Meneghetti v Medical Council of New South Wales - [2022] NSWCATOD 91 - NSWCATOD 2022 case summary — Zoe

NSWNSWCATOD

Meneghetti v Medical Council of New South Wales

[2022] NSWCATOD 91

NCAT Occupational|2022-06-01

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Source facts

Court

NCAT Occupational

Decision date

2022-06-01

Source

Original judgment source is linked above.

Judgment (23 paragraphs)

[1]

apeutic Goods Regulation 2008. 9. Not to possess, supply, administer or prescribe any drug or therapeutic goods that are not listed on the Australian Register of Therapeutic Goods (ARTG). 10. To submit to an audit of her medical practice, by a random selection of her medical records by a person or persons nominated by the Medical Council of NSW and: a. The audit is to be held within 6 months of recommencement of medical practice and a further audit may be held, if required by the Medical Council of NSW, in the period of up to 2 years from the date of recommencement of medical practice. b. The auditor(s) is to examine and assess the following aspects of her practice including: i. Compliance with good medical record keeping standards and legislative requirements ii. Compliance with conditions iii. Appropriate prescribing practices c. To authorise the auditor(s) to provide the Medical Council of NSW with a report on their findings. d. To meet all costs associated with the audits 11. To authorise and consent to any exchange of information between the Medical Council of NSW and Medicare Australia for the purpose of monitoring compliance with these conditions. 12. To forward evidence to the Medical Council of NSW within 14 days of notification that she has provided a copy of her full conditions to the Principal of the practice, supervisor or responsible senior officer in any place that she works. 13. Within 14 days of a change in the nature or place of her practice, she is to forward evidence to the Medical Council of NSW that she has provided a copy of the full conditions to the Principal of the practice, supervisor or responsible senior officer in any place that she works. 14. To authorise the Medical Council of NSW to notify the Principal of the practice, supervisor or responsible senior officer in any place that she works as a medical practitioner in Australia of any issues arising in relation to compliance with these conditions. Health conditions 15. For a period of 2 years from the date the Tribunal makes a reinstatement order, to attend for treatment by a registered psychologist or registered psychiatrist of her choice, at a frequency to be determined by the treating practitioner. The practitioner is to: a. authorise the treating practitioner to inform the Medical Council of NSW of failure to attend for treatment, termination of treatment or if there is a significant change in health status (including a significant temporary change). b. provide the Council with the professional details of the treating practitioner. 16. For a period of 2 years from the date the Tribunal makes a reinstatement order, to attend for treatment by a registered General Practitioner of her choice. The frequency of the treatment is to be determined by the treating practitioner. The practitioner: a. is to authorise the treating practitioner to inform the Medical Council of NSW of any of the following i. failure to attend for treatment, or ii. termination of the treatment, or iii. a significant change in health status (including a significant temporary change) b. must provide the Medical Council of NSW with the professional details of the treating practitioner Review of conditions 17. Dr Meneghetti may apply to the Medical Council of NSW for the alteration or removal of one or more of the above conditions not before the expiration of 12 months from the date of recommencement of practice. The Medical Council of NSW, if satisfied, may alter or remove any of the conditions. Notations A. The Medical Council of NSW is the appropriate review body for the purposes of Part 8, Division 8 of the Health Practitioner Regulation National Law (NSW). B. Sections 125 to 127 of the Health Practitioner Regulation National Law are applicable while the practitioner's principal place of practice is anywhere in Australia other than New South Wales, so that a review of these conditions may be conducted by the Medical Board of Australia. (3) The Applicant pay the costs of the Medical Council as agreed or assessed. Catchwords: OCCUPATIONS - medical practitioners - reinstatement application Legislation Cited: Civil and Administrative Tribunal Act 2013 (NSW) Health Practitioner Regulation National Law (NSW) Cases Cited: Chen v Medical Council of NSW [2021] NSWCATOD 33 Jan v Health Care Complaints Commission [2021] NSWSC 350 Ng v Health Care Complaints Commission [2018] NSWCATOD 105 Qasim v Medical Council of New South Wales [2021] NSWCA 173 Category: Principal judgment Parties: Alicia Meneghetti (Applicant) Medical Council of New South Wales (Respondent) Representation: Counsel: B Zipser (Applicant) A Petrie (Respondent)

[4]

The Applicants written evidence.

The Applicant relied upon a statement dated 27 November 2021 which formed part of exhibit A1. We noted the following in particular from that Statement.
The Applicant attached her CV to the statement. That shows that she was first registered as a medical practitioner in 1995. She had previously been registered as a medical practitioner in 1982 in Uruguay.
Between November 2013 and January 2018 the Applicant practiced at Fairfield in NSW. She practised general medicine and cosmetic medicine. Between December 2017 and April 2020 the Applicant practised cosmetic medicine and laser treatments under the name "Pura Beauty".
In the second half of 2020 the Applicant commenced at the University of New England a course titled Graduate Certificate in Professional Practice. The course was set for two years. The Applicant has completed a subject called "Developing Your Professional Practice" and another titled "Law, Ethics, Advocacy and Health Care". She was scheduled to complete a subject called "Medicine Ethics and Law" in May/June this year. She said that undertaking the course has helped her reflect on the mistakes she made.
The Applicant wishes to re-commence practice. She said: "The decision of the Medical Council dated 24 January 2017 and the decision of the Tribunal dated 16 April 2020 indicate I made grave mistakes in connection with Mr Dank. I have undertaken (study) to improve my standard of practice, which should assist in avoiding the making of mistakes in the future."
In September 2017 the Applicant undertook an Advanced Certificate in Aesthetic Medicine course approved by Bond University and RACGP. During the course she learnt about new cosmetic techniques, new machinery and new cosmetic products. In 2018 the Applicant attended a workshop on "thread lifting methods". In April 2021 the Applicant participated in an on-line international laser training course. In July 2021 she completed a course offered by the World Medical Association in Fundamental of Medical Ethics.
The Applicant said that if permitted to recommence practice she would like to practise in general medicine and cosmetic medicine. She proposes to undertake a course to become a Fellow in Cosmetic Medicine and later she would like to obtain registration as a Vocational Registered Doctor.
Since June 2021 the Applicant has attended upon Ms Gale, psychologist. She has seen Ms Gale on 8 occasions up to October 2021. In her oral evidence she gave updated evidence about her attendance upon Ms Gale. Ms Gale also provided a report which the Applicant relies upon. The Applicant has also attended upon Dr Lennings, consultant psychologist, who also provided a report upon which the Applicant relies. She had seen Dr Lennings on three occasions up to October 2021.
On 16 June 2021 the Applicant changed her surname to Ocampos. She did that because she felt shame about the cancellation of her registration. Ocampos was her maternal grandmother's surname. If permitted to practise again she will resume practice using the surname, Meneghetti. She would not object to a condition of practice that she use that name.
Under the heading of Regret and Remorse the Applicant said: "Patient welfare is at the core of what doctors are suppose to do. I did not comply with the most important commitment as a doctor. It was also serious misconduct to prescribe banned or restricted substances for non-approved therapeutic procedures, and to prescribe drugs for which I did not know the reliability, quality, safety or efficacy in use by humans."
The Applicant set out detail of her community and charity work over many years.
The Applicant attached 18 letters of reference. She said they were from people who know her well.
In relation to her financial circumstances, the Applicant said she was unemployed, she receives an age pension. She has no assts of value and no superannuation.
The Applicant attached a copy of the Tribunal decision of 16 April 2020 to her evidence. She also attached evidence of completion of courses she has undertaken and referred to in her statement. There is a copy of a report of Dr Lennings, 19 references, an income tax return and a copy of a written submission from her solicitor.

[5]

Written Evidence of Dr Lennings OAM.

