Medical Board Of Australia and Boyd - [2013] WASAT 123

JURISDICTION : STATE ADMINISTRATIVE TRIBUNAL

STREAM: VOCATIONAL REGULATION

ACT: MEDICAL ACT 1894 (WA)

CITATION: MEDICAL BOARD OF AUSTRALIA and BOYD [2013] WASAT 123

MEMBER: JUSTICE J A CHANEY (PRESIDENT)
MS F CHILD (MEMBER)
DR H HANKEY (SENIOR SESSIONAL MEMBER)
DR S RESNICK (SESSIONAL MEMBER)

HEARD: 3 MAY 2013

DELIVERED : 9 AUGUST 2013

FILE NO/S: VR 70 of 2010

BETWEEN: MEDICAL BOARD OF AUSTRALIA
Applicant
AND
ALEXANDRA BOYD
Respondent

Catchwords:

Health profession regulation Medical practitioner Participation in alternative treatment Minimisation of involvement in treatment Inadequate treatment Misleading conduct Failing to comply with requirements for administration of drugs Penalty

Legislation:

Medical Act 1984 (WA), s 13, s 37(1)(c)
Poisons Act 1964 (WA), s 22, Sch 4
Poisons Regulations 1965 (WA), reg 36B
Therapeutic Goods Act 1989 (WA)

Result:

Findings made
Order for removal of name from register

Summary of Tribunal's decision:

The Medical Board of Australia made a number of allegations against Dr Boyd in relation to matters concerning her involvement in an unapproved alternative treatment for seriously ill cancer patients. The treatment involved administration of various substances, including some not approved for medical treatment purposes, or subject to strict limitations.
The treatment was carried out, mainly by two nurses, at Dr Boyd's home and she received a substantial payment for her involvement. She maintained however that her involvement was extremely limited.
The Tribunal concluded that Dr Boyd's participation in the treatment was significantly greater than she asserted, and that, in several respects, she had acted in a misleading way to minimise the appearance of her involvement in the treatment. It found that the Board's allegations were established, and concluded that Dr Boyd's name should be removed from the register of medical practitioners.

Category: B

Representation:

Counsel:

Applicant: Ms B Mangan and Ms A Miolin
Respondent: Self-represented

Solicitors:

Applicant: Moray and Agnew
Respondent: N/A

Case(s) referred to in decision(s):

A Practitioner v The Medical Board of Western Australia 2005 WASC 198
Jemielita v Medical Board of Western Australia unreported SCWA, 13 November 1992 Lib No. 920584

REASONS FOR DECISION OF THE TRIBUNAL:

Introduction

Until she relinquished her registration on 10 January 2012, Dr Alexandra Boyd was a registered medical practitioner, and had been for many years. For a relatively brief period in May 2005, Dr Boyd became involved in the treatment of seven cancer patients in circumstances which will be outlined below. The treatment was devised and advocated by one Mr Abdul-Haqq Sartori (Sartori). Sartori had, at the relevant time, been refused entry to Australia, and the treatment was principally administered by two nurses, at least one of whom maintained regular contact with Sartori as to the progress of the treatment. The treatment was administered principally at Dr Boyd's home in Mosman Park.
Seven patients were involved. They were all seriously ill. Four patients died within two weeks of commencing treatment. A fifth died approximately six weeks after commencing treatment and a sixth patient died about nine weeks after commencing treatment. The seventh patient who ceased the treatment after 11 days survived a further four and a half years. The deaths of the five patients who died in the shortest times after commencing the treatment were the subject of a coronial inquest held during 2010 and 2011 (Inquest).
It was not in dispute in the proceedings that the treatment did not accord with accepted medical practice, nor that it had serious and extreme side effects which, in all probability, hastened the deaths of at least four of the patients.
The Medical Board of Australia (Board) makes seven allegations of either infamous or improper conduct in a professional respect, gross carelessness or incompetence against Dr Boyd for her actions in relation to the treatment of the seven patients.
Most of the relevant facts were either agreed or not disputed by Dr Boyd. Dr Boyd agreed some facts, notwithstanding that she said that those facts were not within her knowledge at the relevant time. Other facts were not disputed on the basis that Dr Boyd says she has no knowledge as to whether or not those facts are correct. The Board provided references to the evidence upon which it relied to assert those nondisputed facts, and we are satisfied that those facts are established on the basis of the evidence referred to.
There remained relatively few facts in dispute.
Dr Boyd's response to the seven allegations was not entirely clear. At the heart of her resistance to the application is the proposition that the seven patients were not her patients, but that she merely agreed to help with ordering blood tests for the patients, and to provide her home for the treatment to be carried out. She claimed, in general terms, that she was ignorant of the detail of the treatment being administered, and because Sartori was managing the patients, she did not assume any responsibility for monitoring or overseeing the treatment.
Before moving to the particular allegations made against Dr Boyd, it is useful to place the allegations into a factual context.

