Dr Koniuszko's background, training and current practice

1. Dr Koniuszko is a senior consultant ophthalmic surgeon having graduated from The University of Melbourne in 1968 and having subsequently trained at the Royal Victorian Eye and Ear Hospital. He is a registered medical practitioner with general and specialist registration, the specialty being ophthalmology.
2. After completing his residency at the Geelong Hospital, Dr Koniuszko served as a regimental medical officer in the Australian regular armed forces for three years. He was deployed to Singapore and provided medical support and treatment for wounded Australian soldiers who had fought in Vietnam and were returning to Australia. He attained the rank of Captain and then Major.
3. In 1976, Dr Koniuszko became a member of the Royal Australasian College of Surgeons (Ophthalmology) and entered private practice. For 17 years he worked at the Preston and Northcote Community Hospital teaching ophthalmology and ophthalmic surgery. At the time of the relevant events Dr Koniuszko worked only in private practice. In 2014, he retired from performing intraocular surgery and now refers such cases to colleagues. He continues to be engaged in full-time ophthalmic consultancy and performs minor surgery.
4. In his statement dated 2 February 2016, Dr Koniuszko set out background to his life and his involvement with various disadvantaged people. It is apparent that he has engaged in generous philanthropic work which has, from time to time, led to financial strain.
5. Dr Koniuszko sought to emphasise the fact that he has practised medicine since 1968 without incident and that he has attempted to do so honestly, responsibly and in the best interests of his patients. He noted that the allegations which are the subject of this proceeding all relate to medical treatment he has provided to a range of friends and family and that he continues to treat most of those patients and their family members for their ophthalmological conditions.
6. At the hearing, Dr Koniuszko told us that he intended to continue to practise in ophthalmology only and he had no immediate plans to retire.

The Drugs & Poisons Act and Dr Koniuszko's earlier non-compliance

1. The Drugs & Poisons Act and the Regulations govern the supply and administration of drugs of dependence in Victoria.
2. Relevantly, they provide that:

1. A medical practitioner prescribing a Schedule 8 poison for more than eight weeks must obtain a permit; 2. A medical practitioner prescribing a Schedule 8 poison must keep detailed records of the administration of any such Schedule 8 poison;

1. A medical practitioner who destroys a Schedule 8 poison must keep detailed records of such destruction; and

1. A medical practitioner who stores Schedule 8 poisons must keep those poisons in a locked storage facility and must ensure that facility remains locked and secured to prevent access by unauthorised persons.
2. In 2004 correspondence, the DPRG raised concerns with Dr Koniuszko about his compliance with record keeping requirements for Schedule 8 poisons under the Regulations. Dr Koniuszko acknowledged those concerns and stated that he would undertake to keep a formal register recording the use of Schedule 8 poisons. The DPRG wrote to Dr Koniuszko in July 2004 setting out his obligations relating to storage and record keeping for Schedule 8 poisons.
3. In January 2007, the DPRG wrote to Dr Koniuszko raising concerns about his prescribing of Schedule 8 poisons to a close family member (patient 4), without a permit and contrary to the former Medical Practitioners Board of Victoria's policy on personal relationships.
4. Dr Koniuszko responded by letter dated 17 January 2007 saying:
   • He was now aware that the prescribing of Schedule 8 poisons without a permit for a period of greater than 8 weeks for a specified patient was not permitted;
   • He understood the basis for the Policy of the Medical Practitioners Board that medical practitioners not prescribe drugs of dependence for family members, except in emergency situations;
   • He had ceased the administration of any morphine or pethidine to patient 4; and
   • He had researched the current views on the relevant modalities of the management of chronic-intractable pain, and concluded that the regimen he had employed did not accord with those current concepts. He therefore undertook to seek independent assistance from the appropriate specialities for ongoing management.
5. The DPRG wrote to Dr Koniuszko by letter of 30 January 2007 advising him that the information previously provided did not satisfy the requirements of the Regulations and enclosing extracts of the relevant Regulations relating to record keeping in relation to Schedule 8 poisons.

