Tsigounis v Medical Board of Queensland
[2005] QDC 103
•11 May 2005
DISTRICT COURT OF QUEENSLAND
CITATION: Tsigounis v Medical Board of Queensland [2005] QDC 103
PARTIES: TSIGOUNIS, Helen
Appellant
Against
MEDICAL BOARD OF QUEENSLAND
Respondent
FILE NO: 1136 / 04
DIVISION: Appellate PROCEEDING: Appeal from a decision of the Medical Board of Queensland
DELIVERED ON: 11 May 2005 DELIVERED AT: Townsville HEARING DATES: 23-25 August 2004, 31 January, 1-4 February, 7-11 February, 7 April 2005. Further written submissions received on 13 & 18 April 2005
JUDGE: C.F. Wall Q.C. ORDERS: 1. The appeal is allowed
2. The decision of the Medical Board of Queensland that the Appellant has not satisfactorily completed her internship is confirmed
3. The decision of the Medical Board of Queensland to cancel the registration of the Appellant is set aside and the Board is directed to extend the Appellant’s probationary conditions for a period of 1 year by requiring her to undertake all of the prescribed internship
4. The further hearing of the appeal is adjourned to a date to be fixed to allow further submissions as to the directions to be given to the Medical Board of Queensland under s.240(1)(d) of the Medical Practitioners Registration Act 2001 and the costs of the appeal and in this respect I direct that within 14 days of today the parties file and serve written submissions as to any further directions the Court should make and the costs of the appeal and that within 28 days of today the parties file and serve any submissions in reply.
CATCHWORDS: APPEAL – appeal from administrative body – Medical Board of Queensland – decision to cancel registration of medical practitioner – unsatisfactory performance of internship – onus and standard of proof – completion of internship – whether completed satisfactorily – meaning of satisfactory completion – nature of internship – instances of unsatisfactory performance of internship – relevance of psychiatric evidence – whether registration should be cancelled or internship extended – relevant considerations.
Cases referred to:
Briginshaw -v- Briginshaw (1938) 60 CLR 336 (FAA)
Pillai –v- Messiter (1989) 16 NSWLR 197 (CON)Legislation referred to:
Medical Practitioners Registration Act 2001 (Qld) ss. 9, 11, 15, 56, 57, 94, 239 & 240
Medical Practitioners Registration Regulation 2002 (Qld) ss. 3 & 4COUNSEL: Ms H. Tsigounis - self represented
Mr D. Tait S.C for the RespondentSOLICITORS: Phillips Fox for the Respondent Introduction
[1] This is an appeal against a decision of the Medical Board of Queensland (the Board) made on 23 March 2004 to cancel the conditional registration of the Appellant as a medical practitioner.
[2] The Board is established by s.9(1) of the Medical Practitioners Registration Act 2001 (the Act). It consists of the Chief Health Officer of the Department of Health and at least 6, but not more than 10, registered medical practitioners, persons having an interest in, and knowledge of, consumer health issues and one lawyer. A majority of the members must be registered medical practitioners. At least two of the registered medical practitioners must be nominated by the bodies the Minister for Health considers represent the interests of registered medical practitioners and at least one must be nominated by the governing bodies of educational institutions established in Queensland chosen by the Minister. The Minister may also nominate as members, persons who are not registered medical practitioners or persons having an interest in and a knowledge of consumer health issues. With the exception of the Chief Health Officer the members are appointed by the Governor in Council. See s.15 of the Act.
The functions of the Board include the following, (taken from s.11 of the Act):
(a)
assess applications for registration as a medical practitioner
(b)
register persons who satisfy the requirements for registration as a medical practitioner
(c)
monitor and assess whether registered medical practitioners comply with any conditions of registration
(d)
promote high standards of practice of the medical profession by registered medical practitioners
The Board is thus a specialist body and its decisions are deserving of weight.
Background
(a) Victoria
[3] The Appellant was admitted to the degrees of Bachelor of Medicine and Bachelor of Surgery, Monash University on 3 December 1997. On 7 January 1998 she commenced her internship at the Frankston Hospital, Victoria. Her internship was suspended on 16 October 1998 because the hospital did not believe she was then safe to practise as an intern and because of concerns about patient safety and her “lack of insight”. She was told of “continuing concerns about the quality of her patient care and her ability to practise safely” and that “all doctors working with her thought she was a danger to patients”. The complaints then made about her and her response to them bear a striking similarity to the present complaints (see the letter from Dr Eleanor Flynn, Director Clinical Services (Medical), Frankston Hospital, ex JO5 to ex 34 and “Proof of Evidence” paras 2-33, ex 54).
[4] At the request of the Medical Practitioners Board of Victoria she was examined by Associate Professor Fiona Judd, a psychiatrist on 27 January 1999. She reported that the Appellant did not “currently have any symptoms indicative of a major psychiatric disorder” but there was “evidence of significant personality problems” and that issues relating to her personality raised serious concerns regarding her “ability to take responsibility and function adequately as a medical practitioner.” The present complaints again raise such issues and concerns. Professor Judd saw the Appellant only once.
[5] Two other psychiatrists assessed her following her suspension. They were Dr Ranvir Sood (in November 1998) and Dr Michael Piperoglou (on 19 January 1999). Their reports were provided to the Medical Practitioners’ Board of Victoria and by the Board to Professor Judd. Dr Sood found “no evidence indicative of a major psychiatric illness” but thought the Appellant had “a personality sensitive to criticism”. He believed she should be allowed to complete her internship at a different hospital and should “have the benefit of a mentor in the initial stages”. Dr Piperoglou found “no symptoms or signs of mental illness”. The Appellant told Professor Judd that she was treated by Dr Sood on a weekly basis “for about 12 months in 1995” as a result of stress due to conflict with the Sub-Dean of Medicine when she was a 4th year medical student. He prescribed an antidepressant which she took on and off over the 12 months. Dr Sood did not mention his prior involvement with her in his report.
[6] On 18 February 1999 the Medical Practitioners Board of Victoria determined that she complete a further 6 months intern training with core rotations in general medicine and general surgery prior to being eligible for general registration. The Victorian Board also imposed the following conditions on her registration:
●that a mentor be appointed at her place of employment to provide support, counselling and feedback and three-monthly reports to the Board
●that she attend a psychiatrist approved by the Board with three-monthly progress reports
●that she be reviewed by a Board appointed psychiatrist when deemed necessary
●that the Board receive three-monthly work performance reports from the clinical supervisor
●She did not return to intern training in Victoria, because she says she could not find a hospital willing to employ her.
