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

1. Under section 196(2)(a) of the National Law, the respondent is reprimanded.
2. Under section 196(d) of the National Law, the respondent's registration is suspended for three months starting on 18 June 2025.
3. Under section 196(2)(b) of the National Law, the condition contained in Schedule 1 to these orders is imposed with effect from the date the respondent returns to practice.
4. Under section 196(3) of the National Law, the review period for the condition in order 3 is six months.

1.1 The respondent (referred to in this Schedule as the Practitioner) must be mentored by a registered peer medical practitioner in relation to appropriate prescribing of drugs of dependence and ethical practice.

For the purposes of this condition, 'mentoring' is defined as a relationship in which a skilled registered practitioner (the mentor) helps to guide the professional development of another practitioner.

1.2 The mentoring must comprise a minimum of eight sessions with each session being of two hours duration occurring over a four-month period.

1.3 Within 21 days of the notice of the imposition of these conditions, the Practitioner must, on the approved form (HPN16), nominate a person(s) to be approved by the Medical Board of Australia (the Board) to act as mentor. The Practitioner must ensure that the nomination is accompanied by acknowledgement, on the approved form (HPNA16), from the nominated person.

1.4 Within 21 days of the notice of the imposition of these conditions the Practitioner must provide to ]the Australia Health Practitioner Regulation Agency (Ahpra)], on the approved form (HP16), acknowledgement that Ahpra may seek reports from the approved mentor on any or all of the following occasions:

(a) every month;

(b) at the conclusion of the mentoring relationship in order to confirm the outcomes of the mentoring;

(c) whenever the mentor has a concern or becomes aware of a concern regarding the Practitioner's conduct or professional performance, and

(d) when otherwise requested by [Aphra].

1.5 In the event an approved mentor is no longer willing or able to provide the mentoring required the Practitioner is to provide a new nomination in the same terms as previous nominations. Such nomination must be made by the Practitioner within 21 days of becoming aware of the termination of the mentoring relationship.

1.6 Within 21 days of the conclusion of the mentoring the Practitioner must provide a report demonstrating, to the satisfaction of the Board, that the Practitioner has reflected on the issues that gave rise to the condition requiring they attend for mentoring and outlining how the Practitioner has incorporated the lessons learnt in the mentoring into their practice.

1.7 Within 21 days of the notice of the imposition of these conditions the Practitioner must provide to Ahpra, on the approved form (HPC), the contact details of a senior person, such as the Director of Medical Services, Director of Nursing, Senior Practice Manager, Senior Manager, Senior Partner, Proprietor, Owner, or equivalent (the senior person) at each current place of practice. In providing this form, the Practitioner acknowledges that Ahpra will contact the senior person and provide them with a copy of the conditions on the Practitioner's registration or confirm that the senior person has received a copy of the conditions from the practitioner. The Practitioner will be required to provide the same form:

(a) within seven days of the commencement of practice at each subsequent place of practice, and

(b) within seven days of each and every notice of any subsequent alteration of these conditions.

1.8 All costs associated with compliance with the conditions on their registration are at the Practitioner's own expense.

1. This proceeding concerns the professional conduct of Dr Jajit Rattan[1] and his treatment of a long term Patient at his sole practice.
2. Rattan first started treating the Patient in around 1993. Up until July 2017, the Patient regularly attended consultations with Rattan. From July 2017 to December 2019, Rattan continued to prescribe for the Patient but did not physically consult with her once.
3. The Patient's family told Rattan that she did not want to attend the clinic and so, in order to ensure she received her longstanding prescribed medication, Rattan gave prescriptions to the Patient's Son, based on his reporting of her health status. They included prescriptions for temazepam (a benzodiazepine) and tramadol (an opioid). No management plan was prepared in respect of those medications which are regarded as drugs of dependence and can have adverse impacts when prescribed in combination.
4. Rattan's practise Nurse attended on the Patient at her home from time to time but Rattan did not do so personally in the two and a half year period. Apparently relying on the Nurse's reporting and that of the Son, and despite not having seen the Patient in person over the period, Rattan made clinical records which purported to record the Patient's vital signs and health. Those records were fabricated.
5. Over the two and a half year period, Rattan recklessly billed Medicare for items which applied to in person and similar consultations despite the fact he had not physically seen the Patient. The events occurred before the COVID-19 pandemic and so telehealth appointments were not available, meaning some of the Medicare items could only be claimed if the Patient attended the general practitioner's consulting rooms.
6. On the material before us, it appeared that no harm came to the Patient as a result of Rattan's conduct, however the risks she was exposed to were significant given her age and health conditions.
7. After the Patient's Son made a notification about Rattan's treatment of the Patient (concerning Rattan's refusal to again provide prescriptions without his mother attending Rattan's clinic) in late November 2019, the Medical Board of Australia decided to investigate. Two years later, in November 2021, it decided to refer Rattan to the Tribunal for disciplinary orders under the Health Practitioner Regulation National Law (Victoria) Act 2009 (National Law). The referral was received by the Tribunal on 9 March 2022.
8. Rattan made admissions about the conduct in issue and agreed that it constituted professional misconduct. He provided information about the health issues which were affecting him at the time, his reflections on his past conduct and professional education he had undertaken.
9. After reviewing the parties' joint Tribunal Book (TB) and hearing their submissions, we were satisfied that all facts were proven and that Rattan's conducted as contained in four Allegations constituted professional misconduct.
10. The Board sought orders for Rattan to be reprimanded, for his registration to be suspended for six months and the imposition of conditions for education and mentoring on his return to practise. Rattan sought orders that he be reprimanded and for a fine to be imposed. The latter was sought as an alternative to a suspension in circumstances where Rattan is a sole practitioner and anticipated having great difficulty finding a locum. He was particularly concerned that his absence would adversely affect his longstanding patients, some of whom depended on his ability to speak their language to obtain medical care.
11. While giving weight to Rattan's particular circumstances and satisfied that he would not engage in the same conduct again, we concluded that it was necessary to impose a three month suspension to ensure that other medical practitioners and the community more broadly understood the conduct was unacceptable and brought with it significant consequences.
12. In order to allow Rattan time to engage a locum and make other necessary arrangements, we delayed the start of the suspension period for three months.
13. Given the agreed position, it was not necessary for the Patient, her Son or her Daughter (who was also involved in caring for the Patient) to give evidence. As we understood it, the Board's representatives never spoke with the Patient and her family disengaged from the Board's investigation at an early stage. Given our Reasons concern the Patient's treatment and relied on her health records, we think it appropriate for the Board to make efforts to draw this decision to the attention of the Patient and/or her family.

1. The following comes from the parties' Agreed Statement of Facts and the materials in their TB.

1. Rattan was first registered as a medical practitioner on 4 March 1993 and has remained registered at all relevant times, including during the investigation into his professional conduct and this proceeding.
2. At all material times Rattan held general and specialist (General Practice) registration.
3. Since 1994, he has been the sole general practitioner at the Fawkner Family Centre.

1. On 27 November 2019, the Australian Health Practitioner Regulation Agency (Ahpra), received a notification in relation to Rattan in relation to the Patient which raised concerns that Rattan had, relevantly:

(a) Refused to prescribe the Patient's regular medications; and

(b) Not provided follow up care for the Patient, had not physically reviewed the Patient for years despite writing monthly prescriptions.

1. On 17 December 2019, the Board decided commence an investigation into Rattan's professional performance in relation to his care of the Patient.
2. Nearly two years later, on 17 November 2021, the Board determined to refer Rattan to the Tribunal for disciplinary orders.

1. Rattan started treating the Patient in around 1994. Between then and July 2017, Rattan had regular consultations with the Patient at the Centre.
2. Between 8 July 2017 and 2 December 2019 Rattan did not see the Patient in person whether at the Centre or at her home. He continued to provide treatment to her over that period.
3. There was no dispute that, from around July 2017, the Patient's Son and carer told Rattan and his staff that the Patient either could not or did not want to attend consultations at the Centre. While the Nurse saw the Patient at home on several occasions over the two and a half year period (in order to administer vaccinations and undertake reviews, including completing a 75 Year and Older Health Assessment on 28 November 2019[2]), Rattan did not conduct any home visits or otherwise see the Patient during that time. The Nurse would provide Rattan with updates after the home visits.
4. Rattan's treatment of the Patient included prescribing temazepam on a regular basis from around October 2006 to 2 December 2019 in order to treat the Patient's for problems with sleeping. Rattan also prescribed the Patient with 100mg of tramadol from around September 2013 to on or around 2 December 2019. It was prescribed for the Patient for pain in the hips and legs.
5. Rattan's prescribing of those two substances continued from July 2017 to around December 2019 despite the fact he had not seen the Patient in the Centre or at her home and, as a consequence had neither seen her in person nor undertaken any physical examination of her. Rattan continued to prescribe the Patient those medications without having undertaken any appropriate review or management plan over the two and a half year period.
6. Between July 2017 and December 2019, on 16 occasions, Rattan purported to record the Patient's vital signs and make notes in relation to her health in the clinical records maintained by him despite the fact he had not examined her physically on the relevant dates.
7. On 38 occasions between July 2017 and December 2019, Rattan billed Medicare for consultations and other attendances on the Patient when he did not physically see her.

