Most of the allegations were eventually not disputed, but the Tribunal held a hearing to determine outstanding matters of dispute. The Tribunal found that professional misconduct was established and published reasons for that decision.

A further hearing was then conducted to consider the appropriate disciplinary action to take in respect of the findings made. The parties submitted a joint recommendation as to the sanctions that should be imposed in light of the Tribunal's factual findings.

• The respondent's breaches of the previous conditions on her registration constitute professional misconduct.
• The evidence establishes the respondent's very poor clinical performance and highly irresponsible prescribing of a range of medications.
• The respondent's prescribing of performance and image enhancing medications, where there was no proper therapeutic purpose for it, constituted professional misconduct.
• Failure to obtain informed consent for the type of treatments the respondent was providing and recommending is a very serious matter.
• The respondent's conduct is respect of boundary breaches amounts to professional misconduct.
• The Tribunal is not satisfied that the issues underlying the professional misconduct have been adequately addressed. Should the respondent be permitted to return to practice, there would remain an unacceptable risk of further difficulties arising from her personality characteristics and her mental health in the absence of further treatment. The respondent has not demonstrated that these matters have been adequately addressed or that she is a fit and proper person to be registered at the present time.
• The parties jointly proposed that the respondent should be reprimanded, her registration cancelled and that she be disqualified from applying for re-registration for two years. The Tribunal considers such sanctions to be appropriate.

Health Practitioner - Complaint by the Medical Board of Australia - Professional Misconduct - Breach of conditions imposed, Inappropriate prescribing, Boundary Violations - Reprimand, Cancellation of registration, disqualified from applying for registration for 2 years

Health Practitioner Regulation National Law (South Australia) Act 2010 s 196

Neat Holdings v Karajan Holdings Pty Ltd [1992] HCA 66; (1992) 67 ALJR 170

Rajagopalan v Medical Board of South Australia [1997] SASC 6363; [1998] SASC 7142

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

Prakash v Health Care Complaints Commission [2006] NSWCA 153

Health Care Complaints Commission v Reid [2018] NSWCATOD 162

Health Care Complaints Commission v Epstein [2015] NSWCATOD 21

Medical Board of Australia v Singh [2017] WASAT 33

Singh v Medical Board of Australia [2018] WASCA 125

Medical Board of Australia v Hadges [2018] SAHPT 6

Medical Board of Australia v Heidemann [2020] SACAT 106

Medical Board of Australia v Tunbridge [2020] SACAT 34

Health Care Complaints Commission v Meneghetti [2020] NSWCATOD 39

Health Care Complaints Commission v Nemeth [2012] NSWMT 4

Health Care Complaints Commission v Gorondy-Novak [2011] NSWMT 3

Legal Practitioner Conduct Board v Ardalich [2005] 243 LSJS 145, [2005] SASC 478

Medical Board of Australia v Dapp [ 2008] QCA 44

The Tribunal has prohibited the publication of the name of, or any material tending to identify, any patient of the respondent referred to in the pleadings, evidence or submissions, save and except for the respondent's current partner, referred to as "Patient 44".

As to the respondent's current partner (Patient 44), the Tribunal has prohibited the publication of any information concerning him, other than what appears in the formal decisions and reasons of the Tribunal.

1. This matter concerns disciplinary proceedings against a medical practitioner.

2. The Medical Board of Australia (the Board) alleges that Dr Nijole Lloyd (the respondent) has behaved in a way that constitutes professional misconduct. In broad terms, it is alleged that the respondent

• Inappropriately prescribed or recommended medications and demonstrated poor clinical practices and skills.
• Failed to obtain informed consent to treatments
• Arranged unnecessary tests
• Acted in breach of conditions imposed on her registration by the Board
• Inappropriately provided medical services to a person with whom she was engaged in an intimate and sexual relationship, and
• Breached the "Good Medical Practice: A Code of conduct for Doctors in Australia 2014" (the Code).

3. The respondent was first registered as a medical practitioner on 1 January 1997.

4. A reflective writing document signed by the respondent on 30 September 2019 provides information about her personal background. That information is summarised in the Complainant's Closing Submissions (CCS) (at paragraph 5) in a way that is accepted as accurate by the respondent in the Respondent's Closing Submissions (RCS).[1] For the purposes of these Reasons, we have edited this summary in the interests of privacy and fairness. We have nonetheless had regard to the entire content of the respondent's reflective writing in coming to our decision. Our edited summary is as follows:

5.1. The respondent married in 1995, and subsequently had five children with her husband.

5.2. In 1997, she obtained her primary medical qualification form the University of Adelaide before beginning an intern year at the Modbury Hospital

5.3. In or about 1997, she undertook a 6-week elective in 'mind/body medicine during which she worked with two general practitioners (GPs) who she says:

... did not offer conventional medicine exclusively but rather encouraged positive psychology techniques for cancer patients, provided therapies such as acupuncture and meditation and whose prescriptions included the provision of vitamin and mineral supplements. These treatment modalities were offered alongside conventional treatments. This was my first exposure to a medical practice philosophy that I perceived was offering patients an holistic approach to their medical needs. It was very attractive to me.

... I considered there was no demarcation between conventional treatment modalities and treatments considered to be alternative or complimentary [CAM]. I developed a view that all treatments, regardless of their characterisation, should be available to patients as determined by their needs and wishes and that it was not a matter of exhausting conventional treatments before reverting to CAM. I also believed that it was not inconsistent with competent medical practice to offer patients supplements intended to maximise their wellbeing despite the absence of deficiencies as measured by pathology testing.

5.5. Between January 1998 and December 1999, she worked as an RMO at the Lyell McEwin Hospital and also completed a Diploma of Obstetrics and Gynaecology and a Diploma in Child Health at the Women's and Children's Hospital.

5.6. In January 2000, she began work as a GP registrar at Rhylyn Medical Services at Aldinga.

5.7. In 2001, she undertook a 12-month GP rotation at the Renmark Medical Centre where she cared for patients in the clinic and inpatients at the Renmark Hospital.

5.9. Between 2002 and 2005, she worked at two GP practices at the Handorf Medical Clinic and Hindmarsh Family Practice.

5.10. In 2004, she completed a prolotherapy (also known as 'proliferation therapy') course conducted by a GP she worked with during her intern year.

5.11. By 2004, she considered herself to be an 'Integrative General Practitioner' which she considered to be:

... a practitioner who offered both conventional and complementary medical services determined having regard to the holistic needs of any given patient

5.12. It was also her view that integrative practice met the:

... whole needs of a patient in a way superior to ordinary general practice

5.13. Between February 2004 and February 2009, she worked at the Centre for Health and Wellbeing at Norwood

5.14. In March 2009, she started her own general practice under the name 'The Wellness Oasis' at Payneham (WO Practice) which she operated until 2015

Working at the Centre for Health and Wellbeing at Norwood and subsequently starting my own practice at Payneham afforded me the opportunity to deploy the philosophy I believed in. There is no doubt that as my CAM experience increased, the patients I saw were people actively seeking CAM, most of whom had a conventional GP and many of whom were frustrated by the inability of their GP to provide them with holistic effective treatment.

5.16. In March 2010, she and her husband separated.

5.17. Matrimonial proceedings began in the Federal Circuit Court the same year leading to what she described as a 'six-year acrimonious court battle with [her ex-husband]'.

5.18. She commenced a 'concurrent personal and therapeutic relationship' with her current partner (Pt 44*) in 2010.

[*The indices to Volumes 3, 4, and 5 of exhibit C4 assign a Tab No (36 to 61) to each patient referred to in the complaint. The Tribunal proposes to refer to the patients in these Reasons by reference to that Tab No. The Tab No for the current partner is 44.]