(b) Greece
[7] The Appellant then went to Greece with a view to obtaining registration as a doctor there. She trained in Athens from April 1999 until 2 August 2000 when she gained registration to practise medicine in Greece “without a speciality”. Between August 2000 and 1 November 2001 she trained in anaesthetics at two Athens hospitals. A reference from the Intensive Care Unit Manager at the second of these hospitals speaks highly of her describing her as “a very good doctor” with “appropriate evaluation of ICU patients’ problems”. She returned to Australia at the end of 2001.
(c) Townsville
[8] In early 2002 the Appellant telephoned Dr Barry Hodges, Assistant Director of Medical Services at the Townsville Hospital enquiring about the possibility of a job as a Resident Medical Officer. She “said she had done her training in Melbourne and had just returned from 3 years in Greece where she had worked in anaesthetics.” She was “very vague about her past history” and didn’t tell Dr Hodges that she had been suspended. He was prepared to employ her as he had a need of her particular skills as he perceived them. She commenced her employment at the hospital on 2 April 2002 as an RMO. She was not then registered in Queensland but had applied for general registration on 15 March 2002. She worked in ICU for some 6 weeks until she went on leave without pay whilst her application was being considered. Dr Hodges says she was “temporarily suspended whilst her registration was finalised” and that she had been employed “prematurely.” In considering her application the Board learned of her Victorian history. As a result the Board referred her for a psychiatric examination by Dr Donna Kippax. Dr Kippax assessed her on 23 April 2002 and diagnosed her as having a paranoid personality disorder.
[9] At its meetings of 28 May and 11 June 2002 the Board registered the Appellant, pursuant to s.57(3)(b) of the Act, as a general registrant with probationary internship conditions requiring her to complete 6 months of the prescribed internship with a minimum period of 12 weeks in surgery. The prescribed internship is usually for 12 months including at least 10 weeks practical experience and training in each of medicine other than emergency medicine, surgery and emergency medicine (see s.4 Medical Practitioners Registration Regulation 2002). The Victorian Board’s decision of 18 February 1999 is referred to in the decision of the Board that she be required to complete 6 months rather than 12 months internship in Queensland. Further conditions were imposed on her registration, summarised as follows:
●that she submit to the medical supervision of an experienced general practitioner and attend for treatment by a psychiatrist of her choice at a frequency determined by the treating psychiatrist, and
●that she work only in a supervised position approved by the Board
The general registration period is the period from 1 October in a year to 30 September in the following year. See s. 56(1) of the Act and s. 3 Medical Practitioners Registration Regulation 2002. The Appellant was thus registered as a “general registrant with internship and other conditions” from 28 May 2002 to 30 September 2002. She applied to renew her registration for another year on 23 September 2002 and it was renewed on the same conditions.
[10] After completing the prescribed internship a registrant is required to give notice to that effect to the Board and if the Board after reviewing an internship report from the hospital where the internship was undertaken is satisfied the registrant has satisfactorily completed the internship it may remove the probationary conditions, s.94(1)(a). For present purposes “probationary conditions” means internship conditions.
[11] The Appellant was employed, not as an RMO but as an intern, at the Townsville Hospital from 11 June 2002. Dr Hodges says the Board advised him of the conditions of her registration but did not provide any “background information why those conditions were imposed.” This was unfair to both the Appellant and the hospital.
[12] In December 2003 the Appellant applied for general registration without conditions i.e. for the removal of the probationary internship conditions of her registration. That application was supported by an Internship Report dated 19 December 2002 which pre-dated the completion of her internship. The report is signed by Dr Hodges “for the Director of Clinical Training” because the Director, Associate Professor Peter Keary was on leave. Dr Hodges said the report was prepared by the Department of Clinical Training and his job “was really just to sign off on it.”
The report assumes that the Appellant’s rotation in emergency medicine between the 19 December 2002 and 12 January 2003 would continue to be satisfactory. The report indicates satisfactory performance by the Appellant as follows:
Medicine: 11.6.02 to 14.7.02 5 weeks
Paediatrics/Medicine: 15.7.02 to 13.10.02 13 weeks
Emergency Medicine: 14.10.02 to 12.1.03 11 weeks
As to these weeks see also para [52].
[13] At its meeting of 14 January 2003 the Board “discussed the internship report” and, correctly, did not consider that the Appellant had satisfied the terms of her registration which required a minimum period of 12 weeks surgery and resolved to extend her probationary conditions for a period of three months and she was “required to complete a full term in a surgical discipline.”
[14] The Board then made no decision as to whether the appellant had satisfactorily completed the other aspects of her internship. These were not then considered. Surgery was the only term which she had not then completed. The other terms had been completed but no conclusion had been yet reached as to whether they had been satisfactorily completed. The Information Notice about the decision provided to the appellant is in part in the following terms:
“The Medical Board of Queensland at its meeting on 14 January 2003 decided to extend the probationary conditions of your registration for a further period of three months. During the extended period of the probationary conditions of your registration you must complete a full term in a surgical discipline.
The reasons for this decision are:
●Following consideration of the internship report from The Townsville Hospital regarding the internship undertaken by you, the Board is not satisfied that the required period of 12 weeks in surgery, as stated in the information notice on 21 June 2002, has been completed.
●The Board considers you will satisfactorily complete the internship during the extended period conditions.”
The second of these reasons was required to be reached by the Board otherwise it would have then been required by s. 94(1)(b) of the Act to cancel the Appellant’s registration.
[15] On 29 January 2003 Dr Hodges wrote that the Appellant’s performance as an intern at the hospital “has been considered satisfactory in all respects.” Attached to this letter was a copy of the Internship Report dated 19 December 2002 (see para [12]). In evidence Dr Hodges said he “stood by” this report and at the end of 2002 he considered the Appellant was “performing as an average intern … and could see no reason why she wouldn’t get the registration.” In retrospect he considers though that the Board was correct to require her to complete 3 months in surgery.
[16] The Appellant resigned from the Townsville Hospital on 12 May 2003 and on 16 May 2003 the Board received from her a Notification of Completion of Internship as a Medical Practitioner, in which she gave notice that she had completed her internship on 17th April 2003 and applied for the removal of the probationary internship conditions on her registration. Her application was supported by various documents including satisfactory intern assessment reports completed by various doctors with whom the Appellant had worked.