Dr Lennings provided a report dated 16 October 2021. In that report we particularly noted the following evidence.
The report was commissioned by the Applicants solicitor. The letter of request for the report was attached to the evidence of the Applicant.
Dr Lennings interviewed the Applicant on three occasions between September 2021 and October 2021. Each interview lasted 40 minutes.
Dr Lennings set out his credentials as a clinical psychologist. There is no challenge to his expertise.
The history as provided by the Applicant is set out in the report. He notes the Applicant has been undertaking psychotherapy with Ms Gale, psychologist.
Dr Lennings asked the Applicant about her association with Mr Dank. He asked her why she had not followed a path of due diligence with Mr Dank. He said she seemed "nonplussed, recognising she should have, and unable to account for why she did not."
Dr Lennings said that the Applicant had a strong drive to help people. This led to her working longer and longer hours to see all her patients who sought her care. He said: "Obviously this account raises the concern that with over-work her judgment may have become impaired, an issue frequently referred to as "burnout". She acknowledged working with Mr Dank the way she worked "was totally wrong". It seems he had some hold over her and there may have been a level of fear as he told the Applicant and her daughter, who also worked with the Applicant, that he had associates who were part of an outlaw motorcycle gang. There was, however, no direct threat made.
The Applicant told Dr Lennings that her experience with Mr Dank had caused her to be very careful. Her medicine was everything to her, the only thing she knew, or wanted to do. In the future she would be cautious in how she practised.
The report sets out the detailed personal history and medical history, which was provided by the Applicant to Dr Lennings. Dr Lennings conducted a psychological assessment of the Applicant and reported: "There is no reason to believe she suffers from a psychological disturbance or a personality disorder." … "She does likely have a vulnerability to others taking advantage of her due to her passivity in forming relationships."… "It is likely her future work will need to be in a group practice to avoid her falling into the same traps she reports leading to the current matter."
Under the heading of "Formulation" Dr Lennings reports: "She reported shame and humiliation at her behaviour, deep remorse and a feeling of genuine concern for her patients and that she was complicit in doing harm. She presents as having had a terrible learning experience, but one that has reaffirmed her desire to act professionally in the future." Dr Lennings opined that the Applicant does not have any significant psychological condition. He stated: "It is my view that the events when she was a young woman studying in Uruguay at the university, the incursion of the military and the death of some of her teachers did have an impact upon her, that to a large extent she had suppressed over the many decades since"…… "the underlying anxiety that she experienced remained something that she is well advised to work with through her psychologist."
Dr Lennings opined that although the Applicant has an underlying sense of threat, it was not likely to detrimentally affect her future ability to treat patients. He said further: "She clearly recognises the limits of her medical practise and understands that what she did was wrong and has been able to come up with useful suggestions about how she would prevent that from occurring in the future".
Dr Lennings opined that the Applicant has developed "some insight" into the circumstances which led to the cancellation of her registration and has developed some strategies to guard against those circumstances arising again. He said: "Ultimately, I believe that she has achieved some insight into how her avoidance of facing her trauma memories from her past impacted on her. It is likely that (the Applicant) will continue to need some further work on reflecting how her experiences as a student at university impacted upon her sense of threat seemingly subtly but effectively capitalised on by Mr Dank".
Dr Lennings said: "Three aspects (of the Applicant), namely, a sense of threat, introversion and isolation, and her over work combined, it seems to me, to create an environment in which she was unable to act on the insight that what she was doing was wrong. She now appears to have some awareness of all of these elements." He said that the critical issues advanced in his report, are "the need for her to take more time for herself, the need for her to no longer work in a solo practice, the need for her to be more aware of her gullibility when approached by people who can otherwise seemingly appeal to her underlying medical philosophy of wanting to focus on healthy outcomes for her patients, and her avoidance of shame and unwillingness to engage with her sense of threat."

[7]

Conditions proposed by the Applicant

Conditions proposed by Dr Meneghetti in response to conditions proposed by the Medical Council NSW - should the Tribunal be minded to allow the application for reinstatement Practice conditions 1. To obtain Medical Council of NSW approval prior to changing the nature or place of her practice. 2. To practise only in a group practice approved by the Medical Council of NSW where there are at least 3 other medical practitioners (excluding the subject practitioner): a. Where the patients and patient records are shared between the medical practitioners. b. Where there is always one other registered medical practitioner on site. c. If the group practice is a general practice, it must be accredited. 3. To treat no more than 28 patients per day and practice no more than three days per week: a. Within 14 days of a request by the Medical Council of NSW, the practitioner is to provide the Medical Council of NSW with copies of records confirming the number of patients treated, their consultation times and hours worked on any dates as specified by the Council within a period of 6 months up to the date of the request. 4. To restrict her practice to the following minor (non-surgical) cosmetic medical procedures a. injectables b. laser treatment c. skin treatments d. threads 5. Not to supervise or deliver training to any medical practitioner or student in any context. 6. For a period of 12 months from the date of recommencement of medical practice, to practise under category B supervision in accordance with the Medical Council of NSW's Compliance Policy - Supervision (as varied from time to time), including: a. At each supervision meeting the practitioner is to review and discuss her practice with her approved supervisor with particular focus on: - Appropriate prescribing practices - Workload - Medical record reviews - Progress with return to practice - Professional boundaries and ethics - Consent b. At each supervision meeting the approved supervisor is to review 5 randomly selected patients records from the preceding fortnight. The details, discussion and feedback about the reviewed records are to be included in supervision reports. c. To authorise the Medical Council of NSW to provide proposed and approved supervisors with a copy of the decision which imposed this condition. d. Not to practise until a supervisor has been approved by the Medical Council of NSW. 7. Not to possess, supply, administer or prescribe any drug of addiction (Schedule 8 drug) as defined by Poisons and Therapeutic Goods Act 1966 (NSW). 8. Not to possess, supply, administer or prescribe any substance listed in Schedule 4 Appendix D of the Poisons and Therapeutic Goods Regulation 2008. 9. Not to possess, supply, administer or prescribe any drug or therapeutic goods that are not listed on the Australian Register of Therapeutic Goods (ARTG). 10. To submit to an audit of her medical practice, by a random selection of her medical records by a person or persons nominated by the Medical Council of NSW and: a. The audit is to be held within 6 months of recommencement of medical practice and a further audit may be held, if required by the Medical Council of NSW, in the period of up to 2 years from the date of recommencement of medical practice. b. The auditor(s) is to examine and assess the following aspects of her practice including: i. Compliance with good medical record keeping standards and legislative requirements ii. Compliance with conditions iii. Appropriate prescribing practices c. To authorise the auditor(s) to provide the Council with a report on their findings. d. To meet all costs associated with the audits. 11. To authorise and consent to any exchange of information between the Medical Council of NSW and Medicare Australia for the purpose of monitoring compliance with these conditions. 12. To forward evidence to the Medical Council of NSW within 14 days of notification that she has provided a copy of these conditions to the Principal of the practice, supervisor or responsible senior officer in the place that she works. 13. Within 14 days of a change in the place of her practice, she is to forward evidence to the Medical Council of NSW that she has provided a copy of these conditions to the Principal of the practice, supervisor or responsible senior officer in the place that she works 14. To authorise the Medical Council of NSW to notify the Principal of the practice, supervisor or responsible senior officer in any place that she works as a medical practitioner in Australia of any issues arising in relation to compliance with these conditions. Health conditions 15. For a period of 2 years from the date the Tribunal makes a reinstatement order, to attend for treatment by a registered psychologist or registered psychiatrist of her choice, at a frequency to be determined by the treating practitioner. The practitioner is to: a. authorise the treating practitioner to inform the Medical Council of NSW of failure to attend for treatment, termination of treatment or if there is a significant change in health status (including a significant temporary change). b. provide the Council with the professional details of the treating practitioner. 16. For a period of 2 years from the date the Tribunal makes a reinstatement order, to attend for treatment by a registered General Practitioner of her choice. The frequency of the treatment is to be determined by the treating practitioner. The practitioner: a. is to authorise the treating practitioner to inform the Medical Council of NSW of any of the following i. failure to attend for treatment ii. termination of the treatment, or iii. a significant change in health status (including a significant temporary change) b. must provide the Council with the professional details of the treating practitioner. Review of conditions 17. Dr Meneghetti may apply to the Medical Council of NSW for the alteration or removal of one or more of the above conditions not less than 12 months from the date of recommencement of practice. The Medical Council of NSW, if satisfied, may alter or remove any of the conditions. Notations A. The Medical Council of NSW is the appropriate review body for the purposes of Part 8, Division 8 of the Health Practitioner Regulation National Law (NSW). B. Sections 125 to 127 of the Health Practitioner Regulation National Law are applicable while the practitioner's principal place of practice is anywhere in Australia other than New South Wales, so that a review of these conditions may be conducted by the Medical Board of Australia. Non-publication order Under s 64 of the Civil and Administrative Tribunal Act 2013 (NSW) an order is made prohibiting disclosure of the name of any patients referred to in the materials and to paragraph 36 of the report of Dr Antonella Ventura, located behind tab 7 of Exhibit R1

[9]

