practitioner whose sole responsibility is the provision of anaesthesia care for that patient must be constantly present from induction of anaesthesia until safe transfer to recovery room staff or intensive care unit has been accomplished ...

5.3 In exceptional circumstances brief absences of the anaesthetist primarily responsible for managing anaesthesia may be unavoidable. In such circumstances observation, including recording of observations of the patient and a plan for responding to significant perturbations in monitored physiological variables, must be temporarily delegated to a suitably trained and skilled practitioner who is judged to be competent for the task.

5.4 Permanent handover of responsibility, when required, must be to an anaesthetist who is able to accept continued responsibility for the care of the patient . . .

1. In April 2017, the Department of Health and Human Services issued a guideline, entitled 'Information for registered mobile anaesthesia and IV-sedation services in office settings' (DHHS Guideline). It said relevantly:

The anaesthetist or IV-sedationist must be physically present during the intraoperative period and immediately available until all patients have been recovered to an agreed upon clinical baseline . . .

1. As at September 2020, the 2014 'Good Medical Practice: A Code of Conduct for Doctors in Australia' applied to Dr Canty's conduct (2014 Code). A revised version of the Good Medical Practice Code came into effect in October 2020 (2020 Code) and contained similarly expressed obligations.
2. The most pertinent clauses in the 2014 Code said:[11]
   • Clause 2.1: 'the care of your patient is your primary concern';
   • Clause 2.2.4: it is necessary to consider 'the balance of benefit and harm in all clinical - management decisions'; and
   • Clause 3.6.1: when caring for a child or young person, good medical practice involves '[p]lacing the interests and wellbeing of the child or young person first'.
3. Subsequent to Dr Canty's conduct but before he was advised of the Notification, on 15 March 2021 the Private Hospitals and NEPT Unit of the Department of Health sent correspondence by email to all mobile anaesthetic providers.[12] The DHHS Letter:
   • Stated it had received correspondence regarding absences from theatre by mobile anaesthetists;
   • Stated that it had sought advice from ANZCA; and
   • Included the text of that advice which referred to Guideline PG18(A) and stated that it applied to all environments in which anaesthesia is administered.

1. The Board submitted that the proven conduct was very serious and represented a substantial departure from standards having regard to the following:[13]
   • The conduct was clearly inconsistent with clause 5.2 of Guideline PG18(A). There was no suggestion that the exception to the general rule applied to Dr Canty's absence, for at least 30 minutes for the purpose of attending a Zoom call. That absence was neither brief nor unavoidable and there were no 'exceptional circumstances';
   • Dr Canty's conduct was inconsistent with the DHHS Guidelines which applied to mobile anaesthetists practising in dental offices;
   • The reasons for the general rule in clause 5.2 of Guideline PG18(A) are important. If the responsible anaesthetist is not 'constantly present', the patient is put at risk. Other health practitioners who may be present (in this case, the Dentist and Anaesthetic Nurse) are unlikely to have (and in this case, did not have) the same level of training and experience as the responsible anaesthetist in relation to anaesthetic treatment and/or those other practitioners may be focused on other tasks;
   • While the risk presented by Dr Canty's conduct did not materialise, it was, nevertheless, unnecessarily created by his decision to leave Theatre. The Board accepted that Dr Canty had quite properly accepted that he did not appropriately monitor the Patient after administering the anaesthetic in accordance with the ANZCA's expectations;
   • Dr Canty's conduct was inconsistent with provisions of the 2014 Code; and
   • Its submissions were supported by the Tribunal's decision in Raiz v Medical Board of Australia[14] (Raiz). In that case (which concerned review of immediate action taken under section 156 of the National Law rather than a disciplinary proceeding) the Tribunal accepted that an anaesthetist has an 'obligation ... to remain with a patient under general anaesthesia at all times, subject only to a very limited number of exceptions' and that 'a failure to do so can create serious risks'.[15]
2. At the hearing, the Board's counsel described a patient under general anaesthetic as being in a state of 'radical vulnerability'. We find that to be a useful way of capturing the fact that the anaesthetist literally holds the patient's life in their hands. Those matters illustrate the good reasons why the Guidelines mentioned above call for vigilance and the constant presence of the anaesthetist in theatre with their patient.

1. Dr Canty's counsel adopted much of the Board's submissions as to the appropriate characterisation of the conduct.[16]
2. We mentioned earlier the statement Dr Canty made about where he was located during the Zoom call. While the Board did not dispute the assertion that he was able to see the Patient through glass and hear the relevant medical devices from the adjoining room, Dr Canty's counsel very properly stated that he was not always listening to what was occurring in Theatre because he was also participating in the call. The agreed position was that the door between the tea room and Theatre was closed but also had glass through which Dr Canty could see the Patient.
3. As discussed further below, Dr Canty relied on certain matters to contextualise the conduct but accepted that characterisation calls for an objective assessment.
4. At the hearing, Dr Canty's counsel made submissions about the risk Dr Canty's conduct presented relevant to characterisation and determinations. In short, it was submitted that the risk to the Patient was less than that which would arise if other surgery (such as spinal surgery or a bowel resection) was being undertaken as, in those, the 'insult to the body', was greater and would increase the risk of the patient becoming unstable. As we understood it, the submissions were based on instructions from Dr Canty and views he expressed in a report which concerned a notification about anaesthetist, Dr D Raiz, the subject of the Tribunal's decision in Raiz.
5. We stated that we would not give weight to statements from Dr Canty's counsel where he was, in effect, purporting to give an expert opinion on his own conduct.
6. We noted that no expert evidence was produced by the Board and, while there was some in Raiz, it was not before us and concerned a range of conduct that was self-evidently more serious.
7. In the end, relevant to characterisation, we agreed with the Board's counsel's submission that the fact the risk to which the Patient was subjected could have been greater did not change the fact that Dr Canty's departure from standards presented a risk and was substantial. Further, as the Guidelines referred to above made no distinction between hospital and mobile settings, the expectations of Dr Canty were the same as for anaesthetists involved in more invasive surgical procedures.
8. For completeness, we record that, although the Tribunal in Raiz was critical of some of the views Dr Canty expressed in the report mentioned above (at [47]), he was not called as a witness in that case and no express findings were made. As will become apparent, we have had regard to one of the reports Dr Canty prepared in Raiz in so far as it informed us about Dr Canty's views about leaving patients under general anaesthetic as at the time he expressed those views.

