1. On 21 September 2012 the respondent was working as a midwife at the Mount Barker District Soldiers' Memorial Hospital (the Hospital). She was employed by Country Health SA. She was assigned to care for a patient who was admitted to the labour ward at about 1055 hours for the birth of her baby. We will refer to the mother as AB and the baby as "infant AB".
2. AB was proceeding with a birth in water and had a history of precipitous births. This birth was again precipitous.
3. Dr PS was rostered to attend mothers in labour at the Hospital on 21 September 2012. He was present at AB's admission and provided treatment to her. He left the Hospital but remained on call to be notified when birth was imminent. The respondent was aware of the need to contact Dr PS.
4. The respondent failed to notify Dr PS at any time before the baby was born. The respondent was accompanied by a student nurse but continued to care for AB without the attendance of another registered midwife or medical practitioner.
5. The respondent concedes that it was contrary to the policy of the Hospital to not have a second qualified person present to assist at the time of the birth. It appears that this policy was not reduced to writing and may not have been universally enforced. However, the respondent ought to have called Dr PS. She exercised poor judgement in not doing so, and in not seeking alternative qualified assistance when Dr PS was not present. However, the real gravamen of the respondent's conduct lies in what occurred after birth.
6. Infant AB was born at approximately 1505 hours. At birth the infant was unresponsive and not breathing with the cord wrapped around his body and neck twice. The respondent failed to take the required emergency action.
7. Professional practice requires that within no more than 30 seconds of non-responsiveness, the cord must be cut and neonatal resuscitation commenced. The respondent did not do this until more than two minutes after the infant's birth.
8. The respondent delayed cutting the cord. She allowed the cord and placenta to remain in situ. She wrongly took comfort from the fact that the cord was pulsating. She then placed the infant on AB's chest and asked her to blow gently on the infant. This had no effect. She then attempted to stimulate the infant's breathing by rubbing with a towel. This had no effect. The respondent then used a bag and mask hand set to instil air into the infant's lungs whilst the cord remained uncut and the infant was still on AB's chest. This had no effect and the infant remained not breathing. It was only at this point that the student midwife cut the cord and the infant was transferred to a resuscitation trolley for resuscitation.
9. The student nurse obtained the assistance of a medical practitioner, Dr CB, who fortuitously happened to be in the area. Dr CB commenced emergency resuscitation on the infant who was still not breathing and had a zero heart rate. The infant responded to resuscitation 1 minute 26 seconds after commencing resuscitation and some four minutes after birth.
10. The respondent admits that her actions were contrary to accepted post-partum midwifery and medical practice and to the policy of the hospital. There is no doubt that her failure to follow well-accepted protocols placed the infant at significant risk of serious harm or loss of life.
11. The respondent's conduct fell substantially short of the standard to be expected of a midwife of her training and experience. It constitutes serious professional misconduct.
12. After resuscitation the infant had difficulties breathing autonomously and required oxygen and special observations until about 0400 hours the following day. The evidence suggests that the infant suffered no long-term effects from the incident. This was fortunate, given the great risk at which the infant was placed by the respondent's conduct.

1. On 2 December 2012 the respondent was rostered as a midwife in the labour ward of the Hospital. She was assigned to care for a patient who was admitted for the birth of her baby. We shall call this patient CD.
2. CD was attempting to have her baby vaginally despite having had a previous caesarean section (VBAC). VBAC carries additional risks for the mother, namely risk of uterine rupture of the scar from the previous caesarean or bleeding complications.
3. CD's birth was to be a "medical birth", under the care and supervision of her treating medical practitioner, Dr KA. Dr KA arranged for an epidural to be administered by an anaesthetist at CD's request.
4. At about 1475 hours the respondent was attending CD and CD's partner and mother were also present. The patient's mother was an experienced midwife. The patient was complaining of right hip pain. The respondent observed CD's abdomen and expressed the view to those present that the baby was "asynclitic" and lying to the left and that the right hip pain was related to the baby's position.
5. The respondent then, without any adequate preparation or explanation to CD or the others present, commenced to manipulate the abdomen with her hands on each side of CD's abdomen and pushed and pulled on each side of it, in opposite directions. These manoeuvres were performed in repeated fashion over the course of some 3-5 minutes. The pressure applied to CD's abdomen was strong and caused concern to CD and those present. It caused discomfort to CD. Following the manoeuvres, CD complained of increased hip pain.
6. It is admitted that no adequate information, explanation of risks, or opportunity to consent was given to CD. CD did not give informed consent to the manoeuvres. The respondent performed these manoeuvres without consulting the treating medical practitioner or any other appropriate person.
7. The manual manipulation of the patient's abdomen, in the near vicinity of her pre-existing uterine scar and the foetus, involved unnecessary and unacceptable risks of scar rupture and harm to the mother and foetus. The manipulation ought not to have been attempted. Indeed, the complaint of hip pain may possibly have been an indicator of a problem with the uterine scar, a matter that requires expert medical assessment.
8. It is admitted that the manoeuvres were beyond the respondent's scope of practice, of no utility, and did not represent treatment acceptable for competent midwives or medical practitioners during the labour of a mother attempting VBAC. They constituted a failure to abide by the Perinatal Practice Guidelines. They placed the mother and foetus at unnecessary risk of serious harm.
9. It is also admitted that the respondent failed to adhere to the analgesic medication regime prescribed for CD by Dr KA, failed to make adequate entries in the medical records, and failed to carry out a vaginal examination in an effective way.
10. The Tribunal finds that the respondent exposed CD and her baby to significant and unnecessary risk by performing actions that were beyond her scope of practice, of no utility, and contra-indicated. The respondent failed to seek or obtain informed consent and failed to consult Dr KA who was the medical practitioner responsible for the patient and the prospective birth. The Tribunal finds that the conduct of the respondent on 2 December 2012 was substantially below the standard to be expected of a midwife of her training and experience. The behaviour of the respondent constitutes serious professional misconduct.