Cross-examination of Dr Lennings

Dr Lennings met with Dr Meneghetti on three occasions. The last occasion was 11 October 2021. When he first met with Dr Meneghetti he was aware she had been seeing Ms Gale however he did not know on how many occasions that had occurred. He had not seen the report provided by Ms Gale. He had tried to contact her however his calls were not returned.
Dr Lennings had read Dr Ventura's report and Dr McMillans' report. He had just received a copy of the transcript from the first day of the hearing. He was asked to look at the evidence of Dr Ventura in the transcript. He said that the Applicants response to him was more detailed than that which she apparently provided to Dr Ventura in relation to what she would do if confronted in the future, with a dominating male person or difficult and persistent patient.
Dr Lennings did explore with the Applicant how she would deal with a confronting circumstance similar to that she experienced with Mr Dank. He said that he had to "push to get there" to have the Applicant explain how she would deal with such a circumstance. He felt that was because of the deep shame she had felt, and not wanting to explore the deeply painful experiences. There was also a psychological block caused by some of the trauma of her earlier years and experiences. Dr Lennings was unsure whether the block she illustrated was still existing however he said she seemed to be able to discuss those issues with Dr Ventura. There is still a lack of reflecting.
In relation to the treatment the Applicant was receiving from Ms Gale, Dr Lennings said the Applicant had only just begun working with her psychologist. He considered that there would have been some motivating factor for the Applicant to be working with her psychologist in order that she could obtain reinstatement. He considered that the Applicant should continue to work in weekly sessions with her psychologist for about 16 sessions and then until her psychologist advised otherwise.
Dr Lennings was asked about Dr Ventura's evidence that the Applicant only had "intellectual insight about her vulnerability." Dr Lennings said he had discussed that with the Applicant and concluded, after pushing the Applicant considerably, that she was gaining awareness however, it was not well developed. He did not agree that the Applicant had no understanding of the problems she would face upon returning to practice. He said: "we did discuss that and started to work through that."
Dr Lennings said the Applicant should work in a group practice in the future should she gain reinstatement. He did not hold any concerns about the Applicant not having made any clear inquiries about available work to her in a group practice. He said she needs to know what the outcome of the Tribunal hearing is before she undertakes such inquiries.
Dr Lennings was asked about the proposed conditions which the Medical Council was seeking should the Tribunal grant the application. He agreed that practising in a group practice of four medical practitioners was a good idea. He agreed that a restriction on the number of patients she could see in any one day was appropriate. It would prevent or reduce burn out. He considered supervision at level B or C would be appropriate. He said supervision level B reduces the response time. With supervision in place and practice in a group practice Dr Lennings considered that it would be less likely that the Applicant would suffer anxiety or feel overwhelmed by work.
Dr Lennings was taken to paragraph 41 of Dr Ventura's report. This provided an opinion that the Applicant lacks judgment about her current vulnerability. Dr Lennings said: "I think at the beginning she did lack judgement but she gained awareness as she was going (in our sessions). I thought it would lead to a greater sense of judgement…. In relation to ethics I think she was gaining awareness as we progressed."
In relation to page 9 of Dr Ventura's report (2nd paragraph) Dr Lennings was asked if he agreed that the Applicant has not yet worked through her vulnerabilities. He considered that she had made progress. "She was a person who had experienced very significant trauma during her life." He agreed that she had been vulnerable to prescribing problems under the influence of Mr Dank.
It was put to Dr Lennings that the Applicant had issues with her complying with conditions imposed on her registration in the past. He was asked whether he had a view as to her ability to comply in the future. He said that was very difficult to answer. He said she appeared to be desperate to return to practice and would therefore be aware of mistakes which could put that in jeopardy.

[10]

Documentary evidence of the Medical Council

In exhibit R1 the Medical Council set out 14 Tabs behind which it included the documents it relied upon. In relation to those documents we particularly noted the following evidence.
The decision of the Tribunal made 16 April 202 is included at Tab 5 of exhibit R1. It is important we know the facts upon which the finding of professional misconduct was made in order that we can assess what action the Applicant has taken to address/change the conduct which gave rise to that finding and what is the state of her fitness now to practice medicine safely.
We firstly note that the Applicant admitted "each part of the complaint brought against her and was frank in relation to many aspects of her conduct."
A summary of the Complaint is found at paragraphs 1 to 5 of the decision. We set out those paragraphs hereunder: 1. Dr Meneghetti graduated from medicine in 1982 from the University of the Republic, Uruguay and has worked as a general practitioner in Australia for 24 years. In December 2014, she was practising as a general practitioner when she met Stephen Dank. At the time, Mr Dank was serving a lifetime ban from involvement in all sports that have accepted the World Anti-Doping Code 2015 (WADA code). The Australian Sports Anti-Doping Authority (ASADA) imposed the ban because of Mr Dank's possession, trafficking and prescription of Performance and Image Enhancing Drugs (PIEDs). 2. At Mr Dank's behest, Dr Meneghetti began prescribing various peptide hormones, human growth hormones and other Performance and Image Enhancing Drugs (PIEDs) to him and to eight other patients he referred to her. The Health Care Complaints Commission (HCCC) has complained about these prescribing practices and about the fact that Dr Meneghetti had an inappropriate professional relationship with Mr Dank. 3. The substances Dr Meneghetti prescribed can be divided into two categories according to whether they are, or have been, registered on the Australian Register of Therapeutic Goods (ARTG drugs) or they have never been registered (non-ARTG drugs). The ARTG substances that Dr Meneghetti prescribed were: Human Growth Hormone and the steroids Nandrolone, Primobolan, Primoteston, Proviron and Sustanon, Dexamfetamine, Arimidex and Serophene. For the ARTG drugs, the HCCC complained, among other things, that Dr Meneghetti prescribed them without a proper therapeutic purpose and in excessive quantities and combinations. 4. The non-ARTG substances have never been registered in Australia. They are: CJC-1295, Ipamorelin, IGF LR3, LGD-4033, Mechano-Grown Factor, Bremelanotide, Follistatin 344 and Melanotan 2. For the non-ARTG drugs, the HCCC complained that they were prescribed "without reliable evidence of the quality, safety or efficacy of those drugs for use in humans" and "where there are no valid medical indications for use of those drugs." 5. Dr Meneghetti admitted each part of the complaint (the particulars) and was frank in relation to many aspects of her conduct. She accepted all the trenchant criticisms Professor Handelsman made in his expert report. We agree with each of the findings and opinions in that report. Significantly, Dr Meneghetti admitted that her conduct amounts to "professional misconduct". That term is defined as unsatisfactory professional conduct "of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration": Health Practitioner Regulation National Law (NSW) (National Law), s 139E.
The Medical Council relied upon a report prepared by its' expert Dr Antonella Ventura, Consultant, Forensic and Adult Psychiatrist, dated 19 April 2022. In that very detailed report we particularly noted the following evidence.
We firstly note there is no challenge to the evidence of Dr Ventura as an expert witness in the area of psychiatry.
Dr Ventura set out a list of all the documents which had been provided to her. She then set out the history provided by the Applicant including her detail of the relationship she had experienced with Mr Dank, the person named in the Complaint made against her.
In her interview with the Applicant, Dr Ventura was told of the course the Applicant had completed in relation to medical ethics. Dr Ventura said that she asked the Applicant what she had learned from that course. Dr Ventura noted the Applicant was unable to think of an answer. Dr Ventura asked the Applicant what she understood about professional boundaries. The Applicant gave a number of answers, finally speculating that boundaries meant that the patient had to respect her boundaries and she had to respect the patients boundaries.
When asked about her future work should she return as a medical practitioner, the Applicant told Dr Ventura that she would like to return to general practice. The Applicant told Dr Ventura, when challenged about the difficulty which might be encountered given the time the Applicant has not been practising, the Applicant replied: "Do you think you lose the knowledge that I have had since the age of 18? There are things I have done, just not lodged." The Applicant told Dr Ventura that in the future she proposed to practise in a group practice.
Dr Ventura asked the Applicant why she had continued seeing general practice patients after conditions were imposed upon her registration in 2017. Dr Ventura reports the Applicant told her she had done so: "because she did not understand and because she was exhausted."
Dr Ventura provided her opinion of the Applicants mental state as follows: "I found no evidence of psychosis. She appeared to have some difficulty in remembering dates." "Dr Meneghetti appeared to be generally remorseful about the events that led to her losing her medical registration. She however, appeared to lack judgement into her current vulnerabilities and her training needs to return to practice. She appeared to be poorly prepared for the assessment and I found her lack of knowledge about ethical principles in medicine surprising. She is a 73 year old woman who presents with no evidence of psychiatric disorder. Given the vagueness of her history and lack of judgement, it is possible that she may be suffering from some cognitive impairment. The fact she is currently successfully studying several subjects at universities makes this unlikely; however, formal cognitive assessment from a qualified neuropsychologist would be of assistance in clarifying possible cognitive decline…. there is evidence of avoidance of conflict when she is in a position where she feels vulnerable. She does not appear to have gained any real insight or any strategies on how to manage this vulnerability. This places her at risk of poor medical practise should she be put under pressure in the future. Should she return to medical practise the risk to patients could be mitigated by applying some specific restrictions to her practise."
Dr Ventura opined that the Applicant has intellectual insight into the behaviour which led to the cancellation as a medical practitioner. "She came across as a passive powerless woman who was working in isolation. She has a life long history of abuse and exploitation by male figures as demonstrated by her relationship history." "The Applicant has intellectual insight into the link between her or early trauma and the behaviour which led to her deregistration. In my opinion she has not yet worked through her psychological vulnerability and she remains at risk of exploitation, particularly by powerful male figures. This vulnerability could result in inappropriate prescribing practises."
In relation to knowledge of medical ethics, Dr Ventura said the Applicant: "Appears to have very limited knowledge of professional standards and medical ethics, despite having recently completed formal training in ethics. This is currently demonstrated by the fact that most of her referees are her former patients. She appeared to have no concept of professional boundaries as demonstrated during my assessment."
Dr Ventura, was asked to comment on an opinion of Dr Lennings relating to the Applicants early experiences of trauma and the impact upon her current circumstances. Dr Ventura said: "I do not agree with Dr Lennings' opinion that this underlying sense of threat is not likely to detrimentally effect the Applicant's future ability to treat patients. The Applicant's early years were characterised by severe trauma. The trauma contributed to her passive behaviour during her marriages when she was physically, sexually, and financially abused. This was the same kind of behaviour, which contributed to so-called paralysis when it comes to dealing with Mr Danks. Although the Applicant is aware of the link between early trauma and the so called paralysis, she is yet to work through her psychological issues adequately psychologically. She admits that she is yet to develop coping strategies and she is not sure that she, in her own words, when I asked if she feared that similar situation to what had occurred with Mr Dank may reoccur, she replied, "I don't know if this will happen again."
Dr Ventura concluded her report with an opinion that should the Applicant be returned to practice she should be restricted to cosmetic medicine. She should also be under supervision. She should not be allowed to be in solo practice.