Background facts

The Kathi Preston Memorial Health Centre (KPMHC) was established by one Mr Keith Preston (Preston) in honour of his late wife who had been diagnosed with cancer in 1999 and who had undergone a treatment administered by Sartori in Thailand in 2004 described as a 'caesium and high pH' therapy. Mrs Kathleen Preston died during the course of that treatment. Preston believed that his wife's cancer had been effectively cured by Sartori's treatment and set up his property in Darwin as a venue for Sartori's treatment.
Sartori trained Preston, who was a mechanic, and Ms Simone Phasey (Phasey), a registered nurse, in the administration of his treatment. A number of patients were treated in Darwin through KPMHC by Sartori and Phasey, assisted by two general practitioners in Darwin who arranged PICC lines (for the convenient administration of intravenous drugs), prescribed certain drugs and ordered tests such as blood tests.
In April 2005, Sartori was prevented from entering Australia by the Department of Immigration. As a result the treatment was unable to proceed in Darwin as the two general practitioners who had been involved were not prepared to assist with the treatment in the absence of Sartori.
Dr Boyd had a patient (GB) who had undergone the treatment in Darwin with KPMHC. In a statement provided to Police in November 2005, Phasey said that, because of the success with that patient, Dr Boyd was interested to see how the treatment was done and to witness the results for herself. In a subsequent statement in June 2010, Phasey said that Dr Boyd's Practice Manager, Ms Joanne Firth (Firth) telephoned her around the time that Sartori had been denied entry into Australia, and advised that Dr Boyd had agreed to assist patients who were wanting to undergo the alternative treatment, though she would not supervise the treatment because she was too busy with her own medical practice. She said that 'the assistance Dr Boyd could provide was to order blood and diagnostic tests required to monitor the patients during the treatment. Dr Boyd could also be available to attend on patients as an after hours locum doctor, should patients require such assistance'. Dr Boyd, in her response filed in these proceedings, says that the initial contact with her office came from either Phasey or Preston and was dealt with by Firth. It is not necessary for present purposes to determine precisely how the initial contact occurred.
As a result of that contact, a decision was taken to move the treatment of patients by KPMHC to Perth. In her evidence to the Inquest, Phasey said (Exhibit 3 ‑ 5.188) that, without Dr Boyd 'we wouldn't have had a clinic' because 'I needed a doctor there to be readily available and to come in'. That was because, she said, she was 'not capable about making decisions about patients. That is the doctor's role. There needed to be a doctor on site or nearby'. She said, however, that Dr Boyd was not involved in directing the high pH treatment regime.
Dr Boyd, in her response, said that she initially declined to be involved because she was, at the time, too busy working 70 hours per week in her own breast clinic, as a locum for another doctor two days per week, and three nights a week and Sundays as a locum for the Australian Locum Medical Service (ALMS). However, after further discussions between Firth and either Phasey or Preston, Dr Boyd said that she agreed to a limited involvement by way of ordering blood tests designed to inform Sartori of the progress of the treatment. She was adamant that she did not agree to oversee the patients' treatment which was to be provided by Phasey and overseen by Sartori. We will return to our findings in relation to Dr Boyd's role later in these reasons.
As mentioned earlier, the treatment in Perth commenced on 14 May 2005 at Dr Boyd's home in Mosman Park, at which Dr Boyd was living at the time. Preston, Phasey and some of the patients had arrived a few days earlier, and some of the patients had obtained referrals from Dr Boyd for various tests. A second nurse Ms Merilee Baker (Baker) was recruited to assist. Dr Boyd told Baker, whom she had known previously, that a position was available with the KPMHC programme, although she denied that she encouraged Baker to participate.
Various documents comprising information sheets concerning the treatment, including an indemnity form, were provided to the patients. The indemnity form produced by KPMHC and provided to patients prior to the treatment included 'Dr Alex Boyd' as a person to be indemnified and released from any claims arising from the treatment, although Dr Boyd says that she was not aware of that fact at the time.
Arrangements for the provision of equipment at Dr Boyd's house, and accommodation for Preston, Phasey, Baker and some of the patients were arranged by Firth. Dr Boyd, or her company, received payments from Preston or KPMHC by way of a cheque for $14,240.23 made payable to Dr Boyd personally, and a cheque for $24,000 made to Alex Boyd Pty Ltd in relation to the treatment.
The treatment was administered to the patients at Dr Boyd's house. The substances used in the treatment were largely administered by Phasey and Baker. Each day, following the treatment, patients would return to the accommodation arranged for them, or to their homes. Throughout the treatment, Dr Boyd ordered blood tests for each of the seven patients. The results of the blood tests were sent to Dr Boyd's practice address.
Throughout the treatment, Dr Boyd referred some patients for PICC line insertions, blood transfusions and scans. From time to time, Dr Boyd checked with the nurses to see how things were progressing with the patients' treatment.
In all, there were seven patients treated at Dr Boyd's home. They were Ms Sandra McCarty from Victoria, Ms Deborah Gruber from New York, Ms Sandra Kokalis from Perth, Ms Pia Bosso from Sydney, Mr Daryl Green from Adelaide, Mr Carmello Vinciullo from Perth, and Mr Antonio Ranieri from Perth.
The treatment given to the patients in Perth consisted of, amongst other things:
a)intravenous administration of various nutrients, minerals and substances including:
i)caesium;
ii)magnesium; and
iii)dimethylsulphoxide (DMSO);
b)intravenous administration of laetrile (also known as vitamin B17 and amygdalin);
c)the taking of nutritional substances;
d)specifically prepared foods; and
e)strict adherence to the philosophy of the treatment.
Documents produced by KPMHC or Sartori show that the treatment was marketed as having extremely high success and cure rates, having minimal physical side effects, and offering an excellent chance of permanent recovery. Dr Boyd did not accept that she knew of those documents at the time of the treatment.
At the Inquest, various experts' reports were obtained in relation to the treatment. From the expert report of Professor Joyce and his evidence to the coroner, it can be concluded that many of the substances used in the treatment have known toxicity in humans. In particular, caesium can cause ventricular tachyarrythmias, abnormal rapid cardiac rhythms, disorientation, low blood pressure, gastrotoxicity and seizures. Professor Joyce said that the excessive administration of magnesium can cause hypermagnesaemia, symptoms of which include nausea, vomiting, flushing, muscle weakness, muscle paralysis, blurred or double vision, CNS depression, respiratory depression and paralysis, renal failure, cardiac arrhythmias, coma and cardiac arrest. He said that excessive administration of potassium can cause cardiac rhythm disturbance, and that DMSO administered intravenously can cause vomiting, drowsiness, breakdown of red blood cells, liver damage and impairment of kidney function. Laetrile can cause cyanide toxicity.
Professor Joyce said that caesium is a mineral extracted from iron ore and is used conventionally in making dense solutions in laboratory work for industrial applications. In his evidence to the coroner, Professor Joyce indicated that little was known about the toxicity of caesium, although from what little knowledge there was, it could be said with fair confidence that it was cardiotoxic, and that people could have seizures after exposure to large amounts of caesium and, where it was administered by mouth, often had gastrointestinal disturbances, diarrhoea, nausea and vomiting from it.
Caesium chloride, as used in the treatment, had not been considered for scheduling under the Poisons Act 1964 (WA) (Poisons Act), and did not appear on the Australian Registry of Therapeutic Goods.
Professor Joyce said that DMSO is a solvent, able to dissolve substances that water cannot, that is used in laboratory work and industrial applications. It did not appear on the Australian Registry of Therapeutic Goods for intravenous use, but was a substance for external use which required a valid prescription under the Poisons Act.
Professor Joyce said that, although it is referred to as vitamin B17, laetrile is not a vitamin. It is a substance derived from apricot or almond kernels, and in 2005, use of laetrile in Australia was restricted by the Special Access Scheme implemented by the Therapeutic Goods Administration.
Against that general background, the Board makes seven allegations of either infamous conduct, improper conduct, gross carelessness or incompetency against Dr Boyd. More detailed facts concerning Dr Boyd's conduct, and her role in relation to the treatment of patients, are best dealt with in the context of those allegations. Before turning to the specific allegations, it is appropriate that we remind ourselves of the meaning of the different characterisations of the conduct alleged against Dr Boyd.