5.19. In April 2015, the Complainant imposed conditions on her registration (2015 Conditions) which she admits she breached

5.20. On 21 June 2015, the WO Practice was destroyed in a fire the Police told her was deliberately lit (2015 Fire)

5.21. Between June 2015 and January 2016, she was unemployed

5.22. In January 2016, she joined Integrative Health Solutions (IHS), which was a practice that patients 'sought out for CAM'

5.23. She respected her colleagues at IHS and considered them to follow 'similar practice philosophies' to her

5.24. In November 2016, the Complainant imposed further conditions on her registration (2016 Conditions) which she says she did not breach

5.25. She continued to work at IHS until 31 August 2018 when she gave the Complainant an undertaking not to practice as a medical practitioner (2018 Undertaking). (Emphasis added by the Complainant)

5. The CCS also summarises in paragraphs 7-12 the course of these proceedings before the Tribunal. The respondent agrees[2] that the matters are appropriately summarised as follows:

7. On 30 August 2018, the Complainant filed a Complaint (Complaint) with the Tribunal alleging that the Respondent had:

7.1. provided care to 11 patients (Initial Patients) that was substantially below the standard reasonably expected of a medical practitioner, including by:

7.1.1. prescribing thyroid medications where the thyroid demonstrated normal function;

7.1.2. prescribing thyroid medications excessively;

7.1.3. prescribing medication in circumstances where evidence to support a therapeutic benefit was lacking;

7.1.4. failing to consider diagnostic possibilities while pursuing alternative approaches;

7.1.5. failing to effectively communicate with other practitioners involved in the patients' care to ensure their continuity of care;

7.1.6. failing to obtain patient's informed consent;

7.1.8. arranging for tests to be undertaken that were unnecessary and were otherwise overly diagnostic and overly interventional

7.2. breached conditions imposed by a Performance and Professional Standards Panel (PPS Panel) on 30 April 2015 (ie the 2015 Conditions)

7.3. breached the "Good Medical Practice: A Code of Conduct for Doctors in Australia March 2014" (Code).

8. On 12 September 2019, after discussions between the parties, the Respondent filed a 'Consolidated Pleading' (CP) containing further allegations about the Respondent:

8.1. providing care of the nature referred to at [7] above to 14 patients (Further Patients) in addition to the Initial Patients and providing other care that was substantially below the relevant standard by:

8.1.1. failing to assess patients and formulate a diagnosis appropriately

8.1.2. providing treatment to patients that put their health at potential risk

8.1.3. failing to refer patients for specialist endocrine advice

8.1.4. prescribing peptides and anabolic-androgenic steroids (AAS) for the purpose of body building and/or enhancement of physical appearance of performance rather than for a therapeutic purpose

8.1.5. prescribing human chorionic gonadotropin (HCG) for the purpose of weight loss

8.1.6. prescribing treatment not approved by the Therapeutic Goods Administration (TGA)

8.2. initiating thyroid hormone therapy (THT) and/or failing to obtain informed consent to THT in circumstances that breached the 2015 Conditions

8.3. 'breaching professional boundaries' and, as a consequence, the Code with respect to Pt 44 (her current partner) by commencing and maintaining personal, sexual and professional/clinical relationships with him.

9. On 11 November 2019, after further discussions between the parties, the Respondent filed an 'Amended Response' (AR) repeating the allegations in the Complaint and CP and adding further allegations to the effect that the Respondent provided care to Pt 38 that was substantially below the relevant standard by:

9.2. prescribing Progesterone, Sandrena, Testosterone, DHEA, T3 and T4

9.3. failing to record or maintain adequate records

9.5. not obtaining Pt 38's informed/written consent before initiating THT

9.6. instigating/maintaining THT in circumstances where Pt 38 had demonstrated generally normal thyroid function and normal thyroid antibodies

9.7. diagnosing hypothyroidism and treating Pt 38 with THT without any evidence or other clinical basis

9.8. unnecessarily/excessively prescribing thyroid hormones, T3 and T4

9.9. increasing the risk of Pt 38 having an adverse cardiovascular event

9.10. failing to monitor Pt 38's bone density while prescribing THT

9.11. failing to consider, and if necessary, cease or alter the THT Pt 38 was receiving after being informed that her sister had been diagnosed with breast cancer

9.12. failing to adequately liaise with other medical practitioners or make adequate records after being informed by Pt 38 that her nipples had changed colour after being on THT for approximately 12 months

9.13. inappropriately prescribing DHEA and topical testosterone

9.14. prescribing topical testosterone in a way that resulted in Pt 38 having excessive blood levels for testosterone in early to mid-2013

9.15. prescribing THT for Pt 38 in breach of the 2015 Conditions

9.16. breaching the Code by failing to maintain a high level of professional conduct and failing to maintain adequate records with respect to Pt 38.

10. The subject matter of the allegations made in the Complaint, the 2nd column of the CP and the 2nd column of the AR (collectively, Complaint Documents), are the matters referred to the Tribunal under s 193(1)(a)(i) of the National Law (Referred Matters).

11. On 29 November 2019, the Respondent filed a Further Amended Response (FAR) correcting some typographical errors in the AR and admitting most of the Referred Matters. However, the FAR also confirmed the Respondent was not (then) prepared to admit some of the Referred Matters (Disputed Matters).

12. On 8 January 2020, the Respondent served an amended version of her 'Submissions of Dr Nijole Lloyd for hearing before SACAT January 2020' dated 31 December 2019 (RS) admitting all of the Referred Matters in a general sense, but not admitting certain specific factual allegations. According to the RS, the Respondent (then) admitted:

12.1. prescribing thyroid medications where patients had normal thyroid function

12.3. prescribing medication where evidence to support a therapeutic benefit was lacking

12.4. failing to consider diagnostic possibilities while pursuing alternative approaches

12.5. failing to effectively communicate with other practitioners involved in: 'particular patient's [sic] care'

12.6. failing to assess patients and formulate diagnosis appropriately

12.7. providing treatment to patients that put their health at potential risk

12.8. failing to refer patients for specialist endocrine advice

12.9. failing to obtain consent from certain patients and/or periods of time

12.11. prescribing treatment not approved by the Therapeutic Goods Administration

12.13. arranging for tests to be undertaken by patients that were unnecessary in that they were over diagnostic and overly interventional

12.14. failing to maintain professional boundaries with respect to Pt 44

12.15. breaching the 2015 Conditions imposed by the PS Panel

12.17. that despite the findings made by the PS Panel which led to the 2015 Conditions, continuing to:

12.17.4. demonstrate a lack of insight and knowledge

12.17.5. fail to make substantive changes to her practice or upskill

6. At this stage, most of the detailed allegations against the respondent had been admitted.[3] The Tribunal was advised at a directions hearing on 24 December 2019 that the oral hearing would proceed in order to hear evidence concerning the remaining disputed matters, as well as evidence of a medical nature.

7. The hearing commenced on 14 January 2020 and proceeded over a period of six days during January and March 2020. Books of Documents, comprising over 3000 pages, were tendered together with many other documents. The parties agreed that the respondent should give her evidence-in-chief first. She did so over the first 3 hearing days (some 560 pages of transcript). On the fourth day evidence was heard from Professor Wittert, an expert called by the complainant. On day five, the respondent continued her evidence-in-chief and was then cross-examined. On the final day, evidence was taken from Ms Jane Tiggeman, a clinical psychologist. The matter was then adjourned part-heard until 7 May 2020.