1. We had no difficulty agreeing that Dr Canty's conduct constituted professional misconduct under paragraph (a) of the definition of the term in the National Law.
2. As is made absolutely clear by Guideline PG18(A) and the DHHS Guideline, Dr Canty's conduct was entirely outside the standards to be expected of any anaesthetist, not to mention one who had been practising as a specialist for around 15 years as at the time he treated the Patient.
3. While, happily, the risk posed to the Patient did not eventuate, it was a risk which should never have arisen.

1. Section 196(2) of the National Law sets out the determinations the Tribunal may make where professional misconduct or unprofessional conduct has been proven. They include imposing a reprimand, cancellation of registration, suspension of registration and the imposition of conditions and the imposition of a prohibition order.
2. The well-established principles for consideration when making determinations under the National Law are as follows.[17]
3. The Tribunal's primary role is to protect the public rather than to punish health practitioners who engage in professional misconduct or unprofessional conduct. Determinations also assist to maintain proper ethical and professional standards to protect the public and the profession in the sense of maintaining stature and integrity in the eyes of the public. The Tribunal is also required to, in appropriate cases, make determinations which will deter the individual health practitioner from engaging in the same or like conduct again and/or which serve as a warning to other health practitioners that engaging in the conduct will bring serious consequences - the latter is known as general deterrence.
4. In some cases, specific deterrence is of lesser importance because a practitioner has been rehabilitated, is retired or has otherwise agreed not to practice again. Despite that, general deterrence may call for the imposition of a determination which acts as a warning to other members of the profession that like conduct may lead to significant consequences.
5. It is understood that, although determinations are not intended to be punitive, they can have that effect on individual practitioners.
6. Personal matters such as shame, personal ordeal, and financial difficulty are of little relevance except insofar as they contribute to the specific deterrence of the practitioner.
7. The assessment of the ongoing risk posed by the practitioner is central to the imposition of a determination. The degree to which the practitioner has acquired insight into his or her conduct is relevant to the assessment of the continuing risk posed by the practitioner. Insight can include an understanding of the nature of the conduct, an acceptance that the conduct was wrong, an appreciation of why the practitioner engaged in that conduct, empathy with the consequences, and/or a willingness to take measures to identify risk factors and to do that which is necessary to avoid further transgressions.
8. Any form of official censure is of consequence. A reprimand should not be considered a 'slap over the wrist'; it puts the public and the relevant profession on notice that the practitioner has failed to meet the standards of the profession and is a means by which the Tribunal admonishes the practitioner for their proven conduct.
9. Where parties have reached a proposed agreement of the kind presented in this case, it remains the Tribunal's duty to determine the level of conduct alleged and the determinations to be imposed as no agreement between a regulator and the professional person under review can supplant that duty. However, it is appropriate for the Tribunal to give weight to and take into account the agreement between the parties as a highly relevant and important matter. That is particularly so if it is clear from the face of the agreement that it does not represent an arbitrary outcome but reflects a carefully and extensively negotiated outcome that has proper regard to all relevant facts and circumstances.[18]

1. The parties' agreed that a reprimand ought to be imposed on Dr Canty.

1. The Board submitted that:[19]
   • Dr Canty's conduct represented a serious departure from proper professional standards as articulated in Guideline PG18(A);
   • While it was hesitant about Dr Canty's insight at an earlier stage, including in the context of the remarks he made in a report referred to below (see [120]), it accepted that, as at the time of the hearing, he understood his professional obligations as to monitoring patients when under anaesthetic;
   • It was important for the outcome of this case to send a message to other anaesthetists that leaving an anaesthetised patient, including in a mobile setting, is unacceptable except in very limited circumstances and certainly not for a purpose such as attending a Zoom call;
   • While there are no obviously comparable cases, the decision in Raiz, which concerned more complex and overall professional misconduct, supports the view that Dr Canty's proven conduct requires an appropriate disciplinary response; and
   • In this case, the appropriate disciplinary response is the agreed reprimand.
2. At the hearing, in response to a query from us, the Board's counsel confirmed that it did not consider it necessary for Dr Canty to undertake any further education given that he had already done so (as described below).

1. We summarise next the materials which informed our consideration of the parties' proposed determination order.
2. We record that, at the hearing, we invited Dr Canty to give evidence or make a statement about matters relevant to his current views about his conduct, the reflections contained in the materials and how the changes he had made would ensure there was no repeat of the conduct. As he was entitled to do, he declined to take up the opportunity.

1. Dr Canty submitted that:[20]
   • The appropriate determination in this case was a reprimand, including where the conduct involved an isolated incident occurring 'in a particular context of COVID lockdowns and the stress of competing clinical and academic obligations to his patient and to his student';
   • Dr Canty's long clinical and academic career as summarised in his curriculum vitae 'supported the conclusion that he is a highly qualified and skilled anaesthetist who does not pose a risk to patients or to the standards of his profession'. Further the further education he had undertaken and his personal reflection will ensure that there will be no repetition of the poor judgement he showed in September 2020;
   • Since becoming aware of the Notification, Dr Canty has worked extensively with fellow anaesthetists, ANZCA and the Australian Society of Anaesthetists on 'improving governance, safety practices and practitioner understanding of the applicability of the relevant Guidelines in a mobile anaesthesia setting, as well as focussing on updating them to reflect the regulatory arrangements in Victoria'. Reference was made to policies he has produced to use in the mobile anaesthesia practice in which he worked. He also undertook an audit and sought additional experience in paediatric cases (see further below);
   • Dr Canty is a member of the 'Special Interest Group for Day Care Anaesthesia' and was invited to join its Executive Committee to lead reform for mobile anaesthesia in education, guidelines and engagement of relevant stakeholders including Government (State Departments of Health and Health Ministry). He presented at its Spring 2024 conference which had 125 registrations and 75 attendees from all over Australia and most recently presented at the ANZCA annual scientific meeting in Cairns on 6 May 2025;
   • Dr Canty has been in contact with the relevant ANZCA policy officer in support of foreshadowed revisions of the ANZCA Guidelines to make specific reference to mobile anaesthesia settings and the obligations of clinicians in those settings. He is also in contact with the Victorian Department of Health, regarding an upcoming revision of 'the Private Hospitals Legislation' that will include mobile anaesthesia;
   • Dr Canty's commitment to improving standards of practice is a reflection of his insight into the seriousness of what occurred in September 2020. The submissions stated that by 'his work he hopes to ensure that no other practitioner finds himself in the position he placed himself in, and to improve the quality and availability of mobile anaesthesia in Victoria'; and
   • In those circumstances, a reprimand is a sufficient and appropriate outcome and one which serves the interests of the community and the standards of the profession.

