1. Under section 196(2)(a) of the Health Practitioner Regulation National Law (Victoria) Act 2009 (the National Law), Kathy Zebic is reprimanded.
2. Under section 196(2)(e) of the National Law, Kathy Zebic's registration as a health practitioner is cancelled.

1. The Medical Board of Australia (the Board) has referred to VCAT allegations about the respondent medical practitioner, Dr Kathy Zebic, under section 193 of the Health Practitioner Regulation National Law (Victoria) Act 2009 (National Law).[1]
2. The referral, dated 31 January 2023, was accompanied by a Notice of Allegations that has since been amended.[2] We attach a modified version of the Amended Notice of Allegations to our decision record: Attachment A.
3. Dr Zebic has admitted most of the allegations.
4. Dr Zebic is aged in her fifties. She was first registered as a medical practitioner in 1992. At material times she was practising as a GP at a medical centre in a Melbourne suburb. She now cares for her elderly parents and receives a Commonwealth Government Carer Payment.
5. Dr Zebic has a complex medical history. Of most relevance for the present proceeding, she has -
   • Severe Substance Use Disorder, considered by relevant doctors to have been in sustained remission for several years (while noting that Dr Zebic has been taking certain prescribed medications classified as drugs of addiction)[3]
   • Autism Spectrum Disorder (ASD), diagnosed in 2017 or several years earlier[4]
   • Attention Deficit Hyperactivity Disorder (ADHD) (inattentive type), diagnosed in 2017.[5]
6. In circumstances described below, the Board took immediate action and suspended Dr Zebic's registration in August 2020.[6] (That was the sixth occasion on which her registration has been suspended. The first time was in 1999 after she made a self-notification relating to drug use).
7. We held a hearing via videoconference on 8 and 9 July 2025. While Dr Zebic did not participate at every prior stage of the proceeding, she attended the hearing, supported by her father who spoke briefly on her behalf. Dr Zebic gave oral evidence on oath and was cross-examined by Ms Isobel, counsel for the Board. We heard oral submissions further to the written submissions that had been filed. We made findings in relation to the allegations and the characterisation of Dr Zebic's conduct. After we announced our findings, we heard oral submissions in relation to the appropriate determinations. We reserved our decision, but we allowed time for Dr Zebic to provide supplementary written submissions (in relation to determinations only) and for the Board to make submissions in reply.[7]
8. Having received and considered the parties' further submissions, we now give reasons for our decision.[8]

1. The background to the referral relevantly includes a decision that VCAT made in 2015 concerning Dr Zebic: Medical Board of Australia v Zebic [2015] VCAT 139 (first VCAT proceeding).
2. While Dr Zebic is self-represented in the current proceeding, she was legally represented in the first VCAT proceeding. It is significant to note that the findings of fact made by VCAT in 2015 were based on an agreed statement of facts, undisputed documentary evidence, and oral submissions made at the hearing.
3. VCAT found that Dr Zebic engaged in professional misconduct as defined in legislation that preceded the National Law in that, between 10 and 20 May 2011, she breached conditions on her registration concerning her undergoing urinalysis and hair sampling related to drug use. (While there is controversy about aspects of the matter, VCAT's decision refers to the evidence about Dr Zebic's use of narcotics, among other drugs).[9]
4. VCAT further found that on four dates in 2011, Dr Zebic engaged in professional misconduct as defined in the National Law in that she wrote four prescriptions for medicines while her registration as a medical practitioner was suspended.
5. VCAT reprimanded Dr Zebic and imposed numerous conditions on her registration. (Dr Zebic's registration had been suspended four-and-a-half years beforehand).[10] VCAT's determinations meant that Dr Zebic was able to return to practice subject to the conditions, as the parties had jointly submitted was appropriate.
6. VCAT described the conditions at the time as 'stringent'. The conditions relevantly included that Dr Zebic have hair analysis tests for drug use every three months and random urinalysis at times determined by the Board, according to the Board's protocols; and that she attend her treating psychiatrist and a general practitioner at a frequency determined by those practitioners and approved by the Board.
7. The decision in the first VCAT proceeding contains extensive background information. We attach an extract from that decision to our decision record: Attachment B. We will summarise the most important information soon.

The conditions on Dr Zebic's registration at the material times

1. The Board modified the conditions from time to time in the years after 2015 to reduce the urinary drug screening (UDS) frequency. From July 2019 to August 2020 the conditions relevantly included (in summary) that Dr Zebic must -
   • commence random UDS and hair analysis for drug screening in accordance with the relevant protocols at Group Three frequency,[11] or as otherwise advised by the Australian Health Practitioner Regulation Agency (Ahpra)
   • only take substances prescribed, approved or administered by her nominated treating practitioner(s)
   • undertake treatment with treating practitioners, including but not limited to a treating psychiatrist and treating GP (the treating practitioner(s)) and attend at a frequency determined by the treating practitioner(s).
2. At material times, the treating practitioners were Dr Byron Rigby (psychiatrist) and Dr Aejaz Sheriff (GP).

1. There are three allegations.
2. Allegation 1 is that from October 2019 to July 2020 or thereabouts, Dr Zebic breached the conditions on her registration by failing to -
   • attend for UDS and hair testing as required
   • comply with the treatment directions of her treating psychiatrist, and
   • undertake treatment with a general practitioner and psychiatrist
3. The particulars to Allegation 1 set out numerous dates on which Dr Zebic allegedly failed to attend for UDS and hair testing or otherwise comply with the conditions. (It is relevant to Allegation 2 that one of those dates was 11 March 2020).
4. The particulars to Allegation 1 further allege that during treatment with Dr Rigby, Dr Zebic was advised to take dexamphetamine instead of lisdexamfetamine (alternatively referred to as 'Vyvanse'), but that (on or around 1 October 2019 to 30 May 2020, in breach of the condition that required her to take only substances prescribed, approved or administered by her nominated treating practitioner), Dr Zebic took lisdexamfetamine.
5. The particulars further allege that on numerous dates from February to June 2020, Dr Zebic breached the condition that required her to undertake treatment with her treating practitioners, by self-referring to a specialist and for vascular surgery, pathology, haematology and diagnostic radiology, instead of seeking treatment from Dr Sheriff and/or Dr Rigby.
6. Allegation 2 is that on 20 April 2020, Dr Zebic provided misleading, inaccurate and/or false information to Ahpra in response to a request that she explain her missed UDS test on 11 March 2020.
7. The particulars to Allegation 2 allege that on 20 April 2020, Dr Zebic provided Ahpra with a medical certificate from a doctor who was the principal at the clinic where she worked, (principal). The principal stated that Dr Zebic was 'away from work for most of the month of March with illness related to a medical issue'. Dr Zebic also provided Ahpra with emails in which she stated, among other things, that she was unwell and did not attend work in March 2020.
8. The particulars further allege that in October 2020, Ahpra requested the principal to produce certain information to Ahpra. In response, the principal notified Ahpra that Dr Zebic was working on 11 March 2020. The particulars allege therefore that Dr Zebic provided information to Ahpra that was inaccurate and/or incomplete.
9. Allegation 3 is that from October 2019 to July 2020 or thereabouts, Dr Zebic failed to manage her health by failing to follow the treatment directions of Dr Rigby to take dexamphetamine instead of lisdexamfetamine, and by self-referring to a specialist and for vascular surgery, pathology, haematology and diagnostic radiology.
10. The particulars to Allegation 3 include that Dr Zebic allegedly failed to seek independent and objective advice from Dr Rigby and Dr Sheriff to ensure that her health conditions were treated appropriately in light of the medical treatment that she was receiving from them.
11. The particulars further allege that in or about February 2020, Dr Zebic underwent an independent health assessment with consultant psychiatrist Dr Enrico Cementon, and that in his report in March 2020, Dr Cementon referred to various health problems; expressed concerns about the inappropriate manner in which Dr Zebic was taking dexamphetamine and lisdexamfetamine; and said that her psychiatrist and GP needed to review her treatment to address that issue. Dr Cementon further stated that Dr Zebic continued to be at risk of an exacerbation or relapse of severe substance use disorder.
12. The particulars to Allegations 1, 2 and 3 allege that Dr Zebic's conduct was inconsistent with Good Medical Practice: Code of Conduct for Doctors in Australia (2014) (Code).[12]

Further information derived from the first VCAT proceeding

1. Attachment B contains detailed findings of fact that VCAT made in 2015 in the first VCAT proceeding.
2. VCAT summarised Dr Zebic's complex medical history and noted, among other things, that there were, or had been, conflicting medical opinions as to whether Dr Zebic had underlying porphyria. (Dr Zebic told the Board in 2012 that her behaviour was attributable to untreated porphyria, although on other occasions, she gave other explanations, one being a mental health condition).[13] Similarly, evidence about Dr Zebic's narcotic abuse, and whether it had ceased by 2010, was inconclusive. Nevertheless, the prevailing medical opinion (as expressed by Dr Rigby especially) was to the effect that there were no impediments, from the point of view of Dr Zebic's health, to her being registered as a health practitioner.
3. VCAT made special mention of an episode in July 2009 when Dr Zebic was found face down on the computer keyboard on her desk in her consulting room. However, whereas in 2010 a Health Panel of the former Medical Practitioners Board of Victoria (MPBV) found it likely that Dr Zebic's use of narcotics caused her collapse, VCAT noted subsequent medical opinion that the collapse was likely explained by illness and did not make findings as to the cause of the episode.
4. Among other concerns that arose in and after 2010 - in different ways, and in various stated circumstances - Dr Zebic failed to undergo drug screening as required: for instance, when she forged a nurse's signature on a referral slip and failed to follow the protocol requiring samples to be taken under direct supervision; when she was unable to provide hair for analysis because she had shaved her head; and when she put forward psychosis as the reason for being unable to provide a hair sample.

