Veterinary Surgeons Investigating Committee v Lloyd (Inquiry 2: ‘Gypsy' - Findings)

[2003] NSWADT 96

Set aside by Appeal: Set aside by appeal in part on 13/10/2003

CITATION:	Veterinary Surgeons Investigating Committee -v- Lloyd (Inquiry 2: Gypsy - Findings) [2003] NSWADT 96
DIVISION:	General Division
PARTIES:	APPLICANT Veterinary Surgeons Investigating Committee RESPONDENT Ronald George Lloyd
FILE NUMBER:	40005 of 1998
HEARING DATES:	23/03/1999 - 26/03/1999, 23/11/1999 - 26/11/1999, 21/02/2000, 13/12/2000, 03/10/2002, 22/10/2002, 29/11/2002
SUBMISSIONS CLOSED:	11/29/2002
DATE OF DECISION:	05/09/2003
BEFORE:	O'Connor K - DCJ (President); McGilvray G - Member; Clark F - Member
APPLICATION:	Veterinary surgeon - misconduct in a professional respect - Veterinary Surgeons Act - veterinary surgeon - misconduct in a professional respect
MATTER FOR DECISION:	Principal matter
LEGISLATION CITED:	Administrative Decisions Legislation Amendment Act 1997 Administrative Decisions Tribunal Act 1997 Medical Practitioners Act 1938 Poisons Act 1966 Poisons and Therapeutic Goods Regulation 1994 Veterinary Surgeons Act 1986 Veterinary Surgeons Regulation 1995
CASES CITED:	Veterinary Surgeons Investigating Committee -v- Ronald George Lloyd (Inquiry 1: ‘Chisel’ - Findings) [2003] NSWADT 95 Veterinary Surgeons Investigating Committee -v- Lloyd (Inquiry 3: 'Remus' - Findings: Allegations 1 (a) to (e)) [2002] NSWADT 285 Veterinary Surgeons Investigating Committee v Lloyd (Inquiry 4: Total Eclipse: Findings) [2002] NSWADT 284 Veterinary Surgeons Investigating Committee v Lloyd [2000] NSWADT 98 Lloyd v Veterinary Surgeons Investigating Committee [2002] NSWCA 224 Veterinary Surgeons Investigating Committee v Lloyd [2002] NSWADT 233 Veterinary Surgeons Investigating Committee -v- Lloyd (Inquiry 4: 'Total Eclipse' - Jurisdiction) [2002] NSWADT 283 Qidwai v Brown (1984) 1 NSWLR 100 Health Care Complaints Commission v Litchfield [1997] 41 NSWLR 630 Re Lloyd (His Honour Judge Wall DCJ, Professor C Bellenger and Dr W Howey, unreported, 16 December 1994) Briginshaw v Briginshaw (1938) 60 CLR 336 Marten v Royal College of Veterinary Surgeons’ Disciplinary Committee (1966) 1 QB 1 Beaumont v Beesley [1973] 2 NSWLR 341 New South Wales Bar Association v Murphy (2002) 55 NSWLR 23
REPRESENTATION:	APPLICANT S Burchett, barrister (to July 2002) M Linkenbagh, Secretary to the Committee (since August 2002) RESPONDENT B Green, solicitor
ORDERS:	1. The respondent is guilty of misconduct in a professional respect in relation to Allegations 1(a), 1(b), 1(c), 1(d), 1(e), 1(f), 1(g), 1(h), 1(i), 1(j), 1(k), 1(l), 1(m), 1(n) and 1(o); Allegations 2(a), 2(b) and 2(c), Allegation 3 and Allegation 4 ; 2. After determination of the other three Inquiries, this Inquiry is to be reconvened for determination of orders pursuant to section 32.

1 The Veterinary Surgeons Investigating Committee (the Committee) has referred to the Tribunal for inquiry a complaint against Dr Ronald George Lloyd (Dr Lloyd), a registered veterinary surgeon. The Committee must pursuant to s 28(1)(c) of the Veterinary Surgeons Act 1986 (the Act) make such a referral if it is satisfied that a prima facie case of misconduct in a professional respect has been made out in relation to the complaint and considers that it is sufficiently serious to warrant referral to the Tribunal.

2 The inquiry has been undertaken pursuant to Division 4 of Part 4 of the Act. (Unless otherwise noted, references in this decision to the Act are to the Act as in force at the time of the commencement of the inquiry.)

3 The original complaint was made by Ms Sharon Clee, the owner of a horse named ‘Gypsy’ (Gypsy) treated by Dr Lloyd. Ms Clee’s complaint was made in writing on or about 9 February 1996. Her horse, ‘Gypsy’ had died on 12 January 1996 while under Dr Lloyd’s care. The complaint related to Dr Lloyd’s diagnosis, treatment and care of the horse, and his conduct subsequent to the death of the horse, in particular in the period from 12 January to 23 January 1996. The complaint referred to events that occurred between 26 December 1995 and 23 January 1996.

4 Dr Lloyd was given the opportunity to respond to the complaint in writing, which he did. The Committee then undertook a formal interview, which occurred on 19 August 1996. It decided to refer the complaint. The referral itself occurred on 8 April 1998, and the Chairperson, Veterinary Surgeons Disciplinary Tribunal issued the Notice of Inquiry.

5 The jurisdiction of the Veterinary Surgeons Disciplinary Tribunal was transferred to the Veterinary Disciplinary Panel of the Administrative Decisions Tribunal with its creation on 6 October 1998: Sched 4.3, Administrative Decisions Legislation Amendment Act 1997; Govt Gaz 143, 2 October 1998.

6 The Notice of Inquiry contains twenty allegations of misconduct in a professional respect against Dr Lloyd, each supported by detailed particulars. Allegation 1 is made up of fifteen charges, Allegation 2 is made up of 3 charges, Allegation 3 consists of one charge and Allegation 4 consists of one charge. Allegations 1, 3 and 4 refer to his conduct in his capacity as a registered veterinary surgeon. Allegation 2 refers to his capacity as a superintendent of a veterinary hospital. (The charges are described herein as Allegation 1(a), 1(b) and so on.)

7 The hearing of evidence commenced on 23 March 1999 and proceeded over several days broken by intervals, concluding on 13 December 2000. For reasons explained later, the Tribunal reconvened to conclude the inquiry in August 2002.

8 The Committee’s case during 1999 and 2000 had been presented by Mr Burchett of counsel instructed by a firm of solicitors. The Secretary to the Committee at that time, Mr Michael Harcombe, a public servant, had been appointed the nominal complainant pursuant to s 29(6) of the Act. He had been excused from further involvement in the proceedings.

9 At the reconvened inquiry, the new Secretary to the Committee, Ms Maria Linkenbagh appeared and advised that she would be conducting the case henceforth. She informed the Tribunal that there had been a substantial change in the membership of the Committee as compared to its membership at the time of the investigation in 1996 and the referral in 1998. She said that only one of the members had any prior knowledge of the history of this matter.

10 Ms Linkenbagh has since made a number of submissions as to the jurisdiction and scope of the inquiry, the fairness of the charges and as to the evidence, most of which have been inconsistent with the way in which the case was previously conducted. They are dealt with in the body of these reasons.

General Background
11 Four Inquiries: This is one of four complaints against Dr Lloyd that were referred to the Tribunal for inquiry during 1998. All were heard together in sequence, commencing in March 1999. The parties had agreed to this course prior to the commencement of the first inquiry, relating to the dog Chisel. The Tribunal accepted their request that all evidence in respect of the four complaints be considered before any determinations were made in respect of any of them; and any consideration was given to any further order (Transcript of Proceedings (ts) 15/3/99:3)

12 The four inquiries sat on 28 days to hear evidence (not counting time spent on other time involving hearings for directions, dealing with other motions, and further submissions and the further hearings in relation to reconstitution, final submissions and other issues late in 2002) spread initially over 22 months, commencing in March 1999 and ending in December 2000, as set out below:

• ‘Chisel’, a dog owned by the Girgenti family: 15,16, 17, 18, 23 March 1999 (Inquiry No 1, Matter No. 40004 of 1998). Findings have been made in relation to all allegations: Veterinary Surgeons Investigating Committee -v- Ronald George Lloyd(Inquiry 1: ‘Chisel’ - Findings) [2003] NSWADT 95
• ‘Gypsy’, the present matter: 23, 24, 25, 26 March 1999; 23, 24, 25, 26, 29 November 1999; 13 December 2000 (Inquiry No 2, Matter No. 40005 of 1998).
• ‘Remus’, a dog owned by the Robinson family: 21, 22, 23, 24, 25 February 2000; 11, 12, 13, 14, 15 December 2000 (Inquiry No 3, Matter No. 40015 of 1998). Findings have been made in relation to certain allegations: see Veterinary Surgeons Investigating Committee -v- Lloyd (Inquiry 3: 'Remus' - Findings: Allegations 1 (a) to (e)) [2002] NSWADT 285
• ‘Total Eclipse’, a cat owned by Ms Kim Koroknay: 7, 8 June 2000; 13, 14, 15 November 2000 (Inquiry No 4, Matter No. 40016 of 1998). Findings have been made in relation to certain allegations: see Veterinary Surgeons Investigating Committee v Lloyd (Inquiry 4: Total Eclipse: Findings) [2002] NSWADT 284 (31 December 2002).

13 Prior to the all inquiries being completed, it was necessary to reconstitute the Tribunal. The completion of the inquiry was delayed pending the determination of appeals to the Appeal Panel and the Court of Appeal against the reconstitution of the Tribunal. The outcome of the appeals is dealt with later in these reasons.

14 Complaints Procedure. The Veterinary Surgeons Board (the Board) maintains a register of veterinary surgeons. The Board also has power to license a person to conduct a veterinary hospital. A veterinary hospital must be managed by a superintendent who has been nominated in accordance with s 54 of the Act. The regulations may prescribe different classes of licences for different classes of veterinary hospitals (s 47). There are also provisions in the Act dealing with the practices in relation to animals that unregistered persons are permitted to perform (s 44).The Act confers responsibility for investigation of complaints on a separate statutory body, the Committee.

15 The Committee is (with limited exceptions) required by s 27 to investigate the complaint. When it has completed its investigation the Committee is required to make a decision as to what course of action it will adopt. As noted earlier, the course of action required by Option (c) in s 28(1) was chosen in this case.


‘ 28. Decision of Investigating Committee on complaint

(1) The Investigating Committee:
(a) may dismiss any complaint made to it,
(b) if it is satisfied of the truth of the complaint but considers that the complaint is not sufficiently serious to warrant its being referred to the Tribunal, may do all or any of the following:
(i) by order, caution or reprimand the veterinary surgeon,
(ii) order that the prescribed costs of, or incidental to, investigating the complaint be paid by the veterinary surgeon, (iii) by order impose conditions on the registration of the veterinary surgeon with respect to the practice of veterinary science, being conditions of a temporary nature (including limitations on the right to practise) in connection with the veterinary surgeon's continuing education, acquisition of skills and professional supervision, or
(c) if it is satisfied that a prima facie case has been made out and considers that the complaint is sufficiently serious to warrant its being referred to the Tribunal, shall refer the complaint accordingly.
(2) Where the Investigating Committee considers that the conduct of a registered veterinary surgeon warranted the making of the complaint but the conduct does not constitute misconduct in a professional respect or any other ground on which a complaint may be made under section 26 (1), the Investigating Committee may deal with the veterinary surgeon under subsection (1) (b) in respect of the conduct.
(3) The Investigating Committee must, before exercising its powers under subsection (1) (b) or (c), give the registered veterinary surgeon concerned an opportunity to make written representations to the Committee. If, after receiving written representations, the Committee is still considering whether or not it should exercise those powers, it must give that veterinary surgeon an opportunity to appear before it to make oral representations.’

The Present Inquiry
16 This inquiry has been conducted by a Veterinary Disciplinary Panel of the General Division of the Administrative Decisions Tribunal (referred to herein as the Tribunal): Administrative Decisions Tribunal Act 1997 , Schedule 2, Part 4, Div 3, cl 7. Such a Panel must comprise a judicial member of the General Division of the Tribunal; a non-judicial member who is a veterinary surgeon and a member of the Board and a non-judicial member who is not a veterinary surgeon and was assigned to the Division on the recommendation of the relevant Minister to represent the interests of users of veterinary services. The Tribunal’s powers when a complaint is proved are set out in s 32 of the Act.

17 Reconstitution of Tribunal. The original Tribunal comprised the President; Dr Garth McGilvray, non-judicial member, a veterinary surgeon and member of the Board (currently the President); and Ms Yolande Dubow, non-judicial member, representing the interests of users of veterinary services. Following the expiry of Ms Dubow’s term as a member on 31 March 2000, while the overall hearing was incomplete, it was necessary to reconstitute the Tribunal by replacing Ms Dubow with a new member representing the interests of users of veterinary services, Ms Fiona Clark.