1. On 10 June 2015 the respondent was rostered as a registered nurse in the Recovery Unit ward at the Hospital. At about 1000 hours a patient (whom we will refer to as EF) was brought to the ward from theatre after undergoing a right total hip replacement operation. EF had a history of cardiovascular disease and previous deep vein thrombosis.
2. The anaesthetist attending the patient prescribed (in writing) intravenous fluids for the patient, namely:

(a) immediate intravenous infusion, volume 1000 millilitres over the following 8 hours (ie at the rate of 125mls per hour); and

(b) thereafter, a slower rate of infusion of a further 1000 millilitres of fluids over 18 hours.

1. At about 1118 hours the respondent unilaterally reduced the flow rate for the intravenous fluid for the patient to 80 mls per hour. The respondent had no authority to do this. It is admitted that there was no justifiable, explicable, or valid reason for the respondent to have reduced the rate without first seeking approval from the anaesthetist or another suitably qualified medical practitioner. The respondent failed to notify the anaesthetist or any treating doctor of the action she had taken.
2. In so acting, it is admitted that the respondent acted beyond her scope of practice and contrary to the Country Health SA Local Health Network Medication Administration for Patients in Acute Facilities Policy.
3. The Tribunal finds that the respondent's conduct on this occasion constitutes unsatisfactory professional performance.

1. In late 2015 the respondent was to return to midwifery duties at the Hospital after a period when she was rostered only as a registered nurse. The evidence suggests that she had not practiced in midwifery at the Hospital since December 2012,[3] although she appears to have conducted a private practice in midwifery during that time. It was arranged that she would attend the Gawler Health Service for a "supported re-introduction" to midwifery. She so attended on several days between October 2015 and January 2016.[4] This attendance was initially put forward to the Tribunal as evidence of the respondent up-skilling herself in midwifery practice. However, that submission was challenged, and the submission was withdrawn. The Tribunal indicated that it might be useful to have any documentation concerning the respondent's attendance at the Gawler Health Service and we were eventually provided with relevant documentation by consent.[5]
2. Having reviewed the documentation, we make the following comments. The respondent provided a written reflection following the placement. This document suggests that the respondent regarded it as humiliating for someone of her "extensive qualifications, proven midwifery skills and known history of quality care given to women" to be subjected to this re-introduction programme.[6] In a paragraph entitled "Learning from reflection", the respondent did not identify any area of learning in which she had been assisted.[7] Exhibit X1 contains an email dated 13 January 2016 from the Clinical Services Coordinator Midwifery Services at Gawler Hospital to Michael Davis of Department of Health. It suggests that:

Karen and I believe the conditions agreed at the meeting - evidence of safe practice, working with knowledge and understanding of CHSA policies and protocols, perinatal practice guidelines and the scope of a practising registered midwife employed by CHSA has been achieved.

However, a further document from the same author, also contained in exhibit X1, responds to the respondent's reflection. The author suggests that the respondent's comments:

... indicate this lack of understanding for the rationale behind orientation, education, safe practice, resources and equipment when entering a new working environment.

The author further states that the tenor and language used by the respondent in her document

represents an independent approach to her management and care and not a recognition of the actual indication for care and acceptance of processes, safe practice (as per the Perinatal Practice Guidelines) and CHSA policies and procedures.

Given the respondent's attitude, we think it unlikely that much was achieved by this programme. We certainly could not regard the programme as satisfactorily addressing any concerns arising from the previous professional misconduct.

1. In her reflection, the respondent related an alleged conversation with a midwife at the Gawler Health Service. She did so to assert (by implication) that the Gawler Health Service condoned and encouraged the type of manipulation that she had carried out on patient CD. We were provided with a response to this assertion from the CSC Midwifery of the Health Service[8] and we are satisfied that that Service has in no way condoned or encouraged the use of such techniques in the circumstances that applied to CD. The respondent had reported a conversation, inaccurately and out of its proper context, in an attempt to justify her own erroneous views.