1. The Board carries the burden of proof. The standard of proof is the usual civil standard: on the balance of probabilities. In the context of disciplinary proceedings where serious misconduct is alleged, the Victorian Court of Appeal has observed that the well-known principles in Briginshaw v Briginshaw [1938] HCA 34; (1938) 60 CLR 336 (Briginshaw) 'reflect common sense notions of probability with respect to human conduct and it is entirely proper for [VCAT] to take them into account': see Kyriackou v Law Institute of Victoria Ltd [2014] VSCA 322 (Kyriackou).[14] In Karakatsanis & Anor v Racing Victoria Limited [2013] VSCA 305 (Karakatsanis) the Court referred to Briginshaw before stating that it was entirely proper for VCAT to require that it be 'comfortably satisfied' of the facts in issue.[15] See also Medical Board of Australia v Alkazali [2017] VCAT 39 (Alkazali).[16]
2. The Tribunal Book includes the Board's investigation materials; medical records and reports; 'Pathology Alerts' and similar notifications regarding missed UDS and hair tests; Medicare and related data for items prescribed to Dr Zebic and tests ordered by her; and relevant correspondence, statements and submissions.
3. In relation to Allegation 1 (that Dr Zebic breached the conditions on her registration by failing to attend for UDS and hair testing as required), the main evidence relied on by the Board includes written submissions made to the Board in August 2020 (August 2020 submissions); Pathology Alerts from relevant providers; and communications between Ahpra and Dr Zebic.
4. In the August 2020 submissions (made by her then counsel in response to notice of proposed immediate action to suspend her registration), Dr Zebic made substantial admissions of non-compliance with the conditions while pointing to 'impediments' that impacted on her ability to comply and to communicate with the regulator.[17] (The impediments related to Dr Zebic's health and several logistical problems. Among other things, the logistical problems were that her usual testing centre was destroyed by fire and the next closest one was 30 km from her home; there was a change in her Ahpra compliance officer; and were travel restrictions associated with the COVID-19 pandemic).[18] Dr Zebic's communications with the regulator include one in February 2020 in which she apologised for what she called an oversight, described some measures she was taking to address the problem, and concluded by giving an assurance that it would not happen again.[19] In relation to the missed hair tests, the notice of immediate action that the Board gave Dr Zebic in August 2020 summarises verbal submissions made by and on behalf of Dr Zebic that month. They include that Dr Zebic had 'no particular reason' (except for her making a decision about committing to a particular location for ongoing tests) for not having a 'make-up' hair test after she became aware of her non-compliance.[20]
5. Ms Isobel presented the Board's evidence on the first day of hearing. On the second day of hearing, Dr Zebic confirmed in effect that she admitted the allegation concerning UDS and hair testing.
6. On the basis of the evidence contained in the Tribunal Book we have referred to, and the admissions made by Dr Zebic, we are comfortably satisfied with respect to that part of Allegation 1.
7. Further in relation to Allegation 1 (that Dr Zebic breached the condition on her registration that requiring her to undertake treatment with a general practitioner and psychiatrist, by self-referring on several occasions), the evidence relied on by the Board includes a 'Table of complied data from Services Australia'. The table refers to various tests and studies. Dr Zebic's name appears in numerous instances in column headed 'Ordering Provider Name'.[21] This is mirrored in a Medicare Patient History Report for Dr Zebic.[22] Further to that, the Board relied on the following statements in the August 2020 submissions as evidence of admissions about breaches of the conditions:

Dr Zebic accepts that she has written referrals and pathology tests for herself. These were not with the intention of causing any breakdown in the coordination of her medical care by Dr Sheriff, but rather were done to expedite diagnosis of the cause of her ongoing episodes of cellulitis. She has not written prescriptions for herself.

... In retrospect, Dr Zebic recognises the potential for self-referral to impact on coordination of care. She will not self-refer in future.

1. In her oral evidence, Dr Zebic confirmed that she had written the referrals in question, but she maintained that she did so in conjunction and coordination with her treating doctors - with them knowing about it.[23]
2. Under cross-examination, in relation to the referral to a vascular surgeon, Dr Zebic said that while Dr Sheriff did not 'approve' her self-referring to a vascular surgeon, she and he discussed the matter (in the context of certain treatment she required at the time), and he was aware that she was seeing a vascular surgeon. She didn't ask for his approval. Dr Sheriff had a preferred surgeon he wanted her to see but she declined because she had found a specialist she liked, and Dr Sheriff was 'fine with that'. Dr Zebic said that at the time she wrote the referral she did not believe she had done anything wrong, but now that the Board raised the issue, she could see the point.
3. Responding to questions about the referrals she made for pathology and haematology and diagnostic radiology, Dr Zebic mentioned a consultant who oversaw 'Hospital in the Home' treatment she was having for cellulitis (consultant). The consultant, knowing she was a GP, though unaware of the conditions on her registration, said that she could organise some tests to exclude certain diagnoses. Dr Zebic told us that she 'may have' organised some additional tests, which she conceded she should not have done. She said, however, that she shared the results with her doctors.
4. Ms Isobel took Dr Zebic to a letter Dr Sheriff wrote in August 2020 in which he said that she had self-referred to a vascular surgeon and that this had 'become a concern but this is a one of[f] issue and she has been made aware of this'. Dr Zebic accepted that Dr Sheriff was indeed concerned. She also accepted that Dr Sheriff did not know about all of the other referrals. She maintained that she and Dr Sheriff had a consultation in which he nominated his preferred vascular surgeon. She could not say why his notes did not reflect that. At this point, she conceded that she could have worded things better than to have said that the self-referrals were done in coordination with, and with the knowledge of, her treating doctors. She said that her position was that she was not self-referring and self-managing. She was discussing things and working with her treating doctors. However, she could now see why she should not have done that, because of the conditions on her registration.
5. Dr Zebic agreed with Ms Isobel that she self-referred to the vascular surgeon without Dr Sheriff's knowledge, although she and he had generally discussed her need to see a vascular surgeon.[24]
6. Ms Isobel asked a series of questions that contrasted Dr Zebic's oral evidence (that she acted in coordination with her doctors) with the portion of the August 2020 submissions quoted above (which said she acted without the intention of causing any breakdown in the coordination of her medical care by Dr Sheriff). Dr Zebic said she did not know why the lawyers wrote that. She maintained that the self-referrals were done 'in conjunction with' her treating doctors, but she could (now) understand why the issue had arisen, because self-referrals 'without coordination' with the treating doctors is inappropriate and doctors should not treat themselves. She said in effect that it would have been preferable to have asked the consultant and Dr Sheriff to make the referrals.
7. On the basis of the evidence contained in the Tribunal Book we have referred to, and the admissions made by Dr Zebic, we are comfortably satisfied with respect to that part of Allegation 1 and the related part of Allegation 3. (We mention that after we made these findings, there was further relevant evidence emerged when we were hearing from the parties in relation to characterisation of Dr Zebic's conduct: see further below).
8. Further still in relation to Allegation 1 (that Dr Zebic breached the conditions on her registration by failing to comply with the treatment directions of her treating psychiatrist, Dr Rigby), but also in relation to part of Allegation 3 (that Dr Zebic failed to manage her health by failing to follow those treatment directions), the Board relied on the following evidence.
9. First, Dr Rigby wrote to Ahpra's Senior Regulatory Advisor - Compliance (SRA) in March 2020 and noted that Dr Zebic was prescribed 'Dexamphetamine sulphate 40 mg daily'.[25]
10. Secondly, there was further correspondence between Ahpra and Dr Rigby in May 2020. The SRA sought clarification because Dr Zebic had provided information that she was taking 'Vyvanse (Lisdexamfetamine) at 70mg'.[26] The material part of Dr Rigby's response was:

Both are correct - regarding the time to which the different correspondence applied.

An attempt was made to change treatment from dexamphetamine to lisdexamfetamine as a way of getting a smoother response and an easier medication schedule.

Unfortunately, this did not provide the capacity to titrate and adjust treatment throughout the day, resulting in insufficient response at in (sic) some parts of the day, and to some extent continued response when not needed.

For that reason, the treatment was changed back to dexamphetamine, which is easier to control.[27]

1. Thirdly, there were comments by Dr Cementon in his report made in March 2020 that we have referred to earlier.[28] Specifically, Dr Cementon noted that Dr Zebic was taking dexamphetamine 5 mg and lisdexamfetamine 70 mg for ADHD 'in an alternating manner'. He described her medication takings as often 'inappropriate', among other things. Dr Cementon noted:

Dr Zebic reported that the commencement of psychostimulant medication had improved her symptoms of inattention, distractibility and sleep difficulties and her organisational skills. Her method of taking the stimulant medication was unusual: some days she takes the long-acting lisdexamfetamine and some days she takes the short-acting dexamphetamine, sometimes depending on whether she can find one medication or the other.[29]

I believe Dr Zebic should continue to be subject to Group 4 UDS testing and must continue to attend her treating psychiatrist and general practitioner. As I discussed above, these doctors need to review the current treatment Dr Zebic is taking and address the inappropriate manner in which she is taking the medications.

Severe substance use disorder is usually a long-term disorder and I believe Dr Zebic continues to be at risk of an exacerbation or relapse in this disorder. Objective testing such as UDS and hair testing assist in the monitoring of this.[30]

1. Fourthly, in a report made to Ahpra in August 2020, Dr Rigby responded to aspects of Dr Cementon's report. As to Dr Cementon's comments that we have italicised, Dr Rigby said:

I believe this to be a slight misunderstanding of the way in which this medication has been deployed. In fact, the long-acting agent lisdexamfetamine proved to be both less effective and somewhat expensive, resulting in reversion to the use of dexamphetamine. I have not been aware of any alternation of these two agents.[31]

