Medical Board of Australia v Sadeghi [2025] QCAT 163

Private Health Facilities Regulation 2016 (Qld)

Queensland Civil and Administrative Tribunal Rules 2009 (Qld)

Queensland Civil and Administrative Tribunal Act 2009 (Qld

Alcan (NT) Alumina Pty Ltd v Commissioner of Territory Revenue [2009] HCA 41; (2009) 239 CLR 27

Commonwealth of Australia v Director Fair Work Building Industry Inspectorate & Ors [2015] HCA 46; [2015] 258 CLR 482

Craig v Medical Board of South Australia [2001] SASC 169; (2001) 79 SASR 545

Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630

Health Ombudsman v Baumann [2021] QCAT 68

Health Ombudsman v Field [2019] QCAT 243

Health Ombudsman v Gillespie [2021] QCAT 54

Health Ombudsman v Le [2020] QCAT 170

Health Ombudsman v ORC [2020] QCAT 181

Health Ombudsman v Sharman [2020] QCAT 224

Legal Services Commissioner v Madden (No 2) [2008] QCA 301

Legal services Commissioner v McLeod [2020] QCAT 371

Medical Board of Australia v Alkazali [2017] VCAT 286

Medical Board of Australia v Cukier [2017] VCAT 109

Medical Board of Australia v Dolar [2012] QCA 271

Medical Board of Australia v Duck [2017] WASAT 28

Medical Board of Australia v Griffiths [2017] VCAT 822

Medical Board of Australia v Wong [2015] QCAT 439

Medical Board of Australia v Zhao [2021] VCAT 1053

Nursing and Midwifery Board of Australia v BCD [2025] QCAT 8

Nursing and Midwifery Board of Australia v Faulkner [2018] QCA 97

Nursing and Midwifery Board of Australia v Lockie [2023] QCA 96

Nursing and Midwifery Board v McRae [2018] VCAT 1708

Project Blue Sky Inc v Australian Broadcasting Authority [1998] HCA 35; (1998) 194 CLR 355

SZTAL v Minister for Immigration and Border Protection; SZTGM v Minister for Immigration and Border Protection [2017] HCA 34

• [1] Dr Shahram Sadeghi commenced practice as a registered medical practitioner in this State in 2004. He obtained his qualifications in Iran ten years earlier. In 2016 Dr Sadeghi set up the Elinay Cosmetic Surgery ('Elinay clinic'). He has owned and run it since.
• [2] On 1 May 2019 Dr Sadeghi performed a facelift procedure on RF at that clinic. He had neither the training nor the experience necessary to perform that procedure. He had never previously performed it. He had "assisted" another practitioner at two facelift procedures about seven years previously. RF suffered significant complications; he required emergency transport to hospital by ambulance and subsequent surgery.
• [3] The Referral to this tribunal from the Medical Board of Australia contains allegations of professional misconduct[1] emanating from those facts. The allegations are particularised in five grounds which embrace conduct connected to five identified patients in addition to RF, to facilities at the Elinay clinic, and advertising of it.
• [4] The parties agree professional misconduct is established. Save for one matter, they also agree on the conduct and other facts underpinning that conclusion. For reasons which will emerge, the Tribunal has come to the same conclusion.[2]
• [5] The parties also agree that, as a consequence, Dr Sadeghi should be reprimanded. The central issue to be decided is whether the National Law's paramount purpose of protecting the public is met, as the Board contends, by an order that the doctor's registration be cancelled (with no disqualification period) or whether, as Dr Sadeghi contends, his registration should be suspended for a period of 3 months.[3]
• [6] Two additional issues must also be determined:

(a) Does Dr Sadeghi's admitted conduct in ground 1 constitute, as the Board contends, a breach of s 39 of the Private Health Facilities Act 1999 (Qld) ('PHF Act')?

(b) Is an order for cancellation of Dr Sadeghi's registration dependent upon an antecedent finding that he is not a fit and proper person to hold such registration as at the date of the tribunal hearing?[4]

• [7] In his Response, Dr Sadeghi admits his conduct was "inconsistent with the intention of the PHF Act (and Private Health Facilities Regulation 2016 (Qld) ('PHF Regulation')" and that by performing the procedures on the six patients "his conduct fell short of the standard expected of him as a medical practitioner". Dr Sadeghi contends that this admission is sufficient for the purpose of arriving at an appropriate sanction, and a finding as to whether s 39 is breached is not required and should not be made.
• [8] At the hearing senior counsel for the Board acknowledged that it was open to the tribunal to not make the specific finding sought but on instructions pressed for the finding to be made. Subsequent to the release of the hearing transcript, it was considered appropriate to give both parties an opportunity to provide further written submissions in respect of this issue. Further submissions were received on behalf of Dr Sadeghi. The Board did not provide further submissions.

Licences required to operate private health facilities

A person must not operate a private health facility unless the person holds a licence for the facility.

Maximum penalty - 1000 penalty units. [Note omitted]

• [10] Dr Sadeghi's central contention is that "the referral does not plead, and the Board has not proven, the elements of the offence".[5] His supplementary written submissions contend that the Board does not plead that he "operated" the Elinay clinic; rather he "operated at" that clinic. It is also said that the Board does not plead specifically that the Elinay clinic was a "private health facility".[6]

Does The Board's "Pleading" Preclude a Finding Being Made?

• [11] Referrals in disciplinary proceedings commonly take a form akin to a "pleading"; grounds are enumerated and "particulars" are provided within each ground. However, pleadings are not a prescribed form of procedure. Nor do the tribunal's rules[7] refer to, or seek to regulate, the manner in which a case is outlined or "pleaded".
• [12] To the contrary, the procedure applicable to a proceeding is at the discretion of the tribunal. That specific statutory discretion exists within a broader statutory framework by which the tribunal is required to act with as little formality and technicality as the relevant legislative context demands.[8]
• [13] The National Law is the enabling Act giving the tribunal its relevant jurisdiction[9] and provides the relevant statutory context. It does not otherwise limit the QCAT Act and, in particular, does not limit the manner in which a case may be outlined or "pleaded" nor the manner in which tribunal may conduct the relevant inquiry.
• [14] The tribunal's inquiry is directed to fairness and the substantial merits of the case and the QCAT Act contemplates specifically the tribunal informing itself in any way it considers appropriate.[10] Findings are to be made by reference to all of the relevant material before the tribunal and the parameters of the parties' cases as presented, (and the specific dictates of s 29 of the QCAT Act which requires, in broad terms, the tribunal ensuring the proceedings are understood).
• [15] Of course, that framework also mandates adherence to the rules of natural justice.[11] The Board was required to give Dr Sadeghi clear and timely notice of all contentions made by the Board and the findings sought. The Referral's "pleading" outlined those matters with significant particularity. The Board's other material, including the outline of facts alleged, its evidence, and its submissions made its case in respect of s 39 entirely clear.
• [16] The specific assertions as to matters not "pleaded" do not alter that position. It cannot reasonably be said that the Board's "pleadings" confined, or should be taken as confining, its case to an ambit that does not include an assertion that Dr Sadeghi "operated" the Elinay clinic within the meaning of s 39 and that he, as he admits, failed to obtain a licence for it. Dr Sadeghi was given notice of that contention, had the opportunity to respond to the totality of the Board's evidence and contentions and properly availed himself of that opportunity.