1. Dr Canty's counsel invited us to have regard to the particular context in which the conduct was engaged in.[21]
2. First, reference was made to the fact the procedure was undertaken during a Stage 4 COVID-19 lockdown. That was said to be relevant because:
   • Many medical and dental procedures could not occur at that time and, if they were occurring, they had a degree of priority. At the hearing we were told that Dr Canty was asked at short notice if he could be available to provide anaesthesia for the paediatric case which was proceeding despite lockdown restrictions;
   • Dr Canty felt an obligation to agree to assist although it placed him in potential conflict related to a time-sensitive commitment in his role as an academic supervisor. The Submissions stated that Dr Canty was 'unable to negotiate rescheduling of either commitment'. At the hearing, Dr Canty's counsel told us that the meeting was with several members of the academic faculty and the exams were scheduled for the week after the Zoom call (and not the next day);
   • As set out below, Dr Canty's September 2022 Reflective Report,[22] stated that, when reflecting on the Notification and 'thinking about he had done', the 'only answer' he could postulate was that he 'must have been under significant stress at the time likely because of the stresses of the pandemic and lockdowns' and that he 'had made a "once off" poor decision at the time'; and
   • Dr Canty's counsel proposed that Dr Canty's students would have been experiencing their own reactions to the COVID-19 pandemic, including learning and being examined via Zoom.
3. We record that there was no document or other evidence before us about the arrangements for the Zoom call.
4. Second, in addition to the matters relating to the risks associated with the particular procedure, Dr Canty placed some reliance on the fact that he had a discussion with the Anaesthetic Nurse and he then 'decided to try and meet both obligations'. As set out above, Dr Canty said he initially intended to join the Zoom call in the procedure room but, after realising that would be too distracting to the Dentist, he left the procedure room to participate in the Zoom call in the adjoining tea room. He was said to have recognised that he should have made a different judgment call.
5. On the question of communications with the Anaesthetic Nurse, the TB showed that he agreed there had been a discussion with Dr Canty about attending the Zoom call and that Dr Canty was in the tea room which was 'just next door'. In agreeing to the arrangement with Dr Canty, the Anaesthetic Nurse 'weighed up that he could get [Dr Canty] back in seconds if need be' and that neither he nor Dr Canty expected the Zoom call to go as long as it did.[23]
6. Third, while admitting Dr Canty's conduct was not appropriate and without seeking to minimise, his counsel noted:[24]
   • There was an experienced anaesthetic nurse present with the Patient at all times;
   • The Anaesthetic Nurse had worked with Dr Canty on dental lists on a number of previous occasions and felt confident to manage the patient in his absence;
   • Dr Canty was nearby and available to be called back in 'very promptly' if required;
   • Dr Canty's absence on this occasion was an isolated incident; and
   • There was no impact on the Patient's care.
7. Relevant to Dr Canty's capacity to hear what was occurring in Theatre and return to his Patient 'very promptly', we understood that he may have been wearing headphones for the Zoom call and, in any event, was at least part of the time, listening to and contributing to the discussion.
8. While we accept that the COVID-19 pandemic created significant stresses for many and that those stresses manifested in different ways, we did not accept that the fact of the pandemic was relevant to the circumstances in which the dental procedure went ahead or on how Dr Canty conducted himself. It made no difference at all to the standards he was required to meet.

1. As noted earlier, Dr Canty provided the September 2022 Response after first being informed of the December 2021 Notification (about his September 2020 conduct) in July 2022. It contained the Reflective Report referred to above, along with written statements directed to the events in September 2020, the education he had undertaken and information about changes he had introduced to his practise.
2. Dr Canty submitted that, at the earliest opportunity, he 'acknowledged that his monitoring of the patient had been deficient, and provided extensive details of the reflection and continuing professional education he had undergone'.
3. The Reflective Report included the following:[25]

I take pride in my longstanding and persistent efforts to be a vigilant anaesthetist. Immediately after the anaesthetic, I felt guilty that I had attended the Zoom meeting during the anaesthetic. I vowed not to repeat this behaviour again . . .

Around six months later, I received [the DHHS Letter] that was sent to registered mobile anaesthetists in Victoria that reminded mobile anaesthetists to follow the guideline from ANZCA on monitoring; specifically, that a medical practitioner whose sole responsibility is the provision of anaesthesia care for that patient must be constantly present from induction of anaesthesia until safe transfer to recovery room staff or intensive care unit has been accomplished. Receiving this letter resulted in an acute exacerbation of my feelings of guilt for my poor decision-making on the day of the anaesthetic. I felt a duty to pass this onto my employer and asked them to ensure that the rest of our anaesthetic staff were aware of this. I raised this issue at our next . . . meeting that I chair. I am hopeful that this incident can be used as a learning opportunity not just for me, but for others as well.

I had many restless nights of sleep thinking about this, thinking about what I had done, and I promised myself never to do anything like this again. The thought that troubled me most was why did I do it? As stated above, I felt that I took pride in thinking that I was a vigilant anaesthetist with an outstanding track record both clinically and academically. The only answer that I could postulate was that I must have been under significant stress at the time, likely because of the stresses of the pandemic and lockdowns and that I had made a 'once off' poor decision at that time. I also recall [a family member experiencing an exacerbation of a medical condition] at the time, further compounded by the stress [relating to the time-sensitive call related to the academic commitment]. I do not believe it was any one triggering factor, but the culmination of many that brought me to do something so uncharacteristic.

