Wells v Medical Board of Australia [2025] QCAT 366

Health Ombudsman Act 2013 (Qld)

Wells v Medical Board of Australia [2025] QCAT 366 | Case summary | Zoe

[26]

[4] The Board has received multiple notifications about Dr Wells' alleged conduct and performance of (or performance by way of involvement in) cosmetic surgeries and unsafe surgical and other practices whilst he was employed and practising at what were formerly known as the 'Dr Lanzer Clinics' ('Lanzer Clinics') and also at premises controlled by The Aesthetic Institute, including Queensland Day Hospital ('QDH').
[5] Dr Wells joined Dr Lanzer's group, Dermatology and Cosmetic Surgery Services Pty Ltd ('DCSS'), in March 2018. He performed procedures at the Lanzer Clinics in Victoria, New South Wales and Queensland from about that time, at least some as an assistant to Dr Lanzer. I infer from matters in the hearing brief[1] that, with the advent of COVID-19 and the ensuing travel restrictions, from sometime in or around 2020, he spent more of his time at the Lanzer Clinics in Queensland (Wickham Terrace and thereafter Salisbury and Broadbeach), although he still travelled interstate on occasion and other doctors in the group also came to Queensland from time to time.
[6] On 25 October 2021, the Australian Broadcasting Commission aired a programme on Four Corners called 'Cosmetic Cowboys'. It dealt with a wide range of concerns about how the Lanzer Clinics operated.
[7] Thereafter, Dr Wells took steps to disassociate himself from the Lanzer Clinics, as he published on his social media accounts.[2] Dr Wells established his own practice and became the new licensee of the Salisbury Day Hospital on 8 December 2021, which was later renamed QDH. Dr Wells assumed financial control over the Salisbury facility on 26 January 2022. That facility achieved interim accreditation against National Safety and Quality Health Service Standards on 4 February 2022. Dr Wells practised at QDH full time and performed liposuction procedures almost daily until his registration was suspended on 5 July 2022.[3]
[8] Dr Wells was specifically mentioned in an article in the Sydney Morning Herald ('SMH') entitled 'The glitz and the gore: Behind the scenes of a celebrity cosmetic surgeon's 'abattoir' practice'' published on 10 June 2022.[4] As the surgical associate of Dr Lanzer,[5] he was the subject of (or at least named in) further specific and published media reporting relating to the Channel 9 60 Minutes program, 'A Bad Look', which aired in June 2022,[6] and in further print media articles on 22 August 2022 after he was suspended.[7]
[9] On 4 July 2022, the Board decided to take immediate action under section 156 of the Health Practitioner Regulation National Law (Queensland) ('National Law') to suspend Dr Wells' registration effective from 5 July 2022 ('Initial IA Decision').[8] The Initial IA Decision referred to the Board's reasonable belief of serious risk and that it was necessary to take action to protect public health or safety. It also referred to taking action in the public interest.[9] Dr Wells did not challenge the Initial IA Decision when it was made.
[10] After two years being wholly suspended, in July 2024 Dr Wells asked the Board to review the suspension. He provided a written reflection together with certificates confirming he had undertaken a number of courses of further education covering medical regulation, communication, boundary issues, patient expectations and medical records. He also provided material confirming he had completed a tailored education programme focusing on foundations of professional practice, ethics and ethical decision making and safety and quality in health care.
[11] On 1 October 2024, the Board decided to end the Initial IA Decision under s 159(2)(b) of the National Law and revoke the suspension. It decided, in lieu, to impose an alternative form of immediate action under section 156(1)(a) of the National Law by imposing conditions on Dr Wells' registration ('Reconsideration Decision') which:

[34]

[17] The Board relies on the fact the current conditions do not prevent Dr Wells from practising as a registered medical practitioner. They prevent him from practising only in the fields of cosmetic medicine and cosmetic surgery. The Reconsideration Decision notes the Board is investigating twelve notifications relating to Dr Wells' performance and/or conduct in relation to his cosmetic surgery practice. It contends the material demonstrates that, notwithstanding his subsequent education and reflection, Dr Wells has not properly acknowledged significant issues arising from the notifications in the Lanzer Clinics which causes concerns about his insight and his assurances about future conduct.
[18] The public interest is engaged, the Board submits, because the media coverage has drawn attention to the practice of cosmetic medicine including cosmetic surgery, the risks, what is appropriate in that practice and whether this is an area of medicine which is appropriately and vigorously regulated.[16] The Board accepts there are guidelines in force now, including the Cosmetic Surgery Guidelines, which were not in force when the events the subject of the notifications occurred and which set out a different regulatory environment from that then prevailing. However, it submits the issue is the maintenance of public confidence in the profession; the media coverage has highlighted public concern about the proper practice of cosmetic surgery and it is important that the regulatory response to this case and others maintains public confidence in the profession.[17] Where the allegations involve eleven patients,[18] either his own or shared with other practitioners, over a significant time period and include systemic issue across various places where he practised, the Board submits it would undermine public confidence in the medical profession if he is able to resume practice in cosmetic medicine and cosmetic surgery at this time.[19] The Board submits that Dr Wells' inability to grapple in a meaningful way with the past is very relevant to public confidence.[20]

[40]

[26] 'Serious risk' is not defined in the National Law but the word 'serious' is defined as 'of grave aspect; weighty or important; giving cause for apprehension; critical; to be considered as an extreme example of its kind'.[29] It is not sufficient for there to be some risk, it must be a risk which fairly merits the description 'serious risk'.[30]
[27] Reasonable belief of a serious risk requires the existence of a factual matrix sufficient to induce that belief in a reasonable person. Belief is an inclination of the mind towards assenting to, rather than rejecting, a proposition.[31]
[28] Available material should be carefully scrutinised to determine the weight to be attached to it.[32] An immediate action order does not entail a detailed inquiry and is one which requires action on an urgent basis because of the need to protect the public.[33] Immediate action is not a substitute for action that may be taken after an investigation.[34]
[29] Any immediate action which is taken ought to be the least onerous to address the relevant risk. Whilst protection of the public is and must remain the paramount consideration, the impact of immediate action on a health practitioner cannot be underestimated.[35]
[30] The National Law includes as a guiding principle that the scheme is to operate in a transparent, accountable, efficient, effective and fair way.[36] In analysing the statutory scheme prescribed under the Health Ombudsman Act 2013 (Qld) ('HO Act'), the Supreme Court observed that investigating in a dilatory way, whilst the relevant registered health practitioner is, legally or in a practical sense, suspended from providing health services pending the outcome of an investigation is hardly fulfilment of the object of a system established for dealing with complaints and other matters 'effectively and expeditiously' in a way that is 'transparent, accountable and fair'.[37]
[31] The words used in the HO Act are 'effectively and expeditiously',[38] whilst the words in the National Law are 'efficient and effective'.[39] I accept these are materially equivalent concepts.
[32] The statutory provisions concerning the conduct of investigations in the respective acts are not, however, materially the same. Under the HO Act investigations must generally be completed within one year but three month extensions (recorded on a public register) are permitted.[40] The National Law provides, relevantly, that the National Board must ensure an investigator it directs to conduct an investigation conducts the investigation as quickly as practicable, having regard to the nature of the matter to be investigated.[41] The issue in the case in which the Supreme Court made its observations was whether an investigation which took longer than twelve months was carried out in contravention of the statutory requirement, unless notice had been given to extend the investigation during the initial twelve month period. No such issue arises in this case, where the National Law does not set out any notional prescribed time for an investigation. The Board informed the Tribunal that the investigation was anticipated to be ongoing for up to a further twelve months, in circumstances where it has been on foot for over three years already.[42] Whilst the delay in concluding the investigation is most unfortunate, the Tribunal accepts that the investigation involves a period of several years, practices at several locations in various states, a number of notifications by former patients, former staff and other regulators and consideration of the role played by a number of other registered health practitioners in the various notifications. The Tribunal places on the record that it expects the Board, supported by Ahpra, will act expeditiously in finalising the investigation and bringing any referral as it may be advised within the time frame stated to the Tribunal.
[33] Whether an identified risk posed by a practitioner can fairly be described as serious can be considered through the nature of the risk, the likelihood of it eventuating and the seriousness of the consequences if it does eventuate.[43]
[34] A reasonable belief may be held that a practitioner poses a serious risk to persons if, based upon evidence of past conduct, there is a real possibility that the practitioner will engage in conduct which could be harmful to persons.[44]

