Solaris v Health Care Complaints Commission

(3) Subject to order (6), above, pursuant to s 64(1)(c) of the Civil and Administrative Tribunal Act 2013 (NSW) 2013, until further order of the Tribunal, the publication of, or publication of or matters contained in: (a) the Confidential and Privileged Documents filed on 4 September 2024 and Amended Confidential and Privileged Documents filed on 9 December 2024, and (b) Tab 41 of the Section 58 Bundle filed on 4 September 2024 (the Confidential Documents) is prohibited.

(4) Subject to order (6), above, pursuant to s 64(1)(d) of the Civil and Administrative Tribunal Act 2013 (NSW), until further order of the Tribunal, the disclosure of the Confidential Documents or matters contained in the Confidential Documents is restricted to the respondent, the respondent's legal representatives and the Tribunal.

(5) Subject to order (6), above, pursuant to ss 64(1)(b) and 64(1)(c) of the Civil and Administrative Tribunal Act 2013 (NSW), until further order of the Tribunal, the publication or reporting of the hearing of this application insofar as it relates to the Confidential Documents including any evidence given in the hearing, is prohibited.

(6) Orders 1, 2 and 3 do not apply to Tab 5 of the Confidential Documents.

(7) The Tribunal varies Orders 2, 3 and 4 made on 11 July 2024 so that they do not apply to Tab 5 of the Confidential and Privileged Documents filed on 14 March 2024.

(8) The Tribunal notes: (a) Section 76 of the Coroner's Act 2009 (NSW) provides: A person must not publish any of the following matters without the express permission of the coroner in the coronial proceedings concerned: (i) any question asked of a witness that the coroner has forbidden or disallowed, (ii) any warning that a coroner has given to a witness that he or she is not compelled to answer a question, (iii) any objection made by a witness to giving evidence on the ground that the evidence may tend to prove that the witness has committed an offence, (iv) any submissions made by or on behalf of a person appearing or being represented in the proceedings or by a person assisting the coroner, or any comment made by the coroner, concerning whether an inquest or inquiry should be suspended under section 78. Maximum penalty--10 penalty units or imprisonment for 6 months (in the case of an individual) or 50 penalty units (in any other case).

(b) "Publication" is defined in s 73 of the Coroners Act 2009 (NSW) For the purposes of this Part, matter is published only if it is- (i) inserted in any newspaper or any other periodical publication, or (ii) publicly exhibited, or (iii) broadcast by radio or by television, or (iv) published by means of the Internet.

(c) The Tribunal further notes that these provisions apply to the transcripts contained in the s 58 documents filed in this application from time to time.

REASONS FOR DECISION

1. On 17 October 2021 Mr Jarrad Antonovich died while attending a retreat organised by the Dreaming Arts Foundation. The Applicant, Mr Solaris was, at that time, described on the Foundation's website as the Foundation's "Founder and Lead Practitioner".
2. The Respondent, the Health Care Complaints Commission (the "Commission") received a complaint about the role of Mr Solaris in the death of Mr Antonovich. It commenced an investigation, formed the view that Mr Solaris had provided "health services" to Mr Antonovich and concluded that Mr Solaris continued to pose a serious risk to the health or safety of members of the public.
3. On 21 November 2023 the Commission made an interim prohibition order under s 41AA of the Health Care Complaints Act 1993 (HCC Act). The current order was made on 3 December 2024 and provides: You must not under any circumstances provide, or cause to be provided, any health services, either in paid employment or voluntarily, to any member of the public.
4. Mr Solaris seeks a review of the decision.

What is my role?

