NC (Medical Consent)
[2014] TASGAB 15
•21 July 2014
GUARDIANSHIP AND ADMINISTRATION BOARD
HOBART
NC – Application for consent to medical treatment (special treatment) by Dr. Sue Keating
NC (Medical Consent) [2014] TASGAB 15
REASONS FOR DECISION
Anita Smith (President)
Kim Barker (Member)
Carolyn Wallace (Member)
Date of hearing: 21 July 2014
Consent to Medical Treatment – sterilisation – treatment of last resort – incapacity – best interests – sufficiency of possible alternatives
Guardianship and Administration Act 1995 s.3, 36, 44, 45, 76
Secretary, Department of Health and Community Services v. J.W.B. and S.M.B. (Marion's Case.) (1992) 175 CLR 218.
In the Matter Of: Re Katie [1995] FamCA 130
About NC:
NC is a delightful 14 year old girl who lives with her mother, her siblings and her grandmother. She and her family enjoy a warm and supportive environment. She attends school with support. NC enjoys swimming and sports and is an actively social person. NC was born with chromosome 16p11.2 deletion syndrome which has resulted in a severe intellectual disability.
The Application:
For reasons discussed in detail below, Consultant Obstetrician and Gynaecologist, Dr. Sue Keating, has applied for the Board to give its consent to NC having a laparoscopic hysterectomy for the removal of her uterus and tubes but not her ovaries. While issues of menstrual management and contraception are not irrelevant to the application, they were distinctly subordinate in the application to the ‘surgery being appropriately carried out to treat [a] malfunction or disease’[1] that negatively affects NC’s wellbeing and her quality of life.
[1] Phrase borrowed from paragraph [48] of Secretary, Department of Health and Community Services v. J.W.B. and S.M.B. (Marion's Case.) (1992) 175 CLR 218
A hysterectomy has ‘the effect of rendering permanently infertile the person on whom it is carried out’ and is therefore is a ‘special treatment’ as defined in section 3 of the Guardianship and Administration Act 1995 (the Act). Because it is a special treatment, the surgery would not be lawful unless the Board (or a Court) gives its consent to the procedure in accordance with the tests set out in sections 44 and 45 of the Act.
The status of ‘special treatment’:
The Guardianship and Administration Act 1995 was enacted after the High Court delivered its judgment in Secretary, Department of Health and Community Services v. J.W.B. and S.M.B. (Marion's Case.) (1992) 175 CLR 218. The Court was unanimous in that decision to the extent that:
‘… the authority of parents does not, in the absence of special statutory provisions, extend to authorizing surgery involving the sterilization of a profoundly intellectually disabled child for other than the conventional medical purposes of preserving life and treating and preventing grave physical illness.’[2]
[2] Per Deane J at [1]
The legislature, in enacting this Act, were clearly responding to the terms of the High Court’s decision and extended the authority to consent to a sterilisation procedure upon a child with a disability to the Guardianship and Administration Board, such that the Board holds dual jurisdiction to give such consent with the Family Court of Australia.[3]
[3] The Act expressly limits the operation of Parts 4, 5 and 7 to persons over 18 years of age; therefore the Board’s jurisdiction is limited in those Parts to making orders about adults. Part 6, and in particular section 36, contains no such limit; therefore that Part has application to adults and children with disabilities who are ‘incapable of giving consent to the carrying out of medical or dental treatment’
Whereas the High Court decision allowed parents the authority to consent to sterilisation for ‘conventional medical purposes of … treating and preventing grave physical illness,’ the legislature removed that authority in the enactment of Part 6 because the operation of that Part does not make an exception to section 38 or the definition in section 3 where the procedure is undertaken for the treatment of ‘grave physical illness.’[4] The High Court hesitated to use the terms ‘therapeutic’ and ‘non-therapeutic’ sterilisations[5] because of the uncertainty and the lack of a clear ‘dividing line’ between those two concepts. It is possible that, for the same reasons, the legislature determined that application of a universal rule was preferable to attempting to delineate what was ‘therapeutic’ and ‘non-therapeutic’ in this respect.
[4] The Board observes that section 40(a) allows ‘special treatments’ to proceed without consent where there are circumstances of urgency and the treatment is required for preserving a person’s life.