. . .

Over the following months, I discussed the dilemma of the mobile anaesthetist not having another anaesthetist available to relieve the mobile anaesthetist during anaesthetics (as you ordinarily would in a hospital setting, as detailed in the enclosed new policy that I recently developed for our anaesthetic group) with my mobile anaesthetic group; as the medical director of the group, I felt that it was my responsibility to pass this on and ensure that they were not tempted to stray from the operating theatre unless absolutely necessary. During these discussions, proactive methods to minimise this risk included routinely going to the toilet and having a snack and drink between patients, avoiding answering telephone calls and online activity during cases, and ensuring a good rest the night before theatre. The issue was raised that there is significant pressure from the dental team to minimise the time between patients and that having a rest between patients would irritate the dental team. I discussed this with our head dentist and told him that the medical safety of the patient is the highest priority, that the anaesthetist is responsible for the patient's medical safety and that it was important to allow them some time to rest in between patients. He agreed that we could make some positive changes that would be relayed to colleagues, and I communicated this with the other anaesthetists and anaesthetic nurses.

When I received the telephone call from AHPRA notifying me of the complaint, I felt extremely stressed . . . Whilst writing this, I realised that I had learned from this experience, which is ongoing. I could not recall any subsequent times when I had left the attendance of an anaesthetised patient apart from an urgent bathroom break, for example.

I have completed an education plan and have provided what I learned from this below.

I received valuable advice from my mentoring sessions with [a consultant anaesthetist]. She provided valuable insight and provided very useful suggestions of other ways that I can demonstrate my commitment to providing high-level, patient-centred care.

1. In addition to his acceptance of the inappropriate nature of his conduct, we noted Dr Canty's reflections on his communications with both the Dentist and the Anaesthetic Nurse. Those were contained in the September 2022 Response in the context of his discussion of the Ethics Module we refer to below.
2. The context for some of what follows is that the Dentist had made a statement to the effect that Dr Canty had not informed her about his intention to attend the Zoom call or given her an explanation before he left Theatre.[26] The relevant part of Dr Canty's Response said:[27]

The emphasis [in the Ethics Module] on communication also resonated with me. Although I recall informing the [Dentist] that I would be outside the operating room for a short time, delegating the monitoring of the patient to the [Anaesthetic Nurse, the Dentist] claims that she did not recall this. My thoughts are that I could have communicated more clearly with the [Dentist] about my intended plan, well prior to commencing the anaesthetic. If I had done this, [the Dentist] would likely have opposed this plan, and perhaps I might not have attended the meeting and it would have become a productive discussion. In turn, perhaps I would have quickly come to my senses and realised that what I was proposing was a significant deviation from acceptable practice.

When reading [the Ethics Module document], I became aware that it is possible that I may have been perceived in a position of authority by the [Anaesthetic Nurse] and that he may not have been that comfortable with my plan. He may have felt obliged to agree as he may not have wanted to oppose it for fear of a disagreement and potential consequences. On this point, I apologised to [the Anaesthetic Nurse] for placing this obligation on him, which was not fair. I also apologised for the fact that AHPRA contacted him on account of me, which would have been an unsettling experience. I look forward to developing my working relationships with anaesthetic nurses further with this power imbalance in mind.

1. Dr Canty was correct in his apprehension of how the Dentist might have viewed his plan, had she been made fully aware of it in advance.
2. In the Dentist's statement,[28] she said that, given the procedure involved paediatric care, she would have liked Dr Canty to be in the room despite the Anaesthetic Nurse being present. She acknowledged she was 'not certain of the protocols arranged within an anaesthetic team' but, as she had worked with the Anaesthetic Nurse before, that gave her 'some reassurance' that the Patient was in good hands.
3. Dr Canty's response included the following after reference to the Ethics Module:[29]

Although I am familiar with the Hippocratic Oath, I was not aware of the document or the update. I found this document and webinar very useful as they made me reflect and think about the expected professional and ethical code of conduct of all medical practitioners.[30]

I studied these resources for relevance to my complaint. The principal message that I derived is that the safety and medical care of the patient is the priority above all other factors. Leaving the room to attend a Zoom meeting was not in the patient's best interests; rather, it was in my interest. I should not have done this, even if [the Anaesthetic Nurse] and I thought this to be acceptable at the time. I believe it was poor judgement on my behalf.

1. While the above statements indicate some insight, we found them to be very concerning coming from a senior medical practitioner after around 26 years of practice, and, as at 2022, 17 of which involved him practising as a specialist anaesthetist. So, while we gave Dr Canty some credit for the insight shown by the above, we were concerned that the ethical concepts he discusses appeared to be news to him.

1. The September 2022 Report included details of the education program Dr Canty had undertaken[31] and a Mentoring Report.[32]
2. As to the education Dr Canty completed, it included the Ethics Module mentioned above. It was entitled 'Ethics, obligations, knowledge and skill: Professionalism in medicine' and it took Dr Canty around 25 minutes to complete in August 2022.[33]
3. Other education undertaken in August 2022 focussed on the ANZCA Guideline PG18(A), the DHHS Guidelines, the Code of Conduct and another ANZCA guideline on 'sedation and/or analgesia for diagnostic and interventional medical, dental or surgical procedures'.[34] As part of an education plan, Dr Canty undertook a 90 minute webinar on 'Professionalism in Medicine: exploring the code of conduct' and a two hour Australian Medical Association Code of Ethics seminar.[35]
4. As referred to earlier, in March 2021, Dr Canty received the DHHS Letter. Dr Canty stated that he had also used the DHHS Letter as a further prompt for reflection and to have productive discussions with colleagues.
5. Dr Canty had one on one mentoring with Dr Vida Viliunas OAM, a specialist anaesthetist.[36] During the first session,[37] Dr Canty and Dr Viliunas discussed the Notification, the education and reading he had already completed on the topic. They then agreed that it would be useful for Dr Canty to refresh his 'paediatrics exposure to the latest contemporary practice' via observation sessions at a dedicated children's hospital. It was noted that observations of that kind would meet Dr Canty's CPD and he intended to incorporate into his CPD triennium plan.
6. Relevantly, in her written report, Dr Viliunas said that Dr Canty:

recognised without qualification that he made an error of judgement to leave the operating room and engage in a zoom call. I was impressed by Dr Canty's insight, contrition and resolve to change his behaviour and to never repeat a prolonged absence from an operating room. He completed the activities suggested by [his insurer] conscientiously and thoroughly. Dr Canty engaged with our mentoring earnestly, enthusiastically and acted promptly to organise the logistics necessary to maintain an awareness of contemporary paediatric practice.