1. It is not my role to make any ultimate finding of fact as to the events which occurred during Mr Antonovich's attendance at the retreat but rather to determine the following issues.
2. The Commission can make an interim prohibition order against Mr Solaris if he is an "unregistered health practitioner": s 41AA(1) HCC Act.
3. If he is an unregistered health practitioner, the Commission can only make an interim prohibition order if: 1. It has a reasonable belief that Mr Solaris has breached a code of conduct for non-registered health practitioners: s 41AA(2)(a) HCC Act, and 1. it is of the opinion that- 1. Mr Solaris poses a serious risk to the health or safety of members of the public: and 2. The making of an interim prohibition order is necessary to protect the health or safety of members of the public: s 41AA(2)(b) HCC Act.
4. Mr Solaris may apply to this Tribunal for an administrative review of the Commission's decision to make an interim prohibition order: s 41C HCC Act.
5. The administrative review jurisdiction of this Tribunal is governed by the Civil and Administrative Tribunal Act 2013 (NSW) (the "NCAT" Act), Chapter 3.
6. In determining an application for an administrative review, the Tribunal is to decide what is the correct and preferable decision having regard to the material then before it, including any relevant factual material and any applicable written or unwritten law: s 63(1) Administrative Decisions Review Act 1997 (NSW) (ADR Act).
7. In Youssef v NSW Legal Services Commissioner [2020] NSWCATOD 85 ("Youssef"), the Tribunal considered the nature of a review under s63 of the ADR Act. Citing Donaghy v The Council of the Law Society of New South Wales [2013] NSWCA 154 at [21], the Tribunal emphasised that it is a "review on the merits" and is "not concerned ... whether there was challengeable error in the process or reasoning" by the original decision-maker. Rather, the role of the Tribunal is to "decide what the correct and preferable decision is having regard to the material before it" which includes "any relevant factual material". The review is to be conducted "without any presumption as to the correctness of the decision": Youssef at [24].

History

1. The Commission tendered two large bundles of documents which included the autopsy report, an expert's report, the interim prohibition orders, the coronial transcripts, the statements made to police by attendees at the retreat and others, documents relating to the Dreaming Arts Foundation and the services it offers including the retreat in October 2021, and recent email exchanges between the parties. Mr Solaris tendered his submissions with supporting documents including his statement. This history is prepared from this evidence but are not intended to be factual findings made by me.
2. Mr Solaris provided services through the Dreaming Arts Foundation. It held a "music and meditation ceremonies & retreat" in October 2021.
3. The retreat was a six day event from 12 to 17 October 2021 during which there were sessions in which Kambo, a toxic excretion of the Kambo species of frog, and Ayahusca, a hallucinogenic botanical beverage originally used by indigenous Amazonian tribes, were used by participants.
4. Mr Antonovich was administered Kambo between 10 and 11 am on 16 October 2021.
5. At around 1 pm Mr Antonovich was seen with a swollen neck and face. Those and other symptoms including intense pain in the lower back/kidney area, moaning, difficulty breathing, and walking without assistance, continued throughout the afternoon.
6. Mr Antonovich participated in an Ayahusca ceremony in the evening conducted by Mr Solaris which had been scheduled to commence at 8.30pm. He was assisted to walk into the back of the main hall, which was referred to as the temple, where he sat on the floor. One witness heard Mr Solaris say to Mr Antonovich "I think its a good idea for you to sit in the ceremony tonight, but I think it's a good idea that you only just have a little cup". Mr Antonovich asked for the Ayahusca to be brought to him. Mr Solaris passed a cup of Ayahusca to another person who took it to Mr Antonovich at the back of the temple.
7. While Mr Solaris continued the ceremony, Mr Antonovich's condition continued to deteriorate and he collapsed at around 11.30 pm. He had died by the time an ambulance arrived.
8. The autopsy report lists the cause of death as being a perforated oesophagus.
9. The postmortem toxicology report for Mr Antonovich showed N,N-Dimethyltryptamine (DMT) in his blood. Ayahuasca contains DMT which is a short-acting and potent psychedelic and hallucinogenic agent that, at the level found in Mr Antonovich's blood, can distort an individual's view of reality, and dramatically alter their perception, cognition, consciousness and decision-making skills.
10. Kambo and DMT are prohibited substances under Sch 9 of the Therapeutic Goods (Poisons Standard - July 2023) Instrument 2023 made under the Therapeutic Goods Act 1989 (Cth).
11. A coronial inquest into the death commenced in May 2023 and evidence was led in May 2023, February 2024 and May 2024.
12. The Commission made the interim prohibition order on 21 November 2023.
13. On 19 December 2023 Mr Solaris applied to the Tribunal to stay the interim prohibition order. The Stay application was heard on 19 March 2024 and 7 May 2024. The decision was published on 11 July 2024: Solaris v Health Care Complaints Commission [2024] NSWCATOD 97 (the "Stay decision"). The application for the Stay was refused.
14. The legal issues determined in the Stay decision are raised again in this hearing. On 11 July 2024 the Tribunal member found that: 1. Mr Solaris provided health services within the meaning of s 4(k) of the HCC Act: at [17], [38]. 2. The evidence available to the Commission at the time of issuing the first and subsequent interim prohibition orders, up to and including the interim prohibition order issued on 8 March 2024, "provided a proper basis upon which it could form a reasonable belief that that Mr Solaris failed to provide health services in a safe and ethical way" as required by s.41AA(2) of the HCC Act and contrary to the requirements of the Code of Conduct for non-registered health practitioners: at [46]-[49].
15. Mr Solaris was not legally represented at the hearing before me and appeared initially by an audio-visual link. When difficulties were experienced in maintaining a reliable connection, Mr Solaris continued to make his submissions by telephone.