[5] At [48]
The High Court in Marion’s Case emphasized the special gravity of consenting to an hysterectomy:
“As a starting point, sterilisation requires invasive, irreversible and major surgery. But so do, for example, an appendectomy and some cosmetic surgery, both of which, in our opinion, come within the ordinary scope of a parent to consent to. However, other factors exist which have the combined effect of marking out the decision to authorise sterilisation as a special case. Court authorisation is required, first, because of the significant risk of making the wrong decision, either as to a child's present or future capacity to consent or about what are the best interests of a child who cannot consent, and secondly, because the consequences of a wrong decision are particularly grave.” [49]
The majority of the High Court in Marion’s Case agreed that: “Sterilisation is a step of last resort.” The Board proceeds in this application mindful that we have been called upon to make a decision which will have critical implications for NC’s future. In particular we have been wary that the consequences of a wrong decision are particularly grave.
The investigation process and the hearing:
The Board received the application on 12 March 2014. The following medical reports accompanied the application:
· A covering letter dated 5 March 2014 from the applicant, Dr. Sue Keating
· A pro forma Health Care Professional Report by paediatrician, Dr. Charlotte Whitelaw dated 18 February 2014
· Dr. Narelle Bleasal, Dermatologist dated 3 July 2013
· SX, Senior School Psychologist dated 1 March 2014
· Dr. David Amor, Consultant Clinical Geneticist dated 3 March 2014
The Board’s investigator, Elizabeth Dalgleish, contacted the applicant and NC’s mother shortly after receipt of the application. She sought statements from NC’s support teacher, FN, and support worker, NK. The investigator also obtained a copy of NC’s communication book from 5 February 2014 to 14 April 2014. At the investigator’s request, the applicant supplied two additional reports:
· Report to Dr. Whitelaw dated 23 March 2013
· Report to Dr. R. Ralph dated 3 December 2013
Adopting the Australian Guardianship and Administration Council’s Protocol for Special Medical Procedures (Sterilisation) of 6 May 2009, the Board sought the intervention of the Public Guardian in a role similar to a ‘separate representative’ in Family Court proceedings. The Board also sought an independent medical opinion from paediatrician, Dr. Michelle Williams.
The investigator interviewed and recorded statements from NC’s mother, sister and grandmother. She also sought the views of NC’s father who does not have a day-to-day role in NC’s care.
At the conclusion of the investigation, the application was listed for hearing on 21 July 2014. The following persons attended the hearing:
NC
MC – mother
BN – grandmother
Dr. Sue Keating – applicant
Anne Perks – Office of the Public Guardian
Elizabeth Dalgleish – GAB InvestigatorNo party or witness opposed the application. The various medical reports and witness statements presented a consistent picture of NC’s level of disability and her experience of menstruation. Accordingly, the Board accepted all of the written medical opinions and statements of witnesses as evidence in support of the application.
Formal requirements:
The Board was satisfied for the purposes of section 44(1) of the Act that Dr. Sue Keating, as the treating practitioner seeking consent to a procedure, is a person with a proper interest in this application. The application met the requirements in section 44(2) of the Act.
The Board is satisfied for the purposes of section 45(1)(a) that, where consent exists, a laparoscopic hysterectomy for the removal of a person’s uterus and tubes but not the ovaries is lawful.
Evidence that NC is incapable of giving consent to the treatment:
Part 6 applies to a person with a disability who is incapable of giving consent to the carrying out of medical or dental treatment, whether or not the person is a represented person[6]. Section 45(1)(b) requires that the Board is satisfied that the person is incapable of giving consent. Section 36(2) defines a person as incapable of giving consent to the carrying out of medical or dental treatment if the person:
(a)is incapable of understanding the general nature and effect of the proposed treatment; or
(b)is incapable of indicating whether or not he or she consents or does not consent to the carrying out of the treatment.
[6] Section 36(1)
The reports of Dr. Sue Keating, Dr. Charlotte Whitelaw, SX, Dr. David Amor and Dr. Michelle Williams are consistent in stating that NC has a severe intellectual disability. Dr. Sue Keating, Dr. Charlotte Whitelaw and Dr. David Amor attribute this to a chromosomal abnormality which Dr. Amor describes as chromosome 16p11.2 deletion syndrome. On the basis of these reports, the Board is satisfied that NC is a person with a disability.
SX, a Senior School Psychologist, reported that NC’s general cognitive ability is within the Extremely Low range of intellectual functioning. He notes that:
“NC is clearly unable to provide adequate care for herself even at the most basic level and will require ongoing support in all aspects of her adult life.”
