1. The Tribunal finds proved the single allegation set out in the Amended Notice of Allegations dated 20 December 2022, that Dr Carr behaved in a way that constitutes professional misconduct under (a) of the definition in s 5 of the Health Practitioner Regulation National Law (National Law).

1. Under s 196(2)(a) of the National Law, Dr Carr is reprimanded.
2. Under s 196(2)(c) of the National Law, Dr Carr is fined $12,000.

1. This case concerns a breach of the statutory requirements for the completion of a declaration by a person that they seek to access voluntary assisted dying (VAD) under the Voluntary Assisted Dying Act 2017 (Vic) (VAD Act).
2. Under that legislation, the 'co-ordinating medical practitioner' has a responsibility to certify that the strict requirements of the VAD regime are satisfied, before the process may proceed. That practitioner is required to submit documents to the Voluntary Assisted Dying Review Board (VADRB), which oversees the VAD process.
3. The respondent, Dr Carr, has 35 years' experience as a general practitioner. One of his particular interests is end of life treatment for patients. This has included involvement in the processes of getting VAD legislation enacted, and of establishing systems to make it work safely and effectively, in multiple jurisdictions.
4. Dr Carr was the coordinating medical practitioner for a patient seeking access to VAD in February 2020. There was an error made in the completion of the patient's declaration of seeking access to VAD (written declaration). On 6 February 2020, the patient, Dr Carr, and two witnesses were all present at Dr Carr's medical practice.[1] The required boxes on the form for the names, addresses and signatures of those four persons, and the date, were all completed on the patient's written declaration, except for two of those boxes. By an oversight, and due to some distraction during the consultation, the patient did not actually sign and date the declaration on page 2.
5. Dr Carr submitted the form to the VADRB on 8 February 2020. On 10 February 2020 an the VADRB staff member emailed Dr Carr, asking him to arrange for the patient to sign that document, so it could progress the case.
6. Dr Carr arranged for the patient to attend his practice again, on 11 February 2020. This time, the patient attended alone. The patient inserted the missing signature, and dated the form 6 February 2020.
7. The form was submitted to the VADRB, and the VAD process continued to completion. Using a drug prescribed by Dr Carr, the patient brought about their death on 1 April 2020.
8. In May 2020, it appears the VADRB conducted a review of the process undertaken in this case. It noted that the 'final review form' lodged by Dr Carr on 8 February 2020 was incorrect, in that it stated that the patient's 'written declaration' had been signed in accordance with the requirements of the VAD Act. In particular, the signing of the patient's declaration had not been witnessed by the two witnesses.
9. There is no suggestion that the patient was ineligible to participate in VAD, or that any of the strict statutory requirements relating to the patient's eligibility or voluntary participation in the process were not satisfied. That is, the patient had an incurable disease which was advanced and progressive, and would cause death within six months. And that it was causing suffering that could not be relieved in a tolerable manner. The patient understood the process, and did not act under coercion.
10. The VADRB raised the issue with Dr Carr on 21 May 2020. He provided full and frank responses then, as he has on all occasions since. That is, from the outset, Dr Carr has accepted full responsibility for his errors in the conduct of the VAD process for this patient.
11. On or about 27 July 2020, the VAD referred Dr Carr to the applicant (Board). After conducting an inquiry, on 9 December 2021, the Board formed the belief that Dr Carr had engaged in professional misconduct.
12. On 31 March 2022, the Board commenced this professional disciplinary proceeding against Dr Carr. It brings to VCAT a single allegation of professional misconduct against Dr Carr. This is brought under the Health Practitioner Regulation National Law (National Law).[2]
13. Following discussions between the parties, an Amended Notice of Allegations dated 20 December 2022, and a Statement of Agreed Facts, Findings and Determinations, signed by both parties, dated 23 December 2022 (Agreed Statement) were filed with the Tribunal.
14. Dr Carr admits his actions comprise professional misconduct and the parties jointly seek determinations that he be reprimand, and fined $12,000.
15. While of course it always remains the Tribunal's role to decide what findings and determinations should be made, an agreement reached between the parties is a very relevant consideration, especially where both are legally represented: Commonwealth v Director Fair Work Building Industry Inspectorate.[3] In this case, for the reasons set out below, including the agreement reached between the parties, we are satisfied that the findings and determinations should in fact be made.
16. A hearing was conducted on 1 August 2023, and the Tribunal announced its decision, and indicated written reasons would follow. These are those reasons.
17. At the end of the hearing, the question of whether orders should be made protecting the privacy of the patient's family members, and the witnesses to the patient's declaration should be made. It is noted an order closing the file to public inspection was made on 7 April 2022. Having considered this matter, the Tribunal does not believe in all circumstances that such an order is necessary at this point. These reasons do not identify either the patient or the witnesses.