The Respondent's Professional Qualification and Experience

1. The respondent tendered to the Tribunal a copy of a letter to the Tribunal dated 26 May 2020, incorporating her CV.[9] She completed a degree in nursing in 2003. From February 2004 she worked as a registered nurse. She completed a degree in midwifery in 2008. From 2008 to 2009 the respondent worked firstly in the graduate programme and then as a midwife at the Lyell McEwin Hospital and Women's and Children's Hospital. As well as further studies in Child and Family Health Nursing and Anaesthetics/Recovery, the respondent completed a Master of Midwifery in 2011.
2. From December 2009 to August 2018, she worked at the Hospital at Mount Barker, but also conducted a "private practice" as an "independent midwife".
3. This private practice is described in the CV as follows:

Current- 'Oracle of Life ... Your Midwife' - independent Midwife

Full spectrum of Midwifery care - an autonomous practitioner I am the sole care provider for women during the antenatal, intrapartum and postnatal period. I feel sure you would understand the complexity and high level midwifery skills required for this role

1. From 2018 to current the respondent has worked primarily as a midwife for a Rural & Remote Recruitment Agency and has had placements at Toowoomba, Innisfail, Dalby, Sale, Cooktown, Mackay, and Esperance. Overall, these placements are described as involving "Culturally sensitive - self-directed Midwifery Practice - full continuum of Midwifery care".
2. In her letter to the Tribunal, the respondent states:

My midwifery skills are inclusive of both high risk and low risk women. Areas of practice include Post Natal, NICU, Antenatal Clinic and Birthing Suite. My notation as Eligible Midwife, endorsed to prescribe has enabled me to practice autonomously in independent practice at a much higher level of responsibility, demonstrating my ability to provide high-level women care throughout the whole care continuum.

1. The CV refers to other skills and training completed by the respondent. We take note of these matters. We also note that the respondent had only been working as a registered midwife for about 4-5 years at the time of the 2012 incidents. It appears that only the first year after registration was at a major teaching hospital.

1. The Board submitted that the Tribunal should impose a suspension of the respondent's registration as a midwife for a period of 9 to 12 months. It submitted that conditions should be imposed on such registration requiring the respondent to undertake further education and to be subject to supervision in her practice as a midwife. The respondent should also be reprimanded "in the strongest terms".
2. The Board provided a proposed schedule of conditions for the Tribunal's consideration. These conditions reflect a clear view on the part of the Board that the respondent is not fit to practise in an unrestricted way, but the Board did not otherwise submit that she was presently unfit to be registered. It was submitted that the suspension was necessary to bring home to the respondent the seriousness of her conduct, to assure the public that standards were being maintained and to provide specific and general deterrence.
3. As to the respondent's registration as a nurse, the Board submitted that a reprimand should be imposed for the conduct occurring on 10 June 2015. It was further suggested that conditions be imposed requiring her to complete education. It was not suggested that the respondent be suspended from practising as a registered nurse.

1. The respondent opposed any suspension of her registration. Her counsel pointed to the lapse of time since 2012. He pointed out that the Board had allowed the respondent to practise unrestricted during that time. This demonstrated, it was submitted, that there was no need to protect the public. Counsel pointed to the lack of any submission from the Board that the respondent was currently unfit to be registered.
2. Counsel submitted that the appropriate disciplinary action for the 2012 events would be a strong reprimand. There should also be a period of mentoring and the Tribunal may wish to consider whether the respondent should be required to undertake further education.
3. The respondent opposed any condition that she be required to be supervised in her practice. It was submitted that such a condition would effectively make her unemployable.
4. As to the incident in June 2015 the respondent submitted that there should be a reprimand.