Dr. Whitelaw, paediatrician, indicated that NC cannot understand the nature and effect of the proposed medical treatment. She stated:
“NC functions at the level of a very young child. … She has minimal communication – no speech at all, no signing, some facial expression, some gestures.”
Dr. Sue Keating noted that NC has no real understanding of menstruation and that:
“NC is severely intellectually handicapped and would not be able to bring up a child even with maximum support.”
Dr. Michelle Williams noted NC’s full scale IQ on a WISC IV of 40 and stated:
“NC’s intellectual disability means she is unable to give informed consent for this procedure. She will never achieve fully independent care for herself and would be unable to tolerate childbirth. She would be incapable of parenting a child.”
NC’s mother reports that she has about a five minute concentration span. NC cannot tell her when she is hot and cannot report pain. She has no self-care skills. NC cannot comb her hair or clean her teeth. She is unable to dress herself and feeds with her fingers. She may choke on food if it the pieces are too large. NC’s carers report that she is toilet timed not toilet trained.
As NC attended the hearing, the Board had the opportunity to observe NC. She was quiet but ‘smiley’ during the proceedings. She showed warmth to her mother and grandmother and her behaviour and her interactions were consistent with the level of impairment noted in the above reports.
On the basis of the above evidence, the Board is satisfied that NC is both: (i) incapable of understanding the general nature and effect of the proposed treatment, and (ii) incapable of indicating whether or not she consents or does not consent to the carrying out of the treatment.
Evidence that the procedure would be in NC’s best interests:
A consideration of NC’s best interests under section 45 of the Act requires that the Board examines:
(a) NC’s wishes, so far as they can be ascertained
(b) the consequences to NC if the proposed treatment is not carried out
(c) any alternative treatment available to NC
(d) whether the proposed treatment can be postponed on the ground that better treatment may become available
(e) whether NC is likely to become capable of consenting to the treatment
NC’s wishes – The Board is unable to ascertain any wishes that NC may have with respect to this application because: (i) NC does not have any language skills with which she could convey her wishes, and (ii) NC would not be able to comprehend or respond to the concepts of menstruation, pregnancy, sterilisation, medical procedures, sexuality or motherhood.
The consequences to NC if the procedure is not carried out – Dr. Keating’s application notes that NC’s periods have a severe effect on her quality of life. In her letter dated 5 March 2014 she states:
“NC underwent Menarche over 12 months ago. Periods are somewhat irregular and very heavy when they do occur. NC has extreme difficulty managing her hygiene. She often smears blood over herself, her clothes, and the walls. She is unable to manage pads. Tampons are impossible. She is very distressed at the time of her periods. It would seem that she has pain when periods occur. We have tried to lighten the periods using Tranexamic acid. This is partially improving them but we have a great deal of difficulty getting NC to take the tablets. … All things considered I would think that in the long term a hysterectomy is in NC’s best interest. With her severe disability she is never going to be in a position to raise a child. Hysterectomy would also protect her from an unwanted pregnancy. Hysterectomy could be performed laparoscopically which although still a major operation, it is unlikely to give her any prolonged distress.”
Dr. Williams noted:
“NC’s major health problems are menorrhagia with dysmenorrhea and severe eczema. NC has been menstruating since 11 years of age. Unlike many adolescent girls, her periods have not settled into a more manageable pattern. NC’s periods are extremely long and heavy. NC’s periods last on average 10 days.”
Dr. Williams detailed the heaviness of NC’s menstrual flow and also noted that because of her intellectual disability, NC has a propensity to spread the blood from her night nappy to her bed, face and hair. Sadly NC is distressed by the sight of blood and becomes very upset when she sees that blood whether from her night nappy or in the toilet upon changing. Dr. Williams stated that NC has pain which will start the day before her period and is most noticeable on the first two days of her period. Dr. Williams considered that the distress that NC experiences when toileting during her period is possibly holding her back from independent toileting.
Dr. Williams stated that the large amount of blood associated with NC’s periods limited the number of people prepared to care for NC, having only 3 people who are prepared to assist in this regard. She noted a severe impact on NC’s dignity, independence and ability to self-care. She states:
“In considering NC’s right to participate fully in life and achieve some degree of autonomy in independent tasks, I believe her current severe menorrhagia and dysmenorrhea are providing a major impediment. She deserves the same right to treat this medical problem as any other young woman.
