The decision of the respondent dated 21 April 2016 (and conveyed to the applicant on 13 May 2016) to refuse registration under section 82(1)(c)(i)(E) of the Health Practitioner Regulation National Law (Vic) Act 2009 is affirmed.

1. Dr Rein has previously held registration in nursing in Victoria, New South Wales and New Zealand. Her Division I and Division III Registrations (as they were then described) were cancelled by the Victorian Nursing Council on 10 July 1991. At that time, the Council decided that any application for restoration of her registration would need to be supported by evidence of continuing medical treatment over a minimum period of two years. Since that time, Dr Rein has applied on various occasions for registration as a nurse. On each occasion her application for registration has been refused and various appeals, two of which involved this Tribunal, have been unsuccessful.
2. On 15 May 2003, the Health Committee of the Nursing Council of New Zealand also suspended Dr Rein's licence with the condition that she undergo further psychiatric assessment. That suspension was upheld in 2006, 2010 and 2011. On 11 May 2012, the District Court at Wellington confirmed the decision not to revoke Dr Rein's suspension.
3. The following passages, extracted from the reserved judgement of Judge SM Harrop, provide a succinct, neutral, background history.

[1] Dr Rein, who is now 65, is highly qualified. She not only holds nursing qualifications and registration but also has a medical degree, a law degree and a BSC (sic) honours in psychology. She was first registered as a nurse in New Zealand in August 1969 but her last practising certificate here expired in March 2003. She has lived for many years in Australia. After working for a while in South Australia she obtained registration with the Victorian Nursing Council in about 1985 but did not work as a nurse after 1990 because her registration had lapsed through nonrenewal of her practising certificate. She made various applications for a practising certificate during the 1990s which were all unsuccessful despite several appeals. An appeal against a February 2000 decision again to decline registration was heard by Judge Duggan of the Victorian Civil and Administrative Tribunal with whose lengthy and helpful judgement I have been supplied. That appeal was also unsuccessful. Judge Duggan concluded that she had for many years suffered from a mental illness, at least a personality disorder, which continued significantly to impair her capacity to practice (sic) as a registered nurse. For these reasons, Dr Rein has not practised as a nurse since at least November 1989, more than 22 years ago.

[2] Following this, in 2003, the Queensland Nursing Council advised the Nursing Council of New Zealand that it had refused Dr Rein's application to practice in Queensland and a copy of Judge Duggan's judgement was forwarded. Dr Rein met with the Health Committee of the Nursing Council in May 2003 which resolved to suspend her registration and this was later upheld in October 2003 on consideration of a further psychiatric report from Dr David Codyre. The adverse decisions in Australia had also been based on extensive psychiatric evidence. Judge Duggan had concluded that Dr Rein suffered from at least a severe personality disorder with histrionic, narcissistic and paranoid features and noted that up to that time she had refused to undertake a course of proper psychiatric treatment because she was convinced that she did not suffer from any psychiatric illness which required treatment.

[3] In September 2006 the Health Committee reviewed the suspension of Dr Rein's registration and again resolved to uphold it. The Committee agreed to review the suspension if Dr Rein met the conditions in a report from another psychiatrist, Dr Kirzenblat, which included 12 months' psychiatric treatment and compliance with the psychiatrist's treatment plan and recommendations. Dr Kirzenblat had given evidence before Judge Bowman in the Victorian Civil and Administrative Tribunal in April 2006 who heard and rejected a further appeal by Dr Rein against another refusal to grant her registration in Victoria.

[4] In August 2010 the Health Committee once again reviewed the suspension and again resolved to uphold it. There was no appeal against that decision. In 2011 Dr Rein sought a further review of the suspension of her registration. She filed submissions by email on 5, 6, 7 and 8 August 2011 and attended the hearing of the Health Committee on 11 August 2011 by teleconference from Melbourne, where she lives.

[5] The Committee considered all of the psychiatric reports dating back to 2002 and the two Tribunal decisions to which I have referred. More recent medical reports from Dr Ingram and Dr McArdle, both Melbourne consultant psychiatrists, were considered, as well as Dr Rein's comments on them.