Complaints about the Appellant
[17] At about this time the Board became aware of certain complaints about the Appellant’s work performance at the Townsville Hospital. During March and April 2003 complaints were made to Mr Brian Pugh, Acting Director of Medical Services at the Townsville Hospital. His statement (in ex 1) is illustrative of the apparently spontaneous nature of these complaints and the concern expressed by doctors and nurses about the ability of the Appellant to competently and safely practise medicine. On 15 and 16 May 2003 the Board’s medical advisor, Dr Yuen, visited the Townsville Hospital and investigated these complaints. Her report to the Board is ex JO17 to ex 34. It is factually incorrect in a number of respects e.g. the meningitis patient was not a child and a lumbar puncture was not performed (see also the letter by Dr David Cooksley to the Board dated 22 October 2003, ex DGC3 to ex 5). These do not however affect the overall tenor of the report.
[18] In a letter to the Board dated 20 May 2003 Professor Keary advised that the Appellant “had completed terms in Medicine, Emergency Medicine and Paediatrics by 12th January” (with formal reports showing a pass) but had worked only eight fractured weeks in surgery and final reports for surgery had not yet been received. He considered her surgical attachment “less than satisfactory” and believed she had “not completed the requirements for registration and should be required to do further training.”
[19] In a second letter dated 30 May 2003, Professor Keary advised the Board in the following terms.
“I have received a report from one of the Registrars who Helen worked with who was very dissatisfied with her work and this is Dr Sharmula Balanathan and I enclose a written Intern assessment form from her which suggests she is not ready for unsupervised work.
All of Helen’s other reports actually pass her, this includes reports from various surgical Registrars.
I should point out however, that at no time during her assignment did she spend more than two weeks with any one unit, and for the most part, these people were not really able to assess her properly.
It is mainly for this reason that I am unhappy about the term that she did. This, of course, was not her fault, there was an administrative upset and I think that Dr Hodges, the Deputy Director of Medical Services failed to recognise that she had yet to do a full surgical term and the only one available at the time was the relieving one.
Nevertheless, I have had several verbal reports from people who are unhappy with her work in Surgery and there are written reports of less than satisfactory clinical behaviour.
Therefore, reluctantly I must state that in my opinion at least, Dr Tsigounis has not yet completed her Internship in a satisfactory manner.”
[20] At its meeting of 10 June 2003 the Board resolved that it was not satisfied that the Appellant had satisfactorily completed the internship program or could satisfactorily complete it during the prescribed period. The Board further resolved that the Appellant be given a Show Cause Notice inviting her to make a submission as to why the Board should not cancel her registration. She was given such a Notice and she responded to it.
[21] The Appellant’s registration expired on 30 September 2003 before the Board further considered the matter and she had not applied to renew it. There was therefore in fact no registration to cancel. The Board recognised this at its meeting of 11 November 2003. On 16 December 2003 the Appellant applied for the restoration of the registration. At its meeting of 27 January 2004 the Board resolved that her “general registration be restored effective 27 January 2004 subject to conditions, including probationary conditions attaching to the registration immediately before its expiry”.
[22] At its meeting of 10 February 2004 the Board considered that the Appellant “was performing below the standard expected of an intern, appeared to have little insight into her performance and limitations and did not have the skills necessary to practise medicine in a clinical setting”. The Board also considered that “she was not capable of completing an internship satisfactorily”. It resolved that it was not satisfied that she “has satisfactorily completed an internship programme” and that she be given a show cause notice inviting her to make a submission as to why the Board should not cancel her general registration. The Show Cause Notice is ex JO35 to ex 34 and is dated 16 February 2004. The Appellant’s response is ex JO36 to ex 34 and is dated 12 March 2004.
[23] The Board considered the matter at its meeting of 23 March 2004 and the minutes of that meeting are in the following terms:
“The Board considered the following information:-
(a)submission from Yarra Legal, lawyers on behalf of Dr Tsigounis, received by e-mail on 12 March 2004;
(b)show cause notice dated 16 February 2004;
(c)memorandum dated 9 February 2004 from the Assistant Registrar;
(d) submission dated 13 August 2003 and 10 November 2003 from Holding Redlich, lawyers on behalf of Dr Tsigounis in response to the Board’s show cause notice dated 11 June 2003;
(e)show cause notice dated 11 June 2003 and accompanying documents;
(f) information notices dated 21 June 2002 and 28 January 2003 and the Board’s letter of 29 January 2003 regarding a typographical error in the 28 January 2003 Information Notice;
(g) 38 statements from employees and former employees of The Townsville Hospital, copies of which had been supplied to Dr Tsigounis.
In the Board’s view, the submissions on behalf of Dr Tsigounis failed to provide material sufficient to refute the allegations made in the witness statements referred to in (g) above. In the opinion of the Board, Dr Tsigounis’ responses to adverse material often did not go beyond a claim that she did not recollect the events described, or that the evidence was too vague or that she was not informed of adverse events at the time.
The Board noted that certain information in the statements of employees or ex-employees of the Townsville Hospital was corroborated, and in relation to significant events the Board preferred the evidence of those witnesses to the assertions by or on behalf of Dr Tsigounis where the former conflicted with the later.
In the Board’s view, Dr Tsigounis did not provide it with any, or any sufficient, evidence to show that she can safely and competently practise unsupervised.
Instances of Dr Tsigounis’ practice at the Townsville Hospital which the Board deems unsatisfactory include but are not limited to:-
1. An incident described by Dr Balanathan in which Dr
Tsigounis caused potassium to be added to an
intravenous drip at a time when the patient’s blood level
was already high. In relation to this incident, the Board
prefers the evidence of Dr Balanathan, supported as it is
by the statement of Ms Rutherford;
2.Two incidents concerning the cannulation of child patients in contravention of relevant Townsville Hospital policy. While Dr Tsigounis’ claims that she abided by the Townsville Hospital policy and the instructions of her superiors after one such incident there is evidence - which the Board accepts - that Dr Tsigounis disregarded or departed from Townsville Hospital policy in a second such incident. The evidence of the second such incident is contained in the statements of Ms Buldo, Ms Maloney and Dr Elcock;
3. Dr Tsigounis’ failure to follow the policy of the Townsville Hospital’s Emergency Department relating to the review of patients by senior staff, as evidenced by the statements of Drs Gelhaar and Jessica Lucas - which the Board accepts - in relation to a patient diagnosed with possible meningitis;
4. An incident related by Dr Peter Lucas, neurosurgical registrar, whose statement the Board accepts. According to Dr Lucas, Dr Tsigounis, while acting as night call resident, made what he considers to be two serious errors with respect to a female patient who had undergone a lumber laminectomy on the previous day. It was essential, in Dr Lucas’ view, that the said patient should have received appropriate fluids (either orally or intravenously). However, during Dr Tsigounis’ period of duty, and on her instructions, a diuretic drug was administered to this patient, creating a serious risk of dehydration and renal failure.