… As such, in my opinion, the option of a hysterectomy is the best option available for maximizing NC’s quality of life and ability to be independent.”MC reported:
(i)She notices a marked change in NC’s behaviour in the week before her period, including being more needy of attention. Normally NC will wake twice per night as part of her usual pattern of sleep however, prior to getting her period, NC can be up ten times during the night. When she wakes she turns on lights and disturbs the whole family, needing her mother to settle her again.
(ii)NC is doesn’t cry as a response to pain. It is therefore very difficult to gauge whether NC is experiencing any pain. NC will become quieter and paler when she has her period.
(iii)NC’s eczema flares up in the week before her period. It has also flared up with the treatment options that have been trialed in an effort to reduce the impact of NC’s periods.
(iv)NC is currently taking a trial of oral tranexamic acid to alleviate the heavy bleeding. During her periods, NC turns ‘deathly white’ and will dry retch. The medication may have slightly helped to reduce the severity of bleeding, but not sufficiently so. A further complication with this treatment and other oral medication is that NC finds it difficult to swallow pills.
(v)NC enjoys swimming at school and horse riding but both of these activities are restricted by NC’s heavy periods.
(vi)During a recent family holiday, NC’s period came unexpectedly. NC’s pads needed to be changed five times while walking to the lookout at Coles Bay. There was significant difficulty in making her changing pads in privacy when outdoors. Problems with controlling and cleaning up from blood flow impacted on the ability to stay in a friend’s holiday home. Anxiety about containing the spread of NC’s blood impacted on the whole family’s enjoyment of the holiday.
(vii)Changing NC in a public toilet is difficult, especially as many toilets do not accommodate two people. This difficulty is increasing as NC is growing. Because of her tendency to put her hands in the blood, this can be difficult to manage in a public area.
(viii)NC’s older sister will assist with changes, but finds this task challenging. There has been no other support available to NC other than what is offered through NC’s school. NC’s older brother is unable to cope with NC’s menstruation at all.
(ix)NC enjoys her drama classes and may roll around on the carpet with her legs in the air in a disinhibited fashion during these classes or out in the playground. MC is concerned to preserve NC’s dignity and worries that other children may be insensitive if they observed leakage in her bleeding.
NC’s carers, FN and NK described similar difficulties to MC, and also noted:
(i)NC becomes quiet and withdrawn and is more easily distracted when she has her periods.
(ii)Even shopping can be difficult when NC has her period, due to the challenges in changing her in public places.
(iii)Because of the need to take NC to a designated toilet at school, which is some distance to her classroom, class time is missed when moving between the classroom and the toilet.
(iv)Changing disrupts NC’s adherence to the educational program.
The Board finds that the consequences for NC if the procedure is not carried out include a continuation of :
·Heavy menstrual bleeding (menorrhagia) for up to 10 days in every 28,
·Dysmenorrhea for at least 3 days of her period,
·NC’s distress at the sight of her blood,
·NC’s failure to achieve independent toileting,
·Restriction on NC’s ability to participate in the school program,
·Restriction from full participation in swimming, horse-riding, drama classes for the duration of her periods,
·Reliance on NC’s mother, sister and two other carers to change her pads and clean up after blood loss, and
·Loss of NC’s dignity occasioned by menstrual leakage and the difficulties associated with cleaning and changing especially when in public places.
The Board considers that future consequences might include:
·The pool of persons prepared to assist with changing pads and cleaning up after the change will reduce through normal attrition or carer fatigue, and
·NC’s family will be less likely to take holidays, or include NC in holidays, if the possibility of NC having an unexpected and heavy period will undermine their potential for relaxation.
Alternative treatment available to NC – At the hearing, Dr. Keating confirmed that there are only two methods for treatment of menorrhagia and dysmenorrhea, being hormonal and surgical. Dr. Keating reported that oral medications (Primulot, tranexamic acid) had been attempted but failed or were impossible because NC is resistant to taking any medication. An attempt to use the Mirena IUD caused NC nausea, excessive vomiting and abdominal pain, resulting in two weeks’ hospitalization, and the device needed to be removed after one week.