8. In the course of giving her evidence-in-chief and cross-examination, the respondent had made further admissions concerning matters previously disputed. The parties agreed that they would provide to the Tribunal as an aid (as distinct from a formal pleading) a marked-up copy of the Further Amended Response (FAR), which would indicate what further matters had been admitted by the respondent during her evidence and any matters that the complainant now conceded had not been established on the evidence. The parties were also directed to file written submissions prior to the next hearing.

9. There were delays in the provision and correction of the transcript. Neither the marked-up document, nor the required submissions were filed in a timely way and the hearing planned for 7 May 2020 was therefore abandoned. It was agreed that the parties would instead proceed to file written submissions as to the alleged misconduct and its proper categorisation. The Tribunal would give a decision on these issues and then list the matter for a further hearing on sanction. The marked-up document, entitled "Further Amended Response Following Evidence" (but referred to in both submissions as "FFAR"), and the required submissions were eventually filed.

10. Paragraph 18 of the CCS summarises further admissions made in evidence by the respondent and confirmed in the FFAR. This is accepted by the respondent as an accurate summary of further matters admitted by the respondent.[4] The summary is as follows:

18. On 27 April 2020, the FFAR was filed confirming, most relevantly, that:

18.1. with respect to the alleged prescribing of AAS, peptides, thyroid treatments or other medications excessively, without a proper therapeutic basis, or in circumstances that put patients at potential risk, the Respondent:

18.1.1. now admits that, based on the information provided to her by [Pt 43], she 'should have' known he was seeking Primoteston for body building purposes (although she maintains she 'did not know he was a body builder' or 'know or perceive' he was seeking Primoteston for body building purposes in May 2013)

18.1.2. now admits that patient Pt 43's IGF-1 was elevated and that, while she maintains he was not taking human growth hormone (hGH) at the time she treated him to her knowledge, she 'should have considered whether he was taking hGH in light of his elevated IGF-1 level

18.1.3. now admits the prescription of Testosterone and DHEA to [Pt 56] was inappropriate in circumstances where there was no therapeutic indication illustrating why Testosterone or DHEA was required

18.1.4. now admits the prescribing of DHEA and topical testosterone to [Pt 38 was inappropriate as there was no clinical reason for prescribing this medication

18.1.5. now admits her prescription of AOD 9604 cream would have had no clinical benefit to [Pt 48] in respect of joint pain or soft tissue pain

18.1.6. now admits T3 was off-label and should not have been prescribed

18.1.7. no longer relies the information previously relied on to support the belief she claims to have held on 'reasonable grounds' that [Pt 61] would be assisted by THT other than:

18.1.7.1. her attendance at academic programs presented by the Australian Academy of Anti-Ageing Medicine and the Australasian College of Nutritional and Environmental Medicine which she claims was 'legitimised by the RACGP who allowed attendees to claim CPD points'

18.1.7.2. her reading of a text titled 'The Hormone Handbook', authored by Thierry Hertoghe, MD, published in May 2010 which the Respondent says she 'knows now was not peer reviewed and accepts that peer reviewed research and articles did not support such prescribing'

18.1.8. now admits that if she was concerned about [Pt 61]'s ATPO antibodies as claimed, she should have ordered an antiphospholipid test (ie before providing THT)

18.1.9. now admits she failed to recognise that [Pt 57] had normal thyroid function and negative antibodies before prescribing the NTE and other medications referred to at FFAR111/[269]

18.1.10 now admits there was no evidence or otherwise a clinical basis for diagnosing [Pt 38] as suffering from hypothyroidism and treating her with THT 18.1.11. now admits the prescribing of thyroid hormones, T3 and T4 to [Pt 38] was excessive in its dosage

18.2. with respect to the Disputed Matters involving alleged 'computer software errors', the Complainant accepts it would be open to the Tribunal to accept the Respondent's evidence and find that those Disputed Matters have not been made out to the requisite (Briginshaw) standard

18.3. the Respondent now admits all the Disputed Matters involving alleged failure to obtain consent except that, according to the FFAR, the Respondent maintains:

18.3.1. that [Pt 61] provided 'consent' on 26 October 2016

18.3.2. her non-admission about failing to obtain [Pt 48,s] informed consent prior to the application of the relevant treatments

18.3.3. her non-admission about failing to obtain [Pt 53's] informed consent.

18.4. with respect to the Disputed Matters involving alleged failures to take adequate steps to ensure patients were not prescribed peptides, AAS or other potential performance or image enhancing drugs (PIEDs) without a proper therapeutic basis, the Respondent admits the matters referred to at [18.1.1]-[18.1.2] above.

11. The RCS notes that there are 355 paragraphs in the complaint and that over 1000 assertions of fact made against the respondent. It is suggested that the respondent ultimately disputes only about 60 of those assertions. It is noted that the Complainant has not addressed all of these disputed matters in the CCS. Nonetheless, the respondent identifies, on our reckoning, 58 matters of dispute upon which she "requires" a determination from the Tribunal.[5] Submissions are made on each of these matters with reference to the detailed evidence heard and contained in the documentary materials.

12. In our view, a determination by the Tribunal of many of these matters (one way or the other) would be of no material significance to the central task and function of the Tribunal in these proceedings. It could not affect in any material way the proper categorisation of the respondent's conduct, the overall seriousness of that conduct, or any issue related to the appropriate sanctions.

13. We decline to individually address each and every one of the matters identified. Nor do we consider it necessary to determine all of the issues urged upon us by the complainant. In some areas, we will deal with issues more generally, rather than descend into detail. Where we have not made relevant findings in these Reasons, the issue concerned has not been determined against the respondent. There are, however, some disputed matters with which we will deal.

14. As to the standard of proof in these proceedings we refer to Neat Holdings v Karajan Holdings Pty Ltd [1992] HCA 66; (1992) 67 ALJR 170 per Mason, Brennan, Deane and Gaudron JJ at pages 170-171; Rajagopalan v MBSA [1997] SASC 6363 and [1998] SASC 7142 (Full Court); Briginshaw v Briginshaw [1938] HCA 34; (1938) 60 CLR 336 at 362-363. We note the seriousness of the allegations and the potential consequences for the respondent. Having regard to these matters, we are comfortably satisfied of our findings of fact.

15. We make findings of fact in accordance with the extensive admissions made by the respondent. Our further findings of fact will appear from these Reasons. Where we have found factual matters proved, we accept the expert evidence of Professor Wittert concerning those matters. His evidence is set out in four reports[6] and in his oral testimony.[7]

16. As a matter of background, it is important to note the circumstances in which conditions were placed on the respondent's registration in 2015. A notification had been made to AHPRA in September 2012 concerning the respondent's treatment of a 16-year-old female patient. It was asserted that the respondent had misdiagnosed hypothyroidism and prescribed thyroxine at dangerous levels. The patient had presented as an emergency at the Women's and Children's Hospital after experiencing an unconscious collapse, vomiting and dizziness.[8]

17. In response to the notification, the respondent admitted that she had inadvertently increased the dosage prescribed to the patient to "200mcg to be taken twice daily" when the intention was that it should be "200mcg to be taken daily". She acknowledged that the higher dose was excessively high and expressed regret that this error had caused the patient's hospitalisation.