[46]

[42] Dr Wells was first registered as a medical practitioner in 2013 after completing his medical studies in 2012.
[43] In 2015, Dr Wells began training in cosmetic procedures with a Dr Longin Zurek, who was a founding surgical Fellow of the Australasian College of Cosmetic Surgery and Medicine ('ACCSM'). Dr Wells worked with Dr Zurek for around three years. During this time, Dr Wells explains, he most commonly performed procedures involving facial fat grafting with true tumescent liposuction and non-invasive otoplasty. Dr Zurek also trained Dr Wells in blepharoplasty, facelifts, skin excisions, injectables (botulinum toxin and hyaluronic acid fillers), lip lifts, labioplasty, chemical peels and skin cancer surgery.
[44] Dr Wells was accepted into the ACCSM medical fellowship training program in 2017 and became a Medical Fellow of the ACCSM in 2019.[51] Dr Wells commenced a diploma of lipoplasty through the ACCSM (now called a Certificate in Lipoplasty Surgery). Whilst he had satisfied the necessary training requirements, Dr Wells has not sat the final examinations needed to get his certificate.
[45] In March 2018, Dr Wells entered into a training agreement to gain training, and eventually perform, various cosmetic procedures for DCSS, a company owned and operated by Dr Daniel Lanzer. Dr Wells initially trained under Dr Lanzer and assisted him with a high volume of cosmetic procedures during this training period, including liposuction. Dr Wells told the Board entered into the training agreement because he understood Dr Lanzer to be a world leading liposuction doctor with an excellent reputation in the liposuction/cosmetic surgery industry in Australia. Dr Wells has a strong interest in liposuction (body sculpting) and autologous fat grafting, which is why he wanted to be trained by and work with Dr Lanzer.
[46] Dr Wells says Dr Lanzer told him (i.e., Dr Wells) that he (i.e., Dr Lanzer) was directly involved with developing the Victorian Health Department's guidelines on liposuction and liposuction volumes and had published papers and research on breast reduction with liposuction and mega liposuction. Dr Lanzer also told Dr Wells ACCSM had contacted him multiple times to train the ACCSM surgical trainees but he refused. Further, he told Dr Wells that he served on the Australasian College of Dermatologists' surgical subcommittee as a representative for liposuction. Dr Wells had no reason to disbelieve this information.[52] These matters are not disputed by other material in the HB.
[47] Dr Wells estimates that on a conservative basis, and without undertaking a complete clinical audit:

[63]

[66] Dr Wells told the Private Health Regulation Unit ('PHRU') personnel on 3 November 2021 that, depending on a patient's medical history, up to six litres of lipoaspirate may be removed during a single procedure at the facility, mostly under general anaesthetic. He said he would normally perform more than one procedure to remove this amount.[77] A note Dr Wells added on 19 November 2021 to this section of the report was to the effect that the Director of the PHRU said to him that day there was no specific regulation on taking more than five litres of fat out during a single procedure and if there was such a regulation he would adhere to it without hesitation.[78]
[67] Prior to 2022, a five litre limit was identified on some basis in some states related to licensing requirements, but there were regulatory differences across the different states. Dr Wells has set out the differences in recommendations in various states prior to August 2022.[79] From August 2022, guidelines in Victoria expressly state that five litres is the maximum volume that should be removed at any one time.[80]
[68] Dr Wells, in submissions in March 2022, accepted that it is generally accepted that the maximum amount of lipoaspirate to be taken during a single procedure is five litres but acknowledged that some practitioners assess the maximum volumes based on a percentage of a patient's pre-operative body weight and may exceed the five litre limit if the patient meets specific safety criteria peri-operatively.[81] He stated that given the absence of established guidelines, he had decided since establishing his own practice to take only approximately five litres in a single procedure.[82]
[69] The Board submits there is no evidence in Dr Wells' responses or the material of any assessment that these patients had been assessed to 'meet specific safety criteria peri-operatively'.
[70] On its review of the material, the Tribunal is satisfied there is no evidence that Patient A was assessed peri-operatively as Dr Wells has submitted occurred. Dr Wells has submitted that his involvement in that procedure was as a surgical associate to whom an aspect of the procedure could be assigned;[83] this bespeaks Dr Wells seeking to disassociate himself from involvement in a procedure where, on his own submission, he should have satisfied himself that Patient A had been appropriately peri-operatively assessed as safe for the procedure he was assisting with.
[71] Patient B's clinical records establish that Dr Wells did the initial doctor's consultation on 20 November 2020. Neither it nor later records appear to record any peri-operative assessment of Patient B's suitability for large volume liposuction.[84] The theatre note of the surgery on 29 April 2021 records the surgeons as Drs Wells and Lanzer and that total fat was 6.8 litres[85].
[72] There is no evidence that Dr Wells performed the peri-operative assessment for Patient C. Patient C is highly supportive of Dr Wells' communication, procedural performance and the outcomes she has received.
[73] Patient D's clinical records establish that Dr Wells was the surgeon[86] and he accepts that this was at his Institute of Aesthetics practice.[87] On the Tribunal's review, those records contain no indication that Patient D had been assessed peri-operatively as Dr Wells contends.[88]
[74] On 8 February 2022, Patient D posted on social media, with a photograph, that she had had 8.5 litres of fat removed from just her thighs. That post is broadly consistent with clinical records made on the day of the procedure which record the procedure was a liposuction procedure on thighs and knees performed on 7 February 2022 under a general anaesthetic.[89] The note in the clinical records, which is described as a 'surgery note' made that day, was that the total fat volume was 8.4 litres. The clinical records also contain a note termed '17.03.2022 - Retrospective entry from 14.03.2022'. This is a note of a telephone call between Dr Wells and Patient D which records that Dr Wells told Patient D that:

[69]