• [17] A form of professional misconduct, outlined in ground 1 of the Referral, arises directly from conduct proscribed by the PHF Act. The seriousness of that proscribed conduct is underscored by the potential for a civil penalty to apply. The tribunal is bound to have regard to the provisions of the PHF Act in determining both whether professional misconduct has been established and, if so, its level of seriousness.
• [18] The fact that Dr Sadeghi seeks to frame admitted conduct referable to the PHF Act in a particular way does not inhibit the tribunal determining for itself the precise nature of the conduct and its seriousness and whether, in that respect, s 39 was breached.
• [19] The issue was properly joined and both parties provided considered written submissions. It is appropriate that the issue be considered and a finding made.

• [20] "Private health facility" is defined in s 8 of the PHF Act:

A private health facility is -

(a) a private hospital; or

(b) a day hospital.

• [21] Thus, the Elinay clinic cannot be a private health facility as defined unless it is, relevantly, a "day hospital".[12]
• [22] That term is defined in s 10:

(1) A day hospital is a facility at which day hospital health services are provided to persons who are admitted to, and discharged from, the facility on the same day, but does not include a facility operated by the State.

day hospital health service means any of the following health services -

(a) a diagnostic, surgical or other procedure performed by a medical practitioner involving -

(i) the administration of a general, spinal or epidural anaesthetic; or

(ii) sedation, other than simple sedation;

(i) performed by, or under the direction of, a medical practitioner; and

(ii) involving a significant risk that a person on whom the procedure is performed may, because of cardiac, respiratory or other complications arising from the performance of the procedure, require resuscitation; and

(iii) prescribed under a regulation.

simple sedation means the administration of one or more drugs to a person, that depress the person's central nervous system, to allow a procedure to be performed on the person by a medical practitioner in a way that -

(a) allows communication with the person to be maintained while the procedure is being performed; and

(b) makes loss of the person's consciousness unlikely.

Did Dr Sadeghi Operate a Private Health Facility?

• [23] Dr Sadeghi admits the procedures performed on RF (which involved a breach of the SMAS[13]) and the procedures performed on the other five patients (which involved SMAS plication) was each a "day hospital health service" as defined in s 10(2) because:

(a) Dr Sadeghi, a "medical practitioner", performed those procedures; and

(b) each involved a significant risk that a person on whom the procedure is performed may, because of cardiac, respiratory or other complications arising from the performance of the procedure, require resuscitation; and

(c) Each was a prescribed procedure under regulation 3 of the PHF Regulation in that it was a facelift that "involved" the SMAS.

• [24] Dr Sadeghi also admits the Elinay clinic was at the relevant time "a facility at which day hospital health services are provided to persons who are admitted to, and discharged from, the facility on the same day" (and is not "a facility operated by the State").
• [25] The Board contends Dr Sadeghi's admissions - together with the uncontroversial fact that the Elinay clinic was not licenced as the PHF Act requires - establishes that s 39 of the PHF Act is satisfied. It should also be noted that Dr Sadeghi admits both setting up and owning the Elinay clinic and conducting procedures at it.[14]
• [26] Dr Sadeghi's argument appears to comprise two parts. First, it is contended that notwithstanding the doctor's admissions:

... it would be necessary for the court with jurisdiction to hear the charge to determine whether the performance of six facelifts in 16 months is sufficient to make Elinay a place at which prescribed surgical procedures are provided. The definition of day hospital in s 10(1) of the Act seems to imply at least some degree of regularity in the performance of such procedures in order for a clinic to be a day hospital (and by extension via the definitions, a private health facility for which it would be an offence to operate without a licence).[15] [Italics in original].

• [27] A second argument turns on the interpretation of "operate" as used in s 39:

... the offence is to operate a private health facility, not to operate at a private health facility" and "the conduct of Dr Sadeghi pleaded in particulars (i) to (ix) [of ground 1] is not the operation of a private health facility. Rather, it is the performance of procedures by Dr Sadeghi ...".[16] [Italicised emphasis in original]

• [28] It is said that support is lent to that interpretation by the "use of the continuous tense verb 'are provided' as opposed to the past tense '[were or have been] provided' in the definition of day hospital at s 10 of the PHF Act". That is said to imply "that some continuity or regularity of the provision of "day hospital health services" is required" for s 39 to apply.[17]
• [29] The submission depends upon what is said to be implicit in the statutory definition in light of the (correct) assertion that there is evidence before the tribunal of only six "day hospital health services" performed at the Elinay clinic.

Is the Elinay Clinic a "Day Hospital" as Defined?

• [30] "The starting point for the ascertainment of the meaning of a statutory provision is the text of the statute whilst, at the same time, regard is had to its context and purpose".[18]
• [31] The definition of "day hospital" is clear and unambiguous. Two criteria are essential to its application: the nature of services provided at a facility and the length of time persons spend within the facility receiving, or having received, those services. The number of procedures performed at the facility, or the regularity with which procedures are performed, are not embraced by the plain meaning of the language used.
• [32] No term used within the definition - for example "hospital" - is separately defined within the "basic concepts" otherwise defined in the PHF Act.[19] The ordinary and natural meaning of hospital is of a place or institution referenced to the nature of the activities carried on within it.[20] No part of the ordinary meaning of the term invites an interpretation referenced to the number of procedures performed within it or the regularity of providing treatment.
• [33] The purpose of the PHF Act is protecting the health and wellbeing of patients using health services at private health facilities - a purpose facilitated in part by requiring persons to hold licences for the operation of the facilities.[21] No part of the Act's broadly expressed purpose suggests an application limited by the number or volume of services provided at a facility or the number of patients treated. An interpretation that suggests protection is afforded to patients only if services are provided at a facility treating a particular number or volume of patients is contrary to its broad protective purpose.
• [34] Dr Sadeghi's argument is rejected. The Elinay clinic is a 'day hospital' as defined and thus a 'private health facility" as defined.

Did Dr Sadeghi "Operate" a Private Health Facility?

• [35] The word "operate" is not defined in the PHF Act. It too is to receive its ordinary meaning[22] and to be interpreted by reference to the statutory context and purpose.
• [36] The Act provides a regulatory framework through the issuing of authorities, approvals, and ultimately licences, that are directed to persons who seek to establish and run private health facilities as defined. Dr Sadeghi admits that he set up, owned and, at the relevant time ran, the Elinay clinic. The clinic was his business. He managed it. He directed its workings.
• [37] The evidence before the tribunal is not confined to Dr Sadeghi "operating at" the Elinay clinic. Neither is the Board's case as outlined and presented so confined.
• [38] Dr Sadeghi's argument is rejected. At the relevant time he was "a person who operates a private health facility" within the meaning of s 39 of the PHF Act.