Prescribing and administering of Schedule 8 poisons

1. Between August 2007 and March 2012, Dr Koniuszko prescribed Schedule 8 poisons to seven of his long term patients, including a close family member, for the treatment of non-ophthalmological related pain conditions. The details of the prescribing are set out in the attachment to these reasons.
2. In all cases, the period of prescribing exceeded eight weeks and required a permit under the Drugs & Poisons Act. No permits were sought or otherwise obtained by Dr Koniuszko.
3. Dr Koniuszko's usual practise was to administer pethidine or morphine to the patients at their homes. He did not keep complete and accurate records of the administration. Further, Dr Koniuszko did not keep any records detailing the nature of the assessments and/or examinations that were undertaken prior to prescribing and administering pethidine or morphine.
4. Dr Koniuszko did not inform the patients' treating general practitioners that he was prescribing pain relief to them, including that he was prescribing Schedule 8 poisons.
5. In his evidence before the tribunal, Dr Koniuszko emphasised his sense of responsibility to assist his patients. He explained that he was compelled by his sense of compassion to assist them when they sought help with pain and other conditions. They often called him after hours, including in the middle of the night. Dr Koniuszko said they could not get a locum to attend. He said that he thought he could handle the issue and that it was not out of control. Dr Koniuszko noted that, by the grace of God, no one had been harmed. He understood that the manner of his prescribing and administering of Schedule 8 poisons was a serious omission.
6. Dr Koniuszko was asked by the tribunal whether his patients had pressured him to prescribe and administer the Schedule 8 poisons. He stated that no pressure came from the patients but rather he put pressure on himself. He described himself as compelled to help and said he was his own worst enemy.
7. When asked by the tribunal how it was that, despite the earlier contact from the DPRG, he had continued to fail to comply with the Drugs & Poisons Act and Regulations, Dr Koniuszko said he knew the laws applied and that he should comply but that 'one day slipped into another'. He said it was an omission rather than a deliberate act. He understood that the regime was designed to protect people. He denied the proposition that he thought compliance with the law was not all that important - he knew it was important but the non-compliance 'just happened'.

1. Dr Koniuszko stored Schedule 8 poisons in an in-ground safe at his home, which was located next door to his medical practice. The safe was accessible by him and a person who was not authorised by the Drugs & Poisons Act and Regulations to access those poisons.

Treatment outside area of expertise and competence

1. In addition to the prescription and administration of Schedule 8 poisons, Dr Koniuszko provided medical treatment to each of the seven patients as detailed in the attachment to these reasons and to patient 8 (another close family member), for non-ophthalmological conditions between 17 August 2007 and March 2012.
2. According to the undisputed independent opinion of Dr Michael Steiner,[1] in each case the patients should have been referred to appropriate specialists for management of their non-ophthalmological conditions.
3. In his evidence before the tribunal, Dr Koniuszko referred to his 30 years of experience as a medical practitioner. He said he was aware of general practice and was often referred patients for diagnosis who did not have ophthalmological conditions. Despite that, he often provided a diagnosis and in so doing assisted their treating general practitioners. In the context of explaining how he tried to help people, Dr Koniuszko referred to being a 'fighter' and having fought battles in his life. He said he was aware of the medical status of those he treated with Schedule 8 poisons and did not administer them blindly.

1. Dr Koniuszko provided ongoing treatment to family members over a long period of time, in circumstances where that treatment was avoidable. The treatment included the prescription of pethidine to patient 4 and various medications to patient 8. Dr Koniuszko also referred patient 8 to a number of medical specialists.
2. Although in 2007 Dr Koniuszko undertook to cease treating patient 4, he continued to do so. When asked by the tribunal to explain why, he said that he did not intend to continue but kept thinking that 'tomorrow would be better'.

1. On 3 December 2012, Dr Koniuszko pleaded guilty, at the Broadmeadows Magistrates Court, to nine rolled-up charges under the Regulations. The charges represented a total of 75 breaches of the Regulations relating to failures to comply with record keeping and storage requirements. Dr Koniuszko was fined $4,500 without conviction and was required to pay costs of $7,900.

1. As described above, in August 2012, the Board imposed conditions on Dr Koniuszko. Those conditions were:
   1. Dr Koniuszko was not permitted to prescribe or administer Schedule 8 poisons, benzodiazepines, Imovane, Stilnox and Unisom sleep gel;
   2. Dr Koniuszko was to limit his practice to treating patients' ophthalmological conditions only;
   3. Dr Koniuszko was to cease treating close family members; and
   4. Dr Koniuszko was required to provide a monthly statutory declaration declaring that he had complied with the conditions.
2. The Board's counsel, Ms Ellyard, stated that it was unaware of any non-compliance with the conditions. Dr Koniuszko confirmed to the tribunal that he had supplied the required monthly statutory declarations.