1. As to the observations plan, the materials indicate that Dr Canty attended at Monash Health to observe orthopaedic and emergency paediatric treatment on one day in September 2022.[38]
2. We accepted that the education, mentoring and observation were all appropriate ways for Dr Canty to engage in reflection and consideration of the past conduct and how to shape his future conduct.

1. Dr Canty's September 2022 Response described the following changes he had made to his practice:[39]
   • Avoiding fatigue by ensuring a good night's rest prior to providing anaesthesia;
   • Ensuring he goes to the toilet and has a drink and something to eat in between patients;
   • Ensuring that both the anaesthetic nurse and he are satisfied that a patient has recovered from anaesthesia to a point where the anaesthetic nurse and he can commence anaesthesia on the next patient. This is to reduce the risk that either the nurse or he is required to leave another anaesthetised patient to attend to a patient who is recovering from anaesthesia and may require medical attention;
   • If he must leave the operating room for one of the above reasons or if he is required to attend to another patient who needs urgent medical care, then he follows item 5.3 of the ANZCA Guidelines on monitoring, including limiting his absence to the shortest possible duration, notifying the dentist why he must leave the room, where he is going and an estimate of when he will return; and
   • Limiting use of his smartphone, laptop, the internet and mobile phone calls while monitoring a patient under anaesthesia.
2. Dr Canty described actions he has taken to prevent anaesthetists from his anaesthetic group from leaving anaesthetised patients. They included:
   • Distributing the DHHS Letter;
   • Raising the issue for discussion with the anaesthetic group at a mortality and morbidity meeting of both the policy to only leave an anaesthetised patient if unavoidable and not to commence anaesthesia until the previous patient or patients have recovered adequately from anaesthesia;
   • Developing and achieving approval of the anaesthetic group policy on monitoring during anaesthesia; and
   • Developing a new policy on fatigue.
3. Copies of those polices were in the TB.[40]

1. Dr Canty attached to his submissions an 8 June 2025 reference prepared by Ms Margaret O'Donnell, a registered nurse with qualifications including a Graduate Diploma in Educational Administration and Graduate Studies in Acute Clinical Nursing - Emergency Nursing. She has practised since 1980 and over the preceding 15 years, she specialised in anaesthetic nursing, working across both hospital environments and with several registered mobile anaesthesia services, who provide general anaesthetics to patients in dental surgeries.
2. Ms O'Donnell first met Dr Canty in late 2018 and had the opportunity to 'work alongside him on many occasions with various mobile anaesthesia companies all related to dental procedures'.
3. Ms O'Donnell said she had always found Dr Canty to be 'a highly competent, reliable, and capable anaesthetist who is open to feedback and committed to continual improvement'. She stated he was 'actively involved in updating and refining practices and protocols with patient safety at the forefront'. She had never had any concerns about Dr Canty's clinical practice and always felt 'completely supported when working with him'.
4. She stated that Dr Canty consistently demonstrated 'a compassionate and professional approach with his patients'. As to the events with the Patient, she said she was 'extremely surprised to hear about it', given Dr Canty's 'diligence and the high standards' that he had consistently observed.
5. We noted the opinions expressed by Ms O'Donnell.

1. Dr Canty produced a 17 June 2025 psychological report written by Dr Melissa Marot. The report stated that Dr Canty had attended 30 sessions with her over the period 3 April 2023 to 22 May 2024. The sessions were focussed on assisting Dr Canty to manage the 'intense psychological distress' he was experiencing in light of the possibility that his registration could be suspended. Dr Marot and Dr Canty worked on goals he had identified. The report said relevantly:

During our sessions, we consistently worked on practical strategies to improve focus on patient care during anaesthetic procedures, which included coaching on how to avoid double booking patients and how to stay organised so that he could remain fully attentive to each patient during procedure.

Throughout sessions over 2023 and 2024, [Dr Canty] also focused on developing and trialling a number of strategies to help stay focused and manage workload effectively. He reported that he actively applied these techniques in his practice and kept a personal diary to record experiences and monitor his progress.

[Dr Canty] presented as proactive, motivated and engaged with psychological therapy and coaching towards the goals he outlined above. He also reported progress towards these goals, describing scenarios that demonstrated progress.

1. We acknowledge the stress associated with notifications under the National Law and the exacerbation of that stress when the processes, including at the Tribunal, are prolonged.

1. Dr Canty's submissions attached an ANZCA 'Multi-source feedback responses (anaesthesia practice) - collation form' which was completed on 3 August 2023 (Feedback Report). While we were not taken to the detail of the report at the hearing, we noted the following.
2. The Feedback Report explains that it is designed to be used by a facilitator assessing a CPD participant who collates 'all multisource feedback responses'.
3. The Feedback Report had four categories which were to be considered with several statements in each. We presumed the individual person responded by indicating one of the following for each statement in each category:
   • Not observed;
   • Never;
   • Sometimes;
   • Usually; and
   • Consistently.
4. The individual categories and collated responses to the statements were as follows:
   • Patient management: four 'usually' responses and one 'consistently';
   • Communication and team work: four 'usually' responses and three 'consistently';
   • Advocacy and professional attributes: one 'sometimes' response, 'five 'usually' responses and 'two 'consistently';
   • Teaching and learning: one 'usually' responses and two 'consistently'.
5. The Feedback Report included comments which appeared to be verbatim from responses collected from the people who completed them. The comments included:

[Dr Canty] is a technically proficient practitioner with a powerful skillset. He consistently demonstrates safe, effective and efficient patient management;

Very professional care [Dr Canty] provides.

