Medical Board of South Australia v Alexander No. Dcaat-00-324

[2001] SADC 12

MEDICAL BOARD OF SOUTH AUSTRALIA v ALEXANDER
[2001] SADC 12

Judge Vanstone, Member Pickering, Member Stott, Member Mills
Medical Practitioners Professional Conduct Tribunal

On 27 July 2000 the Medical Board of South Australia (“the Board”) issued a complaint pursuant to section 58 of the Medical Practitioners Act 1983 (“the Act”) against Marie Alexander (“the respondent”) alleging that she was guilty of unprofessional conduct in relation to the practice of medicine.

That complaint was extensively particularised and, as amended, contained some 33 grounds, each of which in turn contained details of allegations of conduct touching various aspects of the respondent’s practice during the period April 1993 to September 1998.

When the matter came before the Medical Tribunal on 29 January 2001 the respondent’s position was that she acknowledged guilt of unprofessional conduct in relation to 29 of the grounds, and acknowledged some or all of the alleged facts in respect of the other 4 grounds - being Grounds 1, 4, 5, and 6 - but denied that the admitted facts amounted to unprofessional conduct.

In view of this stance and also because of the disparate nature of the allegations it is necessary to set out a little more detail about them.

Ground 1 alleged unethical and unprofessional conduct in failing, without reasonable excuse, to attend before a Health Insurance Act Medical Services Committee of Inquiry and to provide certain records to it as required by section 101(2) Health Insurance Act 1973 (Commonwealth), and further of the failure to appear before the Magistrates Court on two occasions when prosecuted for that failure.  The respondent admitted the facts alleged and ultimately she admitted that the failure to appear before the Committee amounted to unprofessional conduct, but she steadfastly denied that she was obliged either in law or ethically to appear before the Magistrate.

Grounds 2 and 3 were in similar terms and alleged a failure to appear as required before a person conducting an investigation pursuant to section 20A of the Act, those failures occurring in December 1994 and April 1995. The respondent acknowledged unprofessional conduct in that regard.

Ground 4 alleged a failure in October 1997 “to maintain examination equipment, including vaginal speculum, in a clean and hygienic state” and to “maintain the examination couch, sheets and furniture within the consulting room in a state of cleanliness”.  Some of the allegations were disputed.

Ground 5 was an allegation that in October 1997 the respondent kept the medical records of different family members in a consolidated as opposed to a separate form.  The respondent admitted the assertion but denied that it amounted to unprofessional conduct. 

Ground 6, which was disputed, contained the following particulars:

1.      At all material times the respondent practised as a registered general practitioner from premises situated at 606 Regency Road, Broadview.

2.      A double sink at the rear of the premises mentioned in particular 1 above was dirty with debris hanging down from the plug hole.  This debris included suture material with a needle attached.

3.      Injection needles had been left uncapped lying in a cupboard in a consulting room.

4.      The respondent failed to provide adequate safe storage of used injection needles in that the provision of empty cordial bottles were unsuitable for this purpose.

5.      The respondent allowed various instruments including vaginal speculums to be left uncovered and gather dust.

6.      The respondent failed to provide and maintain clean linen for the examination couch with no replacement linen available.

7.      The respondent failed to maintain the plunger of an ear syringe in a clean and hygienic state.

8.      The respondent failed to maintain a refrigerator at the said premises in a clean and hygienic state.

9.      The respondent allowed insects and dust to accumulate on the inside of lids of jars which were being used as the base for legs of a desk at the said premises.

10.   The respondent failed to maintain carpet in a clean and hygienic state at the said premises.

Ground 7 alleged a failure to pass on the medical notes of a certain patient upon the repeated requests of that patient and his new doctor.  Unprofessional conduct was admitted in as much as it was acknowledged that a copy of the notes or a summary should have been provided.