[77] The Board submits that the evidence gives rise to a reasonable belief that a number of patients have experienced post-operative complications and poor post-operative care. Specifically, in oral submissions, I was referred to the experiences of Patients E, B, F and a patient identified in a media article as a retired soldier.
[78] Dr Wells performed surgery on Patient E in early March 2021 involving liposuction and a fat transfer to her breasts at the clinic in Brisbane[91] under general anaesthetic. Patient E says she was told she would be fully recovered within two weeks and had planned to go back to work however, it was six to eight weeks before she could put her underwear on. Her recall is that she followed up with the clinic how long it was taking her to recover. She was told it was normal and she had to massage the area every day, but she had not been told to expect this prior to surgery. Whilst she is happy with the results of her surgery as concerns her physical appearance, Patient E says she has had strange side effects that have not resolved since the surgery. The Board accepts the alleged side effects are a little idiosyncratic, however Patient E says that two of those side effects persisted as at February 2023 (and she notes she has not sought medical advice as she thought they would improve in time, but they had not). Another of them she did send an email about in February 2022 and got no response. It appears this went to an email address which may have been associated with the Lanzer Clinics which had, by then, closed,[92] not Dr Wells. Dr Wells' response in respect of the post-operative side effects is that the liposuction was not performed anywhere near the regions where Patient E is experiencing symptoms, this is the first time he has ever heard of these matters as a result of liposuction and Patient E did not raise these issues in the February 2022 email or by ever contacting him directly as she had been advised to do if she had concerns or queries. He otherwise points to several passages in the contemporaneous documents which record that Patient E was advised that healing can take up to six months.
[79] Patient F had surgery in early November 2021 at the Salisbury clinic, performed by Dr Wells under local anaesthetic. She lived regionally and had arranged to fly home the day after her procedure, which she said Dr Wells was okay with and she should go home and rest. She described being in terrible pain post-procedure and having to go to hospital where she spent three days. She describes horrific pain after discharge from hospital, being barely able to walk and taking six to eight weeks to get back to work and to do basic tasks. Patient F says she contacted the clinic a few months after her surgery because she was unhappy and she never got a response, so she called them and scheduled an appointment with Dr Wells by telephone. Then the 60 Minutes episode aired. She went ahead with the telephone appointment. During it, amongst other things, she says Dr Wells said he would rectify her surgery with more liposuction. Patient F reports being extremely unhappy with the results of the surgery, that the parts of her body the subject of surgery have not changed, she cannot go back to the gym and she cannot run. She says she suffered terrible depression after the procedure and Dr Wells has changed her life in an extremely negative way.
[80] Dr Wells through a written response from his solicitors says:

[77]

[88] Patient G's sister, who took her to and from the surgery, observed her sister struggle after discharge and says the surgery has affected Patient G very deeply: G is insecure and self-conscious, particularly about a deformity which has resulted from the surgery.
[89] Contemporaneous records are not necessarily consistent with Patient G's current recall. Both her sister and Dr Wells contest Patient G's recollection of no time in recovery. Dr Wells has otherwise responded, relevantly, that Patient G was Dr Lanzer's patient, he had very limited involvement in her treatment and he was not made aware of her after care appointments or concerns. He notes from the clinic's records that in the twelve months or so after the procedure, Patient G did not mention any serious concerns or issues.
[90] Patient A states she had ongoing pain on the right-hand side of her abdomen after the procedure, she had been diagnosed with a muscle tear and she has been advised the pain in her abdomen is chronic. Apart from stating that his involvement in the treatment of Patient A was limited to acting as the assistant to Dr Aronov in the second procedure and perhaps a follow up visit which he has no independent recollection of, Dr Wells does not address the issue of complications or pain.
[91] Patient H describes that there was no post-operative recovery time from his otoplasty procedure performed by Dr Wells at the Malvern clinic on 16 March 2021. He had blood left on one of his ears after the surgery and immediate bruising. His ears hurt a lot after the local anaesthesia wore off and became excruciating for a few days after the surgery. Medication which had been prescribed did nothing. He made ongoing complaints to Dr Wells of pain and sensitivity in his ears over a fifteen month period post-surgery. Patient H describes significant psychological impacts on him since the surgery.
[92] Dr Wells maintains Patient H was fully informed of the procedures and he is very sorry that Patient H experienced a known complication of this procedure, about which he was warned. Dr Wells kept in touch with Patient H throughout the post-operative period and emphasised to Patient H that he could contact him at any time. COVID-19 pandemic complications and the closing of the Lanzer Clinics complicated Patient H's post-operative period. Dr Wells facilitated numerous options to try to resolve Patient H's post-operative issues and significantly regrets Patient H lost trust in him. Dr Wells, through his representatives, maintains his belief that he provided reasonable care in the circumstances.
[93] Nurse Q and Nurse P speak highly of their observations of Dr Wells' post-operative management. Nurse P, who worked in Brisbane in 2021 and continued when Dr Wells established his own practice, said that Dr Wells would always make sure the patient felt as comfortable as possible. Dr Wells was different from the other doctors (I infer this is a reference to other doctors at the Lanzer Clinics) because he would see patients who were unhappy about the outcome of their surgery and he would address it and help them correct it. He wanted people to be happy and he would never rely on a consent form and say too bad. Nurse Q said if a patient was unhappy with their surgery, Dr Wells would listen; he was a very caring doctor.

[79]

[94] The Board pointed specifically to evidence from Patient A and Nurse K.
[95] Patient A makes a clear complaint of pain during the procedure not relieved by local anaesthesia. She also complains of pain in the immediate aftermath. Apart from Dr Wells saying his role was as a surgical associate to whom an aspect of the procedure could be assigned, he says he does not believe the statements at the paragraph in which they appear in Patient A's statement are accurate.
[96] Nurse K who worked between February and May 2019 at Spring Hill one day a week in the non-clinic weeks and two days a week in clinic weeks stated all the procedures (including liposuction, gynaecomastia and otoplasty) were done under local anaesthetic and this caused a lot of discomfort for patients. Dr Wells disputes this and notes that Nurse K provides no examples or particulars.
[97] There is other material in the hearing brief relevant to these issues.
[98] Patient G complains of pain and feeling everything that was happening in the procedure. She describes the procedure, performed under local anaesthetic, as being so traumatic she felt disassociated from her surroundings. Dr Wells has responded that Patient G was Dr Lanzer's patient, he had very limited involvement in her treatment, he has no independent recollection of the procedure but accepts the records show he assisted Dr Lanzer.
[99] Patient I, who had gynaecomastia surgery and liposuction performed on 14 August 2019 by Dr Wells, said he was 'pretty numb and not in pain' during the surgery.
[100] Patient C, who had three liposuction procedures over a number of months in 2021, each under local anaesthetic, describes 'it was more uncomfortable than anything else' for the first two, with the third one being 'quite a lot more painful' and when she told the nurses it was a bit painful they offered her gas through a little whistle which she was happy to take.
[101] Separately, the Tribunal notes that the evidence suggests that, at least on occasion, patients were given the option to determine whether to have a procedure under local anaesthetic or general anaesthetic, and that according to patients this decision was made based on cost.[97] The professional assessors sitting with the Tribunal inform it that the doctors should be telling the patient what level of anaesthesia is appropriate for their procedure, not presenting them with options, where the patients are ill-equipped to determine what relief may in fact be necessary for pain management, surgical risk and also because being conscious may be psychologically distressing to the patient.

