Medical Tribunal New South Wales

• Medium Neutral Citation: Health Care Complaints Commission v Gorman [2011] NSWMT 7
• Decision date: 17 August 2011
• Jurisdiction: Civil
• Before: Mr Russell Smith; Dr Katherine Ilbery; Dr Helen Pedersen; Judge Peter Johnstone (Deputy Chairperson)

Decision

Findings as to unsatisfactory professional conduct, professional misconduct and incompetence to practice medicine, de-registration of the Respondent and consequential orders, Respondent to pay the Commission's costs

• Catchwords: Medical Practitioner - unsatisfactory professional conduct - professional misconduct - competence to practice medicine
• Legislation Cited: Medical Practice Act 1992; Health Practitioner Regulation National Law (NSW); Poisons and Therapeutic Goods Act 1966
• Cases Cited: Briginshaw v Briginshaw (1938) 60 CLR 336; Neat Holdings Pty Ltd v Karajan Holdings Pty Ltd (1992) 67 ALJR 170; Gorman v Health Care Complaints Commission [2002] NSWCA 396; Lucire v Health Care Complaints Commission (No 2) [2011] NSWCA 182; Ohn v Walton (1995) 36 NSWLR 77
• Category: Principal judgment
• Parties: Health Care Complaints Commission (Complainant); Richard Francis Gorman (Respondent)
• Representation: Ms K Richardson (Complainant); The Respondent was self-represented; Ms M Richmond (Complainant); The Respondent was self-represented
• File Number(s): 40027/10 (Consolidated with 40010/2011)
• Publication restriction: Suppression order in relation to the names of patients the subject of the complaints; Pursuant to Clause 6 of Schedule 2 of the Medical Practice Act 1992, the Tribunal has made a non-publication order in respect of any matter capable of identifying the PATIENTS/WITNESSES referred to in this decision.

REASONS FOR DECISION

The complaints

1 By Notices of Complaint dated 30 June 2010 and 17 March 2011 the Health Care Complaints Commission (the Commission) has made complaints against the Respondent, Richard Francis Gorman, a registered medical practitioner, alleging that he has been guilty of unsatisfactory professional conduct and professional misconduct, and that he is not competent to practice medicine.

2 The Commission seeks a de-registration order. It seeks further orders preventing the Respondent from making an application for review for 3 to 5 years, and an order for costs in its favour against the Respondent.

3 The Commission also seeks a prohibition order preventing the Respondent from either performing spinal manipulations or from educating other persons in the performance of spinal manipulations.

4 The first Notice of Complaint is brought pursuant to s 36 and s 37 of the Medical Practice Act 1992 . The second Notice of Complaint is brought pursuant to s 139B of the Health Practitioner Regulation National Law (NSW) .

5 The complaints were heard together by the present Medical Tribunal over 10 hearing days in May/June 2011. The Respondent was self-represented. During the course of interlocutory appearances he made it expressly clear that he did not wish to have legal representation. However, at his request and with the leave of the Deputy Chairperson, he was assisted during the hearing by a friend and supporter, Mr Jim Sullivan, who sat with him at the Bar table, and who led him through his evidence-in-chief.

6 The four complaints set out in the two Notices of Complaint allege deficiencies in the care and treatment of various patients whilst working as a general practitioner between October 2006 and November 2008:

• Complaint 1.1 in the first Notice of Complaint relates to 5 patients of the Respondent seen at the Bankstown Medical Centre:

Patient KS Paragraphs [141] - [170]

Patient MP Paragraphs [171] - [186]

Patient PD Paragraphs [187] - [206]

Patient JE Paragraphs [207] - [218]

Patient CR Paragraphs [219] - [244]

• Complaints 2.1 and 2.2 in the second Notice of Complaint relate to a further 8 patients of the Respondent seen by him at the Primary Health Care Clinic in Bankstown:

Patient NC Paragraphs [245] - [260]

Patient JEK Paragraphs [261] - [280]

Patient CC Paragraphs [281] - [297]

Patient DL Paragraphs [298] - [313]

Patient ZZ Paragraphs [314] - [328]

Patient ST Paragraphs [329] - [345]

Patient AT Paragraphs [346] - [362]

Patient RP Paragraphs [363] - [386]

• Complaint 2.3 in the second Notice of Complaint relates to the alleged incompetence of the Respondent to practise medicine.

7 The Respondent seeks to justify his care and treatment of these patients, and to answer the complaints, relying upon his particular medical philosophy, involving the application of forceful spinal manipulation therapy.

8 The Commission maintains, however, that the Respondent has demonstrated that the knowledge, skill and judgment possessed, and the care exercised by him is significantly below the standard reasonably expected of a practitioner of an equivalent level of training and experience, and that he breached the Medical Practice Regulation . The Commission also maintains that the Respondent does not have sufficient physical capacity, mental capacity, knowledge and/or skill to practise medicine.