Preliminary issue

1. The interim prohibition order which is the subject of the application by Mr Solaris has expired.
2. An interim prohibition order remains in force for a maximum of 8 weeks: s 41AA(4) HCC Act. The Commission has made further interim prohibition orders since the expiry of the first order which, in effect, means that the order has continued. The most recent order was made on 3 December 2024. Each order that has been made is in the same terms.
3. On 7 May 2024 the Tribunal ordered, pursuant to s 53 of the NCAT Act, that the application made by Mr Solaris on 19 December 2023, which sought review of the interim prohibition order made on 21 November 2023, was amended to seek review of the interim prohibition order in force at the time of the Tribunal's decision which is the order made on 3 December 2024: at [10].

Did Mr Solaris provide a health service?

1. The Commission can make an interim prohibition order against a "non-registered health practitioner": s 41AA HCC Act. That expression is not defined in the Act.
2. A "health practitioner" is defined as "a natural person who provides a health service (whether or not the person is registered under the Health Practitioner Regulation National Law)": s 4 HCC Act.
3. "Health services" includes "services provided in other alternative health care fields": s 4(k) HCC Act.
4. Whether Mr Solaris provided health services was considered in the Stay decision and I agree with the Tribunal member's reasoning.
5. In his submission to the Tribunal member hearing the Stay application, Mr Solaris said he was protected by s 116 of the Commonwealth Constitution as his beliefs are a religion. That ground was not pressed before me.
6. In his submissions Mr Solaris denies that the administration of Ayahusca is the provision of a "health service". He says the purpose is "to commune with our Holy Sacrament and the Kingdom of Juramidam, and we pray at the Holy point of the Estrela da Ciranda. The spiritual essence of our work is made clear in the information for the retreat and is based on traditions that were founder (sic) by Master lreneu, in Brasil in 1929, with roots in Amazonian culture of thousands of years.". He also says he did not administer any substances - the community willingly asks for the Holy Sacrament and choose to drink it.
7. Mr Solaris acknowledges that he does provide other health services in that he offers "counselling, healing and body work".
8. In relation to the retreat generally, the website for the Dreaming Arts Foundation refers to "Ceremonial and Ritual Healing" in which "music, meditation and cleansing processes" are used to "heal and honour spirit". "Energetic and Metaphysical Healing" is used to "reconnect, integrate and strengthen health, well-being and conscious awareness through the body and mind". It is stated that the programs provided by Dreaming Arts Foundation help people to discover new experience of:

• Inner peace and self-confidence
• Healthy relationships
• Connection to community and spirituality
• Expression through creative arts and music
• Life purpose and direction
• Emotional balance
• Physical health and vitality.

