Civil and Administrative Tribunal New South Wales

• Medium Neutral Citation: Health Care Complaints Commission v Qasim [2014] NSWCATOD 42
• Hearing dates: 17 March 2014 to 28 March 2014
• Decision date: 02 May 2014
• Jurisdiction: Occupational Division
• Before: Acting Judge AF Garling, Principal member; Dr. M. Gleeson, Medical member; Dr. P. Anderson, Medical member; Professor D. Chisholm, Lay member

Decision

1.That Dr. Qasim's health practitioner's registration be cancelled as of today.

2.That Dr. Qasim is not permitted to make an application for re-registration or review for a period of four years from today.

• Catchwords: Professional misconduct, physical and/or mental impairment, condition or disorder, not competent to practise the profession of specialist endocrinologist
• Legislation Cited: Health Practitioner Regulation National Law (NSW)
• Cases Cited: Briginshaw v Briginshaw 1938 60 CLR; Tung v Health Care Complaints Commission 2011 NSWCA
• Category: Principal judgment
• Parties: Health Care Complaints Commission (Applicant); Dr. Shaheen Qasim (Respondent)
• Representation: Health Care Complaints Commission; K. Richardson (Applicant); Dr. S Qasim (Respondent in person)
• File Number(s): 1420034
• Publication restriction: Suppression order in respect of patients named

reasons for decision

1 The Medical Council of New South Wales referred this complaint to the Medical Tribunal of New South Wales. The complaint was, in summary, as follows:

Complaint 1

That Dr. Qasim is guilty of unsatisfactory professional conduct under Section 139B of the National Law in that the practitioner has engaged in conduct that demonstrates that the knowledge or judgment possessed or care exercised by the practitioner in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience. Particulars are then supplied.

Complaint 2

Dr. Qasim is guilty of unsatisfactory professional conduct under Section 139B of the National Law in that the practitioner has:

engaged in conduct that demonstrates that the judgment possessed or care exercised by the practitioner in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience.

engaged in improper or unethical conduct relating to the practice or purported practice of medicine.

Again, particulars are supplied.

Complaint 3

Dr. Qasim is guilty of professional misconduct under Section 139E of the National Law in that the practitioner has:

engaged in unsatisfactory professional conduct of a sufficiently serious nature to justify suspension, cancellation of the practitioner's registration, or

engaged in more than one instance in unsatisfactory professional conduct that when the instances are considered together they amount to conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration.

Particulars are supplied.

Complaint 4

Dr. Qasim suffers from an impairment. The impairment alleged is the practitioner has a physical and/or mental impairment, condition or disorder namely a paranoid or delusional disorder which is of sufficient nature and degree to impair the practitioner's mental capacity to practise the profession.

Complaint 5

Dr. Qasim is not competent to practise the profession under Section 139 of the National Law as the practitioner does not have sufficient mental capacity, knowledge and skill to practise the profession. Particulars are supplied.

2 Health Practitioner Regulation National Law ("the National Law") provides:

"139 Competence to practise health profession [NSW]

A person is "competent" to practise a health profession only if the person-

(a) has sufficient physical capacity, mental capacity, knowledge and skill to practise the profession; and

has sufficient communication skills for the practice of the profession, including an adequate command of the English language.

139B Meaning of "unsatisfactory professional conduct" of registered health practitioner generally [NSW]

(1) "Unsatisfactory professional conduct" of a registered health practitioner includes each of the following-

(a) Conduct significantly below reasonable standard Conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of the practitioner's profession is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience.

139E Meaning of "professional misconduct" [NSW]

For the purposes of this Law, "professional misconduct" of a registered health practitioner means-

(a) unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration; or

(b) more than one instance of unsatisfactory professional conduct that, when the instances are considered together, amount to conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration."

ONUS

3 The Tribunal accepts the principles set out in Briginshaw v. Briginshaw 1938 60 CLR at 336 as the standard of proof applicable in this hearing and, that is, the Health Care Complaints Commission bears the onus of proving the matters alleged in the amended complaint to the reasonable satisfaction of the Tribunal on the balance of probabilities applying that standard having regard to the gravity including the gravity of the consequences and importance of the matters to be determined in accordance with the principles set out in that case.

4 An order has been made by this Tribunal prohibiting the publication of the names of any of the persons mentioned in the Schedule attached to the amended Notice of Complaint together with the name of Person A.

5 Dr. Qasim appears for herself. She denies that she is guilty of unsatisfactory professional conduct or that she suffers from an impairment or that she is not competent to practise as a medical practitioner. The doctor further disputes that she wrote a number of the letters the subject of some of the complaints or, alternatively, that she wrote the letters or some of the letters in the form that they have been tendered before the Tribunal.

6 Professor Roger Smith, Professor of Endocrinology and head of the Department of Endocrinology at the John Hunter Hospital within the Hunter New England Area Health Service wrote a letter to the Medical Council of New South Wales expressing concerns about the doctor's competence and enclosing a number of letters which it was said had been written by the doctor to various general practitioners. That letter was countersigned by four other endocrinologists.

7 Dr. Qasim was suspended from practice after a hearing of the Medical Council of New South Wales from 22 December, 2010. Whilst a copy of the judgment of the Medical Council of New South Wales was tendered it was only tendered as background material and is not relied upon by this Tribunal.

8 On 24 February, 2012 and 23 March, 2012 there was a further hearing before the Medical Council of New South Wales who determined that they were not satisfied that there had been a change in Dr. Qasim's circumstances sufficient to justify lifting the current suspension of her registration. That suspension remains in place at the present time.

THE EVIDENCE

9 Bernice Dinkelman gave evidence. She worked as a medical receptionist at the Forster Specialist Centre for a number of years. She said that Dr. Qasim commenced practice at the medical centre in December, 2009. She remained there until the end of December, 2010. Ms. Dinkelman typed the doctor's letters after the doctor had dictated them into a dictation machine. After they were typed the letters were returned to the doctor who would make any necessary change. If there was to be a change the letter would be re-typed. The doctor would then sign the original, a copy would be put in the file, that copy was not signed and the signed letter would be forwarded to the general practitioner who had referred the patient. Ms. Dinkelman said she was the only one who typed letters for the doctor and in evidence identified the doctor's signature.

10 She confirmed that she had typed each of the reports which came from the practice she was employed in and which were the subject of this complaint. She said that, after the doctor left, she packed up the doctor's files. Sometime after she had packed up the files the doctor called in to pick up the files and that the doctor took them with her. About a week later she received a phone call from the doctor saying that one of the files was missing. Ms. Dinkelman said that she told the doctor that she had no knowledge of this, that she had packed up the files some two months before and had not been near the boxes since.

11 Under cross-examination Ms. Dinkelman admitted that a letter dated 4 August, 2010 was one which had not been dictated to her. She had made it up. She said that the reason she did that was that the patient needed injections, those injections needed to be given by a specialist, the patient needed a referral, the doctor had told the patient to do his own injecting, the patient could not do that, the patient arrived at the practice to collect the referral, she was in a quandary as to what to do so she wrote out or typed out the referral letter for the patient. On the same day she sent a copy of the referral letter to Dr. Qasim with a note and heard nothing further. She was in a very difficult position as the doctor had refused to see the patient and the patient needed injections and was at the practice to get a referral.

12 Ms. Dinkelman said she did not provide copies of the letters to Professor Smith or to any other general practitioner or endocrinologist other than those she was directed to send by Dr. Qasim. It was not suggested in cross-examination that Ms. Dinkelman had not typed these reports in accordance with the doctor's instructions. She was asked whether she tampered with the doctor's signature and she denied that, other than signing the letter which has just been referred to. It was not suggested to Ms. Dinkelman that she had altered the doctor's letters in any way before sending them out or that she had pasted the doctor's signature.

13 The Health Care Complaints Commission wrote to the various doctors involved in relation to the reports which were relied on as part of the complaint. Each doctor, or in one case a lawyer on behalf of a doctor, replied confirming they had received the reports from the doctor. There was one exception. Dr. Tavallaie of Taree has not replied, however, there was a letter from the practice he was working for at the time which indicated that he was no longer with that practice.

14 Professor Roger Smith gave evidence and a copy of the letter he had written to the Medical Council of New South Wales was tendered. It was not dated but had a Medical Council date stamp 27 October, 2010 on it. Professor Smith is Professor of Endocrinology and head of the Department of Endocrinology at the John Hunter Hospital within the Hunter New England Area Health Service. He did not know Dr. Qasim.

15 He became aware of concerns regarding her clinical and professional practice through complaints received from colleagues within his department. He determined it was necessary to review these issues with all members of his department and it was done at the conclusion of a regular meeting. As a result of that review, he wrote to the Medical Council of New South Wales. The letter was signed by four of his colleagues. He made it clear that they were not making a complaint but raising various concerns.

16 In that letter he addressed at least five concerns and supplied to the Council copies of letters allegedly written by Dr. Qasim to various general practitioners. There was also referred some other documents relating to tests which had been carried out and a letter from a Dr. Newman dated 22 June, 2010. Most of those letters appear to be signed by Dr. Qasim and the others are under her name.

17 He said it was felt the doctor may be impaired, that there was concern about the advice she was giving to general practitioners and they wanted to ensure that the doctor got appropriate care and assistance. He has not changed his opinion and still feels that the care given as expressed in his letter was far short of the acceptable standard for a practising endocrinologist and he made it clear that his opinion was based, not so much on each individual letter, but the totality of the letters and the totality of the advice being given. He agreed he had not seen the patients nor all their clinical notes and that his letter was written as a result of consideration of the various reports allegedly written by Dr. Qasim.

18 It was further alleged that Dr. Qasim suffers from an impairment, namely, a paranoid or delusional disorder which is of sufficient nature and degree to impair the practitioner's mental capacity to practise the profession. A number of witnesses were called in relation to the doctor's behaviour.