Grounds 8 to 17 and 19 to 34 were repeated instances of essentially the same conduct. That consisted of overcharging for medical services rendered to various patients, the cost of whose medical care was to be met by the Workcover Corporation. This conduct occurred within the period May 1997 to September 1998. Each ground alleged one instance of such overcharging and the amount of the excessive charge in each case ranged from $2 to $20, although the vast majority of the matters alleged an amount of several dollars only. It was further alleged (via Ground 26) that in April 1998 the respondent was charged on complaint with 136 breaches of section 32 of the Workers Rehabilitation and Compensation Act 1986 and that complaint was served upon her on April 16 1998. After that time the respondent continued to overcharge in relation to a number of her Workcover patients and Grounds 27 to 34 reflected some of that conduct. On 21 October 1998 she pleaded guilty in the Industrial Relations Court to 136 breaches of section 32 of that Act and asked for another 64 instances to be taken into account. The Magistrate chose to convict her of Count 1 only and treat the balance of the charges as matters to be taken into account. The respondent was fined the amount of $6,000 in respect of that course of conduct, which was again admitted before us.

Having isolated the areas of dispute the parties then presented evidence going to those matters.  Although the respondent herself did not give evidence before us, her counsel cross-examined the Board’s witnesses and presented evidence going to what might be called mitigation.  We received submissions of counsel in an integrated way as to both the disputed grounds and also as to the appropriate disposition of the matter.

It is convenient to deal with the disputed matters first.  We have taken the view, without any contrary submission from counsel, that in respect of all areas of dispute in relation to the allegations the Board bears the onus of proof on the balance of probabilities.

As to Ground 1 it was ultimately conceded by Mr Halliday, of counsel for the respondent, that a failure to appear when required before the Medical Services Committee of Inquiry, a committee convened pursuant to section 80 of the Health Insurance Act 1973 (Commonwealth) can amount to professional misconduct.  There was no dispute that the respondent was summonsed by that Committee.  We were told she appeared before it four times, but through stress and ill health and feeling that she was being intimidated by the Committee she did not continue to attend.  We consider that this failure does constitute unprofessional conduct and that it is more than a trivial matter.  However we are not satisfied that the failure to appear before the Magistrate when prosecuted for non-attendance before the Committee amounts to professional misconduct.  In this regard we were referred to Plenty v Dillon and Others (1990) 171 CLR 635. In the course of the judgment of Mason CJ, Brennan and Toohey JJ the following observation was made (at page 641);

“A summons to appear before a court of summary jurisdiction to answer an information or complaint does not itself compel a defendant to appear.  Its primary purpose is to ensure that natural justice is accorded to a defendant by giving the defendant notice of the subject of the complaint and an opportunity to be heard.  Service of a summons, unlike the execution of a warrant of arrest, does not coerce a defendant to appear, though a failure to appear in answer to the summons may lead to the issue of a warrant: see Jervis’ Act - the Summary Jurisdiction Act 1848 (U.K.) (11 & 12 Vict. c 43).  The essential nature of a summons as the means of according natural justice has been established by long practice.”

Notwithstanding that passage, Mr Nicholas, for the complainant, asserted that in light of the fact that the summons was the corollary of the respondent’s failure to obey a provision of the Health Insurance Act, she had an obligation as a medical practitioner to answer it.  He characterised her failure to do so as “improper”.  It is sufficient to say that we are not satisfied that the respondent’s obligations when faced with the summons went beyond those of other citizens.  Accordingly we have put aside the balance of the assertions in Ground 1, except insofar as it is relevant to note that the respondent was convicted and fined the sum of $400 for the breach of the Health Insurance Act. 

It was to Ground 4 and 6 that almost all of the oral evidence called by the complainant was directed. 

At all relevant times the respondent was a sole practitioner.  She practised from a large two storey building at Broadview.  In 1997, as a result of the investigations of the Committee of Inquiry already mentioned, the respondent’s entitlement to receive Medicare payments in respect of her patients was suspended for a period of two months.  Consequently she arranged, through an agency, for locum doctors to work at her practice to see her Medicare patients and she continued to see those patients who were funded independently of Medicare.

