THE MEDICAL BOARD OF AUSTRALIA and WOOLLARD - [2018] WASAT 79

JURISDICTION     :   STATE ADMINISTRATIVE TRIBUNAL
ACT: HEALTH PRACTITIONER REGULATION NATIONAL LAW (WA) ACT 2010
CITATION:   THE MEDICAL BOARD OF AUSTRALIA and WOOLLARD [2018] WASAT 79
MEMBER:   PRESIDENT, JUSTICE J C CURTHOYS
SENIOR MEMBER C WALLACE
DR K JEFFRIES (SENIOR SESSIONAL MEMBER)

HEARD:   3 - 6 APRIL 2018 AND 19 AND 20 APRIL 2018
DELIVERED          :   10 AUGUST 2018
FILE NO/S:   VR 239 of 2014
BETWEEN:   THE MEDICAL BOARD OF AUSTRALIA
Applicant
AND
KEITH VICTOR WOOLLARD
Respondent

Catchwords:

Fraud - Incomplete training - Deliberate misstatement of number of procedures completed for purposes of accreditation - Lack of experience - Angioplasty - Failure to inform of risks - Failure to inform of alternatives - Inadequate anticoagulation

Legislation:

Health Practitioner Regulation National Law (WA) Act 2010, s 3, s 4, s 4, s 196

Result:

Practitioner guilty of professional misconduct

Category: B

Representation:

Counsel:

Applicant	:	Ms FA Stanton
Respondent	:	Mr P Morris SC

Solicitors:

Applicant	:	MDS Legal
Respondent	:	Clayton Utz

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

Briginshaw v Briginshaw (1938) 60 CLR 336
Brisbane South Regional Health Authority v Taylor (1996) 186 CLR 541
Chen v Health Care Complaints Commission [2017] NSWCA 186
Giudice v Legal Profession Complaints Committee [2014] WASCA 115
Health Care Complaints Commission v Bours (No 1) [2014] NSWCATOD 113
Medical Board of Western Australia and Bham [2006] WASAT 190
Medical Board of Western Australia and Wright [2010] WASAT 48
Nursing and Midwifery Board of Australia and Jackson [2013] WASAT 140
Pillai v Messiter (No 2) (1989) 16 NSWLR 197

REASONS FOR DECISION OF THE TRIBUNAL:

Introduction

On 16 December 2005, Mr Brown died following an angioplasty procedure carried out by Dr Keith Victor Woollard on 15 December 2005 at the Mount Hospital.
The angioplasty procedure on Mr Brown was intended to place stents in a number of Mr Brown's heart vessels including the Left Anterior Descending Artery (LAD) (see Figure 1 attached).

On 19 December 2014, the Medical Board of Australia (the Board) filed an application against Dr Woollard under the Health Practitioner Regulation National Law (WA) Act 2010 (National Law). The grounds of the application were subsequently amended (Amended Application).
In its closing, the Board listed the six allegations against Dr Woollard that were the subject of these proceedings:
(1)That Dr Woollard made false representations to Dr Crawford and the Medical Advisory Committee (MAC) in each of the letters to Dr Crawford from Dr Woollard dated 10 October 2005 and 14 December 2005, and that he knew that the representations were false and made them for the purpose of misleading Dr Crawford and the MAC in an attempt to achieve accreditation to perform coronary angioplasty procedures at the Mount Hospital without any form of supervision (Amended Application 31.2);
(2)That Dr Woollard attempted to treat Mr Brown's complex multi-vessel coronary artery disease by means of coronary angioplasty when his training in the performance of such procedures was incomplete and when he was not sufficiently experienced in the performance of coronary angioplasty procedures in order to justify attempting that procedure without supervision (Amended Application 31.1);
(3)That Dr Woollard failed to ensure adequate anticoagulation during the procedure (Amended Application 31.6);
(4)That Dr Woollard failed to inform Mr Brown of the risks associated with treating his coronary artery disease by means of coronary angioplasty (Amended Application 31.3);
(5)That Dr Woollard failed to inform Mr Brown of the option of referral to a cardiothoracic surgeon for consideration of a coronary artery bypass grafting procedure (CABG) (Amended Application 31.4); and
(6)That Dr Woollard deliberately misled Mrs Brown as to the cause of Mr Brown's death (Amended Application 31.6).

Legal framework and principles

Section 3 of the National Law sets out the objectives and guiding principles. Relevantly they are s 3(1)(a) and s 3(2)(a):
The object of this Law is to establish a national registration and accreditation scheme for -
the regulation of health practitioners; [and]
The objectives of the national registration and accreditation scheme are -
to provide for the protection of the public by ensuring that only health practitioners who are suitably trained and qualified to practise in a competent and ethical manner are registered[.]
Section 4 of the National Law provides:
An entity that has functions under this Law is to exercise its functions having regard to the objectives and guiding principles of the national registration and accreditation scheme set out in section 3.

Unprofessional conduct

Section 5 of the National Law provides:
unprofessional conduct, of a registered health practitioner, means professional conduct that is of a lesser standard than that which might reasonably be expected of the health practitioner by the public or the practitioner’s professional peers, and includes —
(a)a contravention by the practitioner of this Law, whether or not the practitioner has been prosecuted for, or convicted of, an offence in relation to the contravention; and
(b)a contravention by the practitioner of —
(i)a condition to which the practitioner’s registration was subject; or
(ii)an undertaking given by the practitioner to the National Board that registers the practitioner;
and
(c)the conviction of the practitioner for an offence under another Act, the nature of which may affect the practitioner’s suitability to continue to practise the profession; and
(d)providing a person with health services of a kind that are excessive, unnecessary or otherwise not reasonably required for the person’s well‑being; and
(e)influencing, or attempting to influence, the conduct of another registered health practitioner in a way that may compromise patient care; and
(f)accepting a benefit as inducement, consideration or reward for referring another person to a health service provider or recommending another person use or consult with a health service provider; and
(g)offering or giving a person a benefit, consideration or reward in return for the person referring another person to the practitioner or recommending to another person that the person use a health service provided by the practitioner; and
(h)referring a person to, or recommending that a person use or consult, another health service provider, health service or health product if the practitioner has a pecuniary interest in giving that referral or recommendation, unless the practitioner discloses the nature of that interest to the person before or at the time of giving the referral or recommendation[.]
(See also s 139B(1) of the Health Practitioners Regulations NSW (National Law NSW))

Professional misconduct

The first and second limbs of the definition of 'professional misconduct' incorporate the term 'unprofessional conduct' (see s 139B(1) of the National Law NSW).
The term 'professional misconduct' is relevantly defined in s 5 of National Law as conduct of a regulation health practitioner which includes:
(a)unprofessional conduct by the practitioner that amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and
(b)more than one instance of unprofessional conduct that, when considered together, amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience[.]
(See s 139E of the National Law NSW)

Unsatisfactory professional performance

The term 'unsatisfactory professional performance' is defined in s 5 of the National Law as meaning:
[T]he knowledge, skill or judgment possessed, or care exercised by, the practitioner in the practice of the health profession in which the practitioner is registered is below the standard reasonably expected of a health practitioner of an equivalent level of training or experience[.]

The authorities

The relevant authorities are set out in the reasons for decision of Health Care Complaints Commission v Bours (No 1) [2014] NSWCATOD 113 (Bours):
…
524Interpretation of the legislation is assisted by the body of common law in the area of professional disciplinary matters. The classic common law definition of professional misconduct derives from Allinson v General Counsel of Medical Education and Registration (1894) 1 QB 755, namely:
[Conduct] which could be reasonably regarded as disgraceful or dishonourable by his professional brethren of good repute and competency.
525The essence of this definition was restated by Priestley JA in Qidwai v Brown (1984) 1 NSWLR 100 at 105:
... whether the practitioner was in such breach of the written or unwritten rules of the profession as would reasonably incur the strong reprobation of professional brethren of good repute and competence[.]
…
527Contemporary cases involving unsatisfactory professional conduct and professional misconduct primarily consider the wording of the relevant statute rather than the considerations of moral condemnation found in earlier decisions, expressing their views 'in terms of strong criticism'. (Lucire v Health Care Complaints Commission [2011] NSWGA 99 at 84; Donnelly v Health Care Complaints Commission (NSW) [2011] NSWSC 705).
More recently in Chen v Health Care Complaints Commission [2017] NSWCA 186 (Chen), Basten JA at [19]-[20] (Leeming JA agreeing) stated:
19… The term 'professional misconduct' does not have a specific meaning; it is merely a category of 'unsatisfactory professional conduct' which is sufficiently serious to justify suspension or cancellation [National Law s 5; National Law NSW s 139E]. The phrase 'unsatisfactory professional conduct' is broadly defined by reference to 12 separate categories of conduct relating to professional practice. They include demonstrating competence or care below the standard reasonably expected of a practitioner of an equivalent level of training or experience, [National Law s 5; National Law NSW s 139B(1)(a)] making a referral in circumstances where the practitioner has a financial interest in giving that referral without disclosing the interest, [National Law s 5; National Law NSW s 139B(1)(i)] overservicing [National Law s 5; National Law NSW s 139B(1)(j)] and, finally, any other improper or unethical conduct relating to the practice of the practitioner's profession [National Law s 5; National Law NSW s 139B(1)(l)].
20There is no category of unsatisfactory professional conduct which is not capable, depending on the circumstances, of giving rise to professional misconduct and hence engaging the power of either suspension or cancellation of registration. The only requirement is that it be 'sufficiently serious' to justify such an order, a characterisation which must depend upon an evaluative judgment made by the Tribunal[.]
In reaching a conclusion as to the characterisation of Dr Woollard's conduct, the Tribunal has applied the principles set out in Chen.