THE EVIDENCE

19 Bernice Dinkelman expressed concerns about some of the doctor's behaviour when she was working in the Forster practice. She formed a view that the doctor refused to see patients again if they did not agree with the doctor's thinking. There will be further evidence of the doctor's refusal to see some patients.

20 Ms. Dinkelman gave evidence that, in September, 2010, she had handed the doctor an account for rent which was paid. On 29 September, 2010 a letter was faxed to her from the doctor that is tendered in the proceedings. She said she was surprised by the letter and the next day wrote a letter in reply and gave the doctor notice to quit the practice. In part, the letter from the doctor read:

"You will only get 150. Do agree 8 am - 4 pm otherwise piss off."

21 There were other parts to the letter. She said that subsequently a complaint was made by the doctor about her and she believed that the doctor was trying to have her dismissed. A few days later she received a fax from the doctor which is part of the evidence. That fax makes a number of allegations about Ms. Dinkelman having been "obnoxious, rude and abrupt with patients" and saying she "will come with the police to obtain her files". Ms. Dinkelman said that she had packed up those files ready for the doctor to collect. There was never any dispute that the doctor could collect her files and in the end she did. She said that a patient had come to see her and told her that Dr. Qasim had said nasty things about her and another patient called in to say that Dr. Qasim told her her file had been stolen and she had to explain that she no longer had the files and that Dr. Qasim had picked them up. She denied that she had ever been rude or abrupt with patients over her many years in the practice.

22 Dr. Qasim lives in an apartment in Williams Street, Randwick. This building consisted of four apartments. The doctor owned apartments 3 and 4 which were on the top floor. Apartments 1 and 2 had separate owners. Initially, Anthony Igra and Dr. Rodney Sutherland and his wife. Mr. Igra owned apartment 1 and Dr. Sutherland apartment 2. At a later time Dr. James Miller purchased apartment 1.

23 There was a dispute between the owners of apartments 1 and 2 and the doctor. There was a strata body, a strata committee and various agents. A significant dispute arose out of repairs which were required to the building, as to how those repairs would be carried out, as to who would carry out the repairs and the cost which would be payable to the contractors. There were other disputes between the owners of apartments 1 and 2 and the doctor.

24 The evidence of each of the next three witnesses relates to what they say about the doctor's behaviour and how each individually concluded that the doctor was not fit to practise medicine and made the Health Commission aware of their views. Each made it clear that they had no professional training nor were they holding themselves out to be qualified as a psychiatrist or a psychologist but expressed their concerns about her behaviour.

25 Mr. Anthony Igra wrote to the Medical Board on 30 July, 2004 indicating to them that he had become concerned by the doctor's increasingly abnormal behaviour over the last two and a half years. He said that he eventually sold in April, 2007 selling his apartment to Dr. James Miller. He gave evidence of the doctor's behaviour at meetings of the body corporate. He said that she often attended with someone to assist her, at times a solicitor, at times her brother and others; that she would sit in the meeting mimicking, gesticulating sarcastically with big movements and gesticulations; that they would agree upon a course of action relating to repairs only to find that a short time later she no longer agreed and, in fact, voted against her own interests. He said that there were constant Court or Tribunal applications; that, at one stage, an AVO was sought against him in the Waverley Court; he simply consented to it as he did not want to spend time in Court. He did not consent because he had harassed her in any way but because he was content for the orders to be made so he no longer had to go through the trauma.

26 He provided a number of pages of observations of her behaviour which is tendered. He said that she either wrote or had letters issued. At one stage in cross-examination the doctor asked him about various letters and how he knew she wrote them. He answered that she signed the letters.

27 Dr. Rod Sutherland, who has a PhD in physics and is senior lecturer in physics at the University of Western Sydney, purchased apartment 2 in early December, 1999 and remained there until early 2007. He wrote to the Health Care Complaints Commission on 27 September, 2005 expressing concerns about her mental health. He said the doctor had waged a campaign of harassment and intimidation against him and his wife. Since 1999, he had witnessed a complete change in her behaviour from being a cheerful friendly neighbour to a person who had wild mood swings and acted in a bizarre way. He also recorded her mimicking others at a meeting and bizarre behaviour. Dr. Sutherland had young children and gave a number of examples of the doctor's behaviour.

28 He was also served with an AVO and also agreed, without admissions, to the AVO. As we understand it, on the same basis as Mr. Igra. He gave evidence that her apartment was above theirs, there was loud blaring noise from the apartment, that from 2002 onwards her behaviour changed. At times she was on a high wearing bright colours and happy, at other times being very depressed. She was difficult to deal with in meetings and had extensive mood swings. She constantly changed her opinion and voted in such a way that she was voting against her own interests. She would agree to certain matters and then, a short time later, disagree, vote against them. At one stage some agreements were made at a meeting and the next day she denied that the meeting had taken place. He said that there had been twelve applications to the CTTT in relation to the owners' corporation; that she had moved to have an independent manager appointed; that manager was appointed even though the other residents opposed it as they wanted to retain their voting rights.

29 He said in cross-examination that he was speaking on behalf of his wife as well and suggested that if the doctor doubted what he was saying that she should look at the minutes which had apparently been subpoenaed for this hearing and it would become apparent that she was voting down motions when it was not in her interests to do so. The problem that they had was that she was the owner of two of the four units and, therefore, without her agreement nothing could be done in various meetings which were held.

30 His evidence was very damning of the doctor's behaviour. It was not suggested to him that he was not telling the truth, however, it was quite clear that the doctor, in cross-examination, did not accept all of his evidence.

31 Dr. James Miller gave evidence. He now lives interstate and came to the Court to give evidence. He is a doctor of medicine and is in his final year of studies to become a specialist anaesthetist. In April, 2007 he purchased apartment 1 and the doctor had the apartment above him. He did not reside there the whole time as he was studying but he resided there full-time in 2008 and his wife resided there most of the time. He was able to observe the doctor at strata meetings. Other than that he did not have a lot to do with her as he formed the view she was rather reclusive. He received a number of letters from the doctor, usually pushed under the front door of his apartment. He said the contents and tones of the letters caused him disquiet and concern regarding the doctor's mental stability.

32 On 8 February, 2010 he wrote to the New South Wales Medical Board in relation to her behaviour saying he believed that she suffered from an impairment and was not of good character. He said that he became concerned, he then made enquiries as to whether she was still practising as a doctor, ascertained she was and then felt it was his duty to bring these matters to the attention of the Medical Board. He listed a number of ways in which he said the doctor's behaviour concerned him. He said that once she was told that he was a doctor she showed him patient files and test results and gave detailed, although confusing, histories about the patients and he felt that that was inappropriate. On two separate occasions he reported her to the Eastern Suburbs Mental Health Crisis Team as did Mrs. Sutherland. He had also reported her to the Randwick police.

33 Dr. Miller said the first note was shortly after he arrived. He said it was bizarre. Another one, which was tendered, appears to be addressed to "Mr. Genius (liar) and Blondie" and he regarded it as quite bizarre. He said her behaviour included doing things in a fixed pattern no matter what the circumstances were. For instance, watering the garden at a fixed time on a fixed day and watering it whether or not it was raining. He said that each Friday evening she did copious loads of washing and hung them out on Saturday whether or not it was raining. He said when they did have a gardener, at one stage the gardener had extreme difficulty as the doctor stood over him while he was attempting to do his job and he declined to continue doing it. At times, she would wake them up at 4 a.m. stomping and making a lot of noise and that could go on for five days. His apartment was directly under hers and it was obviously done to deliberately wake them up. Dr. Qasim was always at home, did not appear to have any relationship with anyone, that she would bury rubbish in the garden beds on her side of the units and that was all types of rubbish including normal household rubbish. She would dig in the garden beds and scatter shredded white paper, she would take photographs of him when he was near a window in his apartment, when people had conversations with her she pulled out a tape recorder which she used.

34 He said in cross-examination that the first time he met her she told him she was on the phone to a professor of endocrinology but then spoke to him and his wife for forty minutes whilst the person she was speaking to apparently remained on the phone. The doctor did not challenge the factual evidence given by Dr. Miller although she clearly did not always agree with it.

35 Andrew Sidwell gave evidence. He works in the advertising industry and is married with two children. In December, 2008 his wife and he signed a two year lease and moved into apartment 1. Their children were aged three years and one year. He had taken a two year lease. He subsequently moved out in November, 2009 breaking the lease. He said he broke the lease because of the behaviour of Dr. Qasim. He said the first encounter he had with the doctor was shortly after moving into the apartment and it occurred on 18 December, 2008 when persons to whom he had sold two wardrobes online came to collect them from his garage. After the people arrived he went to the garage area; they had a shared driveway with the doctor; it was partially blocked by the persons picking up the wardrobes for a short period of time. He said that the doctor knocked on his door, he had his daughters with him at the time, Dr. Qasim came to his apartment and said to him "Tell the Polish bitch she cannot do what she does in the backstreets of Poland". He said he was so upset and shaken by the incident that he sent an email to the agent indicating that they were going to immediately vacate the premises and that they would pay the rent up until the time a new tenant was found. He said in the email that he was incredibly shaken by her aggression and disturbed mental state and feared for the safety of his children. After further discussions with his wife, they decided not to move. Having met with the agent that evening, the next day a note from the doctor was sent to them and that is an exhibit. He denied that there was any garage sale. He said during the encounter with the doctor abusive and offensive language was used in front of his children.

36 In November, 2009 they were then forced to break their lease as they had not been able to enjoy the property or living there due to the behaviour of the doctor. He had witnessed her yelling at tradespeople, having arguments with those in apartment 2 and that she had told tenants that the Sidwells were bad people. His complaints and evidence in relation to her behaviour were not challenged in cross-examination by the doctor.