1. The Agreed Statement describes the framework of the VAD Act as relevant, and the detail of the sequence of events concerning the handling of patient's application by Dr Carr. It then sets out the admissions made by Dr Carr, and the findings and determinations which the parties jointly propose be made by the Tribunal. Those admissions, set out in paragraph 27 of the Agreed Statement, reflect the allegation put in the Amended Notice of Allegations. Omitting the procedural history, already recited, the Agreed Statement is as follows:

Statement of Agreed Facts, Findings and Determinations

B. Registration status of Dr Carr

1. Dr Carr holds general registration as a medical practitioner, and specialist registration in the field of general practice.
2. Dr Carr does not have any conditions or restrictions on his registration(s)

C. Agreed facts and matters regarding the Voluntary Assisted Dying Act 2017 (Vic)

1. The VAD Act allows a person in the late stages of advanced disease to take medication prescribed by a doctor that will bring about their death at a time they choose.
2. At all material times, the VAD Act:
   1. provided for and regulated access to voluntary assisted dying in Victoria;
   2. established the VADRB, and prescribed its functions and powers, including to:

a) monitor matters related to voluntary assisted dying; > > b) review the exercise of any function or power under the VAD Act; and > > c) refer any relevant issue in relation to voluntary assisted dying to the Australian Health Practitioner Regulation Agency (Ahpra).

3. At all material times, the VAD Act relevantly provided and provides as follows:
   1. Section 3 of the VAD Act provides that the 'request and assessment process' means the making or conducting of the following under Part 3 of the VAD Act in respect of a person:

a) a 'first request'; > > b) a 'first assessment'; > > c) a 'consulting assessment'; > > d) a 'written declaration'; > > e) a 'final request'; > > f) a 'contact person appointment'; > > g) a 'final review'.

2. Each of the phrases used at paragraph (a) to (g) above is defined in section 3 of the VAD Act and has a distinct meaning for the purposes of the VAD Act. 3. Section 3 of the VAD Act provides that a co-ordinating medical practitioner for a person means a registered medical practitioner who accepts that person's 'first request', or a consulting medical practitioner who accepts a transfer of the role of co-ordinating medical practitioner 4. Section 17 of the VAD Act provides that the co-ordinating medical practitioner must not commence the first assessment unless the practitioner has completed 'approved assessment training' (being the training approved by the Secretary[4] under section 114) (Approved Training). 5. Section 34 of the VAD Act provides that a person assessed as eligible to access voluntary assisted dying may make a 'written declaration' requesting access to voluntary assisted dying. 6. Section 34(2)(a) of the VAD Act provides that the 'written declaration' must specify that the person makes the declaration voluntarily and without coercion, and understands the nature and the effect of the declaration that the person is making. 7. Section 34(2)(b) of the VAD Act provides that the 'written declaration' must be signed by the person making the declaration in the presence of 2 witnesses and the co-ordinating medical practitioner. 8. Section 36 of the VAD Act relevantly provides that a witness who witnesses a person signing a 'written declaration' must certify in writing in the declaration:

a) that, in the presence of the witness, the person making the declaration appeared to freely and voluntarily sign the declaration; > > b) that, at the time the person signed the declaration, the person appeared to have decision-making capacity in relation to voluntary assisted dying; > > c) that, at the time the person signed the declaration, the person appeared to understand the nature and effect of making the declaration.

9. Section 41 of the VAD Act provides that on receipt of a 'final request' made by a person, the co-ordinating medical practitioner for the person must:

a) review the forms completed under Part 3 of the VAD Act, being the 'first assessment report form', all 'consulting assessment report forms', the 'written declaration' and the 'contact person appointment form' (Section 41(1)(a) Forms);

b) complete the 'final review form' in respect of the person;

1. certify whether the request and assessment process has been completed as required by the VAD Act; and

d) give the VADRB a copy of the completed 'final review form', accompanied by copies of the Section 41(1)(a) Forms, within 7 days of completing the final review form.