1. The Board was unable to provide any adequate explanation for the lapse of time since the serious incidents of professional misconduct occurring in 2012. The fact that the respondent repeatedly denied any deficiency in her practice does not adequately explain inaction or delay for so many years. The lack of effective action by the Board over a long period of time is difficult to understand in the light of the submissions now made.
2. However, the task of this Tribunal is to come to the correct or preferable outcome. The paramount objective is the protection of the public. Regardless of any inconsistency in the approach of the Board, the Tribunal must now do what is appropriate and necessary to protect the public.
3. Delay (or lapse of time) since the conduct in question is, of itself, of little or no relevance to the Tribunal's task in imposing disciplinary action. However, what happens during the lapse of time may be of great importance if it reflects on such issues as insight, contrition, rehabilitation, retraining, competence, or fitness to practise.[10] There was initially a submission put on behalf of the respondent that she practised without incident after the event in 2015. It was suggested that the three matters before the Tribunal were the only concerns during her career. Those submissions were challenged and subsequently withdrawn. In those circumstances and given the nature of the respondent's practice since 2012,[11] we do not regard the passage of years as demonstrating the respondent's competence or fitness to practise in the field of midwifery.
4. We have described both incidents in 2012 as constituting serious professional misconduct. In the first incident, the life of a new-born child was placed at significant risk due to the respondent's failure to follow basic accepted protocols. In the second incident, the respondent placed the mother and unborn child at significant unnecessary risk due to her actions.
5. For a very long time the respondent disputed the allegations of misconduct. She attempted to justify her actions in both incidents. Despite being provided with clear written opinions from highly qualified experts, she appeared to have no insight into the deficiencies of her practice. This remained the case until the end of day two of the contested hearing.
6. Her counsel has submitted that she eventually attained insight into her conduct whilst listening to the evidence of Ms Coffey on day two of the hearing. Ms Coffey is a highly regarded senior practitioner. However, Ms Coffey's evidence related only to one aspect of the complaint, namely the care of patient CD. Ms Coffey's views about this aspect had previously been made quite clear in reports dated 17 January 2013[12] and 23 April 2019.[13] The brief oral evidence given by Ms Coffey before adjourning at the end of day two may have added to a feeling on the part of the respondent that the hearing was not going well for her, but it was highly unlikely to have produced genuine insight into the totality of matters that had been firmly disputed over many years. We consider that there was likely to be more pragmatic considerations behind the respondent's change of position. We note that the respondent has still provided no explanation to the Tribunal as to why she engaged in the acts of professional misconduct or why she seemingly had no insight into the deficiencies of her conduct for so many years. The evidence of Ms Coffey was given in August 2019 but there was no suggestion at the final hearing in May 2020 that the respondent had since taken any remedial action based on the insight then acquired. The Tribunal remains unpersuaded as to the degree of insight that the respondent now has. The respondent did not give evidence on this issue even though it was clearly raised in submissions and by the Tribunal.
7. The letter and CV provided to the Tribunal by the respondent in May 2020 suggests that she regards herself as a highly skilled and competent practitioner of midwifery. That claim stands at odds with the serious professional misconduct and her failure over many years to have insight into obvious and fundamental deficiencies. The letter provided to the Tribunal in May 2020 does not acknowledge her deficiencies (as admitted in the "Respondent's Admissions and Statement of Agreed Facts"). There is no indication in the letter of insight or contrition. The letter makes claims of high-level competency without attempting to reconcile such claims in any way with the admitted conduct or her subsequent attempts to defend it. AB could well have lost her child due to the failings of the respondent, but the respondent has not uttered a word of concern or contrition about that in these proceedings. Despite the formal admissions, the Tribunal is not satisfied that the respondent truly acknowledges the extent of the demonstrated deficiencies in her practice or the need to address such deficiencies.
8. The events in 2012 give rise to a concern that the respondent, who in 2012 had practised as a registered midwife for 4-5 years, preferred to follow her own views where they differed from established protocols and policies.[14] The subsequent lack of insight in the period up to the hearing heightens this concern. Such concern has not been adequately addressed by the materials put before the Tribunal by the respondent. We are not satisfied that the respondent would now follow accepted protocols or policies if they differed from her own views.
9. In the absence of:

(a) any adequate explanation for the serious deficiencies exhibited in 2012,

(b) any evidence that such deficiencies have been adequately addressed, or

(c) any explanation for the lack of insight during subsequent years,

we have considerable concern regarding the nature of the respondent's current practice. It appears that she markets herself as a completely autonomous practitioner of midwifery and that her current practice is largely self-directed and carried out at rural and remote locations. It is likely that vulnerable patients would comprise a significant section of her practice. She claims competency to handle high risk births. She promotes herself as a "sole care provider" for all stages of natal care. All of this suggests that her practice of midwifery is likely to be often largely devoid of effective supervision or scrutiny.

1. The submissions made on behalf of the respondent do not respond adequately, in our opinion, to the serious deficiencies demonstrated by the 2012 incidents. The respondent's proposed disciplinary approach would fall far short of protecting the public.
2. The purpose of disciplinary action is entirely protective and does not involve any element of punishment. The purposes for which disciplinary sanctions may be imposed are discussed in many cases and need not be repeated here.[15]
3. In addition to imposing a reprimand, we consider that a substantial period of suspension, namely 12 months, is necessary to bring home to the respondent the seriousness of her conduct and the extent to which that conduct reflects adversely on her level of competence and performance as a midwife. Such suspension will hopefully bring home to the respondent the need to address her deficiencies and ensure that she practises within accepted standards, policies, and guidelines. It is necessary to make clear to the respondent that departures from such standards will not be tolerated and will be met with substantial sanctions.
4. A significant period of suspension is also necessary to reassure the public that conduct such as occurred in this case will not be tolerated. Standards will be maintained to protect the public. Mothers must be confident when they give birth that registered midwives will provide care that is consistent with accepted standards and protocols and that mothers and infants will not be unnecessarily placed at serious risk by a failure to do so.
5. The suspension will apply to the respondent's registration as a midwife. It will not affect her practice as a registered nurse.
6. The Tribunal also considers that conditions should be imposed on the respondent's registration as a midwife. We intend the conditions to have the following effect:

(A) Before returning to practice as a midwife, the following conditions must be met:

(i) the practitioner must undergo a programme whereby she is mentored by a mentor approved by the Board with respect to the deficiencies identified in this Statement of Reasons and in the Statement of Agreed Facts, including (but not limited to)

• Expected practice in the safe resuscitation of newborns upon birth
• The proper scope of practice of a midwife and nurse and adhering to same
• The importance of consultation and communication with treating medical practitioners, colleagues, and patients
• Record keeping including as to progress, findings, partograms and examination results for mothers and babies immediately prior to and during the three stages of labour,
• Treatment and care of mothers attempting a vaginal birth after previous caesarean section and the risks in such cases
• Obtaining and recording of informed consent.