[6] In its decision of 25 August 2011, the Health Committee decided that "the suspension in Ms Rein's scope of practice would not be revoked".

1. In summary and conclusion on 11 May 2012 District Court Judge Harrop said:

Having reviewed all of the information carefully, I am satisfied that the Health Committee was entitled to come to the decision it did. More accurately, Dr Rein has not satisfied me that the Health Committee was wrong to reach the conclusion it did on the information before it. I have come to the same decision and it is not changed by Dr Gordon's report or by confirmation from Dr Rein that she is, if readmitted to practice (sic), willing to be supervised for six months.

1. Turning to the present matter, in November 2014, Dr Rein again applied to the Nursing and Midwifery Board (the Board) in Victoria for general registration under the National Law in the health profession of nursing and midwifery. In May 2015, the Board advised Dr Rein that it required her to undergo health assessment under section 80(1)(e) of the National Law.
2. The health assessment did not take place and the application was accordingly treated as withdrawn. Subsequently, on 21 July 2015, Dr Rein resubmitted her application for general registration and advised the Board that she would undergo a health assessment. On 20 August 2015, the National Board decided to require her to undergo the health assessment. On 22 September 2015, and 22 October 2015, Dr Rein attended a health assessment with Associate Professor Anne Hasssett.
3. Associate Professor Hassett provided a report to the board, dated 23 October 2015. The report did not support Dr Rein.
4. On 13 May 2016, the Board notified Dr Rein that it had decided to refuse her application for registration as a registered nurse. The Board identified three reasons for so doing. It found that Dr Rein:
   • (a) Has an impairment that would detrimentally affect her capacity to practise as a registered nurse - triggering the Board's exercise of its power under section 55(1)(a) of the National Law to decide that the she was unsuitable to hold general registration;
   • (b) Has her registration in New Zealand suspended due to a disability which has affected her ability to satisfactorily practise as a registered nurse, such that under section 55(1)(e) of the National Law she is an unsuitable person to hold general registration in Victoria; and
   • (c) Has not met the Board's recency of practice registration standard under section 52(1)(e) of the National Law.
5. Dr Rein appealed to this Tribunal under section 199(1)(a) of the National Law and the matter proceeded before us on 15 August 2016.
6. We heard evidence and submissions from Dr Rein and submissions from the Board. At the hearing the Board maintained its position as articulated above in relation to Dr Rein's registration.

1. Section 31 of the Health Practitioner Regulation National Law (Victoria) Act 2009 (Vic), (the National Law) establishes National Health Practitioner Boards for the various Health Professions including the Board for the Nursing and Midwifery Professions.
2. The functions of the Board include deciding whether to grant or to refuse to grant registration to a health practitioner in the Nursing and Midwifery Professions under section 82 of the National Law.
3. Section 52 of the National Law sets out the eligibility for general registration and relevantly states as follows:

(1) An individual is eligible for general registration if -

(e) the individual meets any other requirements for registration stated in the approved registration standard for the health profession.

1. Section 55 sets out the circumstances in which an individual may be held unsuitable to hold general registration. Relevantly the Board relied on the following:

(1) A national board may decide an individual is not a suitable person to hold general registration in a health profession if -

(a) in the Board's opinion, the individual has an impairment that would detrimentally affect the individual's capacity to practise the profession to such an extent that it would or may place the safety of the public at risk; or...

(e) the individual's registration (however described) in the health profession in a jurisdiction that is not a participating jurisdiction, whether in Australia or elsewhere, is currently suspended or cancelled on a ground for which an adjudication body could suspend or cancel a health practitioner's registration in Australia...