1. The allegations contained in the Amended Notice of Allegations, filed on 16 August 2023 (Amended Notice), allege that Rattan engaged in:

(a) professional misconduct within the meaning of paragraph (a), (b) and/or (c) of the definition in section 5 of the National Law; and/or

(b) unprofessional conduct within the meaning of the definition in section 5 of the National Law in respect of the following.

Between on or about 8 July 2017 and 2 December 2019, [Rattan] failed to provide [the Patient], with appropriate care and treatment in that he did not conduct a physical consultation with her over that period.

Between on or about 8 July 2017 and 2 December 2019, [Rattan] prescribed [the Patient] with medication, namely temazepam and tramadol, without appropriate levels of ongoing review, assessment and management planning.

Between on or about 4 August 2017 and 4 July 2019, [Rattan] falsified [the Patient's] clinical record by knowingly, incorrectly and misleadingly recording vital signs attributed to The Patient despite not physically attending on [the Patient] during this period.

Between on or about 4 August 2017 and 2 December 2019, [Rattan] recklessly billed the Medicare items listed in Table 1 [of Attachment A] despite not meeting the billing requirements of same, namely that [Rattan] did not physically attend on [the Patient] and/or did not create a patient management plan.

1. Attachment A to these Reasons contains a complete copy of the Amended Notice and the particulars of each Allegation.
2. After being informed of the notification and invited to respond, Rattan wrote to Aphra on 8 December 2019.[3] In that letter, Rattan made admissions to the facts contained in Allegations 1 and 2. In a later email sent on 17 March 2020, Rattan admitted to the facts contained in Allegation 3.[4] In a letter dated 11 August 2021, he admitted to the facts contained in Allegation 4.[5]

1. The Board had the onus of proving all alleged facts.
2. We were required to make our findings of fact on the balance of probabilities, comfortably satisfied they are open on the evidence, taking into account the seriousness of the allegations and the consequences of findings such as these.[6]
3. Having regard to the Agreed Statement, the materials in the TB and Rattan's admissions, we were comfortably satisfied that all of the facts alleged in Allegations 1 to 4 were proven.

1. The Tribunal is required to make findings about the nature of the proven conduct under section 196(1)(b) of the National Law.
2. Section 5 of the National Law provides that 'professional misconduct', of a registered health 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;

(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 A practitioner may engage in professional misconduct which does not fit neatly into one or other of the paragraphs of the definition and more than one paragraph may apply.

1. The definition of 'unprofessional conduct', relevant to this case, is:

professional 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,

1. Characterising proven conduct is an objective assessment which looks towards the conduct in light of the applicable standards and relevant definitions, rather than matters arising later in time, such as remorse, insight, and rehabilitation.
2. In relation to a finding under paragraphs (a) or (b) of the definition, the Tribunal must assess the degree of seriousness of the practitioner's conduct having regard to the extent to which the conduct departs from the proper standards of professional conduct of a registered medical practitioner. The gravity of professional misconduct is not measured by reference to the worst cases, but by the extent to which it departs from the proper standards.
3. In relation to a finding under paragraph (c) of the definition, the term 'fit and proper person' allows for a wide range of matters to be considered. As stated by the Tribunal in Psychology Board of Australia v Griersmith:[7]

It includes not only whether a person has the necessary honesty, knowledge and ability but also whether the person possesses sufficient moral integrity and rectitude of character to permit them to be accredited to the public as a person to be entrusted with the sort of work the relevant registration or licence entails. The decision maker needs to make a value judgment and, in so doing, must make an assessment of the seriousness or otherwise of the particular conduct for evaluation. The same approach is to be applied to weighing matters in favour of the person. The test must be applied in the context of what the person will be authorised to do if the relevant permission is given.

1. The enquiry is as to the whether the conduct is inconsistent with fitness and propriety and does not require a finding that the practitioner is not fit and proper (either at the time of the conduct or at the time of hearing).

1. The Board relied on:
   • 'Good Medical Practice: A Code of Conduct for Doctors in Australia', current on and from March 2014 (Code of Conduct); and
   • Royal Australian College of General Practitioners 'Prescribing drugs of dependence in general practice' (RACGP Guidelines).
2. The Board referred us to the following in particular.
3. Code of Conduct:
   • In respect of Allegations 1 and 2:

2.1 Introduction

In clinical practice, the care of your patient is your primary concern. Providing good patient care includes:

2.1.1 Assessing the patient, taking into account the history, the patient's views, and an appropriate physical examination. The history includes relevant psychological, social and cultural aspects.

2.1.2 Formulating and implementing a suitable management plan (including arranging investigations and providing information, treatment and advice).

2.2 Good patient care

Maintaining a high level of medical competence and professional conduct is essential for good patient care. Good medical practice involves:

...

2.2.3 Maintaining adequate records (see Section 8.4).

...

8.4 Medical records

Maintaining clear and accurate medical records is essential for the continuing good care of patients. Good medical practice involves:

8.4.1 Keeping accurate, up-to-date and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management in a form that can be understood by other health practitioners.

1.4 Professional values and qualities of doctors

...

They must be ethical and trustworthy. Patients trust their doctors because they believe that, in addition to being competent, their doctor will not take advantage of them and will display qualities such as integrity, truthfulness, dependability and compassion.

1. RACGP Guidelines - Part C1:
   • In respect of Allegation 2:

• Opioid treatment seeks to maximise outcomes for health and social functioning of the patient while minimising risks. To minimise risks, opioids should be prescribed at the lowest effective dose for the shortest clinical timeframe.
• ...
• Opioids are generally regarded by clinical practice guidelines as a short-term therapeutic option. Long-term use should be uncommon, undertaken with caution and based on consideration of the likely risks and benefits of opioids.
• ...
• Long-term opioid prescriptions should be at the lowest effective dose, and regular attempts at reduction should be scheduled. Continued professional monitoring of health outcomes is required.

Part 2.4 Accountable prescribing of opioids in general practice

2.4.1 Key prescribing principles

As with any treatment, prescription of opioids should be based on:

Part 2.4.2 Recognising patients at risk with opioid prescribing

Opioids are often useful analgesics, but care needs to be taken when prescribing these drugs in order to limit the risks including inappropriate use and diversion. Clinically, problematic opioid usage is more likely when prescribed to:

...

• patients who use benzodiazepines - concomitant use of opioids substantially increases the risks of side effects, particularly cognitive impairment, sedation and respiratory depression.

3.6.1 Adverse effects:

Table 12. Adverse effects of opioids

• Nausea and vomiting
• Drowsiness
• Urinary retention
• Constipation
• Cognitive impairment
• Weight gain or weight loss
• Respiratory depression
• Falls; and
• Fracture risk

1. The Board relied on two expert reports provided by Dr Simon Torvaldsen, a registered specialist GP. Torvaldsen has been in full time private practice as a general practitioner since 1989. In addition to other roles, he has worked as the Medical Director of a private inpatient palliative care unit. He is the current Chair of the Australian Medical Association (AMA), Western Australia Council of General Practice and Deputy Chair of the AMA Federal Council of General Practice.
2. Torvaldsen's reports were dated 14 January 2021 (First Report) and 28 June 2021 (Second Report).[8]
3. The Board arranged for Torvaldsen to attend the hearing, largely to confirm he understood and had complied with the Tribunal's practice note regarding expert evidence,[9] as it had not been referred to in either Report. Rattan's counsel were satisfied that we could proceed on the basis that he had done so and so there was no requirement for Torvaldsen to give evidence. We further proceeded on the basis there was no dispute as to the contents of the First and Second Reports.[10]
4. Relevant to characterisation of the proven conduct under each Allegation, Torvaldsen expressed the following opinions.

Allegation 1 - failure to conduct a physical examination in the relevant period

1. In respect of Rattan's failure to see the Patient over the nearly two and a half year period, Torvaldsen's opinion included the following, touching on home visits and Rattan's failure to do so:[11]

It is my belief that [Rattan] should have conducted some home visits over the period in question. Exactly how often is open to debate, but in my opinion 2.5 years is too long a period to pass without any face to face consultation. Most PBS prescriptions with repeats have to be re-prescribed after a period of 6 months. In my opinion, this 6 monthly period would have been an appropriate interval at which to conduct home visits, and certainly at least every 12 months even with some nurse visits also occurring in the interim.