[11]

Report of Jillian McMillan Clinical Neuropsychologist 19 May 2022

In this report Ms McMillan advised she had assessed the Applicant over a three and a half hour period on 12 May 2022. She set out the documents which had been provided to her by the Medical Council.
The report sets out a summary of the facts which had been collected by Ms McMillan from the documents provided by the Medical Council. The documents included a copy of the report provided by Dr Ventura. Ms McMillan concludes her summary of background facts by noting: "Concern was raised by Dr Ventura in her report regarding Dr Meneghetti's cognition following observations of the "vagueness of her history and lack of judgment." A formal neuropsychological assessment was recommended."
Ms McMillan set out information in relation to the Applicant's history, being her personal history and her interactions with the Medical Council, and the Tribunal. She noted the Applicant denied any concern about cognition. She denied symptoms of depression and reported sleeping well.
Ms McMillan conducted a series of neuropsychological tests on the Applicant. She provided detailed reports on each test conducted. She then answered specific questions asked of her by the Medical Council. She opined the Applicant does not suffer from a diagnosable condition. She did not consider the Applicant met the definition of impairment within the National Law. She said: "The results from the current assessment would suggest there is no underlying cognitive impairment that can explain previous observations of deficits in Dr Meneghetti's memory and judgement."
Ms McMillan concluded her report with the following: "I agree with the assessments of Dr Lennings and Dr Ventura that Dr Meneghetti may have some personality vulnerabilities that may reduce her level of insight into her actions…… If she were to have her registration reinstated, I agree that Dr Meneghetti should work in a group setting to allow ample oversight of her work. I also consider formal and regular supervision will be helpful to assist Dr Meneghetti in identifying any possible vulnerabilities in her work practice and deal with them in the moment. In light of Dr Meneghetti's responses to questions surrounding her retirement, I would also suggest that she work with a supervisor to formulate a retirement plan for the future."
The Medical Council proposed conditions which the Tribunal could consider imposing on the registration of the Applicant should she be permitted to return to practice. Those conditions we set out here. The Medical Council helpfully worked from the document provided by the Applicant as her proposed conditions and marked up the additional/alternate condition it would suggest. The Medical Council did provide us with a copy of their conditions which show the alterations/additions it has made to the conditions proposed by the Applicant.

[12]

Conditions collated by the Respondent Medical Council NSW - should the Tribunal be minded to allow the application for reinstatement Practice conditions 1. To obtain Medical Council of NSW approval prior to changing the nature or place of her practice. 2. To practise only in a group practice approved by the Medical Council of NSW where there are at least 4 other medical practitioners (excluding the subject practitioner): a. Where the patients and patient records are shared between the medical practitioners. b. Where there is always one other registered medical practitioner on site. c. If the group practice is a general practice, it must be accredited. 3. To treat no more than 28 patients per day and practice no more than three days per week: a. Within 14 days of a request by the Medical Council of NSW, the practitioner is to provide the Medical Council of NSW with copies of records confirming the number of patients treated, their consultation times and hours worked on any dates as specified by the Council, within a period of 6 months up to the date of the request. 4. To restrict her practice to the following minor (non-surgical) cosmetic medical procedures a. injectables b. laser treatment c. skin treatments d. threads 5. Not to supervise or deliver training to any medical practitioner or student in any context. 6. For a period of 12 months from the date of recommencement of medical practice, to practise under category B supervision in accordance with the Medical Council of NSW's Compliance Policy - Supervision (as varied from time to time), including: a. At each supervision meeting the practitioner is to review and discuss her practice with her approved supervisor with particular focus on: - Appropriate prescribing practices - Workload - Medical record reviews - Progress with return to practice - Professional boundaries and ethics - consent b. At each supervision meeting the approved supervisor is to review 5 randomly selected patients records from the preceding fortnight. The details, discussion and feedback about the reviewed records are to be included in supervision reports. c. To authorise the Medical Council of NSW to provide proposed and approved supervisors with a copy of the decision which imposed this condition. d. Not to practise until a supervisor has been approved by the Medical Council of NSW. 7. Not to possess, supply, administer or prescribe any drug of addiction (Schedule 8 drug) as defined by Poisons and Therapeutic Goods Act 1966 (NSW). 8. Not to possess, supply, administer or prescribe any substance listed in Schedule 4 Appendix D of the Poisons and Therapeutic Goods Regulation 2008. 9. Not to possess, supply, administer or prescribe any drug or therapeutic goods that are not listed on the Australian Register of Therapeutic Goods (ARTG). 10. To submit to an audit of her medical practice, by a random selection of her medical records by a person or persons nominated by the Medical Council of NSW and: a. The audit is to be held within 6 months of recommencement of medical practice and a further audit may be held, if required by the Medical Council of NSW, in the period of up to 2 years from the date of recommencement of medical practice. b. The auditor(s) is to examine and assess the following aspects of her practice including: i. Compliance with good medical record keeping standards and legislative requirements ii. Compliance with conditions iii. Appropriate prescribing practices c. To authorise the auditor(s) to provide the Council with a report on their findings. d. To meet all costs associated with the audits 11. To authorise and consent to any exchange of information between the Medical Council of NSW and Medicare Australia for the purpose of monitoring compliance with these conditions. 12. To forward evidence to the Medical Council of NSW within 14 days of [DATE] that she has provided a copy of his full conditions to the Principal of the practice, supervisor or responsible senior officer in any place that she works. 13. Within 14 days of a change in the place of her practice, she is to forward evidence to the Medical Council of NSW that she has provided a copy of the full conditions to the Principal of the practice, supervisor or responsible senior officer in any place that he works. 14. To authorise the Medical Council of NSW to notify the Principal of the practice, supervisor or responsible senior officer in any place that she works as a medical practitioner in Australia of any issues arising in relation to compliance with these conditions. Health conditions 15. For a period of 2 years from the date the Tribunal makes a reinstatement order, to attend for treatment by a registered psychologist or registered psychiatrist of her choice, at a frequency to be determined by the treating practitioner. The practitioner is to: a. authorise the treating practitioner to inform the Medical Council of NSW of failure to attend for treatment, termination of treatment or if there is a significant change in health status (including a significant temporary change). b. provide the Council with the professional details of the treating practitioner. 16. For a period of 2 years from the date the Tribunal makes a reinstatement order, to attend for treatment by a registered General Practitioner of her choice. The frequency of the treatment is to be determined by the treating practitioner. The practitioner: a. is to authorise the treating practitioner to inform the Medical Council of NSW of any of the following i. failure to attend for treatment ii. termination of the treatment, or iii. a significant change in health status (including a significant temporary change) b. must provide the Council with the professional details of the treating practitioner Review of conditions 17. Dr Meneghetti may apply to the Medical Council of NSW for the alteration or removal of one or more of the above conditions not less than 12 months from the date of recommencement of practice. The Medical Council of NSW, if satisfied, may alter or remove any of the conditions. Notations A. The Medical Council of NSW is the appropriate review body for the purposes of Part 8, Division 8 of the Health Practitioner Regulation National Law (NSW). B. Sections 125 to 127 of the Health Practitioner Regulation National Law are applicable while the practitioner's principal place of practice is anywhere in Australia other than New South Wales, so that a review of these conditions may be conducted by the Medical Board of Australia. Non-publication order Under s 64 of the Civil and Administrative Tribunal Act 2013 (NSW) an order is made prohibiting disclosure of the name of any patients referred to in the materials and to paragraph 36 of the report of Dr Antonella Ventura, located behind tab 7 of Exhibit R1.