1. As noted earlier, because of the period of time over which the conduct took place, we are required to consider both the HPR Act and the National Law. The HPR Act applied to the conduct which occurred between 17 August 2007 and 30 June 2010 and the National Law applied to the conduct during the period 1 July 2010 and March 2012.
2. Formerly, regulation 30 of the Health Practitioner Regulation National Law (HPR Regulations) applied in specified circumstances. Relevant here, regulation 30 said:

(a) The National Agency receives a notification about a registered health practitioner...; and

(b) The subject matter of the notification happened while the practitioner ... was registered in a health profession under a corresponding prior Act.

(2) Proceedings may be taken under Part 8 of the Law in relation to the registered health practitioner's... behaviour while registered under the corresponding prior Act as if the person were registered under the Law by the National Board established for the health profession.

(3) However, subclause (2) applies only to the extent -

(a) A notification about the registered health practitioner's... behaviour could have been made under the corresponding prior Act; and

(b) Proceedings of that type could have been taken under the corresponding prior Act.

1. Regulation 30 was a savings and transitional provision which expired on 30 June 2015. It applied to Dr Koniuszko's behaviour between 17 August 2007 and March 2012 and at all relevant times Dr Koniuszko was registered either under the HPR Act or the National Law. The HPR Act falls within the meaning of the term 'corresponding prior Act' for the purposes of regulation 30(2).[2] As to the conduct engaged in before 30 June 2010, there was power to conduct an investigation and hearing under the HPR Act into Dr Koniuszko's alleged conduct.[3]
2. In Dental Board of Australia v Abdullah,[4] the tribunal determined that the matter before it, which also traversed the two Acts, could be dealt with as if regulation 30 had not expired given that the notification of the relevant behaviour, the investigation of that behaviour and the decision to refer the matter to the tribunal was made prior to 30 June 2015.
3. In this case, the notification about Dr Koniuszko's behaviour was made on 9 March 2012. Conditions were imposed on his registration on 9 August 2012. The Board investigated his behaviour and, on 6 March 2014, decided to refer the matter to the tribunal. While the referral did not occur until 11 September 2015, the other events occurred before regulation 30 expired on 30 June 2015. In these circumstances, we respectfully adopt the same approach as was applied in Abdullah.

1. The Board alleged that Dr Koniuszko engaged in professional misconduct and/or unprofessional conduct in respect to Dr Koniuszko's:
   1. Prescribing of Schedule 8 poisons, his record keeping in respect to Schedule 8 poisons and the storage of Schedule 8 poisons;
   2. Failure to maintain clear and accurate medical records for patients to whom he provided non-ophthalmological treatment;
   3. Failure to refer patients to an appropriately qualified medical practitioner when it was appropriate to do so;
   4. Provision of ongoing medical care to close family members including by prescribing drugs of addiction in circumstances where that was avoidable and contrary to relevant codes of conduct; and
   5. Failure to facilitate the central coordinating role of general practitioner in that he did not communicate to them relevant information about his treatment of non-ophthalmological conditions.
2. Section 3 of the HPR Act defined 'professional misconduct' as:

(a) unprofessional conduct of a health practitioner, where the conduct involves a substantial or consistent failure to reach or maintain a reasonable standard of competence and diligence; and

(b) conduct that violates or falls short of, to a substantial degree, the standard of professional conduct observed by members of the profession of good repute or competency; and

(c) conduct of a health practitioner, whether occurring in connection with the practice of the health practitioner's health profession or occurring otherwise than in connection with the practice of a health profession, that would, if established, justify a finding that the practitioner is not of good character or is otherwise not a fit and proper person to engage in the practice of that health profession;

1. Section 5 of the National Law says 'professional misconduct', in the context of a registered medical practitioner, includes:
   • (a) unprofessional conduct by the practitioner that amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and
   • (b) more than one instance of unprofessional conduct that, when considered together, amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and
   • (c) conduct of the practitioner, whether occurring in connection with the practice of the health practitioner's profession or not, that is inconsistent with the practitioner being a fit and proper person to hold registration in the profession.
2. While the wording of the two definitions is different the meanings are similar and focus on conduct that is substantially below what would be reasonably expected from a registered health practitioner of an equivalent level of training or experience. The inclusion of the defined term 'unprofessional conduct' in the definitions and the use of the phrases 'substantial or consistent failure' and 'substantially below' confirms that professional misconduct refers to conduct which may be regarded as more serious than unprofessional conduct.
3. The term 'unprofessional misconduct' is defined in each Act. While particular classes of conduct are included in the definitions, in broad terms it concerns conduct that is of a lesser standard than that which might reasonably be expected of the health practitioner by the public or the practitioner's professional peers having regard to the practitioner's training and experience and the conduct of a reasonably competent practitioner.
4. The tribunal has power to make findings about conduct under section 77(1) of the HPR Act and section 196(1)(b) of the National Law.