1. Section 80 of the VAD Act protects a registered health practitioner who, in good faith and without negligence, takes action under the VAD Act believing on reasonable grounds that the act is in accordance with the VAD Act from legal liability.

D. Agreed facts regarding the respondent's conduct .

11. At all material times, Dr Carr was:

1. registered as a medical practitioner, holding both general registration and specialist registration in the field of general practice, and acting in the practice of the medical profession, under the National Law;

a) Dr Carr's date of first registration is 29 November 1984, > > b) Dr Carr first became a fellow of the Royal Australian College of General Practitioners in 1998

2. a partner of the St Kilda Medical Group General Practice;
3. a co-ordinating medical practitioner under the VAD Act:

a) having completed the Approved Training for medical practitioners in or about May 2019, > > b) who had been the co-ordinating medical practitioner for approximately 8-10 other patients[5] under the VAD Act prior to the Patient; and

4. the co-ordinating medical practitioner for a patient (Patient) within the meaning of section 3 the VAD Act, being a registered medical practitioner who accepted the Patient's first request for access to voluntary assisted dying.

1. On 6 February 2020, Dr Carr conducted a consultation with the Patient in the presence of 2 witnesses, during which:
   1. The Patient wrote his name and address on the 'written declaration', which was signed by Dr Carr, signed and certified by the 2 witnesses, but was not signed by the Patient (Incomplete Written Declaration).
   2. The Patient wrote his name and address on a "contact person appointment form", and then signed the form in the presence of a witness;
2. On or about 8 February 2020, Dr Carr provided the Incomplete Written Declaration to the VADRB by uploading that document to the Voluntary Assisted Dying Portal (VAD Portal), an online webpage administered by the Secretariat of the VADRB.
3. On 8 February 2020, Dr Carr provided a 'final review form' to the VADRB using the VAD Portal.
   1. In the 'final review form', Dr Carr certified that the request and assessment process in respect of the Patient had been completed as required by the VAD Act when in fact it had not, by reason of the Incomplete Written Declaration.

ii. In relation to the 'Written Declaration':

a) In response to the question "Has the written declaration been signed by or on behalf of the person making the declaration in accordance with the Act?" Dr Carr answered "Yes";

b) In response to the question "Has the declaration been witnessed in accordance with the Act by 2 witnesses?" Dr Carr answered "Yes"; when in fact the correct answer to both questions was "No".

1. The 'final review form' at paragraph 14 above was factually incorrect because Dr Carr either:
   1. failed to review the Section 41(1)(a) Forms as required; or
   2. reviewed the Section 41(1)(a) Forms but failed to identify that the Incomplete Written Declaration had not been signed by the Patient.
2. Section 43 of the VAD Act provides that if the co-ordinating medical practitioner certifies in a 'final review form' that the request and assessment process has been completed as required by the Act, the co-ordinating medical practitioner may apply under section 47 for a voluntary assisted dying (self-administration) permit for the person.
3. On 9 February 2020 Dr Carr made an application for a self-administration permit in respect of the Patient in which he:
   1. confirmed he had completed the 'final review form' and reviewed the Section 41(1)(a) Forms;
   2. confirmed he understood that under section 87 of the VAD Act it is a criminal offence to falsify a form or record required to be made under the Act, that it is a criminal offence under section 88 of the VAD Act to knowingly make a false statement in a report or form that the person knows is false or misleading in a material particular, and that both of these offences carry a maximum penalty of 5 years imprisonment or 600 penalty units, or both in respect of a natural person; and
   3. confirmed that he understood that when the form was submitted, the information would be provided to the VADRB.
4. In making the application for a 'self-administration permit' (as defined in section 3 of the VAD Act), Dr Carr either:
   1. failed to review the Section 41(1)(a) Forms as required; or
   2. reviewed the Section 41(1)(a) Forms, but failed to identify the Incomplete Written Declaration.
5. On 10 February 2020, an officer of the Secretariat of the VADRB identified the Incomplete Written Declaration and communicated the same to Dr Carr. The officer said:

"We are process checking your case VAD161 and have noted the Witness declaration is not signed and dated by the patient.

Could you please arrange for the patient to sign and date this document before we can progress the case.