Does Cancellation Require an Antecedent Finding as to Fit and Proper Person?

• [39] The written submissions on behalf of Dr Sadeghi contend:

Accordingly, before cancelling a practitioner's registration, it is necessary for a Tribunal to decide that the practitioner is not a fit and proper person to hold registration at the date of the hearing. If the practitioner is at the date of the hearing, a fit and proper person to hold registration, there is no reason to require that the practitioner demonstrate this at the end of the proposed period of practice. Where the Tribunal is satisfied that, upon completion of the period away from practice, the practitioner will be fit to resume practice, a suspension is suitable.

• [40] Counsel for Dr Sadeghi cites in support of his central contention, the decision of Judicial Member McGill SC in Health Ombudsman v Sharman [2020] QCAT 224 at [30] ('Sharman'):

In order to cancel the respondent's registration it is necessary for the Tribunal to decide that the respondent is not a fit and proper person to be registered as a nurse.

• [41] Three decisions are footnoted in support of that proposition: Medical Board of Australia v Wong [2015] QCAT 439 at [84] ('Wong'); Medical Board of Australia v Duck [2017] WASAT 28 at [33], [34] ('Duck'); and Medical Board of Australia v Alkazali [2017] VCAT 286 at [74] ('Alkazali'). [23]
• [42] Mr Jellis SC submits on behalf of the Board that Wong does not stand for the proposition expressed in Sharman and does not advance the proposition contended for on behalf of Dr Sadeghi. The tribunal respectfully agrees.
• [43] In Wong Judge Horneman-Wren SC said this at [84]:

In this matter the Tribunal's focus must remain firmly fixed on the statutory definition of professional misconduct in the third limb. That definition requires, in order for the Tribunal to find professional misconduct, that Dr Wong's conduct is inconsistent with him being a fit and proper person to hold registration. If the Tribunal would find professional misconduct on that basis then the cancellation of his registration would be almost inevitable. Not cancelling a practitioner's registration would seem inconsistent with having found his or her conduct to be inconsistent with him or her being a fit and proper person to hold registration. This may be contrasted with cases in which there is a finding of professional misconduct on some basis, and the question then arises whether the practitioner is fit and proper to be or remain registered.

[Italicised emphasis added in each case]

• [44] Alkazali cites what was said in Duck and goes on to hold:

Where an order for cancellation of a practitioner's registration is contemplated, the ultimate question is whether the material demonstrates that the practitioner is not a fit and proper person to remain a practitioner...[24]

• [45] Plainly enough, that statement has echoes in what is later said in Sharman. However, the tribunal in Duck, immediately after the passage just quoted, went on to say:

A practitioner is not a fit and proper person to be a registered practitioner and should be removed from the register where the conduct is so serious that the practitioner is permanently or indefinitely unfit to practise ... [25]

The Tribunal does not need to determine at this stage that the Respondent will never be fit to practice again. If his registration is cancelled for a certain period, his fitness to practice again will ultimately be a question for the Board at the relevant time. The question for the Tribunal at this stage is whether the conduct of the Respondent, an otherwise mature aged and experienced practitioner, is as grave in aggregate as to warrant the stronger sanction of cancellation of registration, having particular regard to considerations of insight, remorse and acceptance of responsibility, all of which bear upon his fitness to practice.[26]

[Italicised emphasis added]

• [47] A present unfitness to practice may be, as the Board submits, a relevant consideration in imposing cancellation,[27] but that is quite different to suggesting the imposition of a rule not justified by the terms of the powers granted by s 196 of the National Law. So much is made clear by the Queensland Court of Appeal.
• [48] In Nursing and Midwifery Board of Australia v Lockie [2023] QCA 96, the Court of Appeal said, at [40] and [45] respectively:

Section 196(2) does not contain any express limitation on the Tribunal's discretion to impose one or more of the identified sanctions. ...

... the submission fails to recognise that in circumstances where the Tribunal has decided that a practitioner has behaved in a way that constitutes professional misconduct, the Tribunal has a wide discretion to impose sanctions ranging from a caution or reprimand of the practitioner through to cancellation of registration.[28]

• [49] To require a finding that Dr Sadeghi is not a fit and proper person at the date of the hearing prior to ordering cancellation of his registration is to fetter the discretion otherwise evident in the plain words of s 196 of the National Law.
• [50] The submission on behalf of Dr Sadeghi is rejected.

What conduct founds the allegations of professional misconduct?

• [51] Save for the distinction drawn by Dr Sadeghi in respect of ground 1 earlier dealt with, he admits each ground alleged by the Board and the particulars of conduct alleged within each.
• [52] In broad terms the conduct consists of:

(a) "performing surgical procedures at an unlicensed facility" (ground 1);

(b) "inadequate training and experience to perform facelift procedures" (ground 2);

(c) "failure to exercise appropriate skill, care and judgement with respect to patient RF" (ground 3);

(d) "performing facelift surgical procedures in a facility and otherwise in a manner that was in breach of the legal and professional requirements" (ground 4); and

(e) "false and misleading advertising" (ground 5).

• [53] Despite the admissions made, these reasons should outline aspects of the conduct referenced to each ground so as to underscore and give context to the views of the tribunal both that professional misconduct is established in respect of each ground and that the conduct taken together should be seen as extremely serious.

• [54] The fundamental importance of the regulatory framework mandated by the PHF Act in ensuring the health and wellbeing of patients has already been referred to. Dr Sadeghi operated the Elinay clinic without a licence contrary to the provisions of the PHF Act.
• [55] Dr Sadeghi says he did not hold a licence because, for reasons relating to the definition of a facelift, he wrongly believed it was not required. He says, though, that "he did not consider the full wording of the relevant regulation". The regulation says "not involving the SMAS" and "my belief that "involving" only meant the full incision involved in a full facelift". He accepts that was wrong. The medical members of this panel regard it as remarkable that such a conclusion could be reached - particularly in a doctor with Dr Sadeghi's experience.
• [56] Dr Kennedy, an expert witness in the Board's case, explains the importance of the Act's framework in the case of facelift procedures, pointing out that "male facelifting is a difficult surgical procedure with a higher rate of complications". With specific reference to the PHF legislation, Dr Kennedy says: "the reason behind this legislation is because significant complications can occur during full facelift surgery relating both to the surgery and the level of anaesthesia required".[29] Of course, in the instant case significant complications did in fact occur with respect to the facelift performed on RF.
• [57] Dr Kennedy refers to the importance of having an anaesthetist present for a facelift procedure. However:

... even if the procedure was performed under local anaesthetic and conscious sedation in a registered facility, there would be a minimum number of people in the room that would facilitate the safety of the procedure, including assistant's, scouts and anaesthetic technicians".[30]

• [58] The absence of those nominated persons in the instant case "contributed to the difficulty that Dr Sadeghi met in controlling the bleeding" and "the inability to control bleeding from the branch of the occipital artery in a facelift wound during a surgical procedure represents a serious deficiency".[31]

• [59] Prior to conducting the procedure on RF, Dr Sadeghi had never previously conducted it, including while supervised. His sole exposure to the procedure was to assist a surgeon some seven years previously.
• [60] Dr Sadeghi did not inform RF of his lack of training or inexperience. Indeed, an entirely different impression was created by Dr Sadeghi during his consultations with RF. RF deposes, "Dr Sadeghi told me briefly that he had completed further training in order to become a cosmetic surgeon but he didn't provide me with any specifics about this".[32] That representation to RF was false.
• [61] In the apparent context of comparing the fees charged by Dr Sadeghi with those charged by specialist plastic surgeons, RF deposes:

Dr Sadeghi also explained to me that plastic surgeons held qualifications that were recognised by the Medical Board of Australia and that it was believed that they were more competent in performing plastic surgeries. Dr Sadeghi said that cosmetic surgeons such as himself were just as competent, if not more competent, than a plastic surgeon when performing a facelift and that it was a bit of a 'battleground' between the two professions.[33] [Italics in original]

• [62] The representation by Dr Sadeghi that he is a "cosmetic surgeon" is false. The representation that he is "just as competent, if not more competent than a plastic surgeon performing a facelift" is entirely rejected by the medical members of this tribunal and, in any event, is at odds with his admission in these proceedings that he had neither the necessary training nor experience to perform the procedure upon RF.[34]
• [63] The representation is also at odds with the expert opinion provided to the Board by Dr Bezic that Dr Sadeghi's training at the Australasian College of Cosmetic Surgery is "in less invasive procedures such as injectables; threads; lasers and up to liposuction [but] does not provide formal training in invasive procedures such as breast surgery, abdominoplasty, nor facial surgery such as blepharoplasty and facelifts".[35]
• [64] RF presented to Dr Sadeghi concerned with the effects of bad acne scarring from when he was younger. Dr Kennedy records that a facelift was performed "without reference to a dermatologist or specialist plastic surgeon"; Dr Sadeghi "deemed that the scarring from acne would not be adequately treated with non-invasive means and recommended a facelift".[36]
• [65] There is no suggestion by Dr Sadeghi that he sought advice or guidance from any specialist or other qualified and trained practitioner. Nor is there any suggestion that he sought such advice specifically as to whether his training and experience was such that he could, or should, perform the facelift. Dr Kennedy opines:

All aspects of knowledge, skill, judgment and care exercised were below the standard reasonably expected of a health care practitioner holding themselves out to be a cosmetic surgeon. I would suggest that a responsible health practitioner with an equivalent level of training or experience to Dr Sadeghi would not perform such a procedure.[37]

Ground 3 - Skill, Care and Judgment with respect to RF

• [66] Ground 3 addresses the nature of the procedure undertaken on RF by Dr Sadeghi and the manifest lack of skill involved in doing so. Aspects of that lack of skill, including those referred to by Dr Kennedy in his expert report, have already been referred to.
• [67] The observations during RF's procedure were recorded on a whiteboard - a practice which Dr Sadeghi says he subsequently abandoned. In his expert report, Dr Bezic opines that the documentation of RF's procedure was "inadequate and below what would be expected of his peers". He says, there "is no record of what medications were given, nor what amounts and when they were given [and] there is no operative report what [sic] was completed and no observations were recorded in the notes".[38]
• [68] Dr Kennedy's report is to similar effect. He also makes specific reference to a matter particularised in ground 3: the use of a radiofrequency machine for cautery (a hyfrecator) which, he says, is "well below the standard of care to perform a facelift", which requires "a surgical diathermy unit".[39]
• [69] RF underwent surgery in hospital following a 000 call by Dr Sadeghi and emergency transport by ambulance. During the "exploration and washout" during that surgery, RF's bleeding "was found to be a breach of the occipital artery" and "numerous iatrogenic tunnels traversing through the parotid tissue were also noted".
• [70] Initially, Dr Sadeghi disclaimed responsibility for the same: he claimed to Ahpra that SMAS plication may lead to the appearance of tunnels during the emergency surgery. However, Dr Bezic opines "it is much more likely that Dr Sadeghi inadvertently violated the SMAS during the procedure ... which lead to the exposure and injury of a branch of the occipital artery and the subsequent bleeding and haematoma".[40]
• [71] In his subsequent affidavit, Dr Sadeghi admits that he "inadvertently breached the SMAS during the procedure" and that he did not realise he had done so.[41]

Ground 4 - Breach of Legal and Professional Requirements

• [72] This ground asserts in respect of all six patients named in the referral that Dr Sadeghi's conduct is contrary to a number of specific regulations and guidelines: the Code of Conduct;[42] the Cosmetic Guidelines;[43] the Health (Drugs and Poisons) Regulation 1996 (Qld) and, specifically with regard to RF, the Australian and New Zealand College of Anaesthetists Guidelines. Dr Sadeghi admits all of the particulars alleged.
• [73] More specifically the admitted conduct relates to failures in accepted practice including the failure to have the appropriate number of trained staff as earlier referred to; inadequate recording of medications administered; and the failure to create and maintain protocols for managing complications.
• [74] It should not be thought that the failures in accepted practice were either benign of merely administrative. For example, Dr Kennedy makes the point that, as there were no proper records of the drugs administered to RF, it was not possible for doctors in the handover position at the hospital to know what amount of each drug he had been given.
• [75] The Code of Conduct provides, among other things, that good medical practice involves referring a patient to another practitioner when this is in the patient's best interests; consulting and taking advice from colleagues when appropriate; and ensuring you have adequate knowledge and skills to provide safe clinical care. Dr Sadeghi's conduct falls foul of all three.

• [76] Unsurprisingly, the Code of Conduct stipulates that a medical practitioner must not make claims about their qualifications, experience or expertise that could mislead patients by implying the practitioner is more skilled or more experienced than is the case. Dr Sadeghi admits that his claim on the clinic website to having a fellowship in cosmetic surgery was false and misleading.
• [77] Dr Kennedy makes the point that the Australasian College of Cosmetic Surgery is not an Australian Medical Council recognised body for conferring qualifications and says "it is important to state that Dr Sadeghi advertises himself on the web as a member of this college and a cosmetic surgeon but does not even hold the qualification that his organisation awards to people with those aspirations".[44]

Is the Conduct Professional Misconduct as Agreed?