(ii) Mentoring meetings are to occur on at least six occasions within a period of 12 months and to be for a period of at least two hours on each occasion.

(iii) before commencing the mentoring sessions, the practitioner must prepare a detailed written reflection in relation to the contents of the following documents:

• The Statement of Agreed Facts
• This Statement of Reasons
• The National Guidelines for Consultation and Referral,[16] particularly at s 8 (Labour and Birth) and s 9.2 (Infant postpartum).
• SA Water Birth Policy "First Stage Labour and Birth in Water Clinical Directive"[17]

(iv) the practitioner must provide this reflection to the mentor and to the Board and must discuss the reflection with the mentor to demonstrate her insight, knowledge, understanding and competence with respect to the subject matter of those documents and the issues they identify or address.

(v) the mentor is to report to the Board after every second mentoring session as to the practitioner's participation in the mentoring process and her demonstrated level of insight, knowledge, understanding and competence in the relevant areas.

(vi) the monthly mentoring sessions are to continue (if necessary, beyond the minimum requirement of six meetings) until the mentor is satisfied that such level of insight, knowledge, understanding, and competence is adequate.

(vii) the practitioner must not return to midwifery practice until the mentor has certified that the mentoring programme has been completed.

(viii) the practitioner must not resume practice as a midwife unless she has (within the previous period of 12 months) completed the Newborn Life Support Program (NLS),[18] encompassing both the on-line program and the Face-to-Face Skills Sessions of the NLS, or (if that course is not reasonably available to the practitioner) such equivalent course or courses dealing with safe resuscitation of newborns upon birth as may be approved by the Board. The practitioner must produce proof of satisfactory completion to the Board.

(B) On return to midwifery practice, the practitioner must only practise as a midwife in employment or engagement approved by the Board and at locations approved by the Board.

(C) In each place where the practitioner practices as a midwife, her practice must be supervised by a more senior person (in the organisation) who is a registered midwife. This person must be approved by the Board before practice commences. The supervisor must be able to, and must agree to, oversee and supervise the practitioner's practice of midwifery and confirm that the practitioner's standard of practice is generally of an appropriate standard. This supervisor must report to the Board on the practitioner's standard of midwifery practice every three months and additionally whenever requested by the Board. The supervisor must report immediately to the Board if at any time the practitioner's standard of practice is believed to be deficient.

(D) The practitioner may attend a birth in any location if she is assisting a medical practitioner or an experienced registered midwife who is present throughout and taking primary responsibility for the birth. Otherwise, the practitioner must only attend births occurring at the facility at which she is employed and not at outlying clinics where there is no more senior health practitioner on-site.

(E) The conditions referred to in paragraphs (B)-(D) are intended to operate for a period of nine months of midwifery practice (during which the practitioner demonstrates competent practice) but will continue in force until the Board determines that they are no longer necessary.

(F) Any costs associated with the conditions are to be borne by the practitioner.

1. As to the respondent's conduct in 2015, the Tribunal will impose a reprimand.
2. The Tribunal will also impose a condition on the respondent's registration as a registered nurse, requiring her to complete within 12 months a course approved by the Board in relation to management of medications and compliance with medication orders. The respondent must provide to the Board proof of successful completion. Once again, any costs associated with the condition will be the responsibility of the respondent.

1. As to the incidents in 2012, the Tribunal will impose the following disciplinary orders:

(b) the registration of the respondent as a midwife is suspended for a period of 12 months

(c) conditions will be imposed on the respondent's registration as a midwife as indicated above.

1. As to the incident in 2015, the Tribunal will impose the following disciplinary orders:

(b) conditions will be imposed on the respondent's registration as a registered nurse as indicated above.

1. Subject to any submissions to the contrary, the Tribunal will also make an order pursuant to s 60 of the SACAT Act prohibiting the publication of the names of, or any material tending to identify, the patients who are the subject of the allegations contained in the complaint.
2. The Tribunal invites the parties to confer concerning the drafting of the conditions foreshadowed in these Reasons. The Tribunal invites the parties to submit within 14 days:
   • Agreed wording of the conditions to be imposed (without prejudice to the parties' rights of appeal); and/or
   • Submissions as to the precise wording of the proposed conditions and as to the relevant review periods, and as to the issue of costs
   • Submissions (if any) as to the proposed order under s 60 of the SACAT Act.
3. In the absence of agreement between the parties, the Tribunal may determine outstanding issues on the basis of the written submissions or may list the matter for a short hearing for submissions on such matters.

