Health Ombudsman v LON

QUEENSLAND CIVIL AND
ADMINISTRATIVE TRIBUNAL

CITATION:

Health Ombudsman v LON [2025] QCAT 409

PARTIES:

HEALTH OMBUDSMAN

(applicant)

v

LON

(respondent)

APPLICATION NO/S:

OCR160-23

MATTER TYPE:

Occupational regulation matters

DELIVERED ON:

24 October 2025 (decision)

10 November 2025 (reasons)

HEARING DATE:

On the Papers

HEARD AT:

Brisbane

DECISION OF:

Judicial Member Jones
Assisted by:
Dr J Bayley
Dr P Glazebrook
Dr K Hames

ORDERS:

IT IS THE DECISION OF THE TRIBUNAL THAT:

1.    Pursuant to s 107(2)(b)(iii) of the HO Act, in respect of allegations one to four collectively, the respondent has behaved in a way that constitutes professional misconduct.

2.     Pursuant to s 62(2)(a)(ii) of the HO Act, the immediate registration action taken by the Health Ombudsman in respect of the respondent is set aside.

3.     Pursuant to s 107(3)(a) of the HO Act, the respondent is reprimanded.

4.     Pursuant to s 107(3)(d) of the HO Act, the respondent’s registration is suspended for a period of eighteen months from the date of this decision.

5.     Pursuant to s 107(3)(b) of the HO Act, upon the suspension set out in 4 above expiring, conditions are imposed on the respondent’s registration in the form of Annexure A to the Tribunal’s decision.

6.     Pursuant to s 109(2) of the HO Act, Part 7, Division 11, Subdivision 2 of the Health Practitioner Regulation National Law (Queensland) applies to the conditions imposed.

7.     Pursuant to s 109(3) of the HO Act, the review period for the conditions imposed is twelve months.

8.     Each party must bear their own costs for the proceeding.

THE TRIBUNAL ORDERS THAT:

1.    The non-publication order made by the Deputy President on 18 July 2023 is set aside.

2.     In lieu thereof, pursuant to s 66(1) of the Queensland Civil and Administrative Tribunal Act 2009 (Qld), publication of:

(a)     the contents of a document or other thing filed in or produced to the Tribunal;

(b)     evidence given before the Tribunal;

(c)     any order made or reasons given by the Tribunal;

is prohibited to the extent that it could identify or lead to the identification of the respondent or any family members of the respondent, and any patient of the respondent or any family members of such patient save as provided for by the terms of this order and save as is necessary for the parties to engage in and progress these proceedings, or any appeal or review arising from these proceedings, and for the applicant or the Australian Health Practitioner Regulation Agency to exercise each of their statutory functions under the Health Practitioner Regulation National Law (Queensland).

3.     Any material affected by the non-publication order shall not be copied or inspected without an order of the Tribunal, except by:

(a)     a judicial member;

(b)     a tribunal member;

(c)     an associate to a judicial officer or tribunal member appointed under relevant legislation;

(d)     any assessor appointed to assist the Tribunal;

(e)     the staff of the Tribunal registry;

(f)      any judicial officer, court staff or associate dealing with any appeal or review arising from these proceedings; or

(g)     the parties to these proceedings or any appeal or review arising from these proceedings.

CATCHWORDS:

PROFESSIONS AND TRADES – HEALTH CARE PROFESSIONALS – MEDICAL PRACTITIONERS – DISCIPLINARY PROCEEDINGS – PROCEEDINGS BEFORE BOARDS, TRIBUNALS, ETC – where the respondent was a psychiatrist – where the respondent treated a fifteen-year-old vulnerable female – where the respondent violated professional boundaries by messaging the patient by way of text message and Facebook Messenger – where a number of the messages included expressions of love by the respondent to the patient – where the respondent told the patient about his life burdens including matters of sexual abuse against him when he was a child – where it is also alleged that the respondent failed to provide clinically appropriate treatment by failing to handover care of the patient to another practitioner – where the respondent divulged the patient’s medical and personal information, the conduct of which comprises allegations three and four – where an expert provided a report in relation to the respondent’s psychiatric state at the time of the conduct – where the expert opined that the respondent’s conduct was not sexually motivated but acknowledged it risked being misconstrued by the patient – where the parties have come to an agreed position regarding facts, characterisation and sanction – whether the Tribunal is of the view that the proposed findings and orders are appropriate in the circumstances

Health Ombudsman Act 2013 (Qld)

Health Practitioner Regulation National Law (Queensland)

Queensland Civil and Administrative Tribunal Act 2009 (Qld)

APPEARANCES & REPRESENTATION:

This matter was heard and determined on the papers pursuant to s 32 of the Queensland Civil and Administrative Tribunal Act 2009 (Qld)

REASONS FOR DECISION

On 24 October 2025, the Tribunal made the findings and orders identified above. Following are the reasons for those findings and orders.
This proceeding was concerned with untoward conduct involving LON (‘respondent’) sought to be dealt with by this Tribunal by the Director of Proceedings on behalf of the Health Ombudsman (‘applicant’). There are four allegations made against the respondent. None of those allegations are put in issue to any material extent by the respondent.