Dr Woollard's submissions

Dr Woollard's submissions set out the definition of 'unprofessional conduct' as defined in s 5 of the National Law listed subparas (a) to (h) at para 13 of his submissions:
'professional conduct that is of a lesser standard than that which might reasonably be expected of the health practitioner by the public or the practitioner’s professional peers, and includes:
a.a contravention by the practitioner of this Law, whether or not the practitioner has been prosecuted for, or convicted of, an offence in relation to the contravention; and
b.a contravention by the practitioner of
i.a condition to which the practitioner’s registration was subject; or
ii.an undertaking given by the practitioner to the National Board that registers the practitioner; and
c.the conviction of the practitioner for an offence under another Act, the nature of which may affect the practitioner’s suitability to continue to practise the profession; and
d.providing a person with health services of a kind that are excessive, unnecessary or otherwise not reasonably required for the person’s well-being; and
e.influencing, or attempting to influence, the conduct of another registered health practitioner in a way that may compromise patient care; and
f.accepting a benefit as inducement, consideration or reward for referring another person to a health service provider or recommending another person use or consult with a health service provider; and
g.offering or giving a person a benefit, consideration or reward in return for the person referring another person to the practitioner or recommending to another person that the person use a health service provided by the practitioner; and
h.referring a person to, or recommending that a person use or consult, another health service provider, health service or health product if the practitioner has a pecuniary interest in giving that referral or recommendation, unless the practitioner discloses the nature of that interest to the person before or at the time of giving the referral or recommendation.'
At paragraph 14 of Dr Woollard's submissions stated:
The list in sub-paragraphs (a) - (h) of this definition is exhaustive, that is, the behaviour listed in each of these items constitutes a complete statement of the term 'unprofessional conduct'. The application in these proceedings presumably directs attention solely to subparagraph (a) upon the grounds alleged in paragraphs 31.1 to 31.6 of the Amended Grounds of Application.
The authority relied upon in support of the proposition that the list in sub-paragraphs (a) to (h) is exhaustive is said to be Nursing and Midwifery Board of Australia and Jackson [2013] WASAT 140 (Jackson) at [22].
Given the propositions advanced at para 14 of Dr Woollard's submissions, it is important to set out the relevant passages from Jackson, that is, [20]-[27] in full:
20It is apparent from the word 'includes' in this definition that the intention of the legislation is that the three paragraphs that follow are simply examples of 'professional misconduct' for the purposes of the National Law and are not an exhaustive statement of that term. Thus, 'professional misconduct' under the National Law can include professional misconduct which does not fall within any of the paragraphs in the definition of that term, for example, conduct which was characterised as professional misconduct or equivalent under earlier vocational disciplinary legislation. Furthermore, as is apparent from the example of professional misconduct in the third paragraph of the definition ('… whether occurring in connection with the practice of the health practitioner's profession or not …') and from cases under disciplinary legislation prior to the National Law, 'professional misconduct' can include conduct in a practitioner's personal life where there is a sufficient nexus with the practitioner's profession: see Hoile v The Medical Board of South Australia (1960) 104 CLR 157. In that case, the High Court of Australia held that it was open to the Medical Board of South Australia to find that a medical practitioner, who was the medical superintendent of a country hospital, was guilty of 'infamous conduct in a professional respect' by engaging in sexual intercourse with a nurse during hours of duty in patient cubicles at the hospital. On at least two occasions, the nurse was on night duty at the time that the medical practitioner and the nurse had sex, and on at least one occasion the nurse was the only member of the nursing staff on duty at that time. The High Court reasoned at 163 as follows:
However much the general moral aspect of the matter may be emphasized as going to the relationship between man and woman, it remains true that the place was the hospital, the woman was a nurse, the man was a doctor and moreover superintendent of the hospital. It arose out of a relationship professionally established and it was destructive of the position he should have held in the hospital and of his influence. All these are matters enabling the Board to find as they did.
21The definition of the term 'unprofessional conduct' (which is referred to in paragraphs (a) and (b) in the definition of 'professional misconduct') in s 5 of the National Law begins as follows:
unprofessional conduct, of a registered health practitioner, means professional conduct that is of a lesser standard than that which might reasonably be expected of a health practitioner by the public or the practitioner's professional peers, …
22The definition then states 'and includes' followed by eight paragraphs containing examples of 'unprofessional conduct' which it is unnecessary to set out in these reason. Like the definition of 'professional misconduct' in s 5 of the National Law, the definition of 'unprofessional conduct' is not an exhaustive statement of that term.
23In Physiotherapists Registration Board of Western Australia and Lipscombe [2005] WASAT 314 (Lipscombe), the Tribunal stated at [43] that:
There can be no doubt that sexual involvement of a health professional with a patient amounts to serious professional misconduct.
24This statement was made in the context of determining whether a physiotherapist was guilty of 'misconduct in a professional respect' for the purposes of reg 20 of the Physiotherapists Regulations 1951 (WA) made pursuant to s 16(aa) of the Physiotherapists Act 1950 (WA). However, in our view, the Tribunal's statement in Lipscombe at [43] is equally applicable in relation to the term 'professional misconduct' in the National Law, whether or not the conduct is regarded as falling within paragraph (c) of the definition of 'professional misconduct' in s 5 of the National Law. A sexual relationship between a health practitioner and a patient at a time when there is a professional relationship between them, or shortly afterwards, has a sufficient nexus with the practitioner's profession to constitute 'professional misconduct'. For reasons discussed below, a sexual relationship between a health practitioner and a patient during or shortly after a professional relationship between them constitutes serious 'professional misconduct'.
25Furthermore, in our view, the failure to maintain proper professional boundaries by arranging transport for the patient and her daughter to relocate to crisis accommodation, providing financial assistance to the patient, including paying the patient's rental bond, paying four weeks rent for the patient and purchasing furniture and other household items for the patient, and entering into a residential lease with the patient, also constitutes 'professional misconduct' for the purposes of the National Law. The maintenance of proper professional boundaries is fundamental and essential for appropriate practise as a health practitioner. The failure to do so is serious 'professional misconduct', whether or not it falls within the example of 'professional misconduct' in paragraph (c) of the definition of that term in s 5 of the National Law. Although the professional relationship between the practitioner and Ms L technically ended while she was at the refuge and possibly prior to elements of this conduct, there is a sufficient nexus between the conduct and the practitioner's profession as the course of conduct commenced while Ms L was his patient and all of the conduct occurred during or shortly after their professional relationship.
26In our view, the practitioner's failure to provide adequate documentation of his consultations with the patient also constitutes 'professional misconduct' under the National Law, because it falls within paragraph (a) of the definition of that term in s 5 in that it is 'unprofessional conduct', that is, 'professional conduct that is of a lesser standard than that which might reasonably be expected of the health practitioner by the public or the practitioner's professional peers', 'by the practitioner that amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience'. In our view, the practitioner's failure to provide adequate documentation of his consultations with the patient is conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience, because the maintenance of full, contemporaneous notes of consultations with patients is essential for their future care, the practitioner had at least 12 years' experience as a mental health nurse, and the practitioner kept no notes of his consultations with the patient. For an experienced nurse not to provide any patient notes or other relevant documentation in relation to consultations with a patient is conduct that is substantially below the standard reasonably expected of the practitioner by the public and his or her professional peers.
27The practitioner is therefore guilty of professional misconduct in relation to each of the two respects alleged by the Board.

The proposition advanced by para 14 of Dr Woollard's submissions was plainly incorrect. Jackson makes it clear that the list in subparagraphs (a) to (h) is not exhaustive. It is an inclusive definition. The decision in Jackson is correct for the reasons stated in Jackson.
The Tribunal does not accept Dr Woollard's submissions that 'the application in these proceedings presumably directs attention solely to subparagraph (a)' of the definition of unprofessional conduct. Subparagraph (a) refers to a 'contravention by the practitioner of this Law'.
Paragraph 17 of Dr Woollard's submissions state:
'Substantially below' is not defined. However, by virtue of the hierarchy, professional misconduct should be reserved for the most serious types of conduct, such as sexual misconduct towards a patient or obtaining a drug by false representations, self-administering the drug, and creating false records. It is submitted that, even as currently defined, the concept of professional misconduct still envisages intentionally improper, or unlawful conduct, or some other moral delinquency.
Chen and Bours are authorities to the contrary.
The Tribunal does not accept that even under the previous law, professional misconduct envisaged 'intentionally improper, or unlawful conduct, or some other moral delinquency' as Dr Woollard submitted (see for example Pillai v Messiter (No 2) (1989) 16 NSWLR 197 at 200 per Kirby P).

The requisite intent

The Board had alleged that Dr Woollard made false representations.
In determining whether Dr Woollard made false representations, the Tribunal has applied the standard laid down in Giudice v Legal Profession Complaints Committee [2014] WASCA 115, in which Martin CJ stated at [8]:
As this court has pointed out [Fidock v Legal Profession Complaints Committee [2013] WASCA 108] when a practitioner provides information or makes a statement to a court which is false or misleading, there are (at least) three categories of case in which that conduct will constitute either professional misconduct or unsatisfactory professional conduct. First, the practitioner might know that the statement or information is false or misleading. Second, the practitioner might have a reckless disregard to the question of whether the statement or information is false or misleading, and third, the practitioner might be negligent or careless. Because the first two categories will only apply if, assessed subjectively, the practitioner is either aware that the statement or information is false or misleading, or wilfully indifferent to its truth, in the absence of special circumstances one would ordinarily expect a finding of either category of conduct to be characterised as a substantial departure from the standards of conduct reasonably expected of a practitioner such as to constitute professional misconduct, within the taxonomy of the Act[.]
This is to say that the Tribunal must find that Dr Woollard, assessed subjectively, knew that his statements were false.

Onus and standard

The Board bears the onus of proof. It is to the civil, not criminal standard, but the principles of Briginshaw v Briginshaw (1938) 60 CLR 336 (Briginshaw) apply. That is, while needing to be proved only on the balance of probabilities, the nature and seriousness of the allegations are relevant to the question whether the issues are proved to the reasonable satisfaction of the Tribunal and the process by which reasonable satisfaction is attained.
By reason of the nature of the allegations, the Tribunal must feel an actual persuasion of the occurrence or existence of the relevant facts in determining whether or not the case against the respondent is made out: Medical Board of Western Australia and Wright [2010] WASAT 48 at [31]; and see Medical Board of Western Australia and Bham [2006] WASAT 190 at [144].
The Tribunal notes that the allegations that Dr Woollard made 'false representations' and 'deliberately misled' are particularly serious.

The passage of time

The relevant events occurred in 2005 and earlier. In assessing the evidence the Tribunal has borne in mind what McHugh J stated in Brisbane South Regional Health Authority v Taylor (1996) 186 CLR 541 at 551:
[Where there is delay, the whole quality of justice deteriorates] Sometimes the deterioration in quality is palpable, as in the case where a crucial witness is dead or an important document has been destroyed. But sometimes, perhaps more often than we realise, the deterioration in quality is not recognisable even by the parties. Prejudice may exist without the parties or anybody else realising that it exists. As the United States Supreme Court pointed out in Barker v Wingo 'what has been forgotten can rarely be shown'. So, it must often happen that important, perhaps decisive, evidence has disappeared without any now 'knowing' that it ever existed. Similarly, it must often happen that time will diminish the significance of a known fact or circumstance because its relationship to the cause of action is no longer as apparent as it was when the cause of action arose. A verdict may well appear well based on the evidence given in the proceedings, but, if the Tribunal of fact had all the evidence concerning the matter, an opposite result may have ensued. The longer the delay in commencing proceedings, the more likely it is that the case will be decided on less evidence than was available to the parties at the time that the cause of action arose.

Dr Woollard's closing written submissions

The Tribunal has already noted one error in Dr Woollard's written closing submissions. The Tribunal notes that certain of the statements of fact which appear under the heading 'Facts which do not appear to be in issue' are facts which are very much in issue between the parties. Rather than deal with those alleged facts separately, the Tribunal will deal with them in the course of its reasons where relevant.

The expert evidence

Expert reports were provided by:
(a)Dr Clugston, on behalf of the Board;
(b)Dr Russell, on behalf of Dr Woollard; and
(c)Dr Marmur, on behalf of Dr Woollard.
Dr Clugston's qualifications and experience appear at Exhibit W page 568. He has performed over 10,000 coronary angioplasty and stenting procedures.
Dr Russell's curriculum vitae appears at Exhibit BB pages 649-653.
Dr Marmur's curriculum vitae appears at Exhibit CC pages 615-31.
Each of the expert witnesses was highly experienced and qualified as an interventional cardiologist.
A Joint Statement of Expert Witnesses (the Joint Statement) dated 17 January 2018 was filed on 17 January 2018 (Exhibit Z pages 666688).
The Tribunal thanks the experts for the evident amount of work that went into the Joint Statement. The Joint Statement reveals a high degree of consensus between the experts.
The expert witnesses gave evidence concurrently. Dr Marmur participated by telephone from New York. The Tribunal is particularly indebted to Dr Marmur not only for his expertise but for his stamina. Due to the time difference, Dr Marmur finished his evidence at 2.05 am New York time.