Characterisation of conduct

At the time of the conduct in question, the regulation of the medical profession was governed by the Medical Act 1984 (WA) (Medical Act). Section 13 of the Medical Act provided that disciplinary action can be taken against a medical practitioner for, amongst other things, infamous or improper conduct in a professional respect or gross carelessness or incompetency.
Infamous conduct in a professional respect is conduct that would be reasonably regarded as disgraceful or dishonourable by other medical practitioners of good repute and competency ‑ see Jemielita v Medical Board of Western Australia unreported SCWA, 13 November 1992 Lib No. 920584 (Jemielita).
Improper conduct in a professional respect is misconduct which falls short of infamous conduct. It is constituted by something less than serious misconduct but is, nevertheless, conduct which would reasonably be regarded as improper by professional colleagues of good repute and competency ‑ A Practitioner v The Medical Board of Western Australia 2005 WASC 198 (A Practitioner).
The subject of gross carelessness was also discussed in Jemielita. Gross carelessness involves unacceptable conduct without any intentional wrongdoing on the part of the practitioner. Gross carelessness suggests that the practitioner is unable to give the care required or is indifferent to the need for such care, notwithstanding that he or she may have the intellectual and technical ability to supply the care that is required. Gross carelessness may be limited to individual events, and is not necessarily endemic to the practitioner's conduct generally.
The concept of incompetency involves an unfitness to practise in the particular field of medicine which is under examination or the inability to perform the techniques or reach the judgments needed for the proper practice of medicine in that field. Incompetency suggests a more generalised deficiency in the abilities of a practitioner to handle his or her professional affairs ‑ Jemielita at [17], [18] and [19]. In order to constitute gross carelessness or incompetency, the conduct must be of a scale of gravity which is sufficiently serious to warrant the denunciation by professional colleagues of good repute and competence, and that such other practitioners regard as intolerable and deserving of punishment and disciplinary action ‑ Jemielita at [18].

Allegation 1- participating in and facilitating an unproven and experimental treatment without ensuring proper approval, patient assessment, patient safety and consent

Central to this allegation is the determination as to the precise role which Dr Boyd undertook in relation to the treatment of the patients.
The Board's allegation is that:
i)Dr Boyd agreed to oversee and monitor the patients during the course of the administration of the treatment and received payment totalling $38,240.23 for her services in relation to the treatment;
ii)Dr Boyd effectively recruited Baker telling her that she was to oversee the administration of the treatment in Perth;
iii)Dr Boyd was introduced to each of the patients as the medical practitioner who would supervise the administration of the treatment;
iv)Dr Boyd made rooms available in her home for the administration of the treatment to the patients by the nurses;
v)Dr Boyd liaised with KPMHC, or alternatively instructed Firth to do so, in relation to equipment that would be needed for the provision of the treatment, the accommodation needs of the patients and the nurses, and the payments to be made for Dr Boyd's role;
vi)Dr Boyd made arrangements for, or alternatively permitted, equipment to be set up in her home in preparation for the administration of the treatment to the patients;
vii)the patients attended the rooms at Dr Boyd's home and the treatment was administered there to the patients by the nurses; and
viii)Dr Boyd ordered blood tests for each of the patients, reviewed the results of those tests and referred various of the patients for CT scans and/or xrays and the insertion of PICC lines and reviewed the results of those scans or xrays.
The Board contends that those events occurred in a context where Dr Boyd knew, or ought to have known, what substances would be administered to patients during the course of the treatment, how the treatment would be administered, the risks and side effects of the treatment or the substances used in the treatment, and the facilities and equipment necessary and appropriate for the provision of the treatment.
The Board contends that the treatment was not in accordance with accepted medical practice or alternatively was experimental. It alleges that, in participating or facilitating the administration of the treatment, Dr Boyd ought to have taken a history and performed a physical examination of each of the patients, provided sufficient information to allow the patients to make informed choices, obtained informed consent, and sought and obtained formal approval to the administration of the treatment from a duly constituted ethics committee. It is said that she did none of those things.

By reason of those matters, the Board alleges that Dr Boyd, in the course of her medical practice, is guilty of infamous or improper conduct in a professional respect, or alternatively, gross carelessness or incompetency.
Dr Boyd provided a response to the allegations against her in a document filed in the Tribunal on 23 January 2013. As we have earlier noted, in general terms she denied that she had agreed to oversee the patients' treatment because, at the time, she was too busy with her other professional commitments, although she did agree eventually to involvement by way of ordering blood tests.
With regard to the remuneration paid, Dr Boyd said that she cannot say with confidence whether she was informed about the payments by Firth, who she said conducted discussions in relation to the treatment with Preston. She said that she has always relied on the expertise of others in relation to financial matters, and the fact that there would be a financial reward for her help did not influence her to take part. She said that the clinic which she ran 'was always short of income and we wanted to investigate other physiological methods of breast behaviour that were available in Russia'.
Dr Boyd did not deny all knowledge of the payments to her and it is inconceivable that she was not aware at least of some substantial payment being made for the service she was providing. We find that she must have known, and did know, that her services were significantly remunerated.
Dr Boyd appears to accept that the patients believed that she was overseeing their treatment. She said, however, that that was 'a belief that was given to them by Keith Preston and Simone Phasey and they failed to inform the patients that I would be only taking care of blood and other incidental requests and not overseeing their treatment'. She said that she questioned the patients on their knowledge of the treatment 'and they said that they knew what it entailed'. She said that she informed them that, because of her busy schedule, she was not overseeing their treatment 'but would help whenever needs arose'. She said that she was not aware of what medications the patients were on and that she was 'more concerned about whether they knew how difficult the treatment was to undertake and that it involved vomiting and diarrhoea' as had been explained to her by GB after she returned from treatment in Darwin. She said that she did not enquire as to what the treatment entailed because she did not have time to review the treatment and she was not, in any event, interested in treating cancer patients, something which she had never done. She was also 'under the impression that the treatment although difficult to undertake had some benefits' on the basis that she understood GB to have benefited from it. (Dr Boyd acknowledged in questioning by the Board's counsel at the hearing that, in fact, GB's cancer had not been cured by the treatment, but she said that she had forgotten that by the time these patients underwent the treatment). Her response (which was accepted as her evidence for the purposes of the proceedings) continued:
I would say that lack of time and the apparent urgency presented by Preston and Phasey as to the need to do the treatment straightaway, and the only participation from me would be to order blood tests, overrode any precautions I felt at that time. That it became more than blood tests, but ordering of Picc lines and other interactions became obvious once the journey had started. But at that time, before the treatment started and during the treatment, I did not believe that I was involved with anything more than ordering blood tests. That I said that I was also monitoring the patients was incorrect, as the blood test results always went to Simone who passed them on to Dr Sartori. I was told by Simone that the cancer markers and LFTs appeared to be improving, that the treatment appeared to be working. The reason I did not take histories, medication or other things I would have done if I thought that they were my patients and not Dr. Sartori's, and that he had already done all these things to enable him to advise how the treatment would be administered. Furthermore, the patients presented with their family members and were keen to have this particular treatment and as they were now considered by the medical profession to be past medical help, they were hoping that this would be useful. I felt that they had a right to follow up treatments that they had researched.
Dr Boyd acknowledged that she rang Baker and told her about the treatment and that if she was interested she needed to get in touch with Phasey. She said that she told Baker about her own patient's experience with the treatment, but 'also told her to check it out'. She said that she offered to have Baker stay with her, but that did not eventuate. She denied that she told Baker that she would be overseeing the treatment.
Dr Boyd accepted that she made her home available for the treatment, that the treatment was administered to the patients at her home by the nurses, that she permitted equipment to be set up in the rooms in her home for the treatment, that she ordered blood tests for each of the patients, and CT scans or xrays, or the insertion of PICC lines for some of the patients. She accepted that she reviewed the results of the CT scans and xrays, but said that she did not always review blood test results which were sent directly to Phasey by computer for forwarding on to Sartori. She admitted that she facilitated the treatment by providing premises, but maintained that she did not participate in the treatment of the patients in Perth.
As to her knowledge of the substances to be administered, the manner of administration, the risks and side effects and the facilities and equipment necessary for the administration of the treatment, Dr Boyd said that because she did not see her role as supervising doctor, she did not need to know those matters. Rather, she assumed that Sartori would be able to deal with those issues.
Dr Boyd accepted that the treatment was not in accordance with accepted medical practice but was 'alternative'.
Dr Boyd accepted that, had she been responsible for the treatment, she would have taken a history, performed a physical examination, provided sufficient information to the patients to obtain informed consent, and obtained formal approval for the administration of the treatment from a duly constituted ethics committee. However, she said that she 'believed all this had been covered by [Sartori] through Preston and Phasey'.