The Medical Council provided the Tribunal with information which we had sought about the process of re-registration for the Applicant should she be permitted to return to practice. That information included the following: Dear Registrar We write as the legal representatives for the Respondent Medical Council of NSW in the above proceedings, which are listed for hearing today, Friday 1 July 2022. These proceedings are part-heard. On the last occasion, the Tribunal asked the Council to prepare some information for the Tribunal. This email contains that information. We would be grateful if a copy could be circulated to the panel. If the Tribunal makes an order allowing reinstatement, Dr Meneghetti would be applying for registration afresh; On that application, applicants are asked about recency of practice and will be asked: "What is your full practice history?" The applicant is instructed to attach to their application, a signed and dated curriculum vitae that describes their full practice history and any clinical or skills training undertaken Later in the application, they will be asked: Q 35 "Do you meet the recency of practice registration standard?" if no - next question: Q 36 "Have you previously practised medicine for more than two years? " If no - You are required to commence work under supervision in a training position approved by the Board. You must attach details of the supervised training position you propose to take up. Q37 "How long have you been absent from practise?" if between 1-3 years - You must attach evidence of having completed the equivalent of one year's CPD activities relevant to your intended scope of practice If more than three years - You must attach a plan for professional development and re-entry to practice for consideration by the Board. Refer to information relating to re-entry to practice at www.medicalboard.gov.au/Codes-Guidelines-Policies/FAQ However, if Tribunal conditions are imposed at reinstatement, and these include supervision, the Board will generally view that as a sufficient re-entry to practice and won't usually require separate re-entry to practice supervision If the Tribunal is minded to allow Dr Meneghetti to practice as a GP, however is concerned about her competency as it cannot be assessed, they could be made an order that she must undertake a re-entry course with an accredited body and she would be a trainee GP and go through re-training. Although, this may prove difficult for Dr Meneghetti after being out of practice for 2 years and at the age of 73 yrs. The Board/Ahpra is likely to seek information from the Council regarding Dr Meneghetti's regulatory history when assessing her application for registration.

[13]

The oral evidence of Dr Meneghetti

The Applicant said that her statement dated 27 November 2021, as contained in exhibit A1, was, subject to matters referred to further in her oral evidence, true and correct. She corrected the year date in paragraphs 1, 2 and 3 of her statement in 2017.
In May 2022 the Applicant last saw Ms Gale, her psychologist, on two occasions. If the Tribunal allowed the Applicant to be re-registered as a medical practitioner she said she would continue to seek the assistance of Ms Gale. She informed the Tribunal of strategies she was working on with Ms Gale to overcome her vulnerabilities as identified in the report from Dr Ventura.
The Applicant confirmed that she was seeking general registration as a GP to practise general medicine and also cosmetic medicine. She said she wanted to continue as a general practitioner because there is an overlap with cosmetic medicine and she needs to keep up to date with general medicine.
The Applicant informed the Tribunal that she has now been vaccinated with the first of the Covid vaccinations.
The Applicant was cross-examined. We noted the following evidence.
The Applicant was asked to confirm that in the first s 150 hearing in January 2017 the Applicant was limited by conditions to practise Cosmetic medicine only. She confirmed that was correct. She also confirmed that during the operation of those conditions an audit performed by the Medical Council, disclosed that she had continued to see some general medicine patients. During the period from January 2017 (when the conditions were imposed) until September 2017 when the Applicant faced a second s 150 hearing the Applicant agreed she had serviced some of her existing patients with general medicine services and also saw some new patients. She said the patients she saw for general medicine during that period were "emergencies".
The Applicant was asked to look at the decision of the Medical Council made September 2017, which stated she had conceded some of the general medicine patients she had seen were not emergencies. The Applicant said: "They were emergencies I don't know why I would have said they were not in the hearing in August 2017".
In relation to her work with Mr Dank between late 2014 and 2016 the Applicant agreed she had made no inquiries about his background. The Applicant denied she knew that Mr Dank had been severely sanctioned for his use of PIED's in sport. She said she did not have knowledge of that matter until there was a publication in the Daily Telegraph newspaper in March 2016.
The Applicant denied that she had delegated her role as a doctor to Mr Dank when he worked with her. She acknowledged that was something the Tribunal had found in their decision. She agreed that at a time when she was prescribing peptides it was a regulated medicine. She said that at the time she was prescribing she did not know that. She acknowledged that she should have known. She acknowledged that her lack of knowledge placed the health and safety of her patients at risk and she very much regretted that circumstance.
The Applicant agreed that notwithstanding she had information about Mr Dank from the Daily Telegraph article in March 2016 she continued to work with him until late 2016. She said she had tried to disconnect from him but he had threatened her by referring to the fact that he had friends who were "bikies". She also became aware he was associated with Mafia people.
The Applicant thought that if she was to work in a group practice in the future she would not be vulnerable to people like Mr Dank.
The Applicant was asked some theoretical questions about circumstances which may arise if she returned to practise as a general medicine practitioner. She was asked how she would deal with a patient who was drug addicted and seeking medication from her. She provided her response which included that she would not provide medication to such a patient to support their drug habit. She also said she would not prescribe any of the medications she had prescribed while working with Mr Dank.
The Applicant acknowledged that she should not have been treating Mr Dank as a patient whilst she was working with him as a colleague. She agreed she had prescribed dexamphetamine for Mr Dank without an appropriate authority. She said at the time she prescribed the drug she was not aware it required a particular authority. She also acknowledged that she had prescribed other drugs and medications for Mr Dank and that she should not have done so.
The Applicant acknowledged that the Tribunal had found that she had prescribed CJC-1295 and SARM-S22 for a patient where there was no valid medical indication for that prescription.
The other findings of the Tribunal which were adverse to the Applicant, were also raised with her. She acknowledged her errors as found by the Tribunal.
The Applicant was asked about the Tribunal's findings in relation to the Applicants note making and record keeping for her patients. It was put that the Tribunal found that for some patients there were no notes. The Applicant said she had made notes on her computer however the next day they had disappeared. It was necessary for her to reconstruct some of her patients records and notes.
The Applicant agreed that the Tribunal decision to cancel her registration in 2020 was appropriate given her accepted conduct. She had conceded the case against her.
There having been a break in the cross-examination to allow the oral evidence of Dr Ventura, the cross-examination of the Applicant continued on 1 June 2022 the first day of the hearing. (We note the cross-examination also continued on the adjourned date of the hearing on 1 July 2022.)
The Applicant denied the only work she had undertaken with Ms Gale, her psychologist, was to read a book she had given the Applicant. She said that "hopefully I won't be exposed to such another similar character in my life…. I now have the insight. I can defend myself when something similar happens. I have been confronted to that. If something "no good" happens you have to work on it and apply all of what I have learnt."
Counsel for the Medical Council set out a number of questions designed to elicit responses and show how the Applicant would deal with difficult practical circumstances which a practising medical practitioner might face. These included a child seeking cosmetic procedure, to which she replied "I wouldn't touch a child at least until 18 years". If she was asked to treat a woman with a dysmorphic body image, she said she would assess her for mental illness, get a report from her psychologist and her approach would be very conservative.
The Applicant was challenged about her knowledge in terms of recency of practice. She said: "I know I need to update my knowledge. I don't see a problem to get the information and observe other doctors in order to get to that level again." The Applicant agreed that she had not performed cosmetic medicine for two years and general medicine for five years.
The Applicant denied that her main reason for seeking reinstatement as a medical practitioner was financial. Whilst agreeing that her financial circumstances are very poor and that reinstatement would improve her financial circumstances, it was not the main motivating factor behind her application before the tribunal at this time.
The Applicant was questioned about the references she provided with her application. She agreed she had asked some of the people to provide references for her. She said she had explained her situation to them and asked whether they were willing to provide a reference. She agreed she had provided a "pro forma document" to her referees. She said they were not obliged to use the pro forma. She agreed some of the references were from former patients. She denied that the patients who provided the references were friends of hers.
The Applicant was asked about one of her references which illustrated that a patient had also been a co-worker of the Applicant. She was asked whether she agreed that treating someone as a patient who also worked with her blurred the professional boundaries. She agreed that was what the code of conduct for doctors in Australia said.
The Applicant was further cross-examined on 1 July 2022 by the Medical Council.
The Applicant was asked about her willingness to continue attending upon her psychologist Ms Gale. She said that she would continue to work with her on a weekly basis if "money was not an issue." She said that working with Ms Gale she had learnt to "write down what I was doing. We talked about how to avoid being vulnerable. We talked about working with other doctors. We talked about the code of conduct and also to look at self when under pressure and tired. To look for help. To have my own GP."
The Applicant was asked why, as a proposed condition, she was seeking to work with a three doctor practice rather than a four doctor practice. She said the only reason was that she thought it would be easier to find such a practice.
The Medical Council then moved to ask the Applicant about conditions which might be sought should she be permitted to return to practice. She was asked if she would agree to the removal of skin treatments as part of the cosmetic practice she could undertake. There was some debate about the wording for such a condition as it seemed the Medical Council was wanting to restrict the Applicant to not undertaking surgical skin procedures.
The Applicant agreed that she would practise under her surname Meneghetti.
The Applicant was asked whether she agreed with the opinion of Dr Ventura that she did not have strategies to manage vulnerabilities. She replied: "Now I have no doubt I am back to myself. I now have consciousness of all the problems."
When challenged about a potential issue with her recency of knowledge the Applicant said: "Things do not change apart from what is new. It won't take me long to catch up."
When challenged about a concern that she would not comply with conditions imposed on her registration, she said that she would.