Background

The respondent is a registered medical practitioner with a speciality in psychiatry. In 2003, he completed a Bachelor of Medicine/Bachelor of Surgery at a university in Australia. He was first registered as a medical practitioner in Australia in 2004. The respondent obtained Fellowship of the Royal Australian and New Zealand College of Psychiatrists in 2011.
The respondent has been registered with the Medical Board of Australia (‘Board’) at all material times. The respondent was approximately 46 years of age at the time of the conduct and was self-employed at a practice in the city and at a suburban clinic. The respondent had no prior disciplinary history, however, there was a prior event of intervention, which involved the respondent being reported to the Health Ombudsman and then a referral to Ahpra in 2018. A peer-reviewed consensus was that he had overstepped the boundaries by offering a patient money among other things.[1]
[1]Applicant’s Outline of Submissions, filed in the Tribunal 14 March 2025, 3-4 [6(d)] (‘Applicant’s Outline of Submissions’).

The conduct the subject of the referral

The conduct of the respondent involved a female patient who was, at the time, fifteen to eighteen years of age and was in a very vulnerable state. The respondent had treated the patient at a suburban practice and on occasions in the city. The patient's family could not afford to pay the respondent’s private fees, so the respondent offered to bulk bill for his services. Between 2018 and June 2020, the patient attended appointments with the respondent weekly and sometimes twice weekly. The patient was the same patient that was dealt with under the referral referenced above.
The respondent had diagnosed the patient with Complex Post Traumatic Stress Disorder, Major Depressive Disorder and Anxiety. During the treating relationship the respondent billed the patient for approximately eight appointments and bulk billed the patient for a further 111 consultations. It is to be noted that the patient ended the treating relationship just before her eighteenth birthday. In July 2020, the patient was admitted to a hospital with suicidal ideation; it was during her assessment that she advised the treating doctors of the respondent's conduct.
During the treatment of the patient by the respondent, he prescribed numerous medications designed to treat the mental state of the patient. The respondent's own notes identified that he saw the patient as having moderate suicidal tendencies and that her ‘vulnerability remains chronically high’.[2] Put bluntly, the conduct that brings the respondent before the Tribunal involves his obsessive behaviour towards this young woman.
[2]Statement of Agreed Facts, filed in the Tribunal 24 May 2025, 3 [19(i)].
Brief particulars of the uncontested allegations are as follows. Allegation one involved the following boundary violation:[3]
Between 7 May 2020 and 22 June 2020, the [respondent] and patient communicated by Facebook Messenger. There was a total of approximately 1,092 messages exchanged. On 18 May 2020, approximately 116 messages were exchanged. On 20 May 2020, approximately 168 messages were exchanged in a single day. On 4 June 2020, approximately 92 messages were exchanged. The respondent and patient also communicated during this time by SMS (text) messages. Between 22 June 2020 and 18 July 2020, after the respondent stopped using Facebook Messenger, the respondent and patient exchanged a further 293 SMS (text) messages.
[3]Ibid 5 [33].
The parties agreed that messages were exchanged at all hours of the day and night. Disturbingly, a number of these messages included expressions of love, including, by way of example, the respondent sending the following messages:[4]
(a)‘I love you [name of patient]’; and
(b)‘I love you and I may be falling in love with you’.
[4]Ibid [34].
A number of the messages also placed the respondent’s life burdens upon the patient, including the abuse he suffered as a young man, which is discussed more at [14] below.
Allegation one further includes that respondent:[5]
[5]Ibid 6-10 [35]-[73].
(a)offering the patient money on two occasions;
(b)hugging the patient on two occasions during treatment sessions;
(c)offering to give the patient a massage or a ‘back rub’ during treatment sessions;
(d)telling the patient he would pay for her to go to university;
(e)telling the patient that he was looking into the option of becoming her guardian;
(f)telling the patient that his wife was aware that he wanted to include the patient in his will;
(g)paying a significant sum to a community organisation through a sponsorship arrangement which ensured the patient would receive twelve months of housing;
(h)bringing the patient groceries and gifts on occasion; and
(i)visiting the patient's living premises outside of usual clinic hours on a number of occasions.
The second allegation involves the respondent’s failure to provide clinically appropriate treatment. This can be particularised by way of summary as:[6]
Failing to hand over the patient’s care to another practitioner after being advised to do so by his peer group and a senior psychiatrist and failing to refer the patient to a qualified child and adolescent psychiatrist or to the Child and Youth Mental Health Service for a multidisciplinary team approach.
[6]Ibid 14.
Allegation three involved the respondent divulging the patient’s medical information to others and allegation four involved the respondent divulging personal information about the patient.