Findings in relation to allegation 1

The first allegation is, in essence, participation in, or alternatively, facilitation of, the provision of the treatment in circumstances where the respondent knew or should have known about the nature and effect of the treatment, that it was an experimental treatment, and that she ought to have undertaken appropriate examinations and consent procedures. We consider that that allegation is made out in the sense that Dr Boyd's conduct amounted to infamous conduct in a professional respect contrary to s 13(1)(a) of the Medical Act, and gross carelessness in the terms of s 37(1)(c) of the Medical Act.
In reaching that conclusion, it is not necessary to find, and we do not find, that prior to the commencement of the treatment in May 2005, Dr Boyd 'agreed to oversee and monitor the patients during the course of the administration of the treatment'. We do find, however, that regardless of what she may have seen as her role at the outset, Dr Boyd actively participated in the provision of the treatment to the patients by agreeing to order blood tests, making her premises available for treatment, permitting her practice manager to make arrangements for the provision of equipment and accommodation to enable the treatment to proceed, receiving a payment for her services, and being involved in referrals for CT scans and x‑rays and the insertion of PICC lines during the course of the treatment. As Phasey told the Inquest, without Dr Boyd there would have been no clinic. That must have been obvious to Dr Boyd. It is quite apparent, and acknowledged by Dr Boyd, that at least some of the patients believed that she was overseeing the treatment. That is hardly surprising given the participation which we have outlined above. In questioning from counsel, Dr Boyd described her increased involvement once the treatment had started as the 'slippery slope - one thing led to another'.
The patients were entitled to expect, in the circumstances of Dr Boyd's participation, that she would be something more than a tool used to obtain tests. Her failure to bring to bear her expertise as a doctor to the treatment of people who, at least to some extent, were her patients, organised through her office, carried on at her home, and otherwise facilitated by her was both grossly careless and amounts to infamous conduct, being conduct which practitioners of good repute and competence would find disgraceful.
It is clear from the agreed facts, and in the evidence given at the Inquest, that the side effects of the treatment, and the debilitating effects which it had on the patients, must have been glaringly obvious. So much was not disputed by Dr Boyd. As noted above, Dr Boyd acknowledges that she spoke to the patients about 'how difficult the treatment was and that it involved vomiting and diarrhoea'. It is difficult to understand how a doctor could undertake such a discussion without knowing what the treatment consisted of. To participate in that treatment with, on Dr Boyd's account of events, no regard being given to what substances were being administered, no knowledge as to whether any ethics committee approval had been given, and no knowledge of the patients' histories or medications, amounts to gross carelessness and infamous conduct.

Allegation 2 - participating in the treatment and creating an expectation of the patients concerning care

The formulation of this allegation is somewhat confusing, and appears to substantially replicate allegation 1 and the particulars supporting it. The particulars of allegation 2 set out in the Board's grounds comprise detailed accounts of particular treatment or professional interaction between Dr Boyd and the various named patients. Those matters amount, in substance, to particulars of Dr Boyd's participation in the treatment of the patients, or alternatively, providing professional services to the patients not directly related to the Sartori treatment.
In her response, Dr Boyd largely admits the various particulars of treatment and interaction with the various patients which are set out in the grounds relied upon in relation to the second allegation. As to the allegation that, by her conduct, Dr Boyd created an expectation or belief in the patients or their carers and family members that she was overseeing and monitoring their medical care, Dr Boyd said:
I think that the patient[s'] view of me had been strongly set in their minds by Preston and Phasey, and that as much as I wanted to limit my responsibility for Dr Sartori's treatment, nevertheless I did what I could in the way of [conventional] medical treatment. If I had known that her ascites and Ioedema had been treated with frusemide and spironolactone, then I would not have hesitated to put her back on them. But as Dr Sartori was organising the treatment and would have been aware of these complications, then he is the one who should have put her back on these medications, as he was the one who had ceased them.
In our view, this second allegation simply elaborates on the particulars set out to support the first allegation. The particulars of treatment of the different patients are all established on the evidence. The two allegations are so intertwined in their particulars that they should be considered together as a single finding of infamous conduct and gross carelessness.