Dr Elizabeth Li and Dr Suzanne King, who gave evidence before us, were two of those locum doctors.  Dr Li worked at the practice on the mornings of 27 to 31 October 1997 inclusive.  Dr King went to work at the practice on the following Monday, being 3 November.  She was to attend on subsequent days but because of certain concerns she had she declined to go back in the absence of action taken to address those concerns.  The other main witnesses called by the complainant were Ms Pisano and Ms  Ziernicki who were both formerly employed by the respondent as receptionists over a period including 1997.  The provision of their evidence was designed as a background and setting against which the locums’ evidence could be assessed.  Grounds 4 and 5 of complaint embodied specific allegations based on observations made by Dr Li during her work at the practice.  Ground 6 was based on the evidence of Dr King.

We found Dr Li and Dr King to be impressive witnesses.  We accept their evidence as to all aspects of the condition of the surgery without reservation.  They are clearly competent and committed practitioners whose work as locum doctors accustomed them to various methods and standards used in general practice.  They were each struck by and concerned at the poor condition of the respondent’s rooms and equipment.

Dr Li found that in the consulting room which she was originally offered the examination couch was not covered with a sheet and there was no linen available.  She was able to find what was referred to as an incontinence sheet, but in our view use only of one or more of those is not an adequate arrangement.  Dr Li could not recall whether there was a pillow on the couch.  The two receptionists’ evidence was that there was, but the pillowcase on it was never changed.  Dr King reinforced that the condition of the couch was unsatisfactory.  She recalled that the pillowcase on the examination couch pillow was very dirty. 

Both doctors attested to the unsatisfactory method of disposing of “sharps”.  The receptacles in use were adapted for that purpose rather than designed for it.  Dr King described them as cordial bottles.  Dr Li found that they were so full it was dangerous to attempt to use them.  She said there were several of them in the footwell of the desk which made it difficult to sit at the desk.

Dr Li was at one stage required to take a pap smear from a patient.  She looked for speculums and found only one lying on a bench near a sterilising machine in a large ante-room adjacent to the consulting rooms.  She chose not to use it as it was covered in dust.  On the following Monday, Dr King made similar observations.  It was not apparent to either doctor that the speculums had been sterilised and in any event a method of storage which leaves the instruments exposed and able to collect dust is unsatisfactory.  We infer from the evidence of both receptionists that speculums cleaned in a rather outdated steriliser and left exposed to the air until next required were used by Dr Alexander.  Although she had disposable speculums on the premises they were kept somewhere in the upper storey rooms.  The fact that Ms Ziernicki was accustomed to seeing the metal instruments in the sink in the ante-room, apparently put there by the respondent for cleaning, satisfies us of the use of them and of their use in the condition described by Doctors King and Li.

Ground 5 referred to the condition of patient notes.  On more than one occasion Dr Li found that entries relating to different family members were collected together on the same sheet of paper within a medical record, without there being any clear differentiation as to which patients they concerned.  In the instance of this best recalled by her, a husband and wife happened to attend together and only by checking with both was she able to establish to whom each entry related.

Notwithstanding Mr Halliday’s submission to the contrary we consider that this is an unsatisfactory manner of keeping casenotes.  Entries relating to a particular person should in our view be kept separately, if not in a separate file then certainly in a subfile, and there should be no room for mistake as to the subject of a particular entry.  Any lesser standard could, in extreme circumstances, lead to a danger to the patient. 

We set out the particulars of Ground 6 in full earlier in these reasons.  As mentioned, Dr King’s evidence went to prove those allegations and we are satisfied in relation to each particular, but the evidence of the two receptionists was also relevant to them. 

Neither receptionist continues in the respondent’s employ.  Ms Ziernicki worked in the surgery from December 1996 to October 1997.  In fact her employment ended on Dr Li’s last day.  Ms Pisano commenced in June 1997 and stayed about 8 months, and so there was some overlap between the two employees during which time there was a job sharing arrangement.  Neither had any nursing training.

Apart from a cleaner who worked during one hour per week during office hours (a patently inadequate period) there was no other person employed to help in the surgery in any capacity.  The receptionists’ duties extended to light cleaning, sterilisation of instruments, management of paperwork, liaising with patients and stocking the surgery in terms of stationery and medicines.  In other surgeries a rather more qualified or experienced person might take on or supervise some of these tasks. 