18. The Board sought a report from Dr Jan Fairchild, a specialist Paediatric Endocrinologist, which was received on 3 February 2014. Quite apart from the medication error, the report[9] was highly critical of the respondent's overall treatment of the patient. Dr Fairchild opined that laboratory tests had excluded hypothyroidism and subclinical hypothyroidism as a cause for the patient's symptoms. The advice provided by the pathologist was not heeded by the respondent and the treatment given by the respondent was not indicated. Dual therapy with thyroxine and T3 (as provided by the respondent) was not evidence based or standard practice. A number of criticisms were made of the respondent's prescribing of thyroxine. The report was also critical of the respondent's treatment of the patient for "iron deficiency", "Vitamin D deficiency" and weight loss.

19. In a response sent to AHPRA,[10] the respondent challenged many of the views expressed by Dr Fairchild in her report and asserted that her treatment of the patient (apart from the medication error) was "therapeutically beneficial to her" and "consistent with competent professional practice".

20. The Board referred the matter to a Performance and Professional Standards Panel which conducted a hearing and delivered a decision on 30 April 2015.[11] We regard paragraph 64 of the CCS as providing a fair (but not exhaustive) summary of the Panel's findings and decision:

64. On 30 April 2015, the PPS Panel published its decision (PPSP Decision) finding, among other things, that the Respondent:

64.2. had escalated thyroxine medication to dangerous levels

64.3. had inappropriately administered an iron infusion for a minor iron deficiency

64.4. had inappropriately prescribed Pregnyl (aka 'HCG') for weight loss

64.5. had an overall pattern of investigation and interpretation that constituted practice that was overly diagnostic and overly interventional

64.6. had not demonstrated the necessary insight and knowledge to ensure that a similar course of conduct would not arise in the future

64.7. had exercised inadequate judgment and care with respect to communication with other treating practitioners, obtaining informed consent from patients and the initiation of treatment of hormone medications

64.8. failed to appreciate the implications of her actions on a broader scale, particularly with respect to coordinating care and the prescribing of off-label medications

64.9. had behaved in a manner that constitutes unsatisfactory professional performance

64.10. required substantive changes to her practice as well as up-skilling in the areas of practice that relevantly included:

64.10.1. obtaining informed consent from patients for off-label medications

64.10.2. appropriate initiation of treatment of hormone medications including, but not limited to, Pregnyl (aka HCG) and Thyroxine

64.10.3. appropriate documentation of pathology results

64.11. ought to be cautioned and subjected to the 2015 Conditions.

21. The conditions imposed on the respondent's registration on 30 April 2015 are set out at pages 263-264 of Exhibit C4. The Conditions restricted the respondent's right to provide thyroid hormone therapy by reference to published parameters. They provided for supervision and an audit of practice. As to the issue of consent, the Conditions provided that:

The practitioner will obtain written consent from all patients when prescribing off-label medications. Such written consent needs to include information that demonstrates the practitioner has explained to the patient that the term off-label means that it has not been approved by the Therapeutic Goods Administration and that there is a lack of evidence-base for the medication.

22. The respondent admits breaching the 2015 Conditions in relation to at least nine patients,[12] either by providing thyroid hormone treatment outside the allowed parameters and without required approval from her supervisor or by prescribing off-label medications without appropriate written consent. It is unnecessary to go through the details of each case, but one example will illustrate her approach at that point of time.

23. On 7 April 2016 and 3 August 2016, the respondent provided thyroid hormone therapy to Pt 61 despite demonstrably normal thyroid function tests and normal thyroid antibodies. There was no evidence of hypothyroidism. The treatment constituted a breach of the 2015 conditions as the patient's TSH fell outside of the allowable parameters. The respondent provided this treatment without obtaining informed consent.[13] A consent form signed on 26 October 2016 does not of course apply retrospectively, nor can it be regarded as effective consent if the advice given to the patient was deficient. The respondent conceded that she did not have a proper appreciation of the medical efficacy of the treatments at the relevant time.[14] We share the concerns of Professor Wittert about the inadequate and confusing nature of the consent forms used by the respondent and her colleagues during this period.[15]

24. The respondent claims that she believed at the time that such treatment was clinically appropriate due to opinions she had heard at seminars and her reading of a text. For reasons that were clearly explained by Professor Wittert, her sources of information were not authoritative or evidence-based and should not have been relied upon to form any such belief. The respondent's sources did not provide any reasonable basis for the treatment provided. The treatment was inappropriate. The report of Dr Fairchild and the findings of the Performance and Professional Standards Panel had made it clear that such treatment was inappropriate.

25. Nonetheless, the respondent chose to treat the patient based on her own views gleaned from these unauthoritative sources rather than to have regard to the expert views of Dr Fairchild or the findings and decision of the Performance and Professional Standards Panel. She made a conscious decision in this and other cases to provide the treatment in breach of the conditions of her registration.[16] She essentially ignored the findings and recommendations of the Performance and Professional Standards Panel.

26. When conditions are imposed on the registration of a practitioner, they must be scrupulously observed.[17] Deliberate breach of conditions is a very serious matter. The breaches in this matter clearly constitute professional misconduct.

Inappropriate Prescribing and Clinical Performance

27. Even if the conditions had not been in place, the respondent's prescribing was not justified and her clinical performance was sadly lacking.

28. When Professor Wittert provided his first report dated 5 July 2017, he set out in detail the deficiencies in the respondent's clinical practice and use of hormone therapy. He also offered substantial criticism of other aspects of the respondent's prescribing behaviour, and general clinical approach. Rather than be guided by the views of Professor Wittert, the respondent replied to AHPRA in a letter dated 22 August 2017,[18] taking issue with many of these views. She sought to defend her clinical performance.[19] Professor Wittert responded to this letter in his second report dated 28 September 2017.[20] On matters where there was a disagreement between Professor Wittert and the respondent as to the appropriateness of prescribing or the standard of the respondent's clinical practice, we accept the views of Professor Wittert.

29. In Professor Wittert's third report dated 20 August 2018,[21] he commented on the respondent's treatment of the 14 "further patients". He summarised his overall opinion as follows:

5.1 The performance of the practitioner, in terms of the assessment and management of patients falls well below the expected standard of a practitioner of similar training and experience. Specifically, the practitioner demonstrates a failure to:

• Comply with the standards set out in the Medical Board Code of Conduct, March 2014. In particular Standard 2 - Providing good care, Standard 3.5 - Informed consent, Standard 3.4 - Personal relationships, Standard 7 Maintaining professional performance, 8.2.1 Maintaining professional boundaries, 8.4 Medical records
• Practice medicine in accordance with evidence-based guidelines and/or [refrain from prescribing][22] where the requirement for a therapy does not outweigh the risk including unnecessary costs for patients.
• Assess patients and formulate diagnoses appropriately. Alternative diagnoses are not considered. The potential risk to patients is both from (i) inappropriate treatment (see para 5.2 below) and (ii) errors of omission, for example failing to refer patients for proper pain management, assess and manage depression, refer for specialist endocrine opinion, detect and mange sleep apnoea.
• Demonstrate an understanding of endocrine physiology and competence in assessing, diagnosing and managing patients with abnormalities of hormone levels.
• Refer for specialist endocrine advice either because of a lack of insight into ability and limitations or refusal to do so or both.
• Obtain informed consent.
• Keep adequate follow-up notes.
• Use resources in a prudent and appropriate manner.
• Maintain appropriate boundaries in prescribing AAS and growth hormone stimulating peptides for her partner.