NC experiences extremely severe eczema requiring frequent admissions to hospital. The Board had medical information from dermatologist, Dr. Narelle Bleasel which confirms this and Board members observed NC’s severe eczema on her face and arms at the hearing. Dr. Keating was of the opinion that use of any other form of progesterone for NC would flare up her eczema and other forms such as an Implanon rod are unlikely to give her period control but are likely to form a site of irritation in her skin. She also expressed concern at the possible side-effects of Depo Provera, given (i) the reaction to the Mirena device, (ii) the possibility of a flare-up in NC’s eczema and (iii) the fact that the depo would take 18 months to wear off.
Dr. Williams noted the effect of oral contraceptive pills in causing vomiting for NC and noted that while oral tranexamic acid had given some relief, NC’s periods are still very difficult to manage.
The delegate of the Public Guardian asked Dr. Keating whether an ablation might be a suitable alternative to a hysterectomy. Dr. Keating did not consider it to be so, as it still has the effect of sterilising a patient, it is only 40-50% effective in stopping periods and scar tissue from that procedure obscures the endometrium cells which means if further treatment of the endometrium cells is required for cancer or polyps, they cannot be accessed.
Dr. Keating acknowledged that she had not attempted treatment with every kind of oral contraceptive pill, but the difficulties in having NC accept medication together with the risk that all hormonal medication will cause eczema, nausea and vomiting mean that such trials have a very limited chance of success and further trials will extend NC’s pain, distress and loss of dignity. The Board does not consider that every different brand of oral contraceptive pill needs to be tried to establish that hormonal treatments generally appear to be unsuccessful for NC. In this respect, the Board notes the statements of Warnick J. in In the Matter Of: Re Katie [1995] FamCA 130:
“However, as I have found in this case, that is not to say that every stone lying on the plain of enquiry must be upturned, even if reasonable indications are that nothing will be found thereunder or even if the indications are that there are some risks in the manoeuvre.
I see nothing in the passage in the judgment of the majority of the High Court in re: Marion at page 259, that:
"sterilisation is a step of last resort ..... in the context of medical management, 'step of last' resort, is a convenient way of saying that alternative and less invasive procedures have all failed or that it is certain that no other procedure or treatment will work"
to indicate that the Court is not to balance, in considering the reasonableness of exploring alternatives, what those alternatives might achieve, the risks involved therein, the prospects of success and any discomfort or disadvantage likely to be suffered by the child during the exploration of those alternatives.
Indeed, a little later in the same paragraph from which the quotation above is taken, the majority said:
".... Within that context, it is apparent that sterilization can only be authorized in the case of a child so disabled that other procedures or treatments are or have proved inadequate, in the sense that they have failed or will not alleviate the situation so that the child can lead a life in keeping with his or her needs and capacities." (my underlining)”
The Board was satisfied that any further attempts at hormonal treatment will most likely be unsuccessful because of NC’s reaction of nausea and vomiting and because hormonal treatments will cause flare-ups of NC’s severe eczema. The Board did not consider that ablation presents any advantages or a realistic alternative to the proposed hysterectomy.
The Board notes that Dr. Keating is a senior Consultant Obstetrician and Gynaecologist who specializes in the treatment of adolescents who experience difficulties in menstruation. She told the Board that this is the first application for the Board’s consent to a hysterectomy that she has made. This statement underlined both the rarity of NC’s circumstances and also the thoroughness of Dr. Keating’s exploration of alternatives in each case. She agreed that she would not make this recommendation for a 14 year old child who did not have NC’s disability, but it is relevant that a child without NC’s disability would be able to express a wish to have a child in the future and also would be able to develop independence in coping with the hygiene issues associated with the extreme bleeding and hence not suffer the same loss of dignity that NC suffers.
Can the proposed treatment can be postponed on the ground that better treatment may become available? – Dr. Keating indicated that to her knowledge all treatments currently under development are variations of the oral contraceptive pill and it is likely that all such treatments will attract the same difficulties for NC as those hormonal treatments that have already been tried. In respect of this evidence, the Board again adopts the reasoning of Warnick J. in In the Matter Of: Re Katie [supra] as follows:
“One might speculate that, over the coming years, Katie would be able to stop taking the pill because there will be development in treatment of, for example, pre-menstrual syndrome, or for the suppression of menstruation, which will overtake hysterectomy as an alternative in cases such as this. Perhaps there will be changes in Katie's bodily functioning, so that she does not appear to suffer as much, but this also is not more than speculation.
Though, in one sense, such speculation means that it cannot be demonstrated that sterilisation is at this time “a step of last resort”, I do not consider this a maintainable proposition. It is not that every possible management technique, whether accompanied by undesirable features or risks to health, must be tried before authorisation can be given.”