1. Having regard to the content of the agreed statement and the other material before us, including Dr Koniuszko's admissions, we were satisfied that Dr Koniuszko engaged in the conduct set out in the notice of allegations as summarised in paragraph 44 above.
2. We are satisfied that, to the extent that the meaning of 'professional misconduct' relies upon the meaning of 'unprofessional conduct', Dr Koniuszko engaged in unprofessional conduct. That is because we have no difficulty finding that a failure to comply with the requirements of the Drugs & Poisons Act and the Regulations is conduct of a lesser standard than that which might reasonably be expected of a health practitioner by the public and a practitioner's professional peers. We also have no difficulty finding that poor record keeping, a failure to inform the patients' treating general practitioners about their conditions and the treatment being provided and a failure to refer for specialist treatment amounts to unprofessional conduct.
3. Further, we are satisfied that, Dr Koniuszko's conduct amounted to professional misconduct under the Act. In reaching that conclusion, we have had regard to the words of paragraph (a) of the HPR Act definition and paragraphs (a) and (b) of the National Law definition.
4. In respect of allegation 1, it is incumbent on all medical practitioners to know and comply with the law as it relates to their professional practice. The requirements of the Drugs & Poisons Act and Regulations were known to Dr Koniuszko, particularly after he was contacted by the DPRG in 2004 and 2007. Despite the intervention of the DPRG he continued to fail to comply over a period of around five years. That failure falls within the definition of professional misconduct under both Acts.
5. In respect of allegation 2, the obligation to make and maintain clear and accurate medical records is well known and its purpose is self-evident - medical records show the examination conducted and assessment made by the treating practitioner and set out any planned treatment. Medical records are also important because they may need to be relied on by other practitioners taking up the care of the patient. Dr Koniuszko's repeated failures to maintain clear and accurate records, in respect of his non-ophthalmological treatment of patients, including the prescription and administration of Schedule 8 poisons amounts to professional misconduct.
6. In respect of allegation 3, we note and give weight to the opinion of Dr Steiner. While we accept that as a trained medical practitioner Dr Koniuszko was theoretically capable of treating patients in respect of a range of health conditions, as a specialist ophthalmologist it is unlikely that his experience would have been up to date in respect of conditions outside his speciality. The comments he made to the DPRG in 2007 about learning about pain management are particularly instructive: Dr Koniuszko seemed to acknowledge then that his knowledge was out of date. Despite that realisation, he did not refer his patients and rather continued to treat pain and related conditions himself. Related to this allegation, allegation 5 concerns a failure to inform and work with the patients' treating general practitioners. Again, by not communicating with other medical practitioners, Dr Koniuszko failed to identify the limits of his experience and ensure that the treatment he was providing was appropriate within the totality of his patients' medical conditions and other treatments.
7. As for allegation 4, in 2007 Dr Koniuszko gave the DPRG an undertaking to cease treating one close family member. He not only continued to treat that family member, including by prescribing drugs of addiction, he commenced and continued to treat a second close family member. Having regard to Dr Koniuszko's own undertaking and the various guidelines and codes which have been in place since 2007 and which have, in consistent terms, addressed the inadvisability of such a practice,[5] we are satisfied that Dr Koniuszko engaged in professional misconduct.
8. Accordingly, consistent with the parties' joint submissions on findings, we find under section 77(1) of the HPR Act and section 196(1)(b) of the National Law as applicable that:
   1. Between on or around 17 August 2007 and 30 November 2011, Dr Koniuszko engaged in professional misconduct in that he failed to comply with the Drugs & Poisons Act and/or the Regulations which govern the supply and administration of drugs of dependence in Victoria in that he:
      • 1.1 Prescribed Schedule 8 poisons without a valid permit;
      • 1.2 Failed to keep adequate records in relation to the administration of Schedule 8 poisons;
      • 1.3 Failed to keep adequate records in relation to the destruction of Schedule 8 poisons; and
      • 1.4 Failed to take all reasonable steps to ensure that Schedule 8 poisons were stored in a way that prevented access by unauthorised persons.
   2. Between on or around 17 August 2007 and in or around March 2012, Dr Koniuszko engaged in professional misconduct in that he failed to maintain clear and accurate medical records in respect of patients to whom he provided treatment for non-ophthalmological conditions.
   3. Between on or around 17 August 2007 and in or around March 2012, Dr Koniuszko engaged in professional misconduct in that he failed to refer patients to an appropriately qualified specialist when it was appropriate to do so.
   4. Between October 2008 and March 2012, Dr Koniuszko engaged in professional misconduct in that he provided ongoing medical care to two close family members, including the prescription of drugs of addiction, in circumstances where this was avoidable, contrary to the relevant and applicable codes of conduct for registered medical practitioners.
   5. Between on or around 17 August 2007 and in or around March 2012, Dr Koniuszko engaged in professional misconduct in that he failed to facilitate the central coordinating role of a general practitioner in that he did not communicate relevant information about treatment of non-ophthalmological conditions he provided to patients to their general practitioners.