Angioplasty

Before turning to the specific allegations against Dr Woollard and to put those allegations in context, it is appropriate to explain what an angioplasty is and some background material. Angioplasty is a form of interventional cardiology.
In the early 1980's, angioplasty was a new mode of treatment. Initially it involved the use of a balloon which was inserted within the arteries of the heart and then inflated to expand narrow arteries. Subsequently, it involved the use of a stent in association with a balloon to permanently expand narrow arteries.
Prior to an angioplasty being carried out, an angiogram is taken. An angiogram is a form of radiography used to identify blockages in the heart which are treated by an angioplasty or coronary artery bypass grafting (Exhibit BG).
A cardiologist can carry out an angiogram but must receive additional specialised training and be separately accredited to carry to perform an angioplasty.
Angioplasty is carried out in a catheterisation laboratory. Catheterisation laboratories are called this because a catheter is used to guide the balloon and/or the stent to the heart. Inside the catheter there are guides wires which are used to guide the balloon and/or the stent into the appropriate point in the heart. A catheterisation laboratory is used for both angiograms and angioplasties. Angioplasties are generally carried out in a catheterisation laboratory only when a cardiac operating theatre can be accessed in the event of an emergency.
In his evidence, Dr Clugston described an angioplasty procedure, with reference to some of the particular aspects of this case, in detail as follows:
So we administer some local anaesthetic, and then puncture the artery, and that – that itself is an important part of the procedure, because you have to get the artery punctured, get a sheath into it, and you want to make sure that you don't damage the artery, because if you do, when you administer an anticoagulant, the next thing is the leg is full of blood (indistinct) the abdomen could be full of blood, and you can get catastrophic complications from giving anticoagulation (indistinct)
So you put a sheath into the artery. We make sure that the haemostasis is secure around the sheath. At some stage you choose to give the anticoagulant. Some choose to give it before the sheath. Some choose to give it after the sheath. But the important thing is that (indistinct) it's absolutely crucial that the anticoagulant is administered. That is part of the procedure. If there are consequences from giving too much anticoagulant, from giving an anticoagulant to a patient who's had trauma to the artery, and there are certainly terrible consequences of a patient who's given no anticoagulant or insufficient anticoagulant. So that is all considered part of the procedure.
The next thing is to introduce a guiding catheter. Guiding catheter is the tube that goes up to the heart. So we advance a wire – so we have a sheath in the artery. It's just a little plastic tube, and then the guide catheter goes up advanced over a wire. So under X-ray guidance the wire is passed up carefully through the aorta without causing any damage to the heart or to the area where the heart is. And over that wire we advance the guiding catheter.
At some stage you will have selected a guiding catheter that you're going to use to – there are many, many different kinds of kinds of guiding catheter, and you will select it carefully in advance having reviewed the angiogram initially that you that you've done before. You advance that guiding catheter. Then you gently position it within the artery to the heart. Now, the guiding catheter itself, you're actually putting it into the main artery that main coronary artery in this case that supplies the the blood to the heart.
That is something that takes quite some time to to learn how to do safely. The guiding catheter can damage the artery. It can block the artery. A patient can die as a consequence of (indistinct) So the guiding catheter goes into the artery. The next thing we would do is then take some pictures, and these are what we called setup shots. So we – we make a series of of images of the coronary artery and the the left vein, and the orientation of the left vein, to the left anterior set in the location of the lesion. And then, as you saw from that diagram, we would reconstruct that as a still frame, and it's visualised on a monitor to aid us to allow passage of the guide wire into the into the coronary artery and across the blockage.
So you have the guiding catheter sit there. We take the setup shots, look at the coronary artery, the blockage, carefully examine the nature and extent of the blockage. You've already done it once with review of your diagnostic angiogram, but you do it again when you've made your setup shots with the guiding catheter. The quality of those images is often better. And you're paying particular attention to the orientation of the left vein, the left anterior setting, but particularly the lesion itself if there are specific concerns about getting the wire through that and trauma that you might cause.
At some stage you will measure the ACT [activated clotting time] to make sure that the Heparin has been given and that it has been given in an appropriate dose. Now, you may you may have administered the Heparin yourself, but it's possible you might not have been given Heparin. It's possible that the drip that you were given the Heparin through is tissue, or it might be under a drape. You can't see it. So we measure the ACT. It's it's an absolutely crucial part of the procedure to make sure that the drug that you gave was indeed Heparin and that the patient has been adequately anticoagulated.
And the the various societies around the world have given guidelines and statements of best practice as to the dose of Heparin. When you should measure the ACT. What ACT level it should be to be achieved. So that that is part of the procedure. It's it's an integral part of the procedure, and when I'm teaching trainees, I teach them you've got to give the Heparin. You should give it yourself. You must check the ACT. And I would prefer that you check it after you administer check it after you've given the Heparin just to make sure that you've actually been given Heparin to give.
But there are so many things that can go wrong, and I teach the trainees to do this in a systematic way. They can choose the way they do it, but as long as they do it in a systematic way, when things occur under pressure, they're less likely to make a mistake. So we've reached that part of the procedure, and then we get down to the point of trying to cross the narrowing with a guide wire. Now, prior to the procedure starting, even before you entered the catheterisation laboratory, you will have reviewed the angiogram, and you will have decided what kind of wire you're probably going to use initially.
There are series of wires, and they've got different capabilities. None of them is perfect. They don't steer themselves. They are only wires. They don't steer themselves. You can modify the tip shape, and you can direct the wire up to a point, but they do not steer themselves through cavities and crevasses and angulations and 90 degree bends, and there is a prospect of trauma. So we make a a judgment as to how safe it is for that wire to traverse that blockage. You can stop the procedure at any time. You make that decision.
These are active decisions that are made during the procedure. Just stop it if you feel that it's unsafe to proceed. You gently then pass the wire through the blockage. Now, that the it is difficult with a lesion
like that, when there are there's at least a 90 degree angle and an ulcerated crater, to be sure that you will go through that properly without traumatising the artery. So you're paying particular attention to the nature of the lesion with the setup shots so that you could see if you could do it safely and choose the appropriate wire.
If you have difficulty passing the wire through the LAD lesions, it would ordinarily be that you persisted and then abandoned it if you could not do it. In this case, that is not what happened. Once if you had managed to get the wire across the lesion, which expectation is you would in most cases – perhaps not in this case – then you would advance a balloon catheter, long wire, and position it at the level of the blockage, and the idea of the balloon catheter is just to inflate that balloon to the diameter of the artery where the narrowing is, and essentially push the plug to the edge of the wall and create the channel through which you can then put a stent.
A stent is a small scaffold made out of essentially stainless steel or various different combinations of metals and (indistinct) and the stent becomes mounted on a balloon, and is – once you've got access with the wire, it's relatively easy usually to then just position the stent across the area that it's narrow, inflate the balloon, and the stent then embeds itself into the wall of the artery. So there's an enduring process that has been developed over many, many years so that the stent comes off the balloon, lands in the wall of the artery embedded. Then you instruct the assistant – or you might do it yourself – deflate the balloon, withdraw the balloon gently from that blockage, and then one would then examine the artery and see if there has been any damage done.
Whether the stent has been appropriately deployed. The stent might need to be re-dilated and expanded, and there are things we do to try and make it absolutely perfect in terms of the way it's embedded into the wall. But after you've deployed the stent into the artery, you would withdraw the guide wire, and then you would take a series of photographs to make sure that the left main coronary artery is not in dissectional damage, that the LAD has not been damaged, that there's not areas of dissectional damage of the artery on either side of the stent.
You make sure that you've examined the last portion of the artery so that it has not been perforated, because there are a whole number of complications that can occur during the process. From then you would move, so that if that's another lesion, it's just a (indistinct) lesion, you would then take the wire and reposition it to see in the left anterior the diagonal coronary artery, and you would repeat the process. Wire into the artery. Put the balloon in. Do the diagonal with stent. Take a picture. Make sure that there's the stent is appropriately deployed. That there's not damage either side of the stent. That the end of the wire end of the wire hasn't perforated the artery.
That the guide wire that the guiding catheter has not damaged the left main. And if you're happy with that, you would then move onto the next vessel. And in this in this context one would anticipate perhaps moving onto the circumflex coronary artery doing the same process in the circumflex coronary artery, and then eventually doing the same process in the right coronary artery. All of that could either be done as a single procedure, or occasionally, if if we're doing multi-vessel stenting, occasionally we do it as two separate procedures on separate days, largely because the amount of contrast with dye that we've administered is too much to for the kidneys to tolerate.
So we do have limitations in the time that we can spend doing it, largely because of the contrast that we're administering. For a case like this, it would be reasonable to attempt to do it in one one sitting, or on occasion you might extend to that two separate procedures. Once you've once you've completed the various angioplasty procedures in that in that particular patient, you withdraw the guiding catheter. If you're going to secure haemostasis in the groin that means stop bleeding in the groin and if you want to put a plug in as was the intention in this case you would take a picture of the artery in the the groin.
(ts 5559, 19 April 2018)

The importance of hands-on experience

The importance of the actual hands-on use of the equipment in an angioplasty procedure in gaining experience was explained by Dr Russell in the following exchange with counsel for the Board and the Tribunal:
STANTON, MS:        And when you talk about different wires, and I read to you Dr Cope's evidence about choosing wires, and he mentioned some are floppy and some are slippery
DR RUSSELL:           Yes.
STANTON, MS:        and, you know, they have all these different characteristics. Can you only learn about wire choice by actually using different wires and getting the feel for how they move?
DR RUSSELL:           It's very important to be able to feel the wire as to how it moves down the artery, as to how the balloon tracks on the wire, and, yes, you can only get that by using it yourself.
…
DR RUSSELL:           It's the way it feels to you which is the important thing.
STANTON, MS:        And is that the same with the wire?
DR RUSSELL:           The company might say this is a, you know, a good wire, it will feel that it, you know, negotiating the bends and sliding down the artery, but you don't really know that until you've tried it yourself.
STANTON, MS:        Right. Okay.
HIS HONOUR:          Can I just ask what – what's actually directing it, is it just the - - -
…
DR RUSSELL:           It is you pushing on the end of the wire with the soft end of the wire in the artery and progressing it down the artery, so you get a sensation or feel of the artery wall as you're going down through it, and the ease with which it goes down, the ease with which you can control turning the wire.
HIS HONOUR:          And to turn it, you what, turn it from - - -
DR RUSSELL:           Yes, the device that clamps onto the wire in your fingers and you can rotate the wire. The end of the wire usually made a little bend on the end of it so that you can direct that, and some wires you've got to turn it do more to make it bend than others. Others (indistinct) absolutely correct.
…
DR RUSSELL:            You know, you're a good metre or so away from where the tip of the wire is
…
DR RUSSELL:            so it's very important to be able to control exactly where that goes.
…
STANTON, MS:        And all of that control is manual control by the operator?
DR RUSSELL:           Absolutely by the operator.
(ts 93-94, 19 April 2018; Tribunal emphasis added)

Dr Cope stated that the performance of angioplasty procedures involves a high degree of manual skill (Exhibit H page 510 para 9).
The Tribunal accepted the evidence of Drs Russell and Cope and finds that the manual skill involved in an angioplasty procedure is an essential element.