Discussion and sanction

By reference to the uncontested affidavits of the respondent and the numerous medical reports filed in this proceeding, it is clear that the respondent had a seriously troubled childhood which involved mental and physical abuse including being raped by persons who were meant to care for and protect him. It is also clear that the respondent was subject to a number of stressors in his home life at the time of the conduct.
In this instance, both parties were represented by highly regarded and experienced senior legal practitioners who had reached agreement between them as to the appropriate findings and orders that ought to be made. Those matters will be addressed in more detail below. It is of course the responsibility of the Tribunal to address the appropriate outcomes. That said, there being such an agreement between the parties is a significant factor to be taken into account, particularly where both parties are so ably represented by experienced lawyers. The Tribunal is satisfied that, on balance, the findings and orders sought by the parties are appropriate having regard to the circumstances surrounding this matter, the agreed statement of facts and the respective submissions made to the Tribunal.
Having reached that conclusion, it is unnecessary to dwell on the numerous reports filed. However, some of the observations and opinions expressed by a psychiatrist, Dr N, provide relevant insight into the physical and mental state of the respondent at the time. Dr N reported as follows:[7]
[7]Affidavit of Dr N, affirmed 13 December 2024, FN-2, 16.
Post Traumatic Stress Symptoms
These relate to his experience of abuse during his childhood, with multiple sexual assaults by his parent’s domestic staff and their associates, with threats of violence and harm, and by the bullying in boarding school.
These events occurred in situations when, since his early life, he has not had sufficient support. He felt isolated, helpless, frightened (‘terror’) and vulnerable. He described always having the expectation that: “I had to do it. I was used to being on my own. I was not used to asking for help".
Dr N also referred to conditions the respondent was suffering from which, by way of example, included ‘recurrent intrusive recollections’, ‘avoidance of activities that precipitate recollection of event’ and ‘hyper-arousal’.[8]
[8]Ibid 16-17.
Dr N diagnosed the respondent with the following:[9]
(a)Recurrent Major Depression (in remission);
(b)Complex Post Traumatic Stress Disorder, (in remission) with exacerbations in response to stressors arousing memories of his own traumatic experiences; and
(c)Social phobia.
[9]Ibid 18.
Notwithstanding the conduct of the respondent, Dr N reported that the respondent did not satisfy the criteria of paraphilia and went on to say:[10]
I am not aware of information to support the concept that [the respondent] was grooming his patient with the intention of beginning a sexual relationship for his own gratification, even though it is feasible that his behaviour may have eventually had this effect. By being attractive to his patient, pleasing her and placing her in a position in which she could have believed she was indebted to him, the risk is that his patient may also have responded inappropriately, even if only based on a misunderstanding. [The respondent] left an unacceptable risk that his patient may have developed a misunderstanding in a manner similar to that reported by many women in relation to the obstetricians, whose practice also necessarily involves physical intimacy, which requires skilled personal and professional management.
He should have been aware of such risks, and taken steps to avoid these.
My understanding is that [the respondent’s] behaviour in relation to his patient was not in response to sexual arousal, desire, or intention.
[10]Ibid 19.
Under the heading ‘Practitioner’s Mental State (Historical and Current)’, Dr N reported as follows:[11]
In my opinion, [the respondent] did have impaired judgement influencing his conduct with his patient.
This impairment was greatly aggravated by the effects of accumulated stressors, especially at the time of his declaration of love for his patient.
His behaviour was uncharacteristic, and not consistent with his previous practice in relation to other patients (to my knowledge), nor consistent with his conventional training as a psychotherapist.
My understanding, from discussion with [the respondent] about his responses to the complaints and circumstances since, is that he is now not impaired in the same manner.
In my opinion, he is still a risk of making unwise decisions (eg re eating, exercise, day-trading), though these are consistent with many in the general population and not attributable to any diagnosable disorder.
In my opinion, the errors of judgement of [the respondent] at the time of his severe boundary violations are explainable as the effects of his condition, especially the exacerbation of his PTSD, aggravated after having become ‘burned out’ (a form of depression) by prolonged poor self-care in the context of extraordinary stress, which overwhelmed his ability to function in his usual manner.
He is currently having trouble to the extent that he has decided to cease practice for the foreseeable future.
[11]Ibid 26.
And then later, it was reported under the heading ‘The symptoms of any such impairment’:[12]
The impairment manifested by his making poor decisions, not consistent with his usual practice, nor his usual understanding of appropriate practice.
This was associated with his personal distress in response to re-experiencing aspects of the abuse he experienced as a child.
His ‘burn-out’ manifested with a loss of energy, interest, sleep, self-care, difficulty providing effort to consider the issues presenting with sufficient attention, and withdrawal. It is well known that people in such a condition are less reliable in their management of risk eg when driving.
[12]Ibid 27.
It was Dr N's opinion that the respondent would not have acted in the manner that he did in the absence of the diagnoses identified above. It can be accepted that the respondent is deeply ashamed and remorseful about his conduct; further, that he has a degree of insight into his own vulnerability, how his mental health contributed to his conduct and the need for those issues to be addressed. In this regard, it is also relevant that the respondent voluntarily ceased practice in January 2025.
However, it would seem that, at least to some extent, his insight is more at a personal and intellectual level rather than insight as to the impact of his conduct on the patient. In this regard, during his interview in response to a series of questions, the respondent said:[13]
And the general witness statement, although [the patient] is a very honest person who tries her best to tell the truth, that this witness statements smacks to me of having been contaminated by the opinions and perspectives of the um, mental health help line people that she spoke to and also of other perspectives of the people who treated her in her last admission.
[13]Hearing Brief, filed in the Tribunal 15 August 2025, 819 (‘Hearing Brief’).
The impact of the respondent's conduct on the patient is discussed in more detail below. Even having regard to all of the facts, matters, and circumstances favouring the respondent, the Tribunal agrees with the submission made on behalf of the applicant:[14]
Looked at together, the referred conduct is of a high level of objective seriousness, closely connected with the respondent’s practice as a psychiatrist, and flagrantly inconsistent with the values of the profession. Conduct of this kind has a corrosive effect on public and peer confidence in health practitioners who are expected (and entrusted) to provide appropriate care to vulnerable patients. If the reputation of the profession is undermined, barriers to members of the community accessing treatment are increased.
[14]Applicant’s Outline of Submissions (n 1) 5 [7].
As bizarre as the conduct of the respondent was to the young patient, it seems to be accepted that his conduct was not of a grooming character. Reference has already been made to Dr N's opinion about that. Also in this regard, in the submissions made on half of the applicant, it was said:[15]
The weight of expert opinion is that the respondent’s conduct was not sexually motivated (although a ‘pre-sexual’ or ‘romantic’ relationship may have developed). Notwithstanding the lack of sexual intent, the respondent’s conduct risked being misconstrued by the patient and, consequently, risked a personal sexual relationship developing. As acknowledged by the respondent himself, there was also a risk (which was realised) that the patient would feel that she was being groomed by him, such that his conduct would have the same effect as if this was his actual intent.
[15]Ibid 9 [18].