37 Person A gave evidence. She gave evidence about her sister, Patient I. She said that she assisted her sister who was not well. She said her sister was sent by the general practitioner to see Dr. Qasim for throat problems. Her sister was a serious diabetic. There were three visits to the doctor. On the first visit the doctor spoke to them. She complained about Gosford Hospital and, whilst they were there, she took a phone call with another person which went on for some five to six minutes. During that phone call the doctor swore repeatedly including using the words "fucking idiot". They then went and had further tests done, came back to see the doctor again and, in particular, to discuss whether her sister needed an operation. There was discussion about her sister being referred to another specialist in relation to the operation and discussion whether she would go to Coffs Harbour or Gosford. In the end they elected to go to Gosford and an appointment was made.

38 When they got there the specialist did not have any referral, nothing had been said to him, he had no idea what it was about. Dr. Qasim had made the appointment. The specialist simply sent her sister for blood tests, her sister was subsequently told by Dr. Qasim that she would have to go to Royal North Shore Hospital for an operation and they enquired how she could get to Royal North Shore. They were concerned how they would get there as they lived in Taree. Dr. Qasim said to Person A that Person A did not want her sister to get better so they "could piss off and not come back". Person A succinctly said "so we did". She said the trip from Taree to the hospital was somewhere between three and a half and four hours. She also said that her sister attended the first consultation with a walking frame and, at the end of her treatment by the doctor, she was still on a walking frame.

39 In a letter from Dr. Qasim to Dr. Holiday dated 3 August, 2010, allegedly written by the doctor and signed by her she says that the "two sisters are so intolerably unpleasant and I do not want to deal with the family any more" and he, the doctor, should find a new specialist to put up with them. She says that they are obnoxious.

40 Person A was not challenged on her version or on the conversation she said took place. As far as we can see there has been no explanation as to why a letter in the terms of the letter dated 3 August, 2010 would have been written. It seems that an innocent question as to how they got from Taree to the Royal North Shore Hospital has provoked them being told to "piss off" and not come back in a subsequent letter written to Dr. Holiday. We were impressed by the evidence given by Person A, a very straightforward lady, who had a good memory of what happened.

41 There was also tendered in evidence a reply by Dr. Qasim to the letter written by Professor Roger Smith to the Medical Council of New South Wales.

42 That is a letter from Dr. Qasim dated 2 December, 2010 to a Ms. Sally Pitt in reference to a complaint lodged. In that letter the following is noted by the Tribunal:

She refers to Professor Smith as "Professor His Highness Roger Smith".

She lays the blame for the complaint on Bernice Dinkelman. She alleges Ms. Dinkelman confiscated her files and provided them to others. We should say that Ms. Dinkelman denied any involvement in making any complaint to Professor Smith or to removing any files and we also note that this allegation was not put in evidence to Ms. Dinkelman.

She comments that Professor Smith's comments of unsatisfactory professional performance are malicious, spiteful, totally lacking in logic and repugnant and asks that it be drawn to his attention that he is not protected from criminal defamation.

She alleges that Professor Smith obtained information from a clerical staff who was "dissatisfied for me leaving the premises". None of these matters were put to Professor Smith. The doctor then takes issue with some of Professor Smith's comments.

She alleges it is a criminal act on behalf of the informant, the clerk, no doubt Ms. Dinkelman, for providing such a misconstructed story to Professor Smith so he could beat the drum to boost his morale and his behaviour was unprofessional.

She alleges that Professor Smith's allegations are nothing but an innuendo based on professional jealousy and comments that he should look at his own patients who are suicidal after seeing him. The letter covers many areas and goes on for some ten pages.

43 The matters set out on page 9 of her letter in relation to Professor Smith, including accusing him of unlawful behaviour, are totally irrational and insulting.

44 The evidence before the Tribunal is quite clear. That is, that issues were raised with Professor Smith, that he discussed those with his colleagues and he then wrote the letter, which has been referred to many times in this judgment, raising a concern. Professor Smith has never met or dealt with Dr. Qasim.

45 Dr. Qasim was allowed to call evidence during the course of the Commission's case as they, themselves, had run short of evidence, had no more available on that day and there was no objection and it was felt that this was a useful way of taking some of her evidence.

46 She called Alien Kituz who, as we understand it, was a workman working on the doctor's property. He said there was a garage sale and that he could hear a conversation. It related to not leaving stuff on the garage door as she often pushed the remote control while upstairs to raise the garage door and it may fall and cause an injury and she was quite polite and not offensive. She was talking to a man he did not know and he did not see. The Tribunal does not know what relevance there was to this evidence as it did not appear to relate to the incident spoken about by Mr. Sidwell as there was no garage sale and Mr. Sidwell only spoke very briefly to the doctor in the vicinity of the driveway. The complained conversation took place at Mr. Sidwell's apartment.

47 Dianne MacDonald gave evidence. Her evidence referred to contact with Ms. Dinkelman. She apparently asked Ms. Dinkelman to fax a report. Ms. Dinkelman agreed to do that but it was not received even though Ms. Dinkelman said it had been sent out. She said that she went to the Forster Specialist Medical Centre to get her daughter's patient's file and Ms. Dinkelman said there were no files they had gone and that she should take it up with Dr. Qasim. She apparently had been to the toilet and had complained about the cleanliness of the toilet. She said that she had sworn a statutory declaration, agreed with the contents of paragraph 3 which was exhibited in Dr. Qasim's bundle of documents and she said that the file was still missing and she clearly was not happy with Ms. Dinkelman.

48 Chayce McCudden was a neighbour of Dr. Qasim. He lived at 7A William Street between August, 2009 and January, 2011. He complained about the behaviour of tenants in one of the apartments in the block Dr. Qasim lived in. It went on for six months and involved loud music, noise, people staring at him and he eventually spoke to Dr. Qasim about it. He said that the tenants were Dr. Qasim's tenants staying in one of her apartments and that they eventually moved out. The Tribunal is not aware of the relevance of this evidence.

49 Stephen Smith attended an AGM of the body corporate on 15 May, 2008. He was a strata manager. He said Dr. Miller was not at that meeting but sent a proxy. He was manager for a period of twelve months and that there was no disagreement at that meeting.

50 Mr. Xu was a patient of the doctor's and had been treated by her for some twelve years. He was very satisfied with her treatment.

51 Richard Pickton said he was the agent for Dr. Qasim in relation to her apartment. During his time there had been three sets of tenants. There had been no problems and he had been the agent for about three years.

52 Bryan Mattson was a neighbour of Dr. Qasim over the last fifteen years. He said that he often saw her and had dinner at her place and spoke about his observations including what he did and did not see, who he spoke to and other such observations. None of his evidence was relevant to our considerations although it was quite clear he held the doctor in very high regard.

53 There were a large number of documents tendered to the Tribunal. Some five volumes on behalf of the Health Care Complaints Commission and a volume on behalf of the doctor.

54 There were two series of documents with which the Tribunal had a difficulty. The first were the judgments or reasons for the suspension of Dr. Qasim. They were the comments made by another body after hearing evidence and were of no concern to us as we are to base our decision on the evidence before us. It was agreed that they simply be tendered as background material.

55 The second is a report from Dr. Teoh, a psychiatrist who had treated the doctor at one stage, and in the papers was a short report. The Commission had written to the doctor some time ago indicating that, if she wished to rely on that report, she would need to have the doctor there for cross-examination. There was good reason for that because, as was seen with her general practitioner, he had no idea of the correspondence being written by the doctor and other such matters and eventually, having seen all that, came to a different conclusion. He, not having been brought for cross-examination, we then ruled that his report was not admissible in this hearing.

56 Whilst there was a large number of documents and whilst we considered them all, there were some which were very relevant and we refer to those documents during the course of these reasons. A significant part of the hearing was spent on those documents.

57 Dr. Romney Newman, specialist physician, was called to give evidence. He became involved in this matter when Dr. Qasim in October, 2011 wrote to the Health Care Complaints Commission relating to what she said were significant breaches of the code of professional conduct by Dr. Newman. Her first concern related to unauthorised access and alleged theft of patient files. She alleged that he made unauthorised access of her patient files in September, 2010 and he engaged in such access by liaising with the office clerk on the premises in Forster that she was leasing at the time. She said that, without her consent or knowledge, Dr. Newman not only had unauthorised access to her patient files but physically removed hundreds of files between September and October, 2010. She further alleged that Dr. Newman selectively chose a few files and faxed several pages to Professor Roger Smith and that formed the basis of his allegations.

58 The second concern was that Dr. Newman wrote a very confidential letter regarding a patient. The letter did not have the address for either the patient or the referring doctor and the patient had never been seen by him and other allegations were made.

59 Her complaint was brought to the doctor's attention and in November, 2011 he replied. In evidence before the Tribunal he said that he had not stolen any of her patient files, he has no knowledge about any missing files, he has never taken any files from Dr. Qasim's premises. He said that, in actual fact, he practised from other premises some one hundred metres away but completely separate. He said that when he got the complaint he went to the premises which had previously been occupied by the doctor, spoke to Ms. Dinkelman, as he had to find out what it was all about. It was the first time he had ever seen Ms. Dinkelman and the information he was given was that Dr. Qasim had taken her files.

60 He said that he did not personally know Professor Roger Smith; he had never faxed any documents to the professor; he had never had access to her patient files and he certainly had not removed hundreds of files. He said that he had faxed a letter or perhaps two letters to Dr. McGrath in Newcastle as he was seeking assistance with the treatment of two patients and it was done with the patients' authorities. As far as the confidential letter regarding a patient was concerned, he said that the referral of that patient came from Dr. Qasim and had asked her permission to use the material. The allegations made against him were false and without any foundation.

61 The doctor also pointed out that he had had one of the patients, Patient C, referred to him by the local general practitioner as the patient was distressed at the many diagnoses Dr. Qasim had made when he had seen her earlier. He had the patient's permission to obtain reports and records and test results. He wrote to Dr. Qasim as he was confused about the diagnosis. She replied saying in part "I have not been able to come to grips with this patient on a personal level so I would be very happy to communicate with you if you need assistance but I am not really willing to see this patient ever again".