1. Fifthly, the August 2020 submissions were said to 'admit' that confusion existed as to whether Dr Zebic should take both dexamphetamine and lisdexamfetamine in a daily alternating manner, but that Dr Rigby had provided clarification that she should not. (The submissions went on to say that Dr Zebic was no longer prescribed lisdexamfetamine and was taking dexamphetamine alone, such that there was no longer any potential risk in relation to taking a combination of the two medications).
2. Sixthly, though earlier in time, a Patient History Report for Dr Zebic for the period of about six months from October 2019 shows that dexamphetamine and lisdexamfetamine were dispensed in what was essentially an alternating pattern.[32]
3. Finally, a Pathology Report dated in January 2020 noted the presence of a small amount of amphetamine in Dr Zebic's hair and included the comment that this was 'not inconsistent with [her] declared use of both Dexamphetamine and Vyvanse' (lisdexamfetamine).[33]
4. In her oral evidence, Dr Zebic told us that she has been taking dexamphetamine for many years. It is 'a short-acting release' medication that had to be taken three times a day. At some point she had a discussion with Dr Rigby about making a switch to lisdexamfetamine (which has a long-acting release) so that she would have to take the medication once a day only. She and Dr Rigby discussed trialling this. She would take lisdexamfetamine. Then she would stop. Then she would take dexamphetamine. Her use of the medications did not overlap on any day. In time she found that dexamphetamine was better for her. She said, in the context of Dr Cementon's assessment, that she was advised to take one or the other drug and, she believed, Dr Rigby said she should take dexamphetamine. She said she believed that she did not take lisdexamfetamine after receiving Dr Rigby's advice about that.
5. In relation to the Pathology Report that referred to her taking both dexamphetamine and lisdexamfetamine, Dr Zebic said that she wrote both drugs on the form, not because she had taken both on the same day, but (to the best of her memory) because she was required to record medication she had taken over the past two-three days. She said there had been confusion about the matter. She essentially described the problem as being how she provided information when attending for drug screening and how she explained the situation to Dr Cementon.
6. Ms Isobel cross-examined Dr Zebic in relation to her use of dexamphetamine and lisdexamfetamine. Dr Zebic explained the importance of the medication to her and the practical steps she took to make sure she remembered when she took it so that she did not double up. She maintained that she followed Dr Rigby's instructions regarding dexamphetamine and lisdexamfetamine. Dr Rigby did not ever tell her to alternate the medications, but he did agree to her trialling lisdexamfetamine. Explaining this, Dr Zebic said she took the medication in 'blocks' (as opposed to alternating from day to day): she might take dexamphetamine for a week then stop it and start lisdexamfetamine. She could not be sure, but she said that might have gone for a period of months. (It was 'maybe' three months, she later said). Dr Rigby didn't tell her to do that, but she understood she could. That's what she understood trialling to mean. Dr Rigby did not give her specific instructions as to how to trial lisdexamfetamine, he just gave her instructions to trial it: the rest was her interpretation.
7. Ms Isobel took Dr Zebic to the Patient History Report which showed that dexamphetamine and lisdexamfetamine were dispensed in what was essentially an alternating pattern for approximately six months. Dr Zebic said in effect that she would take one or the other drug for maybe 10 or 12 days because it was hard to compare the impact they were having. She reiterated that Dr Rigby did not know she was alternating between the two drugs in this way for that six-month period. His instructions were to trial lisdexamfetamine.
8. Dr Zebic could not recall precisely when it was that Dr Rigby told her to resume taking dexamphetamine. She thought it was some time after Dr Cementon raised concerns (in March 2020). She said that she had some lisdexamfetamine dispensed after that. Asked why she did that, Dr Zebic said that it was 'not the smartest thing to do'. She explained that she worried about medication and sometimes did 'stupid things'. (Earlier, Dr Zebic said she could be clumsy and forgetful at times). She insisted that she did not take lisdexamfetamine as 'extra' medication or after Dr Rigby told her not to take it. Dr Zebic said in effect that she would want her own patients to follow her treatment recommendations. She thought that her diagnosed (high functioning) ASD meant that she interpreted Dr Rigby incorrectly. Dr Zebic said that, retrospectively, she could see that there was a problem, but she did not believe that she was 'breaking any rules'. That said, she now believed that it was 'probably not the best way to approach taking the medication'. Still, she did not accept 'completely' that she had not followed Dr Rigby's treatment plan, because he asked her to trial the medication. But she could see why the Board would consider it a problem now.
9. Dr Zebic conceded that she didn't ever ask Dr Rigby how she was meant to trial the lisdexamfetamine. Ms Isobel asked Dr Zebic if she accepted now that she should have discussed this with Dr Rigby before alternating between the two drugs for such a long period of time. Dr Zebic said she did accept that, and that she was 'quite happy' for somebody to point out something she might have not factored into her consideration at the time. She said it was a simple misunderstanding between her and Dr Rigby rather than her not following his directions.
10. We are not comfortably satisfied with respect to the part of Allegation 1 that relate to the use of dexamphetamine and lisdexamfetamine. We are not comfortably satisfied with respect to the related part of Allegation 3. That is - essentially - we are not comfortably satisfied that Dr Zebic failed to comply with Dr Rigby's treatment directions.
11. We are mindful that in the first VCAT proceeding the Tribunal made some adverse findings about Dr Zebic's honesty (the findings about forgery) and that in the present proceeding (as we will soon discuss), she admitted to providing misleading, inaccurate and/or false information to Ahpra about one of the UDS tests she missed (although not deliberately, she maintains). Having heard Dr Zebic's oral evidence, including her responses to Ms Isobel on cross-examination, however, even though her recollections and understanding were not always clear, we accept Dr Zebic as credible (including on the key points about ceasing lisdexamfetamine when she was directed to despite still having some of that medication dispensed).
12. There is a degree of conflict or confusion in the material - between Dr Cementon and Dr Rigby's reports, and in other evidence and submissions - as to precisely what the understanding was between Dr Rigby and Dr Zebic. It is significant, in our view, that Dr Rigby was prescribing for a longstanding patient whom he knew to be medically qualified, so that when it came to them having discussions about a 'trial' of lisdexamfetamine, that would or could reasonably have meaning between Dr Rigby and a medically qualified patient that it may well not have - that it probably would not have - between Dr Rigby and a lay patient.
13. Ultimately, because of the conflict or confusion in the material, and because we accept Dr Zebic's sworn evidence, we are not comfortably satisfied with respect to these allegations.
14. In relation to Allegation 2 (that Dr Zebic provided misleading, inaccurate and/or false information to Ahpra in response to a request that she explain her missed UDS test on 11 March 2020), the evidence relied on by the Board includes the relevant Pathology Alert concerning the missed test and Ahpra's email to Dr Zebic requesting an explanation. There are, then, the following items of evidence. There is an email Dr Zebic sent to Ahpra dated 20 April 2020 in which she stated that she had not attended work for the month of March.[34] At or about the same time Dr Zebic sent Ahpra a letter by the principal confirming that she was 'away from work for most of the month of March with illness related to a medical issue').[35] Next, there is an email from the principal to Ahpra dated 12 October 2020 in which he said that he had checked the clinic appointment book and could confirm that Dr Zebic worked on 11 March 2020.[36] Finally, in written submissions by Dr Zebic dated 10 May 2024, she said that she had been under the impression for a few years that she was off work for the whole of March 2020 as she was unwell with a 'septic process'. Dr Zebic said when the issue was brought to her attention she called the medical centre and staff were able to confirm that she worked on 11 March as patient consultation notes appear for that day. She then said that to the best of her knowledge, she felt better that day and attended work (after realising her designated testing location was non-operational due to arson as it was a UDS screening day as well), but as the day progressed she started to feel unwell again. Dr Zebic added:

Being physically unwell for most of the month of March 2020, and being on leave, I lost track of time as I needed to sleep and rest. I feel it is quite unreasonable to read serious significance into a mistake regarding a date while medically unwell, or into an administrative oversight involving the date of a medical certificate that occurred close to four years ago about a [medical] condition that required hospital admission for treatment.

1. In her oral evidence, Dr Zebic acknowledged that she provided the statement inaccurately 'at the time' but said she did not do so knowingly. She said she was overwhelmed, being unwell for most of March 2020. She said that in her mind there was no reason to lie to the Board because the Board 'finds out everything'.
2. On the basis of the evidence contained in the Tribunal Book we have referred to, and the admissions made by Dr Zebic, we are comfortably satisfied with respect to Allegation 2.
3. We announced our findings at the hearing.

1. Section 5 of the National Law includes the following definitions of 'professional misconduct', 'unprofessional conduct' and 'unsatisfactory professional performance':

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; and

(b) more than one instance of unprofessional conduct that, when considered together, amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and

(c) conduct of the practitioner, whether occurring in connection with the practice of the health practitioner's profession or not, that is inconsistent with the practitioner being a fit and proper person to hold registration in the profession.

unprofessional conduct, of a registered health practitioner, means 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 and includes -

(i) a condition to which the practitioner's registration was subject ...

unsatisfactory professional performance of a registered health practitioner, means the knowledge, skill or judgment possessed, or care exercised by, the practitioner in the practice of the health profession in which the practitioner is registered is below the standard reasonably expected of a health practitioner of an equivalent level of training or experience.

1. In relation to paragraph (c) of the definition of 'professional misconduct, Ms Isobel cited Psychology Board of Australia v Griersmith [2019] VCAT 52 (Griersmith). In Griersmith, VCAT said:

The term 'fit and proper person' is not defined in the National Law but its meaning has been the subject of much judicial comment. The test does not carry defined criteria but allows for a wide range of matters to be considered. 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.[37]

1. The Code referred to in the Amended Notice of Allegations is evidence of what constitutes appropriate professional conduct or practice for the medical profession: see section 41 of the National Law. The key provisions of the Code relied on by the Board in the present case concern doctors' duty to make the care of patients their first concern and to practise medicine safely and effectively. The Code recognises that the welfare of patients may be put at risk if a doctor is performing poorly. Doctors must comply with any reporting obligations that apply to the doctor's practice.
2. The Board submitted that Dr Zebic's conduct amounts to professional misconduct, in the following ways:
   • Allegation 1 (Breach of conditions): professional misconduct within the meaning of paragraph (a) of the definition in section 5 of the National Law
   • Allegation 2 (Provision of misleading, inaccurate and/or incomplete information): professional misconduct within the meaning of paragraph (a) and (c) of the definition
   • Allegation 3 (failure to manage health): professional misconduct within the meaning of paragraph (a) and (c) of the definition
3. In summary, our findings are as follows:
   • Allegation 1: We find that Dr Zebic engaged in professional misconduct within the meaning of paragraph (a) and/or (b) of the definition of 'professional misconduct' in section 5 of the National Law
   • Allegation 2: We find that Dr Zebic engaged in unprofessional conduct
   • Allegation 3: We make no finding. (That is, we do not find that there has been unsatisfactory professional performance or unprofessional conduct or professional misconduct on Dr Zebic's part).
4. We announced or findings at the hearing. We now elaborate on our reasons.
5. In her submissions, Ms Isobel took Allegations 1 and 3 together.
6. Ms Isobel submitted that it is inherently serious for a health practitioner to breach conditions imposed on his or her registration and that the nature of Dr Zebic's breaches was inherently serious. We agree - at least so far as the missed drug tests are concerned. Months passed with Dr Zebic avoiding any drug testing, random or otherwise. As Ms Isobel pointed out, it is ultimately unknown, and cannot be known, whether Dr Zebic used such drugs during the time she missed her tests. This was of course against the background we have outlined, including VCAT reprimanding her and imposing stringent conditions on her registration in 2015. This, as Ms Isobel submitted, makes Dr Zebic's conduct even more serious.
7. We digress to make some important observations. Dr Zebic's severe substance use disorder is said by Dr Cementon and Dr Rigby to have been in sustained remission for several years. Dr Zebic is supported by Dr Rigby especially in saying that she has not used illicit or unprescribed drugs for many years.[38] Whether, and to what extent Dr Zebic has been at risk of relapse, may be a matter of controversy.[39] However, we note that when Dr Cementon expressed the opinion in 2020 that Dr Zebic continued to be at risk of an exacerbation or relapse, he prefaced that by saying that severe substance use disorder is usually a long-term disorder. He went on to remark that objective testing such as UDS and hair testing assist in monitoring this.[40]
8. Dr Zebic said at the hearing that she had been required to attend for drug screening for years despite there being no need for that. In her post-hearing submissions, she asserted that her substance abuse is 'old' and 'dates back to 1999' and that her current conditions 'relate to risk assessment rather than fact'. Whatever strength arguments against the imposition or continuation of the conditions may ever have, the conditions were imposed for the protection of the public. Non-compliance with conditions cannot be justified by the health practitioner's opinion that they are unnecessary or excessive. As the New South Wales Civil and Administrative Tribunal (NCAT) remarked in Health Care Complaints Commission v Bainbridge [2018] NSWCATOD 169 (Bainbridge), one of the cases cited by Ms Isobel, '[a]ny practitioner whose registration is subject to conditions could not reasonably hold any view of those conditions other than that they must be scrupulously observed'.[41]
9. We return to the Board's submissions. Ms Isobel submitted that Dr Zebic's conduct was repetitive and persistent. The conduct was connected to Dr Zebic's practice as a doctor, as the conditions were to ensure that she practised medicine safely. The conduct was at odds with community expectations and undermined the medical profession's good standing and the inherent trust that exists between the public and the profession. Dr Zebic's conduct fell substantially below the expected standards of the medical profession, including those set out in the Code which states, in particular, that doctors 'have a duty to make the care of patients their first concern and to practise medicine safely and effectively. They must be ethical and trustworthy'.[42]
10. The Board acknowledges that the requirement for drug screening can be inconvenient, intrusive and expensive, but maintains that it is the best means by which it can be satisfied that a health practitioner is not using illicit substances and is able to continue working safely. In this context, Ms Isobel cited Nursing and Midwifery Board of Australia v Stokes [2021] VCAT 1319 (Stokes). VCAT said in Stokes that requirements that may seem administratively burdensome are -

... part and parcel of the nature of drug testing. Conditions of this nature are inevitably inconvenient, and embarrassing. But they must be adhered to - to the letter. Otherwise, suspicion inevitably arises. That is inherent in the nature of drug testing.[43]

1. In Dr Zebic's own case, VCAT said in 2015 that if the abuse of drugs by health practitioners is detected:

... drug screening is a critical tool to make it feasible to allow their return to medical practice, while protecting the public. Avoiding the surveillance afforded by that screening is a most serious failing in conduct.[44]