• [78] There can be no doubt that Dr Sadeghi's admissions and the expert reports from Drs Kenney and Bezic prove in respect of each ground conduct that is of a lesser standard than that which might reasonably be expected of a medical practitioner by his professional peers and the public. Plainly, the Board establishes unprofessional conduct in respect of each ground.
• [79] As is again made clear by the nature of that proven unprofessional conduct in each ground, and the expert evidence in relation to it, the conduct in each case falls substantially below the standard reasonably expected of a medical practitioner with the equivalent of Dr Sadeghi's level of training or experience. "Professional misconduct" is established in respect of each ground.
• [80] The Board contends that a finding should be made that professional conduct as provided for in sub-paragraph (c) of the definition of professional conduct is established in respect of ground 2. No submissions are addressed specifically to that aspect. No specific finding in that respect will be made.
• [81] The parties' agreement that professional misconduct is established in respect of each ground is appropriate and correct.

• [82] The question of sanction will be approached by reference to the totality of the conduct. Although the grounds contain conduct of different types, all emanate from the operation of the Elinay clinic and what occurred there.
• [83] In imposing sanctions, the tribunal must embrace the paramount guiding principle of the National Law that the health and safety of the public are paramount.[45] The purposes underlying the imposition of sanctions have been referred to in a number of cases.[46] Those purposes include:

(a) preventing practitioners who are unfit to practise from practising;

(b) securing maintenance of professional standards;

(c) assuring members of the public and the profession that appropriate standards are being maintained and that professional misconduct will not be tolerated;

(d) bringing home to the practitioner the seriousness of their conduct;

(e) deterring the practitioner from any future departures from appropriate standards;

(f) deterring other members of the profession that might be minded to act in a similar way; and

(g) imposing restrictions on the practitioner's right to practise so as to ensure that the public is protected.[47]

• [84] So, too, the factors relevant to the imposition of sanctions designed to achieve those purposes are well established and have been cited in numerous decisions of this and other tribunals.[48] Those factors include:

(a) the nature and seriousness of the conduct;

(b) whether the practitioner pleaded guilty or other evidence of contrition or remorse;

(c) whether there is a need for specific deterrence (deterring the particular practitioner from further inappropriate conduct) or general deterrence (deterring other practitioners from engaging in similar conduct);

(d) whether there have been other disciplinary findings before or since the conduct in question;

(e) evidence of character;

(f) evidence of rehabilitation; any delay from the time the investigation started to the end of the Tribunal hearing;

• [85] Submissions on Dr Sadeghi's behalf identify the relevant mitigating circumstances as Dr Sadeghi's admissions; the absence of a disciplinary history; delay in the Board referring to the tribunal; substantial insight and rehabilitation between conduct and hearing; financial ramifications resulting from time out of practice; and good character.[49]

Disciplinary History, Good Character and Impact on Dr Sadeghi's Practice

• [86] It is accepted that Dr Sadeghi has no disciplinary history outside of the instant conduct. It is notable that the absence of a disciplinary history occurs within the context of a lengthy period in practice.
• [87] Statements from colleagues describe Dr Sadeghi as a hardworking, caring and committed doctor and otherwise speak of his good character. That evidence is accepted.
• [88] Each of those matters is important and the tribunal gives weight to each of them
• [89] Dr Sadeghi deposes to a number of significant financial impacts on the Elinay clinic, and him personally. He deposes that, despite attempts at restructuring, the clinic "will not be able to remain open without me practicing".[50] The tribunal accepts the financial ramifications for Dr Sadeghi of both the investigation and ultimate sanction have been, and are likely in the future to be, significant.
• [90] Yet, the clinic at which the conduct occurred was set up as a commercial enterprise without sufficient regard for a regulatory framework designed to protect the public from potentially harmful conduct. Harmful conduct did occur. Appropriate investigation of what was required of the clinic; adherence to promulgated standards for what occurred there; and operating within the bounds of his expertise were all matters within Dr Sadeghi's power and control, including seeking and receiving appropriate advice in each respect.

• [91] Dr Sadeghi submits that his admissions "have allowed this matter to proceed to a hearing without any disputed facts". That is accepted. The Tribunal does not regard the submissions in respect of the PHF Act to derogate from that.
• [92] However, the position taken by Dr Sadeghi needs to also be seen in the context of earlier submissions made to Ahpra on Dr Sadeghi's behalf prior to the expert reports having been received from Dr Kennedy and Dr Bezic.
• [93] Subsequent to the taking of immediate action and the imposition of conditions on his registration, submissions were made by solicitors on Dr Sadeghi's behalf relating in particular to a number of aspects of RF's procedure.[51] In the tribunal's opinion the document attempts to downplay Dr Sadeghi's lack of training and lack of competence to perform the procedure on RF; the seriousness of the situation confronting RF; and Dr Sadeghi's role in causing it. Among other things, it is asserted for example:

(a) That the procedure performed on RF "was both adequate and appropriate";

(b) The procedure "is within Dr Sadeghi's scope of practice and Dr Sadeghi has appropriate training, expertise and experience to perform the procedure;"

(c) Dr Sadeghi "emphatically denies that he operated under the SMAS" and that he "never cuts below the SMAS in any of the procedures he performs";

(d) "Dr Sadgehi became a fellow of [the Australasian College of Cosmetic Surgery] in 2013 and his ACCS surgical training included training on abdominoplasty, liposuction; breast reduction, breast implants, mastopexy and S Lifts under the supervision of Dr John Flynn";

(e) Alleged inconsistencies in the hospital's Operation Record "seem to indicate that operating surgeon (who we understand was a registrar) is not familiar with the anatomy of the SMAS and we query whether this surgeon has ever performed an S Lift procedure";

(f) Dr Sadeghi "denies that [RF's] complications were caused by inadequate or inappropriate technique". (The letter points out that, while maintaining that denial, Dr Sadeghi had undertaken further training "to improve his surgical skills").

• [94] Dr Sadeghi also appears to assert in that submission that the situation was not "a picture of uncontrolled bleeding" requiring urgent washout of a haematoma. Dr Kennedy refers to the 000 call in support of there being uncontrolled bleeding and "the presence of large haematoma certainly demands urgent washout." The bleeding had come under control "with pressure and tranexamic acid" but Dr Kennedy said "this did not cure the haematoma which required washout and re-suture".
• [95] In respect of Dr Sadeghi's "emphatic denial" that he operated under the SMAS, Dr Kennedy says there is a detailed operative record of damage and perforations through the SMAS which were illustrated in the photograph taken at [the hospital]." Dr Kennedy goes on the say that Dr Sadeghi is quite correct that multiple other bleeding points from small vessels is a completely expected finding once a haematoma occurs and that Dr Sadeghi infers that his experience with skin cancers is relevant to the execution of a facelift but Dr Kennedy says "this is clearly a conflation".[52]
• [96] Again contrary to what was asserted on Dr Sadeghi's behalf, the further expert report from Dr Bezic[53] said:

The source of the bleeding was found to be a branch of the occipital artery during an exploration and washout at [the hospital]. Intraoperative photos taken at the time show a clearly incised SMAS and the operative report indicated that the parotid bed was visible at the base of the wound. For the base of the parotid to be visible, the SMAS must have been violated. Numerous iatrogenic tunnels traversing through the parotid tissue were also noted. This indicates that [Dr Sadeghi] performed the surgery at a deeper level than intended.