Whilst there was no evidence specifically directed to the topic, it seems that in respect of both former employees the parting of the ways may not have been amicable.  In addition there was a tension in the evidence of both between the fact that the responsibility for the state of the premises was in part theirs and the fact that the condition of it in terms particularly of cleanliness was entirely unsatisfactory. 

Although we do not doubt that each of Ms Pisano and Ms Ziernicki had no wish to be other than honest in the giving of her evidence, we consider that there may have been at times an element of exaggeration or reconstruction in their descriptions of the premises and their conversations with the respondent.  Accordingly, although accepting the thrust of their evidence, we have confined its use to establishing the systems in place in the surgery and providing a context for the evidence of the locum doctors.  Importantly, while the locums could only speak of the condition of the rooms over an eight day period in 1997, we are satisfied on the basis of the receptionists’ evidence that the conditions they described were typical of the state of the premises over a long period.

Of particular concern in relation to Ground 6 was the condition of the refrigerator.  Quite apart from it being unclean and having a musty smell it is clear on the evidence of the receptionists that it was not in good working order.  In view of the fact that vaccines and other medicines were kept in it - as opposed to there being a dedicated refrigerator with a minimum/maximum thermometer - this gives rise to a serious issue of patient welfare.  Although the matter of vaccines was not specifically adverted to in the particulars, no complaint of lack of notice about it has been made by the respondent.  In fact there were two issues related to the storage of vaccines.

Dr King gave evidence, which we accept, that she found a number of vials of polio vaccine in the refrigerator, some of which were out of date, even to the extent of almost a year.  Ms Ziernicki spoke of an occasion when she alerted the respondent to the presence of out of date polio vaccines in the refrigerator.  She said that the respondent told her that because they were in a liquid form and were kept cold, their effectiveness continued past the expiry date.  Being unsure of the accuracy of this information Ms Ziernicki telephoned a pharmacist she knew of to seek his advice.  We accept Ms Ziernicki’s evidence as to this conversation with the respondent.  We infer from it that the respondent was prepared to use vaccines which had gone beyond their expiry date, and that she probably did.  Why else keep them?  This raises a serious question mark over the effectiveness of all immunisations given by her. 

However that concern is only reinforced by other evidence already alluded to in relation to the refrigerator.  Ms Ziernicki gave evidence that on perhaps ten occasions during her employment the refrigerator would freeze certain of its contents, for example the yoghurt which she would sometimes have for lunch.  To counteract that problem Dr Alexander would turn off the refrigerator at the end of the day and leave it off overnight.  In the morning Ms Ziernicki would turn it back on.  Again we accept Ms Ziernicki’s evidence as to this matter. 

The attitude of the two locum doctors to irregularities with vaccines is instructive.  Dr King’s evidence was that after a significant power failure, such as that which apparently occurred on 31 October 1997, all the vaccines in the refrigerator should have been discarded.  Dr Li said that she would definitely throw out vaccines after, say, a twelve hour power failure.  She also said she would not use an out of date vaccine even if it were only slightly out of date.

In our view the judgment underpinning this evidence is entirely correct.  If there is not adherence to the manufacturer’s guidelines, including to the quite narrow band of allowable temperature variation, the vaccines should, without exception, be discarded.  The same applies to the “use by” date.  Accordingly the effectiveness of all vaccines used by Dr Alexander over this period is open to question.  This evidence - which was not seriously challenged by Mr Halliday - demonstrates a lack of judgment on the respondent’s part which goes directly to the care and wellbeing of her patients.  We consider this to be the most serious of the matters before us.

To recapitulate, in relation to each of Grounds 4, 5 and 6 we find the respondent guilty of unprofessional conduct.  We are satisfied in respect of each particular of those grounds.

It is convenient at this point to make some observations about those allegations which were acknowledged to amount to unprofessional conduct.  There are some important parallels in respect of them and indeed Ground 1.