1. As to Rattan's monitoring and reviews of the Patient, Torvaldsen said:[12]

On the basis of the information provided to me, it is my opinion that the monitoring and reviews of [the Patient] were inadequate. [Rattan] claims that there were nurse home visits to provide 'regular comprehensive health assessments, medical (sic) checkups and vaccinations'. However these visits appear to have been relatively infrequent and I can see no evidence of any medical involvement in the comprehensive health assessments, which appear to been undertaken, formulated and written entirely by his [the Nurse]. As stated above, it is my opinion that at least some GP home visits should have been undertaken over this time period, especially as the patient lived only 5 minutes' drive from [the Centre]. I think that a very relevant example came at the end of his involvement in her care, when he decided to reduce the dose of [tramadol] prescribed solely on the basis of his nurse's assessment, without conducting any medical assessment himself . . . I believe that a significant change in pain medication requires both a medical assessment and a conversation with carers (although I note that [Rattan] did say he discussed the change with [the Patient's Daughter] who was said to be 'pleased with the outcome').

1. When asked to state his opinion on whether Rattan's treatment of the Patient met the standard reasonably expected of a registered medical practitioner of equivalent training or experience, Torvaldsen stated that Rattan's care for the Patient 'progressively fell below that expected of a registered medical practitioner with an equivalent level of training or experience'. When asked if the treatment fell 'substantially below' the standard to be expected, Torvaldsen referred to the difficult family circumstances and his understanding that no harm came to the Patient and expressed the view that the departure from standards was not substantial or severe.[13]
2. We record that, at the hearing, we were informed that the Board's position was that, whether or not harm was caused to the Patient, the potential risk of harm to which the Patient was exposed (including by reference to the risks associated with the combination of medications - see [48] above quoting from Part 2.4.2 of the RACGP Guidelines) meant the departure was substantial.

Allegation 2 - prescribing without appropriate levels of review, assessment and management planning

In my opinion the repeat prescribing of medication (ie medications that have been taken by the patient over a long period) can be undertaken based upon information from a nurse and carers. However, this ideally should involve a medical review after a period of time, especially where drugs such as opioids and benzodiazepines are involved. It should be noted that elderly patients are at increased risk of side effects from these medications. This is especially true when the dose is increased . . . It is my opinion that 2.5 years is too long a period to rely solely on nurse and carer reports and at least some medical examination should have occurred over this time.

1. As to the suitability of the pharmacotherapy provided to the Patient, while Torvaldsen considered the substances and the doses were not 'outside the range used in normal clinical practice' it was not possible for him to determine whether the pharmacotherapy was appropriate, although it may have been.[15] He added that, one of the problems was that it would have been very difficult for Rattan:

to be sure of the appropriateness of his management in the absence of any face to face consultation, very few nurse visits and relying largely on reports from family members.

1. Specifically in respect of a management plan for the Patient, Torvaldsen said:[16]

[I] can see little evidence of any relevant management plans in relation to pain or insomnia. There are two Health Assessments provided, which appear to be from June 2017 and July 2018. Only the first of these mentions pain management and states 'Provide ongoing review of pain and medication efficacy'. I take this to imply that the tramadol would continue to be used for pain management, this would be kept under review and that no other strategy was considered. The 'ongoing review' consisted solely of reports from family members and relatively infrequent nurse visits. However, it must also be recognised that continuing 10mg of temazepam nocte in someone who is elderly and has been taking it for a long time would be a common practice and although less than ideal is often the only practicable course of action in a patient who is resistant to other options, as is often the case in the elderly. I do not believe that of itself, this constitutes an unacceptable practice. Likewise, it is very difficult to engage in non-pharmacological treatments if the patient is unwilling to participate, and the evidence indicates that this was likely the situation with [the Patient]. I note [Rattan's] statement that he suggested further specialist assessment on a number of occasions to which her [Son] refused to consent.

Allegation 3 - falsification of the clinical records

1. In respect of the falsification of the clinical records, Torvaldsen referred first to the role of a practice nurse and then to Rattan's conduct as follows:[17]

It is my opinion that recording vital signs obtained by a practice nurse constitutes normal and appropriate medical practice. Indeed this is what occurs on an everyday basis in most general practices and is one of the purposes of employing nurses, who are fully qualified to take such measurements both in general practice and in hospital. However, such records must be contemporaneous and accurate, and copying measurements from his own earlier records is not acceptable practice and is in effect providing a falsified record. In addition, unless it is recorded elsewhere that the measurements were obtained by the practice nurse, this should have been recorded in the patient notes and especially so where it appears that an examination has been undertaken.

1. Separate from the falsification of the clinical records, Torvaldsen had concerns about the overall quality of the notes and in particular:[18]
   • The comprehensive medical assessments provided were not well documented: in respect of one or more of those, the date on which the assessment(s) was undertaken or completed was not apparent;
   • There 'appeared to be little or no medical input into the assessment or any meaningful plan in terms of her ongoing medical care';
   • 'At best, it could be said that the plans provided barely meet the minimum standard for a comprehensive medical assessment'; and
   • Having regard to the falsifications:

I as another GP would not be able to determine what care was actually provided by reading the records [and so] it is my opinion that the medical record in relation to [the Patient] from 8 July 2017 onwards falls substantially below the standard expected of a registered medical practitioner with an equivalent level of training or experience

1. Torvaldsen prepared the Second Report after being informed that Rattan had stated he had either entered the examination findings made by the Nurse as his own or had copied over previous examination findings into the clinical records. On that issue, he:
   • Noted the information the Nurse had given as to when she made home visits and that there were records for other dates which appeared to have been falsified. He said that it 'would certainly be unusual for a nurse to make a home visit to a patient without making any record of the consultation';
   • Referred to the multiple instances of clinical findings and observations recorded at times the Nurse had not made home visits. He referred to an entry dated 1 September 2017 which said the following:

BP (Sitting): 124/72

Pulse (Sitting): 68 Regular Not clinically anaemic.

Respiratory: Normal air entry on Right. Normal air entry on Left. No creps. No rhonchi. Dual heart sounds, no clinical evidence of CCF

He then described that as 'quite a detailed examination that could only be performed in person' and could not see how it could have been entered into the records by accident;

• Referred to an examination said to have been undertaken on 25 January 2018 that included 'Tender over the right hip lateral aspect with [restricted range of movement]'. He said that finding could only have been made after a physical examination and was not one he would expect to be undertaken by a nurse (also noting the Nurse did not see the Patient on that day); and
• Noted an exact same entry on two dates which had the same examination findings, blood pressure readings and which both misspelt the word 'repeats' as 'reepeats'.

Given the new evidence presented to me that these findings could not have been obtained by his [Nurse], the only reasonable conclusion I can draw is that [Rattan] has deliberately and repeatedly falsified [the Patient's] medical records.

Falsification of medical records is an offence in itself, but my opinion is that the combination with claiming Medicare consultation items when no consultation has occurred makes the matter more serious. I can see no other purpose to falsifying the record in this situation, other than to create the impression that a consultation had occurred when in fact it had not.

1. We record that, at the hearing, the Board's counsel informed us he had spent some time reviewing the falsified entries to determine whether they were copied and pasted from earlier entries. Without taking us to the detail, he asserted that the relevant entries were not always identical to earlier entries and so it seemed, to him at least, that small adjustments were made (such as to blood pressure readings). The Board's Submissions noted that, contrary to Rattan's explanation, none of the vital signs recorded in the clinical record in the period prior to 4 August 2017 were the same as those made before that (although some matched those falsely entered after that date[19]).

It is my opinion that the bulk of the Medicare item numbers listed as claimed by [Rattan] over the period 4/8/17 to 2/12/19 are not valid claims. This is because item 23 (and the attached 10990) require a face to face consultation with the patient. This is a well-known, clear cut and indisputable requirement and I believe that to claim an item 23 when no consultation has taken place is incorrect . . . Item 707 does allow practice nurse involvement, but only to 'assist' the GP. It is implicit in the item descriptor and explanatory notes that the GP have some involvement in the process, and I believe that in most cases a physical examination by the GP would be required to adequately complete the assessment. It therefore appears likely that the item 707 claims are also not valid. Items 721 and 723 . . . imply a physical attendance by the GP, but it is less clear from the item descriptor and explanatory notes whether this is mandatory, if the patient is not mentally competent and the consent and explanations are given to the carer/guardian. However, the records state that [the Patient] was mentally competent and so the plan should have been discussed with her. This appeared to have been done via the [Nurse], the item explanatory notes specify that the provider must undertake this discussion. I am not sure that delegating this task to a practice nurse is permissible by the MBS.