1. Ms Isobel noted that Dr Zebic gave explanations for missing some tests but submitted that it was Dr Zebic's responsibility to comply. She submitted in effect that even if we considered that tests were sometimes missed inadvertently or that some missed tests could (if taken individually) be considered as relatively insignificant, cumulatively the repeated breaches amounted to 'a significant imposition on the regulator'. Ms Isobel submitted that by failing to attend so many times, Dr Zebic undermined a critical safeguard for her patients and the public; showed a lack of insight into the need to prioritise compliance with her conditions in order to ensure her patients and the public were protected; and had inevitably raised suspicion about her conduct.
2. Later in our reasons, when discussing our determinations, we will refer to matters raised by Dr Zebic, supported by Dr Rigby that, while not absolving her of responsibility, might be considered as mitigating factors. For now, we note that Dr Zebic evidently told the Board at the immediate action stage that, despite the impediments to her compliance, she accepted that her non-compliance was ultimately her responsibility and that she had put forward various matters by way of explanation, not as an excuse.[45]
3. Still considering Allegation 1, we turn to the less straightforward matter of the self-referrals.
4. Ms Isobel submitted that Dr Zebic's conduct in self-referring for so many interventions undermined the safeguard that she undertake treatment with her treating practitioners and comply with the treatment. Ms Isobel submitted that Dr Zebic was aware that these conditions were imposed on her registration to ensure that she was able to practise safely and that, in circumstances where the conditions were not new to her and her conduct was repetitious, Dr Zebic's behaviour may indicate a defect of character, rather than an error of judgement.
5. As we have indicated, there was further relevant evidence in relation to the self-referrals that emerged when we were hearing from the parties in relation to characterisation. Among the most significant evidence were a pathology referral for 'supervised uds' which named Dr Zebic as the referring doctor but which also provided that copy reports were to be sent to Ahpra and Dr Sheriff; and a pathology referral for a study related to porphyria which named Dr Zebic as the referring doctor but which also named Dr Sheriff as the addressee.[46] Concerning the referral to the vascular surgeon, Ms Isobel noted that while Ahpra had required Dr Sheriff to produce all the information he held, there was nothing to show that he had received anything from the vascular surgeon. On the other hand, there was evidence that, albeit several months after the referral to the vascular surgeon, Dr Zebic emailed the surgeon's report to Dr Sheriff.[47] In this context, Dr Zebic repeated that she had discussed the choice of vascular surgeon with Dr Sheriff. As we understood her evidence, she said that she had directed that all the reports she sought be copied to her doctors. She said that she probably just forgot to provide Dr Sheriff's name to the vascular surgeon's rooms. She said she was not blaming the surgeon's secretary for the report not being sent to Dr Sheriff (in addition to her) in the first place.
6. We are aware that at the immediate action stage, the Board expressed the problem by saying that whatever Dr Zebic's motivation in becoming involved in her care, the practical consequence was that she circumvented the central coordinating role of her GP and deprived the Board of key information about her health, noting that the Board relied on reports from her treating practitioners in order to monitor her health.[48] Having considered the whole of the evidence, however, we do not find that Dr Zebic intended to circumvent Dr Sheriff's role or that her conduct had that effect to a material degree.
7. Ultimately, we consider there to have been an error of judgement on Dr Zebic's part, rather than conduct indicating a defect of character.
8. Looking at the whole of the matters proved in relation to Allegation 1, we find that Dr Zebic engaged in unprofessional conduct that was substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience. Further or alternatively, we find that there was 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.
9. In relation to the part of Allegation 3 that concerned the self-referrals, in the circumstances we have discussed, we do not consider that Dr Zebic's conduct amounted to unsatisfactory professional performance or unprofessional conduct or professional misconduct.
10. In relation to Allegation 2, Ms Isobel submitted that the conduct was objectively very serious. Registered health practitioners are expected to take care when providing information to Ahpra and the Board, to ensure that the information they provide is true and correct. Dr Zebic provided false information that she had been away from work for the entirety of the month of March 2020, and attempted to support this false information with a medical certificate from a colleague. Had Ahpra not taken further steps to clarify the information from the colleague, Dr Zebic may have been successful in avoiding the consequences of a breach on 11 March 2020. Ms Isobel submitted that Dr Zebic's conduct may have been dishonest - an attempt to mislead the regulator to avoid consequences for missing the test - or it may have been careless or reckless to such a level that the Tribunal should be concerned. She submitted that, either way, the conduct was not consistent with Dr Zebic being fit and proper to hold registration.
11. While acknowledging that the conduct was a 'single event', Ms Isobel submitted that it is important to note the broader context, which includes Dr Zebic having been found to have acted dishonestly in the past to avoid her drug screening obligations. (Ms Isobel referred to the forgery findings VCAT made in 2015).
12. Ms Isobel submitted that the conduct was connected to Dr Zebic's practice of medicine because it was a nearly successful circumvention of the protections that VCAT and the regulator had put in place in relation to her drug use, and this was directly relevant to her ability to practice safely as a doctor. Ms Isobel submitted that the conduct fell substantially below the standards expected of a doctor, including the Code. The conduct called into question whether Dr Zebic can be trusted to deal honestly within the regulatory system in which she practises. Ms Isobel further submitted that the community expects that registered medical practitioners conduct themselves honestly and ethically and that Dr Zebic's conduct undermined the credibility of the profession and Ahpra's regulatory function.
13. For Dr Zebic to have provided misleading, inaccurate and/or incomplete information to Ahpra is obviously a serious matter given role of the regulator and the obligations that health practitioners have. Considering the whole of the evidence, and especially Dr Zebic's oral evidence, we do not consider that Dr Zebic's conduct rose to the level of professional misconduct within the meaning of paragraphs (a) and (c). We find that her conduct was unprofessional conduct, being 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.
14. The importance of health practitioners being honest with the regulator is nevertheless something worth emphasising. As the New South Wales Civil and Administrative Tribunal said Health Care Complaints Commission v Chowdhury (No 2) [2015] NSWCATOD 127 (Chowdhury):

It is critical to the effective operation of a system of regulation that regulated persons co-operate fully with the regulator. Regulated persons practise under a registration or licence bestowed by the community. As a result they acquire an exclusive right to practise the regulated activity. It is intrinsic to the efficient and effective operation of the regulatory system that members of the regulated occupation or profession deal in a frank, candid and truthful way with the regulator ...[49]

1. Our findings in relation to the characterisation of Dr Zebic's conduct is broadly consistent with decisions in previous cases that Ms Isobel cited: Bainbridge; Stokes; Medical Board of Australia v CQW [2021] VCAT 346 (CQW); and Osteopathy Board of Australia v Canagasabai [2024] VCAT 358 (Canagasabai).[50]

1. The Board seeks determinations that we reprimand Dr Zebic; cancel her registration; and disqualify her from applying for registration for two years.
2. Dr Zebic resists cancelation. She maintains that she able to practise safely under supervision. She says that the proposed determinations would be 'a nail in the coffin for [her] hopes of ever returning to practice'.
3. We have been informed about the financial and personal hardship that Dr Zebic has experienced by reason of her suspension. Character references and general letters of support by health practitioners, which span many years, include comments about the impact there has been on Dr Zebic's patients. We have been invited to consider the positive effects that a return to practice would have for her and her patients.
4. We will soon discuss the principles to be applied when considering determinations. There are points arising especially from the parties' post-hearing submissions that we first need to address.
5. Dr Zebic's submissions were accompanied by a report by Dr Rigby dated 15 July 2025. Dr Rigby said there that he would 'not be engaging in advocacy of any kind'. He expressed the opinion (which he believed was shared by all practitioners who have known or examined Dr Zebic, including Dr Cementon) that Dr Zebic is able to practise medicine safely. He described her as 'talented, intelligent and well-read', and said that she 'has weathered the extreme duress of many years of suspension'.
6. While indicating that he is not qualified to comment on the '[a]dministrative and disciplinary' elements of concern to the regulator, Dr Rigby said he believed he could provide clinical evidence that may be relevant. He acknowledged that he was not familiar with all of the regulator's concerns. Specifically in relation to the 'defaults' in drug testing, Dr Rigby said he did not have documentation about all of them, but he remarked that (in ways that he elaborated upon) some of them had been 'incomprehensible unless autistic literal thinking is taken into account'.
7. Dr Rigby said that he had found the diagnosis of ASD to be the best explanation for Dr Zebic's 'occasionally non-standard approach to circumstances and people'. He expressed the belief that a full understanding of Dr Zebic's characteristics (being 'extremely literal', for instance, and often failing to estimate accurately the responses of other people) 'may resolve a number of issues before the Tribunal'.
8. In reply, the Board submitted that Dr Rigby's report should not be accepted into evidence and should be disregarded. The reasons for the submission included that the Board would be denied procedural fairness if the report were received, for the Board had not had the opportunity to cross-examine Dr Rigby on the matters contained in the report. In the alternative, the Board submitted that the report should be afforded no weight. The submission was made on the basis that much of the report is not relevant to determinations. The Board noted that, in the Amended Notice of Allegations, it did not allege that Dr Zebic has a health impairment; and that no findings were made about an impairment. Further, there had been no submission by Dr Zebic, or any opinion proffered, that she has an impairment that contributed to and/or caused her alleged conduct. The Board further submitted, in effect, that there were discrepancies between matters Dr Zebic evidently reported to Dr Rigby (about self-referrals, for instance) and the evidence given at the hearing.
9. We have given the report due consideration. We have disregarded parts that could be said to bear on matters about which we have already made findings. We are mindful of the Board's concerns about procedural fairness and its submissions that the report should be given no weight. It is significant to point out, however, Dr Rigby previously made comparable remarks about the impact of Dr Zebic's ASD and her general capacity to practise medicine safely.[51]
10. Dr Rigby concluded his most recent report with this statement:

There are many effective medical practitioners and academics with high-functioning autistic traits, and who with collaboration and management can pursue their professions safely.

1. There should be no controversy about that. We repeat for emphasis that the Board does not allege that Dr Zebic has an impairment that detrimentally affects or is likely to detrimentally affect her capacity to practise as a medical practitioner.
2. Dr Zebic's made a statement in her submissions to the effect that discrimination on the grounds of neurodiversity is prohibited by Law.
3. There can be no controversy about that. It was not clear however whether Dr Zebic was alleging that she had suffered discrimination in a material way. She did say that she believed that her 'difficulties' had been and continued to be an 'issue with her interactions' with Ahpra. She remarked that clear communication goes a long way in resolving 'these obstacles' and that clear communication was 'absent from [her] last [Ahpra] compliance officer'. Dr Zebic went on to say that she felt that her situation had been 'potentially avoidable' had her last compliance officer communicated with her in the way that she had previously been accustomed to.
4. We return to that point below when considering the question of Dr Zebic's insight. For now, it is important to recall the scope of our functions. We have made findings about Dr Zebic's (substantially admitted) conduct which was set against a background that extends long before the mentioned compliance officer became involved. Now we must make the appropriate determinations, applying the principles we discuss in the next section of our reasons.