[81]

[102] The Board relied specifically on two videos, which it played during the oral hearing.
[103] The first of them is a video in theatre, referred to in [56] above where the patient is awake, and her torso is filmed, post-procedure, to describe a tummy tuck and liposuction of the flanks. The patient's evidence is that she was awake when the video was being taken and that she was naked. When she found the video on Instagram she burst into tears and when she saw how they threw her skin down it made her feel sick again. The patient states she didn't know they were going to film and post the video on social media. The patient's husband has provided a statement relevantly that the patient broke down when she saw the video of her on the clinic's s[98]ial media.98
[104] Dr Wells' response includes that the filming of the procedure was expected as Dr Lanzer required Dr Wells to contribute to providing social media content. The Tribunal's difficulty with Dr Wells' statement is 'expected by who', in that it must be the patient's concern which takes priority, but that is not what happened here. He apologises unreservedly for his part in the video and acknowledges that the patient was in a vulnerable position and may not have felt she could withdraw her consent at the time. Dr Wells notes he did not upload the video and was never made aware of her concerns. If he had been, he would have taken immediate action. On becoming the new licensee at Salisbury, on 8 December 2021 all filming of patients and procedures ceased.
[105] Having watched the video during the hearing the professional assessors informed the Tribunal that in their opinion what appeared on the video was wholly inappropriate. That included that the procedure involved local anaesthesia only, that there was no screen between the patient's head and the area of the surgery, as well as the objectivation of the removed skin. It demonstrates aspects about the approach to procedures which is concerning, as well as the manner in which they are carried out.
[106] The second video shows Dr Wells manually pushing fat out of incisions on a patient's legs. This is the video which was the subject of expert commentary in the SMH article. Its contents are more fully discussed at [113]-[114] below.
[107] The patient states she signed a consent form for her before and after images to be used but she did not know her surgery would be video recorded. If Dr Wells had told her she thinks she would have said yes because she understands that recordings are useful for teaching/education purposes. The patient provides context to what Dr Wells was doing in the procedure which was captured in the video so far as she is concerned. The recording has entered the public domain through unknown channels and was aired on 60 Minutes. The patient says her upset was caused by the doctor who commented on the video for 60 Minutes, rather than what Dr Wells was doing.
[108] Dr Wells says the patient signed a consent form giving permission for the use of photographs and videos for media advertising.[99] Nurse H, who took the footage and did the patient's admission, says the patient asked to have it filmed because the patient suffers from a particular medical condition and she was curious to see it and wanted to share with her online community. The patient consented to the use of the video for educational purposes and the WhatsApp chat was the only communication that team members were involved in. Nurse H says one of the nurses showed the patient the video before it was posted on the WhatsApp chat group, but she could not recall if it was her or the other nurse. The patient had had a number of stages of procedure at the clinic and was quite comfortable.
[109] Nurse H also told the investigators that Dr Wells would discuss with the patients the options to consent to photographs to be taken pre-operation and post-operation for the medical files and for social media. Dr Wells' consent processes were adequate and fairly detailed. Dr Wells never did videos or photographs during theatre; if he was going to use something for social media, it would be photos during the admission process and then an after-care photo. Nurse H had no knowledge of patients who had issues with consent. Dr Wells was always very pedantic that consent had to be done prior to administration of medication or fluids, before patients get drawn on, marked up or undressed.
[110] Nurse O, who had started just out of COVID lockdown, said that Dr Wells hated the social media consent process, which was mostly Dr Lanzer driven. She knew Dr Lanzer was 'down Ryan's throat' trying to get him to do it, especially when the other cities were in lockdown, so they would sign a social media consent form, which would be on their file.

[85]

[113] The Board pointed first to the video of part of a liposuction procedure involving the third such procedure for the patient referred to at [106].
[114] Apparent in the video are, amongst other things, a towel on the floor to capture bodily fluid; bodily fluids spurting out from the patient's body onto the walls and doorknob; and the doctor is not evidently wearing fluid impervious shoes. The expert who commented for 60 Minutes on what could be seen in the video expressed concerns about lack of sterility, lack of infection control and biohazards. Nurse H who took the video stated she was not really sure what to expect with a manual extraction, they have policies for a terminal clean up in the clinic, the theatre was to have a terminal clean afterwards as it was the last case of the day. Dr Wells said a terminal clean was needed. At the time, the manual extraction 'was a learning thing'. There were no other occasions when Nurse H saw the room in that state.
[115] Dr Wells says that manual extraction, which is what is captured on the video, is a well-recognised and common technique used after liposuction to treat lipoedema. He recognises he should have arranged for additional draping and assistance in the particular circumstances but that the extent to which the fat projected in this case was highly excessive and uncommon; it was not a usual situation. He requested a more thorough terminal clean after this procedure. Dr Wells challenges the comments made by the expert about the video as being made without context and uninformed.[100]
[116] The Tribunal watched the video during the hearing. Having done so, with context, the professional assessors sitting with the Tribunal expressed the same opinions about the matters evident on the video as the expert who provided the initial commentary to the media set out at [114].
[117] There is reference to another video of Dr Wells attempting to swat a fly with a blanket in the theatre room. The video is not in evidence but still images from it are. The SMH media article attributes to the same expert the observations that the fact there is a fly in the operating theatre means the system has broken down and it is an absolute litmus test that there is something majorly wrong in the operating theatre.[101] He also expresses concerns about the patient being left without a blanket as one of the most important critically adjustable factors in preventing infection after surgery is keeping a patient warm.
[118] Dr Wells says the episode took place post-procedure whilst nursing staff were retrieving the recovery bed so the patient could be transferred from the operating theatre to the stage one recovery bay. He notes it is not unheard of for an insect to find its way into an operating theatre (having seen an insect find its way into an operating theatre previously) and categorically denies that the conditions were such as to allow a fly to grow in the operating theatre. The protocol is for the staff to 'herd' the insect away from the patient, the surgical field and any sterilised instruments, which was achieved on this occasion. He did not remove the blanket from the patient to swat the fly; the patient had been briefly uncovered for cleaning and post-procedure photography prior to being transferred to the recovery bay trolley for discharge from the operating theatre and the blanket had already been removed. Further, he is very aware that perioperative patient warmth is important and multiple measures (which he lists) were in place to keep patients as warm as possible.
[119] The professional assessors inform the Tribunal that it is rare to see an insect in an operating theatre and, further, that if this occurs it indicates very poor or absent infection control measures and inadequate measures for air conditioning.
[120] Dr Wells points also to part of an inspection report of the PHRU from an unannounced inspection after the Four Corners program in October 2021 and after the video about the fly was made. Paraphrasing the extracted part, that report noted the:[102]

[88]

(a) Nurse J said the rooms in the Spring Hill premises were never up to speed, there were globules of fat from previous surgeries and equipment would be transported in dirty suitcases;

(b) Nurse K, who worked between February and May 2019 at Spring Hill one day a week in the non-clinic weeks and two days a week in clinic weeks, stated:

(i) cleaning would be done with a mop, bucket and wipes between patients. After a procedure nurses used a bucket with cleaning solution to mop the floor and some kind of wipe was used to wipe down the benches, some of the equipment and the bed. There was no specified time to leave the solution on the floor to dry; the cleaning was performed as quickly as possible to turn over the room and get it ready for the next surgery;

(ii) she had received an email about infection control when she started with a generic infection control document which had 'insert clinic here' on the front of it;

(iii) whilst she could not recall observing particular incidents of infection control breaches, the way the tools were handled and the quick turnover of rooms was probably not up to standard;

(iv) the layout and actual environment was not up to standard for the procedures being performed there;

(c) Dr Wells points to this nurse's short employment period and disputes her assertion the floors in the Spring Hill clinic were wood, because they were covered with linoleum;

(d) Nurse M, who worked at the Spring Hill clinic from late May 2019 until 3 July 2019 one day a week, stated:

(i) She had concerns about cleanliness and hygiene at the Malvern and Spring Hill clinics. They were just pumping patients in and out relentlessly at both clinics. It takes time to sterilise between patients, but they were just getting rid of clinical waste and wiping down;

(ii) cleaners would come in at the end of the day to clean the theatre in Spring Hill, but in between it was just cleaned with Tuffy wipes and all the clinical waste was put in a yellow bag. One nurse would clean and the other would take the rubbish down to the clinical waste bins in the basement, taking the public elevator down. The turnover was done really quickly, in less than five minutes. Dr Wells, who has no independent recollection of this nurse, points out that the 'it' which the nurse refers to is not articulated and, she had little opportunity to observe whatever 'it' is, given her short employment;

(iii) she didn't witness any breaches of infection control. Dr Wells points to the internal contradiction in this nurse's statement about inadequate cleanliness and hygiene, whilst, at the same time her evidence is she did not witness any breaches of infection control. The Tribunal observes that Nurse M's period of employment is particularly short (she spent two weeks training in Melbourne, then returned to Brisbane on 6 June 2019, then worked one day per week until she resigned on 3 July 2019 because it was a 'dead end job ... with poor working conditions'. She says she didn't see things on the surgery day in Spring Hill because she was mostly doing consultations and aftercare although there was an operating and consulting day in the Spring Hill clinic when she was there);

(e) Patient I, who had gynaecomastia surgery in Malvern on 14 August 2019 under local anaesthetic performed by Dr Wells, said the rooms were not clean exactly, they looked like someone had been there just before him. Dr Wells has not commented about this in his response in the investigation;

(f) Patient A who went to the Malvern clinic in November 2019 described boxes on the floor being moved out of the way and under the bed in the theatre on the day of the first procedure and that, on the day of the second procedure, the theatre was messy, with plastic buckets lying on the grounds and the benches being full of stuff, a lack of order and that the room did not look like a sterile environment. In respect of the conditions concerning the second procedure, Dr Wells' response is that he does not believe this to be accurate as he understood that anything in the operating theatre met the National Safety and Quality Health Service Standards because the facility and operating theatre were fully accredited;

(g) Nurse G worked from January 2020 to November 2021 at the Salisbury clinic (although she went on maternity leave in May 2021 and says she resigned whilst she was on maternity leave). She was employed as a registered nurse by an entity associated with Dr Lanzer and did some shifts at the clinics on Wickham Terrace and in Melbourne and Sydney.[103] At some point before she went on maternity leave she dropped down to two days per week. On the subject of infection control, her signed statement includes the following:

(i) She decided to resign for a number of reasons including because the surgeries were not kept sterile and while she was on maternity leave she saw a video of fat squeezed out of a leg which really shocked her. The Tribunal observes that based on the timings this is likely to be the video referred to at [106] above;

(ii) At the Salisbury clinic the nurses would be expected after surgery to do a ten to fifteen minute turnaround of the theatre room. As an example, after liposuction, there would be dripping wet drapes and fluid all over the floor. The nurses would be expected to get rid of the drapes, put them in clinical waste bins, wipe down the beds, mop the floor and make the room look presentable for the next patient. She states, without any specific examples, that many patients would comment that they could see drops of fat, blood or other fluid on the walls as they came in. The cleaning should have been more thorough than the time allowed. Dr Wells says these statements are highly exaggerated, it was untrue that many patients would make the comments alleged and he frequently assisted nurses in cleaning the procedure rooms in between patients. Further, if required he would request an additional clean. Dr Wells instructs that he has seen situations requiring additional cleaning of a theatre in private and public hospitals before he started at DCSS and therefore did not find such an occurrence unusual;

(iii) At the Salisbury clinic there were spiders in some of the theatre rooms and a video where Dr Wells swatted a fly in the theatre room. There is a typed version of a WhatsApp chat in evidence which dates to 4 March 2021 and involves her asking about pest control in the context of the occasion with the fly in the theatre swatted by a blanket. She was told that pest control had been done;

(iv) The Salisbury clinic would resterilise single use equipment which she alleges was done under instruction from Dr Wells verbally and she believes was to save money. Dr Wells denies that this occurred or that he instructed it to be done. Whilst he has a vague recollection that there was one instance where this had happened, on discovering the error, the instrument was discarded without being used. He refutes the allegation concerning costs, noting that it is significantly more cost effective to sterilise reusable instruments than it is to purchase single use instruments for every case;

(v) Dr Wells requested that the Wells Johnson fat transfer cannisters be reused when there wasn't enough time to sterilise them. Dr Wells denies that this occurred and denies he ever instructed it to occur;

(vi) She identifies potential concerns about a nurse or nurses not wearing gloves when touching patients in dealing with after care issues for patients who had procedures. She makes these observations from video footage posted on a work group chat, noting she was not present on the occasions when videos were taken. Dr Wells accepts that the nurses should have been wearing gloves on those occasions noting, in relation to one of the occasions, that it was particularly unusual for that nurse not to wear gloves. It seems from Nurse G's statement that although there are several videos, a number of the videos relate to a single occasion;

(h) Nurse C, who worked at the Salisbury clinic between late August 2020 and April 2021 five days a week with Dr Lanzer and Dr Wells, has stated:[104]

(i) She did not recall seeing any policies or procedures on infection control at the Salisbury clinic. The clinic, including the lift and stairs, was really unhygienic and dirty when she started. She did a lot of overtime cleaning theatre and recovery. Patients had to walk past messy areas with rubbish bags and soiled linen to get to the lift. There would be dead skin and fat around the theatre bed and she needed to scrape out the computer, which was quite gross. The trolleys set up for sterile procedures were also quite dirty. They had one bucket and mop to clean both theatre and recovery, which was concerning as there should be a separate one for each. This is because theatre is a sterile area and recovery is not sterile, so there could be cross contamination. She mentioned this within a couple of weeks of starting work there, but nothing was done about it until about February 2020 when new mops and buckets were purchased. There are photographs attached to her statement apparently showing fat and blood on the walls. Dr Wells notes that, whether or not this nurse saw policies and procedures, the clinic would not have been accredited without them, the photographs are more likely a prompt to conduct a more thorough clean and Dr Wells understood there was a bucket for each of the theatre and outside recovery. In any case he does not recall this nurse raising it as a concern;

(ii) There was a lack of infection control and cleaning in the theatres. Nurses would leave bloody, soiled linen on the bed and not wipe down in-between patients. Nurses were required to clean as quickly as possible to get the next patient in and sometimes the cleaning between patients would be done in about ten to fifteen minutes. The number of nurses involved in cleaning would differ depending on whether it was local or general anaesthetic. If it was local anaesthetic, it was generally one nurse's responsibility. For general anaesthetic, there was usually a minimum of two nurses. Procedures under local anaesthetic tended, to some degree, to have less bodily fluid and blood to clean up compared with procedures under general anaesthetic. Dr Wells' response is that it is outrageous to suggest the theatre was not cleaned and linen was not changed between patients, he was never made aware that this happened and he never had cause to believe that it might have happened;

(iii) issues of safety for nurses and patients arose because scalpel blades, which the doctor should have disposed of, were left in the tray of equipment to be cleaned, sterilised or discarded. Sharps such as needles without caps on and suture needles, opened vials of antiseptic and other products, and used gauze were left in the consultation room and in the recovery area on desks. There was incorrect management of sterilisation packaging of surgical equipment such as trays and fat transfer cannisters, which increased the risk of infection to patients. A photograph attached to her statement apparently shows surgical materials left on a desk. Dr Wells' response is he had no involvement with the intricacies of sterilisation processes, but does not accept it was mismanaged by the nurses to such an extent that there was an increased risk of infection. Further, that there were policies and procedures in place as a requirement of accreditation and he was never made aware the nurses had not followed those policies and procedures. If there was an unsheathed needle, it was an unfortunate oversight, he recognises and acknowledges the safety implications of this and will ensure that this never happens again on his return to practise;

(i) Patient G, who went to the Salisbury clinic in August 2020 for liposuction recalls seeing fluids, which she assumes was fat or other bodily fluid, dripping all over the floor and that there were stains all over the floor. Dr Wells has not responded to these comments.