Once completed, please email it through to VADBoard@safercare.vic.gov.au as forms cannot be uploaded to the portal at this point." (the Email)

1. On 11 February 2020 Dr Carr conducted a further consultation with the Patient. The Patient signed the Incomplete Written Declaration and dated the document '06/02/20' (Non-Compliant Written Declaration).
   1. The witness signatures on the Non-Compliant Written Declaration were the same witness signatures on the Incomplete Written Declaration (and this was visible on the face of the document).
   2. The witnesses who signed the Incomplete Written Declaration did not attend the 11 February 2020 consultation and did not, in fact, witness the Patient's signature.
2. On 11 February 2020 at 12:31pm Dr Carr provided the Non-Compliant Written Declaration to the VADRB by email to an officer of the VADRB's Secretariat. In this email Dr Carr said:

1. On 11 February 2020 at 12:31pm an officer of the Secretariat of the VADRB advised Dr Carr by email as follows:

"Dear Nick, Thank you, we have attached this to the file now and can progress the case."

1. In the circumstances set out above, Dr Carr admits he was aware that although the date next to the patient's signature was 6 February 2020, the document was not in fact signed on 6 February 2020.
2. On 11 February 2020 the Secretary issued under section 49 of the VAD Act a voluntary assisted dying self-administration permit to Dr Carr in respect of the Patient.

1. the Non-Compliant Written Declaration was false and misleading in that it purported to have been signed by the Patient, 2 witnesses and Dr Carr on 6 February 2020 when it had not been signed by the Patient on that date;
2. the Non-Compliant Written Declaration was non-compliant with the VAD Act in that it was not signed by the Patient in the presence of 2 witnesses as required by section 34 and section 36 of the VAD Act; and
3. the Non-Compliant Written Declaration was not signed by the Patient in the presence of the 2 witnesses who signed the Incomplete Written Declaration.

1. The Medical Board of Australia, 'Good Medical Practice: A Code of Conduct for Doctors in Australia' (March 2014), as in force in February 2020, relevantly states that good medical practice involves:
   1. being honest and not misleading when writing reports and certificates, and only signing documents you believe to be accurate (clause 8.8.1); and
   2. taking reasonable steps to verify the content before you sign a report or certificate, and not omitting relevant information deliberately (clause 8.8.2).

1. On 31 March 2022 the Applicant filed and served the Notice of Allegations (Notice) which sets out the Allegation made in respect of the Respondent's conduct. Dr Carr admits that:

In his role as co-ordinating medical practitioner for the Patient under the VAD Act, he:

1. provided a 'written declaration' to the VADRB on 11 February 2020 which was false and misleading and non-compliant with the VAD Act;

B. by reason of the conduct at A:

a) A 'final review' form that was submitted to the VADRB under section 41 of the VAD Act, in which Dr Carr certified that the request and assessment process in respect of the Patient had been completed as required by the VAD Act (Final Review Certification) became[6] false and misleading (as the request and assessment process in respect of the Patient had not been completed as required by the VAD Act).

b) A voluntary assisted dying self-administration permit application for the Patient under Section 47 of the VAD Act (the Permit application); in which Dr Carr confirmed he had reviewed the Section 41(1)(a) Forms (which included the 'written declaration') became false and misleading because:

1. Dr Carr ought to have known that the 'written declaration' was false and misleading; and
2. Dr Carr ought to have known the Final Review Certification was false and misleading; and
3. Dr Carr ought to have known that the 'written declaration', Final Review Certification, and Permit application would be relied upon by the Secretary of the Department of Health and Human Services when deciding whether to grant the voluntary assisted dying self-administration permit.

F. Joint submission on characterisation

1. The parties jointly submit that the Allegation admitted at Section F constitutes professional misconduct as defined in paragraph (a) of the definition of professional misconduct in Section 5 of the National Law.

1. The parties jointly submit that the appropriate determination in this matter is that Dr Carr be:
   1. reprimanded; and
   2. ordered to pay a fine in the amount of $12,000.

1. We are satisfied as to the relevant facts set out in the Agreed Statement. These are consistent with the documents provided to us.