On 9 October 2020 the Tribunal made the following further decision and orders:

1. The Tribunal published a Statement of Reasons in this matter dated 5 August 2020. The full findings of the Tribunal are contained in that Statement.
2. At our invitation, the parties then provided joint submissions as to the drafting of conditions foreshadowed in our Statement of Reasons. The proposed conditions differed significantly from the Statement of Reasons and, in the view of the Tribunal, may have operated in a way that was not intended by the Tribunal. The Tribunal redrafted certain aspects. The Registry wrote to the parties on 30 September 2020 with a draft of the proposed amended conditions. The parties were given until Tuesday, 6 October 2020 to indicate whether there was any perceived difficulty arising from the proposed conditions. An extension was granted until 12 noon on Friday 9 October 2020. Neither party has provided any further submissions by that deadline, albeit that the respondent has (after the deadline had passed) asked for a further extension to take instructions.
3. The Tribunal is not prepared to delay the matter further.
4. As to the incident occurring on 21 September 2012, the respondent has behaved in a way that constitutes professional misconduct.
5. As to the incident occurring on 2 December 2012, the respondent has behaved in a way that constitutes professional misconduct.
6. As to the incident occurring on 10 June 2015, the respondent has behaved in a way that constitutes unsatisfactory professional performance.
7. It is appropriate to impose the disciplinary sanctions as set out below.
   1. As to the incident occurring on 21 September 2012, the Tribunal decides pursuant to s 196(1) of the National Law that the respondent has behaved in a way that constitutes professional misconduct in her capacity as a registered midwife.
   2. As to the incident occurring on 2 December 2012, the Tribunal decides pursuant to s 196(1) of the National Law that the respondent has behaved in a way that constitutes professional misconduct in her capacity as a registered midwife.
   3. As to the incident occurring on 10 June 2015, the Tribunal decides pursuant to s 196(1) of the National Law that the respondent has behaved in a way that constitutes unsatisfactory professional performance in her capacity as a registered nurse.
   4. In respect of the respondent's registration as a registered midwife and the professional misconduct referred to in paragraphs 1 and 2 immediately above, the Tribunal imposes the following disciplinary action pursuant to s 196 of the National Law:

(b) The respondent's registration as a registered midwife is suspended for a period of 12 months from the date of this order;

(c) Conditions, as set out in Attachment A to this Order, are imposed on the respondent's registration as a registered midwife. (In these conditions the respondent is called "the practitioner" and the complainant is called "the Board").

(d) The Tribunal fixes a review period of 12 months (from the date of this order) for the conditions.

1. In respect of the respondent's registration as a registered nurse and the unsatisfactory professional performance referred to in paragraph 3 immediately above, the Tribunal imposes the following disciplinary action pursuant to s 196 (2) of the National Law:

(b) Conditions, as set out in Attachment B to this Order, are imposed on the respondent's registration as a registered nurse. (In these conditions the respondent is called "the practitioner" and the complainant is called "the Board");

(c) The Tribunal fixes a review period of 12 months (from the date of this order) for the conditions.

1. The respondent is to pay the complainant's costs of and incidental to these proceedings in the agreed amount of $7,500.00, payable in twelve equal monthly instalments commencing on 1 October 2020 and thereafter payable on the first day of each following month.
2. Pursuant to s 60 of the SACAT Act, the Tribunal prohibits the publication of the names of, or any material tending to identify, the patients who are the subject of the allegations contained in the complaint.

Conditions attaching to the Practitioner's Midwifery registration NMW0001488061

1. The Practitioner must not practise as a Midwife during the period of suspension other than for the purposes of completing the education and mentoring as outlined in the following conditions.

For the purposes of this condition, 'practise' and "practice" are each defined as any role, whether remunerated or not, in which the individual uses their skills and knowledge as a Midwife in their profession. It is not restricted to the provision of direct clinical care and includes using the knowledge and skills of a Midwife in a direct non-clinical relationship with a client, working in management, administration, education, research, advisory, regulatory or policy development roles and any other roles that impact on safe, effective delivery of services in the Midwifery profession.

1. Within 3 days of the notice of the imposition of these conditions, the Practitioner is to provide the following, on the form provided (HPF18), to Ahpra:
   • 2.1 acknowledgement that the Practitioner has read and understood the definition of 'practise' and "practice" as it pertains to this condition;
   • 2.2 the details of the Director of Nursing/Midwifery (the senior person at each and every place the Practitioner was practising immediately prior to the imposition of this condition;
   • 2.3 acknowledgement that Ahpra may notify the senior person as outlined in paragraph 2.2 of the imposition of this condition.

1. Prior to applying for approval of a practice location in accordance with condition 15 below, the Practitioner must be successfully mentored by another registered midwife first approved by the Board in relation to the deficiencies identified in this Tribunal's Statement of Reasons dated 5 August 2020 ("Reasons") and in the Statement of Agreed Facts filed in SACAT proceedings 2019/SA002904 and referred to in the Reasons ("Statement of Agreed Facts"), including (but not limited to)

(a) expected practice in the safe resuscitation of newborns upon birth

(b) the proper scope of practice of a midwife and nurse and adhering to same

(c) the importance of consultation and communication with treating medical practitioners, colleagues, and patients

(d) record keeping including as to progress, findings, partograms and examination results for mothers and babies immediately prior to and during the three stages of labour,

(e) treatment and care of mothers attempting a vaginal birth after previous caesarean section and the risks in such cases

In these conditions this mentoring requirement is called "Mentoring Program".