[14]

Oral evidence of Dr Ventura

Dr Ventura identified her report and was then cross-examined by the Applicant's counsel.
Dr Ventura was asked a number of questions arising from the report obtained from Dr Lennings as the Applicants expert psychologist. Dr Ventura agreed with a number of opinions expressed by Dr Lennings in his report. Those opinions focused upon her vulnerabilities and the advantage and protectiveness to the Applicant if she was to practise in a group medical practice.
Dr Ventura did not agree that having knowledge of your vulnerabilities is a cure for those vulnerabilities. Dr Ventura said that in her interview with the Applicant she was told that the Applicant had learnt no strategies from the therapy she had already engaged in. She said she had been reading a book. When challenged as to how she would respond in the future to the challenges which lead to the cancellation of her registration the Applicant had told Dr Ventura that she could not guarantee it would not happen again.
When questioned about the possibility of the Applicant practising in a group medical practice, Dr Ventura said that working in a group practice is partially protective of future behaviour on the part of the Applicant. However, she said that the Applicant needs to be aware of behaviours which are challenging for her. Dr Ventura said that during her assessment of the Applicant "she was clearly unable to articulate much of what she claimed to have learned from her course in ethics." Further, Dr Ventura said the Applicant "has had a long history of trauma and been very vulnerable, particularly to abuse from powerful men. Unfortunately she has continued to be vulnerable to that. "Very powerful, dominating men is what appears to have influenced her behaviour on this particular occasion that caused her to conduct yourself in a non-professional manner."
When challenged by the Applicant's statements that she has learned from her mistakes and will not fall into error again, Dr Ventura said: "She becomes very, very frightened and retreats and becomes very non-assertive. That underlying dynamic has not been addressed. When I attempted to explore with her how she is addressing the trauma, she is doing it in a very intellectual manner. She is reading a book… Which is rewarding and interesting but it is not therapy. It is not giving her strategies. Therefore, when she says, 'this experience has caused me to be very careful and I am not going to do this again,' as a psychiatrist it does not convince me, as a statement, that it is predictive of changed behaviour."
Dr Ventura was informed of the types of conditions which are proposed by the Medical Council should the Applicant be permitted to return to practice. The conditions included working in a group practice and under strict supervision. Other conditions were outlined to Dr Ventura by the Medical Council's legal representative. Dr Ventura was asked if those conditions were imposed what her view was about the risks to the public should the Applicant be permitted to return to medical practice. Dr Ventura said that she thought those strategies would be protective. Dr Ventura said she would be supportive of the Applicant returning to practice under the type of conditions listed by the Medical Council. She also considered that the Applicant undertaking to continue therapy with her consultant psychologist would be an additional protective strategy.
Dr Ventura was asked whether she would support a recommendation that the Applicant be permitted to practise general medicine under the types of conditions recommended by the Medical Council as outlined to Dr Ventura in this hearing. Dr Ventura raised a concern about the Applicant's cognition. She said it was very difficult for a psychiatrist to assess cognition in someone who is previously very high functioning. She recommended an assessment of the Applicant by a qualified neuropsychologist.
We noted that Dr Ventura had not been advised that the Applicant had been assessed by Ms McMillan following receipt of the report prepared by Dr Ventura.
Dr Ventura did raise a concern about the effectiveness of the treatment/therapy being provided to the Applicant by her psychologist Ms Gale. This was because the Applicant was not able to describe the therapy she was undertaking with Ms Gale. The Applicant told Dr Ventura that Ms Gale had given her a book to read.
Dr Ventura said that in summary, "I think if Dr Meneghetti was to allow herself to undergo regular psychotherapy, that would be of assistance to her in protecting herself from situations where she feels vulnerable."
Dr Ventura was clearly troubled by some of the Applicants statements to her which reflected her confidence in being able to return to general medicine practice without any difficulty. Although she had not practised general medicine for many years she was of the opinion that she would not have lost any of her knowledge even that she learned at the age of 18 at University.

[16]

The Oral Submission of the Applicant on 1 July 2022

The Applicant submitted that the concerns raised by the Medical Council in relation to deficiencies in the Applicant's ability to practise safely can be resolved to the necessary protective requirement by the imposition of conditions to be attached to her registration.
The Applicant consents to the conditions proposed by the Medical Council subject to the following caveat (addressed later in the submission).
The Applicant responded to submissions of the Respondent with the following.
In relation to the submission that the Applicant lacks "recency of practice", the Applicant submitted that if the Tribunal was to grant the application for re-instatement, then the registration authority the Australian Health Practitioner Regulation Agency ("AHPRA") will consider the Applicant's request for registration and may well require her to undertake further refresher courses to ensure her medical knowledge is up to date.
The submission of the Respondent that the Applicant may be vulnerable to being professionally isolated, is met by the Applicant consenting to the proposed condition that she practise in a group medical practice. The Applicant did not make any further submission to support her request that the group practice have three other practitioners rather than four, as sought by the Medical Council.
The Applicant submitted, in response to a submission in relation to whether the Applicant would continue to consult with her psychologist if she was reinstated, that her continued attendance upon Ms Gale had only been restrained in terms of more frequent attendance, by the Applicants ability to pay for those consultations. It was submitted that an attendance of once a month, as illustrated by the evidence, did not suggest the Applicant was "trying to game the system." Once the Applicant's financial circumstances improve she can be accepted on her word that she will be able to attend more frequently if that is what Ms Gale recommends for her therapy.
The Applicant addressed the criticism which had been made in relation to her insight, judgment, and psychological vulnerabilities. The Applicant referred to the differences in some of the opinions of Dr Ventura and Dr Lennings in relation to those matters. She highlighted that both experts accepted the Applicant had displayed remorse and acceptance of self-responsibility for her past professional misconduct. Dr Lennings opined that the Applicant did recognise her vulnerabilities. Paragraphs 23, 25, 51, 52, 55, 58 and 60 of Dr Lennings' report were referenced for the Tribunal's assistance.
In relation to the conditions proposed by the Medical Council, the Applicant submitted: 1. The amendment to condition 3 is no longer pressed. 2. In relation to Condition 4 the Applicant suggested the condition include the words "incisional or excisional procedures". 3. Condition 6. The Applicant said that she was not pressing objection given the inclusion of the term of 12 months in the condition proposed. 4. The Applicants only objection had been based on cost. She said that an audit, as proposed, would cost her $3,000. 5. The Applicant sought an amendment to condition 14 to protect her privacy. The proposed condition authorises the provision of information to the principal of the practice in which the Applicant may work should she fail to comply with any condition imposed. 6. The Applicant consents to the condition that she practise under the name of Dr Meneghetti. 7. The Applicant informed the Tribunal through her counsel, she did not wish to undertake "skin peel" procedures in the future.
The Applicant submitted the evidence of Ms McMillan that she does not have a cognitive inability should provide the Tribunal with confidence that the Applicant is able to practise safely. The Applicant also pointed to the evidence of Dr Lennings that the two occasions in her past where a person took advantage of her vulnerabilities, were not doctor/patient relationships.
In relation to the order sought by the Respondent that the Applicant pay its' costs, the Applicant submitted the power to make a costs order is discretionary by the Tribunal. She submitted a neutral costs order would be the appropriate order to make. The Applicant does not point to any improper conduct on the part of the Medical Council which might be relevant to the determination of a costs order in its favour.
If a costs order was to be ordered the Applicant requested that the order require a payment of costs by instalments.

[18]

Written submission of the Medical Council MFI 2 and MFI3.

The Respondent provided a written preliminary Submission dated 1 June 2022. In that we note the following.
The Respondent confirmed that it neither supported nor opposed the application of the Applicant. If the Tribunal was proposing to allow the application then the Respondent proposed a set of conditions to attach to the registration of the Applicant once that was reinstated.
The Respondent reviewed the findings of the Tribunal made against the Applicant in April 2020 highlighting some paragraphs which the Respondent submitted were crucial for this Tribunal's determination.
The Respondent set out detail of the "Legal Framework" it submitted applied to this hearing. It submitted the Applicant bears the onus of establishing to the Tribunal's satisfaction that reinstatement is appropriate. It cited the decision of the NSW Court of Appeal in Qasim v Medical Council of New South Wales [2021] NSWCA 173 which stated a reinstatement application involved the Tribunal conducting an inquiry into the present fitness of the Applicant and not a review of the original decision.
The Respondent provided submissions on the documentary evidence relied upon by the Applicant. It specifically referred to part of that evidence which it submitted was particularly important for the Tribunal to consider.
The submission highlighted some of the opinions expressed by the Respondent's witness Dr Ventura. In particular the following words from Dr Ventura's report were set out: "Dr Meneghetti appears to have very limited knowledge of professional standards and medical ethics, despite having recently completed formal training in ethics." Also: "Dr Meneghetti appeared to have no concept of professional boundaries as demonstrated during my assessment. A combination of lack of assertiveness, professional isolation and anxious avoidance of conflict particularly when faced with powerful men has contributed to the professional misconduct."
The Respondent noted the recommendation of Dr Ventura that should the Applicant be permitted to return to practice then conditions should be imposed on her registration which include "Restriction to cosmetic medicine; regular supervision and not allowed to be in solo practice."
The Respondent drew our attention to portions of the written evidence of Ms McMillan.