Grounds 2 and 3 were the failure on occasions in 1994 and 1995 to attend for interview before a Mr Talbot, a government investigator appointed by the Board to investigate matters raised, we were told, by the Workcover Corporation.  These failures were subsequent to the respondent’s prosecution and conviction in May 1993 for the failure to attend before the Committee of Inquiry.  It is the continuation of such conduct in the face of the seriousness of it being emphasised which is of particular concern. 

Ground 7 - the failure to send on a patient’s notes or a summary - is most noteworthy as a further demonstration of a disinclination in the respondent to expose herself or her practices to examination by others.  Of itself it does not seem to be a serious matter.

Ground 8 to 17 and 19 to 34 represented, as we have said, some of 200 instances of overcharging for Workcover consultations.  The monetary amounts involved overall were not great, totalling about $500.  But the conduct continued for in excess of a year and occurred despite repeated warnings from the Workcover Corporation of the respondent’s charges being excessive.

In January 1996 the Corporation wrote a standard letter to the respondent advising her of a new regime in respect of charges.  Then in September of that year the Corporation reminded the respondent of the $1,000 maximum penalty provided for charging more than the scale charge.  In January 1997 a further letter referred to the maximum penalty and enclosed details of patients in relation to whom an excessive charge or charges had been made.  The letter asked Dr Alexander for a response in writing.  Then in June 1997 a further letter advised that overcharging had continued and it was requested that it cease immediately.

In April 1998 a complaint alleging 136 breaches of section 32 (14) of the Workers Rehabilitation and Compensation Act was served on the respondent. Notwithstanding that fact she continued to charge in excess of the prescribed amounts. Those further instances of excessive charging were taken into account by the Industrial Magistrate before whom the respondent appeared in answer to the summons and are reflected before us (in part) in Grounds 26 to 34 of the Medical Board Complaint.

In the course of her evidence Ms Ziernicki said that she was aware through examination of the Workcover Payment Schedule and from patients and through communications from Workcover Corporation that amounts in excess of those allowed were being charged.  When Ms Ziernicki raised this with the respondent she was told (at page 149):

“I charge what I like because this is my practice”.

Such an attitude of defiance runs through all these allegations.  It seems that in this period the respondent was simply not prepared to follow a schedule of charges set down by the Corporation and nor was she prepared to submit herself or her practice to examination by bodies such as the Committee of Inquiry or Medical Board, even though those bodies plainly had the statutory power to regulate aspects of her practice, and to demand her attendance before them.  That her disregard of the obligations upon her was wilful rather than negligent is amply demonstrated by the sequence of events.

We turn then to the evidence called by the respondent.  The principal witness for Dr Alexander was Dr Anthony Davis, a psychiatrist who saw the respondent once on 10 January this year.  Dr Davis was given an amount of information and materials by the respondent’s solicitors, including a short report by Dr M Narielvala, senior consultant psychiatrist, concerning Dr Alexander’s admission to Glenside Hospital in December 1996.  That report was already in evidence at the instance of the Medical Board.  Dr Davis’ views were based on his own assessment coupled with the background material, none of which was contentious.

We found Dr Davis to be an impressive witness.  We accept his opinions so far as they go.  But we, like the witness himself, are alive to the necessary limitations applying to those opinions, limitations dictated by the lack of investigation of the respondent’s condition and the extent of its impact on the care of her patients.

Dr Davis took an extensive history from the respondent.  He described the 1996 Glenside admission as being occasioned by the onset of an acute paranoid delusional state.  It is unnecessary to set out any detail of her condition.  Rather it is sufficient to record that the respondent was placed on trifluoperazine, an anti-psychotic medication, and her condition rapidly resolved.  After two subsequent outpatient attendances at Glenside the respondent was advised to have her general practitioner follow up her condition.  She did not do so and in fact we have been told that she did not have a general practitioner.  For a time the respondent was self-medicating on that drug.  Dr Davis accepted that this episode was caused by an accumulation of stresses, some of long standing and connected with her practice, but others related to family members and occurring at a time proximate to the admission.  Dr Davis accepted that in a person with a propensity for a paranoid psychosis - and Dr Davis found the respondent to be such a person - such factors could contribute to the acute condition from which she had suffered.