18 The Tribunal that included Ms Dubow heard the entirety of Inquiry 1 (Chisel) and the entirety of Inquiry 2 (the present matter). Ms Dubow’s term expired when Inquiry 3 (Remus) was part heard. The new Tribunal heard the entirety of Inquiry 4 (Total Eclipse).

19 Section 79 of the Tribunal Act deals with the consequences of reconstitution. Ms Dubow’s term expired when Inquiry 3 (Remus) was part heard. Dr Lloyd did not give the consent necessary for ss79(1) and (2) to be utilised. Accordingly it was necessary to deal with the future course of proceedings pursuant to ss 79(3) and (4). Section 79 provides:

' 79. Reconstitution of Tribunal during hearing
(1) The President may replace the member, or one of the members, constituting the Tribunal after the consideration of a matter by the Tribunal has commenced if:
(a) the member becomes unavailable for any reason, or ceases to be a member, before the matter is determined, and
(b) the parties consent.
(2) The Tribunal as so reconstituted is to have regard to the evidence and decisions in relation to the matter that were given or made before the Tribunal was reconstituted.
(3) If one or more of the parties do not consent to the reconstitution of the Tribunal under this section, the proceedings are to be reconsidered by the Tribunal constituted in accordance with this Act.
(4) If proceedings are reconsidered by the Tribunal, the Tribunal may, for the purposes of the proceedings, have regard to any record of the proceedings before the Tribunal as previously constituted including a record of any evidence taken in the proceedings.'
20 The President gave directions as to how the reconstituted Tribunal was to proceed in relation to the three affected Inquiries, including the present one: see Veterinary Surgeons Investigating Committee v Lloyd [2000] NSWADT 98.

21 There was an appeal against the directions on various grounds. The Appeal Panel dismissed the appeal on 15 August 2001: Lloyd v Veterinary Surgeons Investigating Committee [2001] NSWADTAP 26. On further appeal, the Court of Appeal found that the President in sitting alone to deal with the reconstitution of the Tribunal had exceeded the jurisdiction of the Tribunal. The relevant decision was required to be made by the full Tribunal. Accordingly it set aside the previous decisions, and remitted the matter to the Tribunal for further decision: Lloyd v Veterinary Surgeons Investigating Committee [2002] NSWCA 224 (16 July 2002).

22 The full Tribunal reconvened, and ruled (Veterinary Surgeons Investigating Committee v Lloyd [2002] NSWADT 233 (13 November 2002)) that Dr Lloyd's requests for the recall of certain witnesses were not granted; and that the proceedings in respect of Inquiries 1, 2 and 3 were to be reconsidered by having regard exclusively to the record of the proceedings before the Tribunal as previously constituted, including the records of evidence taken in the proceedings. Closing submissions (which had not been presented pending the appeals) were heard on 29 November 2002.

The Original Complaint

23 Ms Clee’s complaint is set out below. We have retained the original spellings, type sizes, syntax and lettering:

NAME: SHARON CLEE

HORSE: GYPSY

I AM WRITING THIS AS A WRITTEN REPORT OF TREATMENT GIVEN TO MY HORSE, THAT I AM NOT HAPPY WITH.

AS A BACKGROUND TO MY HORSE - HE WAS QUIET TO HANDLE/VERY RESPONSIVE TO RIDE. HE WOULD USUALLY GALLOP UP FOR HIS FEED AND WOULD BUCK MADLY ABOUT WHEN I MOVED HIM INTO A NEW PADDOCK. HE WAS A CROSSBREED WITH A LITTLE ANDALUCIAN, HE WAS VERY HEAVILY BUILT, HAD A CREST. I WAS OFTEN STOPPED AND ASKED (EVEN BY HORSE PEOPLE, (WHEN’S THE FOAL DUE?) I HAD HIM FOR 10 YEARS AND WAS CONSTANTLY HAVING TO WATCH HIS WEIGHT EVEN WITH MINIMAL GRASSING DURING THE DROUGHT.

SINCE I HAVE HAD HIM HE HAS NEVER FOUNDERED HAD COLIC OR A COLD.

HE HAS HAD AN ETHMOID HAEMATOMA IN THE BACK OF HIS NOSTRAL WHICH WAS REMOVED AT SYDNEY UNI IN JUNE 1993 WHICH REACCURED IN DEC 1994 AND WAS AGAIN REMOVED - THEY SENT IT TO PATHOLOGY - I WAS TOLD IT WAS BENINE, IT WOULD NOT SPREAD, IT WOULD NOT KILL HIM, IT MAY REACCUR IN THE SAME SPOT.

HE WAS NOT A VALUABLE HORSE, BUT A TOTALLY RELIABLE PLEASURE TO OWN.

Since July 1995 I had Gypsy in a paddock in Prestons behind my Fiancees house. His neighbour kept his horse in the paddock beside mine, fenced off in between was a septic tank.

In the first week of October we had very heavy rains, the septic tank overflowed into both paddocks, Gypsy had about an acre of which only a little was affected. I moved Gypsy to Punchbowl. The neighbours horse was in a small yard which was swamped.

A view days later the neighbours horse started to get lose poo which steadily increased to diarrhoea, getting worse each week with him losing weight to a stage were the neighbour was about to put the horse down. As far as he knew the horse had picked up a bug from the septic.

TUES 14TH NOVEMBER: I first noticed slight weight loss, thought it was due to lack of grass so I increased hand feeding.

FRI 1ST DECEMBER: Noticed more weight loss.

MON 11TH DECEMBER: Noticed losish poos.

THU 14TH DECEMBER: Called a vet from Randwick Equine Centre. He inspected Gypsy - told me there was a large water content in the grass, so he was effectively eating a lot, but half of it was water. He advised me to increase hand feeding further.

TUE 19TH DECEMBER: Recalled vet out - still losing weight - loser poos. Drinking a lot more (double). (Gypsy was very lively, eating and drinking eagerly).

Diagnosis was he was fine - just increase feed.

A week later his poos were the consistency of a runny cow pad.

I thought I’d better get a second opinion.

I spoke to neighbour, he put me on the Dr Ron Lloyd who was treating his horse for the same symtoms.

I rang Ron Lloyd, asked him to come and see Gypsy - but as he knew the symtoms, we discussed treatment over the phone.

By this time Gypsy has started to mess in his tail and down his legs. He is eating/drinking 3 times normal/but very lively/energetic. I enquired whether it could be a Gardiosis bug, that I had had previously which enabled me to eat heaps but continue to lose weight 60 > 48kg. I was told I picked it up from the horses originally, so maybe it happened in reverse.

He thought this was possible and said he would have to find a similar horse medicine. I rang back later, he had found (Dimetridazole) but the book only referred to quantities for chickens he would have to work out a dose.

I arranged to pick it up. He said he would try it on the neighbours horse as well. Although neighbours horse had gained some wieght and was now starting to recover. Gypsy seemed to be in 1 months delay and so in worse condition at this stage.

He was thin all over EVENLY.

SAT 30TH DECEMBER: I called in to collect medicine. He told me he would have to work out quantities. He poured (Dimetridazole) in another container and said to give about a quarter every second day.

When I went to pay he said to give a quarter every day.

((Dimetridazole) - I’ve since found out is used on birds and pigs - No one (vets) have been able to provide any evidence of it being tested/or used on horses. BUT that it may UPSET matters.

WED 3RD JANUARY: Gave 1st dose, stayed with him, as neighbour had told me it made his horse very groggy, and he went off is feed. I administered it as a paste to the back of the tongue. After about 10 mins he began to stagger sideways almost falling - 10 mins on and all he wanted to do was eat grass - 10 mins more - did a poo and seemed to start to recover.

THU 4TH JANUARY: Gave 2nd dose. Same reaction. Poos more solid/eating/drinking less/(Normal quantity)/not lively.

FRI 5TH JANUARY: Gave 3rd dose. Same reaction. Poos still more solid/eating/drinking less. No enthusiasum for food/not lively, started to lose weight more noticeably.

SAT 6TH JANUARY: Did not give medicine - poos very normal drinking a lot less. He left some food! No enthusiasm for feed. Not lively. Still noticeably more weight loss. Saw Mr Lloyd at Surgery, told him how he was. He said not to give last dose.

SUN 7TH JANUARY: Hardly has drunk. NOT EATING FEED. Seems hot to touch. I thought going off feed for 1 day OK as neighbours horse did the same. Dropped off a lot tucked in noticeably behind last rib, tucked up.

MON 8TH JANUARY: NOT EATING FEED. Little water drunk, Very lose poos. He was laying down. Lost a lot more weight, noticeably more, than previous day, very tucked in. He is sunken in behind the last rib (the LENGTH of my hand). His top hip bones sticking up and his rump was hollow - his ribs still not excessive, his neck straight.

Very distressed I rang Mr Lloyd. He sent someone out to administer injection, his temperature is 39.6.

TUE 9TH JANUARY: Mr Lloyd told me to bring Gypsy to his Surgery at 15th Avenue Hoxton Park. Arranged time off work to take him out to Surgery.

Mr Lloyd looked him over - touched his stomach area and said words to the effect - “How much do you want to spend - Given his age (20) and you have already spent money on him”. He then looked in his mouth and found his gums were yellowish green, he said he was enemic.

I asked if he had had a reaction to the medicine? He said he thought that their was something else wrong.

I was very upset and enquired what he could do, I wanted him well. I asked if he could put him on a drip to try get something in him - he took his temperature 39ish but it was lower then yesterday. He told me he would drench him.

WED 10TH JANUARY: Walked down and saw Gypsy in vets paddock. Found him standing on his lead rope. As far as anyone knew he was contagious, he was with other horses?

There was about 5 inches of water in trough, we released him, he went straight for water. He swished his muzzle in it continuously, after about 10 mins I checked his mouth and found his gums bright red his tongue appeared to be swollen and red. Once released he started swishing his muzzle in the trough again. He had lost more weight. As we left he was still swishing.

Later went back and saw Mr Lloyd. He said redness was due to twitch and drench!

THUR 11TH JANUARY: Walked down to Gypsy - found him swishing musel in same amount of water. He had lost more weight was very tucked in, sunken in the rump I checked his mouth it was still red this time with little sares and cuts and ulsers.

I walked back to the car to wait for the vet to arrive at this surgery. Still waiting I returned to the paddock I walked up to Gypsy, while patting him he laid down. He would never allow anyone near him while he was on the ground before. I waited some more, then later rang Mr Lloyd.

He said he was OK, his mouth was due to the drench and that he had taken a drink from the waterhole outside of the paddock behind the vets surgery “but they had pulled him away quickly.”

FRI 12TH JANUARY: Went to see Gypsy - The vet was driving away, he stopped and informed us - Gypsy had died in his sleep that morning - he had also done an Autopsy! (Without our permission). He told us he had found tumor nodules in his stomach and his liver was gone! We wanted us to see the tumors - but also said he had kept a sample to show us. I was very distressed and said I did’nt wish to see him like that and that I would not know what I was looking at anyway. He said he would keep me the sample. He also offered to bury Gypsy. I enquired were and how (as I had smelt the dams and wondered whether it was the grave yard). He said he’d get a bob cat in and bury him in the paddock.

TUE 16TH JANUARY: I rang the vet recosts - he said about $140, he also wanted to know if I wanted a horse, a thoroughbred - I could have it, he would tell me more about it later.

THUR 18TH JANARY: I went to Mr Lloyd’s Liverpool Surgery, re payment. I started to write a cheque out to Dr, his receptionist told me to make it out to R Lloyd. - The horse he had was a thoroughbred, he could sell it for $600, but I could have it. - ($140 - For three days board, twice daily treatment, medicine, bob cat hire, burial on sight, plus sending someone 30km out to administer treatment plus next days supply for me to give + a free horse - Bargain.)

I asked for a sample it had just the other day been thrown out! I asked for the Autopsy report, (I wanted a written one?) He’d have to do one on letterhead, to whom it may concern. I asked if he’d been buried - he had. He offered to post out a rug I’d left out at Hoxton Park. I asked if the tumors were a deadly type - As I was told you can carry tumors but they may not be the cause of death. (How did he know?) (Did he have it tested?) It wasn’t tested but he knew from sight - besides it would have cost another $150 for testing. (I would like to know where I stated that I didn’t want to spend money on my horse!)

I [was] then told me he would have the Autopsy report ready next week.

MON 22ND JANUARY: 11 days later we were passing Mr Lloyd’s Hoxton Park surgery, so we called in to see if the Autopsy report was ready. We waited for the vet to arrive at this Surgery. While we waited we decided to walk down and see the grave sight. We were half way down to the paddock walking between the two waterholes and I saw what I thought was a horse in the waterhole. It was on the edge, half in the water near side down, head shoulders submerged - offside hind leg tied to a tree on the bank. His leg raised exposing most of his belly/rib area. He did not seem very perised just dirty, I could make out his white markings on his neck, his very long mane - To my shock and horror it was Gypsy!!! After getting over the initial shock, I looked for signs of an autopsy opening on his stomach area! Non that I could see!