Allegation 3 - deficiencies in care of patients

The third allegation against the respondent is that she failed to act in accordance with generally accepted standards of the medical profession and was thus guilty of either improper conduct in a professional respect or gross carelessness or incompetence. In particular, it is alleged that Dr Boyd:
i)ought to have but did not keep an accurate record of her interactions with the patients and the results of tests undertaken by the patients on her referral;
ii)ought to have but did not refer patients for treatment or medical assessment or intervention where such an assessment or intervention was called for, as it was in relation to various symptoms suffered by the particular patients of which Dr Boyd knew or ought to have known;
iii)ought to have provided appropriate monitoring equipment such as ECGs or alternatively referred patients for ECG testing;
iv)ought to have but did not implement protocols for the adequate gathering and recording of observations of the patients' vital signs during the treatment;
v)ought to have but did not implement protocols for adequate gathering and recording of observation of the patients' vital signs during treatment; and
vi)ought to have but did not provide appropriate sterilisation equipment and implement safe practices in relation to the cleanliness and sterilisation of the equipment, the premises and the environment in which the treatment was being administered.
In the last respect, it is alleged that a staphylococcus species was cultured from the tip of the intravenous line used for the administration of vitamins and minerals to Ms Bosso, Ms Gruber was found to be suffering from septicaemia at the time of her death and Ms Kokolis had sepsis at the time of her death.
In her response, Dr Boyd asserts that she did not know of the side effects of the treatment and was unaware of a number of the matters of which the Board contends she ought to have known.
Dr Boyd accepts, 'in hindsight' that she 'could have kept better notes'.
Dr Boyd said that she reviewed patients as often as she was requested to review them, but most of the symptoms which are set out in the allegations were matters of which she was not aware at the time.
As to the provision of monitoring equipment and the implementation of protocols, Dr Boyd said that that was the responsibility of Phasey 'who said she was capable of carrying out the treatment and had all the necessary equipment to do so'.

Findings in relation to allegation 3

There was no issue in the proceedings that the patients suffered the various symptoms set out in the grounds (at paragraph 17). What Dr Boyd contends is that she was not told and did not otherwise know of a number of those symptoms. Dr Boyd acknowledges that she failed to maintain adequate notes in relation to the patients, but otherwise contends that responsibility for providing appropriate equipment, gathering and recording observations of the patients' vital signs, and implementing safe practices were left to the nurses conducting the treatment and were not her responsibility.
Dr Boyd's response to this allegation is essentially dependent upon her contention that these were not her patients and she did not assume any responsibility for their treatment. As our earlier conclusions demonstrate, that is a contention which we do not accept. The level of participation by Dr Boyd in the administration of the treatment gave rise to an expectation amongst the patients that she was providing medical oversight to their treatment. Dr Boyd had an obligation to ensure that the patients were properly cared for where she was the only doctor with whom the patients had contact in relation to the treatment. It is not an answer to say that the patients were Sartori's responsibility. As it happens, although Sartori graduated as a medical doctor in Austria in 1969 and was admitted to work as a general practitioner by the Austrian Chamber of Medical Doctors in 1969, he has not appeared on that list since January 1974. He worked in the United States of America from 1976 to 1998 during which time he apparently came to the attention of the authorities on multiple occasions. He has never been registered to practise medicine in Australia, and an application for registration in 2005 was denied. They are facts of which, we accept, Dr Boyd was not specifically aware, but she accepted under questioning by the Board's counsel that she simply assumed Sartori was a doctor but carried out no checks. It seems inconceivable that Dr Boyd was not aware that the reason the treatment had been transferred from Darwin to Perth was associated with Dr Sartori having been refused entry to Australia and was thus unable to continue the treatment in Darwin. That fact should have alerted Dr Boyd to the need for some confirmation that the patients being treated in her home in a way facilitated by her, with obviously drastic side effects, were under the care of a properly registered medical practitioner.
Having assumed a level of involvement as a medical practitioner in the treatment of the patients, Dr Boyd ought to have ensured that the protections which the Board contends should have been afforded to the patients were in place. In our view, her failure to do so amounts to gross carelessness and, accordingly, allegation 3 is made out.

Allegation 4 - use of laetrile

The fourth allegation is that Dr Boyd knew, or ought to have known, that the patients were provided with laetrile which was administered as part of the treatment, and that laetrile is a prohibited substance in Western Australia in terms of s 22 of the Poisons Act. It is alleged that Dr Boyd ought to have advised the patients that they were taking a prohibited substance, and that it could only be supplied with the written authorisation of the Chief Executive Officer of the Department of Health for the purposes of medical or scientific research or in terms of the Special Access Scheme of the Therapeutic Goods Administration. It is also alleged that she ought to have made enquiries or taken steps to ensure that the supply of laetrile met the provisions of the Poisons Act and the Therapeutic Goods Act1989 (Cth) (TG Act). Her failure to do those things is said to constitute infamous or improper conduct, or alternatively, gross carelessness or incompetence.
In response, Dr Boyd said:
With regard to Laetrile, I know that permission needs to be gained for its use. And I have on three occasions, twice for [GB] and another patient requested this. However, I was not informed that this was part of the treatment, nor was I asked to fill in any paperwork required to access it. It is the responsibility of the patient to provide the necessary paperwork. Again, this treatment, its components were all supplied on behalf of the patients through Preston and Phasey.
Three things can be said about that response. First, the fact that Dr Boyd had obtained permission to obtain laetrile for GB, the patient who had undergone Sartori's treatment in Darwin, strongly suggests that Dr Boyd must have known that laetrile was part of the treatment, despite her assertion to the contrary. We consider it more likely than not that Dr Boyd did know that laetrile was involved in the treatment. Even if she remained uninformed as to the precise course of the treatment, her involvement with GB who had undergone the treatment, and her obtaining laetrile for GB, so strongly suggests the use of laetrile in the treatment that Dr Boyd ought to have ensured that its administration was in compliance with the Poisons Act and the TG Act, and that the patients undergoing treatment on her premises were aware of the nature of the substance they were being administered.
Her failure to deal appropriately with the administration of laetrile at her home in circumstances where she at least ought to have known of the administration of the substance amounts, in our view, to improper conduct and gross carelessness. Allegation 4 is made out.