(j) Patient J who went to the Salisbury clinic in September 2020 described it as being 'one step off being a backyard medical practice' and that the clinic seemed to be relaxed about hygiene and cleanliness. Dr Wells disputes this stating that, to the best of his knowledge, whilst Dr Lanzer was the licensee of the Salisbury Day Hospital, which he was at this time, it was a fully accredited day hospital that met relevant standards.

(k) Patient H who had an otoplasty performed by Dr Wells at the Malvern clinic on 16 March 2021 described that the room where his surgery occurred as looking 'third world' . He took photographs of the room which are not included in the HB.[105] Dr Wells challenges this description by reference to photographs which apparently show equipment open on a sterile sheet on a trolly and a bed which has an unopened sterile sheet which is still to be prepared, in the Malvern clinic of DCSS which was a licensed facility.

[93]

[126] There is material that Dr Wells was concerned about hygiene and infection control in the hearing brief.
[127] Nurse L recounted an occasion when Dr Wells came into the theatre and spotted what she believed was a globule of fat on the roof after the theatre had been cleaned. He quizzed the staff about it, then made a video to show other staff what had been missed. It would have been cleaned off.
[128] A patient who had surgery on three separate occasions throughout 2021 at the Salisbury premises (before Dr Wells took it over) observed it was clean and tidy for her initial consultation and 'lovely and clean' for the first two of her three procedures. The patient does not make any comments about the state of the premises for the third procedure.
[129] There is some evidence of a change in approach once Dr Wells took over the practice. Nurse H told the investigators that when the practice changed over to Dr Wells, they had an outsourced team which helped with new policy and procedure, making sure everything was up to date. Dr Wells made a lot of changes and made them go through a lot more training, upskilling and refreshing on things, and Nurse H said Dr Wells was really good with providing as much information and upskilling as the nurses could do.
[130] Nurse L said that most of the staff who were employed in Brisbane stayed on with Dr Wells after he started the Institute of Aesthetics. She had no issues or concerns whilst working with Dr Wells.
[131] On a related topic, the Board also relies on the keeping and use of expired stock, which Dr Wells denies doing.
[132] Nurse P said in a redacted transcript of an interview that the issue of expired stock was raised often by multiple people and this was never changed. It was raised to Dr Lanzer. The questioner then asks, 'or Wells?' To which Nurse P said, 'mmm' and went on to say 'Dr Lanzer, yeah'.[107] I regard the transcript as equivocal as to whether the nurse ever accepted that these issues were raised with Dr Wells. However, Nurse G says in her statement that nurses at the Salisbury clinic were requested to use out of date medications; she refers to a WhatsApp group message posted by a nurse about powering through old stock so they can get nice new shiny (in date) stock, which is in the hearing brief.[108] The way that message appears suggests it was posted by Nurse P and that the group chat included Dr Wells. Dr Wells' response is that he never encouraged or condoned the use of expired medications and whilst he does not have an independent recollection of the context of the photograph and text message, he believes it may have been said tongue in cheek as a joke.
[133] Additionally, Nurse C says that she noticed a few vials of outdated medication and she told Dr Lanzer and Dr Wells she would dispose of them, but they said not to, because they could be used at some point. Nurse C, who worked at the Salisbury clinic with Dr Wells and Dr Lanzer from 31 August 2020 to mid April 2021, also describes the location where the expired medication was kept in theatre and that Dr Lanzer and Dr Wells said to move everything to the attic when the audit was being done and the expired medications were then moved to the attic. Whilst Nurse C says that Nurse N also noticed the out of date medication, Nurse N says nothing about that in the transcript of her interview. Dr Wells says whilst Dr Lanzer was the licensee of the facility, he had minimal involvement in the auditing processes, and believes staff were directed by Dr Lanzer and the quality control/management team in Melbourne regarding these processes. Dr Wells denies this nurse's statements about expired medication and states he would not encourage anyone to either keep or use expired medications.
[134] Nurse H told the investigators she could not recall any conversations in the group chat which raised alarm bells concerning concealing old stock or expired medications prior to audit, they checked everything was up to date and not expired, but nothing in the chat.
[135] I have set out this material person by person at some length to demonstrate the width and breadth of the evidence of concerns that were raised:

[115]

[154] Nurse P told the investigators in her interview that Dr Wells was really the only doctor who worked there in 2021 and he would see one patient at a time and could give them more of his focus.[117] Patients would not have to wait too long before liposuction commenced - probably ten to max thirty minutes.
[155] Nurse P said that in Queensland, patients under local anaesthetic were monitored during surgery by a nurse and their observations were taken every five to ten minutes. This was Dr Wells' directive; it wasn't policy or procedure that was required in Melbourne and even in Queensland, whilst it was still Dr Lanzer's, it often was not done because it was not part of policies or procedures. Monitoring definitely came in when it was Dr Wells' business.
[156] One further issue which arose here was the taking of telephone calls during procedures. Expressly, Nurse C told the investigators that Dr Wells would often use his phone in theatre in the middle of an operation where a patient may be under local or general anaesthetic. If his phone rang, he would ask a nurse to go and get his phone and he would then grab his sterile gown from underneath with his sterile glove and take the call while holding the phone with the gown. The nurse would take the phone from him when the call finished and he would sometimes change gloves, but not all the time. The calls may be from patients with post-procedure care concerns or a personal call about buying a boat or real estate. Another nurse who was at the Spring Hill clinic told the investigation that when she was doing aftercare appointments, if a patient had concerns, she would Facetime the doctor who could be in the middle of surgery or consulting a patient, but would also be on the phone to her. Dr Wells says doctors taking calls during procedures is not unheard of in all areas of medical practice and, on occasion, he may answer a phone call during a procedure but he would only do so when it was safe. If it was necessary for him to take a call, he would maintain sterility always, e.g., by using the speaker function and/or with a nurse holding the phone for him. In such an instance there would be no need to rescrub. If he left the theatre he would then rescrub and re-gown on his return. He does not address the nature of the calls.
[157] The professional assessors inform the Tribunal that doctors may take an occasional or very rare phone call during a procedure provided it is urgent and related either to the patient in the procedure or another patient. More typically, a doctor would ask a nurse to take a message and for that to be relayed. Calls about real estate or boats would not be acceptable regardless of how the phone was held.
[158] The express reference to there being phone calls about boats receives some inferential support when photographs from Dr Wells' social media contained in the hearing brief are considered, featuring him apparently on several different boats, suggesting he has an interest in boats.[118]

[117]