Extremely angry, (to say the very least) by this stage I returned to the surgery the vet had not arrived, I asked the receptionist if he had left an Autopsy report. He had not, but she was quite frantic to ring him - we left.

I tried to contact the vet all eveing. I slept about 2 hours that night.

TUE 23 JANUARY: I arranged for someone to collect Gypsy/a burial sight and a day off work. With a friend and Glenn we went to see Mr Lloyd at Liverpool. I asked for the Autopsy report he said I could have it next week! I said I did’nt really care, I’d like to know what my horse is doing in the waterhole. He said we shouldn’t have gone there, but that he had previously buried him but he’d washed out and was retrieved. Was due to be buried today. My friend asked again about the sample he’d said he’d just thrown it out yesterday!

He told us that Gypsy was first buried in a washaway area of the embankment on a piece of flat ground by the side of the waterhole. (Why would you drag a head horse from a flat paddock were he died, - through a gate to a sight beside a waterhole?) We told Mr Lloyd we would now bury him properly, he then informed us that he had arranged for him to be buried today in his paddock (this time). We were sceptical at this so we said OK on the CONDITION that WE SEE HIM BEING BURIED. Mr Lloyd said I should just see his head it would be too gory. My friend stated that under the circumstancs we wanted to see all of him, as he was being buried. The vet reiterated that we could see the whole gory lot. These were the only circumstances unto which we would allow him to bury him. We wanted to know what time he would be buried, we would be there. Mr Lloyd said he would ring us at 2.30 to let us know what time to come out, to see him being buried, probably about 3.00.

At 2.45 the Mr Lloyd rang for us to come out between now and 3.30.

We arrived at Mr Lloyd’s Surgery 15th Avenue Hoxton Park at 3.pm with my fiancee’s parents. We waited in the Surgery for a view minutes, my fiancee, and his parents were rather annoyed as they had horses and had had a lot to do with Gypsy in the past.

Mr Lloyd said Sharon is my client you can all stay here. A verbal argument followed. Mr Lloyd ushered us outside, they demanded some answers. In the commotion, Mr Lloyd said words to the effect “Why don’t you take your glasses and hat off and come in side with me” - to Glenn. Glenn replied he did not wish to fight him. His mother offered to call the Police! We just wanted to see the horse being buried properly, we thought Mr Lloyd’s attitude was very unproffessional.

I tried to calm things down, I started to walk down to the paddock.

Mr Lloyd asked his receptionist to show us down to the grave. We started walking with her, he told us we must all drive down, the receptionist said I’ll just walk them down, he said no we must DRIVE down. (A whole 100 metres between the waterholes and the paddock?)

When in the paddock, I couldn’t believe what I saw - THE GRAVE COMPLETELY COVERED UP.

My fiancees mother went right off - she asked the receptionist what was going on? - she asked was Gypsy in there? The receptionist said the vets two young sons had watched the whole thing? (Why was it OK for them?) (Not too gory?).

I was ready to give up; why couldn’t the vet just show us,? was it too much to ask for him to keep his word for one last thing?

We DROVE back past a dirt mound were I had last seen my horse, to the Surgery.

I tried to keep the vet and them apart. I asked why after all this had he been buried without us present?

He explained that he had had one bobcat digging, it broke down, he called another, (next door neighbour) but they could not wait for us to turn up.

He re-explained things - Took me in his office, showed me a book on diarhoea, I asked were abouts he did the autopsy, he said on the near stifle area, he did not have to go digging, he noticed the tumors and a LITTLE of the liver was damaged.

He continued to explain, mentioning that (“if I had have done a postmortom …,”) (Was I hearing things?) I interupted and asked was an autopsy and a post mortom the same thing, he said yes. (?) I let it go, but continued to wonder what I had just heard.

He said he did not want an unhappy customer, and that I could visit the grave anytime.

I left still in shock.

Just the for the record, Glenn’s parents went out early to the Surgery 1.15pm. They waited across the road, up a little. A bobcat came out of the neighbours yard went down the back of the vets and started work. His parents had binoculors & a mobile. (They travel a lot).

When work ceased (Glenns parents rang us), the neighbour went home, Mr Lloyd went inside and phoned Glenn.

A week and a half later I rang to ask if I could pick up the Autopsy report, his receptionist said he would mail it that week.

I have now asked for an autopsy report 3 times, to dated 9/2/96, to no avail.

I have had animals all my life, some with life threatening illnesses/injuries - my mother died of Leucemia 1½ yrs ago - I have never had any queries about any of them in all that time I’m 28.

I respectfully request the board to look into this.

Gypsy did not diserve this.

YOURS FAITHFULLY

SHARON CLEE

Original Reply to Complaint
24 Dr Lloyd replied to the Board by letter dated 20 May 1996 (original spellings and syntax retained), as follows:
‘To Whom It May Concern:

A field Post-Mortem was performed in order to determine the cause of death of an aged (approximate 20 years old) brown and white stock horse owned by Ms Clee.

The previous history being weight loss, depression and chronic diarrhoea for at least the previous three (3) months. The animal had been seen and treated by other Vets to no avail.

I had, based on the owner’s belief that the horse had caught Giardia from an overflowing septic, dispensed Dimetridazole at a dose rate of 50mg/Kg as suggested in the 8th Edition of Veterinary Medicine.

The horse had an adverse reaction to either the drug or the method of administration, the reaction being atoxia and anaemia.

The owner was advised to stop treatment. After 4-5 days with diarrhoea still present the horse was admitted to Rutledge Park Veterinary Hospital. The horse on examination exhibited:

• Severe Emaciation
• Diarrhoea
• Anaemia
• Ventral Oedema
• Pale Mucous Membrances
• Cardinal Signs being HR52
• RR22 and laboured;
• PCV 48 with serum discolouration;
• Faecal flotation exhibited strongyle eggs; and
• The body temperature was 38.8 degrees.



Ms Clee was given by me a very poor prognosis to the extent that if the diarrhoea could not be stopped within a few days (which I doubted and told her) then the horse would be too weak to stand and as a result would have to be put down (euthanised).

On 9 January, 1996 (day of arrival) the horse was given 25cc Penstrep IM tubed and drenched with Mebendazole, piperazine, neguvon, electrolytes, Scourban and Trimethoprim powder.

On 10 January, 1996, there was slight improvement in faecal thickness. The drench was repeated but without the three wormers. Also 25cc of Penstrep was administered IM as well as 20cc of Spasmolgesic IV.

On 11 January 1996, the treatment was repeated.

On 12 January 1996, the horse was found dead at 7.20am.

A Post-Mortem was performed by myself in order to determine the probable cause of death.

A large traverse incision was made on the left flank and the intestinal mass and colon was exposed.

Upon incision of the Colon, large grey modules approximate 1-1.5cm in radius and 1cm in height was seen covering the intestines along their course. In between, the mucosa appeared to be leathery and inactive.

On incision the growths were seen to be composed of a white cellular mass.

On further examination of the abdominal cavity, the liver was seen to contain many metastatic growths surrounded by cirrotic liver mass.

No further dissection was performed, except for taking of samples of the liver, and intestines to show the owner, as in my opinion the hourse had died as a result of complications resulting from cancer of the liver and intestines.

I hired a Mr James Murray to bury the horse on Saturday 13 January, 1996. This was done by dragging the horse into a depression near the outflow of a dam and covering it with soil. After heavy rain the soil was dislodged and the horse was secured to a tree to prevent it being washed away as well.

A bobcat was ordered and the driver dug a deep hole, well away from the water course and buried the horse.

The owner, her boyfriend and Mother and Father arrived, viewed the burial site then unbeknown to me abused my staff and sons, while I was talking to the owner Ms Clee in a consulting room. She did not wish to see the Post-Mortem samples and left.

On leaving the building the boyfriend, from the safety of his car, started to abuse me. I took umbrage at this show of belligerance and asked him to get out of the car and explain himself. This he declined to do. Ms Clees and the three others then exited from my property.

I do not think I was negligent in my treatment of the horse and as to any misconduct by myself in bring the profession into disrepute I can only say that faced with the verbal abuse I received, some form of verbal defence was called for.

Yours sincerely

Ronald G. Lloyd BVSC Sydney

Veterinary Surgeon’

NOTICE OF INQUIRY

25 In September 1996. following investigation and the conduct of a formal interview of Dr Lloyd on 19 August 1996, the Committee resolved to refer the complaint to the Tribunal for inquiry. As noted earlier, the formal referral occurred on 8 April 1998 and the then Chairperson of the then Tribunal issued the following Notice of Inquiry:
Notice of Inquiry
TAKE NOTICE that the Veterinary Surgeons Disciplinary Tribunal has received a complaint referred to it by the Veterinary Surgeons Investigating Committee that you have been guilty of misconduct in a professional respect within the meaning of Section 22 of the Veterinary Surgeons Act 1986 (“the Act”) in relation to your care, treatment and management of the horse “Gypsy”.

The specific allegations which have been made against you and the particulars of those allegations are as follows:

1. That being a registered veterinary surgeon you are guilty of misconduct in a professional respect in that you did breach provisions of the Veterinary Surgeons’ Code of Professional Conduct (“the Code”) established under Section 23 of the Act and prescribed for the purposes of section 22(c) of the Act, as follows:

(a) On or about 26 December 1995 after consulting with a client, you failed to ensure that a detailed record of the consultation was made.

Particulars

A few days before 30 December 1995, Sharon Clee consulted you by telephone about treatment required for her horse, “Gypsy”. In a subsequent telephone conversation you advised using the drug Dimetridazole and arranged for her to collect a supply of it from you for her to administer to Gypsy. You made no record of those telephone consultations.
(b) On or about 30 December 1995 you supplied or arranged for the supply to an animal of a substance included in Schedule 4 to the Poisons List without ensuring that the person who dispensed the substance was provided with written instructions as to any dosage requirement, route of administration or withholding period that was relevant to the use of the substance.
Particulars

On 30 December 1995 you supplied a quantity of the drug “Dimetridazole” to Sharon Clee for her to administer to the horse known as “Gypsy”. You did not provide her with adequate written instructions as to any dosage requirements. You did not provide her with any written instructions as to the route of administration nor any withholding period that was relevant to the use of that substance.

(c) On or about 30 December 1995 you failed to ensure that conditions imposed by legislation relating to dispensing and handling restricted drugs were strictly complied with.

Particulars

On 30 December 1995 you supplied the drug “Dimetridazole” (a restricted substance) to Sharon Clee to administer to the horse “Gypsy” in a quantity exceeding that required for 3 days’ treatment. You did not:

(a) record the name, strength, quantity or the date on which it was supplied;

(b) record the species of animal nor the name and address of the animal’s owners nor;

(c) keep the record of the supply of that substance at your hospital, surgery or office;


although you were required by regulation 59 of the Poisons Regulation 1994 to make and keep such records.
(d) On or about 30 December 1995, after treating an animal and consulting with a client you failed to ensure that a detailed record of the treatment and the consultation was made.

Particulars

On 30 December 1995 Sharon Clee attended your surgery and you dispensed to her a quantity of the drug Dimetridazole and gave her advice about administering that drug to her horse Gypsy. You made no record of that attendance nor dispensing the drug nor of the advice you gave to her.
(e) On 30 December 1995 you failed to carry out professional procedures in accordance with then current standards of veterinary science.

Particulars

On 30 December 1995 you supplied the drug Dimetridazole to Sharon Clee for her to administer to her horse Gypsy although you had not then examined the horse and had not previously used that drug.
(f) On or about 30 December 1995 you supplied a substance that was in Schedule 4 to the Poisons List to a client without ensuring that the substance was correctly labelled.

Particulars

On 30 December 1995 you supplied a quantity of the drug “Dimetridazole” to Sharon Clee. There was no information, warning nor other statement about:

(i) the quantity of the drug;

(ii) the fact that this drug was listed in Schedule 4 of the Poisons List (other than “Caution S4”);

(iii) what to do in the event of anyone coming into contact with or swallowing the drug;

on any label on the container in which it was supplied.

(g) On or about 6 January 1996 after consulting with a client you failed to ensure that a detailed record of the consultation was made.

Particulars

On 6 January 1996 Sharon Clee consulted you at your surgery about the deteriorating condition of the horse Gypsy. You advised her not to give the last dose of the drug Dimetridazole to the horse. You made no record of that consultation.
(h) On or about 8 January 1996 after treating an animal and consulting with a client, you failed to ensure that a detailed record of the treatment and consultation was made.

Particulars

On 8 January 1996, Sharon Clee rang you about the further deteriorating condition of the horse Gypsy. You sent James Murray to the location where the horse then was, to administer an injection to the horse. The injection was given. You made no record of the telephone conversation nor of the administration of the injection.
(i) On 8 January 1996 you failed to carry out professional procedures in accordance with then current standards of veterinary science.