62 Dr. Newman had communicated with Dr. McGrath, an endocrinologist, as he was confused by Dr. Qasim's diagnosis and wanted to speak to another specialist about it. As a result he did send Dr. McGrath some letters. These were with the permission of the patient. He further said that, in relation to her second complaint, the letter she referred to, that, not only was she the referring doctor, but the letter was addressed to her and he was responding to her referral.

Dr. Qasim's Evidence

63 Dr. Qasim gave evidence. She provided evidence of her background. She said she was not suffering from any illness, enjoyed her work and was active in her ongoing education. She explained that she had commenced practise at Forster in the medical centre and had patients from the surrounding area, as far up as Kempsey. She had a holiday house at Old Bar and found that it was very difficult because of ongoing roadworks in the area travelling between Old Bar and Forster. She commenced at Forster in December, 2009. It was a temporary move. She said she had a good relationship with Ms. Dinkelman, there was no falling out. She was extremely busy and always tried to finish her work before the trucks got on the highway but continued to have difficulty, because of roadworks, with the driving.

64 The doctor said that there was a serious issue, that was that she had complaints about Ms. Dinkelman from the first day she was in the practice. She said she had to come in one hour early to fix up her work, in effect, that her work was unsatisfactory and she gave examples of Ms. Dinkelman's behaviour. She denied that she had tried to get Ms. Dinkelman dismissed but said that the patients were unhappy and she had spoken to a lady by the name of Avril. There appears to be no doubt from the doctor's evidence that she was not totally satisfied with Ms. Dinkelman's performance but it seems that Ms. Dinkelman was unaware of that.

65 The doctor gave evidence about her files saying she had files in folders, they were handwritten with notes covering her consultations and they could also include other documents such as test results and other such matters. Dr. Qasim said that she went to Forster on 17 or 18 November, 2010 to collect files. She saw Ms. Dinkelman, asked whether there were any outstanding bills to be paid and she was then shown four or five boxes of files, some had been transferred from larger files into smaller files. She just took them with her and left and went to her holiday home. When she looked at some of the files she found they were not in alphabetical order. She was looking for a particular file of a patient and could not find it. She said that eighty to ninety percent of her files were missing and also missing were the files relevant to the eventual complaints. The doctor said that those files are still missing and, as we understand it, that is the eighty to ninety percent of her files. Dr. Selwyn Smith said that Dr. Qasim told him she had recovered her missing files. It was not long after she had picked up some of her files that she received the complaint initiated by Professor Smith. She then gave evidence of what she did after that and of general practitioners' complaints about Professor Smith.

66 The doctor then moved to each of the issues. Particular 1 was in relation to a letter to a general practitioner, Dr. Nelapati, dated 27 August, 2009. Dr. Qasim said that this was an error, that in actual fact what she had done was to write herself an aide-memoire but, unfortunately, it was sent out as a letter and she had dictated it at the same time as she was writing a letter. It was not meant to be sent out, it was simply an aid to assist her in the future with the treatment of the patient. That related to Patient A.

67 Particular 2 related to a letter of 8 February, 2010 concerning Patient B, she said she had written that letter, that what she said did not apply to every patient.

68 Particulars 4 and 5 related to a letter of 10 May 2010 but there did not appear to be any disagreement that she had dictated that letter.

69 Particular 6 related to a letter of 7 June, 2010. She did not deny writing that but said she spoke to the general practitioner indicating that the patient should have further investigations.

70 Particular 7 related to the same patient. There is no denial the letter was written.

71 Particular number 8 related to a letter of 2 August, 2010. Again, the doctor gave an explanation and did not deny that letter had been written.

72 Particular number 9 related to letters of 8 February, 2010, 1 March, 2010, 22 March, 2010 regarding Patient F and said she stood by the statement she made.

73 Particular number 10 was a letter written relating to Patient G on 8 February, 2010. Again, she did not deny writing the letter and again in Particular 11, a letter of 22 August, 2010, did not say that she had not written the letter.

74 In relation to complaint number 2 and a letter of 12 April, 2010 concerning Patient F, she said she did not write that letter, that the secretary has made that letter up and that was Ms. Dinkelman.

75 Under cross-examination she admitted to writing a number of the letters and only took exception to one letter, that is, the letter of 12 April, 2010 relating to Patient F which she admitted writing but said she had included another sentence which was not in the letter. She also said that she accepted the words were accurately typed in a letter of 27 August, 2009 but it should not have been sent as it was an aide-memoire.

76 The Tribunal was a little unclear in relation to the doctor's evidence as we had understood that she was disputing that she had written some of the letters or, alternatively, disputing that she had written them in the terms in which they eventually went to the general practitioner. We therefore sought clarification. Dr. Qasim then indicated that most of the letters did not appear in the form in which she dictated them. This seemed to the Tribunal to be contrary to her evidence on the previous day. She was then taken through each of the letters and, with the exception of the first one, the doctor then gave evidence from memory of the way, some three and a half years previously, she had dictated each of the letters. There were very significant changes to each of the letters. In other words, they, according to the doctor, in the form they were sent to the general practitioners, did not resemble the letters that she said she dictated. The changes are numerous, they are on the transcript and we do not need to review them at this stage.

77 The Tribunal, however, notes that, even with the changes she said she dictated, as far as those matters to which the complaints refer, the matters which are complained of were not substantially altered. That is, those matters, which it was felt were inappropriate to be put in a letter to a general practitioner by a specialist, were still in the new version. However, in relation to one letter, the subject of complaint 2, which was written to Dr. Holiday, she denies writing it.

78 Dr. Qasim said that, whilst it appeared to be her signature on a number of the letters, that signature could have been pasted onto those letters, obviously by Ms. Dinkelman. Or, alternatively, that the letters could have been put into the file without the doctor ever having seen them and she was therefore not aware that they had gone out in the form in which they were sent to the general practitioners. Dr. Qasim said she did not have the patient files, they had been stolen, and that her evidence was from her memory of what she dictated at least three and a half years ago. They were all typed by the same person, Ms. Dinkelman, other than for the first one which was typed by another typist.

79 The doctor was asked about her not having raised the subject of the altered letters prior to the second day of her evidence. She agreed that in a letter in reply to the complaint of 2 December, 2012, she had not raised this issue and said it was because she was rushed to reply to the letter. There was then a statement written on 17 February, 2012. She said that was done in consultation with her solicitor and other advisers and she said that she had told her legal advisers that the letters were not correct but they had not put that in the statement although she admitted, after reading it, she signed it. She also agreed that in Exhibit 1, that is her bundle of documents, the document she refers to as Exhibit Z which appears to have been signed on 28 February, 2014, again does not mention the inaccurate letters and, again, she said that was drawn with the assistance of lawyers who knew that she was disputing what was in the letters but it did not say so. Again, that document is signed and was dated a short time ago.

80 She also agreed that in the Section 150 hearing, that is a hearing by the Medical Board to decide whether or not she should be suspended from practise, she did not, at that hearing, mention that the letters had not been correctly drawn. She said she was under strain and stress during that hearing.

81 Dr. Qasim was also questioned about serious allegations she made in relation to Professor Smith on 2 December, 2010 and said she accepted that many of the things she said were not matters she now thought.

82 Dr. Qasim could not explain how her signature could have been pasted, as she claimed, on various letters. She agreed it was not done electronically and had no idea how it could have been done.

83 The doctor, during her evidence, also gave some explanations as to why she had written some of those matters in her letters to general practitioners and some of the background of the patients. It should be noted that she put a number of those matters to Professor Proietto and, after those questions, he said that, even accepting what she had said, it did not change his mind.

84 There are a number of matters which are not in dispute or not substantially in dispute and the Tribunal finds that Dr. Qasim was a specialist endocrinologist working out of the Forster Medical Centre at the time that she saw the various patients which the complaints relate to. There is no dispute that the doctor saw each of those patients on referral from various general practitioners or that letters, and indeed the letters produced to the Tribunal, had been received by the general practitioners under Dr. Qasim's name. There is no dispute that she commenced working at this medical centre in December, 2009 and last worked there in about September, 2010. There is no dispute that the doctor dictated letters to go to general practitioners; that, with the exception of the first letter, those letters were typed by Ms. Dinkelman and that the doctor returned to pick up the files in about October, 2010; that a complaint was made by Professor Smith on behalf of other specialist endocrinologists; that the Medical Board wrote to the doctor advising her of the complaint; that she replied in a letter of 2 December, 2010; that she subsequently provided an affidavit of February, 2011; that she attended a Section 150 hearing and was suspended from practise and remains suspended up to the present date, there being a further Section 150 hearing in 2012.

85 There is no dispute that the doctor resided in William Street, Randwick in a building consisting of four apartments, the upper two of which were owned by the doctor and the lower two of which were owned by Mr. Igra, Dr. Sutherland and Dr. Miller; nor that, at one stage, Mr. Sidwell leased one of the downstairs apartments. There is no dispute that there was a significant problem relating to repairs to the building and with issues between the body corporate and Dr. Qasim nor that there was strong feeling from each of the owners and Dr. Qasim about that dispute.

86 There is, however, significant dispute about some other matters and we will deal with those disputes separately.

87 The Tribunal would like to put on record these matters:

The Tribunal found the hearing to be extremely difficult due to a number of matters. The Tribunal did not have any assistance from an associate, nor the assistance of a court officer. The Tribunal did not have a transcript until very late in the second week when two days of transcript were provided and the recordings of other evidence. The Tribunal were required to mark exhibits, to record exhibits and make all other arrangements relating to the hearing. The Health Care Complaints Commission in their case tendered five volumes of material. The doctor tendered another volume of material and there were a number of other documents tendered during the hearing.