[159] The Board relies on material from Nurse C, Nurse J, Patient B and Patient H.
[160] Nurse C said she decided to resign for reasons including that her health started to decline around November to December 2020 because of her long working hours. There was an expectation that she would start work around 5am or 6am and would not leave until 1am or 2am the next morning. This would happen if surgery finished at say 10pm and the nurses were obliged to care for the patients in recovery because neither the doctors nor the anaesthetist wanted to send the patients to hospital. This happened even though it was a day hospital and patients were not to be kept past 12am. She had a lot of concerns about how Dr Wells and Dr Lanzer were practising and what they were telling patients about their care, specifically that they were not acting in the patients' best interests, especially if the patients needed to go to hospital. Dr Wells has not responded to these matters.
[161] Nurse J, who worked for the Lanzer Clinics, also had cosmetic procedures involving gynaecomastia and liposuction by Dr Wells and Dr Lanzer. He describes returning to work at the Lanzer Clinics a few days later in a lot of pain, being unhappy with the procedure and getting 'the usual pep talk' from nurses at DCSS.
[162] Patient B, who lived regionally and had surgery including a tummy tuck in April 2021 (which, based on the dates, would have been very shortly after Nurse C concluded her employment), recounts speaking to Dr Wells about post-surgery concerns and being asked to come back to the clinic. He returned to Brisbane from the regional centre, using public transport, in circumstances where he then received intravenous antibiotics and pain relief medication, on a regime of twelve hourly cycles over several days. He was required to leave the clinic after his first intravenous ('IV') drip, then return twelve hours later (which was about 8:30pm in the evening the first day, and not concluded until about 1am in the morning the next day), so he went to a motel in between using Uber. He says of the second late event that he was required to leave the clinic and wait on the footpath for an Uber, which did not come until about 1:40am. The cycle for the fourth day of IV drips commenced at 4:30am in the morning. He improved and returned home. He dealt with a subsequent bout of infection by going to the emergency department at the local regional hospital.
[163] Dr Wells, through his solicitors, says of events involving Patient B:

[121]

[167] The foregoing is a summary of the almost 1700 pages of material before the Tribunal. Dr Wells' account is gleaned from his solicitors' responses; he has not given a statement or sworn any affidavit.
[168] The Tribunal makes the assessment about serious risk now, in the circumstances known to it as of now.
[169] In this case, there are some occasions where patients or nursing staff are highly or substantially complimentary of Dr Wells. They include Patient C and Nurses L and P who both continued to work for Dr Wells when he was practising on his own account. This must be weighed in the balance for the Tribunal in forming a 'reasonable belief'. Of course, the view of any patient or staff member, for or against, is not, of itself determinative.
[170] Conversely, many of the patients' and employees' accounts differ significantly from Dr Wells' account on issues of concern. In oral argument, Dr Wells accepted, broadly, that he had joined issue in a factual sense on almost all issues other than those the subject of videos. That is his right and this Tribunal does not make any final determinations of factual issues. It means, however, where determinations will turn (at least to some extent) on issues of credit, pointers to credibility, limited as they are at the interim stage of the matter, may assist the Tribunal in determining, objectively, whether, because of his conduct or performance, Dr Wells poses a serious risk to persons which renders it necessary to impose conditions on his registration to protect public health and safety.[119] It is legitimate to examine the respective accounts carefully, as this may assist in ascribing weight, at this stage, to their accounts where they differ.[120] To credibility, I would add indicators of probability can also assist the Tribunal: for example, things recorded contemporaneously and in the ordinary course may suggest a probability of accuracy that things recorded distant in time and where other interests have arisen may not carry.
[171] The Board submitted and I accept that information contained in signed statements given by registered practitioners should carry weight, particularly if those statements may contain matters which are inimical to the practitioners' own interests. Conversely, I am of the view that while there are general statements recorded in redacted partial transcripts of interviews, where it is not clear where events occurred, when those events occurred and which patients, if any were involved in those events, those matters carry less weight. Similarly, matters cast in speculative terms carry little weight.
[172] There is a class action on foot in Victoria, which a number of the patients who have made complaints are involved in, and where Dr Wells is a respondent, along with Dr Lanzer and others. Dr Wells submits that, because of the class action, patients have an interest in giving negative versions of events. It is true that some patients' accounts or parts of them now are inconsistent with their contemporaneous communications.[121] This must be weighed in the balance for the Tribunal in forming a 'reasonable belief'.
[173] The Tribunal acknowledges Dr Wells has:

[123]

[174] One of the Board's identified concerns does not, in the Tribunal's view, enable it to form a reasonable belief that Dr Wells poses a serious risk to persons. Whilst there are two videos in which a patient and Dr Wells appear, the evidence does not support the Tribunal forming a reasonable belief that as at now, Dr Wells presents a serious risk to persons that the filming of procedures and uploading them to social media will continue (2(e) in the Reconsideration Decision). The uncontested evidence is that Dr Wells was an unwilling participant in the practice of uploading to social media whilst working in the Lanzer Clinics and he discontinued this practice when he commenced his own practice.
[175] The position is different, however, when the Tribunal turns to consider factors associated with communication with patients, surgical performance, post-operative performance, prescribing and infection control and referral to other practitioners (2(a), (c), (d), (f), (g), (h), (i) and (j) in the Reconsideration Decision).
[176] The notifications involve eleven patients who complain about the performance of surgical procedures, post-operative care and post-operative outcomes.[123] Dr Wells does not have any formal surgical qualifications. The procedures being performed involved, on occasion, large incisions into complex areas of the body.
[177] Seven of the ten patients have provided signed witness statements. They speak variously to experiencing pain during procedures, significant pain post-procedure, protracted recovery times beyond what they say they were told, complications post-procedure and ongoing distress at outcomes which were not anticipated.
[178] Five of the notifications relate to alleged adverse outcomes where Dr Wells was the primary, equal or only proceduralist.[124] Dr Wells challenges the criticisms by reference to known complications, the credit of a number of those patients, including on occasion by reference to contemporaneous records, the time taken to complain or the potential involvement in a commercially motivated class action. None of those matters alone, or collectively, is determinative of the questions for the Tribunal.
[179] In another five of the cases the subject of the notifications,[125] Dr Wells responds that he was the assistant only, he had extremely limited, if any, prior contact with the patients and he disavows largely any role in their post-operative management. His role in the actual surgery on each occasion is less clear. If his surgical skills are ultimately a concern, that will not be adequately managed by a process which sees him able to return again as a surgical assistant. A mistake, even for one person, can have long lasting and pervasive consequences.
[180] There are other areas of concern in the context of management of surgical procedures. For example, two patients say they were cold[126]. Dr Wells has identified this is a risk in anaesthesia and that there were measures in place to deal with it, but it does not seem to be something being managed for all patients under his care. Evidence from nurses is to the effect that, on occasions, Dr Wells would participate in post operative care of patients by review of photographs or Facetime calls when he was in surgery with other patients. The tenor of the evidence is that this was a not uncommon practice.
[181] Acknowledging some patients and nurses are supportive of Dr Wells, this is still a significant body of patients with complaints, over a relatively lengthy period of time and there is a reasonably common thread of concerns running through the notifications.
[182] Until the issues associated with surgical competence and outcomes are finally determined (2(c), (d) and (h) in the Reconsideration Decision), the Tribunal holds the reasonable belief that Dr Wells presents a serious risk to persons if he is able to return to cosmetic surgery, either unsupervised or as an assistant only.
[183] There is evidence that substantial amounts of fat (2(b) in the Reconsideration Decision) were removed from four patients.[127] The Tribunal does not accept Dr Wells' submission that, as at today, there is no evidence that removal of more than five litres is unsafe, where there have been guidelines in place in Victoria for over three years which expressly mandate the removal of no more than this amount in the tumescent protocol for liposuction and that lesser amounts are the maximum for other techniques. Guidelines exist for a reason; they are to provide indications of what constitutes safe practice in particular circumstances. Dr Wells, when seeking the lifting of the suspension in July 2024, was prepared to undertake that he would only undertake liposuction procedures where the lipoaspirate is less than five litres.[128] This may be troubling, however, if Dr Wells has a different understanding about what is meant by the five litres from that provided for in the guidelines: is it what is removed on the day, or what has occurred after 'settling'. At least one of the patients involved in a notification was one who Dr Wells treated when he was operating his own practice, where he said he had adopted a practice of removing only about 5 litres. The definition of lipoaspirate volume in the Victorian guideline is as a reference to the total volume of aspirate, including infiltrate, blood and fat. It does not contain any reference to volumes 'after settling' but Dr Wells seeks to defend his practice in part by reference to 'settling'. This makes it difficult for the Tribunal to accept that Dr Wells would adhere to the guideline.
[184] So too, the risks associated with hygiene and infection control (2(f) in the Reconsideration Decision). The Tribunal accepts that:

[129]

[188] I also note the professional assessors inform the Tribunal that they have never seen bodily fluids splashed on walls in a theatre, meeting a National Safety and Quality Health Service Standards at a point in time does not equate to an ongoing acceptable standard on a day to day basis and what Nurse G reports about the cleaning of the theatre room after surgery and before the next patient is unacceptable and reinforces concern about the management of sterility, infection control and general hygiene
[189] As to disrespectful manner and communications (2(a) in the Reconsideration Decision), what can be seen in the video involving Patient A is serious. Dr Wells accepts this and apologises for it. It is inescapable that, amongst the cohort seeking out these procedures are people who are highly vulnerable.[131] Patients seem particularly vulnerable in this cohort if they do not achieve their desired outcomes. Clear, comprehensive, unhurried communications about the procedures, their risks, their complications and likely outcomes at the outset of the doctor-patient relationship are vital. The doctor's role in this is crucial: it is the doctor, who has the training and expertise to deploy for the benefit of the patient. It is hard to see that a ten to fifteen minute consultation, sometimes done over Microsoft Teams with photographs, can ever be adequate to obtain informed consent about cosmetic procedures which may have significant and long lasting impacts on people, even if there has been an anterior consultation with a nurse of equivalent length. Whilst there is some evidence, particularly from nurses, which is supportive of Dr Wells' communication abilities and the time he takes, some patients challenge his communication with them. It is concerning that even Patient C, who is highly supportive of him, misunderstands that she has signed a consent form giving permission to make and use videos of her procedure for media advertising.
[190] As to the issues concerning prescriptions (2(g) in the Reconsideration Decision), the fact that the Board is prepared for Dr Wells to work as a medical practitioner under supervision and at approved locations suggests it does not have insuperable concerns about his ability to utilise prescription pads appropriately. In the Tribunal's assessment that is appropriate, particularly where Dr Wells is working in a supervised situation and could observe and participate in proper practices. This concern about prescriptions assumes significance in the Tribunal's decision on serious risk because, as with the issue about infection controls, there is evidence of inappropriate practices which Dr Wells should have addressed or challenged, assuming he did not participate in them. Many of the nursing staff point to practices they say existed, but do not admit to participating in those practices themselves. Accounts given by patients[132] suggest significant irregularities involving prescriptions. In this regard, Patient L's evidence of her experience in obtaining a prescription at the Brisbane clinic at a time when Dr Wells was largely operating from there, is instructive. Dr Wells has not articulated with any level of insight any acceptance of concerns about these practices. Rather, he has largely disavowed that there were any deficits which supports a conclusion of serious risk to persons currently.
[191] Finally, as to discouraging patients to consult other practitioners or getting staff to do so (2(i) and (j) in the Reconsideration Decision), there is evidence from two patients[133] that they were treated post-operatively for complications at the Salisbury Day Hospital, with that treatment requiring attendances very late at night and very early in the morning. This provides support for Nurse C's evidence about her extensive lengthy working hours, which suggests, as a minimum, a stretching of the boundaries of what is appropriate operations in a day surgery situation. There is no evidence that the treatment protocols applied to respond to post-operative infection were unique or unknown to other medical professionals. Whatever Dr Wells may have said to patients about consulting other practitioners, the evidence supports a reasonable belief that at least some patients understood him to be discouraging their attendance elsewhere.[134]
[192] Dr Wells has stated that he has found it difficult to balance defending himself against allegations he believes are (and which may or some of which may prove to be) unfounded whist articulating that he is truly remorseful. The Tribunal accepts he has sought to engage genuinely in a reflective and educative process while he has been suspended.
[193] Whilst he has expressed apology and regret for some things and in his reflection report he has stated he made mistakes, it is not clear from that reflection report what, apart from communication,[135] he thinks his mistakes are. Doing the best I can, it seems Dr Wells has focused on the external environment and influence of others on him as informing his conduct.[136] Without his own articulation of how he came to act as he did then and what he would do differently now, if confronted by the same or similar circumstances, it is difficult to accept his assurances as to his prospective conduct.
[194] The Tribunal is satisfied that the serious risk to persons presented is that there may be adverse:

[138]

[206] The Cosmetic Surgery Guidelines also set out, relevantly, equivalent requirements for equivalent stages relating to non-surgical cosmetic procedures.
[207] With the advent of these additional guidelines, it seems unlikely that a business model akin to one with features I have identified in the matters of contextual framework would be likely to be replicated, as it would fall demonstrably foul of the Cosmetic Surgery Guidelines. Consequently, the current system of guidelines should see industry practices having already altered to afford greater protection to prospective patients in this field of medicine.
[208] However, the field of cosmetic medicine and cosmetic surgery is one which has been in the public eye for some time. An amount of the material filed in this review remains readily accessible in the public domain.[151] The Tribunal holds the view that public confidence in the regulatory system and the profession may well be shaken if Dr Wells returned to practice in these fields, before the existing issues are finally resolved and any further issues occurred involving this practitioner, patients and cosmetic medicine or cosmetic surgery.
[209] The issues currently under investigation involving this practitioner need to be determined to support the guiding principle that the public can have confidence that those working in this field of medical practice have proper technical competence and proper understanding of and commitment to good medical practice to provide safe services.
[210] Until the issues involving Dr Wells in this investigation are resolved it is not in the public interest that he return to practice in the fields of cosmetic medicine and cosmetic surgery.
[211] The Tribunal will hear the parties on the question of costs. If either party seeks to make a submission concerning costs, that party is to file and serve written submissions of no more than four pages within seven days of the delivery of these reasons and the other party may respond by filing and serving written submissions of no more than four pages within seven days of receiving the first party's submissions. Subject to the terms of those submissions, the Tribunal may determine the issue of costs on the papers.
[212] The Tribunal thanks the assessors for their considerable and thoughtful assistance.

At a glance

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Judgment (215 paragraphs)

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