Particulars

On 8 January 1996 after several days during which Sharon Clee’s horse Gypsy had, to your knowledge, been in a deteriorating condition such that you had advised her on 6 January 1996 not to give her horse the last dose of the drug Dimetridazole which you had previously supplied to her, you instructed a person who was not registered under the Veterinary Surgeons Act 1986 nor otherwise qualified to administer an injection of the drug Dexamethasone to that horse without you being present. At that stage you had not:
• examined the horse;
• taken any steps other than talking to the horse’s owner to establish a diagnosis;
• previously used the drug other than in the treatment of that same horse over the previous few days.

The drug Dexamethasone was a Schedule 4 drug on the Poisons List.

You did not in any way supervise the giving on the injection.

(j) On or about 8 January 1996 you supplied or arranged for the supply to an animal of a substance included in Schedule 4 to the Poisons List without ensuring that the person who dispensed the substance was provided with written instructions as to any dosage requirement, route of administration or withholding period that was relevant to the use of the substance.

Particulars

On 8 January 1996 you supplied a quantity of the drug “Dexamethasone” to James Murray for him to administer to the horse known as “Gypsy”. You did not provide him with any written instructions as to any dosage requirements, as to the route of administration nor any withholding period that was relevant to the use of that substance.
(k) Between 9 January 1996 and 12 January 1996 after treating ani (sic) animal and consulting with a client you failed to ensure that a detailed record of this treatment was made.

Particulars

On 9 January 1996, you admitted the horse Gypsy to your surgery or hospital. He remained in your care until he died on 12 January 1996. The only record which you made of your consultations with Gypsy’s owner, Sharon Clee and of his treatment during that period is set out on your file card. The following details have not been recorded;

(a) diagnosis;

(b) clinical signs;

(c) some treatments;

(d) previous history;

(e) consultation with University of Sydney, Camden;

(f) work up.

(l) Between 26 December 1995 and 12 January 1996 you failed to carry out professional procedures in accordance with current standards of veterinary science.

Particulars

Between about 26 December 1995 and 12 January 1996, you were providing treatment to Sharon Clee’s horse, Gypsy. Although you had many consultations with her, and were aware of the poor condition of her horse, at no time before 9 January 1996 did you suggest to her that you should examine her horse. You did not undertake any steps apart from talking to her to establish a diagnosis. You did not advise her that there could be other conditions affecting her horse than the condition which she had suggested to you (namely, that it was the effect of a giardiasis bug), you did not advise her about the possibility of tests being conducted, such as biochemistry, full blood count, and abdominocentesis nor offer her referral to a specialist.
(m) Between 9 January 1996 and 12 January 1996 you failed to carry out professional procedures in accordance with current standards of veterinary science.

Particulars

Between 9 January 1996 and 12 January 1996, the horse Gypsy was in your care. He was tethered in a paddock in which there were other horses. At that stage, you had been treating the horse for a possibly contagious infection but had not taken any steps to establish whether or not it did have a contagious infection.
(n) On 10 January 1996 you failed to consider the welfare of an animal when practicing veterinary science.

Particulars

On 10 January 1996 the horse Gypsy was tethered whilst in your care and was not able to reach water. Immediately upon being released from that tether by the horse’s owner, he went to water trough and kept his muzzle in it continuously for a period of about 10 minutes.
(o) On 12 January 1996 you failed to carry out professional procedures in accordance with the then current standards of veterinary science.

Particulars

On 12 January 1996, the horse Gypsy having died whilst in your care, you agreed with the horse’s owner that you would bury the carcass in the paddock, using a bobcat.

You then caused the carcass to be buried in a shallow grave which was not adequately covered as a result of which the horse’s owner saw the uncovered carcass and was greatly distressed.

2. That, being the superintendent of a veterinary hospital you are guilty of misconduct in a professional respect in that in accordance with section 54 of the Veterinary Surgeons Act 1986 you were throughout January 1996 responsible for the care, control and management of the hospital and:

(a) failed to ensure that a complete record was made at the time of each veterinary treatment and consultation.

Particulars

On 9 January 1996, you admitted the horse Gypsy to your surgery or hospital. He remained in your care until he died on 12 January 1996. The only record which you made of your consultations with Gypsy’s owner, Sharon Clee and of his treatment during that period is set out on your file card. The following details have not been recorded;

(a) diagnosis;

(b) clinical signs;

(c) some treatments’ previous history;

(d) consultation with University of Sydney, Camden;

(e) work up.

(b) failed to ensure that an animal admitted to the hospital for accommodation or treatment was examined daily or more frequently if the circumstances required.

Particulars

On 10 January 1996 the horse Gypsy was tethered whilst in your care and was not able to reach water. Immediately upon being released from that tether by the horse’s owner, he went to a water trough and kept his muzzle in it continuously for a period of about 10 minutes. Gypsy had not been examined by you or by any other employee of your hospital for a lengthy period.
(c) failed to ensure that an animal admitted to the hospital for accommodation or treatment which showed signs of an infectious or contagious disease was effectively isolated from all animals not so effected.

Particulars

Between 9 January 1996 and 12 January 1996, the horse Gypsy was in your care. He was tethered in a paddock in which there were other horses. At that stage, you had been treating the horse for a possibly contagious infection but had not taken any steps to establish whether or not it did have a contagious infection.
3. That being a registered veterinary surgeon you are guilty of misconduct in a professional respect in that contrary to Section 22(a) of the Act, on or about 8 January 1996 you permitted or required an unregistered person employed by you to practice veterinary science.

Particulars

On 8 January 1996, James Murray a person employed by you but not registered under the Veterinary Surgeons Act 1986 at your direction injected a horse known as “Gypsy” with the drug “Dexamethasone”.
4. That being a registered veterinary surgeon you are guilty of misconduct in a professional respect in that contrary to section 26(1)(c) of the Veterinary Surgeons Act 1986, between 12 January 1996 and 23 January 1996 you did not conduct yourself in a manner in accordance with the professional standards expected by other veterinary surgeons, the users of the services of veterinary surgeons and the New South Wales public in general.

Particulars

On 12 January 1996 you informed the owner of the horse “Gypsy” that you had conducted an autopsy on “Gypsy” that morning, that you had found tumor nodules on the horse’s stomach and that “his liver was gone”. You said that you had kept a sample of the tumors to show Sharon Clee and that you would keep the samples. On 18 January 1996 when Sharon Clee asked for a sample, you told her that it had been thrown out. You promised to send her one but despite many subsequent requests, did not do so.

On 23 January 1996 when Sharon Clee advised you that she would arrange to bury “Gypsy” properly, you informed her that you had arranged for the horse to be buried that day in your paddock. She agreed to this on the condition that Sharon Clee was present during the burial. You promised to telephone her to let her know the time to be present during the burial. At approximately 2:45 pm on that day you telephoned her and requested that she be in attendance at 3:30 pm. Although Sharon Clee was present in your surgery from about 3:00 pm, when she was taken to the new grave by your receptionist, she discovered that the new grave was completely covered up.

You subsequently offered the explanation that the bobcat which was used in burying the horse could not wait for Sharon Clee to “turn up”.

During that conversation with Sharon Clee, Glenn Tuinenburg and Nathalie Taimura, who were obviously distressed at the death of the horse “Gypsy” and the circumstances of the first attempt to bury the horse, you referred to the horse’s carcass as “the whole gory lot”.

During the discussion in your surgery at about 3:00 pm at which Sharon Clee and her finance’s (sic) parents were present, there was an argument during which you invited Glenn Tuinenburg to take off his glasses and hat and fight you, at which point Nathalie Taimura offered to call the police.

Admissions
26 None of the Allegations were formally admitted. In his statement of agreed facts filed 22 October 1999, Dr Lloyd agreed sometimes with qualifying or elaborating comments to the principal particulars of 9 of the 20 Allegations, being 1(a), (b), (c), (d), (e), (f) (the whole without qualification), (g) and (h); and Allegation 3. In a table setting out agreed facts and other matters filed in the Tribunal on 3 September 2002, Dr Lloyd also admitted to the particulars supporting two more allegations, 1(i) and (k), leaving 9 fully in contest. Those 9 are: 1(j), 1(l), (m), (n), (o); 2 (a), (b) and (c); and 4. The Committee then entered objections to the continued consideration by the Tribunal of those 9 allegations, with one minor qualification relating to Allegation 1(l).

The Present Committee’s Ultimate Position in these Proceedings
27 The present Committee’s ultimate position in these proceedings was that it only fully pressed 9 of the original 20 Allegations; i.e. Allegations 1(a), (b), (d), (e), (f), (g), (h), (j) and (k); and partly pressed another, 1 (l). As to Allegation 1(l) it transpired that the Committee had a narrow view of the scope of the particulars, a matter dealt with later in these reasons.

28 The Committee said that it pressed only one aspect of Allegation 4, i.e. the conduct of the autopsy without permission, a fact admitted by Dr Lloyd. However, the Notice of Inquiry does not particularise this matter. It is for that reason that it is not the subject of formal findings in this decision.

29 Of the Allegations that the Committee no longer pressed three belong to the four that the Panel saw as the most serious – 1(m), 1(n) and 1(o) (while the other major allegation, Allegation 1(l) continued to be pressed only in part).

30 It emerges from the table of agreed facts dated 3 September 2002 and submissions from the Committee dated 11 November 2002, that the Committee did not press several allegations for one or more reasons. Eight were no longer pressed due to jurisdictional objections (Allegations 1(c), 1(j), 1(m) and 1(n), 2(a), 2(b), 2(c) and 4); five allegations were no longer pressed due to a change in the Committee’s view as to what conduct can amount to professional misconduct or on the basis that there was no evidence to support an allegation (Allegations 1(l) in part, 1(m), 1(n), 1(o) and 4); three allegations were no longer pressed on the basis that a veterinarian can not be charged with professional misconduct arising from failures as a superintendent (Allegations 2 (a), 2(b) and 2(c)); those which were also challenged on the basis that a criminal offence was alleged (Allegations 2 (a), 2(b) and 2(c)); and five allegations were not pressed on the basis that these duplicated other allegations in the Notice of Inquiry (Allegations 1(c), 2(a), 2(b), 2(c) and 3). In total 11 of the 20 Allegations were affected by one or more of these objections.

(1) Jurisdictional Objections
31 It was submitted that certain allegations in the Notice of Inquiry were not matters that had been properly referred to the Tribunal in that the Committee had not formed the opinion that a ‘prima facie case’ of ‘misconduct in a professional respect’ as to those allegations. This was said to contravene s 28(1)(c) of the Act. As a consequence, Ms Linkenbagh submitted that the Tribunal was deprived of jurisdiction in respect of those elements of the Notice of Inquiry so affected. A similar jurisdictional issue has been dealt with in Veterinary Surgeons Investigating Committee -v- Lloyd (Inquiry 4: 'Total Eclipse' - Jurisdiction) [2002] NSWADT 283; Veterinary Surgeons Investigating Committee -v- Lloyd (Inquiry 3: 'Remus' - Findings: Allegations 1 (a) to (e)) [2002] NSWADT 285; and Veterinary Surgeons Investigating Committee -v- Ronald George Lloyd(Inquiry 1: ‘Chisel’ - Findings) [2003] NSWADT 95.

32 The Committee’s procedures in considering Ms Clee’s complaint and forming the opinion to refer, were the subject of material tendered by Ms Linkenbagh: see affidavit sworn and filed 22 October 2002. See also Committee Record of Interview with Dr Lloyd dated 19 August 1996 (Ex G 10). Ms Green and Ms Linkenbagh proceeded to compare the exact text of the Committee’s resolutions of 9/96 in respect of File No 534 (the Clee complaint) with the Notice of Inquiry.

33 The Minutes of 9/96 are as follows:

No 534 Dr R G Lloyd, BVSc – Complaint by Ms S Clee

The Committee considered the transcript of the interview with Dr Lloyd and the documentation received in this matter.

The Committee resolved that Dr Lloyd was guilty of misconduct in a professional respect in that –

1. Dr Lloyd supplied the drug Dimetridazole, a Schedule 4 drug,

(a) without examining the horse,

(b) without having previously used the drug, and

(c) requested a lay person to administer an S4 drug to the same horse and still without an examination.

2. Dr Lloyd maintained inadequate records

3. There was inadequate consultation with the owner and inadequate offers of options available to work up the case.

4. There was inadequate burial of the horse which was subsequently uncovered causing great distress to the owner.

The Committee also discussed whether point 4 could also be a breach of an Act regarding water resources.

The Committee resolved to refer this complaint to the Veterinary Surgeons Disciplinary Tribunal and to instruct Conway Maccallum to prepare the necessary charges.

It was agree that the Secretary would forward the draft charges to the members for comment.