1. The National Law also empowers a Ministerial Council to approve registration standards for members of the health profession. Section 38 requires the Board to develop and recommend to the Ministerial Council, requirements in relation to the nature, extent, period and recency of any previous practise of the profession by applicants for registration. On 27 August 2015, the Australian Health Workforce Ministerial Council approved a Registration Standard: Recency of Practice containing the minimum requirements for recency of practice for enrolled nurses, registered nurses and midwives, effective from 1 June 2016, being that:

Enrolled nurses, registered nurses and midwives will fulfil the recency of practice requirements if they can demonstrate one or more of the following:

• Completion of a minimum of 450 hours of practice within the past five years
• Successful completion of a program of assessment approved by the NMBA
• Successful completion of a period of supervised practice approved by the NMBA

1. This Standard replaced the previous Standard that was effective at the time of the refusal of Dr Rein's application for general registration, the only difference being that the Standard previously required the completion of a minimum of three months full-time equivalent in the profession within the past five years whereas, 450 hours of practice within the past five years is now the requirement.
2. Dr Rein gave evidence that, at the age of 69, she is desperate to utilise her nursing qualifications before she becomes too old to do so.
3. We turn then to a consideration of the issues in dispute.

**(a) Does Dr Rein have an impairment that would detrimentally affect her capacity to practice as a registered nurse? - (**section 55(1)(a) of the National Law).

1. The Board submitted that Dr Rein had a long history of mental health issues which detrimentally affect her capacity to practise as a registered nurse. The Board did not take us to earlier reports, preferring to rely on the most recent report of Associate Professor Hassett, dated October 23, 2015, and the earlier findings of this Tribunal and the New Zealand District Court.
2. Dr Rein contended that she does not have an impairment which would preclude her from nursing.
3. She emphasised that she has not been hospitalised for 10 years, and that there are in existence health assessments which support her position.
4. On 12 April 2010, Dr Nicholas Ingram for example opined:

I think it is possible that Ms Rein may have some personality problems or that in the past she has suffered from a bipolar disorder. However, from the history she has given me today she has been well for at least the last nine years and I did not think there is any evidence of any psychiatric illness at the current time... I can see no psychiatric grounds that would prevent her from working as a nurse.

1. Over the years numerous, (provisional) diagnoses have been made in relation to Dr Rein's health (including schizophrenia, acute psychosis, personality disorder or atypical psychosis with histrionic narcissism as in borderline features, bipolar disorder, underlying personality disorder). There have been varying conclusions reached by health professionals as to whether Dr Rein should be able to return to nursing with or without supervision. Nevertheless the most recent report, obtained for the purposes of the current application, does not support Dr Rein's position.
2. In her Summary and Recommendations Associate Professor Hassett states:

Dr Rein, who is now 69 years old, has accrued an impressive range of qualifications in nursing, medicine, psychology and the law and that is a testament to her intelligence and ability to apply herself in educational pursuits. However, despite her knowledge and skills, Dr Rein's conflicted interpersonal relationships have prevented her from developing a career path in any of the professional areas for which she has trained. Her multiple psychiatric admissions appear to have resulted mainly from her harassing and aggressive behaviour for which she continues to feel vindicated and justified on the basis of being victimised and persecuted, especially by the psychiatric system. Notably, there have been no psychiatric admissions for more than 10 years and Dr Rein's combativeness appears to have attenuated as she has aged. However, her beliefs around being persecuted and her sense of entitlement to engage in aggressive and harassing behaviour remains unchanged.

I concur with previous psychiatric evaluations that have diagnosed Dr Rein with a personality disorder with prominent narcissistic and paranoid features. As to whether she has fulfilled criteria for bipolar disorder in the past, I could not detect significant mood instability in Dr Rein's current presentation. As to whether her persecutory ideas reach delusional intensity, they are, at least, overvalued in nature and some highly improbable. The issue is not so much that Dr Rein has a personality disorder, but the degree to which this is negatively impacted on her interpersonal relationships and, consequently, her capacity to practise in the nursing profession. I consider that this has been quite severe in Dr Rein's case as she lacks empathy, particularly demonstrated by an unwillingness to identify with the feelings and needs of others. As Dr Rein has refused any psychiatric treatment for her personality disorder, which would require long-term psychotherapy, there has been no improvement in her cognitive style, even if her behaviour has modified.