1. In relation to the administration of Kambo and Ayahusca, there is in evidence the Guide issued by the Dreaming Arts Foundation for the retreat. The program included three "medicine ceremonies" facilitated by Mr Solaris where participants would "have the opportunity to partake in a sacred ritual where they could choose to drink the sacred plant medicine known as Ayahusca… while the ceremonial work with this sacred plant teacher is essentially a spiritual practice, it may have many positive and sustained benefits in the healing of mind, body, emotions, relationships, soul retrieval, ancestral connection and spiritual growth and can often lead to significant changes and benefits in the lives of participants". Ayahusca is referred to as medicine, for example "It is important to remember that this is medicine and it is here to help and to heal …": pages 1562-1568 HCCC s58 documents.
2. The program also provided for a "Kambo ceremony" facilitated by another person, Cam, to be available on each day of the retreat at an extra cost. The information pamphlet also describes Kambo as a medicine. It says Kambo "can help us on an energetic, physical and spiritual level … He is amazing at working with physical hearts and all our soft tissue organs … Kambo invites … Increased physical well-being and healing. Relief from pain and suffering": page 982 HCCC s58 documents
3. Mr Solaris' connection with the organisation and his role at the retreat is mentioned in the documentary evidence. I have already mentioned that he is described as the facilitator of the Ayahusca ceremonies in the workshop schedule. A statement in evidence from another person who attended at the ceremony described receiving instructions from Mr Solaris as to how much Ayahusca each of them should drink.
4. The website for the Dreaming Arts Foundation says: Led by Lore Solaris, our integrative, trauma-informed healing services include a diverse range of cutting edge and traditional healing practices. Dreaming Arts has well developed services designed to facilitate profound healing and self-awareness. Participants may have their well-being plan tailored to their individual needs in a non-judgemental and non-denominational care environment.
5. I was not referred to any legal authority in NSW concerning the definition of a health service. In these proceedings and in the stay proceedings, the Commission relied on a decision of the ACT Supreme Court in Hanna v Commissioner for Community and Health Services Complaints [2002] ACTSC 111; (2002) 171 FLR 185. The Court considered the meaning of the term "health service" in the Community and Health Services Complaints Act 1993 (ACT) (now repealed), legislation similar to the HCC Act.
6. In that case a notice was served requiring the production of documents and information concerning a practice of the Church of Scientology known as the "Purification Rundown". The decision to serve the notice had been based on the respondent's view that, in conducting the Purification Rundown, the second applicant was providing health services. As in the NSW Act, this included services in an alternative health care field.

Reasonable belief and opinion

1. As I have said, to make an interim prohibition order, the Commission must have a reasonable belief that Mr Solaris had breached a Code of Conduct for non-registered health practitioners.
2. The Commission says that Mr Solaris breached items (1)(1), 2(l) and (m) of the Schedule 3 Code of Conduct for non-registered health practitioners of Public Health Regulation 2022 (NSW)(the "Code") which relevantly say: Health services to be provided in safe and ethical way. 1. A health practitioner must provide health services in a safe and ethical way. 2. Without limiting subsection (1), a health practitioner must comply with the following principles - … (l) a health practitioner must ensure appropriate first aid is available to deal with misadventure during a client consultation, (m) a health practitioner must obtain appropriate emergency assistance, for example, from the Ambulance Service, if there is a serious misadventure during a client consultation.
3. In addition, to make an interim prohibition order, the Commission must also have a reasonable belief that Mr Solaris poses a serious risk to the health or safety of members of the public and the making of an interim prohibition order is necessary to protect the health or safety of members of the public.
4. Mr Solaris submitted that: 1. He was not involved in the administration of Kambo. 2. Mr Antonovich did not wish to go to hospital. He said first aid would have been provided if Mr Antonovich had consented. He respected Mr Antonovich and his choices. 3. He did not have enough information himself to consider calling an ambulance. He instructed another person to call an ambulance when he observed Mr Antonovich to have difficulty remaining conscious.
5. I am satisfied, however, that the evidence before the Commission was such that it provided a proper basis upon which it could form a reasonable belief that Mr Solaris failed to provide health services in a safe and ethical way and in contravention of the Code, by: 1. Facilitating the administration of a prohibited substance; 2. Failing to understand the gravity of Mr Antonovich's health crisis following his consumption of Kambo and Ayahuasca; 3. Failing to provide appropriate first aid; 4. Not ensuring there was a defibrillator on site; 5. Failing to obtain emergency assistance in time to save Mr Antonovich's life.
6. In addition there is in evidence a flyer from Dreaming Arts advertising a retreat in Melbourne in December 2023. Although Ayahuasca is not mentioned, the language is otherwise strikingly similar to the Guide for the October 2021 retreat and relevantly says:

• "This weekend retreat will include two ceremonies… Participants will have the opportunity to partake in a sacred ritual where they may choose to drink the sacred plant sacrament."
• "The program and ceremonies will be led by Lore Solaris."

1. I am satisfied that the evidence before the Commission was such that it provided a proper basis upon which it could form a reasonable belief that Mr Solaris proposed to continue to conduct retreats similar to the retreat in October 2021 so that he posed an ongoing serious risk to the health and safety of members of the public and that it was necessary to issue an interim prohibition to protect the public.

Finding

1. I am satisfied that the Commission made the correct and preferable decision.

Other Orders

1. In these Reasons I have referred to the Tribunal having made non-publication and non-disclosure orders on 11 July 2024. These were: (2) Pursuant to s 64(1)(c) of the Civil and Administrative Tribunal Act 2013, until further order of the Tribunal, the publication of the Confidential Material or matters contained in the Confidential Material is prohibited. (3) Pursuant to s 64(1)(d) of the Civil and Administrative Tribunal Act 2013, until further order of the Tribunal, the disclosure of the Confidential Material or matters contained in the Confidential Material is restricted to the respondent, the respondent's legal representatives and the Tribunal.
2. Since those Orders were made, further documents have been filed by the Commission. I was informed that the only difference between the confidential documents filed before and after 11 July 2024 was the removal of the claim of privilege over the report of Dr Cala. I accepted that it would be necessary to make additional orders to extend the 11 July 2024 confidentiality Orders to the documents filed after 11 July 2024. I have made those Orders below.