The importance of strict compliance with VAD Act requirements

1. Victoria was the first state to enact VAD legislation. The debate and discussion leading to its enactment reflected the magnitude and seriousness of the moral and ethical issues involved. A great deal of thought and care was devoted to finding a proper balance between, on the one hand, respecting the rights of persons who wish to have some control over the manner of their death, and on the other, ensuring the patient has a full understanding of the process, and safeguarding against coercion.
2. The VAD Act imposes strict rules, for both patient eligibility, and as to the process for participating in the VAD.
3. Under s 9, as noted above, a person must be diagnosed with a disease, illness or medical condition that is incurable, advanced and progressive, and will cause death within no more than six months. Additionally, it must be causing suffering which cannot be relieved in a manner the person considers tolerable.
4. The VAD Act also, amongst other things, provides for what is in effect a second opinion by another medical practitioner, in addition to the initial assessment by the coordinating medical practitioner, and strict prescriptions as to matters of timing, suitability or eligibility of persons involved, and the handling and storage of drugs used for VAD. Criminal penalties apply for breaches of specified provisions. The patient has the opportunity to withdraw from the VAD process at any time.
5. Compliance with all these requirements is vital, not only to protect the rights of patients, but also to ensure that public confidence in the VAD process is not eroded.
6. Medical practitioners have a key role as gatekeepers. They are required to undergo prescribed training before they take on a role under the VAD Act. They have an obligation to ensure that the processes for which they are responsible under the Act are carried out to the letter. Obviously, assisting a person who wishes to bring about their own death under VAD is one of the most solemn and consequential tasks that a doctor may be called upon to undertake.
7. Accordingly, the task of completing documentation for a VAD process carries the highest level of professional responsibility.
8. Medical practitioners are required to complete a large volume of 'paperwork' in their daily work (whether on paper, or online). This includes paperwork to satisfy various regulatory and government requirements. Paperwork completed on a daily basis is often done under pressure of time, with other matters competing for the doctor's attention, and in circumstances where, if a mistake is made, it may or may not have serious consequences, or may be picked up down the line.
9. But completion of VAD documentation requires a different mindset. VAD documentation has an important legal aspect, as well as a medical one. The practitioner needs to be fully focussed on the completion of the documentation, to the exclusion of other distractions.
10. The practitioner (and the two witnesses, who the legislation requires be present)[7] are given solemn responsibilities to ensure that the patient is making their request voluntarily, and with a full understanding of the implications. The Act requires that they observe the patient actually signing their name.
11. While there are other safeguards, such as the responsibilities placed on witnesses, and review by the VADRB, it is the co-ordinating medical practitioner who has the key responsibility. One aspect of this is that medical practitioners are subject to professional disciplinary regulation.
12. The findings and determinations jointly proposed by the parties in this case reflect the unique nature of the medical practitioner's responsibilities in completing the VAD documentation, and in coordinating the process.

1. The completion of false declarations by Dr Carr was not deliberate. Although Dr Carr had been involved in at least six VAD cases before the one the subject of the present proceeding, it appears that the patient was quite talkative, and somehow (inexplicably, in hindsight) Dr Carr was distracted, and omitted to ensure that although the patient had written their name and address on the 'written declaration', the actual signature and date boxes were not completed.[8]
2. Further, on its face, the email from an officer of the VADRB could be interpreted as requesting that Dr Carr simply have the patient insert his signature in the box on page 2 of the written declaration. It certainly did not prompt him that the process of assembling the two witnesses together with himself and the patient (and also the patient's support person) and filling out the whole form all over again, should be undertaken.
3. Dr Carr properly acknowledged that despite these matters, it was his responsibility to ensure that the signing process was conducted properly.
4. In its letter to Dr Carr of 27 July 2020 (sent at the time the VADRB referred Dr Carr to the Board) said:

The signing of [the written declaration] in the presence of independent witnesses is a most significant part of the safety measures contained in this Act. It means that there is clear independent written proof, that can be relied upon by others, such as the Secretary and this Board, that the applicant signed the written declaration for a request to access voluntary assisted dying, and when he did so, it was a voluntary request - not coerced, and that he understood the nature and effect of that request. Failure to comply with the most basic principle of witnesses actually seeing him sign the document causes great concern among those who must rely upon the documents to make important and difficult decisions.[9]