• [97] Dr Sadeghi attributes the appearance of tunnels as emerging during the surgery at the hospital. Dr Bezic says, "However it is more likely that [Dr Sadeghi] inadvertently violated the SMAS during the procedure..." Like Dr Kennedy, Dr Bezic also refers specifically to the absence of two staff members "with appropriate training assisting the proceduralist" by reference to ANZCA Guidelines.
• [98] Subsequent to receipt of Dr Kennedy's and Dr Bezic's reports, Dr Sadeghi admitted that he had inadvertently breached the SMAS.
• [99] So, too, the weight given to assertions by Dr Sadeghi as to the gaining of insight and to rehabilitation is diminished for the following reasons.
• [100] In the document from Dr Sadeghi's solicitors to Ahpra (dated 21 February 2020) no reference is made to the impact of the procedure upon RF save that it is said "on 18 May 2019, Dr Sadeghi reviewed [RF] in his rooms and noted that he was recovering well".[54]
• [101] RF says he recalls little of the procedure itself as he was "drifting in and out of consciousness". He says he could recall the assisting nurse saying "he's bleeding too much" and "this isn't right". He spent two days in hospital subsequent to the surgical intervention dealing with the procedure. He says it took him approximately three weeks to fully recover.
• [102] RF deposes that Dr Sadeghi visited him the day after surgery, bringing him flowers. He recounts Dr Sadeghi saying to him that he shouldn't have to pay the full amount for the procedure and that he had "done everything by the book". He also recalls him saying "you do recall signing that waiver and acknowledging that there were certain medical risks involved". RF says he was left with the impression that Dr Sadeghi "was trying to smooth things over after what had happened".[55]
• [103] RF says approximately six weeks after leaving hospital he visited Dr Sadeghi to "see if anything could be done to restore balance to my face". At that time, the doctor said he was "happy with the surgery he performed". He also asked "whether my friends had commented on how much better I looked". He offered "some fillers" at no charge which he accepted.
• [104] In his affidavit Dr Sadeghi deposes to arranging to attend the day surgery lists of a cosmetic surgeon shortly after the Ahpra notification. He deposes:

... that was an eye-opener for me. I realised during this time that I did not appreciate the limits of my training and experience in performing surgical procedures".[56]

• [105] Dr Sadeghi relies upon a "reflective practice report" dated 26 July 2022.
• [106] The reflective practice document also refers to participation in "ongoing professional development to ensure that I provide high quality non-surgical cosmetic procedures ..."; says that there is no intention to conduct "cosmetic surgical procedures" and that the names of plastic surgeons will be provided to patients requiring the same.
• [107] He says in that document that the immediate action taken by the Board "has been a wakeup call for me" and:

... has caused me to reflect on the current issues within the fields of cosmetic surgery and medicine. I acknowledge that without the action taken by the Board that other surgical patients were at risk.

• [108] Dr Sadeghi's written submissions state that he "offered an apology to patient RF". That appears to be a reference to what was said in the reflective practice document some three years after the event: "I sincerely apologise to [RF] for any hurt and distress I have caused".
• [109] The written submissions on Dr Sadeghi's behalf point to the matters just mentioned as Dr Sadeghi being frank about his "errors and shortcomings". The tribunal considers the frankness exhibited subsequent to receipt of the expert reports should be compared with that contained in the letter to Ahpra to which reference has been made.
• [110] The tribunal considers the attribution of weight to Dr Sadeghi's statements as indicative of insight and remorse needs to be seen in, and tempered by, the wider context in which they appear.
• [111] First, the comments made at the initial consultation with RF exhibit a hubris entirely inconsistent with predominating the safety of the patient. The same comments are also inconsistent with a later-expressed realisation of inappropriateness.
• [112] Second, the comments made to RF after his hospital admission speak more of self-protection than remorse and contrition.
• [113] Third, the submissions made to Ahpra on 21 February 2020 - after its notification and the commencement of its investigation - speak more of self-justification rather than reflection and remorse.
• [114] Fourth, that submission also reflects, in the Tribunal's view, an incapacity to reflect with appropriate professional objectivity on deficiencies in the conduct of the procedure and the facilities at which it was conducted. That realisation, or reflection, appears to have come only after the receipt of the expert reports from Drs Kennedy and Bezic.
• [115] Fifth, the tribunal finds it difficult to accept that an obviously highly intelligent and experienced general practitioner should require hindsight (gained over time) to bring home what should plainly have been evident at the time of setting up the clinic and performing the procedures. For example, it is as remarkable as it is surprising that observing cosmetic surgery (notably, after the Ahpra notification) should be an "eye opener" to a doctor of Dr Sadeghi's experience.
• [116] Sixth, although the frankness in Dr Sadeghi's admission that "without the action taken by the Board ... other surgical patients were at risk" is acknowledged, it too is a remarkable and worrying statement from a doctor of his experience. Apparently it was not what occurred to RF, or any contemporaneous self-reflection, which precipitated Dr Sadeghi's self-assessment of being a risk to surgical patients; rather it was the Board taking immediate action against him.

• [117] Sanctions will be imposed by this tribunal some six years after the incident involving RF and the other conduct the subject of the Referral. No part of the delay is attributable to any actions or inaction by or on behalf of Dr Sadeghi.
• [118] The Board, referring to Health Ombudsman v ORC [2020] QCAT 181, submits that the doctor has "complied with stringent conditions on his registration for a lengthy period and not been subject to any other complaints".
• [119] The tribunal also accepts Dr Sadeghi's assertion that the period of delay has been stressful and, as he deposes, that his life and career have been effectively on hold awaiting the outcome of the proceedings. It is also accepted that the imposed conditions have been stringent and restrictive.
• [120] The financial and emotional costs to Dr Sadeghi exacerbated by the delay are relevant and given weight. However, where the mandated statutory aim is protection of the public other factors weigh more heavily in the balance. Decisions of this and other tribunals refer to the potential importance of delay in illuminating or rendering more reliable a process of rehabilitation and the gaining of insight. The weight given to that consideration is tempered significantly in this case for the reasons earlier identified.
• [121] As has been seen, the delay here has involved further training and observations that have illustrated to Dr Sadeghi the limitations of his training and surgical competence. It is accepted this has been of benefit. In the tribunal's opinion, the real impact of the delay in the instant case is to remove specific deterrence as a factor impacting upon an appropriate sanction.