1. The objectives of the national registration and accreditation scheme for the regulation of health practitioner and the guiding principles are expressed in sections 3(2) and 3A of the National Law. As Ms Isobel noted, the 'foundational concept' that underpins any decision to take regulatory action is protection of the public.
2. In Craig v Medical Practitioners Board [2001] SASC 169 (Craig), Doyle CJ said:

The purpose of disciplinary proceedings is to protect the public, not to punish a practitioner in the sense in which punishment is administered pursuant to the criminal law. A disciplinary tribunal protects the public by making orders which will prevent persons who are unfit to practise from practising, or by making orders which will secure the maintenance of proper professional standards. A disciplinary tribunal will also consider the protection of the public, and of the relevant profession, by making orders which will assure the public that appropriate standards are being maintained within the relevant profession.[52]

1. In Medical Board of Australia and Pharmacy Board of Australia v Lee [2019] VCAT 311 (Lee), VCAT summarised the law relating to the making of determinations as follows:

(a) the purpose of the imposition of determinations is to protect the public;

(b) determinations are intended to maintain proper ethical and professional standards for the protection of the public and also for the protection of the profession in the sense of maintaining stature and integrity in the eyes of the public;

(d) the objectives of determinations can be achieved by specific deterrence, that is, the deterrence of the person concerned from further inappropriate conduct; by general deterrence, that is, the deterrence of other practitioners minded to conduct themselves similarly; and by facilitation of rehabilitation on the part of the practitioner;

(e) personal matters such as shame, personal ordeal, and financial difficulty are of little relevance save insofar as they contribute to the specific deterrence of the practitioner;

(f) the likelihood of recidivism, or, put another way, an assessment of the ongoing risk posed by the practitioner, should be central to the imposition of a determination;

(g) the degree to which the practitioner has acquired insight into his or her conduct is relevant to the assessment of the continuing risk posed by the practitioner;

(h) insight can include an understanding of the nature of the conduct, an acceptance that the conduct was wrong, an appreciation of why the practitioner engaged in that conduct, empathy with the consequences, and/or a willingness to take measures to identify risk factors and to do that which is necessary to avoid further transgressions; and

(i) any form of official censure is of consequence. It has been observed by the Courts that a reprimand is a serious matter for a professional person and should not be considered a 'slap over the wrist'.[53]

... [A]ppropriate determinations cannot be reached according to a set formula, rather, every case must be determined on its own unique facts; including mitigating circumstances. In appropriate cases, the Tribunal also recognises the need to impose determinations which support rehabilitation and give weight to periods of time already away from practice.[54]

1. In support of the Board's position as to determinations, Ms Isobel emphasised the following matters especially. Dr Zebic's long history of breaching conditions. The paucity of evidence that Dr Zebic has developed meaningful insight into her conduct. Dr Zebic's apparent failure to prioritise compliance with the conditions as a precondition to practice and as an essential safeguard to protect the public, her colleagues, and her patients.
2. In the context of specific deterrence, Ms Isobel made a submission to the effect that where all other measures have failed, cancellation of registration is required to bring home to Dr Zebic the seriousness of her conduct and to deter her from any further transgressions.
3. We observe that the Board's submissions were made initially (in writing) at a time when it was not known whether Dr Zebic would be participating in the hearing. It was therefore not known what she might say as to any steps that she has taken to ensure she is managing her health and would be able to comply with any conditions that might be imposed on her registration now.
4. Of course, Dr Zebic did participate in the hearing, and she has given evidence and made submissions.
5. While we bear in mind what Dr Zebic and Dr Rigby especially have said about the impact of ASD on Dr Zebic's communications with other people, we remain concerned that Dr Zebic does not have adequate insight into her conduct.
6. In post-hearing submissions, Dr Zebic said that she takes responsibility for her actions. She added in effect that if she knew at the time what she knows now, she would have submitted to every test required. She said that she believes she was doing the best she could and that her intention was never to deceive or display disrespect to the regulator or VCAT's authority.
7. On the other hand, Dr Zebic has argued that for some time there has been no need for the conditions on her registration. She also made the general statement about discrimination we have mentioned. Over time, she has put forward various explanations for missing drug tests. Concerning the problems Dr Zebic said there were with her last Ahpra compliance officer, we now mention that she said that - whereas previous officers might call her if she overslept, and she would immediately attend for her test - the last compliance officer would speak to her when requiring something but was 'distinctly absent' when she (Dr Zebic) was the one making an enquiry. (In this context Dr Zebic reiterated some related problems that concerned the pandemic and her access to legal assistance).
8. Specifically in relation to the missed drug tests, there may be a reasonable explanation for Dr Zebic to have missed some of them. But, as has been identified, the problem is that she missed tests repeatedly over a period of many months. This was against a background of her being suspended so many times over the years for similar conduct. Her past non-compliance on occasion was associated with dishonesty or what Dr Rigby described as 'folly' (when she shaved her head prior to attending for hair analysis).[55] VCAT reprimanded Dr Zebic in 2015 and imposed conditions on her registration, but still she was non-compliant.
9. Many of Dr Zebic's submissions indicate to us that she has not developed adequate insight into her conduct. We cannot be confident that if Dr Zebic returned to practice now the situation would be materially different.
10. The concerns we have about Dr Zebic's ability and willingness to comply with conditions are similar to, but can now only be greater than, the concerns VCAT expressed in 2015.[56]
11. At this point we mention Ms Isobel's further submission that Dr Zebic's conduct has the capacity to undermine the regard in which the medical profession is held by members the public. The conduct also has the capacity to undermine the regard in which the regulator is held. Ms Isobel said that Ahpra and the Board have attempted to manage the risk posed by Dr Zebic while allowing her to remain in practice whenever possible. The Board has committed significant resources and time engaging with Dr Zebic over the decades that she has been required to be monitored and regulated. This includes undertaking immediate action processes; requiring independent health assessments; reviewing and 're-reviewing' the suspensions and conditions; and investigating allegations of breaches of the conditions.
12. Ms Isobel said that it appears that, unfortunately, these significant efforts by Ahpra and the Board have been unsuccessful. She therefore submitted that cancellation of registration is required, arguing in the context of Dr Zebic's 26-year disciplinary history and her continued, repeated breaches of conditions on her registration, that nothing else would assure the public that appropriate standards are being maintained. Referring to Medical Board of Australia v Kemp [2024] VCAT 34 (Kemp), Ms Isobel submitted that there is a now need to put a price on contravention that is sufficiently high to deter repetition by Dr Zebic and by others who might be tempted to engage in similar conduct.[57]
13. We agree. We consider that there is a strong need for specific deterrence. We have concluded that in addition to a reprimand, cancellation of registration is required.
14. We consider that there is also the need for general deterrence. We make clear that by our determinations we intend to signal to other members of the medical profession that serious adverse consequences will follow non-compliance with conditions on their registration (and the provision of misleading, incorrect and/or incomplete information to Ahpra or the Board), so as to deter other members of the profession from the same conduct.
15. We intend that the message we send will contribute to maintaining public confidence in the medical profession.

1. We reprimand Dr Zebic. As VCAT said in Lee, quoted earlier, a reprimand is a serious matter for a professional person.

1. Cancellation of registration involves a finding that, at the time of the determination, the health practitioner is not suitable for registration, and that if the practitioner seeks to return to the profession, he or she must re-apply. In contrast with suspension, which assumes suitability at the end of the period of suspension, cancellation sends a clear message of unsuitability to practise by reference to the impugned conduct: see, for instance, Honey v Medical Practitioners Board of Victoria [2007] VCAT 526 (Honey).
2. We have considered the range of available determinations. In the past, suspensions and the imposition of conditions upon return to practice have not been sufficient measures. We have concluded that cancellation is the appropriate determination in all the circumstances.

1. While acknowledging that it usual for responsible tribunals to have regard to the time for which a practitioner has been out of practice, Ms Isobel made a submission to the effect that the two-year disqualification sought by the Board should operate from the date of our orders, rather than be reduced or 'backdated' in circumstances where Dr Zebic has been under suspension since August 2020.[58] Ms Isobel submitted that we should not take the delay into account.
2. We have come to the view that there should be no disqualification period.
3. We have come to this view not simply because we did not find every allegation proved and did not characterise Dr Zebic's conduct in precisely the way the Board submitted we should. We also consider that a period of disqualification, in all the circumstances, would not be necessary for the protection of the public. It would not support rehabilitation.
4. This means that Dr Zebic can apply for registration at any time. This is not to say that she would be likely to be granted registration straight away, of course. Dr Zebic will have to persuade the Board that she is a fit and proper person to hold registration.[59]

1. Ms Isobel cited Health Care Complaints Commission v Cakan [2018] NSWCATOD 5 (Cakan), CQW and Bainbridge as the most helpful comparable cases. It is of course desirable that our determinations be consistent with determinations made in previous cases, though we exercise caution in making comparisons.[60]
2. In Cakan, the allegations included that on numerous occasions the doctor failed to comply with conditions on his registration for regular testing for drugs of addiction. NCAT found that the doctor 'repeatedly breached conditions designed to protect the public'. NCAT further found that the doctor gave false or misleading information to the Medical Council, gave dilute samples for testing, and misled the Medical Council with documents. NCAT cancelled the doctor's registration. The doctor's registration having most recently been suspended in mid-2016, NCAT (in 2018) disqualified him until mid-2019, being three years after he was suspended.[61]
3. CQW, decided in 2021, concerned a doctor who had a drug addiction since she was a teenager. The doctor breached conditions on her registration in 2015-2018, including by failing to attend for UDS when required, returning dilute results without a valid reason, and using prohibited drugs. The doctor also 'knowingly and willingly' provided false and/or misleading information to the Board and/or Ahpra about her drug use and some other matters. The parties submitted an Agreed Statement in relation to facts, findings and proposed determinations. That included a joint position for a reprimand; suspension of registration for six months; and the imposition of conditions for supervision, drug testing and other matters. VCAT heard that the doctor had been drug-free for four years. VCAT was also informed that she had 'never been completely suspended from practice for any period'. The Tribunal considered that the doctor had developed '(belated) insight' and had taken steps to get her life back on track. In the individual circumstances of the case, VCAT agreed that the proposed determinations were appropriate.
4. Bainbridge concerned a nurse who misused Endone (oxycodone). The nurse self-notified and conditions were imposed on her registration, including for drug testing. There followed what NCAT described as a series of both inadvertent and overt breaches of the conditions. The nurse was suspended in 2017 after testing positive for oxycodone. The Tribunal commented on the cumulative effect of certain breaches that might individually appear relatively insignificant.[62] In contrast to Dr Zebic's case, Bainbridge involved a finding that the nurse had an impairment that affected her capacity to practise. Still, there were comments by NCAT that resonate:

A period of suspension followed by conditions would in effect continue a regime that has failed to date to produce lasting change in the practitioner's conduct. Based upon all of the evidence, the Tribunal cannot have any confidence that such conditions would be complied with in the future without a contemporaneous assessment of the practitioner's capacity to practise.

1. NCAT cancelled the nurse's registration without setting any period to pass before she could reapply for a review of that order.[63]

1. The Board does not allege that Dr Zebic has an impairment that is likely to detrimentally affect her capacity to practise as a medical practitioner.
2. Dr Zebic has been diagnosed with a severe substance use disorder, but it is considered by doctors to have been in sustained remission for several years.
3. In 1999, Dr Zebic's registration was suspended in relation to her drug use after she made a self-notification. Over the years, she has been suspended six times, the last time being in 2020. Before that suspension, in 2015 VCAT reprimand her for conduct including non-compliance with conditions on her registration and imposed stringent conditions.
4. The main allegations that we have found proved involve further and repeated non-compliance by Dr Zebic with conditions for drug testing. Conditions of the kind exist for the protection of the public.
5. If Dr Zebic's non-compliance with the drug testing conditions could ever have been reasonably explained by factors beyond her control, by no means could all her non-compliance be explained that way.
6. Whatever a health practitioner may say as to whether conditions on their registration are necessary, or continue to be necessary, for as long as the conditions are in place, the practitioner must comply with them. Dr Zebic has been unable or unwilling to do that.
7. This proceeding is not the review of a decision by the Board about conditions. The proceeding is a disciplinary proceeding. The purpose of the proceeding is to protect the public, not to punish Dr Zebic.