ACTION 1. Secretary to draft charges

2. Secretary to circulated charges

3. Secretary to advise Solicitors

4. List on next agenda.

34 To reiterate, s 28(3) provides:
(3)The Investigating Committee must, before exercising its powers under subsection (1) (b) or (c), give the registered veterinary surgeon concerned an opportunity to make written representations to the Committee. If, after receiving written representations, the Committee is still considering whether or not it should exercise those powers, it must give that veterinary surgeon an opportunity to appear before it to make oral representations.’
35 Ms Green and Ms Linkenbagh do not challenge as invalid those elements of the Notice of Inquiry that they see as corresponding to the four particular matters itemised above. Their challenge is directed to those parts of the Notice of Inquiry that do not appear to correspond to the particular matters set out in the resolution.

36 Ms Linkenbagh also makes a general challenge to the adequacy of the resolution and its effect on the referral. She contends that the referral is defective because the words ‘prima facie case’ were not used in the text of the Committee’s resolution. It is clear from the material that the Committee resolved in September 1996 that in its view Dr Lloyd was ‘guilty of misconduct’. The absence of the words ‘prima facie view’ is not fatal. It is the substance of the intention of the Committee as conveyed by the resolution that must be discerned. The words used by the Committee clearly embrace the conclusion that they are satisfied that a prima facie case has been established in their mind. It is clear from the immediate context (the surrounding text of the minutes for that day, and the place where this record appears in the history of the Committee’s handling of the matter) that the Committee is exercising its s 28(1)(c) discretion.

37 As the above record indicates, there were two major resolutions. The first resolution, properly construed, involved a provisional finding of professional misconduct. The Committee itemised the matters that it regarded as constituting misconduct in a professional respect. The second resolution is a response to the next step required of the Committee under s 28(1)(c), formation of the view that it was ‘sufficiently serious’ to refer to the Tribunal.

38 The question these submissions raise is whether matters not encompassed expressly by the provisional findings as to misconduct may be the subject of a Notice of Inquiry.

39 The following allegations were said to be defective: Allegations 1(c), 1(j), 1(m) 1(n), 2(a), 2(b), 2(c) and 4. We turn to consider the issues raised in relation to each of these Allegations.

40 Record Keeping: In total there were seven allegations relating to record keeping (Allegations 1(a), 1(c), 1(d), 1(g), 1(h), 1(k) and 2(a)). Only Allegation 1(c) is challenged on the present ground. The objection is that the Committee did not put Dr Lloyd on notice of specific charges in relation to breach of the record making requirements of regulation 59 of the Poisons Regulation 1994 when dispensing Dimetridazole on 30 December 1995.

41 There can, in our view, be no dispute that the Committee canvassed with Dr Lloyd at the statutory interview the general adequacy of his record keeping: see Ex G 10, pp 23-25. The Committee also referred directly to his admission that he dispensed a prescribed substance on 30 December 1995. Dr Lloyd conceded at interview that he kept no record at all of events prior to the horse’s admission to Hoxton Park on 9 January 1996. The Committee’s decision to proceed with charges is minuted at 9/96, p 748. At point 2 it states: ‘Dr Lloyd maintained inadequate records’.

42 The Committee’s decision is clearly not didactic under point 2 as to the matters to be charged. It is not, in our view, required by s 28(1)(c), that the level of particularity found in the ultimate Notice of Inquiry be reflected in the Committee’s finding of a prima facie case. What must be examined is the nature of the complaint, the matters put in issue by the Committee, the way in which the Committee conducted its interview and the responses given by the veterinarian. The record of decision should be read in light of that information.

43 Having regard to the relevant material in this case (Ms Clee’s complaint, the matters put in issue by the Committee, the responses by Dr Lloyd), it would, we consider, have been reasonably apparent to Dr Lloyd that the Committee’s prima facie finding as to inadequate record keeping would have included the lack of an adequate record in relation to all events up to at least 9 January and covering 30 December . His supply of a Schedule 4 poison on 30 December was plainly a matter of great concern to the Committee. It is disingenuous to suggest that he was not made reasonably aware by point 2 that he was liable to be charged not only with failing to keep to a record conforming to general professional standards but also with failing to adhere to the strict statutory record keeping requirements governing the supply of poisons.

44 Written instructions: Allegation 1(j) alleges failure to carry out professional procedures in accordance with current standards of veterinary science, and refers to the inadequacy of the written instructions given to James Murray when he went out to attend the horse on 8 January 1996 to administer a Schedule 4 poison Dexamethasone.

45 The general issue of the use made of James Murray on 8 January 1996 was covered in the Committee interview (Ex G 10, pp 22-23). The adequacy of Dr Lloyd’s conduct in engaging James Murray is examined. The Committee finds a prima facie case that ‘he requested a lay person to administer an S4 drug to the same horse and still without an examination’. On the other hand, the record of interview does not specifically refer to the question of the inadequacy of any written instructions.

46 For similar reasons to those already given, we consider that it was made sufficiently clear to Dr Lloyd that the special requirements that attach to the administration of Schedule 4 poisons were in issue; and the opinion stated by the Committee at point 1(c) of its resolutions clearly conveyed that. This would have been understood by a reasonable veterinarian to raise the question of the need to give adequate written instructions in relation to the administration of poisons, and the use of unregistered persons for that purpose.

47 While we have considered the objections to Allegations 1(c) and 1(j) first on the narrower basis of whether they could be said to fall within the scope of the opinions expressed in points 1 to 4, we do not regard that as being the ultimate test. We do not accept the premise that the opinions expressed by the Committee in its referral resolution have the effect of removing from the scope of inquiry matters raised in the original complaint that could properly be the subject of a charge of professional misconduct at the point at which the formal referral occurs.

48 The scheme found in the Act is one where the complaint goes to the Committee, it is considered by the Committee after giving the veterinarian an opportunity to be heard, and the fundamental task then is to determine whether the complaint makes out a ‘prima facie case’ of professional misconduct at least in some respects. It is not necessary at that point for the Committee to engage in a process of such length and exactitude that it begins to resemble the process of inquiry that will occur at the final hearing. The focus of s 28 is the exercise of powers conferred on the Committee. It is obliged to reach a state of satisfaction in relation to the complaint as a whole that meets the standards set out in s 28(1)(c). The nominal complainant appointed under s 29(6) then prosecutes the complaint made by Ms Clee before the Tribunal.

49 The Committee will as a result of its examination and because of its special expertise often be able to see deficiencies in the practitioner’s conduct which could not reasonably be discerned by a lay client. It should raise those matters with the practitioner at the interview and give him or her an opportunity to respond. In this instance the matters that the Committee identified using its expertise included such issues as record keeping and the special requirements surrounding the supply and administration of poisons. They also included the range of options for treatment offered to the owner.

50 These are matters that naturally arise for consideration in the minds of qualified veterinarians of standing. Ms Clee concentrated on what was said to her, what she was told to do, what Dr Lloyd did and the condition of her horse, as well as the events surrounding her request for an autopsy report and the burial.

51 The Committee, as we see it, in its final resolution made specific reference to issues that it had identified using its special expertise. It was not thereby seeking to dismiss the seriousness of the other matters raised by Ms Clee; or somehow limit the scope of the referred complaint.

52 This is not a situation like the one that arose in Inquiry 3: see Veterinary Surgeons Investigating Committee -v- Lloyd (Inquiry 3: 'Remus' - Findings: Allegations 1 (a) to (e)) [2002] NSWADT 285. There the circumstances that formed the basis of Allegation 2 in the Notice of Inquiry were unknown to the Committee at the time of the formal interview. The circumstances only became known when the complainant made a further statement in the course of drafting the Notice of Inquiry. They were not put to Dr Lloyd for a written reply and oral representations in the manner contemplated by s 28(1)(c).

53 Conditions of Care: Allegations 1(m) [risk of contagion] and 1(n) [access to water] relate to the way in which the horse was treated after it was taken into care.

54 The matter to which Allegation 1(m) relates [the risk of contagion] was clearly raised by Ms Clee in her original complaint where she stated about her visit on 10 January: ‘As far as anyone knew he was contagious, he was with other horses?’. There was no reply to this comment by Dr Lloyd either in his written reply or at the Committee interview. The matter was not raised at the interview.

55 The matter to which Allegation 1(n) relates [the arrangements made by Dr Lloyd once the horse was in his care to ensure that it had reasonable access to water] was also raised by Ms Clee in her original complaint. She referred to her concerns about the horse standing on a lead rope and the steps she had to take to release the horse so that it could reach water. This issue was canvassed in the Committee interview (see Ex G 10, p 5). Dr Lloyd had failed to respond to her criticisms in his original reply. He asserted to the Committee that his arrangements had been adequate.

56 (The Committee’s resolution did refer to ‘water’ in another context. It stated, ‘There was inadequate burial of the horse which was subsequently uncovered causing great distress to the owner.’ The Committee then adds: ‘The Committee also discussed whether point 4 could also be a breach of an Act regarding water resources.’ We accept that this is a reference to the horse’s carcass being found floating in the dam, as distinct from water-access issues while the horse was in care.)

57 In our view Dr Lloyd was clearly on notice of the matters referred to in Allegations 1(m) and (n). It is not necessary that it be recited in the text of the resolution. Both matters were clearly embraced by the complaint that was the subject of the resolution. Dr Lloyd failed to respond to them in his original reply, and did not respond to them when given the further opportunity to appear before the Committee.

58 Allegations 2(a), 2(b), 2(c):The Committee also submits that Allegation 2, which relates to Dr Lloyd’s alleged misconduct in his capacity as a superintendent of a veterinary hospital was expressly excluded from being charged by the Committee in the minutes of its meeting from December 1996. The relevant paragraph states: ‘Charges relating to superintendent of veterinary hospital - The committee resolved that as the animal treated was a horse and not a small animal, the requirements relating to superintendent of a licensed veterinary hospital do not apply in this case. Mr Stinson is to be advised to delete all charges relating to superintendent.’ The reason stated in these minutes is clearly misconceived. Dr Lloyd’s status as a superintendent attaches to the hospital (in this case a Class A hospital) not to the type of animals treated there.

59 There is no further mention of the superintendent charge in the minutes, however there is reference in the 27 & 28 October 1997 record of meeting to continued consideration of the charges, that ‘The Committee noted that finalisation of the charges was awaited from Conway Maccallum [the firm of solicitors representing the Committee]. It was agreed to also raise this matter with Mr Stinson at the meeting on 28 October 1997’. There is no reference to what ‘this matter’ was or what was discussed with Mr Stinson. Additionally, the minutes from the 28 January 1998 meeting note that ‘the Tribunal charges had been received back from Conway Maccallum. It was agreed to consider the suggested changes and report at the next meeting’. The Tribunal has no other documentary evidence on the issue of the attitude of the Committee to the superintendent charges.

60 The records that have been produced showed continuing attention to the terms of the draft Notice of Inquiry brought back by their solicitor at the time, Mr Stinson. In these circumstances we are not satisfied that the record of the meeting of October 1997 represents an ultimate conclusion of the Committee to which we should attach significance.

61 Allegation 4: Ms Linkenbagh also submits that Allegation 4 alleges facts which are not part of the findings of the Committee. The facts asserted were clearly raised by Ms Clee in her original complaint. Dr Lloyd was clearly on notice of the matters referred to in Allegation 4. The verbal altercation was canvassed in the interview. It is not necessary that it be recited in the text of the resolution.

62 All of the objections under this heading are rejected, and the Tribunal will proceed to deal with the evidence presented in relation to them.


(2) Conduct not Professional Misconduct and/or No Evidence to support findings of Professional Misconduct
63 On 3 September 2002 the parties filed a joint table setting out ‘agreed facts and other matters’. This was intended to assist the Tribunal, and was seen as a means by which a very long inquiry might be brought to a reasonably speedy resolution. The table recorded that certain matters were no longer pressed.

64 No Evidence. The table referred to two allegations, Allegations 1(m) [risk of contagion] and 1(n) [water-access], being defective as there was ‘no evidence’ to support the allegation.

65 We have dealt with the jurisdictional objections to Allegations 1(m) and 1(n). The further objection was that there was ‘no evidence’ to support those two objections, and also Allegation 1(o).

66 As to Allegation 1(m), there was no dispute that a sick horse, Gypsy, was placed in the same paddock as healthy horses. The submission in relation to Allegation 1(m) is possibly best described as one that the evidence could not sustain any adverse finding against Dr Lloyd. The basis for this assertion is that there could be no risk to the other horses as they were owned by Dr Lloyd. This submission (embraced, we reiterate, by the Committee) appears to rest on the assumption that the consideration to be given to the welfare of animals can be lower where the veterinarian places his own animals at risk. It is not clear what point is being made here. It is immaterial to the allegation who owned the other horses in the paddock.

67 The charge is an animal welfare charge. We have observed in an earlier decision that one of the fundamental objects of professional standards in the field of veterinary practice is the welfare of animals: Veterinary Surgeons Investigating Committee -v- Lloyd (Inquiry 4: 'Total Eclipse' - Findings) [2002] NSWADT 284 at [35]-[37].