The Tribunal will proceed on the basis that the respondent’s conduct was not sexually motivated towards the patient and that he was not grooming her for that purpose. There is, however, a level of concern about that conclusion.
The reasons for those concerns is not only the overall conduct of the respondent, but in particular the expressions of love, the episodes of actual physical and offered physical conduct, the giving of gifts, and the making of home visits on the patient outside of professional hours. The conduct of the respondent not only amounted to a gross breach of trust, but it had a devastating and long-lasting impact on the patient, leaving her with a raft of negative emotions, including a sense of betrayal, distrust, guilt, anger, and self-disgust.[16] Unsurprisingly, the patient had understandable concerns that she was in fact being groomed by the respondent.
[16]Hearing Brief (n 13) 332.
The draft orders sought by the parties are as follows:[17]
(a)Pursuant to s 107(2)(b)(iii) of the Health Ombudsman Act 2013 (Qld) (‘HO Act’), in respect of allegations one to four collectively, the respondent has behaved in a way that constitutes professional misconduct.
(b)Pursuant to s 62(2)(a)(ii) of the HO Act, the immediate registration action taken by the Health Ombudsman in respect of the respondent is set aside.
(c)Pursuant to s 107(3)(a) of the HO Act, the respondent is reprimanded.
(d)Pursuant to s 107(3)(d) of the HO Act, the respondent’s registration is suspended for a period of 18 months from the date of this decision.
(e)Pursuant to s 107(3)(b) of the HO Act, upon the suspension set out in 4 above expiring, conditions are imposed on the respondent’s registration in the form of Annexure A to the Tribunal’s decision.
(f)Pursuant to s 109(2) of the HO Act, Part 7, Division 11, Subdivision 2 of the Health Practitioner Regulation National Law (Queensland) applies to the conditions imposed.
(g)Pursuant to s 109(3) of the HO Act, the review period for the conditions imposed is twelve months.
(h)Each party must bear their own costs for the proceeding.
[17]Parties’ Joint Submissions, filed in the Tribunal 8 August 2025.
Orders were also sought regarding non-publication of certain matters.
It is noted that the conditions the parties propose to impose on the respondent’s registration upon his return to practise are designed to, amongst other things, address the risk of a recurrence of untoward conduct. As such, the conditions impose limits on the respondent’s capacity to practise in certain areas and require him to be supervised across the entire practice area in which he is able to practise.
The conditions also include mentoring and auditing. In respect of the latter, the conditions say:[18]
The [respondent] must undergo an audit of their practice (the audit), including any supporting records, by an approved auditor. The audit is to focus on the [respondent’s] compliance with the restrictions relating to practice and patients at item 1, and must include, at a minimum, a review of 10% of total patients seen or 20 randomly selected patient records per month (whichever is greater).
The [respondent] must comply with the Ahpra Protocol: Audit in force at the date these conditions are imposed and then as updated from time to time.
The [respondent] must complete a period of audits, with the first audit being within 1 month of the [respondent’s] return to practice and thereafter on a monthly basis.
[18]Ibid Annexure A.
As already mentioned, the conditions are to be reviewed after a period of twelve months. Without wishing to express a final view on the matter, as it will be a matter for the Board, given the nature and extent of the conduct, including his conduct despite the earlier intervention, it would seem that a high level of confidence would be needed before the conditions imposed are set aside or watered down to any material extent.
In respect of the orders concerning non-publication, the Board does not take issue with a non-publication order being made which includes any reference to the respondent and his family. This is understandable particularly in circumstances where, amongst other things, the various medical reports reveal highly personalised and sensitive matters concerning not only the respondent, but also his parents (now both deceased), but in particular his wife and children, especially his daughter. Accordingly, Tribunal agrees that fresh non-publication orders ought to be made.