[19]

Oral submission of the Medical Council made 1 July 2022

The Medical Council neither supports nor opposes the application before the Tribunal. The Medical Council seeks an order for its' costs to be paid.
The Medical Council listed the following matters for our assistance.
The Applicant has not provided any evidence of having organised a place at which she may be able to practise should her application be granted. She has consistently said she would await the outcome of the Tribunal determination before making enquiries.
The Medical Council submits that the Applicant has been out of practise as a general medical practitioner for five years and two years as a cosmetic practitioner. She has not shown evidence of continuing medical education which would make up for her lack of recency of practise in general medicine.
The Applicant was professionally isolated when she last practised. That meant she had no colleagues immediately available to refer to when she was being controlled by Mr Dank. She was not part of a structure which would have detected inappropriate medical practices, such as might be in place in a multi-medical practitioner practice.
The evidence of insight which might normally be expected in an application of this kind was not available. Although the Applicant is working with her psychologist Ms Gale, that psychologist did not give oral evidence. (We note the evidence of both Dr Ventura and Mr Lennings in relation to each of their views as to the insight of the Applicant or lack thereof. We also note the oral evidence of the Applicant on 1 July last where she detailed what she had been undertaking with Ms Gale in addressing her vulnerabilities.)
The evidence of Dr Ventura addressed the ongoing vulnerabilities of the Applicant and her reservations as to the Applicants ability to appropriately address those vulnerabilities. There is also evidence from Mr Lennings as to the Applicants vulnerabilities and how they may be addressed/contained, to maintain safe practice and safety of patients.
A concern as to the ability of the Applicant committing to continuing therapy with Ms Gale or other psychologist was held. (We note her undertaking to do so. She said she would attend as often as her financial circumstances allowed and at the request/suggestion of Ms Gale.)
There is a concern that the Applicant may cut corners on ethical issues because of her financial pressures.
There is also a concern arising from the Applicant not having complied with conditions in the past.
The Applicant has been involved in a lengthy process of disciplinary proceedings since 2017 and it is unknown how that has affected her capacity to function as a medical practitioner.
The Medical Council submitted the Tribunal should not give any probative value to any of the references provided by the Applicant. It is submitted where the references involved persons completing a pro-forma reference document created by the Applicant, the real value of such references to the Tribunal is limited.
The concerns raised by Dr Ventura in her evidence remain a major consideration for the Tribunal. Her opinions, submits the Medical Council, were unmoved by the cross-examination. It is accepted that Dr Lennings is a reliable witness and the Tribunal would note the recommendation that the Applicant should work in a group practice if permitted to return to registration.
The Medical Council submitted that the Applicant had "downplayed" her conduct which led to her registration being cancelled. It was submitted she had an inflated view of her skills as a medical practitioner. She has a limited insight into her vulnerabilities.
The Medical Council pressed for the Conditions it sought should the Applicant be permitted to apply for re-registration. It submitted such conditions would be protective of the Applicant. A four person group practice in which the Applicant could practise was pressed. In relation to paragraph 4 of the Conditions, which sought a restriction on skin condition procedures, the Medical Council said such a condition would be too difficult to monitor as there are no Medicare claims for those procedures. The Medical Council pressed for supervision at level "B".
In relation to the power of the Tribunal to impose conditions which only take effect when the practitioner is re-registered by the relevant authority/authorities, the Medical Council referred the Tribunal to the decision of the NSW Supreme Court in Jan v Health Care Complaints Commission [2021] NSWSC 350. In that decision the Respondent submitted paragraphs 62 to 64 support the jurisdiction. Those paragraphs are as follows: "62. However, in supplementary written submissions, the HCCC said: "Although subsection (4) is clumsily worded the use of the expression 'is to be subject' supports an interpretation that the Tribunal (as the appropriate review body) has the power to impose conditions on a person's registration once a person is to be registered by way of a reinstatement order. Those conditions will not operate until the person is in fact registered by the relevant National Board under Part 7 of the Act. Such an interpretation is also consistent with the terms of s163B(3A) which restricts the power of a National Board under Part 7 of the Act to impose conditions on a person's registration so that such restrictions are not inconsistent with conditions imposed or altered by the appropriate review body under subsection 163B(4)." 63. In his supplementary written submissions, the plaintiff agreed, noting decisions where NCAT had ordered reinstatement subject to conditions, including Ng v Health Care Complaints Commission [2018] NSWCATOD 105 at [55] (which included, by way of example, a condition that Dr Ng not engage in solo practice or work as a locum for a 12 month period). 64. The parties' eventual agreement on a question of power is not dispositive. However, I think the parties' ultimate joint position that there is power to impose conditions attaching to a reinstatement order is correct. True it is that when the power is exercised, the practitioner will not be registered. That will only occur when the relevant National Board makes its decision. However, the words "alter the conditions to which the person's registration is to be subject under the reinstatement order" can bear no meaning at all unless they refer to conditions to be imposed in the future following the relevant National Board effecting the registration which has been ordered by NCAT, and there is no reason to construe the powers conferred upon the specialist "appropriate review body" narrowly."

[20]

Determination

We have had the opportunity of seeing and hearing the Applicant give her oral evidence over a reasonable lengthy period of time. She was cross-examined on both the 1st June and 1st July 2022 (no intended criticism). We only set that out to illustrate that we have had a considerable amount of exposure to the Applicant giving evidence, under oath, and it permitted us to form our own view of her as a witness and as a person.
Our assessment of the Applicant as a witness and as a person is as follows.
The Tribunal is required to assess the suitability of the Applicant to return to practice now. It is not required to rehear the complaints which led to the cancellation of the Applicants registration in April 2020. It is necessary that we know what those complaints were and why the Applicant was found to be guilty of professional misconduct. That is required because one of the matters we need to consider is whether the Applicant is vulnerable to reoffending due to the aspects of her personality, which led to the original conduct found by the Tribunal in April 2020 to be professional misconduct and consequently the cancellation of her registration.
Decided cases, to which we turn for guidance, make clear that a cancellation of a medical practitioner's registration by the Tribunal, does not mean that the practitioner cannot be returned to registration once the period during which he/she has been prevented from applying has expired and where the Tribunal can be satisfied that it is appropriate to permit re-registration, subject to conditions or otherwise. Such a circumstance falls for determination in this case.
The Applicant is a medical practitioner aged 73 years. She practised for many years without complaint being found against her. In 2017 the Medical Council found complaints made against her established. It imposed conditions on her registration. Those complaints were the subject of a formal application to the Tribunal which in April 2020 determined to cancel the Applicants registration.
The Applicant has not practised general medicine for 5 years and cosmetic medicine for two years. Issues of recency of practice and continuing education to maintain a proper level of knowledge are raised against the Applicant. As against that, communication from the Medical Council (as set out in the evidence we have considered) addresses how any concern about the level of knowledge required to permit registration will be addressed. Further the imposition of conditions, as proposed by each of the parties, is said by the Applicant to be sufficient to satisfy us that with such conditions applying to her practice as a medical practitioner, we can be satisfied it is appropriate for the Applicant to be given the opportunity to re-register.
As can be seen from the evidence of Dr Ventura and Dr Lennings, there are aspects of the Applicants psychological makeup which have probably led to the circumstances she finds herself in today. There are aspects of her insight into how she came to conduct herself whilst under the influence of Mr Dank which Dr Ventura raises a concern. There are concerns about the effectiveness of the psychotherapy which the Applicant is undertaking with Ms Gale which have been addressed by both Dr Ventura and Dr Lennings. There appears to be a concern expressed by both Dr Ventura and Dr Lennings that any insight which the Applicant has into her vulnerabilities is embryonic and will require continued psychotherapy to enhance that insight and then reinforcement of that therapy.
The Medical Council has raised a concern that once the Tribunal permits re-registration for the Applicant she will not proceed further with her psychotherapy with Ms Gale.
The Applicant commenced the hearing before us seeking that she be re-registered as a general medical practitioner who also practised as a cosmetic medical practitioner. It is not entirely clear to us whether the Applicant will still pursue general practice registration given her consent to a condition that she practise only in cosmetic medicine.
The restriction to practise as a cosmetic medical practitioner is sought by the Medical Council for a period of 12 months. As we understand the evidence obtained from the Medical Council, at the end of that time, if the Applicant sought to be permitted to practise as a GP, she would need to establish recency of knowledge and satisfy the Medical Council she is competent to practise as a GP.
To the extent there are established concerns about the Applicant being able to practise in a manner which does not lead to further professional misconduct, we also need to be satisfied that permitting her to return to practice, subject to conditions, will contain the risk of reoffending. We conclude that both Dr Ventura and Dr Lennings are of the view that the conditions proposed by the Medical Council will ensure an appropriate level of safety for the public and a means of overseeing her practice during the currency of the conditions. Further it will permit the Applicant to fulfill one of the conditions which will help protect her into the future, namely the continued attendance upon Ms Gale for psychotherapy.
We are satisfied that there are sustainable concerns about the ability of the Applicant to know what her vulnerabilities are and to be able to resist the attempts of powerful men to control her. We also accept those vulnerabilities have their roots in traumatic events the Applicant was exposed to as a young person. We accept that she is working with Ms Gale to be able to have insight into her vulnerabilities and be able to recognise if she was in a situation where someone was taking advantage of her and pressing her to make decisions which are contrary to her obligations as a medical practitioner.
Having considered all of the evidence in this hearing we are satisfied that the Applicant has made sincere efforts to address her vulnerabilities. We find that she has taken personal responsibility for the actions which led to her registration being cancelled in April 2020. We accept she is very embarrassed that such a circumstance arose. We are satisfied that she has commenced to have some insight into her vulnerabilities and to seek help to address them and gain some control over them or at least be able to recognise when she is being used by a patient for an end which is unethical.
We are satisfied that the Applicant is very aware that her registration is at risk if she was to re-offend in any manner. She is sincerely seeking to pursue her medical career for the purpose of serving the public need and to engage herself in meaningful employment. That when her financial circumstances permit she will be able to attend more frequently upon Ms Gale should Ms Gale recommend that.
The proposed conditions as sought by the Medical Council are very restrictive on the practice of medicine by the Applicant. Such conditions ensure a high level of supervision of the Applicant. The conditions create a circumstance of practice which provides the best form of protection to the public of any future reoffending by the Applicant. We therefore propose to grant the application of the Applicant subject to the imposition of the conditions proposed by the Medical Council as we have set out above. In such a circumstance we conclude it is appropriate for the Applicant to be re-instated as a medical practitioner.
There was a difference in the level of supervision which the Applicant was proposing and that proposed by the Medical Council. We conclude that the level proposed by the Medical Council is a necessary part of the conditions which we consider will permit the Applicant to practise safely. There was another difference in a condition proposed by the Applicant, namely the number of practitioners to be participating in the Medical Practice which the Applicant joins is to be three rather than the four proposed by the Medical Council. Again we err on the side of caution and we find that a medical practice with four other medical practitioners will add safety to the practise of the Applicant until the conditions are reviewed, at an appropriate time, by the Medical Council of NSW.
During the hearing there was submission made as to the restriction on the type of medical practice the Applicant could conduct. The restriction being discussed was cosmetic medical practice and the words "incisional or excisional" were used. This was a departure from the term "non-surgical" which the Medical Council had originally used. That departure occurred because it was considered that "injectables and threads", which were to be permitted, could be characterised as surgical procedures.