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

1. The Practitioner must not return to midwifery practice until the Mentor has certified that the Mentoring Program has been successfully completed

1. The Mentoring Program must comprise a minimum of six (6) sessions with each session being of two hours duration and all must take place within a period of no greater than 12 months.

1. Before commencing the Mentoring Program, the Practitioner must prepare and provide to the mentor and the Board a detailed report, demonstrating that the Practitioner has reflected on the matters in 6(a) -(d) below and how the Practitioner's conduct in these proceedings fell substantially below the accepted standards of midwifery practice and led to the imposition of these conditions and how she will incorporate the lessons learnt into the Practitioner's midwifery practice upon her return to same. The report must cover the contents of the following documents:

(c) the National Guidelines for Consultation and Referral, particularly at sections 8 (Labour and Birth) and 9.2 (Infant postpartum);[19]

(d) SA Water Birth Policy "First Stage Labour and Birth in Water Clinical Directive"[20]

The practitioner must discuss this report with the mentor to demonstrate her insight, knowledge, understanding and competence in respect to the subject matter of those documents and the issues they identify or address.

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

1. Within 21 days of the notice of the imposition of these conditions the Practitioner must provide to Ahpra, on the approved form (HP16), acknowledgement that Ahpra may seek reports from the approved mentor ("Mentor") on any or all of the following occasions:

(a) every two months or after every other mentoring session whichever is greater;

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

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

(d) when otherwise requested by Ahpra or the Board.

1. Each of the Mentor's reports must include the Mentor's assessment of the Practitioner's participation in the Mentoring Program and as to her level of insight, knowledge, understanding and competence in the areas described in condition 3 (a)-(f ) and condition 6 (a)- (d) above.

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

1. Within 30 days of the conclusion of the Mentoring Program, the Practitioner must provide a report demonstrating, to the satisfaction of the Board, that the Practitioner has reflected on the issues that gave rise to the condition requiring they attend the Mentoring Program and outlining how the Practitioner has incorporated the lessons learnt in the Mentoring Program into her practice.

Undertake education in midwifery

1. In the twelve months prior to applying for approval of a practice location in accordance with condition 15 below, the Practitioner must undertake and successfully complete the Newborn Life Support Program ("NLSP") or (if that programme is not reasonably available to the practitioner) another equivalent program of education dealing with safe resuscitation of newborns at birth, approved by the Nursing and Midwifery Board of Australia.

1. Within 30 days of the notice of the imposition of these conditions, the Practitioner must, on the approved form (HPN24), nominate for approval by the Board an education course, assessment or program, whether the NLSP or an equivalent education program ("the Midwifery Education'), addressing the topics required by condition 12. The Practitioner must ensure that:

(a) the nomination includes a copy of the curriculum of the education.

(b) the education consists of the NLSP online program and face to face skills session(s) or the equivalent.

1. The Practitioner must provide evidence to Ahpra of the successful completion of the Education before applying for the approval of a practice location in accordance with condition 15.

1. Save for the exception in condition 16 below, the Practitioner may practise midwifery only in or at a place of practice approved by the Board, being a place where the Board considers that there is adequate on-site supervision and scrutiny of the Practitioner's performance. To this end, the Practitioner's practice of midwifery must be limited to geographical locations which have been approved.

For the purposes of this condition, "practise" is defined as any role, whether remunerated or not, in which the individual uses their skills and knowledge as a Midwife in their profession. It is not restricted to the provision of direct clinical care and includes using the knowledge and skills of a Midwife in a direct non-clinical relationship with a client, working in management, administration, education, research, advisory, regulatory or policy development roles and any other roles that impact on safe, effective delivery of services in the Midwifery profession.

For the purposes of this condition, the following practice locations have been approved: Nil.

1. Notwithstanding condition 15 above, the Practitioner may (in the course of, and for the purposes of, her employment at an approved place of practice) practise midwifery at any location whilst working under the direct personal supervision of an experienced registered midwife who is present and taking primary responsibility for the provision of care.

1. Within 21 days of notice of a place of practice being approved by the Board, the Practitioner must provide to Ahpra, on the approved form (HP7), acknowledgement that Ahpra may:

(a) seek reports from the Director of Nursing/Midwifery (the senior person) at each place of practice on at least a 3 monthly basis or as otherwise required;

(b) request and access from the senior person at each place of practice copies of rosters, pay slips, or the equivalent;

(c) have contact with and access information from, where relevant, Medicare, private health insurers and/or practice billing data.

1. Within 21 days of notice of a place of practice being approved by the Board, the Practitioner must provide to Ahpra, on the approved form (HPS7), acknowledgement from the senior person at each place of practice that they are aware Ahpra will seek reports from them.

1. Upon return to midwifery practice at a place approved by the Board, the Practitioner must be supervised by a more senior person in the organisation who is a registered midwife (the Supervisor) who is in a position to generally oversee and assess the practitioner's standard of practice as a midwife and who agrees to take on that role and to report to the Board concerning such standard of practice.