1. We note that Torvaldsen's view of the Patient's capacity appeared to us to be confirmed by the content of a health assessment dated 28 November 2019.[21] She is referred to as being 'alert', having no issues with 'orientations, memory, thinking or planning' and was 'aware of all of her medications'.
2. The Second Report included the following in respect to Rattan's presentation of examination findings made by the Nurse as his and his copying of findings he had made earlier:

if no face to face consultation occurred during the preparation of the care plan and team care arrangements (item 721 and 723) documented on 17th June 2017, then this would not have fulfilled the MBS criteria for claiming these items. Whilst a practice nurse may assist in the preparation of a care plan, it is not adequate for a care plan to be prepared wholly by a nurse and simply signed by a doctor. I refer you to the item 721 descriptor which states: 'Attendance by a general practitioner for preparation of a GP management plan for a patient'. I cannot see evidence of a face to face consultation (ie attendance) in the notes . . .

Arrangements for the collection of prescriptions

1. While the arrangements which were in place for collection of prescriptions by family members was not the subject of an Allegation, we considered it appropriate to quote the following from Torvaldsen which addressed the practice:[22]

I think that given the longstanding nature of the relationships involved, the infirmity of the patient and the prevailing circumstances, that providing prescriptions for relatives to collect was reasonable and in itself did not put the patient unduly at risk. I think that many GPs would allow relatives of elderly patients to pick up prescriptions on their behalf in situations such as this.

1. The Agreed Statement said the parties had agreed that Rattan's conduct taken together constituted professional misconduct under paragraphs (a) or (b) of the definition in section 5 of the National Law.
2. At the hearing, the Board's counsel informed us that a global finding of professional misconduct was sought under paragraph (a) of the definition, but also that it was open to the Tribunal to also make a finding under paragraph (b). It was submitted that the latter finding could be made in respect of individual conduct (such as the falsification of notes and/or Medicare billings) on the basis of Torvaldsen's reports but that the Board considered each instance of conduct constituted professional misconduct under paragraph (a).
3. Rattan's counsel accepted that a global finding could be made under paragraph (a) of the definition but that a finding could be also or alternatively be made under paragraph (b) of the definition. He went on to say that, if the Tribunal was minded to make individual findings on the four Allegations, Rattan would not seek to be heard on that. Further, he stated Rattan had no wish to minimise the conduct.
4. As to paragraph (c) of the definition, we invited the parties to make submissions about why it had not been raised by, in particular, the Board. We were informed that, while the Board's original allegations had relied on that paragraph, as a result of negotiations between the parties, a finding under paragraph (c) was not being pressed by the Board.
5. Rattan's counsel stated that his client would not stand in the way of the Tribunal making a finding under paragraph (c) if it considered it appropriate. He noted that paragraph (c) was usually relied on for conduct outside professional practise (which did not apply here).

1. In circumstances where the Board's referral to the Tribunal contained four Allegations which all alleged that the conduct described constituted professional misconduct or unprofessional conduct as defined in the National Law, we considered our task was to make individual findings on each.
2. We accepted that there were factual commonalities between all of the Allegations and that there was overlap between Allegations 1 and 2, with the latter perhaps able to be regarded as a sub-set of Allegation 1. Despite that, we considered it to be important that the Tribunal make findings as to how each category of conduct was to be characterised because each was capable of being engaged in separately. In that way, we intended to make plain to Rattan and the profession as a whole how conduct may be assessed.

Allegation 1 - failure to conduct a physical examination in the relevant period

1. Having regard to the Code of Conduct, Torvaldsen's opinion and the parties' agreement, we found that Rattan's failure to, between on or about 8 July 2017 and 2 December 2019, provide the Patient with appropriate care and treatment, by not conducting a physical consultation with her, constituted professional misconduct within the meaning of paragraph (a) of the definition.
2. In making that finding, we accepted that it was not of itself inappropriate for Rattan to provide treatment without having physically examined the Patient on each and every occasion. In expressing that view, we had regard to Torvaldsen's opinion that, having regard to the longstanding nature of the relationships involved, the Patient's infirmity and the family circumstances, that providing prescriptions for relatives to collect was reasonable and in itself did not put the patient unduly at risk.
3. However, providing treatment for around two and a half years without seeing the Patient was below the standard to be expected of any general practitioner but particularly one with Rattan's experience. In this case, it was a substantial departure from standards because, by not physically seeing the Patient, there was no opportunity for Rattan to update his knowledge and assessment of the Patient, including as to her physical symptoms, her psychological state or her social circumstances.
4. As the events in issue occurred before the COVID-19 pandemic, telehealth consultations were not available. Rattan's options were to either persuade the Patient to come to (or be brought to) the Centre, to make a home visit or to perhaps arrange for a locum doctor to attend in his place.[23]
5. Although Rattan asserted that 'we were in constant touch with [the Patient] through our practice nurse', the records do not reflect that level of contact between the Patient and the Nurse. We understood the evidence to show that, in the period July 2017 to November 2019, the Nurse attended the Patient's home (at most) on three occasions.[24]
6. Rattan referred to having telephone conversations with the Patient[25] but there was no record of any of those. On 22 November 2019, Rattan described a 'Surgery Consultation' with the Patient's Son and wrote that the Patient had refused to attend for a health assessment the week before.
7. While we do not have knowledge of the full background to the way in which the Patient was being cared for, the clinical records demonstrate how Rattan's failure to personally consult with the Patient risked potentially important information about her overall wellbeing and the care she was receiving being missed.
8. The clinical record shows that the discussion about the November 2019 health assessment and the need for her to attend physically was initially held between the practice manager and the Patient's Son. The practice manager later called and, after the Son refused to bring the Patient to the Centre, Rattan told her to speak to the Son when he came to the Centre. The practice manager also spoke to The Patient on the telephone and wrote as follows:[26]

[The Patient] so abrupt and quick to get me off the phone, very unusual of [The Patient].

1. The final two entries in the Patient's clinical record at the Centre were made by the practice manager on 6 and 18 December 2019 and said:

[the Daughter] called [the Patient] had home visit booked with podiatrist which main rooms called to confirm [Son] declined the visit, [the Daughter] was so upset wanted to rebook phone number was given. [The Daughter] was also aware [of] her mother's medical request to another clinic is very upset about it she said her mother would have been forced by her brother to sign release form. [The Daughter] claims she has power of attorney I advised [the Daughter] you need to work it out between the two of you.

. . .

[The Daughter] called clinic wanting to make appointment for scripts, [the Patient] has had her files transferred to another clinic at the request of her family, that clinic wouldn't give her scripts because [the Patient] won't go to the clinic, [Son] trying to get scripts on her behalf

1. While these records raise concerns with the benefit of hindsight, they illustrate the importance of a treating medical practitioner seeing their patient, obtaining an updated history and eliciting information about their social and other circumstances.
2. The effect of the TB materials (and Rattan's admissions) is that the Patient was only seen physically three times in the period 8 July 2017 to 28 November 2019[27] and that otherwise, assessments of her health and wellbeing were undertaken via the Nurse (and practice manager) having discussions with her Son and, on some occasions, her Daughter.
3. Rattan's conduct as described above was a substantial departure from the standard of medical care which is expected to be provided by a medical practitioner.

Allegation 2 - prescribing without appropriate levels of review, assessment and management planning

1. Having regard to the Code of Conduct (Parts 2.1 and 2.2), the RACGP Guidelines (Part C1), Torvaldsen's opinion and the parties' agreement, we found that Rattan engaged in professional misconduct under paragraph (a) of the definition when, between on or about 8 July 2017 and 2 December 2019, he prescribed the Patient temazepam and tramadol, without appropriate levels of ongoing review, assessment and management planning.
2. As stated above, the conduct in Allegation 2 could be viewed as conduct which is a sub-set of that in Allegation 1.
3. In our view though, the particular conduct in Allegation 2 must be viewed separately because of the substances Rattan was prescribing to the Patient and the risks they carry in combination for someone of her age. As referred to in the RACGP Guidelines, the combination of medications could increase the risk of a patient experiencing:
   • Nausea and vomiting;
   • Drowsiness;
   • Urinary retention;
   • Constipation;
   • Cognitive impairment;
   • Weight gain or weight loss;
   • Respiratory depression;
   • Falls; and
   • Fractures.
4. While we accept that the Patient had been prescribed temazepam and tramadol for many years, that does not mean there was no potential risk attached to the ongoing use of the medications. The absence of a management plan and given her age, risked the Patient experiencing the side effects of those medications referred to above.
5. In all of the circumstances, we considered it appropriate to make a separate finding that Rattan's conduct in respect of the prescribing was a substantial departure from standards and so within paragraph (a) of the definition of professional misconduct.