On the whole of the evidence before the Board, the Board is of the opinion that the action proposed in the show cause notice issued on 16 February 2004 should be taken, on the basis that Dr Tsigounis has not completed the requisite period of surgery at the Townsville Hospital to the satisfaction of the Board.
The Board finds that the professional performance of Dr Tsigounis at the Townsville Hospital raises serious concerns about her ability to practise medicine without undue danger to members of the public who may come under her care.
Further, the Board does not consider that Dr Tsigounis can achieve the necessary level of competence to practise unsupervised within a reasonable period of time, without undue risk to members of the public and without unreasonable burdens being placed upon those who might be given the task of supervising her.
RESOLVED that:-
(i)pursuant to Section 88 of the Medical Practitioners Registration Act 2001, the Board:-
(a)believes the ground exists to cancel Dr Tsigounis’ registration; and
(b)believes that cancellation of her registration is warranted;
(ii)pursuant to Section 88(3) of the Act, Dr Tsigounis’ registration is hereby cancelled;
(iii)the reasons for the decision are:-
(a)the Board does not consider that Dr Tsigounis has satisfactorily completed internship requirements in accordance with her conditional registration in that she has not reached the necessary level of competence to practise unsupervised.
(b)the Board does not consider that Dr Tsigounis can achieve the necessary level of competence to practise unsupervised;
(c)the Board does not consider that Dr Tsigounis has the ability to practise medicine without undue danger to members of the public who may come under her care;
(iv)an information notice be given to Dr Tsigounis;
(v) pursuant to Section 257(4) of the Act, foreign regulatory authorities, including those of the United Kingdom and Greece, be advised of this decision, after expiry of the period in which Dr Tsigounis may appeal;
(vi) if Dr Tsigounis lodges an appeal against the decision, foreign regulatory authorities shall only be advised should the appeal be dismissed.”
This is the decision that the Appellant has appealed against.
[24] Section 239(2) of the Act provides that the appeal is by way of rehearing, unaffected by the original decision, on the material before the Board and any further evidence allowed by the Court. In deciding the appeal the Court has the same powers as the Board, is not bound by the rules of evidence and must comply with natural justice. See s.239(1). The powers of the Court in deciding the appeal are contained in s.240.
[25] The 38 statements from employees and former employees of the Townsville Hospital which were considered by the Board are in ex 1, documents B3 - 40. Affidavits by the authors of most of those statements were tendered. They are exhibits 2-30. All except the authors of exhibits 17, 19, 21, 24 and 30 were required for cross-examination and gave evidence. Additional evidence was also led by the Board. The Appellant gave evidence and called witnesses.
Onus Of Proof
[26] During the hearing I ruled that the onus was on the Board to uphold the decision under appeal and that there was no onus on the Appellant to establish that the decision was wrong.
Standard of Proof
[27] As to the standard of proof the Appellant submitted that it should be in accordance with Briginshaw v. Briginshaw (1938) 60 CLR336. The Board submitted that it should be the balance of probabilities simpliciter.
[28] The relevant authorities are summarised in the Appellant’s written submissions. The matters that persuade me that the standard of proof should be as submitted by the Appellant are these
●Serious allegations of professional incompetence are levelled against the Appellant
●If resolved adversely to the Appellant they are likely to impact severely on her standing, reputation, career and livelihood.
●No greater penalty could be suffered by a medical practitioner than deregistration
●If the findings made by the Board stand, the Appellant will find it extremely difficult if not impossible to obtain future employment as an intern and her registration as a medical practitioner in Greece would be at risk
[29] I recognise that the degree of satisfaction may vary according to the gravity of the fact to be proved and that it could be argued, for example, that the normal standard of proof should apply to whether the Appellant has completed 12 weeks surgery and the higher standard to whether she has done so satisfactorily or the normal standard of proof should apply to both of these aspects and the higher standard to whether her registration should be cancelled. In my view that would be somewhat artificial when the graveman of the case against the Appellant is a failure to complete her internship to the satisfaction of the Board because incurable incompetence.
[30] The authorities referred to by the Appellant variously describe the Briginshaw standard of proof as “reasonable satisfaction”, “comfortable satisfaction”, “more than mere negligence”, “higher than mere balance of probabilities”, “something more than a mere mechanical balance of probabilities”, “a very high standard of probability” and “a high standard of proof.” In my view these are all different ways of saying the same thing.
[31] In applying the Briginshaw standard I also recognise, as the authorities referred to by the Appellant emphasise, that the matter should not be approached with hindsight or by the drawing of indirect inferences and that the evidence relied on by the Board must be precise and cogent, not loose and inexact, and the allegations should be approached cautiously. I also recognise that “mistakes can happen to the most conscientious professional person” (Kirby P., Pillai v Messiter (1989) 16 NSWLR 197 at 202.)
Issues on the Appeal
[32] Section 94(1) of the Act is in the following terms :
“94(1) After reviewing the internship report or supervised practice report and any information or document about the registrant obtained under section 93, the board must decide –
(a) if the board is satisfied the registrant has satisfactorily
completed the internship or program – to remove the
probationary conditions; or(b)otherwise –
(i) to cancel the registrant’s registration under division 6; or
(ii) to extend the probationary conditions for a period of not more than 1 year, by requiring the registrant to undertake a part of the internship or program, if the board considers the registrant will satisfactorily complete the internship or program during the period.”
[33] In relation to whether the Board concluded that it was not satisfied that the Appellant had satisfactorily completed her internship generally or only the surgery component the minutes of the meeting of 23 March 2004 (see para [23]) are somewhat equivocal but on balance I am satisfied the decision reached was in relation to her internship generally and not just the surgery component. This is also apparent from the Show Cause Notice and the accompanying evidence statements. Further, of the particular incidents highlighted by the Board one occurred in paediatrics (the second cannulation incident) and two in the emergency department (the second cannulation incident and meningitis patient).
[34] The Board’s conclusion that she “had not completed the requisite period of surgery at the Townsville Hospital to the satisfaction of the Board” was expressed to be based on “the whole of the evidence” before it whereas in fact it could probably only have been based on the surgical evidence. The “whole of the evidence” included the evidence in relation to her surgery rotation and also evidence of complaints made when she worked in Paediatrics, (September and October 2002), Emergency (late 2002, January 2003) and Cardiology (second half of April 2003).