Allegation 1 False representations in order to obtain accreditation

Accreditation as an interventional cardiologist

A doctor must be accredited by the hospital in which the angioplasty is carried out before he or she can perform an angioplasty procedure.
The Cardiac Society of Australia and New Zealand (the Cardiac Society) produced guidelines for accreditation as an interventional cardiologist carrying out angioplasty procedures. The decision whether or not to accredit a medical practitioner as competent to carry out angioplasty procedures is the decision of the hospital, although it is guided by the Cardiac Society's guidelines (ts 18, 23, 4 April 2018).

The Guidelines for Competency in Coronary Angioplasty

The relevant 'Guidelines For Competency In Coronary Angioplasty' (the 2001 Guidelines) issued by the Cardiac Society covering the period that is relevant to this matter, and in particular, the death of Mr Brown on 16 December 2005, were as follows:
TRAINING CENTRE:
The desirable characteristics of a training centre are:
•At least 2 experienced interventional cardiologists as trainers
- both having performed 500+ cases, and more than 1 year post-training
- one performing 150+ cases per year, the other 100+ cases per year.
•Centre performing 250+ cases per year per interventional/angioplasty trainee.
•Ongoing internal audit of centre/operators procedural outcome and complications.
•Regular mortality / morbidity reviews by the cardiologists and others as appropriate.
•Centre and trainer requirements might be met by the collaboration of 2 sites.
TRAINEE EXPERIENCE:
The trainee experience specifically refers to training in interventional Cardiology. Angioplasty training is separate to and not part of FRACP training. Angioplasty training should therefore commence once FRACP training is completed. It is recommended that a trainee in coronary angioplasty should only undertake interventional training after competency in coronary angiography has been achieved.
•Interventional experience, at a training centre in Australia, New Zealand or overseas.
•At least 200 procedures, with significant contribution to the preprocedure assessment, the interventional procedure, and post-operative patient care.
•At least 75 cases as primary operator.
•Logbook of cases: detailing clinical indications including assessment of procedural risk, interventional procedure, outcome and complications. This log book must be certified by the director of the training unit.
•Participation in interventional cardiology research.
•Attendance at one or more international interventional cardiology course/meeting.
•Interventional experience at another recognised Australasian or overseas centre remains strongly encouraged.
•Significant proportion of training experience should be spent at a unit with on-site surgery.
MAINTENANCE OF COMPETENCE:
•Individual - 75 cases per year is the recommended minimum.
•Centre - 200 cases per year is the recommended minimum. The centre volume can be less when operators are concurrently practising at another centre.
•Ongoing audit of centre/operators procedural outcome and complications.
•Regular case and angiogram usage review by the cardiologists and others as appropriate.
•Regular mortality / morbidity review by the cardiologists and others as appropriate.
(Exhibit V page 225; Tribunal bold emphasis added)
Of critical significance in this case is that at the relevant time angioplasty training required at least 200 procedures with at least 75 cases as primary operator. The 2001 Guidelines also required the provision of a logbook of all cases.
The 2001 Guidelines were published in a publication of the Cardiac Society entitled 'on the pulse' Volume XIII, No 4, December, 2001 (Exhibit V page 225).
It is not in issue that Dr Woollard was aware of the 2001 Guidelines. He actively sought to prevent the 2001 Guidelines being amended by the Cardiac Society to require more procedures in order to be accredited (see for example, his letter of 4 November 2004 (Exhibit V page 226A) and of 18 November 2004 (Exhibit V page 230)).
The draft 2005 Guidelines which were approved by the Council of the Cardiac Society on 22 April 2005, 'were applicable to those practitioners commencing training in interventional cardiology after the 1 January 2006' when the 2005 Guidelines were to take effect (Exhibit V page 244).

Primary operator and secondary operator

The 2001 Guidelines referred to a 'primary operator'. The 2001 Guidelines did not define the difference between a 'primary operator' and a 'secondary operator'. Nevertheless, the oral evidence established that there was a clear understanding of the fundamental difference between the two.
In the evidence there were references to a supervisor, a primary operator and a secondary operator in relation to the angioplasty procedure when training was taking place. In the initial phase of training, the insertion of a balloon and/or stent was carried by the primary operator. As training progressed the secondary operator played an increased role in the angioplasty procedure until eventually in the latter part of training, the trainee acted as the primary operator with the trainer, that is, the initial primary operator, acting as a supervisor during the procedure.
Dr Cope gave evidence that the supervisor, who would be the primary operator, would, prior to the performance of the angioplasty procedure, discuss the case with the secondary operator and that this discussion would involve inspection of the angiogram, discussion of possible difficulties, the approach to be taken and what equipment should be used (ts 38, 4 April 2018).
Dr Cope gave evidence that the secondary operator is scrubbed up and physically involved in the performance of the procedure (ts 38, 4 April 2018; see also ts 25, 4 April 2018).
Dr Cope gave evidence that during the procedure the primary operator would explain to the secondary operator what he was doing 'step by step' (ts 38, 4 April 2018) and would address matters such as:
1)'what sort of guidance he might select, what sort of guide he might select that would give the best support and would engage the artery in the best way and which ones would be better than others and which one may not be desirable';
2)which wire was selected;
3)how the wire was to be manipulated and 'shaped and bent so it can get around corners';
4)if one wire was unsuccessful, the best choice for another type of wire as 'They all varied in their characteristics … as to how stiff they were or how floppy or how slippery' to use;
5)the appropriate size and type of balloon and stent;
6)at which segment of the vessel a stent should be applied; and
7)the pressure to which a balloon should be inflated.
Drs Clugston (ts 72, 19 April 2018) and Russell agreed with Dr Cope's description of the role of supervisor, primary operator and secondary operator respectively (ts 73-74, 19 April 2018).
Dr Marmur's description of the role of the secondary operator was:
Yes. I mean, what you're describing, these discussions go on. You can have a medical student in the room and have discussions like this. No. The role of secondary operator okay. So, first of all, you have the primary operator who is in the closest proximity to the say, in this case, the groin if it's a a femoral approach; okay? So the primary operator is standing at the groin of the patient, in the primary position, closest to the image intensifier and has control of the of the most important equipment. The secondary operator is really acting as a technical assistant and as a sounding board for ideas and discussion. It's a it's a dual role, if you like.
But an important part of the second operator is assisting in the in the procedure. So if you're for example, if you're using an over-the-wire technology, someone has to hold the wire. If you're making catheter exchanges, someone has to clean the wire. Someone may have to flush the catheter, and you're the nurse has your balloon. Someone has to prep the balloon. There are a thousand things going on during a case where you prefer the primary operator to be focusing on the more important things and the secondary operator is standing there supporting those activities.
In the context in the in the scenario where you have multiple trainees and in particular towards the end of their training it's not unusual to have a a more junior trainee take the primary position and the secondary operator position which, in my experience, is usually the attending who is in close proximity and and guiding the primary operator who is the trainee. You could have a scenario where there are two trainees. The senior is in the secondary position and the attending is actually even can even be in the control room watching the case or standing further back along the table.
But the the the secondary operator isn't just an intellectual exercise. It's a someone who's actively involved in the procedure. For example, not infrequently the secondary operator is injecting the dye while the primary operator is bringing the stent down into the appropriate position. So both the primary and secondary operator are intimately involved in the actual completion of the procedure.
(ts 76-77, 19 April 2018)
Dr Hockings' evidence as to the difference between a primary operator and a secondary operator was:
You're familiar with this term that's used in some of the guidelines of primary operator and secondary operator, a term that doesn't seem to be defined in any paperwork. What does a secondary operator do seeking accreditation? Does he do anything different to the scrub nurse? I think the way it would – he largely practically performs the duties that the scrub nurse would perform, but probably well, definitely should be involved in case selection, planning the procedure, discussing the various techniques. And then gradually there would be this transition from the primary operator who is making the decisions, whose responsibility it is, and then as the secondary operator gained more experience, those roles would swap over and then ultimately the supervisor would no longer be scrubbed in. The trainee would be scrubbed with the scrub nurse, and the supervisor would be sitting in the control room, not scrubbed.
In your case, with Dr Sinclair, was it the case that he would be doing the procedures initially and you would be watching, and talking to him about what he was doing and learning from that process? That's correct, that's correct. I would be scrubbed in with him, but I would he would be
He would be doing it? He would be doing it. He would be questioning me and but he would be performing the procedure initially.
And did you then try to be a primary operator before you had finished your secondary role, or did it go backwards and forwards like that, or did you finish your secondary role and then go straight to primary? I think there was a there's a gradual transition. Normally I think what happened as I shifted to be the primary operator, I was the primary operator in all the cases, perhaps – perhaps in the very early ones, there might have been a bit of chopping and changing if something was difficult or tricky, but it was a gradual transition from secondary to primary operator, and then I continued as the primary operator with him ultimately in the control room, not actually scrubbed next to me.
So how far would he be from you in the control room? Perhaps from here to the member on the bench.
And he would be just watching a screen, would he? Yes.
And if there was a problem, he would have to scrub up to come and help you? That's correct.
(ts 3536, 3 April 2018)
The evidence from the interventional cardiologists as to the role of a secondary operator required the secondary operator to be either physically engaged in the angioplasty procedure or sufficiently close to engage in discussion with the primary operator. None of the evidence suggests that presence in the control room as an observer was sufficient to constitute a practitioner being regarded as a 'secondary operator'.

The number of angioplasties performed at Royal Perth Hospital (RPH) 19801982

Angioplasty began to be performed at RPH in August 1980 (Exhibit G page 395 para 2). The first angioplasty at RPH was performed by Dr Cumpston in August 1980 (Exhibit K page 1 para 4). Throughout the whole of the 1980's there were only three interventional cardiologists in Perth, Drs Cope, Cumpston and Mews all based at RPH (ts 17, 4 April 2018).
From 1980-1983 there was only one catheterisation laboratory in Perth, which was at RPH (ts 7, 4 April 2018; ts 89, 19 April 2018; ts 153, 19 April 2019; Dr Woollard's closing submissions para 29). At RPH, the catheterisation laboratory was set up so that there were two rooms in which the procedure was performed. Between the two rooms there was a control room.
Drs Cope and Mews performed angioplasty procedures together during this period (ts 10, 4 April 2018; Exhibit H para 7 and Exhibit Y para 21).
The use of stents for angioplasty procedures was not introduced in Western Australia until the late 1980's. Initially all stent angioplasty procedures were done by Dr Cope and Dr Mews (Exhibit H page 509 para 7).