[21]

Costs

The Medical Council seeks an order that the Applicant pay its costs of the proceeding. Such costs to be as agreed or as assessed.
The Applicant opposes that order and seeks that there be a neutral costs order (each party pay their own costs).
It is necessary for the Applicant to apply to the Tribunal to obtain the order she seeks. That follows from the cancellation order being made by the Tribunal. The Medical Council is a necessary party to the proceeding and has taken, in this case a neutral position whilst at the same time providing evidence which is essential for the Tribunal to have in order to be able to make a proper determination.
It is appropriate, in our view, because the Medical Council is required to be a party and because the Medical Council has provided important evidence to assist us in this determination, that its costs are paid by the Applicant.
The Applicant has said she is impecunious and unable to meet any such order which may be made against her. She seeks that she be able to make payment by instalments. We are not able to make such an order however, to the extent it may be helpful to the Applicant, we would recommend to the Medical Council that it consider any such application by the Applicant to pay be instalments.
The orders will be as follows: 1. The Applicant is permitted to apply for re-registration as a medical practitioner. 2. The registration, when granted is to be subject to the following conditions. Practice conditions
To obtain Medical Council of NSW approval prior to changing the nature or place of her practice.
To practise only in a group practice approved by the Medical Council of NSW where there are at least 4 other medical practitioners (excluding the subject practitioner): a. Where the patients and patient records are shared between the medical practitioners. b. Where there is always one other registered medical practitioner on site. c. If the group practice is a general practice, it must be accredited.
To treat no more than 28 patients per day and practise no more than three days per week: a. Within 14 days of a request by the Medical Council of NSW, the practitioner is to provide the Medical Council of NSW with copies of records confirming the number of patients treated, their consultation times and hours worked on any dates as specified by the Council, within a period of 6 months up to the date of the request.
To restrict her practice to the following minor (non-incisional and non-excisional) cosmetic medical procedures including: a. injectables b. laser treatment c. skin treatments d. threads
Not to supervise or deliver training to any medical practitioner or student in any context.
For a period of 12 months from the date of recommencement of medical practice, to practise under category B supervision in accordance with the Medical Council of NSW's Compliance Policy - Supervision (as varied from time to time), including: a. At each supervision meeting the practitioner is to review and discuss her practice with her approved supervisor with particular focus on: - Appropriate prescribing practices - Workload - Medical record reviews - Progress with return to practice - Professional boundaries and ethics - Consent b. At each supervision meeting the approved supervisor is to review 5 randomly selected patients records from the preceding fortnight. The details, discussion and feedback about the reviewed records are to be included in supervision reports. c. To authorise the Medical Council of NSW to provide proposed and approved supervisors with a copy of the decision which imposed this condition. d. Not to practise until a supervisor has been approved by the Medical Council of NSW.
Not to possess, supply, administer or prescribe any drug of addiction (Schedule 8 drug) as defined by Poisons and Therapeutic Goods Act 1966 (NSW).
Not to possess, supply, administer or prescribe any substance listed in Schedule 4 Appendix D of the Poisons and Therapeutic Goods Regulation 2008.
Not to possess, supply, administer or prescribe any drug or therapeutic goods that are not listed on the Australian Register of Therapeutic Goods (ARTG).
To submit to an audit of her medical practice, by a random selection of her medical records by a person or persons nominated by the Medical Council of NSW and: a. The audit is to be held within 6 months of recommencement of medical practice and a further audit may be held, if required by the Medical Council of NSW, in the period of up to 2 years from the date of recommencement of medical practice. b. The auditor(s) is to examine and assess the following aspects of her practice including: i. Compliance with good medical record keeping standards and legislative requirements ii. Compliance with conditions iii. Appropriate prescribing practices c. To authorise the auditor(s) to provide the Medical Council of NSW with a report on their findings. d. To meet all costs associated with the audits
To authorise and consent to any exchange of information between the Medical Council of NSW and Medicare Australia for the purpose of monitoring compliance with these conditions.
To forward evidence to the Medical Council of NSW within 14 days of notification that she has provided a copy of her full conditions to the Principal of the practice, supervisor or responsible senior officer in any place that she works.
Within 14 days of a change in the nature or place of her practice, she is to forward evidence to the Medical Council of NSW that she has provided a copy of the full conditions to the Principal of the practice, supervisor or responsible senior officer in any place that she works
To authorise the Medical Council of NSW to notify the Principal of the practice, supervisor or responsible senior officer in any place that she works as a medical practitioner in Australia of any issues arising in relation to compliance with these conditions. Health conditions
For a period of 2 years from the date the Tribunal makes a reinstatement order, to attend for treatment by a registered psychologist or registered psychiatrist of her choice, at a frequency to be determined by the treating practitioner. The practitioner is to: a. authorise the treating practitioner to inform the Medical Council of NSW of failure to attend for treatment, termination of treatment or if there is a significant change in health status (including a significant temporary change). b. provide the Council with the professional details of the treating practitioner.
For a period of 2 years from the date the Tribunal makes a reinstatement order, to attend for treatment by a registered General Practitioner of her choice. The frequency of the treatment is to be determined by the treating practitioner. The practitioner: a. is to authorise the treating practitioner to inform the Medical Council of NSW of any of the following i. failure to attend for treatment, or ii. termination of the treatment, or iii. a significant change in health status (including a significant temporary change) b. must provide the Medical Council of NSW with the professional details of the treating practitioner Review of conditions
Dr Meneghetti may apply to the Medical Council of NSW for the alteration or removal of one or more of the above conditions not before the expiration of 12 months from the date of recommencement of practice. The Medical Council of NSW, if satisfied, may alter or remove any of the conditions. Notations A. The Medical Council of NSW is the appropriate review body for the purposes of Part 8, Division 8 of the Health Practitioner Regulation National Law (NSW). B. Sections 125 to 127 of the Health Practitioner Regulation National Law are applicable while the practitioner's principal place of practice is anywhere in Australia other than New South Wales, so that a review of these conditions may be conducted by the Medical Board of Australia. 1. The Applicant pay the costs of the Medical Council as agreed or assessed.

Meneghetti v Medical Council of New South Wales

At a glance

Court

Decision date

Source

Judgment (23 paragraphs)

Parties

Legislation Cited (2)

Cases Cited (4)