However it was not that propensity nor the aftermath of the acute condition which in Dr Davis’ view led to the problems seen in the respondent’s practice of medicine.  Rather Dr Davis saw those as a reflection of a personality disorder from which he considered she suffered, one accompanied by prominent obsessional and paranoid traits.  These traits were manifested in such things as episodic panic, hoarding, checking and ruminating over problems at great length.  Dr Davis saw the respondent’s difficulties with such authorities as the Workcover Corporation, the Health Insurance Commission and the Medical Board as symptomatic of the paranoid dimension of her disorder, giving rise to a mistrust and wariness of others and a fear of being exploited or manipulated.  The lack of cleanliness and efficiency in the surgery was also said to fit with an obsessional personality.

Dr Davis’ opinion was that none of these matters should necessarily preclude the respondent from continuing to practise.  He advocated the putting in place of measures designed to address potential stressors and assist in dealing with them before they got out of control and affected her wellbeing or her practice.  He suggested the development of a solid relationship with a mentor or therapist with whom current problems could be discussed.  He also suggested the overseeing of her practice by a senior colleague from whom the respondent would have to be prepared to take advice.  And in addition, Dr Davis thought it desirable that the respondent have the services of a practice manager to look after the running of the surgery.  He further recommended that the respondent establish a relationship with a general practitioner of her own.  These measures, Dr Davis said, did not guarantee success but were (page 267) “the only way forward”.  In expressing views as to a regime designed to keep Dr Alexander practising safely and effectively, Dr Davis assumed (see page 265) that to this point there had been no evidence giving rise to a concern about patient care.  He took this to be a good prognostic feature.  In the absence of that assurance his opinion was more guarded.  The following passage occurred at page 288:

“HER HONOUR

Q. ... Dr Davis, in expressing your opinion about the ability of Dr Alexander to keep practising with certain measures in place to control her practice - that that’s viable - you’ve drawn some comfort from the fact that you know of no patient complaints or instances where patients have somehow been jeopardised by her clinical treatment, haven’t you.

A.     That’s right.

Q...... If in fact, and I ask you to assume this for the purpose of my question, if in fact Dr Alexander had administered vaccines which were ineffectual by reason of being out of date, and if in fact she had used instruments on patients which were not sterile and thereby given rise to the possibility of infection, would that rather undermine your view.

A.Yes.

Q...... To what extent.

A.Considerable concern, if unsterile methods were being used or old vaccines, yes, I mean then patients are being put at risk.

Q...... Would you still say then that the measures you’ve spoken of would be a sufficient safeguard.

A.I think they could be.  I think if the inputs were rigorous and pretty tough, you could take steps to ensure that the vaccines are up to date and the procedures were sterile and so on.

Q...... Yes, you could look to those measures, but if that was symptomatic of a wider invasion of her personality disorder into her clinical practice, then would you agree that it might be harder to put in place measures that would safeguard the patients.

A. Yes, it creates a lot more discomfort.”

Finding as we have that in the material before us there are areas in which patient care has been jeopardised, that passage of evidence has importance.

In addition to Dr Davis the respondent called Dr Suzette Blight, a rehabilitative physician.  She did not know the respondent personally but had accepted referrals from her over a period of about six years, those referrals numbering something more than 25.  Dr Blight told us that without exception those patients spoke exceedingly well of Dr Alexander, regarding her as a caring general practitioner.

In addition the respondent submitted, by consent, a document containing “proofing” notes of a conversation with Dr Darcy Economos, an ENT specialist.  He too spoke well of the respondent’s reputation among patients whom she had referred to him and among some medical colleagues.

We turn then to consider what orders should be made in relation to the respondent.

The disciplinary powers of the tribunal are set out in section 58 of the Act. They are to be exercised not to punish the respondent but in order to protect the public. (See NSW Bar Association v Evatt (1968) 117 CLR 177, 183-4; Rajagopalan v Medical Board of SA, Judgment of the Full Court No. S6667 delivered 5/5/98; Chan v Medical Board of SA (1986) 14 SASR 434, 442.)