On the basis of the evidence given at the hearing by Dr. Keating, the Board is satisfied that there is no research or upcoming development which would justify the postponement of this application or this treatment.
Can the proposed treatment can be postponed on the ground that NC will become capable of consenting to the treatment? – NC’s intellectual disability arises from a chromosomal abnormality. Dr. Whitelaw reported that NC’s disability is static and no improvement is expected. SX’s reports notes that she will need significant support as an adult. Dr. Williams noted that NC: “will never achieve fully independent care.” The Board is satisfied that NC will not become capable of consenting to the treatment. This is not an appropriate basis upon which to postpone the application and the procedure.
Other factors: Although the Board, unlike the person responsible in section 43(2)(d) of the Act, is not required to examine the nature and degree of any significant risks associated with the treatment, it is a matter that we have investigated. Dr. Keating confirmed that the procedure carries with it the usual risks associated with having a general anaesthetic and the usual risk of post-operative infection. NC is at no special risk by reason of her medical conditions or her disability. A result of having the hysterectomy may be that she reaches menopause one to two years earlier than she otherwise might. The Board does not consider that there is any special or significant risk in having the procedure such that we might come to a different conclusion about the procedure being in her best interests.
Conclusion regarding NC’s best interests: The Board is satisfied that Dr. Keating had conducted all necessary investigations prior to making this application for the Board’s consent. We are satisfied that NC’s mother and the care team have supported this application entirely from the perspective of NC’s best interests. Although the management of her menstruation has put some stresses on them, it is their concern for her physical and mental wellbeing, and her dignity, that has underlined each of their statements.
The Board is satisfied that this is essentially a treatment that is being carried out to treat a malfunction or disease which negatively affects NC’s wellbeing and her quality of life, being menorrhagia and dysmenorrhea. The contraceptive effects of the treatment of that malfunction or disease are also considered to be of benefit to NC, given the reports that she would be incapable of parenting a child. Also, the excessive bleeding has presented a significant challenge to her carers and the cessation of periods will reduce the burden on her carers. However these are secondary considerations. The main motivator for this procedure is to reduce the excessive bleeding, pain and distress associated with NC’s menstruation, to moderate the effects upon her eczema and to enhance her personal dignity. The Board gives its consent to NC having a laparoscopic hysterectomy for the removal of her uterus and tubes but not her ovaries.
Terms of the Board’s consent:
NC will undergo this procedure at the Royal Hobart Hospital in the public system and therefore will be placed in a queue for the treatment. It was anticipated that this may take some months. The Board considers that its consent should extend for 12 months to cover any period of delays in surgery times.
The Board did not consider that the treatment is required urgently, so this consent has no effect until the period of appeal under section 76 of the Act has expired or, if an appeal has been instituted, it is set aside, withdrawn or dismissed.
The statement of reasons:
The Board considered that this case is a matter of public interest, particularly as it is an exemplar of an application for consent to a therapeutic sterilisation. Therefore the Board has decided to prepare a statement of reasons, although no request has been made. This means that the delivery of this statement of reasons is unrelated to the extension of an appeal period as set out in section 76(3)(c) of the Act and, in the absence of any other proceedings, the relevant appeal period referred to in paragraph 47 above will be 28 days from 21 July 2014 or 18 August 2014 and the consent can take effect from that date.
Conclusion:
After hearing an application pursuant to section 44 of the Act made by Dr. Susan Keating for the consent of the Board to special treatment for NC (hereafter ‘the person’)
The Board is satisfied, in accordance with section 45 that:
• the medical treatment is otherwise lawful, and
• the person is incapable of giving consent to the medical treatment, and
• the medical treatment would be in the person’s best interests.
THE BOARD hereby consents to special treatment for the person comprising a laparoscopic hysterectomy to remove her uterus and tubes, but not her ovaries.
THE BOARD FURTHER ORDERS
That this consent remains valid until 20 July 2015.
That this consent does not take effect until the appeal period under section 76 has expired or, if an appeal has been instituted, it is set aside, withdrawn or dismissed.
That the treating practitioner shall provide a report to the Board when the procedure has been successfully completed.
DATED this 21st day of July 2014.
Anita Smith Kim Barker Carolyn Wallace
PRESIDENT MEMBER MEMBER
Statement of reasons delivered 28 July 2014
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