[35] In its reasons for its decision the Board concluded that it “does not consider that Dr Tsigounis has satisfactorily completed internship requirements in accordance with her conditional registration in that she has not reached the necessary level of competence to practise unsupervised.”
That conclusion was most probably reached relying on “the whole of the evidence”, including the cardiology complaints.
[36] The Appellant’s work in medicine, paediatrics, emergency medicine and surgery was performed as part of her internship. Her work in cardiology was not required for completion of her internship but was nevertheless work performed by her as a doctor subject to internship and other conditions.
[37] The appeal involves a consideration of the Appellant’s work in paediatrics, emergency medicine and surgery and a determination of whether she has completed 12 weeks surgery and whether her internship as it relates to paediatrics, emergency medicine and surgery has been satisfactorily completed. The parties agreed with this course. They also agreed that if either issue was resolved adversely to the Appellant it was then necessary to consider whether the Board was correct to cancel her registration rather than extend her internship.
[38] If it is decided that she has not satisfactorily completed her internship all of the evidence - paediatrics, emergency medicine, surgery and cardiology - is also then to be considered on the s.94(1)(b) issue of whether her registration should be cancelled or her internship extended to enable her to satisfactorily complete it. The Board could only extend her internship if it considered she would satisfactorily complete it within the extended period.
[39] Relying on all of the evidence the Board effectively concluded that it was not satisfied that she would satisfactorily complete an extended period of internship in which case the only course open to the Board was to cancel her registration. The relevant findings/reasons of the Board for this conclusion are the following:
“The Board finds that the professional performance of Dr Tsigounis at the Townsville Hospital raises serious concerns about her ability to practise medicine without undue danger to members of the public who may come under her care.
Further the Board does not consider that Dr Tsigounis can achieve the necessary level of competence to practise unsupervised within a reasonable period of time, without undue risk to members of the public and without unreasonable burdens being placed upon those who might be given the task of supervising her.
The Board does not consider that Dr Tsigounis can achieve the necessary level of competence to practise unsupervised.
The Board does not consider that Dr Tsigounis has the ability to practise medicine without undue danger to members of the public who may come under her care.”
[40] The minutes of the Board meeting of 23 March 2004 indicate that satisfactory completion of internship (see s. 94(1)(a) of the Act) requires a conclusion that the individual has demonstrated the ability to safely and competently practise medicine unsupervised without undue danger or risk to members of the public who may come under his/her care and I am content to proceed on that basis. No argument to the contrary was addressed to me. See also para [19].
Internship
[41] Internship is an extremely important practical learning year. Interns make mistakes. The doctors and nurses who gave evidence conceded this and recognised that the Appellant was an intern:
●Dr Sharmila Balanathan didn’t expect an intern to know everything and said “It’s not unusual for interns to make mistakes. That’s part of the learning process.”
●Dr Katrina Gelhaar said that generally most problems were “resolved with good communications with my resident. I pointed out the mistake and we moved on. Hopefully this discussion (would) be used as an educational experience” without the need for any formal complaint.
●Nurse Gayle Doe felt the Appellant was “very antagonistic against any attempts to bring errors to her attention”.
●Nurse Rachel Neil said that interns new to the cardiac unit made mistakes about cardiac drugs and she would initially make allowance for this; normally the interns were receptive to advice but the Appellant was not.
●Dr Keary said it was common for interns to make mistakes “and hopefully they tend to learn from them and admit their mistakes”. Most do this.
●Professor Rodney Judson accepted that drug “transcription errors can occur”. He said “we will all make mistakes but we must learn from them and address them. When interns are assessed we are asked by hospitals (about) their response to criticism or suggestions. It is a very important aspect of their behaviour that they can acknowledge that what they did was not appropriate and address it appropriately”.
●Professor Patrick Dewan said that all doctors made mistakes and errors of judgment and that interns should be guided through them; they are still in training and it’s not expected that they are able to do everything perfectly which is why they are under supervision.
●Dr Arthur Papagelis said it would be worrying if an intern did not learn from and understand the significance of a mistake and make sure it didn’t happen again. He said “it’s extremely important that you learn. The mistake isn’t so important so long as you learn from it and it wasn’t made in a way that could be held incompetent”. It is important that interns “approach their superiors with an open and receptive attitude to learning … and being prepared to be corrected”. A contrary attitude could “result in more complaints than you would otherwise expect”. It is not unusual for “rushed” interns to make mistakes.
●Dr Simon Rosenblum said that interns must be able to learn from mistakes and “although some clinical skills are expected of an intern, what is more important is a preparedness to follow (the) advice of seniors.” He agreed that “often nurses know a great deal more about practical medicine than interns”. He well summarised the position of an intern as follows (T1169):
“We have the most inexperienced doctors in the system sleeping the least having to make important decisions about doses possibly being very tired and then perhaps someone says a word that they don’t like or a patient is perhaps a little bit confrontational or whatever and then suddenly you’re then put in a situation under pressure, it’s very very difficult.”
He said interns should do what a registrar tells them “unless they have a very solid reason for not wanting to do it. It is medico-legally indefensible if they don’t follow instructions unless they have a good reason for it.” (T1170)
12 Weeks Surgery?
[42] The hospital records - reproduced in exs 50 & 50A - leave much to be desired and I have some reservations about their accuracy and reliability. Doctors did not always work as earlier rostered or at all and the base document for each pay period (PP) - the time sheet - is completed by the employee and is often incomplete leaving it for others to discern what work the employee may have performed in that pay period. Ms Debra Davis, the hospital’s manager of payroll services gave evidence and I accept what she said about what the records mean. She did not though have personal knowledge of the work performed by employees and when they performed that work. A pay period is a fortnight and pay calculations are based on a time sheet submitted by the employee for each week in each pay period.
[43] The board accepts that the Appellant worked in surgery for “probably” 10 weeks only. Those weeks are, by reference to pay periods and weekly commencing dates:
PP158-114 October 2002
PP158-221 October 2002
PP166-210 February 2003
PP167-224 February 2003
PP168-13 March 2003
PP168-210 March 2003
PP169-117 March 2003
PP169-224 March 2003
PP170-131 March 2003
PP170-27 April 2003
[44] The Appellant contends that she also worked in surgery in the weeks commencing 3 February 2003 (PP166-1) and 17 February 2003 (PP167-1).