In his submissions Mr Halliday suggested that the imposition of conditions on the respondent’s right to practise along the lines suggested by Dr Davis would be a measure sufficient to protect the public from further unprofessional conduct by the respondent.  In our view that is not so.  Our judgment is that it needs to be brought home to the respondent that the course of conduct involved in refusing to submit herself to the regulatory processes of the Committee of Inquiry and the Medical Board and the refusal to adhere to the scheme of prescribed payments under the Workcover legislation applicable to all practitioners is not one which will be tolerated.  The adherence to her own scheme of Workcover fees even in the face of being charged with offences for just such conduct, demonstrates the degree of re-appraisal of her rights and duties which needs to take place in the practitioner’s mode of thinking.  Whilst we recognise the contribution of the respondent’s personality disorder in taking the stand she did with respect to these authorities, we do not consider that these matters are so simply excused. 

Moreover these complaints do not stand alone.  Our findings as to the physical state of the respondent’s rooms, and particularly the cleaning and storage of instruments and the position with respect to vaccines have caused us great concern.  Whilst those matters could no doubt be addressed by a practice manager, the flawed judgment which could allow such conditions to persist could not.

Again it is necessary in our view to demonstrate to the respondent by a period of suspension how seriously these failings are viewed and to deter her from a repetition of such conduct in the future.

We have considered whether it would be appropriate to impose conditions under section 58 (3)(a)(iii) to operate on a resumption of practice. Indeed Mr Nicholas suggested that would be appropriate if we rejected his first position, being that the respondent’s registration should be cancelled.

For the reasons which follow we have determined not to impose such conditions.  First it is important to remember that Dr Alexander is before us in relation to certain instances of unprofessional conduct.  The inquiry into those matters and how they came to occur has touched upon the question of her fitness and competence as a practitioner.  But this hearing has not been directed at that very issue.  An inquiry focused principally on that issue might well have involved further and different investigations in respect of her condition.  Furthermore the only current psychiatric opinion before us - that of Dr Davis - was couched (appropriately) in quite qualified terms.  Dr Davis is not the respondent’s treating psychiatrist and he has only seen her once.  His views on the safeguards necessary to enable her to continue to practise were based on assumptions which are not, as was demonstrated, necessarily correct.  Even then his confidence in the effectiveness of the “safety net” was far from overwhelming.  In addition the respondent’s state of health may alter over the ensuing months, especially as she faces a period of suspension.  For these reasons we lack confidence that the suggested conditions of practise - which certainly seem at this time to be appropriate so far as they go - would necessarily be the appropriate ones many months into the future.

If at the end of the period of suspension the respondent applies to the Medical Board for reinstatement of her name on the register, then, in accordance with its duties under section 34 (4) of the Act, the Board will be called upon to determine (among other things) whether she is a fit and proper person to be registered and under what conditions. If it is thought appropriate, further investigations can then be conducted. If we were to now set conditions restricting the respondent’s right to practise that may well have the effect of pre-empting a subsequent well informed decision of the Board.

We turn to consider the length of the period of suspension.

Dr Alexander is a 49 year old practitioner.  She obtained her MBBS in Adelaide in 1977.  For a time she worked in public hospitals and she later entered private practice with another practitioner.  They parted company over a dispute about money which has been long running and which is not yet resolved.  Since then she has practised alone.  We have taken into account all the matters put to us by Mr Halliday including that the respondent has already suffered various financial losses through her difficulties with the HIC and Workcover Corporation.  In addition we have noted that because of Dr Alexander’s rather isolated life, both personally and professionally, suspension will be a heavy burden upon her.

Nevertheless the respondent’s conduct, in what can be seen as two distinct areas, has fallen very far short of the standards expected of medical practitioners.  We consider that only a substantial period of suspension can mark its seriousness and adequately protect the public in the future.

The order of the Tribunal is that the registration of Dr Alexander as a medical practitioner be suspended by removing her name from the general register for a period of nine months from today.