Other matters

1. Mr Solaris did make a number of other submissions which I do not accept for the reasons set out below.

Failure to provide documents

1. Mr Solaris strongly believes that the Commission, amongst other entities, is deliberately keeping documents from him.
2. Orders were made by the Tribunal member on 11 July 2024 prohibiting the disclosure of certain documents to anyone other than the Commission. Those orders were made after legal submissions from the Commission as to the non-disclosure regimes in legislation such as the Coroner's Act 2009 (NSW).
3. In addition the Commission served on Mr Solaris the transcript of the coronial inquiry in which some passages had been redacted. I was told that this was done for the same reason, that is to comply with non-disclosure provisions in other legislation, although the Commission admitted that some portions had been redacted in error. Ultimately the unredacted version is in evidence before me, however I have made orders for non-publication of parts of the transcript.
4. In his written submissions Mr Solaris says that the Commission and the Coroners Court have obstructed his attempts to obtain all the evidence, including unredacted transcripts. He believes this may constitute obstruction of the course of natural justice leading to a lack of procedural fairness, thus prejudicing him in his appeal. He suspects they are attempting to conceal important evidence.
5. In the absence of any evidence which could support such a finding, I decline to find that there was any improper purpose when Mr Solaris was not provided with a document or was given the redacted version of the transcript.
6. Mr Solaris also says he was denied procedural fairness because he had not been given a copy of the complaint and had not had a chance to respond to it. This is denied by the Commission which, in its letter dated 5 December 2024, told Mr Solaris it had complied with s 16 of the HCC Act by giving him written notice of the complaint, details of the nature of the complaint and the identity of the complainant within 14 days, together with the first interim prohibition order, both of which had been served on him by a police officer on 4 August 2023.
7. I am satisfied that the Commission complied with the relevant legislation in providing information about the complaint to Mr Solaris and there was no denial of procedural fairness.
8. Mr Solaris considers that the ongoing concealment of the autopsy report of Dr Cala may constitute an obstruction of the course of natural justice. He thinks it is highly doubtful that Dr Cala is a genuine expert and is of the view that his opinion is contrary to overwhelming scientific research and evidence and international legal precedents, easily sourced from over 70 years of documented evidence.
9. That report was a subject of the confidentiality ruling on 11 July 2024. The claim for privilege was abandoned by the Commission on 11 December 2024. Mr Solaris confirmed that he did have a copy of the report, he had served it on the Commission and had attached it to his submissions dated 3 December 2024. It was also before the Coroner at the inquest when Mr Solaris was legally represented.
10. I decline to find that there was any improper purpose on the part of the Commission in relation to service of the report of Dr Cala.
11. Mr Solaris believes that some of the evidence that has been concealed and omitted, is directly related to his appeal and to investigations being undertaken by the ombudsman and the Bar Association and is deliberate and an attempt to pervert the course of natural justice.
12. There is no evidence to support this submission.

Improper conduct

1. Mr Solaris does not accept that he is accusing various entities of conspiring against him. However he does say in his written submissions: 1. The Commission is persecuting him. There is no reliable evidence to support this claim. 1. The police falsely characterised the events because they were enmeshed in the claims and agenda of the family of the deceased. There is no reliable evidence to support this claim. 1. The Commission made a vexatious complaint about him in which it referred to his sexuality in a misleading way that seemed to come from the police. When he traced the time and location of the evidence, it showed the distance to be exactly on a police station, the one that was responsible for taking his phone. The document Mr Solaris has attached to his written submissions in support of this issue, is a letter from the Commission dated 25 October 2024. It concerns a different complaint and asks for further information including whether he had promoted a health service on a dating app while the subject of an interim prohibition order. There is no evidence supporting Mr Solaris' submission. 1. In many documents, including in most of the interim prohibition orders the retreat has been described as a festival. Mr Solaris considers the use of the word to be misleading and defamatory, He has made a complaint to the Bar Association about the term being used in the coronial inquiry. The relevance of this concern was not explained. 1. Mr Solaris accuses the Commission of relying on misleading claims of purging and retching that no witness had attested to. However the only possible reference to vomiting in the interim prohibition order is a statement that, much earlier in the day, after having been administered Kambo, Mr Antonovich had been seen with a bucket in front of him. This statement is consistent with the evidence of a witness in the coronial inquiry. There is no evidence to support the submission. 1. On 19 August 2024 Mr Solaris asked for the interim prohibition order to be limited so that he could undertake counselling and other therapies. He asserts that the Commission has not provided a response or reasons as to why he is banned from these practices. However on 23 August 2024 the Commission had sought further details from Mr Solaris about the other therapies he intended to provide, the qualifications he had to perform those therapies and his employment history since September 2013. In their email to Mr Solaris on 5 December 2024 they told him that they had not received a response. Mr Solaris said he had replied shortly after receiving the email. The Commission had made up its own list on a website and he had told them to use that list. He did not feel safe talking to them. He did not say that he had provided the information which had been requested. The submission does not reflect the evidence.