5.2 The practitioner has engaged in inappropriate and non-therapeutic prescribing of:

• Thyroid hormones to people with normal thyroid function.
• Peptides and AAS in combinations and in circumstances that indicate that the purpose was for "body building", enhancement of physical appearance and/or performance.
• AAS in excessive doses and/or in combinations leading to unnecessarily high blood levels and with other medications leading to a risk to health.
• Growth hormone and growth hormone secretagogues in the absence of GH deficiency and to levels that exceed the upper limit of normal.
• HCG for the purposes of weight loss.
• Treatments that are not approved by the TGA or any other regulatory agency anywhere in the world e.g. CJC1295, Ipamorelin, and Follistatin. The combined use of CJC1295 and Ipamorelin derives from the practice of those engaged in body-building and performance enhancement. Follistatin is used by the body-building community to increase muscle size and strength.
• Treatments associated with significant risk e.g. Artesiane administered by injection, T3 for a patient who already had had mild hyperthyroidism, growth hormone secretgogues for a patient with very poorly controlled diabetes, without consideration of the presence of a significant retinopathy, and 28 vials of parenteral iron to a patient with apparently normal iron stores.
• Treatments to mitigate risks (e.g. anastrozole, finasteride) from prescribed treatments, and in so doing creating additional risks.

30. Whilst not suggesting that every detail in this summary has been proved to our satisfaction, we note that most of the criticisms made by Professor Wittert in his reports and oral evidence have eventually been admitted by the respondent. Other matters that we have found proved are discussed in these Reasons. It is clear that the general picture painted by the summary - very poor clinical performance and highly irresponsible prescribing of a range of medications - is accurate.

31. Whilst the respondent now largely accepts the criticisms of Professor Wittert, she did not do so for a long time. Even during the hearing before this Tribunal, the respondent challenged some views of Professor Wittert and dismissed certain of his views as the views of "one expert".[23] This was despite the fact that she had produced no expert evidence to challenge such views.

32. It is fair to comment that the respondent has grudgingly accepted the views of the experts as the case against her has progressed. She seeks to argue that her beliefs appeared reasonable to her at the time of the prescribing due to the non-authoritative materials she had accessed. It is concerning to the Tribunal that she stubbornly adhered to these beliefs in the face of all of the authoritative information and advice to the contrary. The respondent states that: "I wasn't just doing it to be rebellious",[24] but she clearly knew that her views were controversial and nonconventional and nonetheless continued to put them into practice despite the 2015 Conditions of Practice, the findings of the Performance and Professional Standards Panel, and the expert advice. She says that she did not breach the November 2016 Conditions (and the Board does not allege otherwise), but her aberrant prescribing continued after that time. She states that her views as to the appropriateness of her prescribing did not substantially change until late-2018 (when she undertook to cease practice) and even then she continued to dispute many of the expert opinions given concerning her conduct and prescribing. As will be apparent from these Reasons, her approach was still somewhat combative when the hearing commenced, but further significant admissions were made by the conclusion of her evidence.

33. The Complainant in its submissions pointed to the respondent's reliance on unauthoritative sources as an illustration of her inability to properly research and assess medical information on a scientific basis. We accept the evidence that Professor Wittert gave concerning this aspect.[25]

34. Many authorities have emphasised the importance of medical practitioners not prescribing peptides, AAS, or other performance and image enhancing drugs (PIEDs) where there is no proper therapeutic basis for doing so.[26]

35. In February 2013 the Australian Crime Commission published its report: "Organised Crime and Drugs in Sport[27] which contained a wealth of information concerning the use and abuse of PIEDs. It was noted that an earlier report published in 2011 had "identified the widespread use of PIEDs by persons from a broad cross section of the community and noted that the distribution of PIEDs can be highly profitable".[28] The 2013 report identified "some medical practitioners" as one of the chief conduits through which people were obtaining PIEDs and "some anti-aging clinics" as a major source of peptides, hormones and other PIEDs.[29]

36. The respondent conceded that she was generally aware of the "Essendon supplements controversy" when it occurred in 2012-2013.[30] She states that she was not aware of the ACC report until 2016 or 2017.

37. There is no suggestion, of course, that the respondent was involved in organised crime or in systematic prescribing to sportspersons. However, there was a significant amount of information available to general practitioners to alert them to the problems associated with prescribing of PIEDs. Professor Wittert gave evidence about this, including reference to materials published by the Endocrine Society of Australia and the RACGP.[31] In this context, the respondent claimed a concerning level of naivety in respect of her prescribing for some patients referred to in the complaint. In answer to a question from the Tribunal as to whether, in May 2013, she had an understanding that there were people that were body-builders and who would seek out these drugs for the purpose of body-building, she responded:

I didn't have a full appreciation of that.[32]

38. With respect to Pt 43, the respondent admitted prescribing multiple androgens in combination, growth hormone stimulating peptides, HCG and Anastrozole when there was no clinical reason to do so.[33]

39. The respondent stated that she "did not know that he [Pt 43] was a body-builder"[34] despite the fact that he advised her that he trained five days a week with weights and cardio fast walking and despite conceding that there was "a bit of a theme" about "fitness training" in the notes.[35] She prescribed primoteston and showed Pt 43 how to inject it,[36] but says that she did not perceive that he was seeking it for body-building purposes. She admits that she should have realised this based on the information provided to her by the patient.[37]

40. The respondent stated in evidence-in-chief that she "should have turned [her] mind to the fact that he might have been just utilising the drugs that [she] was giving him for body-building purposes and not for a therapeutic purpose". She said:

At the time, I assumed it was more wellness and the mood and stress.[38]

41. The vagueness of this contemporaneous justification highlights the lack of any proper therapeutic purpose and makes the respondent's claimed naivety even more concerning. We accept the evidence of Professor Wittert as to the inappropriateness of the respondent's prescribing to Pt 43.[39]

42. Pt 42 was referred to the respondent by another GP on 5 December 2013. The referral included reference to "feels flat ... wants to find out re HGH in relation to tiredness and energy".[40] It appears that he did not attend for examination until 12 June 2014.

43. On 2 July 2014, the respondent prescribed primoteston, DHEA and Vitamin D. Subsequently, she prescribed CJC1295, and Ipamorelin and NTE.[41]

44. Despite the referral letter quoted above, the respondent states that she did not consider or perceive that Pt 42 was actively seeking testosterone treatment.[42] The respondent's evidence-in-chief about this included the following:

MS O'CONNOR: The complaint is that you didn't actively consider that he might have been actively seeking testosterone only. How old is [Pt 42]?

DR LLOYD: 1968.

MR HOPPRICH: He was 45 at the time.

MS O'CONNOR: And that's a matter that you've had to consider since the complaint has been made against you about whether patients are actively seeking some of the drugs that you are complained about?

DR LLOYD: Yes

MS O'CONNOR: Do you say you didn't turn your mind to it at the time?

DR LLOYD: Not at the time and certainly having a letter from his GP in my mind almost, well, it legitimised the consult in my mind, but definitely, in hindsight, I would treat this sort of patient completely differently and have that in mind.

MS O'CONNOR: Did this patient ever tell you, either when you were consulting with him at any time, that in fact he was actively seeking testosterone from you?

DR LLOYD: No

MS O'CONNOR: Were you recommending testosterone or was it him asking for testosterone?

DR LLOYD: I think as part of my assessment I tested testosterone. I don't think, from memory, that this patient requested testosterone from me.

MS O'CONNOR: Do you know now what a reason might be for a 45-year-old man to request testosterone?

DR LLOYD: Legitimately or not legitimately?

MS O'CONNOR: Not legitimately. The complaint is that it's not...

DR LLOYD: Certainly, it's a performance and image enhancing drug and it will improve muscle mass. It's used by people wanting to enhance their appearance and muscle mass. Yes, certainly.