1. We have concluded that in addition to reprimanding Dr Zebic, we should cancel her registration. We have not ordered a period of disqualification.

ATTACHMENT A -Amended Notice of Allegations[64]

In the allegations, the following terms are defined:

• Code of Conduct - Good Medical Practice: Code of Conduct for Doctors in Australia, 2014 (in effect until 30 September 2020).
• Ahpra - Australian Health Practitioner Regulation Agency.
• Board - Medical Board of Australia.
• Group Four - Five to ten urine screen tests per year, as required by the Protocol.
• Health Assessment Report - the Health Assessment report prepared by consultant psychiatrist Dr Enrico Cementon on 11 March 2020.
• National Law - Health Practitioner Regulation National Law (Victoria) Act 2009_.1_
• Protocol - Ahpra's Drug and Alcohol Protocol updated February 2019.
• Schedule - Schedule to these allegations.
• Tribunal - the Victorian Civil and Administrative Tribunal.
• UDS - Urinary Drug Screening.

1. On or about 1 October 2019 to on or about 30 July 2020, Dr Zebic engaged in:

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

(b) unprofessional conduct within the meaning of the definition of unprofessional conduct in s 5 of the National Law; and/or

(c) unsatisfactory professional performance within the meaning of the definition of unsatisfactory professional performance in s 5 of the National Law,

in that she breached the conditions imposed on her registration by failing to undertake treatment with a general practitioner and psychiatrist, comply with the treatment directions of her treating psychiatrist, and attend for UDS and hair testing at the required place and/or times as required by those conditions and/or the Protocol.

1.1 In 1992, Dr Zebic was first registered as a medical practitioner.

1.2 Following the commencement of the National Law on 1 July 2010, Dr Zebic was registered with the Board.

(a) was a registered health practitioner within the meaning of the National Law;

(b) was registered with the Board as a medical practitioner with general and specialist registration (general practice), registration number MED0001153290; and

(c) practised as a medical practitioner at Brunswick Central Medical Centre, 1/200 Sydney Road, Brunswick, VIC 3056.

(a) found that between 10 May 2011 and 20 May 2011, Dr Zebic engaged in professional misconduct as defined in paragraph (b) of the definition of professional misconduct in s 3(1) of the Health Professions Registration Act 2005 (Vic), as she breached the conditions imposed on her registration concerning urinalysis and hair sampling;

(b) found that on 10 August 2011, 4 September 2011 and 5 October 2011, Dr Zebic behaved in a way that constituted professional misconduct as defined in paragraph (a) of s 5 of the National Law as she wrote four prescriptions while her registration as a medical practitioner was suspended;

(c) reprimanded Dr Zebic; and

(d) imposed conditions on Dr Zebic's registration. Of relevance, these conditions included requiring Dr Zebic to:

(i) attend for treatment with a psychiatrist and general practitioner;

(ii) undertake random urinalysis at times determined by the Board, according to the Board's protocols; and

(iii) have hair analysis tests for drug use every three months, according to the Board's protocols.

• 1.5 The conditions imposed by the Tribunal were subsequently modified by the Board from time to time, in accordance with s 125(5) of the National Law. Relevantly:

(a) on 24 March 2016, the Board granted Dr Zebic's request of 15 February 2016 to reduce her UDS frequency to Group Two (48 tests per year), as set out in the Protocol;

(b) on 8 November 2018, the Board granted Dr Zebic's request on 7 October 2018 to reduce her UDS frequency to Group Three (12 tests per year), as set out in the Protocol; and

(c) on 23 July 2019, in response to Dr Zebic's request to remove all conditions from her registration on 17 June 2019, the Board notified Dr Zebic that her UDS frequency was reduced to Group Four, as set out in the Protocol.

• 1.6 From 18 July 2019 to 20 August 2020, Dr Zebic's registration was subject to the following conditions:
  1. The Practitioner must only take substances prescribed, approved or administered by a nominated treating practitioner(s) and such nominated treating practitioner(s) may not be a relative, friend, professional colleague, or in a contractual or financial relationship with the Practitioner.

1. Within 3 days of the notice of imposition of these conditions, the Practitioner must commence random urine drug screening (UDS) and hair analysis for drug screening (hair analysis) in accordance with AHPRA's protocol for UDS and hair analysis (the protocol) in force at the date these conditions are imposed and then amended from time to time.
2. The Practitioner must commence UDS and hair analysis at Group Three frequency or as otherwise advised by AHPRA and must continue to attend at this frequency until the Board approves otherwise.

15. The Practitioner must undertake treatment with treating practitioners, including but not limited to a treating psychiatrist and treating general practitioner (the treating practitioner(s)) and attend at a frequency determined by the treating practitioner(s).

• 1.7 From 18 July 2019 to 20 August 2020, Dr Byron Rigby was Dr Zebic's treating psychiatrist, and Dr A. A. Sheriff was Dr Zebic's treating general practitioner.
• 1.8 Between 1 January 2020 and 30 July 2020, Dr Zebic breached the Protocol and conditions 12 and 13 as set out in [1.6] in that:

(a) on 2 January 2020, Dr Zebic failed to attend a scheduled UDS test;

(b) on 13 February 2020, Dr Zebic failed to produce a UDS sample and/or missed a scheduled UDS test;

(c) on 14 February 2020, Dr Zebic failed to call the UDS telephone number to determine if her screening group was required to provide a sample for UDS on that day;

(d) on 11 March 2020, Dr Zebic failed to attend a scheduled UDS test;

(e) on 6 April 2020, Dr Zebic failed to attend a scheduled UDS test;

(f) on 28 April 2020, Dr Zebic failed to attend a scheduled UDS test;

(g) on 29 June 2020, Dr Zebic failed to attend a scheduled UDS test;

(h) on 29 July 2020, Dr Zebic failed to attend a scheduled UDS test;

(i) Dr Zebic failed to attend for quarterly hair testing by 30 April 2020; and

(j) Dr Zebic failed to attend a quarterly hair test by 30 July 2020.

• 1.9 During treatment with Dr Rigby, Dr Zebic was advised to take dexamphetamine instead of lisdexamfetamine. On or around 1 October 2019 to 30 May 2020, Dr Zebic breached condition 11 as set out at [1.6] as she took lisdexamfetamine, and in doing so failed to comply with the treatment directions of Dr Rigby.
• 1.10 From 18 February 2020 to 11 June 2020, Dr Zebic breached condition 15 as set out at [1.6] by self-referring herself to a specialist, and for vascular surgery, pathology, haematology and diagnostic radiology, instead of seeking treatment from Dr Sheriff and/or Dr Rigby on the following occasions:

(a) on 18 February 2020, Dr Zebic self-referred to a specialist;

(b) on 13 March 2020, Dr Zebic self-referred for pathology and haematology;

(c) on 16 March 2020, Dr Zebic self-referred for pathology;

(d) on 2 April 2020, Dr Zebic self-referred for pathology and haematology;

(e) on 3 April 2020, Dr Zebic self-referred for vascular surgery and diagnostic radiology;

(f) on 16 April 2020, Dr Zebic self-referred for vascular surgery;

(g) on 29 April 2020, Dr Zebic self-referred for pathology and haematology;

(h) on 30 April 2020, Dr Zebic self-referred for vascular surgery (specialist attendance);

(i) on 5 May 2020, Dr Zebic self-referred for vascular surgery (specialist attendance);

(j) on 21 May 2020, Dr Zebic self-referred for vascular surgery; and

(k) on 11 June 2020, Dr Zebic self-referred for vascular surgery.

• 1.11 Dr Zebic's conduct was inconsistent with the principles 1.4, 2.2, 6.1, 6.2, 6.3, 8.1, 8.3, 9.1 and 9.2 of the Code of Conduct, set out in the Schedule.

Provision of misleading, inaccurate and/or incomplete information

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

(b) unprofessional conduct within the meaning of the definition of unprofessional conduct in s 5 of the National Law; and/or

(c) unsatisfactory professional performance within the meaning of the definition of unsatisfactory professional performance in s 5 of the National Law,

in that she provided misleading, inaccurate and/or incomplete information to Ahpra in response to a request from Ahpra that she explain her missed UDS test on 11 March 2020.

2.1 The Board refers to and repeats paragraphs [1.1] to [1.6].

2.2 On 9 April 2020 Dr Zebic's Compliance Officer at Ahpra, Ms Sonia Ruhland, notified Dr Zebic of the missed UDS test on 11 March 2020, and asked her to provide an explanation for the missed UDS test.

2.3 On 20 April 2020, Dr Zebic provided Ahpra with:

(a) a medical certificate from Dr Roland Lee, stating that Dr Zebic was "away from work for most of the month of March with illness related to a medical issue;" and

(b) a number of emails which stated, amongst other things, that she was unwell and did not attend work in March 2020.

2.4 On 9 October 2020, Ahpra requested that Dr Roland Lee, principal doctor at Brunswick Central Medical Centre and Dr Zebic's former supervisor, produce information to Ahpra under schedule 5 of the National Law.

2.5 On 12 October 2020, in response to Ahpra's request for information under schedule 5 of the National Law, Dr Lee notified Ahpra that Dr Zebic was working on 11 March 2020.

2.6 Dr Zebic's provision of information to Ahpra at paragraph [2.3] was inaccurate and/or incomplete.

2.7 Dr Zebic's conduct was inconsistent with principles 1.4, 2.2 and 8.3 of the Code of Conduct, as set out in the Schedule.

1. On or around 1 October 2019 to 30 June 2020, Dr Zebic engaged in:

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

(b) unprofessional conduct within the meaning of the definition of unprofessional conduct in s 5 of the National Law; and/or

(c) unsatisfactory professional performance within the meaning of the definition of unsatisfactory professional performance in s 5 of the National Law,

in that she failed to manage her health by failing to follow the treatment directions of Dr Rigby to take dexamphetamine instead of lisdexamfetamine, and by self- referring to a specialist and for vascular surgery, pathology, haematology and diagnostic radiology.

• 3.1 The Board refers to and repeats paragraphs [1.1] to [1.6] and [1.9] to [1.10].
• 3.2 On or around 1 October 2019 to 30 June 2020, Dr Zebic failed to manage her health in that she failed to:

(a) follow the treatment directions of Dr Rigby to take dexamphetamine instead of lisdexamfetamine; and

(b) seek independent and objective advice from Dr Rigby and Dr Sheriff to ensure that her health conditions were treated appropriately in light of the medical treatment that she was receiving from Dr Rigby and Dr Sheriff.