[45] There is no time sheet for PP166-1. Exhibits 50 & 50A are to the effect that the Appellant was rostered for work in the emergency department which is not surgery and that the department “costed” was the emergency department. In the past, according to Dr Hodges, sometimes the Board accepted emergency medicine as surgery but that is not the case here. The Appellant said (T1008) that her emergency rotation finished on 6 February 2003 and she then “started in surgery” on that date. If that is correct she would have started half-way through a week. Notwithstanding reservations about the reliability of a rostered work entry I am satisfied she did not work in surgery during this week.
[46] For PP167-1 the Appellant was rostered as RMO Night. The time sheet is incomplete and does not record the department she worked in. Ms Davis said she worked RMO Internal Relief which is not surgery. The Appellant concedes that RMO Night “cannot be interpreted as surgery”. The roster is not a reliable indicator of work actually performed. Dr Peter Lucas was the neurosurgical registrar at the hospital at this time. His complaints about the Appellant relate to events which occurred on 20 February 2003 when the Appellant was the night call surgical resident. Dr Lucas said “there is an on-call surgical resident for the three surgical wards”. Dr Hodges said that the complaints were “during (the Appellant’s) surgical rotation”. In these circumstances I am satisfied that the Appellant did work in surgery during this week.
[47] Even though the Appellant’s internship at the Townsville Hospital formally commenced on 11 June 2002 it appears she may have been on leave from then until the week commencing 1 July 2002. There are no time sheets for this period and she was not paid. I cannot accept her written submissions that in the week commencing 10 June 2002 (PP149-1) she worked in orthopaedics which would qualify as a week of surgery. The Appellant’s work summary sent by Mr Pugh to the Board (ex BJP 6 to his statement, ex 1) is I think inaccurate. It records that the Appellant worked in orthopaedics in this week and is most probably based on where she was initially rostered to work. Exs 50 and 50A record the same unit but indicate she was not paid for this week. The Appellant’s evidence about whether she was in fact on leave at this time (T982-990) is quite confusing. Exhibit JO13 to ex 34 (the Internship Report by Dr Hodges) suggests she worked in “Med. Onc. and Medicine” from 11 June - 14 July 2002 but that I think is an error and is based on what she was rostered to do rather than what she in fact did. Exhibit 50 in fact records that she was rostered in orthopaedics in the week commencing 10 June 2002 (PP149-1). In her cross-examination of Dr Keary (T550-556) she put it to him that she was on leave from 29 April - 8 July 2002. In her cross-examination of Dr Hodges (T503) she seemed to suggest she returned to the hospital in “early July 2002.”
[48] In her written submissions she also argues that she worked in surgery in the week commencing 7 October 2002 (PP157-2). Exhibits 50 & 50A indicate she was rostered for “Med 1 & Remote Relief G Dance” in the emergency department. The time sheet (completed by the Appellant) records she worked in the emergency department. The evidence of Ms Davis, which I accept, is that she was relieving for Dr G Dance who was doing a medical, not surgical, rotation.
[49] The evidence satisfies me that she did not work in surgery in PPS149-1 and 157-2.
[50] The evidence establishes 11 weeks only and not 12 weeks surgery as required by the Appellant’s internship conditions. In these circumstances the Board was correct to conclude that the Appellant had not completed the requisite period of 12 weeks surgery.
[51] Dr Keary’s concession in cross-examination that it was “possible” that the Appellant “did do 12 weeks of surgery” was based on his state of knowledge when he wrote his letter to the Board dated 29 August 2003 and was expressed without the benefit of an examination of the hospital records.
[52] If I am correct about the week the Appellant worked in surgery the number of weeks attributed to Emergency Medicine in para [12] should be reduced by two. An adjustment may also be required to the 5 weeks attributed to Medicine to take account of the time the Appellant was on leave.
[53] The Appellant’s position is not helped by what she told her former solicitors. Holding Redlich in their letter to the Board dated 13 August 2003, (paras 2.1 and 2.2 ex JO24 to ex 34) said:
“Our client in fact completed 10 weeks in surgery…The fact that our client failed to complete 12 weeks in surgery was the result of an administrative error…”
Yarra Legal in their letter to the Board, dated 12 March 2004, pages 6, 8 and 31 (ex JO36 to ex 34) said:
“Our client…had completed 10 weeks (of surgery)… We submit that our client’s 10 weeks (surgery) term … Our client, through no fault of her own, was unable to comply with the Board’s conditions as to completion of 12 weeks surgery… In addition to the 10 weeks worked by our client in various surgical roles from October 2002 to 6 March 2003 … The surgery rotation which Dr Tsigounis did undertake (10 wks) …”
To be fair to the Appellant when these letters were written she probably did not have access to hospital records such as exs 50 and 50A.
[54] In para 23 of her affidavit, ex 56, the Appellant says she completed 2 weeks surgery in the period 28 October 2002 – 12 January 2003. This is contrary to the case she presented at the hearing of the appeal and is not supported by the hospital records.
[55] If all that was preventing the Appellant gaining unconditional registration was one uncompleted week of surgery I would be inclined to the view that the many weeks she worked in emergency medicine would qualify. Dr Hodges said (T504) that in the past and during the Appellant’s employment at the hospital the Board was on occasions prepared to accept emergency medicine as surgery.
[56] It is necessary though to next determine whether the Appellant satisfactorily completed 11 weeks surgery or 12 weeks should I be wrong in relation to PP166-1.
Satisfactory Surgery?
[57] The relevant dates are 14-27 October 2002 and 10 February – 13 April 2003. I will deal separately with each incident relied upon by the Board.
(a) Surgical ward 20 February 2003
(i) Lumbar laminectomy patient – diuretic incident 20 February 2003
[58] This is the fourth “instance of unsatisfactory practise” referred to by the Board at its meeting of 23rd March 2004. See para [23].
[59] I accept the evidence of Dr Peter Lucas who was the neurosurgical registrar at the time. Had the Appellant personally reviewed the patient as she should have done (rather than prescribing the diuretic over the telephone) it would have been apparent to her that it was not appropriate to prescribe a diuretic and that by doing so the patient was at risk of dehydration and renal failure. The Appellant also made no notes on the patient’s chart. When the patient was reviewed by Dr Lucas during his morning round her urine output had dropped to nil and she was very dehydrated; she required 7 litres of fluid intravenously. Her urine volume returned progressively over the morning and the pain that she described as “being throughout her whole body” resolved. The prescription of a diuretic for this patient could never have been appropriate.