MR HOPPRICH: Excuse me. So on page 1408[43] there's mention of muscle mass decrease---

DR LLOYD: Yes.

MR HOPPRICH: --- and gym three times a week?

DR LLOYD: That's right.

Mr HOPPRICH: And he does mention that he is a body builder?

DR LLOYD: Yes

MR HOPPRICH: So there was some discussion about him being a body builder and looking at muscle, and then on page 1412 there is mention that strength could be better?

DR LLOYD: Yes.

MR HOPPRICH: So I wonder if that was something about his angle?

DR LLOYD: NO, you're right.

MR HOPPRICH: His angle, yes?

MS O'CONNOR: So he was open with you, at least as far as you know, in terms of what he was trying to achieve health wise; is that right?

DR LLOYD: I looked at it more as health wise at the time, helping enhancement rather than body building appearance. Yes, as I said, I would certainly look at this, as a patient, a lot differently.

...

MS O'CONNOR: And certainly there's nothing in the GP referral note that indicates that the patient was actively seeking testosterone treatment for any purpose at all?

DR LLOYD: No.

MS O'CONNOR: It's not mentioned in there, is that correct.

DR LLOYD: Certainly human growth hormone was and I think Dr Chin knew that I had attended those A5M conferences so that was probably where Dr Chin thought it might be appropriate.

MS O'CONNOR: Did you consult at all with Dr Chin?

DR LLOYD: No.

MS O'CONNOR: --At all in the management of this patient?

DR LLOYD: No.

MS O'CONNOR: The allegation is that you did not consider his being referred to you for that purpose of actually seeking testosterone treatment. Was there anything in this letter at all that indicated to you that you should have warning?

DR LLOYD: That is straight up for HGH. In hindsight, having a look at that now, but no, I didn't think it was simply for testosterone.[44]

45. We accept the evidence of Dr Wittert that the prescribing was not for a therapeutic purpose. That should have been obvious to the respondent. Despite the concessions made in the above passage of evidence, the respondent does not seem to acknowledge this. We find that the respondent ought to have been aware that the patient was seeking drugs for body building purposes. Once again, her claims that she did not even consider this reflect a concerning level of naivety.

46. With respect to Pt 45, we accept the evidence of Professor Wittert that there was no proper therapeutic purpose for the prescribing of testosterone or DHEA.[45] The prescribing of testosterone put the patient at increased risk of cardiovascular events.[46]

47. In summary, the prescribing of PIEDs by the respondent was conduct that fell substantially below the standard to be expected of a practitioner of the respondent's training and experience. Looking overall at the respondent's prescribing and clinical performance, there is no doubt that it constitutes professional misconduct.

48. The respondent has generally admitted the allegations with respect to her failure to obtain informed consent and many of them have already been referred to in the context of breach of conditions. We state for the sake of clarity that we accept the evidence of Professor Wittert as to what is required to constitute a valid informed consent when prescribing PIEDs, off-label medications, or prescribing or recommending medications outside of the conventional.[47] Informed consent is about ensuring that patients are properly informed about medications that are prescribed or recommended, including full disclosure of potential adverse effects. Failure to obtain informed consent for the type of treatments the respondent was providing and recommending is a very serious matter.

49. Ultimately, the facts in relation to the boundary issues were not in dispute. The respondent met her current partner (Pt 44) on-line during 2010. He was then still cohabitating with his wife and the respondent was aware of that at all relevant times.

50. They met in person for the first time at a coffee shop on 4 June. They commenced an intimate relationship on 6 June, which has continued to the present time. Shortly after this they talked about the respondent's work and it was agreed that Pt 44 would attend the respondent's surgery for a consultation. At some stage between 6 June and 8 July, the respondent provided Pt 44 with a blood test form. The consultation occurred on 8 July 2010.

51. It was wholly inappropriate for the respondent to treat a person with whom she having a sexual relationship. Pt 44 was in the process of considering whether he would leave his wife. He was experiencing anxiety and depression, as well as problems of a sexual nature. The respondent was obviously compromised in her ability to provide objective and impartial medical treatment and advice on these issues, given that she was having an extra-marital affair with him. Cross-examination of the respondent demonstrated that the care he received was compromised by the dual relationship.

52. From the very first appointment, the respondent prescribed hormone therapy. She continued to have consultations with Pt 44 and to prescribe off-label medications for him and order blood tests, albeit that he also retained his usual GP. The respondent did not advise the GP that they were in a relationship. The respondent accepts that at no stage did she discuss with the patient the potential for a conflict or the fact that her ability to provide objective and impartial treatment was compromised. It was a circumstance of aggravation in this context that she was providing to him treatments that were non-conventional and controversial.

53. In about mid-2011, Pt 44 decided to leave his wife. The respondent completed a mental health plan, which enabled Pt 44 to have subsidised psychological treatment. She ought not to have done that for a person with whom she was having a relationship.

54. The respondent and Pt 44 commenced living together in 2012. She continued to treat him, in controversial ways that became the subject of allegations in the complaint.

55. The respondent continued to treat Pt 44 until the boundary breach was reported in about 2018. Medicare benefits were claimed for the consultations which was also inappropriate.

56. True it is that the sexual relationship commenced before the professional relationship. There is no suggestion that the respondent used the therapeutic relationship to instigate an intimate relationship. That would be a more serious scenario. However, this conduct was very serious as well.

57. The respondent submits that it is appropriate to categorise the conduct as "treating a family member" even though the respondent and the patient did not cohabit until 2012. This focus, in our view, overlooks the real gravamen of the misconduct. The respondent embarked upon treating a patient with whom she was having an affair and who was still cohabitating with his wife and in the course of considering whether to leave her. This situation made the boundary breach far worse than many cases of treating a family member. It was a circumstance certain to impact on the respondent's ability to be objective and impartial in all the circumstances. The dual relationship was certain to impact the nature of the doctor-patient relationship for both parties. It was highly irresponsible for the respondent to commence a therapeutic relationship in these circumstances. It was just as irresponsible to continue that dual relationship for eight years. The ethical requirements are well-known and we find the respondent's claim that she gave no consideration to this issue to be quite extraordinary.

58. We have no hesitation in finding that the boundary breach amounts to professional misconduct.

59. It is relevant to enquire how and why the respondent became involved in such extensive misconduct. We have already referred to the fact that she became involved with and embraced various alternative approaches and philosophies which were not consistent with the demands of conventional medicine. Why did she persist in utilising these approaches in the face of expert advice to the contrary from senior specialists? Why did she essentially reject and ignore the findings and recommendations of the Performance and Professional Standards Panel? Why was she prepared to deliberately breach her 2015 Conditions of Practice?

60. The most obvious answer to these questions lies in personality traits of the respondent as revealed in the evidence. Ms Jane Tiggeman, an expert registered psychologist, was engaged by the respondent to conduct a thorough psychological examination and report to the Tribunal. In her report dated 22 November 2019,[48] she describes the respondent's personality characteristics as including:

Having a rebellious nature, needing to be autonomous, needing to please her patients[49]

61. This included a "high need to be autonomous and not rule-bound".[50]

62. In the context of explaining her boundary breach with Pt 44, the respondent stated: "I take a lot of risks. I'm quite bold on the one hand and I often don't stand up for myself when I need to".[51]

63. The respondent explained to Ms Tiggeman that she had embraced the Islamic religion (after her marriage), partly because it was in line with her values of having autonomy of "doing what you want and I do what I want".[52]

64. In relation to the 2015 Conditions, Ms Tiggeman's report included the following:

In relation to the conditions by AHPRA she said "Having to get permission to write a script I found difficult, super onerous. I was anti-authority, anti being told ... I found it devastating. I never thought I'd be able to work.