I have been involved in a number of situations with [Dr Canty] where a high level of effective communication has been required and he has consistently demonstrated he is up to the task. This has included two significant anaesthetic crisis as well as communication in the non clinical academic context; and

Great teacher, always keen to discuss and impart evidence-based techniques and research.

[Dr Canty] is exceptionally commited to his academic work. This involves both teaching as well as research at the University of Melbourne as well as Monash Health. Through his involvement in various research projects and teaching, he has positively impacted the learning experience and skill development of hundreds of Anaesthetic practitioners (trainees and consultants). His non clinical work is a real asset to the profession and his workplace.

1. In response to the statement 'It would be helpful to the team if he/she', the Feedback Form said:

Generally very positive comments from participants. On rare occasions, could be more focused on patient care and avoid distraction. But overall, clinical care and teamwork seen as very patient care focused.

1. The Feedback Form listed, in de-identified form, the roles and workplaces of the people who provided the feedback. They included anaesthetists at public hospitals, anaesthetic trainees, registered nurses, surgeons, a cardiologist, dentists and practice managers.
2. At the hearing, we asked for clarification about four registered nurses who were described as working for a 'Mobile Anaesthesia Service' to clarify whether Dr Canty was the employer of those individuals. We were informed that Dr Canty did not own the relevant business and was not the employer. While it was of assistance to know that the people being surveyed were not Dr Canty's employees, we presumed that, if he was working with the registered nurses regularly, there may be some element of a power imbalance of the kind Dr Canty described was in play with the Anaesthetic Nurse (see [82] above). The same imbalance may have been present in respect of the anaesthetic trainees and practice managers.
3. While we have given weight to the positive comments made in the Feedback Report, as we stated at the hearing, we found the Feedback Form somewhat underwhelming overall. We were concerned that, a year after the education and reflective work had been done by Dr Canty, he was not rated more highly by his colleagues including in respect of :
   • The statements 'Provides effective clinical assessment and plans', 'Demonstrates proficient technical/procedural skills' and 'Provides clear post-anaesthesia care/instructions' - the collated response for each was 'usually';
   • Statements directed to effective communication with patients, families, carers and colleagues - the collated response for each was 'usually';
   • The statement 'Acts in an ethical manner' - the collated response was 'usually'; and
   • The statement 'Is contactable and responds appropriately when needed' - the collated response was 'sometimes'.
4. We noted the psychological sessions with Dr Marot addressed one of Dr Canty's goals, being improving focus on patient care. While we do not know when the information which formed the basis of the Feedback Form was collected, the comments and ratings in August 2023 do not seem to demonstrate the work Dr Marot described Dr Canty undertaking in around the same time in 2023.
5. As Dr Canty did not give evidence or make any statement before us, we had no opportunity to hear from him about those or other matters.

1. Dr Canty's September 2022 Response said that the conduct involving the Patient was 'not representative of my usual practice and the events that transpired represented a severe lapse in judgment'.
2. There was no material before us to show that there had been any other lapse of the kind in issue before us, nor that Dr Canty had left a patient while under general anaesthetic.
3. Having said that, there was material in the TB, including relating to Raiz which indicated that, as at two months after the events involving the Patient (and around eight months before he was informed of the Notification), Dr Canty did not understand the nature of the obligations to which he was subject.[41]
4. The context for what follows is clauses 5.2 and 5.3 of Guideline PG18(A) which are set out in [37] above.
5. A report Dr Canty wrote in support of Dr Raiz on 17 November 2020 (November 2020 Raiz Report) included the following (underlining our emphasis):[42]

How and when it is reasonable for the anaesthetist to be absent from theatre for short periods of time, when the patient is being monitored by the nurse or surgeon.

[Clause 5.3 of Guideline PG18(A) says] . . .

ANZCA policy document PS09 Guidelines on IV-sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures that states 'General anaesthesia is sometimes indicated during diagnostic or interventional medical or surgical procedures and requires the exclusive attention of an anaesthetist, or other trained and credentialed medical practitioner within his/her scope of practice', i.e., continuous presence of an anaesthetist during the anaesthesia.

These policies refer to a hospital or day surgery facility where the number of anaesthetists rostered to work is adjusted to the number of operating lists (rooms) so that there are spare anaesthetists available to provide 'relief' for anaesthetists who are providing anaesthesia. By 'relief' I refer to rest breaks, toilet breaks, and other clinical duties such as urgent or semi-urgent clinical care of patients and non-clinical duties such as meetings or important phone calls.

In the mobile anaesthesia environment is unique in that it is standard for there to be only one anaesthetist and one anaesthetic nurse on site and hence there is no 'spare' anaesthetist available to provide relief. The [DHHS Guideline] states that there must be an assistant dedicated to the anaesthetist. However, this document does not provide guidance on if or how long an anaesthetist should be reasonably allowed to leave the anaesthetised patient. It states that if a patient that is recovering from anaesthesia has a clinical deterioration then the anaesthetist or anaesthetic nurse is to instruct a dental staff member to contact the ambulance service to attend to care for the patient.

I have heard from [an Officer within DHHS] that it is acceptable for a mobile anaesthetist to delegate the monitoring and care of anaesthetised patients and leave the operating room when necessary. [The Officer] is in charge of provision of mobile anaesthesia licences. I have heard from other anaesthetists that hold a mobile anaesthetic licence that according to the DHHS mobile anaesthesia licensing authority, that anaesthetists are allowed to leave an anaesthetised patient with an anaesthetic assistant but I have not been able to locate a publication stating this yet. I have heard from one mobile anaesthesia service in Melbourne that the Health Act has a short statement on whether or not an anaesthetist is allowed to leave an anaesthetised patient when there is no other anaesthetist present to attend to go to the toilet.

In the absence of published guidelines, my opinion on how and when it is reasonable for the anaesthetist to be absent from theatre for short periods of time, when the patient is being monitored by the nurse or surgeon, is based on experience . . .

When is it reasonable to leave?