[60] In her affidavit, ex 56 para 184, the Appellant says she reviewed the patient and determined it was appropriate to prescribe a low dose of Lasix but did not record this in the patient’s notes at the time. In my opinion she has endeavoured to justify events by manufacturing a scenario to support the prescription of Lasix. Had she properly understood the patient’s clinical situation she would not have prescribed Lasix.
(ii) Atrial fibrillation incident
[61] This happened on the same night shift as (i). Again I accept the evidence of Dr Peter Lucas. What the Appellant did was inappropriate. The Appellant did not, but should have, first attended and reviewed the ECG and the patient before prescribing a drug rather than making enquiries over the phone and then prescribing Digoxin. Digoxin was not appropriate in the circumstances. In para 185 of her affidavit, ex 56 the Appellant says:
“I do not recall this incident … I can say that it is not my usual practice to rely a nurse’s interpretation of an ECG over the phone prior to prescribing Digoxin. My usual practise would have been to view the ECG results myself, determine whether or not the atrial fibrillation was transient or ongoing and assess the rate. Only after being satisfied from the information that Digoxin was warranted, would I have prescribed it.”
In fact the Appellant did not view the ECG results herself before prescribing Digoxin but asked the nurse to read out the result displayed on the top of the ECG over the phone.
(iii) The Appellant’s response
[62] Dr Lucas was sufficiently concerned by (i) and (ii) that he raised what he considered “the inappropriate management” of these patients with Dr Hodges later that morning. He didn’t then know the name of the night resident. He suggested that the doctor’s “performance perhaps needed review and that further training seemed appropriate.” In evidence he said (T487):
“My concern was that this seemed to be a systematic error rather than a singular one-off thing.”
[63] Dr Hodges says he discussed the incidents with the Appellant and she satisfied him that she had actually seen the patients but belatedly because she had been busy with other patients that night. I am unable to accept this explanation. Dr Hodges took no further action.
[64] The next day the Appellant rang Dr Lucas complaining about what he had done and that he had not first spoken to her. She “disputed” his concerns about her management of the patients. She refused to concede that her treatment of the first had been flawed in any way and suggested that Dr Lucas was “deficient in (his) management of the patient.” She said she had managed the second patient appropriately and again questioned Dr Lucas’ management strategy. Dr Lucas was concerned about “her inability to accept constructive criticism and her poor clinical knowledge.” In cross-examination of Dr Lucas the Appellant maintained her stance that her treatment of each patient was appropriate.
[65] I am satisfied that both incidents evidence unsatisfactory performance as an intern on the part of the Appellant.
(b) Vascular Surgical Ward 24 February – 9 March 2003
[66] The Appellant worked with Dr Sharmila Balanathan, surgical registrar, in this unit for 2 weeks from 24 February – 9 March 2003. This period post dates that covered by the “satisfactory” progress report on the Appellant completed by Dr Hodges which is exhibited to his affidavit, ex 3.
[67] Dr Balanathan had “grave concerns about her performance” and, not without anxious consideration and time for reflection, failed her as an intern. See her Intern Assessment Form dated 28 May, ex 4. Dr Hodges believes the problems between them “commenced due to a personality conflict” but I think it was deeper than that. I consider Dr Balanathan had a genuine basis for her concerns about the Appellant. I prefer her evidence about their relationship and the Appellant’s ability to work satisfactory to that given by the Appellant.
[68] An Intern Assessment Form “is a tool to assess interns on their professional performance.” Dr Balanathan reported that the Appellant
●required substantial supervision and was not a reliable or dependable resident
●was not progressing satisfactorily towards full registration, and
●was not up to the required standard.
In the 23 different categories of knowledge, skills and professional attributes she assessed her as less than satisfactory in all except one. Her assessment for the various categories was:
● Satisfactory – 1
●Just adequate – 13
●Requires some assistance and supervision – 7
●Requires substantial assistance and extensive supervision and
guidance - 2
[69] The two categories in which she recorded the lowest assessment possible were “clinical judgment” and “reliability, dependability and efficiency.” In arriving at this assessment Dr Balanathan felt the Appellant’s “clinical performance” was “poor and she did not accept constructive feedback when offered.” The evidence supports this assessment. Dr Balanathan said the Appellant is the only intern she has ever failed.
[70] In her letter dated 4 November 2003 Dr Balanathan outlined her observations of the Appellant. She amplified these in her affidavit, ex 4. I accept what she says. She impressed me as having been firm but fair and I do not consider the demands she placed on the Appellant to have been so unreasonable that the Appellant was justified in disregarding them. Likewise I cannot accept Professor Patrick Dewan’s opinion that Dr Balanathan “bullied” the Appellant and that her complaints about the Appellant are due to “personal conflict.” Professor Dewan has accepted the Appellant’s version of events which I have rejected and also appears to have latched onto a passing remark of Dr Hodges.
[71] Much time on the hearing of the appeal was spent on the absence of the Appellant for afternoon ward rounds with Dr Balanathan on 24 and 25 February 2003. See para 4 of her letter, ex SB2 to ex 4 and paras 10.2 and 10.1.11, ex 4. I prefer Dr Balanathan’s account of what was said in the phone call on 25 February 2002. The Appellant’s version was made up to suit her own purposes in an attempt to justify unsatisfactory conduct; she was manipulating the facts to suit herself. The Appellant said Dr Balanathan ordered her back to work. Dr Balanathan denied this. in cross-examination of Dr Balanathan the Appellant said (T230):
“I came back to the ward and carried on with the ward round, completing those tasks until 8 p.m. And I’m quite happy to produce the time sheet for that if need be.”
The time sheet is in ex 50 and it shows that the Appellant finished work at 4 p.m. and did not return. In her affidavit (ex 56 para 64) the Appellant said she phoned Dr Hodges and he told her not to go in and “relying on this advice I did not return to the hospital.” See also page 11 of ex JO36 to ex 34. Dr Hodges said (T513) that he advised her that she should go back.
Dr Hodges sent an email to some staff seeking their views and in it said that the Appellant had been “ordered back to the ward.” This was based on what the Appellant told him which is not what in fact happened. Dr Rossato’s response is based on this incorrect factual premise. I find that the Appellant knew she should wait and didn’t. The advice to her by Dr Hodges – “Obey your registrar” – was sensible and correct and the Appellant should have known that. Dr Hodges conceded that by itself this type of conduct would not warrant dismissal. A major concern of Dr Hodges was the payment of overtime. The Appellant to this day maintains that Dr Balanathan was in error and that she did nothing wrong. A week later Dr Balanathan told Dr Hodges that the Appellant “was making a greater effort to comply with her required duties.”