Dr Woollard's account of his training in the 1980's

Dr Woollard was a Visiting Cardiologist at Fremantle Hospital from 1982 to 2005 (Exhibit N page 433 Book of Witness Statements).
Dr Woollard's evidence was that 'the actual period where I was watching angioplasties was only one or two years from the end of 1981 to 1982' (ts 75-77, 4 April 2018).
In his first statement (29 September 2015, Exhibit N, Book of Witness Statements, pages 407408 paras 23 to 25), Dr Woollard stated:
23.In the early 1980's when angioplasty was first introduced at Royal Perth Hospital, I indicated a desire to participate.
24.There was no formal training program. However, over a subsequent period of 1-2 years, I was involved with more than 100 angioplasty procedures carried out by Dr Geoffrey Cope at Royal Perth Hospital. Many, but not all, of the patients were my patients from Fremantle Hospital who I had referred for angioplasty. I stayed on after my angiogram sessions at Royal Perth Hospital for Dr Cope's subsequent angioplasty sessions on patients who were not mine.
25.Dr Cope has acknowledged that it was possible that I observed cases performed by him, although he has no memory of me doing so. However, his statement says he did not perform any cases with my assistance. In answer to this I expressly recall having both observed and assisted Dr Cope perform those procedures in the 1980s. I have a clear recollection of being scrubbed and performing tasks at his instruction, including insertion of catheters, inflation of balloons and injection of contrast. These tasks are identical to those performed by a 'secondary operator' in a formal program. In relation to those patients who were my patients, I was also responsible for the decision on whether they should undergo angioplasty (rather than medical treatment or bypass surgery) and for the post procedural care. During these procedures there were usually 4 people in the room (Dr Cope, myself, a nurse and a radiographer) and a technician in the control room adjacent to the procedure room.
Dr Woollard accepted that he was not in a training program in the early 1980's. He had expressed his interest in angioplasty but had not been invited to participate in a training program (ts 77, 4 April 2018).
The Tribunal notes that Dr Woollard's witness statement of 29 September 2015 was the first occasion on which Dr Woollard identified any involvement with Dr Cope. Dr Woollard did not identify Dr Cope in his Response Statement or Amended Response Statement.
Dr Woollard gave evidence that 'there were a few occasions' where his patients were being dealt with by Dr Cope apart from the first two years (ts 77, 4 April 2018).
In cross-examination the following exchange took place:
Okay. And what is it that you say you did during the 100 to 200 procedures that you assisted Dr Cope with? I observed and assisted. I was the sometimes I would put the sheath in the groin. These are tasks that could be done by anybody. They're not different to any other assistant of the procedure. I would hand him the catheters. I would often be basically doing a lot of the tasks that the nurse would do, handing him catheters, inflate the balloons on instruction. Inject the just sometimes inject the contrast because that was a separate syringe at the other end of the catheter, while he did all the intricate work of feeding the catheters and the wires into the arteries and carrying out the this procedure. I was simply assistant an assistant in some respects just replacing the nurse.
(ts 90, 4 April 2018)
The evidence of Dr Geoffrey Cope which appears at Exhibit G, Book of Witness Statements, page 395 paras 2 to 5 was:
From 1980, when angioplasty began to be performed at Royal Perth Hospital, until I retired in 2008, I performed angioplasty procedures at Royal Perth Hospital.
The only other medical practitioners, apart from myself, who were able to train anyone In angioplasty procedures at Royal Perth Hospital from 1980 until 2005 were Dr Neil Cumpston, Dr Geoffrey Mews and, from the time of completion of his training in the early 90's, Dr Richard Clugston.
I did not perform any angioplasty cases with the assistance of Dr Keith Woollard. It is possible that Dr Woollard observed cases performed by me, although I have no memory of him doing so. Dr Woollard was never a participant in any angioplasty training program at Royal Perth Hospital at any time whilst I worked there.
If Dr Woollard asked me to train him in angioplasty I do not recall the year in which he made this request. Dr Woollard said that he would supply the cases. I declined to train Dr Woollard in angioplasty procedures.
Dr Woollard accepted that Dr Cope refused to accept him as a trainee in angioplasty procedures on multiple occasions (ts 92, 4 April 2018).
Dr Cope provided a responsive witness statement, Exhibit H, Book of Witness Statements where at pages 509910 paras 2 to 9 he stated:
I have previously given a witness statement in relation to this matter which was signed on 22 April 2015 (my previous statement).
I am advised that Dr Woollard has stated in his witness statement filed in these proceedings that at some time during the 1980s he performed a significant number of angioplasty cases with me in respect of which his involvement amounted to that of a 'secondary operator'.
That assertion is false.
If Dr Woollard scrubbed up and attended any cases performed by me, he certainly did not participate in them. Mere observation does not constitute training.
[see also ts 11, 4 April 2018]
If Dr Woollard had been present for any significant number of cases, for example, 100 cases, I would definitely remember that that had occurred.
The use of stents was not introduced in Western Australia until the late 1980s. At that time, all stents were done by myself and Dr Geoffrey Mews together. Dr Woollard was definitely not present or observing any of these early cases involving deployment of stents in the late 1980s.
Angioplasty equipment and techniques developed dramatically between the 1980s and the mid-2000s. Any training received in the 1980s would not have included training in techniques and equipment used in the 2000s.
The performance of angioplasty procedures involves a high degree of manual skill and training must be continuous in order to ensure the attainment of an adequate level of manual skill.

Dr Cope was firm in his evidence that Dr Woollard was not involved in any angioplasty procedures with him. In reexamination Dr Cope gave the following evidence:
You were asked a question as to whether if Dr Woollard came up from Fremantle and did an angiogram in the morning in your one of your labs at Royal Perth, and if in the afternoon he might have stayed on to see you it was put to you as, 'be ballooned', and you answered, 'He could have'. Can you estimate, and I don't mean by a precise number but somewhere between zero and 200, can you estimate how many times that could have happened? - - - I cannot recall very many specific times at all. I would estimate it to be very few. It would certainly be less than 10. It would be nowhere near 100 if, indeed, it happened at all. I would be prepared to concede that it may well have happened but I don't specifically recall it but it may well have. It would certainly have been very infrequent. I think the implication is that I was giving Dr Woollard some form of training in angioplasty at Royal Perth Hospital for 100 cases and that is absolutely incorrect.
(ts 42, 4 April 2018; Tribunal emphasis added)
Dr Cope's oral evidence was that he refused to train Dr Woollard because he regarded him as being 'far too fast, far too aggressive and potentially dangerous' to perform angioplasty procedures (ts 32, 35, 4 April 2018).
The evidence of Dr Cope was corroborated by Dr Cumpston's recollection during re-examination:
Well, I remember well and truly that one of Dr Woollard's problems was that he was always in a hurry and despite my pointing this out to him on numerous occasions he didn't change and I believe that it's his rush at doing angiograms that maybe maybe was pertinent to his procedure doing angioplasty. But, certainly, I mean, I can remember patients when the artery was being prepared the artery in the arm for the procedure that there would certainly be more rapidly drawn breaths and squeaks coming from the patient, indicating considerable discomfort[.]
(ts 5152, 4 April 2018)
It is unlikely that Dr Cope would have provided Dr Woollard with any training as a secondary operator as he did not consider that Dr Woollard was a suitable person to be trained in interventional cardiology (Exhibit I para 18).
Under the heading 'Obstacles' in Dr Woollard's witness statement of 29 September 2015 (Exhibit N pages 408410 paras 26-34), Dr Woollard asserts that in effect he was not permitted to take part in angioplasty procedures or receive training from RPH and was denied access to facilities at other hospitals. The basis for the leading of this evidence appears to be to establish that somehow Drs Cope, Mews and Cumpston had some motivation for denying him training. In particular the Tribunal notes that in para 29, that Dr Woollard states 'Dr Jeffrey Cope denied these requests without providing reasons'. Dr Woollard also refers to Dr Hockings being prevented from carrying out angioplasty procedures at RPH following his appointment as a cardiologist despite the fact that Dr Hockings was adequately trained (see also ts 1221, 4 April 2018).
The Tribunal notes that Dr Hockings refused to act as Dr Woollard's supervisor (Exhibit A page 400 para 5). No criticism was made or ulterior motive suggested by Dr Woollard for Dr Hocking's refusal to supervise him.
Dr Cope's evidence is that he encouraged doctors at Charles Gairdner Hospital to set up their own catheterisation laboratories. He was not in favour of Fremantle Hospital performing angioplasty because Fremantle Hospital did not have surgical standby (ts 1213, 4 April 2018).
Insofar as Dr Woollard is trying to assert that there was some ulterior motive for him not being granted entry to a training program, the Tribunal does not accept that there was any ulterior motive. Equally, the Tribunal does not accept that this demonstrates any motive for Dr Cope not to give accurate evidence.
Despite the efforts of counsel for Dr Woollard to suggest Dr Cope had some motivation not to give accurate evidence because of his conflicts with Dr Woollard on a professional basis, the Tribunal has no hesitation in accepting Dr Cope's evidence.
Dr Cope was an excellent witness who was totally credible. He retired 10 years before this hearing. He has no personal interest in the outcome of these proceedings.
A witness statement was obtained from Dr Mews prior to his death. He stated that Dr Woollard asked him to train him in angioplasty but Dr Mews declined to do so. Dr Mews' witness statement (Exhibit U, Book of Witness Statements, page 397 paras 2 to 4) stated:
I performed angioplasty procedures at Royal Perth Hospital from 1980 until 2005. From 2000 until July 2011 I primarily performed angioplasty procedures at Hollywood Private Hospital, but I continued to work at Royal Perth Hospital on a part-time basis until 2005.
I am certain that Dr Woollard did not ever assist me in the performance of any angioplasty procedures.
It is possible that Dr Woollard observed some procedures from a control room at Royal Perth Hospital, but I certainly did not ever see him act as a secondary operator in the performance of any coronary angioplasty procedure. Dr Woollard was not ever a participant in any training in angioplasty at Royal Perth Hospital.
There was no reason for Dr Mews not to have given a statement that was true. He had no personal interest in the outcome of these proceedings.
A statement was also obtained from Dr Neil Cumpston, Exhibit K. He stated at paras 3 to 5:
In 1980 I introduced coronary angioplasty to Royal Perth Hospital having undertaken training in coronary angioplasty at the University Hospital, Zurich, Switzerland.
In August 1980 the first coronary angioplasty procedure ever performed at Royal Perth Hospital took place. This was the second coronary angioplasty procedure performed in Australia.
I am certain that Dr Keith Woollard has never been in the same room as me when he or I performed a coronary angioplasty procedure.
Dr Cumpston had no personal interest in the outcome of these proceedings. The Tribunal accepts Dr Cumpston's evidence that Dr Woollard was not involved with any angioplasty procedures with him.
Given the very limited number of angioplasties that took place in 19801983, Dr Woollard would have had to be involved in a substantial number of the total procedures that took place at RPH during this period if in fact he was involved in well over 100 patients.
The Tribunal does not accept that Dr Woollard would have been present for 100 or more cases performed by Dr Cope alone at that time. It is also inconceivable he was present at angioplasties so regularly in the 1980's without each of Drs Cumpston and Mews being aware of it.
Despite the fact that the evidence from Drs Cope, Cumpston and Mews relates to events over 30 years ago, the Tribunal does not find that the delay has impacted on the memory of any of the doctors. The events were at a very significant time in the development of angioplasty at RPH. At the relevant time, angioplasties were performed by a very small group and a relatively small number of angioplasties were performed. If Dr Woollard had been involved the doctors would have remembered him despite the passage of time. Equally, Dr Woollard could not have mistakenly believed that he had been involved in over 100 angioplasty cases with Dr Cope simply because time has passed.
The Tribunal finds that Dr Woollard did not receive any training from Dr Cope as alleged by Dr Woollard, that is, being present for over 100 cases performed by Dr Cope. Nor, to make it clear, was he supervised by Dr Cope nor did he assist Dr Cope in any way. Dr Woollard was not a secondary operator to Dr Cope. Dr Woollard did not receive any training from Dr Cope, let alone any training that would amount to the completion of any procedures as a secondary operator for the purposes of the 2001 Guidelines.
Given that the Tribunal accepts the witness statements of Drs Cope, Cumpston and Mews, the Tribunal finds that Dr Woollard did not have any initial training as a secondary operator assisting with angioplasty procedures carried out on his patients at RPH nor did he participate in angioplasty procedures in the early 1980's in a manner that constituted him being a secondary operator. Dr Woollard's training in angioplasty dates only from 2004.
The Tribunal finds that Dr Woollard did not receive any angioplasty training as either a primary operator or a secondary operator in the 1980's.