88 The hearing was complicated by the fact that Dr. Qasim elected to appear for herself. She had difficulty in the phrasing of questions. She constantly led witnesses and constantly made statements, which were not evidence, to a witness and then had to be asked what the question was. This resulted in the principal member, Acting Judge Garling, having to constantly direct the doctor in such a way that she put acceptable questions to witnesses and meant that, instead of the evidence flowing in the normal way, it was disrupted as the doctor was given assistance. Ms Richardson, on behalf of the Health Care Complaints Commission, took a very helpful view, did not object to leading questions and, generally, did not object to the questions being asked by the doctor and that, at least, allowed the hearing to proceed although at a much slower rate than would normally occur.

89 In addition, although the doctor was reminded of it a number of times, it is apparent from the evidence that she did not put important matters to the various witnesses, particularly to Ms. Dinkelman, Dr. Newman and Dr. McGrath and this makes it difficult for the Tribunal when assessing the evidence.

90 These matters are recorded to explain the number of times the principal member had to deal with matters in the evidence and with the difficult conditions under which the Tribunal heard this matter. However, the Tribunal is confident that at the conclusion of the hearing they were in a position where it could fairly assess the evidence and make various findings.

91 The Tribunal makes these findings in relation to the various witnesses:

Professor Smith, Dr. McGrath, Dr. Newman, Professor Proietto, Dr. Samuels, Dr. Kwan and Dr. Selwyn Smith were all good, straightforward witnesses who gave their evidence in a straightforward manner and impressed the Tribunal as persons doing their best to assist the Tribunal.

90. Ms. Dinkelman who has been severely criticised by Dr. Qasim was, in the opinion of the Tribunal, a good, accurate and honest witness. We will analyse the complaints against her further.

91. Mr. Igra, Dr. Sutherland, Dr. Miller and Mr. Sidwell were all very straightforward witnesses whose evidence appeared to be accurate and whose evidence was consistent with each other on the main issues. It should be noted that there was obviously some feeling between those witnesses and Dr. Qasim particularly their view of Dr. Qasim's behaviour. However, they all appeared to be good witnesses who we could accept.

92. Person A, who was also criticised, was in our view a very good and accurate witness.

93. Those witnesses called on behalf of Dr. Qasim all gave acceptable evidence. The one exception being Dianne MacDonald who obviously had some very strong feelings in relation to the Forster practice and Ms. Dinkelman and some of those matters, we felt, were exaggerated.

92 The Tribunal, unanimously, is not prepared to accept the evidence of Dr. Qasim on any contentious matter unless it is supported by other independent evidence. The Tribunal finds that significant parts of Dr. Qasim's evidence are untrue and not acceptable.

93 There have been a number of allegations made by Dr. Qasim in relation to various people including serious allegations relating to Professor Smith, Dr. Samuels, Dr. Newman, Dr. McGrath and Ms. Dinkelman and we are required to deal with those allegations. In the doctor's closing submissions she contended that evidence given by all witnesses called on behalf of the Health Care Complaints Commission was either false or untrue. She later exempted Professor Proietto from that criticism. She also made a submission relating to the ethnic background of Dr. Samuels, Dr. Adelstein, Mr. Igra and Ms. Dinkelman which was totally inappropriate.

94 The first series of allegations are against Professor Smith which include allegations in an extraordinary letter of 2 December, 2010. Those allegations made in relation to Professor Smith are unanimously rejected by this Tribunal. We are satisfied that the evidence, which we accept and find, is that Dr. Qasim had written a number of letters to various general practitioners; that there had been concern at least by some of those general practitioners as to what was contained in those letters from a specialist endocrinologist; that a number of those letters had been referred to Dr. Sean McGrath; that Dr. McGrath brought them to the attention of Professor Smith; Professor Smith was the head of the Department of Endocrinology at the John Hunter Hospital; that he placed a number of those letters before a meeting of specialist endocrinologists who agreed that he should write a letter to the Medical Board on their behalf expressing concerns as to the advice being given. Professor Smith did not know Dr. Qasim. He wrote the letter, which was tendered in evidence, which is a constructive, straightforward letter setting out the concerns of other specialist endocrinologists. What he did was absolutely correct and proper and, indeed, it was his duty to bring these matters to the Medical Board's attention. We reject any allegation that he was involved in any conspiracy. He did not know Ms. Dinkelman, he did not steal files, he did not receive stolen files and his only connection was as we have set out above. There was no reason for him to have any professional jealousy of Dr. Qasim. It is a ridiculous allegation. Professor Smith is a highly qualified and respected endocrinologist.

95 Allegations were made in relation to Dr. Romney Newman who practices at Forster. The Tribunal rejects any criticism of Dr. Newman or criticism of any part he played in the referral of these letters to Dr. McGrath and, subsequently, to Professor Smith.

96 Allegations were made that Dr. McGrath acted improperly in obtaining and passing on letters written by Dr. Qasim to various general practitioners. Dr. McGrath gave evidence and the Tribunal accepts that he was provided with those letters quite legitimately and there could be no criticism of what he did. In fact, what he did was quite proper. Dr. McGrath had never met Dr. Qasim.

97 Criticism was made of Dr. Samuels. He was a doctor qualified by the Health Care Complaints Commission to examine Dr. Qasim on several occasions. We are unsure of what the criticism is except he expressed a view unfavourable to Dr. Qasim. Dr. Samuels had at least two consultations which he found difficult as Dr. Qasim had with her her brother who played an active part in the consultation and her accountant who also played an active part and, as Dr. Samuels said, made it difficult for him. We are satisfied that Dr. Samuels acted in a very professional manner, provided accurate reports to the Tribunal and, eventually, we will accept his opinion.

98 Serious allegations were made against Bernice Dinkelman. Ms. Dinkelman was the receptionist at the Forster practice. We accept that it was her duty and, indeed, she typed out letters dictated by Dr. Qasim, she gave the original to the doctor and, if any alterations were noted, she carried out those alterations. She placed a copy of the doctor's letter in the file and sent the doctor's letters after they were signed by the doctor to the general practitioner.

99 The Tribunal does not accept Dr. Qasim's evidence as far as it relates to Ms. Dinkelman substantially altering letters in the form dictated by the doctor. We do not, for a number of reasons including that it would be ridiculous to accept that a competent receptionist and typist, who has worked at this practice for many years, would leave out large portions of dictation from a letter, alter each of the letters in a very substantial way for no apparent reason.

100 A reading of the letters as tendered would indicated that they are written in a normal pattern which would be expected of a specialist writing to a general practitioner and there is nothing unusual about their format.

101 Had this happened, the doctor would have realised the letter was not in the form she had dictated and required it to be amended to the way she dictated the letter and not sent out. If the allegation is that the doctor did not see the letters to the general practitioner but they were simply put in the file then this is rejected. It is inconceivable that a doctor would not be conscious of letters she had written to a general practitioner and, when she had not seen the original to ensure it was in the correct form, she would have looked in the file to check the letter and would be conscious of her obligations to send a report to the general practitioner.

102 The letter she claims was sent in error as it was an aide-memoire for herself is clearly a letter written to a general practitioner in the same terms as she has written letters to other general practitioners. It is clearly not a note to herself to put in the file.

103 Importantly, there is no mention of this allegation in a letter to the Health Care Complaints Commission on 2 December, 2010; in the next statutory declaration in February, 2011 which she signs; in the Section 150 hearing nor in the document which she placed before this Tribunal in Exhibit 1Z. We reject the doctor's evidence that part of the reason for this was that her legal advisers did not include it in the affidavit and that affidavit is signed by the doctor obviously after she read it.

104 In addition, the doctor gave evidence before this Tribunal, and did not mention the alterations. She was cross-examined on the first day of her evidence, there was no mention of these matters and it was not until the second day and she was asked about that, for the first time, these allegations were made. In addition to that, the Tribunal does not accept that she could have a memory of the exact words she dictated three and a half years earlier in a number of letters.

105 There is no evidence before the Tribunal that her signature was pasted or cut and pasted nor does the Tribunal have any evidence as to how that could be done. This was not something put to Ms. Dinkelman and has absolutely no merit at all.

106 It was very important that the doctor put to Ms. Dinkelman her very serious allegations. Those allegations included conspiring with Dr. Newman and the altering of letters and the pasting of a signature. She did not. The Tribunal unanimously accepts the evidence of Ms. Dinkelman and rejects the evidence of Dr. Qasim.

107 The next issue is in relation to missing files. The Tribunal comments that they were unable to get a satisfactory answer as to the relevance of the missing files. Obviously, the doctor would have been assisted had she had her files available to her if, indeed, they are missing. In addition, Dr. Qasim did not appear to have any difficulty in remembering everything that was in the files. Ms. Dinkelman gave evidence as to what happened to the files; that she packed the files; that she left them there and did not look at them again until they were picked up by Dr. Qasim. She denied any of the files were missing. Dr. Qasim said eighty to ninety percent of the files were missing yet she picked up four to five boxes of files which obviously represent ten to twenty percent of her files and she would have known at the time of picking them up that numerous boxes of files were not there. She would have queried that rather than taking them to her holiday house and eventually looking at them. In addition to that, a short period after picking them up, she only took issue with one file not being there. Her allegation that these files were stolen by Dr. Newman which we have found to be false and her evidence in general in relation to these files is unacceptable. However, the Tribunal does not find it a matter of importance except when the Tribunal has to assess the doctor's mental capabilities.

108 In relation to the problems surrounding the apartments in which she resided and the other owners, we have found and basically we accept what the other owners have said to us. However, as we said at all times, we do not intend to make any findings relating to the doctor's dispute with the other owners or the body corporate. We note that there was a significant dispute, however, there is no dispute that various letters, which have been tendered before the Tribunal and which may have relevance in relation to her mental capacity, were sent by the doctor. That is not in issue and there is no dispute that the various parties were not cooperating with each other in relation to these disputes.

109 There was also an allegation made by the doctor in her statement which appears to be signed on 12 March, 2014. Dr. Qasim states: "My persistent beliefs that there is some conspiracy between the Medical Council, HCCC, Ms. Dinkelman and other practitioners in regard to unauthorised access to my clinical records has been proven to be true". We wish to place on record that there is absolutely no evidence of any conspiracy between the Medical Council, the HCCC and anyone else in relation to this matter.