Allegation 3 - falsification of the clinical records

1. Having regard to the Code of Conduct (Parts 1.4 and 8.4), Torvaldsen's opinion and the parties' agreement, we found that Rattan engaged in professional misconduct under paragraph (a) and (c) of the definition when, between on or about 4 August 2017 and 4 July 2019, Rattan falsified the Patient's clinical record by knowingly, incorrectly and misleadingly recording vital signs attributed to the Patient despite not physically attending on the Patient.
2. In respect of our finding of professional misconduct under paragraph (a), we noted the way Torvaldsen described the importance of clinical records being made contemporaneously and accurately. We noted that he said, as a general practitioner, he would not have been able to determine from the clinical record what care was actually to the Patient. That demonstrates the risks associated with inadequate and inaccurate notes.
3. More generally, as explained in the Code of Conduct, good medical practice involves keeping accurate, up-to-date and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management in a form that can be understood by other health practitioners.
4. While we accept the conduct was engaged in within Rattan's practise, we found that the falsification of the clinical record was dishonest and so warranted a finding under paragraph (c) of the definition. It was clearly dishonest for Rattan to have manufactured entries (whether by making them up or copying them from earlier physical examinations). We also considered that his adoption of the Nurse's examination findings when he knew very well he had not seen the Patient was dishonest.
5. We noted and agreed with the following Board submissions which, in our view, captured the relationship between the substantial departure from standards and our finding that the conduct was not that of a person suitable for registration (within paragraph (c) of the definition of professional misconduct):[28]

Recording false vital signs has the potential to cause substantial harm to a patient. It can create a false appearance that the patient's vital signs remain steady and healthy, when in reality they are deteriorating. In the event that another medical practitioner attempts to understand when a patient began deteriorating, false medical records can give the appearance that deterioration commenced more recently (and potentially in a more severe manner), prejudicing proper diagnosis and treatment.

[Rattan's 17 March 2020 explanation[29]] that he wanted to ensure 'the perfection of my medical record' is not a reasonable explanation. A false medical record is, by definition, a non-perfect one, and other entries of consults do not contain the vital sign information. As such, it appears that [Rattan] deliberately falsified [the Patient's] medical [record] to give the appearance that he had attended upon [the Patient] face-to-face, either to justify Medicare billing or to cover up his failure to properly care for [her]. Had [Rattan] believed that consulting with [the Son] was appropriate, he could have written in the clinical record that the consult occurred with [the Son] and not included the vital signs.

1. For completeness, we record that we did not consider there was any utility in making a finding under paragraph (b) of the definition of professional misconduct in respect of this Allegation because we considered that each and every instance of falsification of the clinical record was a substantial departure from standards.

1. Having regard to the Code of Conduct (Part 1.4), Torvaldsen's opinion and the parties' agreement, we found that Rattan engaged in professional misconduct under paragraph (a) when between on or about 4 August 2017 and 2 December 2019, he recklessly billed the relevant Medicare items despite not meeting the applicable billing requirements given he did not physically attend on the Patient or create a patient management plan.
2. As is apparent from the facts in this matter, the Medicare billings were not the result of inadvertent errors which, we accept, can be made from time to time.
3. As agreed between the parties, it was not alleged that Rattan inappropriately billed Medicare fraudulently or knowingly.
4. The significant departure from standards was twofold.
5. First, Rattan must have known very well that he had not consulted with the Patient at the Centre on the 34 occasions when he billed Medicare for those consultations using item 23 (for face-to-face consultations). As noted by Torvaldsen, that item is the most commonly used by general practitioners and so should be well understood by all which to be for face-to-face consultations. Further, Rattan must also have known he had not prepared a patient management plan himself at the time he instructed his staff to bill Medicare.
6. Second, Rattan appears not to have, at any stage, turned his mind to the billing items he was routinely using when the Son and not the Patient attended nor considered whether there were other more appropriate billing items. Had he done so, he might have turned his mind to the wider question of the manner in which he was treating the Patient and her ongoing medical conditions.

1. Section 196(2) of the National Law sets out the determinations the Tribunal may make where professional misconduct or unprofessional conduct has been proven. They include cancellation of registration, suspension of registration and the imposition of conditions.
2. The Tribunal's primary role is to protect the public rather than to punish health practitioners who engage in professional misconduct or unprofessional conduct. Determinations also assist to maintain proper ethical and professional standards to protect the public and the profession in the sense of maintaining stature and integrity in the eyes of the public. The Tribunal is also required to, in appropriate cases, make determinations which will deter the individual health practitioner from engaging in the same or like conduct again and/or which serve as a warning to other health practitioners that engaging in the conduct will bring serious consequences - the latter is known as general deterrence.[30]
3. When making determinations, the Tribunal has regard to section 3A of the National Law which says relevantly:

(1) The main guiding principle of the national registration and accreditation scheme is that the following are paramount -

(a) protection of the public;

(b) public confidence in the safety of services provided by registered health practitioners and students.

(2) The other guiding principles of the national registration and accreditation scheme are as follows -

. . .

(c) restrictions on the practice of a health profession are to be imposed under the scheme only if it is necessary to ensure health services are provided safely and are of an appropriate quality.

1. After the parties made their submissions on determinations, we raised some queries about matters we considered relevant to the parties' proposed outcomes. Rattan gave evidence in order to address those and more generally. We take this opportunity to record that Rattan's evidence, which appeared to us to have been genuine and heartfelt, was very helpful to us when it came to deciding what determinations ought to be imposed.

1. The following comes from Rattan's evidence, supplemented by material in the TB and a letter he wrote addressed to the Tribunal on 13 March 2025 (Rattan's Letter).
2. In around 2018 to 2019, when Rattan was treating the Patient, he was ill with worsening renal failure. Its consequences included tiredness and reactive depression. In January 2021, Rattan had a successful kidney transplant, his wife having donated a kidney and them being part of a kidney donor chain. Rattan has been taking immunosuppressant medication since and his renal function is normal.
3. Due to being immunosuppressed, Rattan takes particular care to avoid contracting infections. When seeing his patients he wears an N95 mask and uses other protective equipment such as medical grade gowns and face shields.
4. At the hearing, Rattan's evidence was that he is now in good health 'in body and mind'. He is currently aged 69 years and intends to retire in the coming two to three years.

1. Rattan gave the following evidence about his practice:
   • Since 1994 he has been the sole general practitioner at the Centre;
   • He employs a practice manager and is currently looking to employ a practice nurse;
   • He now works from 9am to 5pm Monday to Wednesday and Friday and he works until lunchtime on Thursdays. He reduced his work hours following the COVID-19 pandemic and his health issues;
   • His patient cohort is mixed, ranging from infants to older people. Most are repeat patients. He closed his books to new patients around four years ago; and
   • He speaks and so consults in English, Hindi, Punjabi and Urdu.
2. Rattan gave evidence about his training which included obtaining his medical qualifications overseas and then completing the required Australian Medical Council program to be registered in Australia. He referred to the latter as 'rigorous'. He made good friends through that program and maintains contact with them. He informed us that his pre-registration training in Australia included working in emergency departments and as a locum a few times. Otherwise, almost of his practice had been as a solo practitioner. He referred to a colleague who worked with him for a short time but, as we understood it, she decided it did not suit her.
3. In respect of a query we had about how he managed being a sole practitioner and the risk of professional isolation, Rattan gave evidence that, when he faced a difficult situation, he turned to a group he and his old friends had formed to seek support and information from each other. We understood they meet reasonably regularly. We understood that group is part of his more reflective mode of practice.
4. Rattan informed us that he had made changes to his practice including having a face-to-face consultation with all patients at least every three months and having a consultation every two months for those patients who are on medications which carry the risk of addiction.
5. He said his prescribing of such medications (including temazepam and tramadol) had changed, including by him assessing alternative options first, ensuring the lowest dose possible was prescribed and having a management plan in place.
6. Rattan gave evidence that he now practises with more of a medical ethics focus, with medical ethical considerations coming first. He understood that his professional obligations may not allow him to do what he considered to fall within his compassionate instincts.
7. Rattan gave evidence about the challenges of finding a locum practitioner - a topic that was the subject of submissions in respect of the Board's proposed suspension of his registration. Rattan had six weeks off work when he had the kidney transplant and had difficulty finding a locum willing to cover his absence. He was able to engage a locum but they only worked for mornings in the practice.
8. Rattan's Letter included the following:

If I am suspended from practice, I am very concerned about what will happen to the clinic and my patients. Other than the six weeks off I took following my kidney transplant, and the more limited services I offered in 2024, I have never taken any extended period of time off since I took over [the Centre] in 1994.

The staffing limitations I have already experienced are such that I am concerned [the Centre] would have to shut down on short notice and a large number of patients would be without a primary care doctor overnight. I am very worried about that happening to my more vulnerable patients, such as my non-English speaking, financially conscious and elderly patients for whom continuity of care is particularly important. As it is, it is difficult for patients in the Fawkner area to find new doctors as many clinics are overloaded and do not take new patients especially with complex health care needs.