Dr Woollard's training in 2004 and beyond

Dr Woollard's evidence was:
35.In 2004, Dr Kalarickal offered to assist in training Dr O'Shea and I in coronary angioplasty. Dr Kalarickal is an internationally recognised angioplasty expert based in India:
36.A program was developed by myself and Dr O'Shea with the assistance of Dr Kalarickal and accepted by the Mount Hospital. Seven expert cardiologists from the eastern states, India and the United Kingdom attended for repeated one week sessions during which Dr O'Shea and myself would carry out angioplasty procedures at the Mount Hospital in Perth under their supervision. These are the procedures listed in the log book attached to the letter to Dr Peter Crawford dated 14 December 2005.
37.The training program was discussed with the Mount Hospital, and the Manager subsequently gave his approval to conduct the training program. The supervising cardiologists were all accredited for that purpose by the Mount Hospital prior to their participation in 2004 and 2005.
38.I kept the Medical Advisory Committee [MAC] at the Mount Hospital informed about my progress in angioplasty procedure training.
(Exhibit N page 410 paras 3538)

Dr Woollard's application for accreditation

On 10 October 2005, Dr Woollard formally sought accreditation from the MAC to carry out angioplasty procedures by writing to Dr Patrick Crawford, the Chairman of the MAC:
I wanted to keep you and the MAC advised of my progress.
As you know, I have been undertaking angioplasty procedures utilising visits by international and interstate experts.
As mentioned I have reached the numbers required for training as suggested by the Cardiac Society current guidelines (75 procedures as the primary operator and 125 as the secondary operator). The only major adverse event was a single episode of stent thrombosis seven hours after the procedure which resulted in a small infarct. The patient remains well.
I believe it would be appropriate to continue in a training model. Dr Peter Illes, a highly experienced and well respected proceduralist, has agreed to continue as a mentor with whom I could discuss cases and receive advice. Dr Bernard Hockings carries out procedures in the other cardiac catheter facility at the same time as my session. He has agreed to provide backup in case of a major problem developing which requires immediate assistance.
This new training model will be more efficient for the hospital and my patients.
(Exhibit B page 113)
Significantly, Dr Woollard stated that he had reached 'the number of required for training' as suggested by the 2001 Guidelines. Dr Woollard's letter of 10 October 2005 did not provide any evidence to support his assertion that he had complied with the 2001 Guidelines 'the current guidelines'.
It is clear from Dr Woollard's letter of 10 October 2005 that he is relying on compliance with the 2001 Guidelines as a basis for accreditation. There is no suggestion in the letter that he is relying on his previous experience as a cardiologist. Dr Woollard clearly sought to establish that he had complied with the number of procedures set out in the 2001 Guidelines.
In Dr Woollard's closing submissions he stated that the words 'as mentioned' in his letter of 10 October suggested some 'prior conversation' with Dr Crawford and, possibly, with other members of the MAC. Dr Woollard gave no evidence as to any 'prior conversation'. Accordingly, the Tribunal has placed no weight on this submission.

Unsupervised training

Dr Woollard's letter of 14 December 2005 stated that '[t]he supervisors involved in my training at the Mount Hospital have felt confident with my technical skills and have allowed me to perform as the primary operator without a preliminary period as a secondary operator'. Dr Woollard's letter of 14 December 2005 did not disclose that 14 of the procedures were unsupervised, that is, the MAC would not have been aware from the letter that 14 of the procedures were unsupervised.
A trainee cannot be trained without a trainer.
Dr Marmur's evidence in relation to unsupervised procedures was:
DR MARMUR:          I mean they count as a procedure performed, but they don't I'm not sure they would count as procedures performed under supervision or as part of a training program.
…
STANTON, MS:        And if you count down under the heading Training Experience [Exhibit V at page 225], if you count down to the fourth bullet point, you will see that paragraph refers to a log book of cases detailing clinical indications including assessment of procedural risk, interventional procedure, outcome and complications, and it then says:
This log must be certified by the director of the training unit.
On the basis that if they're unsupervised cases they can't be certified, are you happy to accept that they can't form part of the 200 procedures needed for the 2001 guidelines?
DR MARMUR:          I agree with that. They're not part of a training experience, no, because they're not he's not they're not being performed in the context of the role of a trainee.
(ts 115, 19 April 2018)
Dr Marmur's evidence was:
STANTON, MS:        Okay. And so are you in agreement with I think both Dr Clugston and Dr Russell that Dr Hockings was not in any sort of supervisory role? He was just performing his own cases in the next-door lab?
DR MARMUR:          I agree with that.
STANTON, MS:        And he was disadvantaged in terms of salvaging the situation for Mr Brown?
DR MARMUR:          I agree with that.
(ts 120, 19 April 2018)
The 2001 Guidelines required certification by the director of the training unit. An unsupervised procedure could not be used to meet the 2001 Guidelines.
Dr Russell's evidence in relation to unsupervised procedures was:
DR RUSSELL:           I think he makes it quite clear that he's not part of the training program, but and would be of assistance if there's an emergency situation.
STANTON, MS:        That is obviously subject to his own clinical situation, isn't it? If he's already performing a procedure and he can't leave because he's the only doctor in the room, there's not much he could do in that situation, is there? That doesn't count as supervision of any kind, does it?
DR RUSSELL:         No, that would not be supervision.
(ts 116, 19 April 2018)

How often had Dr Woollard acted as primary/secondary operator in 2004-2005 for the purposes of the 2001 Guidelines?

As the Board submitted, Dr Woollard had ready access to data as to the number of angioplasties he had been involved in (Vicky Taylor) (ts 102-102, 5 April 2018).
Dr Woollard did not suggest in his evidence that records he used to compile the logbook summary for 2004-2005 which he sent to the MAC in December 2005 were insufficient.
There is no basis for a finding that Dr Woollard was unaware of the total number of angioplasty procedures he was involved in as a primary operator or as a secondary operator in 2004-2005.
The number of 'procedures' carried out by Dr Woollard as at 10 October 2005 is to be found in a logbook summary he forwarded to the MAC under cover of a letter dated 14 December 2005 (Logbook Summary Exhibit Q page 1-3).
Exhibit Q comprises a number of logbook summaries prepared on Dr Woollard's instructions. Pages 1-2 shows Dr Woollard claims as a primary operator and page 3 shows his claims as secondary operator. There is a dispute as to what constitutes a 'procedure' but for present purposes it is unnecessary to resolve that issue. This will be dealt with later in these reasons.
The logbook summary referred to in the letter of 14 December 2005 was in fact not attached and was faxed by Dr Woollard's secretary on 16 December 2005 (Exhibit B pages 124126). The logbook summary shows 104 angioplasty entries as a 'primary operator' and 49 entries as 'secondary operator'. It is apparent from the logbook summary that these procedures were carried out in 2004-2005.
The logbook summary referred to in Dr Woollard's letter of 14 October 2005 purported to show what Dr Woollard had done in 20042005 as part of establishing that he met the 2001 Guidelines (Exhibit Q page 1).
The logbook summary referred to 104 primary procedures and 49 secondary procedures. The summary is not in date order. Numbers 1 (3.11.2005), 2 (27.10.2005), 29 (24.11.2005), 65 (10.11.2005), 88, 89 (03.11.2005), 97, 98 (1.12.2005), 99, 100, 101, 102, 103 and 104 (1.12.2005), that is, 14 procedures were performed after 26 October 2005 and were not supervised (Exhibit Q pages 12). No procedures were claimed between 10 October 2005 and 26 October 2005. One hundred and four procedures minus 14 procedures leaves a total of 90 procedures as a claimed primary operator.
At best, Dr Woollard had carried out 90 procedures as a primary operator when considering whether he complied with the 2001 Guidelines. The need for logbooks and certification by the director of the training unit is a specific requirement of the 2001 Guidelines (Exhibit V page 225).
At at 10 October 2005, Dr Woollard had carried out 90 angioplasty procedures as a primary operator and 49 as a secondary operator, that is, a total of 139 procedures, under the 2001 Guidelines. His statement in his letter of 10 October 2005 was therefore incorrect.
Dr Woollard knew that his statement that he had completed the necessary number of procedures under the 2001 Guidelines in his letter of 10 October was untrue. He knew that he had not carried out the number of procedures required under the 2001 Guidelines. Dr Woollard therefore knew that his representation to the MAC was false. It also follows that Dr Woollard's statement in his letter of 10 October 2005 to the MAC that he had carried out the necessary number of procedures was false. The Tribunal finds that Dr Woollard knew his statement was false and that he subjectively intended to make that false statement.
In making this finding, the Tribunal is conscious of its seriousness. A possible outcome of the finding is that Dr Woollard's registration as a practitioner may be cancelled. These considerations apply equally to other serious findings in these reasons.

Dr Hockings' evidence as to his 'supervisory' role

Dr Woollard's letter of 10 October 2015 stated that Dr Hockings 'has agreed to provide backup in case of a major problem developing which requires immediate assistance'. Dr Hockings' evidence as to his discussions with Dr Woollard concerning his role in relation to Dr Woollard's attempts to obtain accreditation in the performance of angioplasty procedures at the Mount Hospital is set out in Exhibit A pages 400401 paras 5 to 7:
5.Dr Keith Woollard asked me on more than one occasion if I would act as his supervisor in relation to his attempts to obtain accreditation to perform angioplasty procedures at the Mount Hospital. I cannot recall when or on how many occasions Dr Woollard made this request. I declined to act as Dr Woollard's supervisor on each occasion that he made this request
6.In December 2005, after Dr Woollard had made a request that I act as his supervisor in respect of his performance of angioplasty procedures, I wanted to make clear to Dr Woollard that I was not prepared to act as his supervisor but that I would always help if an emergency occurred whilst I was working in the adjacent catherisation laboratory at the Mount Hospital, provided that my own clinical circumstances allowed me to do so. I also wanted to make clear to Dr Woollard that I would not be available to 'cover' Dr Woollard at other times or after hours.
7.In order to clarify these things I sent Dr Woollard a letter dated 8 December 2005 and had a copy of the letter sent to Dr Peter Thompson and Mr Sebbes of the Mount Hospital,