Findings and orders

For the reasons given, it is the decision of the Tribunal that:
Pursuant to s 107(2)(b)(iii) of the HO Act, in respect of allegations one to four collectively, the respondent has behaved in a way that constitutes professional misconduct.
Pursuant to s 62(2)(a)(ii) of the HO Act, the immediate registration action taken by the Health Ombudsman in respect of the respondent is set aside.
Pursuant to s 107(3)(a) of the HO Act, the respondent is reprimanded.
Pursuant to s 107(3)(d) of the HO Act, the respondent’s registration is suspended for a period of eighteen months from the date of this decision.
Pursuant to s 107(3)(b) of the HO Act, upon the suspension set out in 4 above expiring, conditions are imposed on the respondent’s registration in the form of Annexure A to the Tribunal’s decision.
Pursuant to s 109(2) of the HO Act, Part 7, Division 11, Subdivision 2 of the Health Practitioner Regulation National Law (Queensland) applies to the conditions imposed.
Pursuant to s 109(3) of the HO Act, the review period for the conditions imposed is twelve months.
Each party must bear their own costs for the proceeding.
The Tribunal orders that:
The non-publication order made by the Deputy President on 18 July 2023 is set aside.
In lieu thereof, pursuant to s 66(1) of the Queensland Civil and Administrative Tribunal Act 2009 (Qld), publication of:
the contents of a document or other thing filed in or produced to the Tribunal;(a)
evidence given before the Tribunal;(b)
any order made or reasons given by the Tribunal;(c)
is prohibited to the extent that it could identify or lead to the identification of the respondent or any family members of the respondent, and any patient of the respondent or any family members of such patient save as provided for by the terms of this order and save as is necessary for the parties to engage in and progress these proceedings, or any appeal or review arising from these proceedings, and for the applicant or the Australian Health Practitioner Regulation Agency to exercise each of their statutory functions under the Health Practitioner Regulation National Law (Queensland).
Any material affected by the non-publication order shall not be copied or inspected without an order of the Tribunal, except by:
a judicial member;(a)
a tribunal member;(b)
an associate to a judicial officer or tribunal member appointed under relevant legislation;(c)
any assessor appointed to assist the Tribunal;(d)
the staff of the Tribunal registry;(e)
any judicial officer, court staff or associate dealing with any appeal or review arising from these proceedings; or(f)
the parties to these proceedings or any appeal or review arising from these proceedings.(g)

[2025] QCAT 409

24 October 2025 (decision) 10 November 2025 (reasons)