68 As to Allegation 1(n) it was asserted that there was ‘no evidence of tethering’. The ‘no evidence’ submission seems to depend on whether ‘tethering’ was proven. There was clear evidence before the Tribunal that the horse was standing on its lead rope and needed to be released (see various statements of Ms Clee and Mr Tuinenburg and their evidence). Their evidence was in contest and we deal with that contest later in these reasons. It can not be said that there was no evidence of the horse being inappropriately restrained. We deal with the significance of the use or otherwise of the word ‘tethering’ to describe this situation later in our reasons.

69 It was also said, in objection to Allegation 1(n) being dealt with any further, that there was water available. This is not a relevant objection. There is no assertion in the particulars accompanying Allegation 1(n) that there was no water at all available. The issue is whether the horse was able reasonably to reach what water there was. There was an issue raised during the case as to the adequacy of the water maintenance practices of Dr Lloyd and the amount of water available; and this is dealt with later in the reasons.

70 Not Professional Misconduct. Ms Linkenbagh said that the Committee no longer pressed Allegation 1(o) [adequacy of burial practices] and part of Allegation 4 [the behaviour towards the owner and family in connection with the burial] on the basis that even if the particulars were made out the conduct could not amount to professional misconduct. We do not agree with this view; and give our reasons later in this decision.


(3) Professional Misconduct as a Superintendent
71 Allegation 2 in the Notice of Inquiry refers to the duties of a superintendent of a veterinary hospital. A superintendent is responsible for the care, control and management of the hospital. The Board may only license a registered veterinary surgeon as a superintendent. Dr Lloyd was a licensed superintendent.

72 Made pursuant to cl 17 of the Regulation, Schedule 2 sets out the minimum standards for veterinary hospitals. All veterinary hospitals, whether Class A, Class B or Class C, must conform to the minimum standards set down in Part 1 of the Schedule 2. There are additional standards for both Class A and Class B hospitals (see Part 2 of Schedule 2); and further standards again for Class A hospitals (see Part 3 of Schedule 2). The hospital relevant to this case, Hoxton Park, was a Class A hospital; so it was required to conform to the standards set out in Parts 1, 2 and 3.

73 The Regulation cl 20 sets down the duties of a superintendent of a veterinary hospital. The duties relevant to this case follow:

‘ 20. Duties of superintendent of veterinary hospital
(1) The superintendent of a veterinary hospital who is nominated in accordance with section 54 of the Act is responsible for the care, control and management of the hospital.
(2) The superintendent of a veterinary hospital must also:
(a) ensure that a complete record is made at the time of each veterinary treatment and consultation (including any x-ray film, radiograph or ultrasound image) and that the record is retained for at least 2 years from when it is made, …
(c) ensure that any animal admitted to the hospital for accommodation or treatment is examined daily or more frequently if the circumstances require, …
(f) ensure that any animal admitted to the hospital for accommodation or treatment which shows signs of an infectious or contagious disease is effectively isolated from all animals not so affected, and
(g) ensure that sufficient competent staff are present when elective surgery is being performed and when animals are being prepared for any such surgery, and
(h) ensure that clauses 21--25 are complied with, …
Maximum penalty: 4 penalty units.
Note. Section 54 of the Act enables the licensee of a veterinary hospital to nominate the superintendent of the hospital ’
74 Ms Linkenbagh for the Committee submitted that the Notice of Inquiry was defective in that it was only open to charge Dr Lloyd with professional misconduct in his capacity as a registered veterinary surgeon not a licensed superintendent. The Committee now also contended that the allegation was bad for duplicity in that it relied in its particulars on the same facts that supported charges under Allegation 1. Ms Green for Dr Lloyd, as is to be expected, adopted these submissions. Ms Green submitted that professional misconduct can only be committed by a veterinary surgeon in that capacity pursuant to ss 22 and 26 of the Act.

75 However, the submissions overlook s 54 which provides that a person is not qualified to be nominated as the superintendent of a veterinary hospital unless the person is a registered veterinary surgeon. The effect of s 54 is to confer additional professional responsibilities on veterinary surgeons who chose to become superintendents.

76 The proposition being advanced has an absurd quality. It is being suggested that where veterinary surgeons take on, and then hold themselves out to the public, as being permitted to exercise more onerous and demanding responsibilities, they are immune from being called to account for a failure to meet those responsibilities in a disciplinary context.

77 Ms Green submits that breach of the superintendent’s duties is not expressly stated as deemed misconduct in a professional respect under the code of conduct (s 22(c)). This does not conclude the discussion as to what amounts to professional misconduct. In our view a failure to adhere to the standards required of a superintendent in any serious way could fall within the common law standard as to misconduct in a professional respect. The statutory definition supplements the common law standard. The common law standard is necessarily a flexible one, the content of which may vary over time. Legislatures have deemed certain conduct to be professional misconduct so as to avoid doubt as to where it falls. It is not a comprehensive code. The provision makes that plain, beginning with the words ‘[w]ithout limiting the meaning of the expression ‘misconduct in a professional respect’. An accepted modern common law definition, as previously noted, is found in Priestley JA’s judgment in Qidwai v Brown (1984) 1 NSWLR 100.

(4) Chargeable Conduct
78 Another submission was to the effect that it is not lawful to recite as particulars in support of an allegation of professional misconduct conduct that is chargeable as a criminal or regulatory offence. There is no substance in this submission. It is the case that both s 54 of the Act and cl 20 of the Regulation are penalty provisions. They also reflect required professional standards, ones of such importance that the legislature has attached penal consequences to their infraction.

79 It is well established that the same set of factual circumstances may result in civil proceedings, criminal proceedings and disciplinary proceedings: see Health Care Complaints Commission v Litchfield [1997] 41 NSWLR 630. The existence of a criminal penalty provision does not preclude the finding of professional misconduct on the same statutory responsibilities by a disciplinary body.

(5) Duplication
80 The Committee suggested that a number of allegations in the Notice of Inquiry were otiose, as they were ‘duplications’ of other charges. The Allegations said to be affected by ‘duplication’ were 1(c), 2(a), 2(b) and 2(c) and 3.

81 These objections are rejected. Allegation 1(c) relates to a failure to comply with a regulatory requirement relating to the making of a dispensing record for a poison. Allegation 1(d) relates generally to Dr Lloyd’s failure to make a detailed record of treatment and consultation on 30 December 1995. These allegations arise in two separate and different contexts, under two separate legislative schemes. Allegation 1(c) relates to requirements under the Poisons Regulation 1994 and Allegation 1(d) relates to requirements under the Code of Conduct found within the Veterinary Surgeons Regulation 1995. Allegation 2(a), (b) and (c) relate to allegations of misconduct in a professional respect against Dr Lloyd in his capacity as a superintendent of a veterinary hospital. Allegation 2(a) is expressed similarly to Allegation 1(k). Allegation 2(b) is similar to Allegation 1(n), but is more expansive and concentrates on the responsibilities of a superintendent. Allegation 2(c) is similar to 1(m). The Tribunal’s reasons are given later under the heading ‘Conduct as Superintendent of a Veterinary Hospital’..

500 As noted earlier, theses cases are to be contrasted with the present case where the conduct involved the relationship with a client in respect of a matter commonly undertaken by veterinarians (burial of animals). Dr Lloyd’s conduct in this case is of a kind that brings the profession of veterinary science into disrepute.

501 Finding as to Allegation: The Tribunal agrees with Dr Rawlinson that ‘proper, mutually agreeable, arrangements [should have been] made for disposal of the carcass’; and moreover they should have been performed competently.

502 This allegation is established.

503 The misunderstandings held by the new Committee and by some leading veterinarians as to what is unacceptable conduct (and may if sufficiently reprehensible to give rise to a finding of professional misconduct) revealed by these recent submission are of serious concern to this Panel.

504 Clause 2(1) provides that a veterinary surgeon must at all times consider the welfare of animals when practising veterinary science; breach of which constitutes misconduct in a professional respect. Allegation 1(n) alleges breach of that standard. (We reiterate that we have rejected the present Committee’s submission that Allegation 1(n) no longer be considered).

505 The particulars refer to the horse being found ‘tethered’ on 10 January 1996, and suggest as a result the horse was unable to reach water. The particulars then refer to the horse keeping his muzzle in the trough for 10 minutes.

506 We have accepted the evidence of Ms Clee and Glenn Tuinenburg as to the horse having a lead rope, and being impeded by the lead rope in getting to water. We also accept that the horse spent some time with its muzzle in the trough.

507 The lead rope, we are satisfied, was caught up in some way around the hoof of the horse sufficient for it to act as a restraint. The word ‘tethered’ is not the most apt way to describe this situation.

508 The word ‘tether’ is defined in the Macquarie Dictionary (3rd ed, 1997) as: ‘a rope, chain, or the like, by which an animal is fastened, as to a stake, so that its range of movement is limited.’ We understand tethered ordinarily to refer to the use of a rope or similar piece of equipment to restrain the horse so that it is confined within an area, but still has some capacity to move available to it. The object of the tether is to prevent the animal moving outside the area defined by the length of the tether.

509 We are satisfied, though this may not have been usual practice, that the horse had a lead rope attached to the halter. It is an undesirable practice to leave a horse in a paddock with a lead rope attached to the halter of sufficient length that it could limit movement in the way described by Ms Clee and Mr Tuinenburg.

510 It is impossible to assess how long the situation that Ms Clee and Mr Tuinenburg had encountered had gone on.

511 Amount of Water. As recorded earlier in these reasons, A good deal of evidence was heard on Dr Lloyd’s practices in ensuring that the water troughs were kept replenished

512 We are satisfied that Dr Lloyd had no orderly and supervised arrangements in place to make sure they were attended to. He left to it to staff to attend to these matters at their convenience subject to the duties in the surgery. Such an approach clearly carries the risk that things may not get done. He was also asked about his procedures for checking horses in the paddock, and whether they had access to feed. Again his answers were lackadaisical.

513 He was unpersuasive in his replies seeking to dispute the suggestion that leaving a horse with a lead-rope on could cause it to become impeded, and therefore unable to access food and water sources.

514 We are satisfied that the circumstances proven are sufficient to warrant a conclusion that Dr Lloyd failed to consider the welfare of the animal (by leaving the lead rope on, which gave rise resulting difficulties for the horse). That it is not good practice to leave a lead rope on, because of the difficulties that may result, was, we consider recognised by several of the witnesses who gave evidence for Dr Lloyd (for example, Dr Lloyd himself, James Murray and Mellony Johnston). While they all said Dr Lloyd would never leave a lead rope on a horse placed in a paddock, we are satisfied that on this occasion this did occur.

515 As to the interpretation to be placed on the horse swishing its muzzle in the water for some time, inference that we are, we consider, invited to draw is that the horse was very thirsty. It was a hot time of year. But the swishing of a muzzle is also consistent with a horse trying to relieve soreness in the mouth or gums. It may be therefore that the horse was not as thirsty as his actions might have suggested. On the other hand it is of course one of the functions of water that it provides horses with an opportunity to relieve soreness. Water access is also important for reasons of that kind.

516 Findings as to Particulars and Allegation: The particulars are established. Accordingly misconduct in a professional respect is established, though we should indicate that we do not regard this instance as falling at the most serious end of the spectrum; primarily for the reason that it is unclear how long the situation had gone on.


The Poisons and Drugs Requirements Allegations
517 For the gazettal period affecting this case, 22 December 1995 to 22 March 1996, Dimetridazole [the drug provided to Ms Clee to administer on 30 December 1995] and Dexamethasone [the drug injected on 8 January 1996] were included in Schedule 4 of the New South Wales Poisons List (Ex G19).

518 Each of the four Allegations, 1(b), 1(c), 1(f) and 1(j) relate to Dr Lloyd’s action in relation to the dispensing of those two poisons. Clause 6 of the Code provides a basis for these charges. Breach of a cl 6 requirement constitutes misconduct in a professional respect (Regulation, cl 10).

519 The first three allegations refer to the provision of Dimetridazole on 30 December (failure to provide appropriate instructions in relation to administration of a Schedule 4 poison, as required by cl 6(4) of the Code; failure to comply with relevant legislative conditions (1(b)), as required by cl 6(1) of the Code (1(c)); failure to meet labelling requirements, as required by cl 6(3) of the Code)(1(f)).

520 The fourth allegation in this group, Allegation 1(j), refers to failure to provide on 8 January 1996 appropriate instructions in relation to administration of a Schedule 4 poison, as required by cl 6(4) of the Code, in this instance Dexamethasone.

521 As noted earlier, the principal particulars in respect of these allegations were admitted (with the particulars of Allegation 1(j) admitted in whole).