It was Dr Marmur's opinion stated in Exhibit Z, the Joint Statement that:
The occlusion of the patient's LAD coronary artery was likely due to trauma induced by the Whisper guidewire, and thrombosis. There was likely inadequate anticoagulation due to a low dose of heparin. Although dissection may have played a role, saw no definite evidence of dissection on my review of the angiographic data.
Dr Marmur's oral evidence was:
It's it's not a great reproduction. Yes, I see it's 2005. Thank you for that that correction. Absolutely, I stand corrected on that. With respect to the mechanism of occlusion, I am in disagreement with my colleagues. I do not believe there is any firm evidence of dissection. I reviewed the angiograms myself that were sent to me. I never saw a flap. In fact, I felt very strongly about it to the point where in my report I included an image of what a dissection looks at looks like. And although dissections can be microscopic and not angiographically visible, there does require some evidence to make that diagnosis.
Furthermore, in this case you have a very simple, plausible explanation for the closure of the vessel and that's thrombosis. It's a clotting. The patient has a very tight lesion. It was probably destructed by wiring attempts. And, as Dr Clugston pointed out, he used the operator used borderline acceptable, very small dose of anticoagulation in the form of his Heparin dosing. So, in my opinion, what you have evidence for is an abrupt occlusion in the setting of a of of a number of factors favouring thrombosis. And, therefore, I think top of the list of mechanisms for closure are thrombosis.
However, it is certainly possible that dissection has played a role. There's just no evidence for it, other than the patient underwent an intervention, and we know these type of vessels can dissect. In any case, I'm not sure it's that relevant with respect to the the the judgment about the behaviour of this physician whether the mechanism of closure is dissection or thrombosis. The issue is is he addressing the concerns. I do suppose though, in part of this discussion about his behaviour, was the was the explanation to the family.
And I do think it's important for the tribunal to appreciate the fact that if experts in the cold light of day can have disagreements about the mechanism, it's not surprising that the physician himself in the heat of the moment, may have had some challenges in explaining the exact mechanism of the complication at the time he was talking to the family I think the wife, the the the family relative.
(ts 20, 19 April 2018)
Dr Marmur's oral evidence was:
I I don't believe the manipulation of the guide catheter is at issue here because the closure that happens is in the distil left main at a distance from the guiding catheter. The tightest lesion that he's working on is the LAD. He can't wire it properly. He has he has probably traumatised that area, exposed prothrombotic factors. His Heparin dosing is low. … he then goes in and does I think the circumflex with a stent and the circumflex at some point, and all this disruption of the tightest area of the vessel the LAD that, I believe, is the site of closure.
And … the real problem in this case, in my opinion, is whereas it was reasonable to try to wire this LAD, at the time he could not wire the LAD, in my opinion, was a time where a physician with better judgment would have said, 'Okay. I can't do this. I'm going to stop'. The problem is he goes and he stents the diagonal. He's playing around with other vessels. And it ultimately leads to what I think is a thrombotic closure at the area that's tightest, namely the angulated, ulcerated LAD that was well-described by Dr Clugston.
I think that's the site of of closure. And it comes from the wire manipulation and passage of balloons and those type of equipments, much more so than the guide because I don't see evidence of a dissection at the at the beginning of the left main. I I never saw a picture convincing a a linear radiodensity that that is typical of dissection. I never saw that.
(ts 21, 19 April 2018; Tribunal emphasis added in bold)
The Tribunal finds that once Dr Woollard was unable to enter the lesion in the LAD, he should have abandoned the procedure.

The additional dose of heparin at 2.52 pm

A second dose of heparin was given at 2:52 pm. The oral evidence concerning the second dose was:
MORRIS, MR:           You mentioned, as well, repeating a dose, and it seems from the records that an additional 5000 was added at some point during the procedure. Is that significant?
DR MARMUR:          I think that happened when the at the time of the closure, when they realised there was a thrombotic they presumed a thrombotic component, I think, when the more experienced operator came in, or the surgeon came in. There was a statement about increasing the anticoagulation.
MORRIS, MR:           If you assume that the 5000 units were added before the problem arose, does that make a difference?
DR, MARMUR:         Yes. No. I think if he gave a second dose of 5000, that … that's a positive on his side.
HIS HONOUR:          Well, I think if you go to page 68, you have 2.50. If you go to page 38, you have the heparin added at 2.52.
…
HIS HONOUR:          - - - that's the ECG you will see 2.50. It looks as though that's a point at which things are not going well.
DR MARMUR:          Right.
HIS HONOUR:          And then if you go to page 38, and look at 2.52, that's when the 5000 units of heparin appear to have been added. One - - -
DR MARMUR:          Right. So that's when he's that's when he crashes.
HIS HONOUR:          Yes.
DR MARMUR:          Yes. Yes. That's what I'm saying, that the second dose is given in response to a … catastrophe.
(ts 136-140, 19 April 2018)
Dr Marmur's oral evidence was:
DR MARMUR:          You're saying if if the second dose of heparin was given before or after the occlusion, it does not matter; is that what you're asking?
MORRIS, MR:           Well, how long does heparin take to have an effect?
DR MARMUR:          It's very fast. Seconds.
MORRIS, MR:           Seconds. If the heparin dose had been given immediately before the occlusion, would it necessarily have made any difference?
DR MARMUR:          I mean, … it speaks to better behaviour of the operator if he gave the heparin additional heparin independent of a major complication. It -it speaks to him thinking about it, being aware of it, being concerned about it, but it it the his overall behaviour and the timing of this suggests that, at the time of an abrupt closure is when there was an urgency to give additional heparin. That's just the way the record looks to me.
In any case, it's not the as I said, it's not a breach I … would not I would not stand up in a court of law and and say, 'You committed malpractice with this heparin regime'. All I'm saying is it's a it reflects a somewhat cavalier attitude and, in my opinion, some lack of judgment and a and and risk assessment. To be using a borderline does of heparin in such a high risk scenario is to me, is pushing the envelope unnecessarily.
MORRIS, MR:           But like the initial failure to fully appreciate the concerns, it was a rooky error in the sense that it was driven by a lack of experience; is that right?
DR MARMUR:          Yes, exactly. Exactly. That to me, it's - - -
…
DR MARMUR:          Right. … I think in the future, if he is so operating, he is going to be a lot more meticulous about it, a lot more careful. I think his behaviour reflected a lack of appreciation of the extent of risk he was facing, or the patient was facing. Yes.
(ts 141-143, 19 April 2018)

Dr Woollard's lack of experience

Dr Woollard was added to the WGGRC following his letter of 12 August 2004 (Exhibit V page 226).
Dr Woollard wrote to Professor Brieger on 4 November 2004 (Exhibit V page 226A). The final paragraph of the letter was:
I will be vigorously defending the status quo. I will declare an interest (and doesn't everybody have one!). I am halfway through a training program designed to meet the current Cardiac Society guidelines. I look forward to the teleconference.
On 18 November 2005, Dr Woollard wrote to the President of the Cardiac Society. In that letter he stated:
…
The major concern is that no case has been made for a change in the Guidelines on angioplasty training. Making the Guidelines more restrictive may make services less accessible to the community and may cause damage to both institutions and individual cardiologists (such as myself) for which the Society could be liable.
…
A subsequent requirement is that a trainee undertake 400 angioplasty procedures including at least 50 cases of primary angioplasty and 50 complex interventions. This doubles the current requirement and for the first time specifies the type of patients that needs to be included. A requirement of 400 supervised procedures is unreasonable.
(Exhibit V page 230)
The 2005 Guidelines (Exhibit V page 244) were approved on 22 April 2005.
As Professor Brieger notes, Dr Woollard's suggestion regarding training for angioplasty across multiple sites was incorporated in the 2005 Guidelines (Exhibit E page 1001 para 18).
Professor Brieger also notes that other than Dr Woollard, the WGGRC was unanimously in favour of a greater number of procedures in training (Exhibit E page 1001 para 17).
Dr Woollard was well aware that the Cardiac Society regarded the 2001 Guidelines as inadequate.
Dr Woollard knew that he had not met the 2001 Guidelines.
Dr Woollard had insufficient experience and he knew that he had insufficient experience according to the standards of the Cardiac Society, both under the 2001 Guidelines and the 2005 Guidelines.
Dr Marmur's evidence was:
MORRIS, MR:           Yes. Now, you have spoken about experience and its relevance in terms of the recognition of risk associated with a procedure, and you have agreed that an experienced proceduralist might have seen things that a less experience proceduralist might not; is that right?
DR MARMUR:         May may have seen, is that what you said?
MORRIS, MR:           I should go back to the actual quotation, because I think I've noted, 'what experience gives you is the capacity to appreciate the level of risk'; is that right?
DR MARMUR:          Right. So … a more experienced operator would would would be more fearful of a case like this. … this is, you know, all indirect, as I've never met Dr Woollard and I don't know exactly how he felt about the case, but one has the sense of a lack of appreciation of the risk of the risks he was facing in doing this case, and I say that because, despite the fact that he can't wire the LAD, he goes again and stents the the diagonal (indistinct)
There's a certain a sense of slightly cavalier attitude, when, in fact, a more experience operator would would be fearful of this, but that's true of all less experienced doctors. There's an expression which is that, you know, 'Good judgment comes from experience, and experience comes from bad judgment.' So it part of the learning process of becoming a higher a a good physician is living through these complications.
We try to learn from our colleagues, but it's not always the case, so a more experienced operator would have been more fearful, more careful, made sure the anticoagulation … was documented, been very careful, … and may also, if had the appropriate fear reaction, have aborted the case earlier and called for surgical help earlier.
MORRIS, MR:           And when we're talking about the levels of experience, we're not talking about credentialed operators, we're talking about those who have been in the field as a interventional cardiologist for a longer period than those who are just beginning their careers as interventional cardiologists; is that right?
DR MARMUR:         Yes.
(ts 135, 19 April 2018)
Dr Woollard submitted:
48.The problematic lesion was in the Left Anterior Descending Artery ('LAD'). In the event, Dr Woollard was unable to achieve entry to the LAD and may have considered abandoning the procedure. However, the Left Main Artery ('LM') completely occluded, probably as a result of dissection by the guide catheter.
49.Dr Woollard's understanding of what had occurred was included in a letter to his 'mentor' Dr Illes. Dr Illes' reply was sent on 16 January 2006. Dr Illes made the following comments with respect to the procedure:
•'Regarding the actual procedure I do not think you fundamentally did anything wrong here. It is the sort of thing that could happen to anyone and certainly Left Main Stem Dissection is a well-documented and accepted complication of LAD stenting.
•It unfortunately usually has an unhappy outcome unless one is immediately able to stent the Left Main and pass a stent down the LAD.
•in retrospect, perhaps if you were having great difficulty getting a wire down the LAD it would have been reasonable to not proceed to do anything as this was the main prognostic vessel.
•These are obviously very easy observations to make retrospectively.'
…
50.Accepting the views of the experts, then the decision to attempt the procedure seems to have been an error of judgment which would not have been made by a much more experienced interventional cardiologist. As Dr Marmur said 'good judgment comes from experience and experience comes from bad judgment'. What experience gives you is the capacity to assess the risks associated with a case. Dr Woollard clearly underestimated the risk and it seems he did so because the lesion did not occupy much of the LAD and to his mind was suitable for stenting.
52.It is submitted that such an error of judgment does not in itself constitute a conduct issue.
If Dr Woollard's submission is correct, the more inexperienced the practitioner, the more his errors can be put down to learning by experience. That is an untenable submission.
In is closing submissions, the Board noted:
106.Even after Mr Brown's death, Dr Woollard wanted to continue unsupervised. He wrote to Dr Same on 16 December 2005 (BD p128) saying:
Fortuitously I had yesterday sent my completed log book of angioplasty procedures and I enclose a copy. As you can see from that list. This is a single isolated event.
I am happy to discuss the issue with you in more detail. Following the event with this patient, I proceeded with the rest of the list and the subsequent two angioplasty procedures went smoothly as usual.
I have a significant number of patients awaiting angioplasty. It is difficult for me to conceive that this tragic event represents more than just an accidental event.
The Board contended that:
74.Dr Woollard's involvement in that Committee was entirely selfserving and aimed at ensuring he would not be hampered in becoming accredited to perform angioplasty procedures, yet he later portrayed that involvement to the MAC as motivated by his desire to ensure adequate training standards. All of this suggests that Dr Woollard knew that his training was inadequate but single-mindedly pursued accreditation at the expense of patient safety, including in the case of Mr Brown, probably for financial gain.
Lack of supervision
…
77.Dr Hockings knew nothing of Mr Brown or the procedure Dr Woollard was attempting to perform on Mr Brown before the emergency arose. Dr Hockings was performing his own work on his own patients and happened to have just completed a case and to be making notes when the emergency arose.
78.No analogy can be drawn between the presence of Dr Hockings and proper supervision of a trainee in interventional cardiology, and it is irrelevant how the catheter laboratories were connected. A supervisor would be responsible for the patient, would have ensured proper case selection, would ensure that the trainee was the primary operator only in a case appropriate to his level of skill and experience, would be scrubbed and standing at the table or at least in the control room watching the procedure, would be instructing and guiding the trainee as the procedure was performed and would be immediately available to assist. In a case as complex as was the procedure attempted on Mr Brown, if it was selected as a training case, supervision would be expected to be very close and involve the supervisor being scrubbed at the table and focused on the performance of the procedure.
In proceeding with Mr Brown's angioplasty, Dr Woollard demonstrated an unjustified self-confidence that went beyond a clinical error and constituted arrogance. He purported to know better than qualified and experienced interventional cardiologists.
Dr Woollard's conduct went far beyond an error of judgment. Dr Woollard knew that he had not met the 2001 Guidelines. Even in the face of the evidence of three eminent experts, Dr Woollard refused to concede that he lacked experience.
Experience is not gained at the risk of the lives of the practitioner's patients. The whole point of training and the whole point of supervision is that a practitioner learns the capacity to assess the risks as a result of training and experience under supervision.
An error of clinical judgment involves reasoning based on sound premises, for example, if Dr Woollard chose the wrong guidewire. A practitioner's false sense of his level of experience does not constitute an error of clinical judgment. For Dr Woollard to proceed with Mr Brown's angioplasty, despite all the evidence suggestive that he ought not, that is, his failure to achieve the number of procedures as set out in the 2001 Guidelines, his awareness that the Cardiac Society had decided that the 2001 Guidelines were inadequate and that the 2005 Guidelines required twice as many procedures for accreditation and the fact that he proceeded with Mr Brown's angioplasty without a supervisor, establishes that his decision was not reasoned and that he proceeded on a false premise. Namely, that he knew better than highly competent and experienced interventional cardiologists, that is, those who constituted the WGGRC and those who established the 2001 Guidelines. The Cardiac Society was the body that made recommendations for accreditation.
Dr Woollard did not have sufficient experience. He knew he did not have sufficient experience. Dr Woollard's conduct was substantially below the standard reasonably expected of a registered medical practitioner of an equivalent level of training and experience. He engaged in professional misconduct.