Allegation 5 ‑ misleading and obstructive conduct

Allegation 5 is that Dr Boyd misled, or sought to mislead, the Board and obstructed the Board's inquiries in relation to her involvement in the treatment, in correspondence which passed between the Board and Dr Boyd between June 2005 and October 2006.
In early June 2005, the Registrar of the Board made inquiries of Dr Boyd's then solicitors as to her involvement in the treatment of patients the subject of these proceedings, which had apparently been the subject of media reports around that time. In response to that inquiry, Dr Boyd's solicitors wrote to the Registrar on 3 June 2005, saying:
We confirm that you have requested that we write, on behalf of our client, Dr Boyd, to advise the Board of the following:
1.with respect to the recent publicity and media reports regarding an alternative treatment being administered to terminally ill cancer patients ('the alternative treatment'), we confirm that the 'Breast Check' premises owned and operated by our client, the treatment administered and researched conducted at the premises, is not in any way related to the administering of the alternative treatment;
2.no patient, past or present, of Dr Boyd, who has been treated by Dr Boyd at 'Breast Check', has ever been administered the alternative treatment; and
3.Dr Boyd herself has not been involved in administering the alternative treatment or creating the relevant protocols in respect of the alternative treatment. Any involvement of Dr Boyd has been in a monitoring capacity only and we reiterate no treatment or research that is being conducted from the 'Breast Check' premises is related to the alternative treatment.
That letter was followed with a further inquiry from the Registrar of the Board, which led to the following response from Dr Boyd's solicitors on 10 June 2005:
We confirm that you requested, on behalf of the Medical Board, that Dr Boyd provide you with further details of any work she may be performing at a 'hospice', and any other work Dr Boyd may be performing outside of the Breast Check Centre.
We advise, in response to the Board's request, the following:
1.Dr Boyd is registered with the Australian Locum Medical Service.
2.Dr Boyd works as a locum approximately 3 nights per week and all day on Sundays. On average, Dr Boyd would work as a locum for 28 hours per week. This work represents Dr Boyd's major source of income and assists Dr Boyd in the running of 'Breast Check'.
3.Dr Boyd is not a registered hospice worker and does not perform work at any hospice in Western Australia.
4.In the course of Dr Boyd's regular work as a locum, Dr Boyd visits private homes as well as nursing homes. In the course of visits to nursing homes, Dr Boyd may be required to treat terminally ill patients who may be in their last stages of life and require palliative care treatment, for which Dr Boyd must prescribe appropriately. This is the only contact Dr Boyd may have with what might be considered hospice patients.
5.None of the patients Dr Boyd treats in the course of her work as a locum have been subject to the alternative treatment referred to in our previous correspondence to you of 3 June 2005.
Dr Boyd's work as a locum, along with her work at 'Breast Check', constitute the totality of the medical services Dr Boyd provides to the Western Australian community.
A further inquiry was made by the Board following a complaint to it concerning Dr Boyd's involvement with the patients. In response, Dr Boyd's solicitors wrote a letter dated 6 September 2005 saying:
In your correspondence, you advise that the Board has received a complaint about our client's conduct from Dr Dorothy Jones, A/Chief Medical Officer of the Department of Health. You also state that the allegations are set out in your correspondence and in this regard, upon our reading of your correspondence, the allegations are as follows:
1.an allegation that our client provided medical treatment to three patients who were admitted to Fremantle Hospital emergency department from Tuesday 24 May 2005 to Thursday 26 May 2005; and
2.an allegation that there was a suggestion that vitamin 17 (laetrile) may be involved.
It is not clear that the second allegation relates to the conduct of our client, but in any event, we are instructed to advise that our client has never had any involvement in the ordering, prescribing or administering of laetrile in respect of any persons.
(a)With respect to the first allegation detailed above, as previously advised to you in our letter of 3 June 2005, our client has not been involved in administering any alternative cancer treatment or creating the relevant protocols in respect of any alternative cancer treatment. Any involvement of our client in respect of these three patients was in a monitoring capacity only and was extremely limited.
In respect of your request for copies of our client's clinical progress notes and copies of any relevant letters, summaries or other investigations, we advise that, due to my client's very limited involvement with these three patients, she did not keep clinical progress notes.
However, the blood tests ordered by our client, in her monitoring capacity referred to above, were ordered through Clinipath, and results of these tests may be obtained from Clinipath or alternatively, our client, through her own enquiries, may be able to provide you with copies of these results.
On 19 September 2005, the Board wrote to Dr Boyd's solicitors seeking details of Dr Boyd's involvement with Ms McCarty, Ms Bosso and Ms Gruber. The Board also specifically asked:
·Who created the protocols for the alternative cancer treatment of the above named patients, and who administered the treatments to these patients?
·Who asked Dr Boyd to monitor the patients, and what did that involve?
·Who initiated the blood tests ordered by Dr Boyd, and who reviewed them?
·How often did Dr Boyd see the patients? Please provide details of the dates when each patient was seen.
·Does Dr Boyd have any information of how the treatments were advertised or the fees charged or know where that information can be obtained?
Dr Boyd's solicitors responded by letter dated 21 October 2005 in which they said:
We are instructed to respond as follows:
1.the protocols for the treatment provided to Ms Sandra McCartney, Ms Pia Bosso, and Ms Deborah Gruber were created, to the best of our client's knowledge, by Dr A Sartori. The treatment was administered to these patients, to the best of our client's knowledge, by registered nurses;
2.our client was requested by Dr Sartori to order and review blood tests for these patients;
3.the blood tests were ordered and reviewed by our client. The blood tests were reviewed by our client to ascertain the wellbeing of the patients;
4.it was at the time of ordering and reviewing the blood tests that our client had contact with these patients. As mentioned previously, our client was not the doctor responsible for administering any treatment to the abovementioned patients; and
5.our client does not have any information as to how the treatments were advertised, or the fees charged for such treatments.
By letter dated 21 September 2006, the Board sought further information from Dr Boyd in relation to the treatment. In response, by letter dated 23 October 2006, Dr Boyd's solicitors said that Dr Boyd was not asked to monitor the patients, but 'had very limited involvement with these patients, which consisted of ordering blood tests for the patients'. It continued:
The blood tests were ordered by my client and then reviewed, to the best of my client's knowledge, by Dr Sartori and/or the registered nurses who were responsible for administering treatment to the patients. The blood tests were not reviewed by my client, as my client was not involved in the treatment of the patients.
In relation to a question concerning whether Dr Boyd knew what, if any, agency provided the nurses involved in administering the treatment, Dr Boyd's solicitors said 'It was not my client's impression that the nurses were supplied by an agency'.
The Board asserts that the responses on behalf of Dr Boyd set out above are conflicting in that, in June 2005, she said that she had been asked to monitor the patients and to order blood tests and review the test results, and in October 2006 she said that she was not asked to monitor the wellbeing of the patients. The responses are said to be misleading in that they indicated that her knowledge of the treatment and its protocols, the parties associated with the treatment, her involvement with the treatment and the patients, was very limited and comprised of ordering only blood tests for the patients. That was said to be misleading because, the Board asserts, the DrBoyd was asked to, and agreed to, monitor and oversee the administration of the treatment, and had far greater knowledge and involvement of the treatment and those associated with it than she disclosed. The Board asserts that by her misleading responses or her obstruction of inquiries in relation to the treatment, she may be guilty of infamous or improper conduct in a professional respect in terms of s 13(1)(a) of the Medical Act.
In her response, Dr Boyd said that the contents of the letters of 3 June 2005 and 10 June 2005 were correct, save that she was in error in saying, in the letter of 3 June 2005, that she had been involved in a 'monitoring capacity'. Rather, she says the monitoring was done by Phasey and Sartori.
Dr Boyd said, in effect, that the contents of her solicitor's letters of 21 October 2005 and 23 October 2006 were correct.
Given our findings in relation to allegation 1, it follows that the responses provided by Dr Boyd were misleading. It is of concern that she continued to minimise her involvement in the treatment throughout the proceedings before the Tribunal, despite the compelling evidence of her participation which we have cited earlier in these reasons. It was undoubtedly material to the Board's inquiries that the treatment had been conducted in Dr Boyd's own home, that she had had more involvement with the patients than merely ordering blood tests, and that she had received a substantial sum of money for her involvement in the process. Instead, the responses made through her solicitors revealed none of those things. The responses were clearly designed to deflect the Board's inquiries away from her.
Membership of an honourable profession requires frankness and cooperation with the profession's regulatory body. Dr Boyd's failure to adhere to that requirement constitutes improper conduct. Allegation 5 is made out.