For my part, I am concerned that if [the Centre] closes down suddenly, it will be hard to restart. I was born in 1955 and am now 69 years old.

1. In his evidence before us, Rattan stated that locums were not interested in working on the north-west side of Melbourne and they preferred multi-doctor to sole practitioner practices. Those difficulties were not alleviated by him offering higher than usual rates of pay and offers to cover the costs of travel. He also referred to the requirement that overseas doctors work outside the Melbourne metropolitan area as a factor increasing the challenge of recruiting a locum. His evidence was that, on his prior experience, he would need around three months to secure the services of a locum (in the event he was suspended).
2. Rattan referred to complaints he had received about locums he had used in the past. Patients told him that the locum had not examined them (for example taken their blood pressure), issued prescriptions without checking with them and not listened to them.
3. He expressed concern about the impact a suspension would have on his practice by reference to the above issues and about what would be left of his practice when he returned. His opinion was that a locum could not 'do justice' to his patients.
4. Rattan stated that his longer term goal was to find someone to purchase the practice over time to allow a gradual handover to that person over around two to two and a half years so his patients could get to know them.

1. In correspondence to the Board and the Tribunal, Rattan offered reflections on his conduct in respect of the Patient.
2. In an 11 August 2021 letter to Ahpra, Rattan stated:[31]
   • He 'fully' admitted that he 'failed to provide [the Patient] an adequate medical care under very difficult circumstances presented to me';
   • He accepted that the Medicare claims 'were not valid and were made in error';
   • He 'fully' admitted 'my multiple mistakes in this case'. He added that he expressed his 'deep regrets and remorse' to the Board and stated that the invalid Medicare claims were not a true reflection of his practice performance. He offered to have an audit undertaken in respect of his clinical records and billings (we were informed that the Board/Aphra did not consider that was necessary);
   • He had learnt multiple lessons and would continue to implement changes to his practice and the supervision of his practice nurse; and
   • 'This has not been and will never be repeated again in my practice'.
3. Rattan's Letter to the Tribunal included the following:

Since this matter was first brought to my attention by AHPRA in 2019, there has not been a single day that it has not weighed heavily on my mind. The shortcomings of the care I provided to [the Patient] are a matter I think back on with regret. I am now in a much clearer headspace owing in part to my recovered health and the education I have undergone. I believe that I am now providing better patient care than I was before and am certainly enjoying my practice more than I did. I would be most grateful for the opportunity to continue.

1. Rattan confirmed the above statements in his evidence, again saying he thought about his shortcomings daily and apologised to God for 'this mistake'.
2. In his evidence, Rattan suggested that, when it came to his continuing treatment (including prescribing) of the Patient despite not seeing her personally, perhaps compassion have overtaken medical ethics. He spoke of the education he had undertaken and having learnt that, at the top of the pyramid, is the practitioner's ethical obligations. Since these events, he had applied that approach to his treatment of patients.
3. When asked what he would do differently if faced with a longstanding patient who required pain relief but whose carer would not bring them to the Centre, Rattan said he would:
   • Take more time to think about the issues;
   • Contact another member of the family (separate from the carer) to discuss the situation;
   • Speak to the patient; and
   • 'Perhaps' do a home visit.
4. Rattan also referred to checking there was no abuse occurring and contacting the local police if he had concerns about that.
5. It was put to Rattan that his 'good intentions' had led him astray and he was asked how he would ensure that did not happen again. Rattan referred to medical ethics coming 'on top' of compassion. In cross-examination, Rattan was again asked about the role 'good intentions' played in his treatment of the Patient. He said those were not the cause of him not undertaking a home visit - rather he was not thinking about the situation sufficiently. He added he should have done that and he accepted he did not provide the Patient with adequate care.
6. In re-examination, Rattan was asked about whether his then state of health impacted on his decision making about home visits: Rattan said he was extremely tired then and had mobility issues. He is now able to do home visits and he wears personal protective equipment if the patient is infective.

1. Rattan relied on an education program he undertook in September 2023 through Morrison Consulting & Advisory.[32] The Education Report which was prepared after the education had been completed showed that the program was designed after initial discussions and identification of Rattan's needs.
2. The topics covered were:
   • Foundations of professional practice;
   • Professional ethics;
   • Safe and ethical prescribing;
   • Record keeping; and
   • Compliance with the Medicare Benefits Scheme.
3. The topics were covered by a combination of written and scenario/cases based assessments. Rattan completing workbooks in advance of face-to-face sessions, with those sessions totalling nine and a half hours. The Education Report commented on Rattan's work on each session in detail. The educator's final 'Impressions' were as follows:

[Rattan] was an enthusiastic participant in the program. He was very reflective about the situation that led to the requirements that he undertake this education. He identified and acknowledged deficiencies in his practice that he has now corrected.

[Rattan] took notes throughout the sessions, and whilst his workbooks (in particular workbooks 3, 4 and 5)[33] were 'light' in regard to the content of his responses, he was clearly able to expand on his responses during the face-to-face discussions and came across as a thoughtful, careful and considerate solo GP.

Applying the concepts and principles addressed during the education program will now be a matter for [Rattan] to incorporate into his practice.

1. The Board's written submissions sought conditions for education and mentoring but, at the hearing, the Board's counsel stated that only mentoring conditions were sought. We took that as an indication that the Board was satisfied that the Education Report (and the work it described) met its concerns as to education.

1. Rattan relied on two personal references.[34] We were informed that the referees had not been informed of the Allegations due to the humiliation Rattan felt.
2. We acknowledge that each spoke highly of Rattan.
3. The first reference described Rattan as a 'perceptive, caring and thorough physician', as having the 'highest ethical and moral standards of practice' and a focus on his patient's best interests.
4. The second said the author was 'not aware of a more competent, caring, trustworthy and dedicated General Practitioner' who has 'an extraordinary professional relationship with all of his patients who invariably speak particularly highly of his dedication and manner in dealing with their issues'.
5. Where the referees were unaware of the matters before us, we could give very limited weight to the references.

1. The Board sought the following determinations:
   • A reprimand (under section 196(2)(a) of the National Law);
   • The suspension of Rattan's registration for six months from the date of the Tribunal's orders (under section 196(2)(d) of the National Law);
   • The imposition of conditions for mentoring on Rattan's return to practice (under section 196(2)(b) of the National Law); and
   • A review period of six months in respect of the conditions (under section 196(3) of the National Law).
2. The Board described Rattan's conduct as involving 'prescribing opioid medications without face-to-face physical assessment, recklessly billing Medicare items to which he was not entitled, and falsifying patient records'. It submitted a period of suspension was required to demonstrate public denunciation of Rattan's conduct and to deter him and others from engaging in similar conduct. Such a period was said to be necessary to maintain public trust in the profession. As stated earlier, it considered a period of mentoring would be appropriate on Rattan's return to practice.
3. The Board relied on a number of cases in support of its proposed determinations as summarised below.
4. The Board submitted that a period of suspension was required to meet the requirements of general deterrence, particularly relating to our finding that the conduct in Allegation 3 fell within paragraphs (a) and (c) of the definition. It also noted that the purpose for which the falsifications were made remained unclear.
5. It submitted that the fine Rattan asked to be imposed was a less appropriate outcome for the purposes of general deterrence.
6. The Board submitted that any reliance Rattan placed on his ill health at the time he was treating the Patient ought not to be accepted. It noted that Rattan elected to continue to practice despite his health issues and that the standards to be met by medical practitioners cannot be reduced to accommodate a practitioner's health.
7. It reminded us that the conduct was engaged in for a two and a half year period and so it was not momentary.
8. The Board very appropriately stated that specific deterrence was a lesser consideration in this case.