The investigation

1. Mr Solaris also believes that the Commission is not acting expeditiously. An example he gives is that it was slow to respond to an enquiry made by the NSW Ombudsman. After prompting, they did respond after a further 10 days, but with incomplete information. In making this submission Mr Solaris relies on an email from the Ombudsman which says: "I hope you have been well since we spoke last week. I just wanted to touch base and let you know that I have now received a response from the HCCC to my initial enquiries. As we discussed, I do have additional questions to ask the agency based on the correspondence you have provided me in the meantime, but now I also have further questions arising from the response that they have provided. I'm in the process of drafting all of these and will be in touch with an update as soon as I can." The email does not support the submission.
2. Mr Solaris says the investigation is prejudiced and biased and enmeshed in policing agendas and appears to be solely based in an inquest that appears to have been biased and prejudiced, was not heard under rules of evidence and did not investigate all issues. The assisting counsel was more interested in targeting him with her prosecution agenda, than finding out what happened. There is no evidence to support these submissions.
3. In relation to the complaint of delay, this inquiry is not a review of the investigation itself, but a review of the decision to make an interim prohibition order: s 41C of the HCC Act. Accordingly, the issue of delay, if it has occurred, is not relevant to this application.

Outcome

1. I make the following Orders: 1. The Respondent's decision of 3 December 2024 is affirmed under s 63(3)(a) of the Administrative Decisions Review Act 1997 (NSW). 2. The Application is dismissed. 3. Subject to order (6), below, pursuant to s 64(1)(c) of the Civil and Administrative Tribunal Act 2013 (NSW), until further order of the Tribunal, the publication of, or publication of or matters contained in: 1. the Confidential and Privileged Documents filed on 4 September 2024 and Amended Confidential and Privileged Documents filed on 9 December 2024, and 2. Tab 41 of the Section 58 Bundle filed on 4 September 2024 (the Confidential Documents) is prohibited. 1. Subject to order (6), below, pursuant to s 64(1)(d) of the Civil and Administrative Tribunal Act 2013 (NSW), until further order of the Tribunal, the disclosure of the Confidential Documents or matters contained in the Confidential Documents is restricted to the respondent, the respondent's legal representatives and the Tribunal. 2. Subject to order (6), below, pursuant to ss 64(1)(b) and 64(1)(c) of the Civil and Administrative Tribunal Act 2013 (NSW), until further order of the Tribunal, the publication or reporting of the hearing of this application insofar as it relates to the Confidential Documents including any evidence given in the hearing, is prohibited. 3. Orders 1, 2 and 3 do not apply to Tab 5 of the Confidential Documents. 4. The Tribunal varies Orders 2, 3 and 4 made on 11 July 2024 so that they do not apply to Tab 5 of the Confidential and Privileged Documents filed on 14 March 2024. 5. The Tribunal notes: 1. Section 76 of the Coroner's Act 2009 (NSW) provides: A person must not publish any of the following matters without the express permission of the coroner in the coronial proceedings concerned: 1. any question asked of a witness that the coroner has forbidden or disallowed, 2. any warning that a coroner has given to a witness that he or she is not compelled to answer a question, 3. any objection made by a witness to giving evidence on the ground that the evidence may tend to prove that the witness has committed an offence, 4. any submissions made by or on behalf of a person appearing or being represented in the proceedings or by a person assisting the coroner, or any comment made by the coroner, concerning whether an inquest or inquiry should be suspended under section 78. Maximum penalty--10 penalty units or imprisonment for 6 months (in the case of an individual) or 50 penalty units (in any other case). 1. "Publication" is defined in s 73 of the Coroners Act 2009 (NSW). For the purposes of this Part, matter is published only if it is- 1. inserted in any newspaper or any other periodical publication, or 2. publicly exhibited, or 3. broadcast by radio or by television, or 4. published by means of the Internet. 1. The Tribunal further notes that these provisions apply to the transcripts contained in the s 58 documents filed in this application from time to time.

I hereby certify that this is a true and accurate record of the reasons for decision of the Civil and Administrative Tribunal of New South Wales. Registrar DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment or decision. The onus remains on any person using material in the judgment or decision to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court or Tribunal in which it was generated. Decision last updated: 18 December 2024