For more than twenty years Dr Rein has dedicated herself to acquiring more qualifications and pursuing recognition of these through legal processes. Unfortunately, through lack of insight she has been unable to modify her persecutory assertions and unrealistic demands when she presents in a legal setting. Her emails to AHPRA staff this year reveal ongoing entrenched persecutory ideation about the Nurse's (sic) Board and psychiatrists.

Dr Rein argues that her completion of a medical internship in India in 2009 and current teaching of IMEs demonstrates that she is capable of working collaboratively with other health professionals. Her preference is to work in a hospital and this would inevitably have to be a relatively junior position given her years away from nursing. From my assessment of Dr Rein and the entitled and angry manner in which she approached AHPRA regarding her application for nursing registration, I consider that she would not be capable of accepting direction, deferring to authority and containing her anger when she disagreed with a colleague or perceived herself unappreciated in her work. I, therefore, consider that Dr Rein has an impairment which would detrimentally affect her capacity to practise as a registered nurse.

1. Before reaching her conclusions, Associate Professor Hassett had regard to the extensive medical and hearings history. She carefully contextualised and examined that history. She then reached her own conclusions having conducted an extensive assessment of Dr Rein.
2. We accepted the report of Associate Professor Hassett.
3. Before giving our reasons for doing so, we note that, in previous hearings before the Tribunal, comment was made about the negative behaviour of Dr Rein in the way in which she conducted the hearing. We experienced no such conduct and found Dr Rein to be a pleasant and cooperative witness and advocate on her own behalf.
4. Turning to our reasons.
5. Given the history, it was entirely appropriate for the Board to require Dr Rein to undergo an independent assessment. That assessment conducted by Associate Professor Hassett provides was the most recent assessment. It addressed the criteria under the National Law.
6. Many of the same concerns raised and observations noted by Associate Professor Hassett in conducting her assessment surfaced during the hearing.
7. Dr Rein took issue with most factual findings in Associate Professor Hassett's report. She made similar comments about the findings in each of the previous Tribunal hearings. Although many of the facts relate to events which took place many years ago, it is Dr Rein's current perception of those events which raises concern.
8. Dr Rein, in the proceedings before us, described herself as having lived a life of achievement with no difficulties with anyone. Such comments flew in the face of facts compiled over many years, (many of which we understand Dr Rein disputes). Associate Professor Hassett observed that:

Dr Rein believes that all her psychiatric admissions had been unjustified and denied that she had had difficulty in relating to her peers and work colleagues. She could provide no explanation as to why she was thrown out, as she described being treated in various courses she had undertaken, nor why she had been admitted to psychiatric hospitals on multiple occasions. She referred to herself as "gentry", "distant royalty" and "a golden haired girl" and appeared incapable of any reflection on her own behaviour as a consequence of the concerns of others.

1. Dr Rein denied in her evidence before us, that she had ever had any mental health issues. She took issue with any and all opinions suggestive of mental health issues, either current or historical. She gave lengthy and derogatory descriptors of the individuals responsible for having her hospitalised over the years. She described hospital admissions as "illegal jail sentences and incarcerations". Dr Rein described unjustified admissions to hospital in terms which would have required mass corrupt collusion of any number of different individuals. She maintained a similar stance in relation to why her registration had previously been refused.
2. Similarly Associate Professor Hassett records, that Dr Rein said:

Psychiatrists make diagnoses on the basis of gossip and referred to one particular psychiatrist who assessed her as "a nut and a creep".

She believes that the Nurses' Board, police, lawyers and psychiatrists were colluding against her and the chief psychiatrist at the time, Dr Pereira, wanted to lock her up.

1. Dr Rein sees nothing in her history that should prevent, or should have prevented, her from regaining her nursing registration. We were concerned that she demonstrated no insight into her health issues and accordingly has sought little treatment.
2. Much of Dr Rein's evidence appeared factually unlikely, such as describing multiple sexual assaults upon her by various health professionals and downplaying previous incidents in which she had behaved inappropriately, preferring to deflect the blame onto others instead.
3. Similarly Associate Professor Hassett said:

When asked about her past assaultive behaviour, Dr Rein acknowledged that she had pulled someone's hair on one occasion, but her perspective was that she was the one who had been assaulted on many occasions. She described being assaulted by security guards in 1995 when she was leaving the city building where the Nurses' Board was located. In the same year, she described being assaulted by security guards several times at Sydney University. She believed that this had been ordered by the forensic psychiatrist who was lecturing in the legal course she was taking.