1. Rattan sought the following determinations:
   • A reprimand; and
   • Instead of imposing a suspension which would penalise Rattan's patients, a fine up to the maximum amount of $3000 (under section 196(2)(c) of the National Law).
2. Rattan's counsel submitted, and we accepted, that there were no indication that determinations were called for due to a risk to patient safety. He drew our attention to the fact no immediate action suspension or other step was taken when the Board received the notification (under section 156 of the National Law).
3. Weight was placed on the time that had passed since the relevant conduct - six to eight years - and the fact that there had been no like conduct before or since.
4. Emphasis was placed on Rattan's previous proper practise and his good character. His counsel described the behaviour in respect of the Patient as having been 'once in a lifetime' which was abnormal with him having returned to his 'normal' behaviour since.
5. While it was accepted there was no clear evidence on whether the Patient had suffered harm, Rattan's counsel noted that no such allegation had been made. He accepted that the vice of the conduct was the risk of harm to the Patient.
6. It was submitted that Rattan had done all that could have been asked of him - he had:
   • Fixed his health;
   • Made admissions, including throughout this proceeding;
   • Repaid Medicare voluntarily; and
   • Undertaken the professional education described above.
7. Rattan's counsel informed us that he had been instructed to make a submission he had never before been asked to put: that Rattan be fined up to the maximum (or more) so that he would, in effect, work for free and there be no interference with the continuity of care for his patients. They were foremost in Rattan's mind.
8. It was submitted that Rattan was worried that he would not be able to see his patients because a locum 'was always second best'. As indicated in Rattan's Letter, he was concerned about the practice he would return to after a suspension as a practitioner aged 69 years. We understood the concern was for the wellbeing of his patients, that the practice would have reduced and, at his age, it would be difficult to rebuild.
9. Rattan's counsel drew a limited comparison between his client and medical practitioners who work in remote or rural locations where consideration is given to the impacts on their patients if they are suspended. In this case, Rattan's capacity to consult using a number of languages was said to place him somewhat in a similar category.
10. Rattan's counsel queried the basis for the Board submitting that a suspension has greater effect in respect of general deterrence than a fine. He asked rhetorically who would look at what Rattan had been through and not be deterred.
11. It was suggested that suspending Rattan might be counterproductive in terms of encouraging practitioners to respond to disciplinary matters in an appropriate manner.
12. It was submitted that the determinations ought to respond to the overall justice of the circumstances and punish to the maximum extent without stopping Rattan from providing services he was safe to provide. Rattan's counsel submitted that a suspension would do more harm than good.

1. The parties referred us to a number of cases in support of their submissions on determinations organised by reference to the kinds of conduct we have found proven.[35]
2. As is more often than not the case, none of them were sufficiently on all fours as to be of direct assistance to us. Many were the product of agreed positions on different combinations of allegations and facts and so they were of limited assistance when it came to us deciding how to resolve the differences between the parties' proposals for determinations.
3. For example, there were cases concerning improper prescribing of drugs of addiction to multiple patients who were vulnerable or who had or developed addictions.[36] Some of that group of cases involved charges for breaches of the Drugs, Poisons and Controlled Substances Act 1981 (Vic) and guilty findings or convictions.[37]
4. A case involving falsification of clinical records concerned a practitioner who had failed to make notes of required observations and then amended the notes to cover up the failure after the aged care resident had a fall and was hospitalised.[38] Another involved inadequate notes where the practitioner had in fact provided relevant care.[39]
5. A group of cases concerned Medicare and other billing where criminal charges were laid and the practitioners were convicted.[40] The funds in issue ranged from around $13,000 to around $64,000 as compared to a sum (in the order of around $2,000) Rattan recklessly billed.

1. We concluded that it was appropriate in this case to make global determinations where the conduct across the four Allegations was engaged in as a course of conduct in respect of Rattan's treatment of the Patient. Having said that, we have made comments below on some of the conduct and its connection to the determinations we have made.

1. We were readily satisfied that it was appropriate to reprimand Rattan for his conduct in respect of the Patient over the period July 2017 to December 2019 and in respect of each of the four Allegations.
2. As is apparent from our description of the nature and seriousness of the conduct in Allegations 1 and 2, Rattan failed to treat his Patient with the care and attention to be expected of a medical practitioner of his experience.
3. As to Allegation 3, any practitioner who acts in a dishonest manner is to be denounced.
4. Allegation 4 concerned reckless inattention to the correct Medicare item numbers rather than knowing dishonesty or fraud. Nevertheless, the proven conduct was serious and concerning given that an experienced medical practitioner failed to charge with care and so display the integrity to be expected by the public, who ultimately fund Medicare. A reprimand was an appropriate response for the conduct.

1. We accepted that specific deterrence had a limited if not negligible role to play in this case. We were satisfied that the specific conduct described in the Allegations will not be repeated by Rattan, including because of the changes he has made to how he manages issues with patient attendance. We accept that his conduct was an aberration and not reflective of his usual practice.
2. Having said that, we maintained some concerns about the degree of insight shown by Rattan in respect of Allegations 1 and 2. As is apparent, the hallmark of Rattan's professional practice has been his wish to serve his patients. The materials indicate that he is dedicated to them and that his patients have appreciated his care and attention.
3. What concerned us was Rattan's ongoing belief that he, and only he, can provide his patients with appropriate care. He said words to the effect that a locum 'was always second best' and could not do justice to his patients. That seemed to us to give an undue weight to Rattan's perception of his skills and the role other practitioners may play in treating his patients. We have presumed that Rattan's views have been influenced by the fact that, since 1994, he has worked as sole practitioner and so has not seen the benefits that may come from collaborative practice and shared care. As we understood it, beliefs such as those have led to Rattan rarely having time away from work to rest and rejuvenate.
4. While we accept Rattan's experience of using locum doctors has not been positive, he seemed not to have appreciated that the complaints he said patients made about his past locum - not examining them (for example, not taking their blood pressure), issuing prescriptions without checking with them and not listening to them - was the same conduct he engaged in with the Patient.
5. For reasons related to the above concerns, we did not consider that a fine should be imposed so as to ensure only Rattan was adversely impacted. That was in part because the submission seemed to presume that no other medical practitioner could care for his patients.
6. We did not accept that Rattan's state of health at the time of the conduct in any way excused or reduced the seriousness of his conduct or acts as a mitigating factor. If anything, Rattan's failure to take stock of his capacity to continue practising at that time raises a question about his judgment and reinforced our assessment of his excessive belief in his unique capacity to care for his patients.
7. We concluded that it was necessary in the interests of general deterrence for a period of suspension to be imposed and were satisfied that would address the need to maintain public confidence in the profession and uphold the profession's standards.
8. We considered it to be imperative that we make plain to other practitioners and the community more broadly that the conduct Rattan engaged in, particularly as described in Allegations 1, 2 and 3, was unacceptable and would likely lead to time out of practice.
9. The risks that accompanied Rattan's failure to consult personally with the Patient for two and a half years have been discussed above.
10. We wish to denounce Rattan's falsification of records which was dishonest and carried the risks described by the Board (see [97] above). That aspect of Rattan's conduct, which remained unexplained, was entirely inconsistent with responsible and ethical practice and, when taken with the conduct in Allegations 1 and 2, called for a suspension to be imposed.
11. We were conscious of the impact Rattan's absence may have on his patients, including those who benefit from his capacity to consult in many languages. As explained further below, we took that matter into account when deciding on the period of suspension.
12. For completeness we record that, had only the conduct in Allegation 4 been before us, given the conduct was not deliberate and was rather reckless and confined to a relatively modest amount, a suspension would not have been required.

1. We decided to impose a three month suspension in order to balance the particular needs of Rattan's patients with the purpose of determinations.
2. In deciding the appropriate period was three instead of six months, we also gave weight to Rattan's evidence before us as to his genuine remorse and the changes he has made to his management of patients who have difficulty attending the Centre. Highly relevant was the fact that the conduct concerned only one patient in some 30 years of practice.
3. As is apparent from our orders, we concluded that, where there is no risk to patients or of repetition, we considered it appropriate for Rattan to have adequate time to make arrangements for a locum to take over his practice. We accepted that will be a challenge and were satisfied three months was an acceptable period before the suspension should take effect.

1. Noting the discussion above about Rattan's views about his role and to ensure that the lessons learned through these events are fully absorbed, we considered it appropriate to impose conditions for mentoring.
2. A mentor can discuss the subject matter of these Reasons with Rattan and also provide a sounding board for clinical and practice related issues he faces on his return to practice.

The allegations in respect of [Rattan] referred to the Victorian Civil and Administrative Tribunal (Tribunal) by the [Board] pursuant to s 193(1)(a) of the [National Law], are:

a) professional misconduct within the meaning of paragraphs (a), (b) and/or (c) of the definition in section 5 of the National Law;

b) unprofessional conduct within the meaning of the definition in section 5 of the National Law

in that between on or about 8 July 2017 and 2 December 2019, [Rattan] failed to provide [the Patient] with appropriate care and treatment in that he did not conduct a physical consultation with her over that period.