Allegation 6 ‑ misleading as to capacity as a locum

The sixth allegation against Dr Boyd is that she conducted herself in a misleading way. The Board's submission is that she did so in an attempt to create the impression that her association with two of the patients was as a locum, and thereby to distance herself from the treatment and protect herself from scrutiny or criticism. Three matters are identified as the basis for that contention.
The first is that, on 23 May 2005, Dr Boyd wrote a prescription for Ms Bosso, on which she deleted the practice address of Morley Medical Practice, and, in its place wrote 'ALMS', a reference to the Australian Locum Medical Service (ALMS).
Dr Boyd was asked about that alteration to the prescription form during her evidence at the inquest. She said that she had crossed out 'Morley Medical Practice' because she was no longer at that practice. She acknowledged that she was not seeing Ms Bosso in any capacity to do with ALMS, but said that 'was a more accurate address than Morley Medical Practice'. When asked why she did not put her own clinic address, she said 'I suppose because I didn't see her at the clinic, I saw her at the house'.
The alteration to the prescription supports the inference that, even during the course of the treatment, Dr Boyd was seeking to minimise the appearance of her involvement.
The second matter concerns Ms McCarty. On 24 May 2005, Ms McCarty, who was staying in an apartment organised through Dr Boyd's office by Firth, passed a large amount of blood. Phasey attended her and called Dr Boyd who then attended at the apartment. The records of ALMS show that, at 8.35 pm on 24 May 2005, Dr Boyd rang ALMS and recorded that she had attended Ms McCarty and sent her to Fremantle Hospital via ambulance. Dr Boyd was not on call with ALMS on 24 May 2005, and Ms McCarty was not a patient of ALMS. In response to an inquiry from the Board, ALMS wrote to the Board on 13 November 2006 identifying that it had no knowledge of, or involvement with, patients Ms Deborah Gruber and Ms Sandra McCarty. ALMS suggested that they may have been patients of Dr Boyd's private practice in Mosman Park and been attended by her at times when she was consulting in her own practice and 'certainly not when working for the Australian Locum Medical Service'.
Dr Boyd was asked at the inquest why she rang the locum service on that occasion. She responded (Exhibit 3 ‑ 6.75) as follows:
Well I didn't feel that she was my patient and then to go and then see her and order treatment ‑ and as I was acting as a locum I felt it better to have a record of what I was doing.
She then conceded that she was not working for the locum service that night.
The third matter also concerns the referral of Ms McCarty to Fremantle Hospital. Dr Boyd wrote a referral on an ALMS pad which stated:
Dear Dr
Thank you for admitting Sandra McCarty (5.11.51) a 54 year old with breast cancer, metastases and ascites. She has been having (illegible) therapy to improve her quality of life. However today she developed PR bleeding (bright red) and a rash on her L upper thigh/abdomen. Her therapy precludes saline rehydration.
Alex Boyd
In her evidence at the inquest, Dr Boyd suggested (Exhibit 3 ‑ 6.79) that the illegible word in the referral may have been 'vitamin'.
In its written submissions, the Board made reference to other alleged conduct by Dr Boyd said to be misleading or obstructive, in support of allegation 6. That conduct was not, however, the subject of the particulars set out in the re‑amended grounds of the application, and therefore did not form part of the case which Dr Boyd had to meet. We are accordingly having no regard to those additional alleged actions.
In her response to this allegation, Dr Boyd said that with regard to the prescription for Ms Bosso:
It happened to be the only script pad available at the time. I usually wrote ALMS on the script pad because it came out of my doctor's bag.
In relation to the allegations concerning Ms McCarty, Dr Boyd said that because she did not believe herself to be Ms Carty's doctor, she 'placed the call to visit her with ALMS even though I was not on that night. Looking back it was a foolish thing to do which I deeply regret'.
The Board contends that it may be inferred from Dr Boyd's conduct in relation to those three matters that, because she was concerned about her association with the treatment and the patients' consequent disturbing medical conditions, she attempted to create the impression that her association with the patients was as a locum and to distance herself from the treatment. We agree that that inference should be drawn. No other inferences are reasonably open. At no time has Dr Boyd proffered any explanation as to why she could not conduct herself on the basis that her services were provided as a private medical practitioner acting on her own account. Dr Boyd's misleading conduct in relation to the capacity in which she wrote the prescription for Ms Bosso on 23 May 2005 and dealt with her attendance on Ms McCarty on 24 May 2005 in our view amounts to improper conduct. Allegation 6 is made out.

Allegation 7 ‑ breach of requirements in relation to prescription of schedule for medications

The final allegation against Dr Boyd is that at various times, she supplied or administered medicines listed under Sch 4 of the Poisons Act to Ms Gruber and Ms Bosso. In particular, it is said that:
i)On or about 25 May 2005, she supplied or administered dexamethasone to Ms Gruber;
ii)On or about 14 May 2005, she supplied or administered adrenaline to Ms Bosso.
iii)On or about 22 May 2005, she supplied or administered hydrocortisone to Ms Bosso.
The Board alleges that, in breach of the requirements for prescribing the Sch 4 medicines in Western Australia, Dr Boyd failed to provide a valid prescription for medications so supplied, and failed to record and keep any adequate notes in respect of the supply of the medications.
In neither the grounds of the application nor in its written or oral submissions did the Board identify with precision the provisions of the Poisons Act or the Poisons Regulations 1965 (WA) (Poisons Regulations), which it contends were not complied with. In the absence of clear evidence as to the circumstances in which Dr Boyd dispensed the medications from her doctor's bag, all that can be said with confidence is that Dr Boyd failed to comply with reg 36B of the Poisons Regulations, which requires a medical practitioner to record in his or her client record cards every occasion on which he or she supplies a substance included in Sch 4 of the Poisons Act. It is not in dispute in these proceedings that the substances supplied to Ms Bosso and Ms Gruber were Sch 4 medicines, and Dr Boyd admits that she failed to record the administration of those substances.
That failure, particularly when viewed in the context of her general participation in the treatment of those patients, and the minimisation of her involvement with the patients as discussed in relation to earlier allegations, the administration of Sch 4 medicines without record amounts to improper conduct.
Accordingly, allegation 7 is made out.