I have been performing mobile anaesthesia for dental procedures for three years with four different mobile anaesthesia groups. On the provisor that the patient's airway is secured with an endotracheal tube, the patient's condition is stable (adequate depth of anaesthesia and stable and acceptable vital signs), the anaesthetic director at each group has been comfortable with allowing the anaesthetist to leave an anesthetised patient for activities such as (but not restricted to) toilet breaks, coffee and meal breaks, assessing the next patient on the list or assessing a patient recovering from anaesthesia, taking phone calls and leaving the dental surgery building to fetch items from a car. One anaesthetic director of a mobile anaesthesia service in Melbourne encourages mobile anaesthetists to assess the next patient during anaesthesia to reduce the delay between patients.

It is important that the anaesthetic nurse who remains with the patient has an agreed method for communication with the anaesthetist whilst they are out of the operating room. Prior to leaving the anaesthetised patient with the anaesthetic nurse, the anaesthetist should hand over to the anaesthetic nurse and provide them with relevant instructions . . .

How long is it reasonable to leave?

The short answer is as short as time as possible. However, the time allowance is directly dependent on several factors including the expected duration of the procedure, the stability and medical comorbidities of the patient, and any intraoperative dental surgery events such as an increase in surgical stimulus or bleeding. Most implant surgeries take at least 2 and up to 6 hours duration and most of that time is spent by the anaesthetist in simply changing the propofol syringe when it runs low . . .

Summary

Although I have not found specific information in an official policy or procedure document regarding the details of when or how long an anaesthetist should leave the care of an anaesthetised patient with an anaesthetic nurse and dentist, I believe that it can be done safely in certain circumstances:

. . .

The acceptable duration that an anaesthetist should be allowed to leave the care of an anaesthetised patient to the anaesthetic nurse depends on the circumstances of the anaesthetic and dental stability and if a prolonged time was required, such as beyond 40 minutes, then the anaesthetist should check with the anaesthetic nurse whether they are required to return to the patient. I think that this issue is not covered adequately in the current guidelines and is worthy of review by ANZCA and DHHS.

1. First, it was of concern to us that in the November 2022 Raiz Report, Dr Canty did not refer to clause 5.2 of Guideline PG18(A) which sets the standard: namely that a medical practitioner providing anaesthesia care must be constantly present from induction of anaesthesia until safe transfer to recovery room staff or intensive care unit has been accomplished. As indicated by our summaries above, the September 2022 Response and related documents did not engage with clause 5.2 either.
2. It appeared that Dr Canty's focus lay with when an anaesthetist could leave their patient instead of proceeding on the basis that an anaesthetist must not do so unless the circumstances are 'exceptional' and the absence is 'brief'.

1. The parties submitted that specific deterrence did not feature significantly in this matter noting Dr Canty's early acceptance of the breaches of standards and the insight and remorse he displayed. The Board and Dr Canty's counsel directed our attention to the education Dr Canty had undertaken and the changes he had made to his practice.
2. As stated earlier, while the Board expressed hesitation about Dr Canty's insight at an earlier stage, it accepted that, as at the time of the hearing, he understood his professional obligations as to monitoring patients when under anaesthetic.
3. We make the following comments relevant to Dr Canty's insight.
4. We treated the opinions Dr Canty expressed in the November 2020 Raiz Report as those he held then, before he was aware of the Notification. We have used them to compare with the opinions Dr Canty expressed immediately after he received the Notification and up to the time of the hearing. We have taken that approach in the absence of evidence or a recent statement from Dr Canty. As indicated by the comments we have made above, the materials before us include what we regard as incomplete responses and descriptions of the standards which apply to Dr Canty and all other anaesthetists in all settings.
5. We urge him to reflect further on the underlying basis for the Guidelines, the DHHS Letter and the 2014 and 2020 Codes. That includes the requirement that, in all forms of medical practice, the patient's interest and wellbeing must come first. In the context of anaesthesia, that calls for the physical presence and vigilance at all times by the anaesthetist who is responsible for ensuring the patient remains safe throughout the procedure.
6. The circumstances where the anaesthetist may leave their patient must be 'exceptional', that is 'forming an exception or rare instance; unusual; extraordinary'.[43]
7. We do not consider needing to use the bathroom (except in the case of an unusually long procedure, due to a sudden illness or the like) is within the meaning of exceptional. Aiding efficiency by prepping other patients while the primary patient is anaesthetised does not seem to us to fall within the exception.
8. In case Dr Canty or others think otherwise, an anaesthetist should not be using their smartphone, laptop, the internet or taking mobile phone calls while caring for a patient, unless that use is directly related to and necessary for that patient's care or is required due to an emergency with another patient (where no other anaesthetist is available).
9. Returning to specific deterrence and taking all of the material together, we accepted that Dr Canty made admissions at the earliest point in time possible, carefully reflected on his conduct and made improvements to his practises. We recognised his efforts to educate others and, as needed, lift standards in his workplaces and amongst colleagues. We noted his engagement in some mentoring an observation session and his psychological treatment.
10. In all of the circumstances, we did not consider that the shortcomings in Dr Canty's performance when caring for the Patient and in some of his subsequent responses warrant interference with his registration, by way of suspension in order to achieve specific deterrence. Despite the concerns expressed above, we did not consider imposing conditions requiring more to be done by him would be of utility.
11. We reached those views taking into account the blemish free almost five years since the conduct was engaged in, the length of time between when Dr Canty received the Notification and when the Board's application was heard (around three years), the public nature of this proceeding, the significance of a finding of professional misconduct and the professional impact of a reprimand. Irrespective of how he expresses himself on paper, we were satisfied that Dr Canty has learned the necessary lessons and is unlikely to engage in like conduct again.
12. We noted and gave weight to the efforts Dr Canty has made to improve understanding of Guideline PG18(A) and like standards amongst the profession. That leadership presents as a concrete and meaningful way to make good.
13. Balancing all of the above matters, we considered that, while not significant, specific deterrence had a role to play in the determinations. We concluded that the public admonishment a reprimand carries for a professional person would satisfy the aim of specific deterrence.

1. For the same reasons as given above, we were satisfied that the public will be protected from any repeat of the professional misconduct Dr Canty engaged in when he cared for the Patient in September 2020.