1. It was common ground that there were no concerns about the patient's eligibility to participate in the VAD process. Had there been, the practitioner's conduct would be much higher order of seriousness.
2. Nor is there any allegation that Dr Carr stood to benefit from his error in any way.
3. On the other hand, as the VADRB stated in its referral letter to the Board, in the context of the need to preserve the integrity of the VAD process, this matter is 'too serious to be ignored'.
4. As agreed, Dr Carr's conduct was a breach of his obligations under The Medical Board of Australia, 'Good Medical Practice: A Code of Conduct for Doctors in Australia' (March 2014).[10] Any departure from the obligation not to provide misleading reports for certificates, or to take reasonable steps to verify content before signing any certificate can be serious. But as we have indicated, that obligation is of the utmost seriousness in relation to certification as part of the VAD process.
5. In these circumstances, we are satisfied that Dr Carr's conduct amounted to unprofessional conduct as defined in s 5 of the National Law. That is, it was of a lesser standard than that which might reasonably be expected by the public and his professional peers. Further, it was substantially below the standard reasonably expected of a registered medical practitioner of an equivalent level of training and experience. Here, we note that Dr Carr is a highly experienced medical practitioner, including in relation to end-of-life care. Accordingly, we find it comprised professional misconduct under (a) of the definition of that term in the National Law.

1. The Board referred to the summary of factors relevant to the making of determinations in Medical Board of Australia v Jansz.[11] The predominant purposes relevant here are to protect the public, and to maintain ethical and professional standards and the good reputation of the profession in the eyes of the public. In this case, a key consideration in this regard is public confidence in the operation of the VAD regime, in which doctors play the pivotal role. Both general and specific deterrence are to be considered.
2. There is one relevant prior matter against Dr Carr. In February 2013, Dr Carr wrote a death certificate for an 83-year-old patient. This stated the cause of death as acute myocardial infarction. While this was a reasonable possibility, Carr was aware that the patient intended to take her own life at the time of her choosing. There was very strong evidence reported to Dr Carr by the practitioner who attended the patient at the time of death, that she had in fact taken her own life. Further, the patient had told Dr Carr in their last consultation that she was ready to die, and he was aware she had acquired a drug to bring this about.
3. Ten years earlier, the patient had asked Dr Carr whether, if she took her own life, it would be possible for him to write a death certificate which avoided any kind of fuss, such as an autopsy. He agreed that it should be possible for him to certify that she had died of a heart attack. This remained a tacit agreement between them for the next 10 years.
4. The patient's death became the subject of a coronal inquiry, including evidence provided by Dr Carr, and the finding was that she had taken her own life by taking pentobarbitone. Following publication of the coroner's report, Dr Carr self-notified to the Board. He said it was his personal decision to accede to his patient's request, as he felt it would dishonour her to do otherwise than complete the death certificate in accordance with her stated wishes.
5. On 19 December 2014, the Board decided to caution Dr Carr to ensure in his future medical reports and certificates are not misleading, in accordance with section 8.8 of Good Medical Practice: A Code of Conduct for Doctors Australia.
6. As agreed by the parties, this is a relevant prior matter, albeit 10 years ago, where Dr Carr was cautioned for providing formal certification, in relation to an end-of-life matter, which was false and misleading, in his capacity as a medical practitioner. This is an aggravating factor in considering determinations.
7. Concerning remorse, on the other hand, we accept without hesitation the statement by Dr Carr that he is 'incredibly upset' that he has lodged non-compliant VAD documentation. This was reinforced by the oral evidence which Dr Carr briefly gave in the hearing, apologising for his mistake.
8. In his interview with the Board, Dr Carr said:

I should perhaps preface this by saying I've been deeply involved with voluntary assisted dying from prior to the legislation beginning, involved in trying to help the political process. I've been deeply involved in voluntary assisted dying in Tasmania, talking to parliament there with New Zealand. I've worked with WA in their implementation protocol and I'm doing some work with Queensland. So, voluntary assisted dying is something which is something I take extremely seriously and feel very passionately about. It is it is one of the most emotive and crucial areas of work I've ever been involved in... But it's the first State to have ever had voluntary assisted dying legislation. So, we've - myself and everyone involved feels there's an extra onus of responsibility to get it right, which is one reason I feel so mortified that on this occasion I've got an aspect of it wrong.