• 3.3 On or around 21 February 2020, in accordance with s 80(1)(e) and s 169 of the National Law, Dr Zebic underwent an independent health assessment with consultant psychiatrist, Dr Enrico Cementon.
• 3.4 In Dr Cementon's Health Assessment Report dated 11 March 2020, he reported that:

(a) Dr Zebic continues to experience a number of different health problems that are both physical and psychiatric in nature;

(b) Dr Zebic takes dexamphetamine 5 mg and lisdexamfetamine 70 mg, in an alternating manner;

(c) Dr Zebic takes stimulant medication in a way that was unusual: some days she takes the long-acting lisdexamfetamine and some days she takes the short-acting dexamphetamine, sometimes depending on whether she can find one medication or the other;

(d) Dr Zebic's medication taking was peculiar and often inappropriate and must be reviewed and more closely managed;

(e) Dr Zebic's treating psychiatrist and general practitioner needed to review the current treatment that Dr Zebic was taking and address the inappropriate manner in which she was taking the medications; and

(f) Dr Zebic continues to be at risk of an exacerbation or relapse of severe substance use disorder.

3.5 Dr Zebic's conduct was inconsistent with principles 6.1, 6.3 and 9.2 of the Code of Conduct, referred to in the Schedule.

ATTACHMENT B - Extract from VCAT's decision in Medical Board of Australia v Zebic [2015] VCAT 139.

1. The following findings of facts are based on an agreed statement from the Board and Dr Zebic, supplemented by the documentary evidence which is not in dispute and oral submissions made to us.
2. The current suspension, on 3 June 2010, of Dr Zebic's registration as medical practitioner (see below), followed previous suspensions in relation to her drug use in:

(b) February 2000 (following self-notification); and

(c) August 2004 (failure to comply with urine screening protocol).

1. On 21 July 2009, Dr Zebic was found face down on the computer keyboard at her desk in her consulting room while at work.
2. It appears Dr Zebic had been alone in the consulting room for approximately 30 minutes before being found. After being roused, she was initially disoriented and incoherent. She had left sided facial weakness.
3. By letter dated 9 March 2010, Professor Bruce Singh, Psychiatrist, reported to the Medical Practitioners Board of Victoria (the MPBV) concerning Dr Zebic. He discussed her complex history including suffering an eating disorder during adolescence and early adulthood (completely resolved), a psychotic episode in 1994, being diagnosed with schizophrenia (she did not comply with treatment), no recurrence of psychosis, narcotic abuse from 1998 for a number of years (Professor Singh was unable to reach a view on whether this had ceased), a diagnosis of borderline personality disorder in 2000 (with which Professor Singh agreed) and mild to moderate sleep apnoea.
4. He doubted that she had any great insight into her "profound psychiatric problems", nor the effect that had on her ability to practise medicine. In his view, the critical question with respect to her registration was whether she continued to abuse drugs. While he had suspicions, he did not have sufficient information to come to a firm conclusion on that.
5. On 22 April 2010, a Health Panel of the then Medical Practitioners Board of Victoria (the MPBV) found it was likely Dr Zebic's use of narcotics caused the incident and found her ability to practise was affected because of her physical or mental health. The Panel imposed conditions on Dr Zebic's registration. She was to attend a psychiatrist and general practitioner who could report to the Panel, not possess or administer various drugs, work in an approved group practice (not after hours or on weekends), with the practice reporting to a health committee and to attend for urinalysis and hair analysis.
6. While we note some much later medical professional opinion that her collapse and subsequent behaviour was likely explained by illness, we do not make findings as to the cause.
7. Concerning the registration conditions that she attend for hair analysis every three months and random urinalysis according to a MPBV protocol, on 7 May 2010, Dr Zebic signed the MPBV protocol for random urinalysis.

Facts directly relevant to the allegations in the proceeding under the HPR Act

1. That same day, Dr Zebic missed her first screening. Her work supervisor provided a statement that, to the best of his knowledge, she had been too busy to attend.
2. On each of 10 and 14 May 2010, Dr Zebic both forged the signature of a practice nurse on a referral slip used for urinalysis and failed to follow the MPBV's protocol for random urinalysis, by not having her samples taken under direct supervision.
3. On 20 May 2010, when requested to attend for hair analysis, Dr Zebic was unable to provide hair for analysis because she had shaved her head.

1. By email dated 19 May 2010, the doctor in charge of the medical practice where Dr Zebic was working reported to the Board concerns about, among other matters, Dr Zebic's inadequate or missing practice notes and "at least 50 reports or results not looked at or actioned", some going back to October 2009.
2. On 3 June 2010, as a result of Dr Zebic's above apparent breaches of conditions on her registration, the MPBV suspended her registration having found her ability to practise was, or may have been, affected and that she had, or may have, engaged in unprofessional conduct or professional misconduct. Her registration remained and remains suspended until the Board registers her in accord with our determinations in this proceeding.
3. On 1 July 2010, the National Law came into effect and the Australian Health Practitioner Regulation Agency (AHPRA) and the Board replaced the MPBV.
4. By letter, dated 18 November 2010, AHPRA notified Dr Zebic that her apparent failure to abide by conditions on her registration was under investigation.
5. Dr Zebic responded by letter, dated 12 April 2011, and other undated letters, explaining that, among other things, she had "paranoid persecutory delusion of the psychotic kind possibly dampened by medication prescribed by my colleague with acute flare post removal of medication". She acknowledged substituting urine tests. Dr Zebic stated that her inability to provide a hair sample arose from her psychosis.
6. On 8 June 2011, Dr Zebic emailed AHPRA saying, among other things, that her problem was "high functioning autism spectrum disorder".

Facts directly relevant to the allegations in the proceeding under the National Law

1. In 2011, Dr Zebic practised as a medical practitioner whilst not registered. She wrote four prescriptions being one dated 10 August 2011 (Serepax and Tramal), two dated 4 September 2011 (one for Duromine and one for Serepax and Tramal) and one dated 5 October 2011 (Serepax and Tramal).

1. On 30 January 2012, Dr Zebic responded to AHPRA's request for a formal response to the allegation that she had practised as a medical practitioner while suspended (writing the prescriptions). She claimed, among other things, that the prescriptions were not written for patient usage or as a false representation of herself as a registered medical practitioner. She said that she had written on prescription paper all of the things that she had been accused of self-administering. She said [that] she wrote no names or dates and many had no signature and that she discarded the prescription pads after writing in them. She said that was all that she could remember.
2. In February 2012, Dr Zebic requested that her suspension be lifted. She stated, among other things, that her behaviour, "was appalling and attributable to the neuropsych manifestations of untreated porphyria".
3. In March 2012, the Board refused her request.
4. Dr Zebic then submitted a medical report, dated 23 April 2012, by her treating psychiatrist, Dr Byron Rigby, who had treated her since July 2010. He could find no reason (from a health point of view) why Dr Zebic should not be re-registered, with perhaps a period under supervision.
5. In June 2012, Dr Zebic applied for renewal of her registration and the removal of the suspension (a necessary pre-condition for registration). She said, among other things:

(a) A new diagnosis of porphyria had been made of her condition, which she believed to be the primary diagnosis for all of her "previous presentations which have been attributed to other conditions"; and

(b) The event which led to the conditions being imposed in April 2010 was not substance related but, she believed, could have been a porphyriac vasomediated left insular ischaemia/seizure.

1. On 27 June 2012, the Board received a letter from Dr Gayle Ross, Dermatologist. Dr Ross said on 31 May 2012, she, Dr Amanda Nicoll, Gastroenterologist, and Dr George Varigos, Dermatologist, saw Dr Zebic in their multidisciplinary porphyria clinic at Royal Melbourne Hospital. They considered her history and investigations fitted with a diagnosis of hereditary coproporphyria (HCP). Dr Ross also wrote they did not believe that Dr Zebic was a drug seeker or opiate-dependant.
2. On 28 June 2012, the Board received a letter from Dr Sophie Adams, Consultant Psychiatrist, Royal Melbourne Hospital. She said when she last saw Dr Zebic, about two months earlier, Dr Zebic showed no evidence of ongoing psychiatric symptoms.
3. On 28 June 2012, the Board decided to refuse to revoke the suspension of Dr Zebic's registration. However, it decided to refer the matters regarding her conduct to VCAT.
4. However, when making those decisions, the Board did not have Dr Ross' or Dr Adams' letters. Therefore, on 30 August 2012, it reconsidered the matter. It remained concerned about Dr Zebic's ability to practise medicine safely and competently because of:

(b) The long period of time in which she had engaged in the conduct;

(c) The lack of a definitive diagnosis of porphyria; and

(d) The lack of information about the possible effects of the illness.

1. The Board sought guidance to determine whether Dr Zebic had an impairment and whether any such impairment affected her ability to practise medicine safely.
2. In an undated report, Associate Professor Peter Stewart, a joint director of a pathology service, opined Dr Zebic did not suffer porphyria. Biomedical and genetic findings did not support a diagnosis of hereditary coproporphyria (or plumboporphyria, acute intermittent porphyria or variegate porphyria).
3. In August 2013, the Board decided the referral to VCAT should proceed and it was made.
4. By letter dated 9 September 2013, Professor Edward D. Janus, Consultant Physician, who had seen Dr Zebic several times from at least 2011, noted Associate Professor Stewart's opinion. He discussed her symptoms, saying while it was now clear she did not suffer porphyria (he had previously accepted that diagnosis), the appropriate diagnosis was clearly something else, but unknown. In his opinion, she had been quite well over the last year and a half, after about two years when she was unwell, including when she lost consciousness at work. He wrote of his discussion with her about her finding alternative employment, such as medical writing, which, if successful, could assist her in seeking reinstatement of her registration as a medical practitioner.
5. By letter dated 18 November 2013, Dr Rigby, psychiatrist, who had treated Dr Zebic for over three years, opined her health and wellbeing had improved over the past year and she was fit to practise medicine, saying in part:

Dr Zebic's health and well-being have improved considerably over the past year. In my opinion, she is fit to practise medicine. To my knowledge the only impediment to this is that her re-instatement is contingent upon a VCAT Hearing of an application by [AHPRA] to be held in the near future.

Dr Zebic is an academically inclined professional, and I am aware that she has continued to engage in continuing medical education of a substantial nature, owing as much to her natural interest as to the necessity of remaining up-to-date from the point of view of her registration.

1. By letter dated 21 January 2014, Dr Rigby updated his earlier letter. He briefly discussed Dr Zebic's complex medical history, saying Dr Zebic is an unusual person who at times appeared to be unwell and who engaged in some episodes of injudicious behaviour. He regarded her as well adjusted and fit to be registered to practise medicine. While he did not think she required psychiatric treatment, she appeared to find consultations helpful.
2. By letter dated 27 February 2014, Dr Kym Jenkins, Medical Director of the Victorian Doctors Health Program (VDHP) confirmed that if Dr Zebic was considered fit to return to practice, and should the VDHP continue to work under its current model, it would consider her for its case management program. She would have a case manager appointed by the VDHP, who would take a "pivotal role" in liaising with her treating practitioners and her workplace monitor. She noted Dr Zebic had advised while genetic testing was negative for porphyria, adopting a lifestyle that avoids triggers for the condition enabled her to maintain good physical and mental health.
3. Dr Jenkins also summarised Dr Zebic first presenting to VDHP in 2003, when a 34 year old general practitioner, by then having experienced significant problems with drug abuse, including 'section 8 drugs', her 2004 suspension, 2005 return to work and a couple of years case management. In 2008, there were concerns about Dr Zebic appearing drug affected. While a case management response was tried, her adherence to the program was inconsistent. VDHP questioned its value. When Dr Zebic advised VDHP of her 2010 collapse on her keyboard, Dr Jenkins no longer supported a CAMP [(Case Management, Aftercare and Monitoring Program)] agreement being in place. In late 2010, Dr Zebic undertook a residential detox program. She continued limited contact with VDHP. While a new case management was drawn up in 2012, it was to manage porphyria.
4. By report dated 6 March 2014, Professor Trevor Kilpatrick, Neurologist, among other things, concluded the diagnosis of Dr Zebic's condition was uncertain, although the possibility of an underlying porphyria could not be excluded. Professor Kilpatrick also opined Dr Zebic's current extended period of stability suggested that it would not be unreasonable to consider Dr Zebic's gradated return to work, under appropriate supervision.
5. At the Board's request, on 11 April 2014, Dr Zebic again saw Professor Singh, psychiatrist. He said in part:

She has over more recent years had a range of weird and bizarre medical symptoms for with no organic cause which has been found leading to a suspicion on my part that they may be manifestation of a somatoform disorder. ...