522 Dimetridazole (the 30 December drug). There is a short report from Dr Jill Maddison, Department of Pharmacology, University of Sydney (G21). She was asked by the Committee to provide information on the use of Dimetridazole in horses. She noted that it was difficult to find any specific information on this drug as it was not registered for use in horses. She said, ‘I can only assume that it was used in a horse because it is cheaper than metronidazole.’ She did note that the references she had consulted ‘all seem to indicate that the mechanism of action and pharmacokinetics of dimetridazole is very similar to metronidazole which of course is widely used in horses.’

523 Dr Rawlinson states, ‘an S4 drug was prescribed over the phone, with no knowledge of the animal’s condition and compounded by prescribing and providing a therapeutic substance not registered for use in horses.’

524 Dr Rawlinson acknowledges Dr Lloyd’s point that in the standard text a dose of 50 mg/kg is recommended, he notes that this is for agricultural animals, i.e. cattle and sheep. He notes that because chronic diarrhoea syndrome in horses has a ‘complex and largely unknown aetiology’ it was once ‘fashionable to incriminate protozoans [such as giardia].’ He said that it is ‘now accepted that these organisms are normal or opportunistic inhabitants of equine gut.’ He states that in any case ‘an inappropriate drug was prescribed’. Further there were no written instructions as to dose rate or route of administration for an animal whose condition and weight were unknown, and no accurate dose rate appears to have been calculated.

525 In evidence he noted that Dimetridazole has a range of applications in poultry and pigs. But giardia in horses was so rare he had never seen it, and he agreed with Dr Maddison that there is no research evidence to support is use in a horse.

526 We agree with Dr Rawlinson’s assessment.

527 Dexamethasone (the 8 January drug). Dr Rawlinson said that Dexamethasone is not a normal recommended treatment for colic (ts 690). (Dr Dart commented that Buscopan (which was also given on this occasion) is commonly used for treatment of abdominal pain.)

528 Dr Dart noted and we agree that Dexamethasone is a corticosteroid and antiinflammatory drug that is not commonly used in the treatment of abdominal pain in horses. He noted that the corticosteroids, more commonly prednisalone are used in the treatment of some horses with specific types of chronic diarrhoea.

529 Dr Lloyd referred in his evidence to the markings he placed on the two medications when he gave them to James Murray. Those markings did not meet the standards required, or the criticisms made by Dr Rawlinson.

530 Dr Lloyd said it was his understanding that veterinarians could use and prescribe unregistered products such as Dexamethasone in 1995.

Allegation 1(b). We are satisfied that the particulars are established with one exception. One aspect of the particulars is not relevant, i.e. the particular that no instructions were given as to any withholding period. Withholding periods are relevant to, for example, racehorses or slaughter of animals for animal or human consumption: see further Code, cl 6(2), quoted earlier). Neither of these circumstances were relevant to this case at the point of the treatment. While one particular is not established, we are satisfied that the allegation is established.

531 Allegation 1(c).We are satisfied that Dr Lloyd failed to ensure that the conditions relating to the making of records in respect of the supply of restricted substances imposed by regulation 59 of the Poisons Regulation 1994 were complied with, as set out in the particulars. The allegation is established.

532 Allegation 1(f). We are satisfied that the drug was supplied without ensuring that it was correctly labelled. The container did not contain any information, warning or other statement about the quantity of the drug, an adequate statement as to its being a poison subject to Schedule 4 (the statement ‘Caution S4’ was insufficient) and what to do in the event that a person came into contact with it or ingested it. The allegation is established.

533 Allegation 1(j). The charge is similar to Allegation 1(f) in that it goes to the adequacy of the instructions given on 8 January to James Murray. The particulars are established. We are satisfied that there were no written instructions as to dosage requirements, as to the route of administration (the markings IV and IM were inadequate in the circumstances) and any withholding period. The allegation is established.


The Record Keeping Allegations
534 The allegations of inadequate records refer to each of the consultations with Ms Clee. Allegation 1(a) relates to 26 December 1995, 1(d) to 30 December, 1(g) to 6 January 1996, 1(h) to 8 January, and 1(k) to the period of hospitalisation, 9 to 12 January. No record was maintained by Dr Lloyd until 9 January 1996. The principal particulars were admitted in relation to Allegations 1(a), (d) and (h). Those relating to 1(g) are denied. Some of the particulars were admitted in relation to Allegation 1(k)(the record in respect of 9-12 January). Most were denied in respect of 1(g). Dr Lloyd, in effect, contends that the record he made during the period of hospitalisation was adequate. He seeks to excuse himself in relation to the omissions prior to that time on various grounds, which we have already canvassed to some extent.

535 Allegation 1(a) deals with the failure to record the original telephone call. The allegation depends on the premise that what was involved was a consultation. In our view that was plainly the case. A person previously unknown to Dr Lloyd had made contact. He offered professional advice and promised to undertake research. The client received and acted on advice given at that point. The rendering of the advice involved a consultation. A client relationship had been created, whether or not it was intended to charge a fee at that point.

536 This omission was exacerbated a few days later when on 30 December 1995, Ms Clee attended the surgery to pick up the drug. This is the subject of Allegation 1(d). Again no record was made. The seriousness of this event can not be underestimated. A potent drug was placed in the hands of an owner with no satisfactory written instructions.

537 Then on 6 January 1996 Dr Lloyd advised Ms Clee to change the course of treatment, and again no record was made. This is the subject of Allegation 1(g). Dr Lloyd disputed this allegation on the ground that Ms Clee contacted him by telephone, as distinct from consulting him ‘at [his] surgery’. The difference is immaterial. The contact remains, on either version, a consultation for the reasons that we have given in relation to Allegation 1(a); and should have been noted.

538 On 8 January 1996 Ms Clee called in distress over the state of her horse, and James Murray was despatched to administer two injections. It is plain on any view that by this stage a series of veterinary services had been supplied. Again no record was created. This is the subject of Allegation 1(h).

539 Findings in relation to Allegations 1(a), 1(d), 1(g) and 1(h). All of the above particulars are established. The circumstances are ones of escalating seriousness. Clause 5(12) reinforces the importance of keeping adequate records. It is required that a veterinary surgeon ensure that a detailed record be made of a consultation; and that is kept for at least 2 years. Clauses 5(4) and (5) refer to appropriate practice in relation to referral to another veterinarian. Clearly a good record is required for a range of obvious reasons: to enable the treating vet to continue to give appropriate treatment; to assist another vet taking over the case, whether within the practice or after referral; in the event of a further presentation of the animal; or in the event or later dispute or inquiry; for research, statistical and billing purposes.

540 Breach of cl 5(12) constitutes misconduct in a professional respect. These allegations are established.

541 Allegation 1(k). The creation of a record at this point, approximately two weeks after contact with Ms Clee had commenced, would appear to reflect a view on Dr Lloyd’s part that it is not until he has physically sighted an animal that it is necessary to keep a record. When asked in cross-examination why he did not start a card when he supplied the Dimetridazole (on 30 December) he replied: ‘Well, I hadn’t seen the animal yet’ (ts 781). The reply crystallises the shortcomings of Dr Lloyd’s understanding of the need to keep adequate veterinary records.

542 As to the record that was created as from 9 January, Dr Rawlinson made the following criticisms of the record: no record of prior treatment recorded; no adequate history, clinical examination, investigation plan, differential diagnosis and treatment plan; no record of the alleged telephone conversation with the veterinarian at the Rural Veterinary Centre. Dr Rawlinson attached to his statement the Case Records Guidelines issued by the Board in September 1994. Dr Rawlinson was critical generally of the absence of a clinical record, and noted on the occasion of the administration by the unregistered person still no clinical record was generated.

543 He noted that there was nothing on the card for 9, 10 or 11 January indicating a suspicion of cancer (ts 681). He notes that a rectal examination was recorded for 11 January, but in his view that should have been done on admission on the 9th (ts 682).

544 Dr Dart also commented that the records kept on Gypsy were ‘well below the standards expected of the veterinary profession, irrespective of the failure to record any client communications.’ More specifically he noted that the description given to him by Dr Lloyd as to what occurred at the first examination was ‘more comprehensive’ than that noted on the card. Appropriately, in our view, this led Dr Dart to comment that this made ‘it difficult to determine what exactly transpired.’ His assessment of what should have been done and recorded is very similar to Dr Rawlinson’s.

545 Dr Lloyd agreed that he did not include previous history, and that the conversation he said he had with the University veterinarian (Dr Dart) was not recorded. He disputed the assertions that he did not record diagnosis, clinical signs, some treatments and the work up. While there was some information on the card into the latter matters, we are not satisfied that they were at an appropriate level of precision.

546 We agree with the criticisms of both veterinarians. The particulars are made out, i.e. that diagnosis, clinical signs, some treatments, previous history, consultation with the University of Sydney and work up are not recorded. These are each important deficiencies and in combination the record is seriously defective.

547 Finding as to Allegation 1(k). The particulars are established. The allegation is established.

Conduct as Superintendent of a Veterinary Hospital

548 Allegations 2(a), (b) and (c) deal with this matter. For reasons given earlier, we regard these allegations as properly before the Tribunal. As noted earlier, the principal particulars in support of these allegations were not admitted. As noted earlier, cl 20 of the Regulation imposes special duties on the superintendent of a veterinary hospital.

549 Under cl 20(a) a superintendent is required to ensure that a complete record is made at the time of each veterinary treatment and consultation. Allegation 2(a) alleges such a failure.

550 Under cl 20(c) a superintendent must ensure that any animal admitted to the hospital for treatment is examined daily or more frequently if the circumstances require. Allegation 2(b) alleges such a failure.

551 Under cl 20(f) a superintendent must ensure that any animal admitted to the hospital for treatment which shows signs of an infectious or contagious disease is effectively isolated from all animals so affected. Allegation 2(c) alleges such a failure. Proceedings may be brought against a superintendent who fails to comply with cl 20, maximum penalty as at the time of this inquiry was 4 penalty units (now 5 penalty units).

552 Allegation 2(a). This allegation itemises the same particulars as support allegation 1(k). For the reasons already given the particulars are established. A failure to maintain adequate records is clearly a more culpable breach of standards in circumstances where the veterinarian is also the approved superintendent of a veterinary hospital. Conferral of the status of superintendent carries with it a higher responsibility to ensure the maintenance of professional standards than might be seen as required of the ordinary veterinarian. Clause 20(a) of the Regulation reflects this view.

553 We acknowledge that this is a case where Dr Lloyd was both the treating veterinarian and the superintendent. He breached the general standard applicable to all veterinarians. He also breached the special standard applicable to a superintendent. While all breaches are not deemed to be professional conduct by cl 10 of the Regulation, nonetheless a serious breach of cl 20(a) could, we consider, constitute misconduct in a professional respect at common law. A minor transgression of this cl 20(a), while it might lead to the imposition of a penalty in proceedings brought to enforce the provision would probably not constitute professional misconduct. In this case, however, the breach was a serious one. We have found that 14 relevant items of information were omitted from the record. The allegation is established.

554 Allegation 2(b). The allegation refers to the standard of conduct required by cl 20(c), which provides that ‘any animal admitted to the hospital for accommodation or treatment is [to be] examined daily or more frequently if the circumstances require’.

555 The question raised by the allegation is whether the animal should have been examined ‘daily or more frequently’. The first two sentences of the particulars refer to the issues relating to tethering and access to water, on which we have made findings previously.

556 The third sentence alleges that ‘Gypsy had not been examined by you or by any other employee of your hospital for a lengthy period.’ While it is not stated precisely when the ‘lengthy period’ commenced and ended, this sentence read in the context of the first two sentences, refers back, we consider, to the situation in which the horse was found on 10 January. For present purposes we will treat the ‘lengthy period’ to which the particulars refer as the period between hospitalisation and when the horse was found impeded in the paddock; as distinct from the entire period that the horse was in care.

557 The only evidence from the record and from Dr Lloyd is that rudimentary examinations were performed by Dr Lloyd on the 9th, 10th and 11th. The horse’s condition was so serious that a more frequent level of activity in relation to examinations was to be expected. Dr Lloyd relied on visual observation from the distance of his surgery as his way of keeping track of the horse’s condition (statement p 15).

558 We consider that the standard of practice required of a veterinarian in these circumstances in 1996 was and remains that sick animals should be examined regularly as to their appearance (bright/alert, dull/depressed, drinking, eating, passing urine and bowel motions), their clinical signs (temperature, heart rate and respiration rate) with these observations recorded twice a day. Very sick animals would have these observations taken and recorded more frequently (every 1 to 2 hours). These observations are often taken by veterinary nurses. If there was a failure on the part of the veterinary nurses to take observations (as one of Dr Lloyd’s comments in the course of the case implied), this does not exonerate the veterinarian from ultimate responsibility.

559 The allegation is established.

560 Allegation 2(c). The particulars cover the same ground as Allegation 1(m). For the same reasons as previously given, the particulars are established. A higher standard is expected of veterinarians entrusted with the right to supervise veterinary hospitals, as is reflected in cl 20(f). A minor breach would not give rise to a finding of professional misconduct.