1. Dr Carr has made early admissions, and cooperated fully throughout the VADRB and Board investigation processes.
2. He clearly understands the potential implications of any failure to comply with all the statutory processes prescribed by the VAD Act.
3. Dr Carr has now instituted a methodical process for signing of VAD forms in the proper sequence, so that such an error does not occur again. Additionally, he has arranged for his practice manager to review every VAD form for errors before being lodged on the VAD portal. It was said on behalf of Dr Carr, without demur from the Board, that this has been effective, and he has lodged compliant documentation in relation to 39 cases after the one the subject of this proceeding.
4. We received written statements from five personal referees. Two are from professional colleagues and two from persons who have acted as witnesses in relation to the VAD processes coordinated by Dr Carr. These attest to his compassion for patients, the care he takes in completing VAD documentation, and to ensuring the patient has made the decision of their own free will, that there is no coercion and that they fully understand the process and the choices available to them.
5. The manager of the voluntary assisted dying care navigator service in Victoria describes Dr Carr as providing an invaluable service in the VAD space. He is one of the few VAD trained doctors capable of managing complex cases, and also being willing to travel to see patients at home.
6. Dr Carr is a board member of the organisation Dying with Dignity Victoria. A colleague on that board said he displays moderation, reason and balance in consideration of VAD issues.
7. We heard that VAD work is time-intensive, and not well remunerated.
8. The parties urged us to accept the proposed determinations of a reprimand and a $12,000 fine.
9. Clearly, a reprimand is appropriate in this case. It is a formal statement of condemnation of Dr Carr's conduct (amounting to professional misconduct) in providing false and misleading declarations, albeit not deliberately, in this highly sensitive area. It will appear on the public register of medical practitioners.
10. Turning to the proposed fine, it was put that even though the amount suggested is reasonably high relative to those imposed in prior cases (albeit that some of these are some time ago) it is appropriate in this case. That said, we agree that there are no cases (that we are aware of, at least) which are relevantly similar to this one, for the purpose of consideration of proportionality or parity.
11. While Dr Carr's response to his lodging of the false declarations indicates clear remorse and insight, the fact of the prior caution being imposed for providing false certification entails that specific deterrence is of relevance here.
12. Of greater significance, however, is general deterrence. Again, it was put to us strongly by both parties, including, if anything, more forcefully by Dr Carr, that $12,000 is the appropriate amount. His submission to the Tribunal stated that:

...he is anxious that the outcome in this case support, rather than undermine, the importance of strict compliance. In order to maintain public confidence, and therefore public and political support, for the VAD scheme in Victoria.

1. This recognises the seriousness of the conduct here. After all, the written declaration that was not properly witnessed is arguably the most critical document in that process. It includes the statement_, 'I understand... I will be prescribed a voluntary assisted dying substance and I expect to die when I self administer or I am administered that substance '._
2. In our view, this is a case where it is particularly appropriate to give credence to the joint position urged on us by both parties. We note Dr Carr is knowledgeable about, and involved in, the regime created by the VAD Act. He is invested in ensuring its successful operation. His submission as to determinations rightly recognises the importance of sending an emphatic message that scrupulous compliance with the requirements of the VAD Act is essential.
3. In the circumstances, we determine, first, that a fine is an appropriate sanction, and second, that $12,000 is the appropriate amount.
4. We agree with the parties that this is not a case where further education is required.
5. Accordingly, we will order that Dr Carr is reprimanded, and that he is to pay fine of $12,000.

[1] A support person for the patient was also present.

[2] The National Law as applicable in Victoria is set out in a schedule to the Health Practitioner Regulation National Law (Victoria) Act 2009.

[3] [2015] HCA 46; (2015) 258 CLR 482 at [46]- [64].

[4] Secretary" means the Department Head (within the meaning of the Public Administration Act 2004 (Vic)) of the Department of Health and Human Services: section 5 of the VAD Act.

[5] On information later provided in the submissions on behalf of Dr Carr, it appears the number was in fact 6, but nothing turns on this.

[6] There was discussion in the hearing to the effect that the Final Review Certification was in fact false and misleading from the start, but nothing turns on this.

[7] We note that the two witnesses also did not notice that the signing error had occurred. So it appears their declarations were false also.

[8] It is noted that another form was completed on occasion, namely, the contact person appointment form, and that the patient did properly sign and date that form.

[10] Under s 41 of the National Law, that Code is admissible as evidence of what constitutes appropriate professional conduct for the medical profession.

[11] [2011] VCAT 1026 at 358 - 373.