110 There is a further allegation relating to assistance allegedly given by the Medical Council to Mr. Igra and others relating to her disputes with the body corporate. There is absolutely no evidence to suggest that and we reject it totally.

111 The findings which the Tribunal makes are that Dr. Qasim wrote the letters which form the complaint or complaints to the Tribunal; that they were sent to various practitioners nominated in those letters; that the letters were obtained quite properly by Professor Smith; that Professor Smith and his colleagues, quite rightly, referred these matters to the Medical Council as a concern; that the Medical Council, quite rightly, called upon Dr. Qasim for an explanation. There was no conspiracy of any type. Ms. Dinkelman typed the letters as she was instructed to do and the letters were forwarded, as instructed by Dr. Qasim, to the various general practitioners; a number of the letters contained her signature; that Ms. Dinkelman was not involved in any missing files and it then becomes a matter for the Tribunal to consider the evidence relating to each of the complaints.

112 We firstly deal with the complaints relating to advice the doctor gave to various general practitioners in her role as a specialist endocrinologist. Professor Smith, when giving evidence, said that their concern was generated by the body of data before them from multiple letters. It was not one issue it was multiple issues in many different areas of endocrine practice and that the practice described within the letters deviated significantly from usual current practice and deviated in a way that might lead to adverse outcomes for patients. In addition, the letters before them indicated significant problems with interactions with patients and doctors that raised concerns for their department. They were concerned that the person was impaired and were significantly enough concerned to pass on the information. Professor Smith was cross-examined about a number of matters but did not change the view he expressed in his letter to the Medical Council.

Expert Evidence

113 Professor Proietto, a very highly qualified endocrinologist was called as an expert. In two very carefully prepared reports and two supplementary additions he set out his opinions and, having been cross-examined by Dr. Qasim, he said there was nothing she put to him that changed his opinion.

114 In regard to the Tribunal's assessment of Dr Qasim's professional competence as a consultant physician ("Specialist") in Endocrinology, the expertise and high professional standing of both the principal complainant, Professor Roger Smith, and the independent expert, Professor Joseph Proietto, were recognised. Both gave clear and convincing evidence and both remained of the opinion that Dr Qasim's care, as judged particularly by a number of letters about patients to referring general practitioners, fell clearly below the standard of a practitioner of an equivalent level of training and experience. Additional clinical information put to them by Dr Qasim in cross-examination did not alter this opinion. As discussed elsewhere, the Tribunal did not accept Dr Qasim's evidence that the letters in question were not a true record of her dictation or were not intended as a true report. Therefore Professors Smith and Proietto's judgment of those letters was considered a valid and important component of assessment of her competence. The Tribunal did, however, recognise that it had seen no evidence of serious harm resulting from Dr Qasim's management of her patients.

115 Detail regarding individual patients:

Patient A (Eunice Philp), letter 27 August, 2009 to Dr Nelapati: Dr Qasim asserted at the hearing that a decision on use of Radioiodine in an individual patient with thyrotoxicosis was dictated by individual circumstances and patient wishes. However, the statements "...Radioiodine therapy is now completely out for the management of thyrotoxicosis. It causes more harm than good. Radioiodine treatment is only recommended for treatment of thyroid cancer with metastases" are completely at odds with current international endocrinological practice which uses Radioiodine as the most common form of definitive therapy for thyrotoxicosis.

116 This departure from current practice is compounded by another letter of 7 June, 2010 re patient D which states; "I am amazed that people are still using radioactive iodine for thyroid treatment, other than thyroid cancer it is no longer recommended therapy".

117 Patient B letter 8 February, 2010 to Dr Merhulik. The statement that thyroxine therapy alone is no longer recommended for Hashimoto's disease and that a combination of T3 and T4 is required, is again a major departure from current expert opinion. Dr Qasim previously and in this hearing argued that she considered the patient had thyroxine resistance. Professor Proietto pointed out that this is a very rare diagnosis. Moreover, during this hearing it was put to Dr Qasim that the modest elevation of TSH levels in the presence of low to moderate replacement doses of thyroxine (information apparently not provided to Professor Proietto) would be incompatible with such a diagnosis. Dr Qasim was not able to defend her position on this point.

118 Patient C C letters 12 April, 2010 and 10 May, 2010 to Dr Islam. It was considered that the diagnosis of diabetes in the presence of a normal glucose tolerance test (GTT) was most inappropriate. Dr Qasim defended this diagnosis on the basis of other clinical information, including strong family history of diabetes, elevated triglycerides, recurrent infection and elevated finger prick blood glucose levels done by the patient's mother (a nurse). It was pointed out that family history, elevated triglycerides and infection are indicators of diabetes risk but not diagnostic criteria. Moreover, a normal HbA1c level (5.7%) at the time of the GTT should have negated the suggestion of elevated finger prick blood glucose levels reported by the mother. In any case, as Professor Proietto pointed out, such levels, which have a significant degree of imprecision, are useful in management but should not be used for diagnosis.

119 Patient C was also stated by Dr Qasim to have osteoporosis when he did not meet accepted criteria of bone mineral density. She stated that she felt he had a low trauma fracture in addition to his osteopaenia but no evidence of this was provided. On the other hand, the patient did have risk factors for further bone loss which might justify a therapeutic approach as though he did have osteoporosis. But a proper expert opinion would spell this out rather than simply diagnosing osteoporosis.

120 Patient D, letter of September, 2010 to Dr Tavallaie. The use of Amaryl alone in a patient with impaired glucose tolerance or diabetes with mildly elevated blood glucose levels is not recommended but could be justified if there was a contra-indication to metformin (Dr Qasim suggested cardiac failure was such a contra-indication here) or in the presence of more substantial elevation of blood glucose levels. Dr Qasim claimed blood glucose levels were up to 20 mmol/L but this was not supported by evidence. The Tribunal felt the action here may have been acceptable, although a clearer explanation in her correspondence would have been desirable.

121 Patient E letter to Dr Fernando 2 August, 2010. Although Dr Qasim's assertion that Vitamin D assays are subject to a degree of variability was accepted, it was felt that the unqualified statement "she is severely deficient in vitamin D" when the reported level was 49 nM/L was inappropriate as that level certainly does not indicate severe deficiency. Dr Qasim's contention that she was able to reach this diagnosis on clinical symptoms and signs was not accepted by Professor Proietto or the Tribunal in view of the non-specific nature of these symptoms and signs. A repeat Vitamin D level would have been highly desirable before reaching a diagnosis.

122 Patient F letters to Dr Sadiq 8 February, 2010, 1 March, 2010 and 22 March, 2010. Here the Tribunal agreed with Professor Proietto's criticism of statements that chronic steroid use causes vitamin D deficiency; that Actonel does more harm than good; and that he has developed "secondary Addison's". In this case the Tribunal felt there was mitigation in that steroids may impair vitamin D function; Actonel use may be inadvisable in the presence of a recent fracture (which was suggested by Dr Qasim without supportive evidence); and that Dr Qasim's meaning by the term "secondary Addison's" was pituitary-adrenal suppression due to prolonged steroid therapy, which was a reasonable diagnosis and her terminology would probably have been understood by a general practitioner - though technically the term Addison's disease is inappropriate as it refers to primary adrenal gland failure.

123 In a fourth letter of 12 April, 2010 Dr Qasim states that she does not want her letters forwarded to any other specialists. Such a statement is unprofessional and contrary to the interests of the patient.

124 Patient G letter of 8 February, 2010 to Dr Holliday. The statement "he does not need to be on Lipitor as itself is a poison" was considered most inappropriate by Professor Proietto and the Tribunal, especially as the patient was at very high cardiovascular risk with diabetes and renal disease. Dr Qasim argued that it was only intended there be a brief interruption of Lipitor during an infective illness with antibiotic treatment but there is no indication of this in the letter - in fact her wording suggests the reverse.

125 Patient H letters of 3 August, 2010 and 27 August, 2010. This correspondence contains some assertions which are not well supported by the literature eg low estrogen levels causing erratic behaviour and violence; a "flat glucose tolerance curve" indicating increased risk of Type 2 diabetes; diagnosis of thyrotoxicosis by thyroid scan (a scan should be used to indicate the particular type of thyrotoxicosis not to make the diagnosis); and marijuana being the cause of thyrotoxicosis. There are some reasonable recommendations but the overall content of the correspondence is considered below what might be expected from a specialist in this area. Professor Proietto in his reports was of the opinion that in most of the letters he was satisfied there was a departure from good standard of care and it invited his strong criticism.

126 In addition to these specific issues there were substantial concerns about the general nature of the reports to general practitioners including:

lack of clarity in recommendations re diagnosis and therapy. Dr Qasim said she frequently phoned general practitioners for additional discussion but this does not lessen the need for adequate reporting as letters may be relied on by other general practitioners or specialists on future occasions.

Excessively opinionated statements of doubtful validity eg "Lipitor is a poison"; "radio-iodine treatment is completely out".

Statements indicating a lack of concern for patient well being, eg instruction not to forward letters re patient D to other specialists; apparent failure to make proper referral arrangements and adverse comments about patient and her sister and refusal to see patient I; letter to patient E of 27August, 2010 saying she was no longer prepared to treat her - without suitable alternative arrangements.

Gratuitous adverse comments about other treating practitioners as in the same letter to patient E.

127 For the reasons provided, complaints 1, 2 and 3 are made out.

128 Complaint 4 is that Dr. Qasim suffers from an impairment. She has a physical and/or mental impairment, condition or disorder namely a paranoid or delusional disorder which is of sufficient nature and degree to impair her mental capacity to practise the profession and, under Complaint 5, that she is not competent to practise the profession as she does not have sufficient mental capacity, knowledge and skill to practise the profession.