• [122] The Tribunal regards the seriousness of the conduct outlined in the five grounds, and general deterrence, to be overwhelmingly important factors in this case.
• [123] Where actual harm is caused to a patient and where that harm results from an invasive procedure conducted without the requisite training or experience, that patient and that procedure become a particular focus. But the tribunal is mindful of the totality of the conduct particularised in the five grounds. The Tribunal - including, notably, the medical members of it - regard the totality of Dr Sadeghi's conduct as extremely serious and a very significant departure from proper standards.
• [124] The tribunal is of course conscious that the purpose of sanction is protective not punitive (albeit that sanctions might have an effect seen as punitive).[57] The Tribunal also very much has in mind that the seriousness of conduct is not measured by reference to the worst cases but rather the degree of departure from proper standards.[58]
• [125] The misconduct covers a broad ambit: it concerns the setting up of the clinic; the advertising of it; its clinical facilities; procedures performed at it; and harm to a patient of it.
• [126] Dr Sadeghi was prohibited from operating the Elinay clinic without a licence. He did not hold a licence. He took no steps to obtain one. Dr Kennedy's comment as to the medical reasons underlying the PHF Act earlier quoted pertains.
• [127] Dr Sadeghi's misreading of a regulation central to the operation of a clinic set up specifically to undertake cosmetic procedures is of itself serious as is the fact that there is no evidence that Dr Sadeghi sought any advice from any source as to the how the regulations might apply to the clinic he was establishing.
• [128] The seriousness of a doctor undertaking any procedure, much less an invasive procedure, that he or she has neither the training nor experience to carry out is self-evidently extremely serious. It is all the more so when the proposal to carry out such a procedure is accompanied by false and misleading statements to a patient as it was here. RF deposes:

Dr Sadeghi also explained to me that plastic surgeons held qualification that were recognised by the Medical Board of Australia and that it was believed that they were more competent in performing plastic surgeries. [Dr Sadeghi] said that cosmetic surgeons such as himself were just as competent, if not more competent, than a plastic surgeon when performing a facelift and that it was a bit of a "battleground" between the two professions.

Dr Sadeghi told me briefly that he had completed further training in order to become a cosmetic surgeon, but he didn't provide me with any specifics about this.[59]

• [129] The tribunal agrees with the submission of the Board that attempting to perform procedures on the relevant patients was "reckless". It also agrees with the submission that:

The errors were not in the nature of an inadvertent mistake or oversight, which can occur to any practitioner but were the result of the practitioner choosing to hold himself out to perform, and to perform, a procedure outside the scope of his training and practice.

• [130] The conduct strikes at the very heart of medical training and the trust that the public at large reposes in the profession.
• [131] The separate contention founding ground 3 is equally serious. Again, the lack of appropriate skill and care in carrying out the procedure on RF is not only admitted but self-evident. The breach of the SMAS was inadvertent and resulted in uncontrolled bleeding. Reference has earlier been made to the expert opinion of Dr Bezic in that respect.
• [132] Dr Kennedy opines "it would be well below the standard of care to perform a facelift with a hyfrecator rather than a surgical diathermy unit".[60] Equally, he opines as to the need for a minimum number of people present during the procedure "that would facilitate the safety of the procedure". The lack of those personnel "contributed to the difficulty Dr Sadeghi met in controlling the bleeding" which represents "a serious deficiency".[61] There is no apparent explanation for either.
• [133] Dr Sadeghi's failure to observe and record the dose of medications given to RF meant that upon RF's admission to hospital Dr Sadeghi could not accurately say what medications had been administered and in what amount. Dr Kennedy opines that "even if the medication were appropriately given, they were not safely administered as it was not possible for doctors in the handover position to know what amount of each drug he had been given".[62]
• [134] Dr Sadeghi's conduct was inconsistent with a number of specific Guidelines and Code of Conduct. For example, there was a failure to comply with the ANZCA Guidelines on procedural sedation; the Cosmetic Guidelines in respect to informed consent and record keeping; and Regulation 111 of the Health (Drugs and Poisons) Regulation 1996 (Qld) with respect to the record keeping of controlled drugs. Obviously enough, the Code of Conduct and Guidelines are designed to protect the public.
• [135] In admitting the Board's allegation of false and misleading advertising in ground 5, Dr Sadeghi says "I appreciate that the reference to me holding a fellowship in cosmetic surgery was misleading. I should have recognised this and removed it earlier". It remained there for about two years.
• [136] The important matter of accurately reflecting Dr Sadeghi's qualifications on the Elinay clinic website, was left to a friend of his daughter who wrote the profile description for him. Apparently it was not sufficiently checked. A subsequent update of the website, apparently done by another person, occurred after the restrictions on practice imposed by the Board. The error was not corrected - the false statement as to holding a fellowship was "inadvertently missed". It has "since been removed".[63]
• [137] The asserted oversight on Dr Sadeghi's website is repeated on his curriculum vitae which is before the tribunal. The falsity was, on RF's sworn statement, repeated to him (albeit not in the precise language of "fellowship") in the context of his making enquiries of Dr Sadeghi as to a prospective procedure.
• [138] The Cosmetic Guidelines makes the obvious, but nonetheless telling, point that false claims about "qualifications, experience or expertise" have the potential to "mislead patients by implying the practitioner is more skilled or more experienced than is the case".
• [139] The matters just discussed underscore the Tribunal's view of the seriousness of the conduct, but they also underpin the importance of general deterrence as a factor in this case.
• [140] Each aspect of the very serious conduct in all five grounds requires a clear and unequivocal message to be sent to other practitioners. That might be thought to be particularly true of grounds two and three that strike at a fundamental maxim often expressed as medical practitioners "should first do no harm".
• [141] However, the tribunal is of the view that a strong deterrent message to the profession is also required in respect of the conduct underlying the balance of the grounds which underscores the tribunal's conclusions about their significant departure from accepted standards.