561 But this was, in our view, a serious transgression of the standard in that no adequate steps had been taken by Dr Lloyd to exclude the possibility of the animal having a contagious disease in circumstances where he had treated the animal on that basis. The allegation is established. Dr Lloyd’s response essentially was that he used his ‘clinical experience’ to make a judgement that the horse was not contagious.

562 We consider that a competent veterinarian would have examined a faecal sample to rule in or out the possibility of protozoans (a negative finding may not be conclusive), and he or she would have performed a full blood count which would have included a white cell count that could rule in or out an active infection. Then the practitioner would have to decide if the infection was ruled in, if that infection was contagious or not and then decide on the level of isolation required.

563 The allegation is established.


The Unregistered Person Allegation
564 As noted earlier, the particulars in respect of Allegation 3 were admitted.

565 The present Committee said that it did not press Allegation 3 in its entirety as it is affected by duplicity. The allegation is clear, and is not affected by two possibly conflicting meanings: see generally the comments on what duplicity covers earlier in these reasons.

566 This allegation relies on one particular – the despatch of James Murray, an unregistered person to administer the prescribed substance – and that is the same as one of the many particulars that are recited in support of Allegation 1(i). The present Committee may be asserting that Allegation 3 is unnecessary in the sense that the matter has already been dealt with by Allegation 1(i). This is not so.

567 It is clear that Allegation 1(i) and Allegation 3 deal with different disciplinary concerns. In the case of Allegation 1(i) the charge is one of professional incompetence and a number of failures are recited including but not limited to the use of an unregistered person to administer the drug on 8 January 1996. Allegation 1(i) deals with a range of omissions, and then invites the Tribunal to determine whether there was a failure to carry out professional procedures in accordance with current standards of veterinary science.

568 Allegation 3 does not invite such a discussion. Its establishment does not require an overall assessment of the quality of the professional conduct on that day. It focuses on one element of the events, the use of the unregistered person. It is conceivable that a veterinarian might deliver a competent service viewed in totality even though an unregistered person was used. In such a case there would be no basis for a finding of the kind sought in this case by Allegation 1(i), but there would be a case for a finding of the kind sought by Allegation 3. Allegation 3 deals with a matter that is in the nature of a strict liability breach of professional standards.

569 In his statement of agreed facts Dr Lloyd admitted the particulars of Allegation 3 without qualification. Yet at hearing he sought to argue that the situation he found himself in fell within one of the narrow statutory exceptions allowing administration by an unregistered person. The Act, s 44(1)(k) provides that an unregistered person may ‘where a registered veterinary surgeon is not available, attend and treat an animal in urgent need of veterinary attention or treatment.’

570 So as to avoid any doubt on this matter, we are not satisfied that Dr Lloyd’s situation fell within those circumstances. He worked on the outer western edge of the metropolis of Sydney near an area given over to semi-rural activities. There were numerous veterinary practices between Hoxton Park and Casula/Punchbowl. If he was busy and unable to undertake the task himself it was open to him to enquire of other veterinarians to undertake the work. We are satisfied that he gave no consideration to that possibility.

571 The duty laid down by s 22(a) is reinforced by the Code at cl 5(9). It is obligatory that a veterinarian supervise all clinical activities undertaken by lay staff. Dr Lloyd acknowledged in cross-examination (ts 805) that only a ‘competent’ layperson could be left to administer intramuscular and intravenous injections. He was cross examined at some length as to the skills involved in and the implications that attach to the giving of injections. He gave no adequate answer for his decision to use James Murray to undertake the task, especially in a situation where the horse was effectively unknown to Dr Lloyd and where scheduled poisons were to be used.

572 Dr Dart was critical and noted the gravity of what occurred set in the overall context of the case in these terms:

‘At this time Dr Lloyd had not examined the horse yet had been prescribing medication. The suggestion was made that this horse had adversely reacted to a medication prescribed by Dr Lloyd and that medication was used off label. Dr Lloyd then presumed the symptoms described to him over the phone related to signs of abdominal pain. He then prescribed further medication based on an estimated weight and had these administered by an unsupervised, untrained part-time employee. The situation is inappropriate irrespective of the circumstances.’
573 We fully concur with this assessment.

574 This conduct clearly amounts to misconduct in a professional respect within the meaning of s 22(a) of the Act.

575 The allegation is established.


The Personal Conduct Allegation
576 Allegation 4 relates to the way Dr Lloyd dealt with Ms Clee between 12 and 23 January. It alleges that he did not conduct himself in accordance with the professional standards expected by other veterinary surgeons, the users of the services of veterinary surgeons and the New South Wales public in general. The allegation reflects the standard required of veterinary surgeons by cl 9 of the Code. Breach of that standard constitutes misconduct in a professional respect (Regulation, cl 10).

577 The particulars refer to three sets of circumstances. First, the information given to Ms Clee about the autopsy; and associated undertakings. Secondly, the particulars refer to more specific undertakings given to Ms Clee in relation to the reburial of Gypsy in her presence and the allegedly hurtful way in which Dr Lloyd spoke to her. Thirdly, the particulars refer to the invitation made to Glenn Tuinenburg to settle his difference with Dr Lloyd by way of a fight.

578 We are satisfied that Dr Lloyd did during the afternoon of 12 January 1996 inform Ms Clee when she came to the property that he had performed an autopsy that morning, and had found tumour nodules, and said that his liver was gone. We are satisfied that he informed Ms Clee that he would keep the samples and show her. Dr Lloyd does not dispute these matters. What he disputes is whether his action thereafter was unacceptable.

579 He disputes that Ms Clee asked for the samples again on 18 January, and says that in any case he had discarded them by then. We are satisfied that Ms Clee did ask for the samples on 18 January and that her friend, Nathalie, asked on 23 January. As noted earlier, we are not satisfied that Dr Lloyd had discarded the sample either on 17 January or on 21 or 22 January.

580 Ms Clee’s evidence was that Dr Lloyd promised on many occasions to send her the autopsy reports.

581 In summary sentences 1, 2 and 3 of the Paragraph 1 of the particulars are established. We are not satisfied that similar promises were made by Dr Lloyd in relation to the sending of a sample. Sentence 4 is not established in relation to a promise to send a sample. While the evidence was that on several occasions he promised to send an autopsy report, there was no evidence that he promised to send a sample. The only evidence that might support such a finding is that of Ms Clee in relation to 12 January where she states that Dr Lloyd said he would ‘keep’ a sample for her. We do not think that can be interpreted as a promise to send a sample.

582 Paragraph 2 of the particulars refers to Dr Lloyd’s promises and conduct in respect of the reburial of Gypsy on 23 January. The particulars contained in this paragraph are all established. There are some variances in time estimates as between Ms Clee, Glenn and the Tuinenburgs. We are satisfied that the times given in the particulars are broadly accurate.

583 We note that Ms Clee had indicated on the morning of 23 January that she intended burying the horse herself. She was dissuaded by Dr Lloyd’s promises. We accept the statements in Ms Clee’s original letter that Dr Lloyd had promised to ring her at 2.30 to let her know what time Gypsy would be buried.

584 Paragraph 3, as to the explanation offered by Dr Lloyd as to why he proceeded without honouring his promise, is established.

585 The use of the words ‘that conversation’ at the commencement of paragraph 4 reads as a reference to the conversation mentioned in the immediately preceding paragraph. It is clearly meant to be a reference to a separate conversation which we have found occurred on the morning of 23 January. Dr Lloyd has admitted that he referred to the horse’s carcass as ‘the whole gory lot’. In the context of a discussion with a distressed owner who had just seen her dead horse floating in the dam, this was an unprofessional comment suggesting a dismissive attitude to the horse, albeit dead, who was still an object of great affection. This paragraph is established.

586 Paragraph 5 refers to the discussion at the surgery that was said to have involved a threat by Dr Lloyd against Glenn Tuinenburg. These particulars were vigorously contested by Dr Lloyd. We have dealt with these events at considerable length in our reasons. For the reasons given there we are satisfied that the particulars are established.

587 We note that the particulars do not purport to quote Dr Lloyd directly. They speak of Dr Lloyd inviting Glenn to ‘take off his glasses and hat and fight you’. Dr Lloyd admits saying that he said to Glenn that he should ‘take off your funny hat and glasses and act like a man’ [statement to Tribunal, p25] or ‘If he had anything to say he should take off his hat and glasses and step outside the car and have a chat to me’ [interview with Committee p19]. The Tribunal has found that the conversation happened just outside the surgery before the party went to the burial site (as is particularised).

588 Dr Lloyd contended his words did not involve a threat of violence or were intimidatory. This contention is far-fetched. The words were plainly intimidatory, and would be understood by most members of the community (especially men) as signifying an intention to fight.

589 A veterinary surgeon should avoid ever using language to a client which might be interpreted as intimidatory. It is not enough that the surgeon may not ever have intended to act on the words used. The standard to which Dr Lloyd is subject is that of the reasonable expectations of the community, in particular users of veterinary services.

590 Dr Lloyd in his original reply to the Committee (20 May 1996) said that faced with the ‘verbal abuse’ he received some form of ‘verbal defence’ was called for. We accept that it may be appropriate for a practitioner to reply immediately and directly to criticism of their professional competence. That reply, as we see it, should be a constructive one; and go no further than seeking to meet the complainant’s substantive points of criticism in a measured and restrained way. In many circumstances the best course may be to close the conversation, and invite the complainant to arrange a separate time to discuss the issues or advise the complainant to refer them to a complaints body. The comments made by Dr Lloyd were not along any of these lines. The remarks were not constructive and could have well have led to a melee.

591 Ms Clee and Glenn were upset over why the horse had became uncovered, and, as Dr Lloyd well knew, were very suspicious of his conduct. They asked a lot of questions. It was a tense situation. We are satisfied that at this point Dr Lloyd had not told them that the horse had been buried.

592 Dr Lloyd let his nurse Mellony Johnson escort the party to the site. Mellony knew the horse had been buried. She did not know that it was reburied. Mellony did not know about the prior promises to witness the burial. She found herself engulfed by a storm of anger and distress, with Ms Clee breaking down on discovering her horse had already been buried and Glenn swearing (possibly profusely). When queried as to whether this was definitely Gypsy’s grave, there was further anger and distress when Mellony told them that Dr Lloyd’s boys had seen the horse buried. They then heard one of the boys chime in and say ‘the horse’s foot fell off’.

593 The community would, we consider, see Dr Lloyd as having behaved contemptibly in leaving Ms Clee and her family to find out in this way that they were not going to see their horse buried. When Dr Lloyd phoned her telling her to come he had already buried the horse. The Clee party’s anger at his actions was perfectly understandable.

594 His conduct on 23 January was, we consider, unacceptable, and plainly of a kind that would bring the profession into disrepute in the eyes of the community. That morning he promised the the Clee/Tuinenburg family that the reburial would be conducted in their presence. He then moved quickly to have that occur before they were called back to the property. He has given various inconsistent justifications for his actions. We have listed some of them earlier in our reasons. We will not set out at length many of the explanations that Dr Lloyd gave for his conduct in re-examination (ts 940-947) but many of them disturbed the Tribunal for their dismissive view.

595 His conduct was such as to give the impression that he had something to hide. One of his explanations was that he did not want to expose Ms Clee to more distress. The explanation is patronising. It is not consistent with the respect that must always be shown for the reasonable requests of the client, as well as the client as a person, in the modern professional relationship.

596 We note that the particulars state that Nathalie Taimuri offered to call the police. This is not correct. We are satisfied that there was an offer of a call to the police, but it was made by Mrs Tuinenburg not Ms Taimuri.

597 Findings as to Particulars and Allegations. The particulars with the qualifications noted above, are established. The allegation is established. The misconduct described is of great seriousness.


Summary
598 All Allegations are found proven to our comfortable satisfaction.

OTHER MATERIAL
599 A number of issues arose in the course of the evidence that were not the subject of allegations or particulars in support. These related to the standard of the autopsy; the extent of the incisions and the occurrence of spillage in the course of moving the carcass; the lack of prompt notification of death to the owner; treatment of colic; and the cause of death. We have not made findings on these matters.

600 As to cause of death, we note that Dr Lloyd has at all times submitted that he was not responsible for the death of Gypsy. The Notice of Inquiry does not require the Tribunal to make a finding on this matter. The Tribunal makes no finding as to whether Dr Lloyd was or was not responsible for the death of Gypsy.


DETERMINATION

1. The respondent is guilty of misconduct in a professional respect in relation to Allegations 1(a), 1(b), 1(c), 1(d), 1(e), 1(f), 1(g), 1(h), 1(i), 1(j), 1(k), 1(l), 1(m), 1(n) and 1(o); Allegations 2(a), 2(b) and 2(c), Allegation 3 and Allegation 4.

2. After determination of the other three Inquiries, this Inquiry is to be reconvened for determination of orders pursuant to section 32.