1. at all material times [Rattan] held a General and Specialist (General practice) registration with the [Board] as Medical Practitioner;
2. at all material times, [Rattan] practiced at [the Centre].
3. since between on or about 1993 [Rattan] was [the Patient]'s general practitioner;
4. since between on or about 1993 and July 2017 [Rattan] attended on [the Patient] regularly to conduct physical consultations;
5. since between on or about 8 July 2017 and 2 December 2019 [Rattan] did not conduct a physical consultation on [the Patient] despite continuing to provide treatment to her over this period;
6. [Rattan] has admitted to the facts and matters particularised in paragraph above in a letter to [Aphra] (the December Letter) dated 8 December 2019;
7. [Rattan] was at all materials time required to following and abide by the [RACGP Guidelines] and the [Board's Code of Conduct].
8. at the time of the conduct set out in paragraph v) above, the [RACGP Guidelines] adopted by the [Board] provided that . . .
9. at the time of the conduct set out in paragraph iii) above, the [Code of Conduct] provided that . . .
10. by engaging in the conduct above [Rattan] has failed to comply with the [RACGP Guidelines] and the [Code of Conduct].

a) professional misconduct within the meaning of paragraphs (a), (b) and/or (c) of the definition in section 5 of the National Law;

b) unprofessional conduct within the meaning of the definition in section 5 of the National Law

in that between on or about 8 July 2017 and 2 December 2019, [Rattan] prescribed [the Patient] with medication, namely temazepam and tramadol, without appropriate levels of ongoing review, assessment and management planning.

1. the [Board] relies and repeats the particulars at paragraphs i) to vii) at Allegation 1;
2. [Rattan] prescribed [the Patient] with temazepam on a regular basis since on or around October 2006.
3. [Rattan] prescribed [the Patient] with 100mg of tramadol on a regular basis since September 2013.
4. [Rattan] continued to prescribe [the Patient] with temazepam and tramadol between 8 July 2017 and 2 December 2019 despite not conducting a physical assessment on [the Patient] since 8 July 2017;
5. [Rattan] continued to prescribe [the Patient] the medication described in paragraph ii) above during the period described in paragraph ii) above without any appropriate review or management plan;
6. [Rattan] has admitted to the conduct particularised at paragraphs iv) and v) above in the December Letter;
7. at the time of the conduct set out in paragraphs iii) and iv) above, the [RACGP Guidelines] provided that . . .
8. at the time of the conduct set out in paragraphs iii) and iv) above, the [Code of Conduct] provided that . . .
9. by engaging in the conduct above [Rattan] has failed to comply with the [RACGP Guidelines] and the [Code of Conduct].:

a) professional misconduct within the meaning of paragraphs (a), (b) and/or (c) of the definition in section 5 of the National Law;

b) unprofessional conduct within the meaning of the definition in section 5 of the National Law

in that between on or about 4 August 2017 and 4 July 2019, [Rattan] falsified [the Patient]'s clinical record by knowingly, incorrectly and misleadingly recording vital signs attributed to [the Patient] despite not physically attending on [the Patient] during this period.

1. the [Board] relies and repeats the particulars at paragraphs i) to v) at Allegation 1;
2. it was common practice for [Rattan] to record [the Patient]'s vital signs and make notes in relation to her health after physically examining her from time-to-time in [the Patient]'s clinical record.
3. [Rattan] did not physically attend on [the Patient] from on or about 8 July 2017.
4. [Rattan] knowingly and intentionally falsified [the Patient]'s clinical record by relying on physical assessments of [the Patient] conducted by the [the Nurse] and/or copied vital signs recorded from previous attendances he conducted on [the Patient] on a total of 17 occasions on the following dates:
   • (A) 4 August 2017;
   • (B) 1 September 2017;
   • (C) 28 September 2017;
   • (D) 24 October 2017;
   • (E) 15 January 2018;
   • (F) 25 January 2018;
   • (G) 12 February 2018;
   • (H) 9 March 2018;
   • (I) 6 April 2018;
   • (J) 7 July 2018;
   • (K) 22 August 2018;
   • (L) 12 December 2018;
   • (M) 10 January 2019;
   • (N) 14 February 2019;
   • (O) 11 April 2019;
   • (P) 9 May 2019; and
   • (Q) 4 July 2019.
5. [Rattan] admitted the conduct particularised in paragraph v) above in an email [to Ahpra] dated 17 March 2020 (the Email).
6. at the time of the conduct set out in paragraphs iii) and iv) above, the [Code of Conduct] provided that . . .
7. By engaging in the conduct above [Rattan] has failed to comply with the [Code of Conduct].

a) professional misconduct within the meaning of paragraphs (a), (b) and/or (c) of the definition in section 5 of the National Law;

b) unprofessional conduct within the meaning of the definition in section 5 of the National Law

in that between on or about July 2017 and 2 December 2019, [Rattan] recklessly billed the Medicare items listed in Table 1 below despite not meeting the billing requirements of same, namely that [Rattan] did not physically attend on [the Patient] and/or did not create a patient management plan.

1. the [Board] relies and repeats the particulars at paragraphs i) to v) at Allegation 1;
2. on the dates and times outlined in Table 1 below, [Rattan] billed the Medicare items listed in Table 1;

1. in order to properly bill Medicare item 23, 'professional attendance by a general practitioner at consulting rooms' is required;
2. in order to properly bill Medicare item 10990, the relevant medical services must be 'provided at...a practice location';
3. in order to properly bill Medicare item 707, 'professional attendance by a general practitioner...including...extensive examination of the patient's medical condition, and physical, psychological and social function' (emphasis added) is required;
4. in order to properly bill Medicare item 36, 'professional attendance by a general practitioner at consulting rooms' is required;
5. in order to properly bill Medicare item 721, 'attendance by a general practitioner for preparation of a GP management plan for a patient' is required; and
6. in order to properly bill Medicare item 723, 'attendance by a general practitioner to coordinate the development of team care arrangements for a patient' is required;
7. [Rattan] billed Medicare items 23, 10990, 707 and 36 on the dates and times listed in Table 1 despite knowingly did not meeting the billing requirements for those items, namely that [Rattan] did not physically attend on [the Patient];
8. [Rattan] billed Medicare items 721 and 723 on the dates and times listed in Table 1 despite knowingly not meeting the billing requirements for those items, namely that [Rattan] did not development a GP management plan or team care arrangements for [the Patient] and instead instructed [the Nurse], to do so;
9. [Rattan] admitted to the conduct outlined in paragraph iii) above in a letter to Ahpra dated 11 August 2021 (the August Letter);
10. [Rattan] admitted to the conduct outlined in paragraph x above in the August Letter;
11. at the time of the conduct set out in paragraphs iii) and iv) above, the [Code of Conduct] provided that . . .
12. By engaging in the conduct above [Rattan] has failed to comply with the [Code of Conduct].

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

[2] Nurse's witness statement dated 18 May 2021 (TB 314-315) and Health Assessment report dated 28 November 2019 (TB 274-279).

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

[7] [2019] VCAT 52 [67], citations omitted.

[8] TB 307-312 and TB 473-474 respectively.

[10] Also, on the understanding that we would have no regard to emails Torvaldsen sent with the Reports which expressed views on matters not before us.

[23] We make that comment noting the records before us showed that a locum (from the National Home Doctor Service) attended on the Patient in February 2017 - see TB 128.

[27] While noting the Board's submissions referred to the Nurse attending at the Patients home on seven occasions ([10(a)]), according to the Nurse's witness statement and a file note of a discussion with an Ahpra officer (TB 314-315 and 294); she believed she saw the Patient at her home on 8 June 2017; she believed she saw the Patient at her home or at the Centre on 15 June 2017; the progress note dated 17 June 2017 was made to create a referral; the progress note made on 19 April 2018 was the result of printing a form for a home visit which did not occur until 7 July 2018; the Patient was expressly stated not to be present on 13 April 2019; the progress note dated 26 April 2019 was the result of printing a form for a home visit conducted on that day; and a health assessment was done at the Patient's home on 28 November 2019.

[28] Board's Submissions [44]-[45].

[29] Contained in an email sent to Ahpra on that date (TB 510).

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

[32] Supplementary Tribunal Book (STB) 152-166.

[33] Addressing 'Safe and Ethical prescribing', 'Record keeping' and 'Compliance with the Medicare Benefits Scheme'.

[35] Medical Board of Australia v Watts [2019] VCAT 1471 (Watts); Medical Board of Australia v Sosnin [2018] VCAT 221 (Sosnin); Medical Board of Australia v Bajpe [2014] VCAT 1162 (Bajpe); Medical Board of Australia v Zhao [2021] VCAT 1053; Medical Board of Australia v Torres [2024] QCAT 459 (Torres); Medical Board of Australia v Kozminsky [2024] VCAT 789 (Kozminsky)' Nursing and Midwifery Board of Australia v Thomas [2022] VCAT 291 (Thomas); Nursing and Midwifery Board v McRae [2018] VCAT 1707 (McRae); Medical Board of Australia v Jigau [2022] VCAT 30; Pharmacy Board v Hopkinson [2018] VCAT 982 (Hopkinson); Psychology Board of Australia v Nguyen [2011] VCAT 2437 (Nguyen); and Osteopathy Board of Australia v Rowe [2014] VCAT 867 (Rowe).