Dr Lloyd told me that when she was asked by patients for scripts that she felt she had to put them first over her own needs and requirements from AHPRA and this, combined with a sense of frustration and feeling anti towards authority caused her as I understood it, on some occasions not to follow the conditions.[53]

65. The evidence before the Tribunal clearly demonstrated the existence and impact of these personality characteristics throughout the respondent's adult life. She has consistently demonstrated an aversion to being told what to do, rebelliousness, risk-taking, and poor judgement. She has been "anti-authority". There is no doubt that these factors go a long way towards explaining the breadth and seriousness of her misconduct.

66. However, we must also have regard to the respondent's personal circumstances during the relevant period. We have paid careful attention to her reflective writing dated 30 September 2019 and to the events outlined therein. We do not wish to canvass those personal circumstances in this Statement of Reasons, but they were significant. We accept that the respondent was under a significant degree of stress at and from the time of her separation in March 2010 and through the ensuing years. This was heightened when her surgery was destroyed by fire in June 2015, an event which occurred shortly after the decision of the Performance and Professional Standards Panel.

67. In 2013 the respondent was referred to Ms Michelle Murphy, Clinical Psychologist, with symptoms of anxiety and depression. She ceased treatment after three sessions, indicating that she was "going well".[54] In late 2015 she was referred to Anthony Smith, clinical psychologist. She was assessed as in the moderate range for depression and the acute range for anxiety. She was treated with Eye Movement Desensitisation and Reprocessing (EMDR), reducing her scores for anxiety and depression to within normal levels. She was invited to return if her situation regressed, but did not do so.[55]

68. Ms Tiggeman first saw the respondent on 4 October 2019.[56] She formed the view that the respondent had suffered at relevant times from a mental health condition, specifically Post Traumatic Stress Disorder (PTSD), which aggravated her pre-existing personality characteristics and thus contributed to the misconduct. Ms Tiggeman made it clear that there was no basis to diagnose PTSD at the time of her consultations with the respondent.[57] Her opinion was based primarily on the respondent's own ex post facto description of her mental state at the relevant times. Ms Tiggeman concedes that the records of more contemporary examinations do not necessarily support her views. She suggests that the respondent may not have been as open with previous examiners.

69. It transpired that Ms Tiggeman had sent an earlier version of her report to the respondent's solicitor. The respondent had emailed Ms Tiggeman and asked her to remove certain matters contained in the report. Ms Tiggeman did so and produced the version of the report that was initially before the Tribunal. We do not consider that either party was attempting to mislead the Tribunal. The respondent was concerned about her privacy and Ms Tiggeman genuinely considered that the changes did not compromise the report in any way. In this regard, we consider that Ms Tiggeman's judgement was astray. The changes should not have been requested or acceded to. The information removed was of potential relevance and should not have been removed at the respondent's request. Whilst making it clear that this ought not to have occurred, we do not regard it as a relevant factor in assessing the weight of Ms Tiggeman's evidence

70. In her report, Ms Tiggeman opined that the respondent suffered PTSD, particularly after the fire in June 2015 (although this may have been an exacerbation of PTSD suffered in earlier years).[58] She opines that this may have aggravated the pre-existing personality characteristics so as to explain the respondent's breaches of the 2015 conditions occurring in 2016. Ms Tiggeman points to the respondent's compliance with the November 2016 conditions in 2017 and 2018 as being consistent with recovery from such condition.[59]

71. At the time of writing this report, Ms Tiggeman was not aware of the EMDR treatment provided by Mr Smith in 2015 or the reported good result from that treatment.[60] She was of the understanding that the respondent was so overwhelmed by her mental health problems that she could not return to work after the fire until January 2016.[61] In fact, she was due to return in October 2015 but practical matters caused it to be deferred. Ms Tiggeman also appeared not to be aware that the respondent had continued to prescribe in an irresponsible and defiant manner in 2017, albeit whilst complying with the 2016 conditions. Finally, we consider that Ms Tiggeman's opinion was possibly influenced by a false understanding that psychiatrist, Dr Jo Hill, was treating the respondent for PTSD in 2018 and 2019, when that was not the case and Dr Hill had made no such diagnosis.

72. It is true that Ms Tiggeman still adhered to her opinion after being advised of these matters, albeit with not quite the same degree of certainty.[62] Her opinion, however, was based on the history of symptoms given to her by the respondent and she conceded that the contemporary medical records did not entirely support that history.[63] Furthermore PTSD had not been diagnosed by any other practitioner.[64] On the whole of the evidence, we have reservations as to whether the diagnosis of PTSD is necessarily accurate. However, we consider it likely that the respondent was experiencing extreme stress at relevant times and significant depression and anxiety. We have little doubt that these factors may have affected her awareness and judgement. As Ms Tiggeman stated in her report:

The exacerbation of personality characteristics under stress would have also contributed to increased frustration and less awareness to observe rules / conditions set down by the Board.

73. In summary, we consider that mental health issues very likely had a part to play as factors contributing to the very poor professional decisions made by the respondent, but that part was secondary to the operation of the respondent's personality characteristics as described.

74. The respondent made it clear that the evidence as to her mental health was not called to excuse the misconduct but to explain and mitigate it. Such evidence can clearly affect the view that the Tribunal takes of the conduct by explaining how it occurred. It can assist the Tribunal in determining the risk of such conduct recurring.

75. However, it cannot affect the proper categorisation of the conduct under the National Law. That must be determined objectively.[65]

76. Both parties made some submissions about the issues arising from this evidence, including the degree of risk the respondent might pose in the future, but reserved the right to address such matters further at the "sanctions" stage of the hearing.

77. We have touched on some of these issues in these Reasons, but they are not for determination at this stage. It would be wrong for us to pre-judge such matters before the parties have completed their "sanctions" submissions.

78. We find that the respondent has behaved in a way that constitutes professional misconduct. We adjourn the matter to Monday, 18 October 2021 for submissions on sanction.

80. On 1 October 2021 the Tribunal published a Statement of Reasons in this matter. It found that the respondent had behaved in a way that constituted professional misconduct. The matter was adjourned to receive submissions as to the appropriate disciplinary action.

81. On 18 October 2021 the Tribunal, after considering such submissions, including a joint recommendation of the parties, made orders as follows:

1. The Tribunal decides pursuant to s 196 (1) of the National Law that the respondent has behaved in a way that constitutes professional misconduct.

2. The Tribunal imposes the following disciplinary action pursuant to s 196 (2) and (4) of the National Law:

1. The respondent is reprimanded.
2. The registration of the practitioner is cancelled.
3. The respondent is disqualified from applying for registration as a registered health practitioner for a period of two years from the date of this order.

3. The respondent must pay the costs of the Board to be agreed or fixed by the Tribunal.

82. We now provide our reasons for this further decision.

83. We will not repeat what was set out in our Statement of Reasons dated 1 October 2021. In summary, we found that the respondent had deliberately and repeatedly breached conditions that had been imposed on her registration in 2015 following a hearing before a Performance and Professional Standards Panel. She essentially ignored expert advice and the decision and recommendations of that Panel. She chose instead to continue to follow her own aberrant clinical and prescribing practices. She provided unconventional treatments without tendering adequate advice to patients or obtaining informed consent.