My diagnosis based on all the evidence remains the same. This woman has a cluster B personality disorder with antisocial, borderline and narcissistic features who in addition has had various behavioural disorders which those with this condition are prone to develop i.e. psychosis, eating disorder, drug abuse, depression and anxiety.

... Dr Zebic did not demonstrate any great insight into the major psychiatric problems she has had. In fact if possible her insight is less now because she now understands how all her symptoms have come about - namely the porphyria like condition of unknown name or aetiology. In addition she believes that by treating this condition by avoiding triggers [like alcohol, insomnia, anaesthesia, overseas travel, over-exertion, medical and emotional stress] she is much better which medical attendants also attest to.

1. Professor Singh said Dr Zebic's avoidance of urine and hair sampling was best explained by her personality disorder because of paranoia that the Board was out to get her.
2. In his view, while a personality disorder is not in itself a contraindication to be able to practise medicine, of more concern was the risk of drug misuse or other manifestations of the personality disorder which might emerge when she was confronted with the challenges of medical practice. He was not confident if she was allowed to practise, even subject to strict supervision and regular urine and hair tests, she would not again try to find a way around the requirements.
3. However, Professor Singh did not regard himself as in a position to disagree with the view expressed by Dr Rigby, her treating psychiatrist, that from a health point of view, there were no impediments to Dr Zebic's re-registration.
4. He concluded that, if Dr Zebic were to be re-registered, strict conditions should be imposed. His suggestions are incorporated into the conditions imposed by the orders in this proceeding ...

[1] The referral came after a series of events. They included a notification containing certain allegations and an application by Dr Zebic to the Board to remove conditions on her registration. We do not need to describe the allegations in that notification. The Board decided not to investigate the matter. The Board however required Dr Zebic to undergo a health assessment to determine whether she had an impairment and whether the conditions should be removed. The Health Assessment Report was made in March 2020 by consultant psychiatrist, Dr Enrico Cementon. In August 2020 the Board suspended Dr Zebic's registration and in October 2020 the Board decided to investigate her compliance with conditions.

[2] Among other things, the Board withdrew an allegation that Dr Zebic has a physical and/or mental impairment, condition or disorder that detrimentally affects or is likely to detrimentally affect her capacity to practise as a medical practitioner.

[3] Report of independent medical expert Dr Enrico Cementon (psychiatrist) dated 11 March 2020, Tribunal Book (TB) 53 and various reports by Dr Zebic's treating psychiatrist, Dr Byron Rigby, including a report dated 6 August 2020, TB 66.

[4] Dr Rigby has noted that ASD was mentioned in a discussion with another doctor sometime prior to 2010: TB 69. VCAT recorded in 2015 that Dr Zebic told Ahpra in 2011 that 'her problem was "high functioning [ASD]"': Medical Board of Australia v Zebic [2015] VCAT 139 [24].

[5] Dr Cementon and Dr Rigby's reports cited above. In a report dated 18 February 2024, Dr Rigby mentioned 2019 as the year it was brought to his attention: TB 539.

[6] The Board acted on the essential basis that it formed a reasonable belief that, because of Dr Zebic's conduct and/or health, she posed a serious risk to persons.

[7] The parties made extensive written submissions in May 2024 that were included in the Tribunal Book. Ms Isobel and Dr Zebic also made oral submissions at the hearing. Later, Dr Zebic requested an extension of the time allowed for her to file supplementary submissions after the hearing. She also indicated that she wanted to file further medical evidence. The request was refused on the essential basis that Dr Zebic had already been given a reasonable opportunity, and because the only remaining issues in the case concerned determinations. Dr Zebic provided further written submissions in mid-July. She included a new report by her psychiatrist, Dr Rigby, dated 15 July 2025. The Board's submissions in reply were dated 30 July 2025. (Among other things, the Board submitted that Dr Rigby's report should either be disregarded or given no weight). In the months that followed, Dr Zebic sent emails to VCAT in which, expressly or impliedly, she requested the Tribunal to reopen the proceeding. To a substantial degree, the emails reiterated her earlier submissions or sought in essence to recontest findings of fact. Dr Zebic did not put forward sufficient grounds for reopening the proceeding and it was not reopened.

[8] Dr Zebic expressed concerns about publication of our decision. Among other things, she referred

us to an article published in The Medical Law Review in 2023 entitled The publication of impaired doctors' identity by Australian and New Zealand tribunals: law, practice, and reform: https://academic.oup.com/medlaw/article/31/3/391/7147089. The authors discuss the possible harm that publication of decisions in disciplinary proceedings may do to doctors with mental health or substance use disorders, and they consider whether disclosing 'the intimate details of their medical condition' serves the public interest in open justice. The authors argue that Australian tribunals 'could be more circumspect' when dealing with sensitive information in published decisions, especially where such information does not directly form a basis for the decision reached. Given especially what VCAT has already published (in 2015), and what the media has previously reported, we did not consider Dr Zebic's case as a suitable case for any pseudonym order or suppression order. However, we have intended to strike a fair and appropriate balance when dealing with sensitive information. We note, incidentally, that in the present proceeding VCAT made an order in February 2023 under section 146 of the Victorian Civil and Administrative Tribunal Act 1998 (Vic) (VCAT Act) with the effect that only the Board and Dr Zebic are permitted access to the proceeding file.

[9] We do not need to give a comprehensive history of Dr Zebic's use of narcotics and various other drugs. In February 2024, Dr Zebic's psychiatrist wrote that substance abuse disorder 'has been described as present in the past, is acknowledged as having been in abeyance for many years': TB 539. We note, for instance, that the decision in the first VCAT proceeding refers to evidence that Dr Zebic abused narcotics for years from 1998. The controversy mostly concerned whether (and when) she had ceased to do so. (In 2010 Dr Zebic reportedly told a Health Panel of the Medical Practitioners Board of Victoria (MPBV) about a period of pethidine abuse dating from the late 1990s: TB 639). We also refer to a decision of the MPBV which records that Dr Zebic tested positive for opiates in early 2003: Re Dr Kathy Zebic [2004] MPBV 13, TB 621 ff. (We observe that Dr Zebic's representative submitted to the MPBV that the levels of morphine recorded were such that the results should have been reported as 'not detected'). Significantly, the MPBV gleaned the test results information from an Agreed Statement of Facts.

[10] As detailed in Attachment B, Dr Zebic's registration was suspended in 2010 in relation to drug

use. Her registration had been similarly suspended on previous occasions in 1999, 2000 and 2004.

[12] The current version of the Code came into effect on 1 October 2020.

[13] Notably, Professor Bruce Singh, a psychiatrist who provided a report in 2014 at the Board's request, expressed the opinion that Dr Zebic's avoidance of urine and hair sampling was best explained by a personality disorder 'because of paranoia that the Board was out to get her'.

[17] TB 455. The submissions state that, in retrospect, Dr Zebic accepted that she could have been 'more proactive' in informing Ahpra about the impediments to testing.

[18] Dr Zebic's former solicitor and Dr Zebic herself wrote to Ahpra earlier in 2020 about issues of the kind: TB 383, 388. In a written submission to VCAT, Dr Zebic said her Driver licence was cancelled in April 2020 due to an updated medical report not being received: TB 556.

[20] TB 468. The summary in the notice of immediate action goes on to say: 'Dr Zebic indicated that in the past she has gone to only one centre, and that because of her health concerns and other issues and the changing environment she was careful to consider how it might affect her in where she nominated as her new centre. She is happy to attend now that she has committed to a location'.

[23] Dr Zebic pointed to screen shots of text messages she sent Dr Sheriff that she said supported her case: TB 495

[24] In a written submission to VCAT in May 2024, Dr Zebic said this: 'It seems my GP doesn't recall that we had discussed the referrals and tests in consultation and that we had a choice between two vascular surgeons ... Dr Sheriff kindly deferred to my preferred choice [of surgeon]: TB 560.

[25] TB 63. In an earlier letter to Ahpra, dated 29 November 2019, Dr Rigby wrote that Dr Zebic 'She was compliant with her prescription of lisdexamfetamine (slow release), but has found the immediate release form more effective. Her regime has been altered accordingly to a dose of 8 x 5 mg or 40 mg daily' (of dexamphetamine): TB 60.

[28] TB 51. Dr Cementon previously assessed Dr Zebic in 2017, we note incidentally.

[32] TB 162-163. The Patient History report refers to lisdexamfetamine by the name 'Vyvanse'.

[38] Dr Rigby has said that he has seen no evidence of 'significant drug use, intoxication or an interest in drugs on the part of Dr Zebic': report dated 18 February 2004, TB 539.

[39] At the immediate action stage, Dr Zebic's lawyers noted that her tests were consistent with occasional use of buprenorphine patches as prescribed, and submitted that it was 'difficult to see' how that would put her at risk of relapse. They also made a submission to the effect that a risk of relapse was identified by Dr Cementon on the basis of a medication regime (referring, it seems, to the use of dexamphetamine and lisdexamfetamine) that is no longer extant: TB 458, 459.

[50] Ms Isobel cited a handful of further cases as offering useful guidance: Medical Board of Australia v Anwar (No 2) [2020] VCAT 462 (Anwar); Dental Board of Australia v McKenna [2022] SACAT 114 (McKenna); and Health Ombudsman v Park [2021] QCAT 309 (Park). It is sufficient for us to say that those cases were materially different to the present case.

[51] We refer especially to Dr Rigby's report dated 18 February 2024: TB 534. We add that, while the

comment concerned ADHD rather than ASD, Dr Rigby also said in that report: 'It is likely that the difficulty in organisation caused by Dr Zebic's attention deficit may have been implicated in her missing urine drug screening'. (Dr Rigby added that he had not examined whether this problem diminished after treatment for ADHD).

[56] Especially at [61]. VCAT also referred at [46] to Professor Singh's statement that he was not confident if Dr Zebic was allowed to practise, even subject to strict supervision and regular urine and hair tests, she would not again try to find a way around the requirements.

[58] Ms Isobel cited Medical Board of Australia v Nguyen [2024] VCAT 233 (Nguyen) and Dental

Board of Australia v Nairn [2022] WASAT 86 (Nairn).

[59] As to the potential timeframe for consideration of an application for re-registration, in the context of a medical practitioner with a health impairment, see the discussion in Medical Board of Australia v KFM [2021] VCAT 1479 (KFM) at [87]-[91].

[60] See Medical Board of Australia v Bradshaw [2020] VCAT 585 (Bradshaw) at [109].

[64] We have omitted the Schedule to the Amended Notice of Allegations and the one footnote.