129 Evidence was called from Dr. Samuels, a highly qualified psychiatrist, who was retained on behalf of the Health Care Complaints Commission to provide reports.

130 Dr Samuels provided reports dated 21 September, 2004, 27 April, 2011, 25 May, 2011 and 1 February, 2012 and gave oral evidence on 21 March, 2014. In response to questions during examination in chief he explained the roles of the treating psychiatrist as compared to those of an assessing or independent psychiatrist. The treating psychiatrist was to maintain a relationship with the patient. There was confidentiality. On the other hand, the assessing or independent psychiatrist was independent. There was no therapeutic relationship. There was no confidentiality.

131 Asked whether a "paranoid condition" affected cognitive ability, Dr Samuels said that the condition produced difficult interactions with people such as patients and other doctors and others and that some of these had felt obliged to report the matters to the Medical Board. He had a working hypothesis that there was a paranoid disorder. It was at the level of hypothesis because Dr Qasim was guarded. It appeared she was thought disordered at times when under pressure, and was then impaired with respect to thinking and then there was an impact on thinking and interpretation. Diagnostically there was a spectrum of paranoid disorders from personality disorder at the milder end of the spectrum to paranoid schizophrenia at the more severe end of the spectrum where there was complete delusion.

132 Dr Samuels had reviewed reports provided by Dr Smith, the treating psychiatrist, and this did not change his views. He thought that Dr Smith's report did not add to understanding and it was remarkable for its brevity and lack of information, without background or personal matters or career trajectory. He was asked about Dr Smith's view that behaviour at a Section 150 hearing could not be judged as indicating mental illness. Dr Samuels indicated that intelligent people usually contain unusual ideas if they have insight and judgment at all but, under pressure, there may be decompensation. This was seen during his own second interview and at the Section 150 hearing.

133 Dr Samuels was asked about Dr Qasim's letter to the Board dated 2 December 2010 in response to a complaint made about her and said this was significant because of the tone of the letter which indicated lack of judgment and also indicated likely thought disorder, plus grandiosity.

134 Dr Samuels was asked about witness statements of Dr. Miller and Mr. Sidwell and he said these reinforced his opinion. There was prima facie evidence of mental illness contained in these letters. Back in 2004 he had seen Dr Qasim after a complaint to the Board by one neighbour and if he had had evidence of the same difficult interactions with other neighbours he would have taken a different attitude in 2004 when he had in fact dismissed the complaint of one neighbour as being in the context of a neighbour dispute. Furthermore he thought that there was a boundary violation in the matter of Mr. Sidwell in that the mother of the neighbour had been contacted and he thought this went "beyond impaired judgment".

135 Dr Samuels agreed that the proceedings at the Medical Board and in the Medical Tribunal were highly stressful but was of the view that there was a longstanding pattern of difficulty experienced by Dr Qasim that was in part evidenced by the lack of career trajectory and in part evidenced by the sheer lack of information provided by her to examining doctors which he thought was additional information in favour of the diagnosis.

136 In cross-examination Dr Samuels was asked a series of very detailed questions about the neighbour dispute and he replied that he was not interested in details of the dispute or in taking sides but there was a pattern of complaints from people with whom Dr Qasim was offside and she then became entrenched and "stuck" and furthermore that was what was happening during the process of cross-examination.

137 Asked further about the Section 150 hearing, Dr Samuels adhered to the view that she was thought disordered during that proceeding and he said that Dr Qasim had a strategy of limiting opportunities to know anything about her mental state but when under pressure, such as in a Section 150 hearing or in a Medical Tribunal, the mental state became apparent.

138 Dr Samuels was asked questions by the Tribunal, firstly about diagnosis. He said the DSM diagnosis was a difficult matter and not of crucial importance. The diagnosis was of paranoid disorder somewhere along the spectrum from personality disorder to paranoid schizophrenia. Impairment within the meaning of the Act was the relevant issue. Dr Qasim decompensated at times.

139 Dr Samuels was asked whether his assessment was strengthened or weakened by the experience of giving oral evidence in court and he said it was unchanged. Dr Qasim was "entrenched and stuck" when cross-examining, there was an inability to move on, no response to cues provided, a lack of judgment, she was overwhelmed by a sense of wrong.

140 In making his assessment, he had been most influenced by patterns of entrenched behaviour rather than by a review of mental symptomatology. He found she was an impaired practitioner within the meaning of the Act. The outlook was guarded. It would be difficult to establish a therapy relationship. The problems were of long standing and were entrenched. They would be, in all likelihood, unresponsive to pharmacological treatment. Insight was lacking and there was no foundation on which to proceed in any treatment.

141 The outlook with respect to supervision by other practitioners was considered. Control would be important. This would be difficult because of grandiosity and narcissism and suspiciousness.

Evidence of Dr Edmund Kwan Chingkun

142 Dr Kwan is the treating general practitioner and he was called by Dr Qasim.

143 In cross-examination he said he found her story about stolen files incredible but put that to one side and tried to examine her as to any underlying illness and found that she was always well presented, articulate, organised and without evidence of thought disorder at his consultations. He had seen her for the first time after the complaint was made late in 2010 and he saw her in 2011 and he referred her to a psychiatrist, Dr Teoh. He later referred her to Dr Smith. Both agreed that there was no diagnosable mental illness other than adjustment disorder in the view of Dr Teoh.

144 When asked to review Dr Qasim's letter of 2 December 2010 in response to the complaint, Dr Kwan expressed surprise that the document had been written. It told him of the "personality". He agreed the tone was threatening and there was fatuousness, grandiosity and persecutory ideas to the point of delusion. He agreed that the thought processes displayed linked up persecution in the home premises with persecution by the secretary at the workplace and a further link with Professor Smith, the complainant. He was concerned about a persecutory belief system indicating that a neighbour was a blood relative of the secretary. He said that had he been able to read this letter when he first saw his patient he would have regarded her then as in remission from mental illness. He agreed that a person with a paranoid disorder could be asymptomatic unless pushed on a difficult topic. He agreed that with stress there could be decompensation and the disorder become manifest.

145 He agreed that she was delusional as at October 2011 as evidenced by the complaint to the Health Care Complaints Commission about Dr Newman having stolen her files. He agreed that delusions drove her to make complaints to the Health Care Complaints Commission regarding her colleague.

146 Regarding the fax to the Medical Board dated 30 November 2010, he saw evidence of aggression, lack of understanding and lack of judgment. With regard to the letter of 8 December 2010 to the Medical Board, he saw threatening tone and thought disorder and grandiosity with lack of judgment.

147 Regarding material filed on 28 February 2014 - Exhibit B - he agreed there was delusional material in evidence, likewise in Exhibit E and Exhibit A paragraph 150. He accepted that there was a delusional/persecutory belief system as of February 2014.

148 He agreed that if there was evidence of querulous aggressive behaviour prior to 2010, then a diagnosis of adjustment disorder could not be correct.

Evidence of Dr Selwyn Smith

149 Dr Smith provided reports and gave oral evidence on 25 March 2014. Dr Smith is the treating psychiatrist. He first saw her on 24 May 2012 and provided a letter to the general practitioner on 25 May 2012. His role he described in oral evidence as assisting Dr Qasim to cope with her current difficulties with the Health Care Complaints Commission. He later was asked by lawyers to provide reports, which he did on 6 February 2013 and 11 September 2013. He was provided with four volumes of Health Care Complaints Commission files and his attention was directed to specific items within these files.

150 When asked questions in examination he said there was no diagnosis. He agreed with the first report of Dr Samuels, the 2004 report, and disagreed with later reports.

151 Under cross-examination, with regard to her letter of 2 December 2010, he thought she was expressing distress and her style was to shoot from the hip. He agreed that it showed poor judgment but that did not equate with paranoid schizophrenia. He thought that her various references to the complainant contained in that letter indicated anger. He was asked to assume there was a benign explanation for how the letters ended up attached to Professor Smith's complaint, rather than the explanation of theft of files, and Dr Smith said that someone should have told Dr Qasim about this. It was pointed out that this had been done during the Section 150 hearing. Dr Smith thought the Section 150 hearing was confrontational. Dr Smith did not accept that she linked the matters of neighbours, the matter of the secretary and of Professor Smith in a persecutory manner. He thought it was true that she was being persecuted or that she was "under siege". He also had no doubt that she had distorted the facts and where there was a nidus of suspiciousness, that was exaggerated.

152 He was asked about the complaint against Dr Newman. He agreed it sounded fantastic that the colleague would steal hundreds of files. However, he did not think it was necessarily delusional and that was why it did not warrant mention in his report. He thought there was unwarranted suspicion not necessarily delusion.

153 He was asked about Dr Qasim's Exhibit A indicating ongoing harassment by the Medical Council of New South Wales with respect to her home premises and he agreed that it was paranoid. He agreed that she alleged conspiracy and he was concerned but thought this was "subthreshold". He said he would take these matters up with her in consultation to see how important they were. Dr Smith thought, even granted she had paranoid or delusional disorder, that would not necessarily intrude into capacity to practise medicine. He has seen no such linkage.

154 He was asked about complaint 2 in which she writes letters refusing to see patients and disparaging colleagues and about the unchallenged evidence of Person A who said that Dr Qasim "flew off the handle and told the patient to piss off". Dr Smith agreed that a person with a paranoid disorder was more likely to overreact. He agreed that her language was poor and her commentary inappropriate but could not link that to her competency to practise.

155 He answered that he was not aware of gaps in her career trajectory.

156 Reviewing statements of Mr. Sidwell and Dr. Miller, he thought the fact that there was conflict operating in the home environment was a powerful explanation. He agreed that the letters were "over the top" but threatening only in that she was "pushing back". He agreed she had rigidity or fixed ideas with respect to the building. He could not reach any definite conclusion about four different neighbours describing aggressive and threatening behaviour.