1. Having regard to the matters discussed above in the context of specific deterrence, we were satisfied that, alongside the history of this matter, a reprimand would serve as a loud and clear warning for any other anaesthetist who has yet to absorb the importance of Guideline PG18(A), the DHHS Guideline and the 2020 Code in anaesthetic practice.

Maintenance of standards, the reputation of the profession and the confidence of the public

1. We intend the content of these Reasons to add to the existing statements of the standards to be applied by anaesthetists. We intend that the fact of this proceeding serve as a means to give the public confidence that, even where there is no adverse outcome for a particular patient, the regulatory processes will be engaged where standards are not met.
2. We were satisfied that the reprimand would support those aims.

1. On 24 September 2020, Dr Canty engaged in professional misconduct and/or unprofessional conduct in that he failed to provide safe and appropriate anaesthetic care to a paediatric patient (the Patient), by leaving the operating theatre for a period of no less than 30 minutes, leaving the Patient unattended by an anaesthetist whilst under general anaesthetic.

1. At all material times:
   1. The Guideline PG18(A), published by [ANZCA]:
      1. applied to all anaesthetists;
      2. detailed what was expected of an anaesthetist in monitoring a patient for whose care they were responsible, including:
      3. "5.2 A medical practitioner whose sole responsibility is the provision of anaesthesia care for that patient must be constantly present from induction of anaesthesia until safe transfer to recovery room staff or intensive care unit has been accomplished".
      4. 5.3 In exceptional circumstances brief absences of the anaesthetist primarily responsible for managing anaesthesia may be unavoidable.
   2. replaced PS18 in April 2017.
   3. the obligations in [Guideline] PG18(A) are expressed in the same terms as those in PS18.
   4. the ANZCA first published PS18 in 1988.
   5. In April 2017 the [DHHS] published [the DHHS Guideline] that:
      1. applied to all anaesthetists practising in Victoria as mobile anaesthetists in dental offices.
      2. detailed what was expected of an anaesthetist in monitoring a patient for whose care they were responsible, including:
      3. "The anaesthetist or IV-sedationist must be physically present during the intraoperative period and immediately available until all patients have been recovered to an agreed upon clinical baseline".
      4. "(Please see ANZCA PS18 Recommendations for Monitoring during Anaesthesia...)".
2. On 24 September 2020 the Patient . . . underwent a dental procedure at . . .
3. The Patient's dental procedure included . . .
4. The Patient's dental procedure was performed by [the Dentist] a general dentist. Prior to commencing the procedure, [the Dentist] had assessed the Patient as requiring a general anaesthetic for the procedure.
5. Dr Canty was engaged as the anaesthetist, and was responsible for managing the anaesthetic care of the Patient, including monitoring their health and wellbeing throughout the procedure and ensuring ongoing maintenance of anaesthesia.
6. Dr Canty:
   1. Placed the Patient under general anaesthetic . . .;
   2. after placing the Patient under general anaesthesia, handed the monitoring and care of the patient, including ongoing maintenance of anaesthesia, to the [Anaesthetic Nurse];
   3. left the theatre for reasons unrelated to the clinical care of the Patient, namely to attend a zoom conference call; and,
   4. was absent from the theatre for at least 30 minutes; and,
   5. returned at the end of the procedure.
7. [The Dentist] states that Dr Canty did not inform [her] of his intention to leave the procedure room or explain the reason for his absence prior to his sedation of the Patient or at any other point.
8. The conduct particularised at [1.vi]-[1.vii] above is inconsistent with the 2014 Code including, but not limited to, clauses 2.1, 2.2.4, 3.6.1, 4.2, and 4.4. The conduct is also inconsistent with the [Guideline PG18(A) and the DHHS Guideline] set out above at [1.i.a] and [1.i.e].

1. Dr Canty's conduct as alleged above constitutes professional misconduct in that it is conduct that is substantially below the standard reasonably expected of a registered anaesthetist of Dr Canty's level of training or experience.

[1] On 25 July 2025, the Tribunal made an order amending paragraphs 3, 71, 72 and 80 in these Reasons to modify references to third parties who were not directly involved in the proceeding so as to protect their identities.

[2] In these Reasons definitions are shown through the bolding of names or terms. Italics and bold are used to define cases.

[3] In order to avoid identifying the child, we have used descriptors for them and others whose identities were not relevant to our decision and where they were not required to give evidence. For the same reasons, we have not identified specific locations.

[6] TB 24-31. We noted that it appeared Dr Canty received some notice of an unspecified concern about his treatment of the Patient in around mid-September 2021, given emails he exchanged at that time with the Dentist (see TB 38-40).

[10] Briginshaw v Briginshaw [1938] HCA 34.

[11] In the 2020 Code, see clauses 2.1, 3.2.4 and 4.6.1 respectively.

[13] Board's Written Submissions dated 29 May 2025 [26]-[30].

[14] [2023] VCAT 459.

[16] Dr Canty's Written Submissions dated 16 June 2025 [9].

[17] See Medical Board of Australia v Jansz [2011] VCAT 1026 [358]-[373]; and Medical Practitioners Board of Victoria v Naik [2009] VCAT 755 [60]-[61].

[18] Commonwealth of Australia v Director, Fair Work Building Industry Inspectorate & Ors [2015] HCA 46 [46]-[49]. See also Medical Board of Australia v Fox [2016] VCAT 408 [6] as confirmed in Medical Board of Australia v Willcourt [2018] VCAT 1032 [13].

[19] Board's Written Submissions [35]-[40].

[20] Dr Canty's Written Submissions [10]-[16].

[21] Dr Canty's Written Submissions [4].

[24] Dr Canty's Written Submissions [5].

[26] Statement dated 30 May 2022, TB 35-37 (Dentist's Statement).

[30] Apparently a reference to the AMA Code of Ethics.

[34] Avant Mutual Education Plan, TB 63-71.

[37] It was not apparent how many were held in total but an email at TB 74 suggested there were at least two.

[41] See TB 145-146 for the relevant part of Dr Canty's report.

[42] TB 133-154. A second report was written on 20 October 2021 (TB 155-158) but its contents are not relevant to this proceeding.

[43] Taken from the Collins Dictionary.