Summary of findings

In summary, the findings which we have made above are as follows:
1.Dr Boyd is guilty of gross carelessness and infamous conduct by participating in the treatment of the seven named patients without regard to the nature and effect of substances being administered, and without knowledge as to whether ethics approval had been given, or as to the patients' histories or current medications.
2.Dr Boyd is guilty of gross carelessness in:
a)failing to keep accurate records of her interactions with seven patients or of the results of tests undertaken by those patients on her referral;
b)failing to refer patients for treatment or medical assessment or intervention where assessment or intervention was called for;
c)failing to provide appropriate monitoring equipment such as ECGs or alternately to refer the patients for ECG testing;
d)failing to implement protocols for the adequate gathering and recording of observations of the patients' vital signs during treatment; and
e)failing to provide appropriate sterilisation equipment and implement safe practices in relation to cleanliness and sterilisation of equipment, the premises and the environment in which the treatment was being administered.
3.Dr Boyd is guilty of improper conduct and gross carelessness in failing to deal appropriately with the administration of laetrile at her home in circumstances where she ought to have known of the administration of that substance.
4.Dr Boyd is guilty of improper conduct in misleading or obstructing the inquiries of the Board.
5.Dr Boyd is guilty of improper conduct by acting in a misleading way in relation to the capacity in which she wrote a prescription on 23 May 2005 and attended upon a patient on 24 May 2005.
6.Dr Boyd is guilty of improper conduct by failing to keep an adequate record of Sch 4 medicines dispensed on 14, 22 and 25 May 2005.

Penalty

The parties were invited to make submissions at the hearing as to the question of penalty in the event that the Board's allegations were established. Written submissions on the question of penalty had been made by the Board in its written outline of submissions. Dr Boyd did not suggest an appropriate penalty in the event that findings were made against her, but simply submitted that the State Administrative Tribunal (SAT) should bear in mind that these events took place at a time when she was very busy and in a context where all she thought she was doing was ordering blood tests.
The relevant provisions of s 13(3) of the Medical Act which deals with penalties which SAT may impose are:
i)an order for the removal of the name of the medical practitioner from the Register of Medical Practitioners (Register);
ii)the imposition of a fine not exceeding $10,000; and
iii)a reprimand of the practitioner.
As noted earlier, Dr Boyd surrendered her registration on 10 January 2010. Notwithstanding that she is not currently registered, SAT may exercise its powers under s 13 to order removal of her name from the Register ‑ s 13(9d) of the Medical Act.
The Board contends that SAT should order that Dr Boyd's name be removed from the Register, that a fine in the maximum sum of $10,000 be imposed, that Dr Boyd be reprimanded, and that she be ordered to contribute to the Board's costs of the application. It argues that Dr Boyd failed to meet the high standards and good reputation of the medical profession in that she:
•facilitated the treatment for the patients and at the same time applied no professional standard or rigour at all;
•disregarded the accepted medical standards and protocols in relation to unproven and experimental treatments;
•purported to have ignorance of the treatment whilst at the time treating the patients;
•provided clearly deficient treatment to the patients;
•disregarded the legal requirements for supplying laetrile and Sch 4 for medicines;
•represented that she was acting as a locum when in fact she was not; and
•blatantly attempted to mislead the Board and obstruct its inquiries.
That submission is supported by the findings which we have made. The infamous, improper and grossly careless conduct which we have found to have occurred constitute an abject failure by Dr Boyd to meet the standards expected of a medical practitioner by the public.
Despite the fact that Dr Boyd took issue with very few of the facts upon which the Board relied to establish its case, she continued 'throughout the proceedings right up until closing submissions' to minimise her role as simply ordering blood tests. That assertion was made notwithstanding, Dr Boyd's acknowledgement of all of the interactions with the patients which the Board had identified, some of which are referred to in these reasons. Those interactions went far beyond merely ordering blood tests. Dr Boyd's continued minimalisation of her participation in the treatment of these patients demonstrates a worrying lack of insight. That lack of insight heightens the necessity to make orders which adequately protect the public.
In our view, the findings which we have made support the conclusion that Dr Boyd's name should be removed from the Register. By her conduct, she has demonstrated that she is not fit to practise medicine.
As Owen J said in Jemielita at [147] the public needs to be protected from people who are ignorant of basic rules and indifferent to rudimentary professional requirements. DrBoyd demonstrated that indifference.
The Board seeks, in addition, the imposition of a fine and a reprimand. Those additional penalties are sought in order to demonstrate the seriousness with which conduct of this kind is viewed and dealt with.
DrBoyd is, we understand, presently bankrupt. The efficacy of the imposition of a fine is therefore somewhat questionable. In any event, removal from the Register is clearly the heaviest penalty available under the Medical Act. It deprives a person of their capacity to make a living in their field. The financial consequences of striking from the Register are therefore already severe. The object of disciplinary penalties is not to punish. In our view, an order removing Dr Boyd's name from the Register is a clear demonstration of the seriousness with which the conduct is treated, and is sufficient to serve as a deterrent to other practitioners from similar conduct. We propose to order that Dr Boyd pay the Board's costs to be assessed by the Tribunal if not agreed. The costs are likely to be substantial. To add a fine would simply be a crushing burden on Dr Boyd, probably for no practical purpose.
For the same reason, we do not consider that the issue of a reprimand adds anything to the achievement of the proper objectives of disciplinary penalties.
Each of the findings against Dr Boyd is concerned either with her involvement in an unproven and clearly dangerous treatment with indifference to the patients and proper professional standards, or is concerned with attempts to minimise the possibility of the detection of her participation. Viewed in that context, removal from the Register is a penalty available in relation to any one of the findings. Viewed together, the findings lead inexorably to the conclusion that Dr Boyd's name should be removed from the Register.

Orders

1.The practitioner's name be removed from the Register of Medical Practitioners.
2.The practitioner to pay the applicant's costs of the application in an amount to be agreed by the parties, or failing agreement to be assessed by the Tribunal.

I certify that this and the preceding [111] paragraphs comprise the reasons for decision of the State Administrative Tribunal.
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JUSTICE J A CHANEY, PRESIDENT