157 He thought the Section 150 transcript indicated that she was interrupted and not fairly treated. He did not see decompensation of a psychiatric disorder. He had not listened to the tape but had read the transcript. He disagreed with the proposition that he had picked out the odd thing to suggest unfairness rather than taking the overall context. It was put to him that most of the interrupting was done by Dr Qasim.

158 In the course of cross-examination Dr Smith did not alter his opinion that there was no formal psychiatric disorder.

159 He was then asked questions by the Tribunal concerning the respective roles of medico-legal expert and treating psychiatrist in current proceedings. He said the medico-legal expert was to assist a legal body and that the context of examination was confrontational or adversarial, the patient was on the defensive particularly if returning after a previous negative report. On the other hand, the treating psychiatrist had an open, trusting, relaxed relationship.

160 He agreed there was confidentiality in the treating relationship but this had been terminated, as discussed with his patient, when legal requests for reports were forthcoming.

161 When asked whether he was independent, he said he tried to be independent. Asked whether he had an ethical duty to assist and advocate for his patient, he agreed this was so and that that ethical duty continued up to the present.

The Tribunal's View

162 The Tribunal preferred the evidence of Dr Samuels as compared to that of Dr Smith. Dr Samuels is viewed as an independent expert. Dr Smith was viewed as a treating psychiatrist trying to carry out a perceived ethical duty of assisting his patient.

163 The Tribunal accepted the opinions of Dr Samuels as given in his two recent reports and in oral evidence. The Tribunal further considered that the behaviour of Dr Qasim during the hearing was further evidence in support of Dr Samuels' opinion.

164 The Tribunal accepts that there is a serious psychiatric disorder and accepts Dr Samuels' comments about the difficulties or uncertainties about exact diagnosis on a paranoid spectrum. The Tribunal is of the view that the psychiatric disorder constitutes an impairment and specifically causes impairment in interactions with patients, colleagues and with the community in general. All of this was in evidence before the Tribunal.

Complaint 4

165 For reasons that the Tribunal has provided, that complaint is made out.

Complaint 5

166 Competency - Section 139 of the National Law provides:

"A person is "competent" to practise a health profession only if the person-

(a) has sufficient physical capacity, mental capacity, knowledge and skill to practise the profession; and

has sufficient communication skills for the practice of the profession, including an adequate command of the English language. "

167 The Tribunal has found there are two separate and distinct bases upon which it can find that Dr. Qasim is not competent to practise medicine within the meaning of the National Law. The first relates to her views about endocrinology and her explanations and evidence relating to endocrinology arising out of those matters in the amended complaint.

168 The Tribunal's finding is that, whilst those complaints are made out and that, at the time of the complaints and at the present time, she does not have sufficient knowledge and skill to practise the profession and that the doctor engaged in unethical conduct relating to the practice of medicine and that the doctor engaged in unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of her registration and, further, that she engaged in more than one instance of unsatisfactory professional conduct and, when these instances are considered together, they amount to conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration and, that being the only evidence before the Tribunal, the Tribunal would have made an order that her further practice of medicine as an endocrinologist would have been subject to further training, supervision and other necessary orders.

169 The Tribunal still had doubts as to whether such an order would be satisfactory as Dr. Qasim would not accept Professor Proietto's evidence in relation to statements she made nor Professor Smith's evidence and that, of course, raises a question as to whether she would be suitable for supervision and retraining. In the end the Tribunal would have made orders along those lines.

170 The second relates to her mental capacity which, for reasons the Tribunal has already given, the Tribunal is of the opinion that the doctor does not have sufficient mental capacity, knowledge and skill to practise the profession and that there is an impairment which interferes with the doctor's judgment, communication skills and clinical ability and that is for a number of reasons.

171 The Tribunal is referred to a decision of Tung v. Health Care Complaints Commission 2011 NSWCA 219 at 56:

"There is some overlap between the two grounds for complaint in s 39 of the Act, being lack of competence on the one hand and impairment on the other. The definitions of these terms have been set out at [20] above. A physical or mental impairment, disability, condition or disorder which detrimentally affects the person's physical or mental capacity to practice medicine may mean that the person does not have sufficient physical capacity, mental capacity or skill to practice medicine. But that is not necessarily so, and particularly it is not necessarily so in the case of a physical or mental impairment, disability, condition or disorder which is likely to detrimentally affect the person's physical or mental capacity to practice medicine. Thus in Lindsay v Health Care Complaints Commission Sackville AJA observed at [169] that the Tribunal "merely asserted, without further reasons, that by reason of his impairment, the appellant was not competent to practise medicine", and continued -

" [170] The absence of further reasons supporting the finding of lack of competence perhaps suggests that the Tribunal assumed that the existence of an impairment, at least of the kind attributed to the appellant, necessarily meant that he lacked the mental capacity or communication skills to practise medicine. Such an assumption would be incorrect. Even a serious psychiatric condition does not necessarily lead to the conclusion that the medical practitioner concerned lacks competence in the relevant sense. Whether it does or not will depend on such considerations as the nature and likely duration of the impairment, the kind of practice carried on by the medical practitioner, the extent to which the impairment interferes with the practitioner's judgment, communication skills and clinical ability, and other relevant circumstances."

172 Many of these reasons are set out in submissions made to the Tribunal and in no particular order they include getting offside with people, getting stuck on a particular pathway that she cannot get off, rigidity, developing grievances, grandiosity, inability to reflect, paranoia. In addition to these matters, Dr. Qasim did not show herself to be a person of good character. She was not frank and truthful in her evidence to the Tribunal. The way she conducted herself during the hearing, particularly her attitude towards Ms. Richardson for the Health Care Complaints Commission was not the conduct expected of a doctor. Dr. Qasim was not only rude to Ms. Richardson but then commenced to blame Ms. Richardson for what was happening.

173 There was other behaviour taken into account by the Tribunal which, of course, included matters we have set out previously including her paranoid behaviour, not replying properly to legitimate complaints, lashing out at Professor Smith and Ms. Dinkelman in an irrational way, making serious allegations against those persons together with serious complaints against other doctors without any basis for them, making serious allegations against the Health Care Complaints Commission, becoming fixated with various arguments and disputes which occurred surrounding repairs to the building she lived in, her irrational behaviour as set out in Exhibit H of her Exhibit 1 in relation to the Section 150 hearing when she says that the panel were "not qualified, they were extremely hostile, inappropriate, absurd, aggressive, ignorant, ill-informed", that there were malicious and false reasons in written decisions and remarking on the CV of the members of the panel and saying they were "ill-informed, unqualified and inappropriate". All the panel had done was consider the evidence before them and rule that she should be suspended from practice. As a result of this they were personally attacked. There were the other matters we have earlier set out in this judgment.

174 The Tribunal also has evidence, which was not denied, of bizarre correspondence she wrote to the other owners of the premises in which she lived and there is other evidence we do not highlight here.

175 What began as an expression of concern has resulted in a pattern of behaviour which causes the Tribunal, after considering the expert evidence before the Tribunal, to accept that there is a serious psychiatric disorder and that that disorder constitutes an impairment and, as a result, we are satisfied that Dr. Qasim is not competent to practise medicine and that she suffers from an impairment of a nature that renders her not competent to practise. The Tribunal is satisfied that each of the complaints is made out.

ORDERS:

176 The Tribunal is also satisfied that Dr. Qasim has limited insight into her impairment. She does not accept that the advice she gave to general practitioners is contrary to the advice a specialist endocrinologist should give. She does not accept the evidence given by Professor Proietto, a very highly qualified endocrinologist. She has said that she would be prepared to work under supervision and undergo some retraining, however, as she has not admitted that her advice is wrong, as she will not accept what highly qualified experts say, the Tribunal has significant doubts as to whether supervision and further training would assist. Importantly, as far as the Tribunal is concerned, Dr. Qasim will not accept that her behaviour in making very serious allegations of which there is no evidence; that her blaming of virtually everyone who has had anything to do with the matters raised for her to answer or nearly anyone involved in any of the hearings was correct in what they said. She will not bring her mind to bear on the real issues. She does not accept that she has a mental illness which requires treatment or, at least, an acceptance of the problems she has so as she can be given assistance.

177 Dr. Samuels has said that people with paranoid conditions often do not accept that they have a mental illness. They do not respond well to interventions. Dr. Samuels said it would be difficult for Dr. Qasim to develop a therapeutic relationship with a psychiatrist which would allow her to be treated effectively for her condition. The doctor declines to have any appropriate treatment; the doctor cannot accept that her conduct is inappropriate for a medical practitioner.

178 The Tribunal has therefore formed the view that it is unlikely, at least for a significant period of time, that Dr. Qasim will change her conduct or get to a position where she is competent to practise.

179 The Tribunal orders:

1. That Dr. Qasim's health practitioner's registration be cancelled as of today.

2. That Dr. Qasim is not permitted to make an application for re-registration or review for a period of four years from today.

180 The Health Care Complaints Commission seeks the costs of this hearing. Dr. Qasim also seeks her legal costs. The Tribunal would have made an order that each party pay their own costs on the basis that these complaints were brought by the Health Care Complaints Commission and that she therefore had the right to defend them in a proper manner. However, her evidence, which we have found to be untrue, relating to the typing of the reports and the form in which the reports went to the various doctors has clearly extended the length of the Tribunal hearing as has her unfounded allegations as we have set out earlier.

181 We therefore order that Dr. Qasim pay her own costs and, in addition, pay two-tenths of the costs of the Health Care Complaints Commission, the hearing having been extended by at least that time in dealing with the matters we have set out above.

182 We assess the Health Care Complaints Commission's costs at $70,000.00 which appear to be reasonable on the evidence we have and reasonable when viewed in light of Dr. Qasim's claim that her costs were over $110,000.00. Therefore, the costs payable to the Health Care Complaints Commission are $14,000.00.

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I hereby certify that this is a true and accurate record of the reasons for decision of the Civil and Administrative Tribunal of New South Wales.
Registrar

Decision last updated: 02 May 2014