Allegation 6 deliberately misleading Mrs Brown as to the cause of death

At para 28 of its Grounds the Board alleged:
Following the death of the Patient, [Dr Woollard] said to the wife of the Patient, Mrs Valerie Brown, words to the effect that the Patient had died because a section of plaque had dislodged and occluded the Patient's main coronary artery.
Paragraph 23 of Dr Woollard's Response was:
(a)says that during a conversation with the wife of the Patient, Mrs Valerie Brown, subsequent to the death of the Patient, he described the damage caused to the wall of the left main coronary artery that occurred during the Procedure which caused the occlusion to the artery and a massive heart attack from which the Patient died during the surgery; and
(b)otherwise does not admit the matters contained in paragraph 28.
At para 29 of its Grounds, the Board alleged:
[Dr Woollard's] advice referred to at 28 [of the Grounds] misrepresented [Dr Woollard's] opinion as to the cause of the Patient's death, which the respondent believed was a dissection of the Patient's LM.
In paragraph 24 of his Response, Dr Woollard denied that any advice he gave to Mrs Brown was wrong.
The Board alleged that Dr Woollard gave the advice referred to at paragraph 28 of the Grounds:
1)knowing that the advice was wrong; and
2)for the purpose of misleading Mrs Brown as to the cause of Mr Brown's death.

Mrs Brown, Mr Brown's widow, made an application to AHPRA on 22 May 2012 (Exhibit V pages 146152). At question 21 of the complaint form she described what happened as follows:
…
Dr Woollard admitted to me directly after the incident that 'Something went terribly wrong' and that a section of plaque had occluded the main coronary artery.
…
At question 23 of the complaint form, Mrs Brown provided details of her discussion with Dr Woollard as follows:
[He] stated 'Something went horribly wrong' and 'Plaque was dislodged and occluded main coronary artery'.
In Mrs Brown's witness statement she stated:
When I was at Andi's house Dr Woollard rang. He said to me over the telephone:
Something has gone terribly wrong and he had gone into surgery he is having open heart surgery.
(Exhibit C page 390)
Mrs Brown subsequently spoke briefly to Dr Woollard. Dr Woollard told her:
[A] piece of plaque dislodged and blocked the artery.
(Exhibit C page 391)
In Mrs Brown's responsive statement dated 2 November 2015 (Exhibit D page 506 para 12) she stated:
I was certain that, at the meeting I attended with Dr Woollard, Dr Woollard did not mention that damage was caused to John's artery by any equipment. That is why I was shocked to read about a guidewire dissection when I receive the Coroner's Record of Investigation in 2008.
Dr Woollard's evidence was:
124.Once Mr Brown's interests had been dealt with and he had been transferred to the operating theatre, my first priority would have been to speak to his wife. I do not remember the details of the conversation but I would have explained exactly what happened and advised Mrs Brown of the nature of the emergency bypass surgery and the serious risk to Mr Brown and his survival.
125.I would have waited 1-2 weeks so that the immediate issues relating to the death of her husband had been dealt with before inviting Mrs Brown to come and see me. It is possible that Mrs Brown instigated that meeting before 1 contacted her, but I can't now remember. Mrs Brown did attend and during my conversation with Mrs Brown, I informed her that the problem was likely due to lifting of a plaque by the equipment used for the procedure. I explained that it was not possible to salvage the situation despite the efforts of Dr Hocking to re-open one branch of the vessel and Dr Alvarez's coronary artery bypass procedure.
126.I described to Mrs Brown the damage caused to the wall of the left main coronary artery during the procedure. I explained that this damage caused the occlusion of the artery and a massive heart attack from which Mr Brown died after the procedure.
127.I deny that I misinformed Mrs Brown as to the cause of Mr Brown's death, or that I gave her any other advice which was wrong.
(Exhibit N pages 427428 paras 124 to 127)
Dr Woollard's Coronary Angioplasty Report for Mrs Brown dated 15 December 2005 stated:
INDICATION         Ischaemic heart disease
PROCEDURE DETAILS
Under local anaesthesia via the right femoral, an XB 3.5 guide was passed to the left main. A BMW wire passed easily into the diagonal and circumflex but would not enter the LAD. The severe proximal diagonal stenosis was dilated with a 2x8 Voyager to. 18 atmosphere for 16 seconds. A 12x2.5 Taxus was applied from just beyond the origin of the diagonal across the lesion and the bifurcation. The stenosis was reduced to 0% and both distal branches remained widely patent.
Despite various curves in the BMW and change to a Whisper wire, the LAD itself was not entered. During manipulation of the guide catheter to try and obtain a better approach the left main dissected and occluded. The patient slowly deteriorated haemodynamically. Dr B Hockings passed a BMW back into the circumflex and ' applied a 3x12 Voyager to the circumflex stenoses. A 20x3 Taxus was then delivered from the left main well into the circumflex. There was a residual severe stenosis more distally in the circumflex. Two episodes of VF occurred during the procedure.
A balloon pump was inserted into the left groin during the emergency and the patient was transferred forthwith for bypass surgery. Aramine 0.5 mg was given early in the resuscitation.
CONCLUSION
1.    Successful diagonal angioplasty.
2.    Left main dissection.
(Exhibit V page 83)
The following day Dr Woollard sent a letter to Dr Saralam, Mr Brown's general practitioner which stated:
15 December 2005
Dr S Saralam
3 Halliburton Avenue
WARNBRO 6169
Dear Sacha
re:John BROWN DOB: 08-01-41
Your patient had one of his vessels dealt with by angioplasty today but during the second procedure, he developed a dissection of the left main coronary artery and has been transferred for emergency bypass surgery.
Sadly he died post operatively.
(Exhibit V page 84)
Although the letter is dated 15 December 2005, it must have been written or completed on 16 December 2005 because it notes Mr Brown's death. Mr Brown died on 16 December 2005.
The conversation between Dr Woollard and Mrs Brown took place nearly 13 years ago. Over that length of time memories fade.
The Tribunal is not persuaded that Dr Woollard did not give a frank and detailed account to Dr Saralam. Although Dr Woollard used the expression 'developed a dissection of the left main coronary artery' which might imply a gradual process, that is one of a number of interpretations that are open. Dr Woollard's Coronary Angioplasty Report makes a reference to the use of the wire and dissection and occlusion of the left main artery.
Even now, the experts cannot pinpoint the exact cause of the dissection and occlusion of the left main artery (see above).
There was expert evidence as to what would constitute sufficient information to be given to Mrs Brown as to the cause of Mr Brown's death.
Although both Drs Clugston and Russell were of the opinion that the information provided was inadequate and Dr Marmur's opinion was that he was uncertain as to its adequacy that does not provide a sufficient basis for a finding that Dr Woollard deliberately misled Mrs Brown.
The Tribunal is not satisfied to the requisite standard of proof that Dr Woollard gave the advice knowing it was wrong and for the purpose of misleading Mrs Brown.
Allegation 6 is not proved.

Orders

The Tribunal finds that the following five allegations against Dr Keith Victor Woollard made by the Medical Board of Australia pursuant to the Health Practitioner Regulation National Law (WA) Act 2010 are made out and that Dr Keith Victor Woollard is guilty of professional misconduct in that:
1.Dr Keith Victor Woollard made false representations to Dr Crawford and the Medical Advisory Committee in each of the letters to Dr Crawford from Dr Keith Victor Woollard dated 10 October 2005 and 14 December 2005, and that he knew that the representations were false and made them for the purpose of misleading Dr Crawford and the Medical Advisory Committee in an attempt to achieve accreditation to perform coronary angioplasty procedures at the Mount Hospital without any form of supervision;
2.Dr Keith Victor Woollard attempted to treat Mr Brown's complex multi-vessel coronary artery disease by means of coronary angioplasty when his training in the performance of such procedures was incomplete and when he was not sufficiently experienced in the performance of coronary angioplasty procedures in order to justify attempting that procedure without supervision;
3.Dr Keith Victor Woollard failed to ensure adequate anticoagulation during the procedure;
4.Dr Keith Victor Woollard failed to inform Mr Brown of the risks associated with treating his coronary artery disease by means of coronary angioplasty; and
5.Dr Keith Victor Woollard failed to inform Mr Brown of the option of referral to a cardiothoracic surgeon for consideration of a coronary artery bypass grafting procedure.
6.The Medical Board of Australia is to file and serve its written submissions on penalty and costs by 30 August 2018.
7.Dr Keith Victor Woollard to file and serve his written submissions on penalty and costs by 21 September 2018.
8.Subject to any further order of the Tribunal, the question of penalty and costs is to be dealt with entirely on the documents.

I certify that the preceding paragraph(s) comprise the reasons for decision of the State Administrative Tribunal.
JUSTICE J CURTHOYS, PRESIDENT
10 AUGUST 2018

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