84. The evidence and admissions before the Tribunal demonstrated very poor clinical performance and highly irresponsible prescribing of a range of medications. Thyroid hormones were prescribed for persons who had normal thyroid function. Various other medications (including non-TGA approved substances) were commonly prescribed without adequate justification or informed consent and in circumstances giving rise to risk of harm to patients. Performance and image-enhancing drugs were prescribed or provided to patients in circumstances where there was no proper therapeutic basis for doing so.

85. Finally, the respondent had engaged in a serious boundary breach by treating her current partner whilst in an extra-marital sexual relationship with him. As indicated in our Statement of Reasons, the respondent was obviously compromised in her ability to provide objective and impartial treatment by virtue of the dual relationship.

86. The background to the misconduct was that the respondent had embraced certain alternative approaches which had led her away from the practice of evidenced-based medicine. When challenged concerning the appropriateness of her clinical and prescribing practices, she chose to defend her conduct and resist and ignore advice to the contrary.

87. We found that the primary reason for the professional misconduct related to personality characteristics of the respondent. During her life, she had consistently demonstrated an aversion to being told what to do, rebelliousness, an anti-authority approach, risk-taking, and poor judgement. However, we also had regard to her personal circumstances during the relevant period. We acknowledged that she was under significant stress over an extended period and had suffered from high levels of anxiety and depression. She had experienced serious trauma. We concluded that mental health issues very likely had a part to play as factors contributing to the very poor professional decisions made by the respondent, but that part was secondary to the respondent's personality characteristics as described.

88. Insight and personal growth or development can occur at different levels.

89. There is a level at which the respondent has demonstrated some insight and willingness to change. In the end, she admitted most of the allegations made against her. She gave evidence that her views as to the efficacy of alternative treatments had changed[66]. She deposed that she accepted and had taken seriously criticisms made by the expert witness for the Board. She acknowledged that she had practised with a very narrow focus[67]. She would practise differently in the future.[68]

90. However, at a deeper level, we continue to have serious reservations. Ms Tiggeman was engaged by the respondent to give an expert opinion. She expressed the view that the respondent was still processing events and coming to a full understanding of herself. Her ability to be more self-aware and have a clearer sense of self-identity were still in the earlier stages of development. Ms Tiggeman suggested that more professional treatment was required to reduce the risks that would accompany any return to practice by the respondent. The respondent needed to identify and establish a relationship with a therapist that she could trust. In the absence of such treatment there would continue to be risks associated with her personality characteristics and her mental health.[69]

91. The respondent was present when this evidence was given. There has subsequently been ample time for her to act on this advice, but she has not done so. Since that time, she has ceased attending her then psychiatrist (after just one more attendance) and not identified any alternative psychologist or psychiatrist to assist her in dealing with such issues. We understand that it may be very difficult to deal with painful past events, but the importance of addressing these issues is clear from Ms Tiggeman's evidence.

92. On the evidence before us, we do not consider that the issues underlying the professional misconduct have been adequately addressed. Should the respondent be permitted to return to practice, there would remain an unacceptable risk of further difficulties arising from her personality characteristics and her mental health in the absence of further treatment. The respondent has not demonstrated that these matters have been adequately addressed or that she is a fit and proper person to be registered at the present time.

93. The professional misconduct in this case is particularly serious. The clinical and prescribing conduct must give rise to a strong disciplinary response. The failure to obtain informed consent is equally serious, particularly where unconventional treatments are involved. The boundary breach is professional misconduct in its own right. However, the most serious aspect of this matter is the deliberate contravention of conditions imposed to protect the public. Such conduct strikes at the heart of the regulatory system. The Tribunal must impose sanctions that leave no doubt as to the seriousness of such conduct and the importance of compliance with conditions.

94. Given that the underlying issues have not yet been adequately addressed, it was inevitable that the respondent's registration should be cancelled. The Tribunal was also required to impose a period of disqualification. This will enable the respondent time to address outstanding issues and demonstrate her fitness to practise. It will also serve as a clear message to the respondent and other practitioners that standards within the profession will be maintained and that serious misconduct will not be tolerated. Finally, it will serve to assure the public that it can have confidence in the profession and its regulation.

95. It was also appropriate to administer a formal reprimand.

96. We note that the respondent gave an undertaking on 31 August 2018 that she would not practise as a medical practitioner. She has not practised since that time. She gave the undertaking due to the allegations that we now deal with and the prospect that she would otherwise be suspended by way of immediate action. It would be unwise to lay down any hard and fast rules as to how such an undertaking (or even an immediate action suspension) will affect the determination of a subsequent period of disqualification. It may depend on the circumstances of a particular case. We accept that an undertaking not to practise is not the same as a suspension. It does not have exactly the same impact on a practitioner and would be perceived differently by members of the profession and the public. We do not regard the undertaking as justifying an automatic mathematical reduction of any disqualification. Nonetheless, the respondent has been prevented from practising for a substantial period due to the misconduct with which we are dealing. That is a very significant matter that we should take into account in determining the period of disqualification. It is a matter that will not be lost on members of the public or the profession when they consider the matter. We have appropriate regard to the period for which the respondent has not worked pursuant to her undertaking.

97. The parties jointly submitted that there should be a reprimand, a cancellation of registration, and a disqualification for two years (from the date of our order).

98. We considered that this joint proposal was appropriate in all the circumstances of the case (including the fact that the respondent has been prevented from practising since 31 August 2018 by her undertaking). We made orders accordingly.

99. The Tribunal has prohibited the publication of the name of, or any material tending to identify, any patient of the respondent referred to in the pleadings, evidence or submissions, save and except for the respondent's current partner, referred to as "Patient 44".

100. As to the respondent's current partner (Patient 44), the Tribunal has prohibited the publication of any information concerning him, other than what appears in the formal decisions and reasons of the Tribunal.

[5] RCS paras 18 vi and 23-171 of the RCS.

[7] Transcript Day 4 (T4) at pages 5-111.

[12] FFAR paras 21, 38, 54, 110, 119, 220, 310 and 323.

[15] Especially at T 92/3/20) at pages 24-28.

[16] Transcript (T) (4/3/20) at page 103.

[17] Prakash v HCCC [2006} NSWCA 153 at [45] and [74]; HCCC v Reid [2018] NSWCATOD 162 at [131].

[22] Our edit to capture the sense of the Professor's evidence, as we understood it.

[25] Eg at T (2/3/2020) at pages 23-24, 45-51; 96-100.

[26] HCCC v Epstein [2015] NSWCATOD 21; MBA v Singh [2017] WASAT 33; Singh v MBA [2018] WASCA 125; MBA v Hadges [2018] SAHPT 6; MBA v Heidemann [2020] SACAT 106; MBA v Tunbridge [2020] SACAT 34; HCCC v Meneghetti [2020] NSWCATOD 39; HCCC v Nemeth [2012] NSWMT 4; HCCC v Gorondy-Novak [2011 NSWMT 3.

[35] C4 Tab 43 pages 1546ff; T (15/1/2020) page 153.

[39] Third report C4 page 161ff. T (2/3/2020) pages 67.73.

[47] Especially at T (2/3/2020) page 25-28.

[61] C4 page 707; T 6/3/2020 page 86 and 102-104.

[62] Eg T (6/3/2020) at pages 7, 102-103, 105.

[65] LPCB v Ardalich [2005] 243 LSJS 145, [2005] SASC 478 at [42] - [49]; MBA v Dapp [ 2008] QCA 44 at [21 - [33].

[69] T (5/3/20) pages 12-18, 119-124, 125-126.