For the purposes of this condition, 'supervised' is defined as:

The Practitioner must consult with the Supervisor who must be generally available to observe and discuss the management of patients and/or performance of the Practitioner when necessary and otherwise at regular intervals.

1. Within 21 days of notice of a place of practice being approved by the Board, the Practitioner must, on the approved form (HPN10), nominate a primary supervisor and at least one alternate supervisor to be approved by the Board. The Practitioner must ensure that each nomination is accompanied by an acknowledgement, on the approved form (HPNA10), from each nominated supervisor that they are willing to undertake the role of supervisor and are aware that Ahpra will seek reports from them.

1. In the event that no approved Supervisor is willing or able to provide the supervision required the Practitioner must cease practice immediately and must not resume practice until a new supervisor has been nominated by the Practitioner and approved by the Board.

1. Within 21 days of notice of a place of practice being approved by the Board, the Practitioner is to provide to Ahpra, on the approved form (HP10) acknowledgement that Ahpra may:

(a) obtain information from relevant authorities (such as but not limited to Medicare)

(b) obtain information and/or a report from the senior person at each place of practice on a three monthly basis, and

(c) obtain a report from the approved Supervisor on a three monthly basis.

1. Within 21 days of notice of a place of practice being approved by the Board, the Practitioner is to provide to Ahpra on the approved form (HPS10), acknowledgement from the senior person at each place of practice that Ahpra may seek reports from them.

1. Conditions 19 -23 are to remain in force until:
   • 24.1 The Board is satisfied that the practitioner has substantially practised in the area of midwifery for a total period of at least 9 months since the imposition of these conditions; and
   • 24.2 The Supervisor has certified, and the Board is satisfied, that the Practitioner has continuously demonstrated competence in all facets of midwifery practice.

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

1. The review period for these conditions is 12 months.

1. All costs associated with compliance with these conditions are to be the responsibility of the practitioner.

Conditions attaching to the Practitioner's nursing registration NMW0001339601

Undertake education in nursing

1. The Practitioner must undertake and successfully complete a program of education, approved by the Board and including a reflective practice report, in relation to management of medications and compliance with medication orders.

1. Within 30 days of the notice of the imposition of these conditions, the Practitioner must, on the approved form (HPN24), nominate for approval by the Board an education course, assessment or program ("the Nursing Education") addressing the topics required. The Practitioner must ensure that:

(a) the nomination includes a copy of the curriculum of the Nursing Education; and

(b) the Nursing Education consists of a minimum of six hours undertaken over no more than 12 months.

1. Within 30 days of the completion of the Nursing Education, the Practitioner is to provide:

(a) evidence of successful completion of the Nursing Education; and

(b) a report demonstrating, to the satisfaction of the Board, that the Practitioner has reflected on the issues that gave rise to this condition requiring that they undertake the Nursing Education and how the Practitioner has incorporated the lessons learnt in the Nursing Education into the Practitioner's practice.

1. The review period for these conditions is 12 months.

1. All costs associated with compliance with these conditions are to be the responsibility of the practitioner.

[1] The National Law is found in Schedule 2 to the Health Practitioner Regulation National Law (South Australia) Act 2013 (the Act). Pursuant to s 4 of the Act, the National Law forms part of the law of this jurisdiction.

[2] See s 6 of the Act and the Statutes Amendment (SACAT) Act 2019 s 112.

[4] We note that this did not occur in 2017 as had been put to us in submissions on behalf of the respondent.

[10] HCCC v Litchfield [1997] NSWSC 297, (1997) 41 NSWLR 630 at 637; Craig v MBSA [2001] SASC 169; (2001) 79 SASR 545 at [61]; cf. MBA v Lee [2019] SACAT 72 at [57] and MBA v Konidaris [2019] SACAT 52 at [48] - [50].

[14] The event in 2015, whilst far less serious, reflects a similar attitude in relation to general nursing.

[15] Craig v MBSA [2001] SASC 169; (2001) 79 SASR 545; NMBA v Symons [2020] SACAT 8 at [50]- [51]; PBA v Bryant [2018] SAHPT 22 at [41]; MBA v Singh [2017] WASAT 33 (S) at [23] - [30]; CMBA v Zhou [2020] SACAT 23 at [76] - [78].

[16] Published at https://www.midwives.org.au/resources/national-midwifery-guidelines-consultation-and-referral-3rdedition-issue-2-2014.

[17] Published at https://extapps2.sahealth.sa.gov.au/PracticeGuidelines/.

[18] Refer to the Perinatal Emergency Education Strategy published at hppts://extapps2.sahealth.sa.gov.au/Practice Guidelines/. The NLS online program can be accessed at http://digitalmedia.sahealth.sa.gov.au.

[19] Published at https://www.midwives.org.au/resources/national-midwifery-guidelines-consultation-and-referral-3rdedition- issue-2-2014

[20] Published at https://extapps2.sahealth.sa.gov.au/PracticeGuidelines/