1. In her attempts to address the conclusions of Associate Professor Hassett, Dr Rein moved from using ill-informed examples (both before us and in communications to AHPRA) to demonstrate the diagnosis could not be accurate to personal attacks on Associate Professor Hassett. While some leniency can be extended to Dr Rein, as a self-represented litigant, nevertheless, Dr Rein has extensive relevant qualifications, which she could have called upon to present a relevant and measured case. She gave evidence that was frequently peripheral to the issues.
2. Dr Rein was aware of the contents of the report of Associate Professor Hassett, in advance of the hearing, but did not obtain any current psychiatric reports. Instead, she engaged in an extended argument with AHPRA over the credentials of Associate Professor Hassett.
3. We accepted the findings contained in the comprehensive report. We consider that Dr Rein has an impairment: namely, a personality disorder in the terms described by Associate Professor Hassett. We are further satisfied that the impairment would detrimentally affect her ability to act as a registered nurse. Her thought processes are not compatible with working in a profession that requires her to cooperate with, and respond to, others in an appropriate manner. She has not yet addressed any of the mental health issues raised, over many years, preferring to ignore their existence.
4. This would be sufficient, of itself, to lead to the conclusion that the decision of the Board should be affirmed. Nevertheless, for the sake of completeness, we will briefly address the following issues raised by the Board.

(b) Does the fact of the applicant's registration in New Zealand having been suspended due to a disability which has affected her ability to satisfactorily practice as a registered nurse, render her an unsuitable person to hold general registration in Victoria? - (section 55(1)(e) of the National Law).

1. We received a certificate from the Registrar of the Nursing Council of New Zealand, dated 18 February 2015, certifying that the registration of Dr Rein was suspended under section 32 of the Nurses Act 1977, on 21 May 2003.
2. In 2012, New Zealand engaged in a comprehensive Inquiry into the suitability of Dr Rein to practise nursing and concluded that she would not be suitable for practice.
3. In a careful and well-reasoned decision of the Court, Judge Harrop analysed the factors leading to the rejection of Dr Rein's application. An analysis of her mental health issues and the manner in which she conducted the hearing lead to the conclusion that she was not suitable.
4. We have reached similar conclusions, but would otherwise have found her unsuitable on this basis.

(c) Can Dr Rein meet the Board's "Registration Standard: Recency of Practice" registration standard - (section 52(1)(f) of the National Law).

1. Dr Rein does not accept that she does not meet the "Recency of Practice" requirements, despite not having worked in nursing since 1992. She gave evidence of her additional nursing and psychology degrees and medical training in India. Dr Rein also gave some verbal evidence of having undertaken voluntary nursing work in the United Kingdom.
2. These matters have been addressed in each of the earlier determinations of this Tribunal. Dr Rein does not meet the "Recency of Practice" standards.
3. Dr Rein placed great emphasis on her 2009 to 2010 employment in the Indian hospital setting. It is unnecessary to analyse in any great detail what she did at that time. The employment did not occur in the last five years.
4. In any event, she was training as a registrar on a pathway to registration as a doctor. This falls outside the scope of "Recency of Practice" for the purpose of registration as a nurse.
5. Dr Rein also described working in a voluntary position in Great Britain in 2013. She had no paperwork or other documentation to support what she said she did at that time. She said she worked in a small ICU unit and was left in charge and did really well. Whether or not the evidence was plausible, it was insufficient to satisfy us that Dr Rein could meet the Standard.
6. Dr Rein has attended various workshops over the years. Once again, none of these meet the "Recency of Practice" standards.

1. We are satisfied that Dr Rein is not a suitable person and accordingly must refuse to grant her registration under section 82(1)(c)(i)(E) of the National Law.
2. The decision of the respondent will be affirmed.