1. Having found that Dr Koniuszko engaged in professional misconduct, we must consider what determinations to make under section 77(4) of the HPR Act in respect of Dr Koniuszko's conduct between 17 August 2007 and 30 June 2010 and what decisions to make under section 196(2) of the National Law in relation to Dr Koniuszko's conduct between 1 July 2010 and March 2012.
2. Those provisions grant the tribunal the power to make one or more of a range of determinations/decisions. The available options include cautioning or reprimanding the practitioner, imposing conditions on the practitioner's registration, requiring payment of a fine, suspension of the practitioner's registration or cancellation of registration.
3. The parties have jointly submitted that the tribunal should order as follows:
   1. Dr Koniuszko be reprimanded (section 77(4)(c) of the HPR Act and section 196(2)(a) of the National Law); and
   2. Conditions be imposed on Dr Koniuszko's registration (section 77(4)(e) of the HPR Act and section 196(2)(b) of the National Law) as follows:
      • 2.1 Dr Koniuszko not be permitted to prescribe Schedule 8 Poisons, benzodiazepines, Imovane, Stilnox and Unisom sleep gel;
      • 2.2 Dr Koniuszko not be permitted to administer or possess Schedule 8 poisons, benzodiazepines, Imovane, Stilnox and Unisom sleep gel except if prescribed for him by his own treating doctor;
      • 2.3 Dr Koniuszko to limit his practice to treat patients' ophthalmological conditions only;
      • 2.4 Dr Koniuszko not be permitted to provide any medical treatment to family members; and
      • 2.5 Dr Koniuszko to provide a monthly statutory declaration addressed to the Compliance Manager, Australian Health Practitioner Regulation Agency (AHPRA) by the fourth day of every month declaring that he has complied with the conditions listed above in the preceding month.
4. Section 196(3) of the National Law requires that, if a condition is imposed on a practitioner's registration, a review period must be set. The parties agreed on a review period of five years.
5. It is well established that the primary objectives of disciplinary proceedings are the protection of the public, maintenance of professional standards, and general and specific deterrence. Determinations are not intended to have a punitive effect.[6] The likelihood of repetition is central to the imposition of a determination.[7]
6. A reprimand is not a trivial determination. For a professional person it has the potential for serious adverse implications.[8] It tells the public, patients and other practitioners that the standards expected of a practitioner have not been met and that the practitioner has been censured. The imposition of conditions on a practitioners' registration is also a serious matter. Conditions are imposed with the objective of allowing the practitioner to continue to practise but ensuring that is done in a manner which protects the public. While there is no automatic correlation between a finding of professional misconduct and recourse to suspension or cancellation, those decisions are often open to the tribunal because, inevitably, the conduct in issue is of a more serious nature.
7. Dr Koniuszko produced to the tribunal letters of recommendation from a number of the patients referred to in this proceeding. We have paid little regard to those as they do not demonstrate the authors have an understanding of the significance of Dr Koniuszko's professional conduct as it arises in these proceedings. While it is pleasing they seem to be in good health and regard Dr Koniuszko as a friend, in general terms it is inappropriate for health practitioners to seek and make use of recommendations from patients whose treatment has been the subject of the tribunal's consideration.
8. In this case, we were concerned that Dr Koniuszko continued to breach the requirements of the Drugs & Poisons Act and Regulations and accepted standards in relation to the treatment of close family members despite having given undertakings to the DPRG not to do so in 2007. Having heard from Dr Koniuszko, we remain concerned that he still has not explained those actions in a way that shows he regards compliance with the law and good practice as of equal, if not greater, significance as his subjective assessment of the needs of his patients in areas beyond his specialty. His evidence that one day ran into another and that he kept hoping his close family members would improve and no longer need his treatment, revealed little insight on the part of Dr Koniuszko and a lack of understanding about his professional obligations.
9. However, we have taken account of the approximately four years' that have elapsed since those breaches were first referred to the Board (March 2012) and now. In August 2012, the Board imposed conditions which were almost identical to those proposed by the parties. We understand that Dr Koniuszko has complied with the conditions to date. In doing so he has demonstrated that the risk of similar conduct, including any consequent risk to the public, is minimal.
10. The review period of five years is lengthy. We are satisfied that the concerns we have described above are addressed by that period and the nearly four years during which the conditions have already applied. The review period of five years from the date of our order means that the status quo will continue to apply and that the conditions cannot be changed or removed without the matter first being considered and decided upon by the Board.[9]
11. We have also taken account of the fact that the patients involved had a close personal relationship with Dr Koniuszko and those relationships were an essential component of his conduct. The acts of professional misconduct did not extend to all patients he treated as an ophthalmologist and we emphasise that Dr Koniuszko's professional practice as an ophthalmologist has never been in issue.
12. The above matters address protection of the public and specific deterrence.
13. We are satisfied that the findings of professional misconduct, the imposition of a reprimand and the lengthy period over which the conditions have and will continue to apply, make it plain to other medical practitioners and the public that Dr Koniuszko's conduct fell outside the standards of the professions and was unacceptable. Those matters also stand as a deterrent to other practitioners.
14. In those circumstances, we are satisfied that a reprimand and the imposition of ongoing conditions for five years are appropriate determinations/decisions under the relevant Acts. We will so order.