• [142] Reprimand is agreed between the parties. That component of sanction is not trivial. The tribunal agrees that reprimand is appropriate.
• [143] Dr Sadeghi's contention is that a period of three months suspension is appropriate, acknowledging that "the period of suspension must reflect the seriousness of the conduct" but must also allow for the mitigating factors enumerated thereafter, discussed earlier in these reasons.[64] The tribunal has considered those mitigating factors.
• [144] The tribunal is conscious that cancellation, for which the Board contends, will mean Dr Sadeghi being precluded from working as a general practitioner - until the Board decides otherwise upon his application for re-registration. He has been working as such subject to the imposed conditions. That fact, together with the absence of specific deterrence as a significant factor in arriving at an appropriate sanction, has caused the Tribunal to consider carefully whether a significant period of suspension together with conditions appropriately balances the relevant considerations.
• [145] However, the tribunal is of the view that the seriousness of the conduct; the degree to which it departs from acceptable practice; and the need for a strong general deterrent message outweighs the mitigating circumstances.
• [146] Cancellation of Dr Sadeghi's registration is the proper sanction in addition to a reprimand sends the clearest possible deterrent signal to other medical practitioners about the dangers and inappropriateness of acting beyond their training and experience. Furthermore, it sends a clear message to the public that they can trust medical practitioners not to engage in conduct of the type particularised in these grounds and that if that trust is breached - as it is here - very serious consequences will follow.
• [147] The effect of that order is that Dr Sadeghi can reapply to the Board for re-registration immediately. The Tribunal has also given consideration to whether a disqualification period should be imposed. The Board's statutory process will involve it in deciding if Dr Sadeghi is a "suitable person to hold general registration" [65] and to consider what conditions, if any, should be imposed on his registration. That decision is not likely to be immediate.
• [148] The tribunal considers that no disqualification period is required.

[1] Health Practitioner Regulation National Law (Queensland) ('National Law'), s 5 (definition of "professional misconduct").

[2] The tribunal must pay due regard to an agreed position properly reached but is not bound by it and must arrive at its own conclusion: Legal services Commissioner v McLeod [2020] QCAT 371 at [31]- [32]; Health Ombudsman v Gillespie [2021] QCAT 54 at [22]. See also Commonwealth of Australia v Director Fair Work Building Industry Inspectorate & Ors [2015] HCA 46; [2015] 258 CLR 482 at [46]- [48].

[3] Each party posits an alternative position which involves a suspension with conditions. The terms of the latter have not been agreed.

[4] If such a finding is necessary, the determination is to occur by reference to the proven circumstances existing at the time of the hearing rather than those pertaining at the time of the conduct. See Medical Board of Australia v Cukier [2017] VCAT 109; Health Ombudsman v Field [2019] QCAT 243 at [36].

[5] Supplementary written submissions Dr Sadeghi, sub-heading at [4].

[6] Supplementary written submissions Dr Sadeghi, [6], [7].

[7] Namely the Queensland Civil and Administrative Tribunal Rules 2009 (Qld).

[8] Queensland Civil and Administrative Tribunal Act 2009 (Qld) s 28 ('QCAT Act').

[9] QCAT Act ss 9 (3), 10(1)(b), 15(b); National Law s 193B.

[12] PHF Act, s 8. (The clinic is not a "private hospital" because "health services are [not] provided to persons who are discharged from the facility on a day other than the day on which the persons were admitted to facility": PHF Act, s 9(1)).

[13] Superficial musculoaponeurotic system.

[14] Affidavit Dr Sadeghi filed 11 October 2024, [1]; [12], [14].

[15] Written submissions Dr Sadeghi, [17], [18].

[16] Supplementary written submissions Dr Sadeghi, respectively [5], [6].

[18] SZTAL v Minister for Immigration and Border Protection; SZTGM v Minister for Immigration and Border Protection [2017] HCA 34, citing Project Blue Sky Inc v Australian Broadcasting Authority [1998] HCA 35; (1998) 194 CLR 355 at 381-382 [69]- [71]; Alcan (NT) Alumina Pty Ltd v Commissioner of Territory Revenue [2009] HCA 41; (2009) 239 CLR 27 at 46-47.

[20] See, for example: "an institution providing medical and surgical treatment and nursing care for ill or injured people" - Australian Oxford Dictionary, 2nd ed and; "an institution in which sick or injured persons are given medical or surgical treatment". - Macquarie Dictionary 3rd ed.

[22] For example: to "bring about, effect or produce, as by action or the exertion of force or influence" - Macquarie Dictionary 3rd ed. "To manage a business, service etc and make it work - Cambridge Dictionary.

[23] An identical statement was made by the Judicial Member, citing the same three cases in Health Ombudsman v Le [2020] QCAT 170 at [29].

[24] Medical Board of Australia v Duck [2017] WASAT 28, at [33]-[34].

[26] Medical Board of Australia v Alkazali [2017] VCAT 286 at [81].

[27] Noting that the Board does not submit that, as at the date of the hearing, Dr Sadeghi is not a fit and proper person.

[28] See also the statement to similar effect made in the earlier decision of the Court of Appeal in Nursing and Midwifery Board of Australia v Faulkner [2018] QCA 97 at [12].

[29] Report Dr Kennedy, p 2.1, 2.5 respectively.

[30] Report Dr Kennedy, p 2.5 respectively. See also the expert opinion to similar effect Dr Bezic, 29 July 2021, p 6.5

[32] Affidavit [RF], 27 June 2022, [32].

[33] Affidavit [RF], 27 June 2022, [30].

[34] See, for example, Affidavit Dr Sadeghi, 10 October 2024, [27].

[35] Report Dr Bezic, 29 July 2021, p 7.8.

[38] Report Dr Bezic, 29 July 2021, p 8, [5].

[40] Report Dr Bezic, 29 July 2021, p 6.1.

[41] Affidavit Dr Sadeghi, 10 October 2024, [40].

[42] Good medical practice: a code of conduct for doctors in Australia (October 2020).

[43] Guidelines for registered medical practitioners who perform cosmetic medical and surgical procedures (1 October 2016).

[46] For example, Craig v Medical Board of South Australia [2001] SASC 169; (2001) 79 SASR 545, 553-555; Medical Board of Australia v Zhao [2021] VCAT 1053, [115] ('Zhao'); Health Ombudsman v Baumann [2021] QCAT 68, [15].

[48] For example, Medical Board of Australia v Griffiths [2017] VCAT 822; Nursing and Midwifery Board of Australia v BCD [2025] QCAT 8.

[49] Written submissions Dr Sadeghi, [25].

[50] Affidavit Dr Sadeghi, 10 October 2024, [58].

[51] Letter Dr Sadeghi's solicitors to Ahpra, 21 February 2020.

[53] Expert report, Dr Bezic, 29 July 2021.

[54] Letter Dr Sadeghi's solicitors to Ahpra, 21 February 2020, p 4.10.

[55] Affidavit [RF] 27 June 2022, [48], [49].

[56] Affidavit Dr Sadeghi 10 October 2024, [42].

[57] Legal Services Commissioner v Madden (No 2) [2008] QCA 301; Medical Board of Australia v Dolar [2012] QCA 271 at 30.

[58] Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630, 638.

[59] Affidavit [RF], 27 June 2022, [30], [32] respectively.

[62] Report Dr Kennedy, p 3.7. As to the importance of proper record keeping and the potentially serious ramifications of failing to do so, see Nursing and Midwifery Board v McRae [2018] VCAT1708 a [67] cited by the Board.

[63] Affidavit Dr Sadeghi, 10 October 2024, [48], [49] respectively.

[64] Written submissions Dr Sadeghi, [50].

[65] See for example National Law, Section 52.