[72] The “satisfactory” Work Progress Reports on the Appellant by Dr Hodges for the two periods 1 – 31 December 2002 and 1 January – 28 February 2003 were not based on personal knowledge and his judgment that the Appellant had performed satisfactorily was made “on the basis at that point in time I’d heard nothing to the contrary.” Dr Hodges ceased his employment at the hospital in mid March 2003.
[73] Dr Balanathan made a number of specific complaints about the Appellant’s work in her unit. These are dealt with in her affidavit and in her evidence. I accept what she says. I thought her recollection of events and meetings was much better than the Appellant’s. Summarised they are:
●Her failure to advise of a patient’s abnormal blood coagulation profile, her failure to investigate the cause or seek advice about how to do so and her apparent inability to understand the implications of an abnormal profile on surgery with the result that the operation had to be postponed. This is compounded by her insistence that Dr Balanathan should have used a particular anti-coagulant and was wrong not to when the use of such a drug could in fact have caused complications
●Her failure for some hours or at all to carry out tests on a patient as instructed including an ECG, chest x-ray and ABG. When done she failed to advise Dr Balanathan of grossly abnormal ABG results leading to a delay in addressing the abnormality, ICU assistance and adverse consequences for the patient. She was not apologetic nor did she appear to realise the seriousness of the situation or that the result was so abnormal. I cannot accept her account (Holding Redlich letter 10 November 2003, para 10.3, ex JO26 to ex 34) that she paged Dr Balanathan when she received the abnormal results but she was not available
●Her failure to insert an IV cannula in a patient as instructed so that anti-emetics could be administered. It was inserted some 6 hours later by a nurse; she did not respond to her pager during this period and went to the bank.
●Ordering potassium for a patient before an operation (when she had been instructed to give the patient only fluids and fast him) in circumstances where there was no valid reason to do so and it was contra-indicated by high existing potassium levels and existing kidney failure. (This is first “instance of unsatisfactory practise” referred to by the Board on 23 March 2004. See para [23].) When queried the next day she denied doing so saying “I didn’t do it. It was a mistake by nursing staff” or “I didn’t give the order. I’m sure I did not say to add potassium. The nursing staff must have just added it.” I do not believe her. I am satisfied from the affidavit of Nurse Susan Rutherford (ex 12) (see also her statement to Mr Pugh dated 23 August 2003) that the Appellant gave the order over the phone and that the nurses confirmed it with her. Nurse Rutherford was not required for cross-examination. Likewise I do not believe her explanation in para 141 of ex 56. It was her responsibility to first check the patient’s blood results.
[74] During the 2 weeks the Appellant worked with her Dr Balanathan “became increasingly concerned about her reliability and skills” (ex 4 para 13.2.4). At the end of the 2 weeks both met with Dr Hodges and the “pros and cons” of the Appellant’s performance were discussed. After that meeting Dr Balanathan privately told Dr Hodges of the grave concerns she had about the Appellant’s performance. A few weeks later she told Professor Keary of her “grave concerns about her clinical skills and that she was considering failing her for the 2 weeks she was with me but wanted to give some thought to it.” Her Intern Assessment Form is dated 28 May 2003. This was one of the “final reports for surgery not yet received” which Professor Keary was referring to in his letter to the Board of 20 May 2003 (see para [18]).
[282] The Show Cause Notice dated 16 February 2004 (para [22]) whilst stating that the Board had resolved that she was “incapable of satisfactorily completing the prescribed internship” primarily directed attention to the Board’s decision to consider cancelling her registration. The Appellant’s submissions in reply opposed that course, took issue with the allegations against her and contended that she had satisfactorily completed her internship. No alternative submission was advanced in relation to whether her internship should be extended should the Board reach a conclusion adverse to her on the issue of satisfactory completion of internship.
[283] The evidence before the Board was primarily, if not only, directed to past events and it was left to the Board to reach a decision on the s.94(1)(b)(ii) issue on the basis of that evidence alone and in the absence of any direct evidence to the effect that the Appellant’s faults were incurable.
[284] The preponderance of evidence before me on this issue is to the effect that the Appellant will, subject to a properly conditioned and structured internship of 12 months, satisfactorily complete that internship.
[285] I incline to the view that “will” in s.94(i)(b)(ii) should be interpreted as “may” but this was not argued and I need not express any definitive view on the matter.
[286] The onus will be on the Appellant. If her performance to date is any indication she will have to make significant changes to her way of doing things and her attitude to others. She must be prepared to learn and to admit mistakes and learn from them. In my view it is likely that she needs psychiatric assistance of the nature referred to by Dr Kippax or at least assistance in relation to the personality problems highlighted by Professor Judd.
[287] Any extended internship should not be undertaken at the Townsville Hospital because of the personalities involved including hers. See for example the evidence of Dr Rosenblum, para [275].
[288] For these reasons I consider the decision of the Board to cancel the Appellant’s registration should be set aside and the Board should be directed to extend the Appellant’s probationary conditions for 1 year by requiring her to undertake all of the prescribed internship.
[289] If the Board has power to vary the Appellant’s probationary conditions I consider it should be directed to do so by imposing additional conditions to the effect that during the prescribed internship the Appellant should submit to and undergo such psychiatric treatment as is considered appropriate by the Board with regular reporting to the Board by the treating psychiatrist/s and that during the prescribed internship there be such mentoring and supervision as is considered appropriate by the Board, together with contemporaneous advice to the Appellant of any perceived deficiencies in the performance of her internship and definitive assessment of her progress.
Result
[290] At this stage the orders I make are these
1.The appeal is allowed
2.The decision of the Medical Board of Queensland that the Appellant has not satisfactorily completed her internship is confirmed
3.The decision of the Medical Board of Queensland to cancel the registration of the Appellant is set aside and the Board is directed to extend the Appellant’s probationary conditions for a period of 1 year by requiring her to undertake all of the prescribed internship
4.The further hearing of the appeal is adjourned to a date to be fixed to allow further submissions as to the directions to be given to the Medical Board of Queensland under s.240(1)(d) of the Medical Practitioners Registration Act 2001 and the costs of the appeal and in this respect I direct that within 14 days of today the parties file and serve written submissions as to any further directions the Court should make and the costs of the appeal and that within 28 days of today the parties file and serve any submissions in reply.
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