Schedule 8 drugs prescribed for in excess of eight weeks

43 prescriptions for pethidine between 17 August 2007 and 30 November 2011

23 prescriptions for pethidine between 31 January 2010 and 17 November 2011

54 prescriptions for pethidine between 1 October 2010 and 20 November 2011

27 prescriptions for pethidine between 30 May 2008 and 26 September 2011

19 prescriptions for pethidine between 15 November 2010 and 26 October 2011

54 prescriptions for pethidine between 10 October 2008 and 29 October 2011

4 prescriptions for morphine between 11 February 2009 and 25 June 2008 and

38 prescriptions for pethidine between 24 July 2008 and 14 August 2011

[1] Exhibit FS-72 to Fiona Sinnamon's witness statement dated 13 October 2015.

[2] See National Law, section 5 definitions.

[3] See sections 42, 45, 76 and 77 of the HPR Act.

[4] [2016] VCAT 19 at paragraphs 9 to 13.

[5] Good Medical Practice - Guidelines on professional conduct - published by the Medical Practitioners' Board of Victoria and operative between December 2006 and 1 July 2009; the Australian Medical Council's Good Medical Practice - A Code of Conduct for Doctors in Australia - published by the Medical Practitioners' Board of Victoria and operative between 1 July 2009 and 1 July 2010; Good Medical Practice - A Code of Conduct for Doctors in Australia - published by the Medical Board of Australia and operative between 1 July 2010 and 16 March 2014; Good Medical Practice - A Code of Conduct for Doctors in Australia - published by the Medical Board of Australia and operative since 16 March 2014; and policy document titled Doctors Treating Members of Their Family - published by the Medical Practitioners' Board of Victoria and operative from 15 July 2004 to at least 28 October 2009.

[6] Ha v Pharmacy Board of Victoria [2002] VSC 322.

1. [7] Health Care Complaints Commission v Litchfield [1997] NSWSC 297; (1997) 41 NSWLR 630 at 637.

[8] Peeke v Medical Board of Victoria, Unreported, Supreme Court of Victoria, 19 January 1993 at p 6.

[9] See sections 125, 126 and 127 of the National Law.