9 The Tribunal accepts the Commission's submission that it bears the onus of proving the complaints to the Tribunal's reasonable satisfaction on the balance of probabilities. In applying that standard, the Tribunal will have regard to the gravity and importance of the matters to be determined in accordance with the principles in Briginshaw v Briginshaw (1938) 60 CLR 336, such that the Tribunal should not lightly make any findings in respect of the serious allegations made against the Respondent: Neat Holdings Pty Ltd v Karajan Holdings Pty Ltd (1992) 67 ALJR 170.

The Respondent's medical philosophy

10 The Respondent was born on 24 August 1932. He is now 78 years old and will shortly turn 79. He comes from a medical family: both his mother and father were medical practitioners. He went to school in Victoria and then to the University of Melbourne graduating MBBS in 1955.

11 His clinical training was undertaken at St Vincent's Hospital. He undertook post-graduate training in general medicine, surgery, anaesthesia, orthopaedics and ophthalmology. He was awarded a diploma in ophthalmology in London in or around 1965, became a member of the Royal Australian College of Ophthalmologists in or around 1969 and was subsequently "grandfathered" to fellowship status. In 2004 he qualified as a fellow of the Royal Australian College of General Practitioners by examination.

12 He practised in the United Kingdom, Africa and Australia, in Victoria, Western Australia, the Northern Territory and New South Wales. From 1967 to 1970 he worked as an ophthalmologist at the Bendigo Regional Hospital. From 1971 to 1983 he was in private practice in Darwin and Mt Isa, concentrating on ophthalmology. After this period of 12 years the Respondent came to Sydney, where he was in private practice in Sydney from 1983 until December 2008 when he was suspended under s 66 of the Medical Practice Act 1992 .

13 During the period that the Respondent worked in the Northern Territory and North Queensland he met Dr Eric Milne, a general practitioner working at Mt Isa, who developed a technique of forceful spinal manipulation that in his view led to the recovery of patients suffering from migraine headaches. Dr Milne believed that spinal derangement was the cause of migraine headaches and 'many other mental and physical disabilities'.

14 The Respondent embraced Dr Milne's philosophy and his technique of forceful spinal manipulation and it became the guiding force in his approach to the practice of medicine. He now describes himself as a "spinomigrainologist" (T 356.33 and T 551.30).

15 The Respondent's medical philosophy is described in his own words as follows:

"I have developed a medical philosophy (which is repugnant to orthodox medicine)...which has formed the basis of my life in medical practice...I have strongly and repeatedly recommended that this new medical philosophy should supersede orthodox medical practice where appropriate to do so."

16 In his view, the medical philosophy that he espouses has been deliberately suppressed by an 'arch-villain', the Royal Australian and New Zealand College of Ophthalmologists (RANZCO): see Exhibit 2 at p 240.

17 Accordingly, he regards himself as a whistleblower, seeking to alert the community to aspects of orthodox medicine, which, he alleges, damage New South Wales citizens, and their fellow citizens worldwide, on a daily basis:

"The failure of this Tribunal to take its place in the history of mankind is augured by his Honour's legal inability or disinclination to publicly acknowledge that I am a whistleblower of the major travesty in health care since homo sapiens appeared on earth."

18 It is the Respondent's view that his philosophy is outside conventional medical practice, such that he should not to be judged by the Medical Tribunal, where 'the theme, the bias, is that orthodox medicine rules supreme': cf Gorman v Health Care Complaints Commission [2002] NSWCA 396 at [69]ff. Rather he should be judged in some other court where medical innovations can be assessed (T 30.35). He says:

"I see medical practice in two lights: 'commonsense' medical practice and 'medical practice is an ass' medical practice. Commonsense medical practice generally involves resuscitation, trauma, complicated obstetrics, anaesthesiology and public health. Essentially it deals with measurable pathologies. Medical practice is an ass medical practice is the inferior way that medical practitioners deal with nonmeasurable pathologies: illnesses which do not have finite dimensions; the best example is mental health. My philosophy replaces medical practice is an ass medical practice with the treatment of interictal migraine by spinal manipulation therapy. Thus my philosophy involves best practice in resuscitation, complicated obstetrics, anaesthesiology, public health and interictal migraine."

19 Broadly speaking, the Respondent's philosophy is that there is a universal illness, for which there is a single, standard, effective cure, namely forceful spinal manipulation therapy. The procedure is not dangerous, and is cheaper and more effective than conventional medical treatment.

20 The Respondent believes that orthodox medical practice is not competent or complete once it leaves the parameters of trauma, resuscitation, complicated obstetrics, pain relief and public health. Thus:

"My style of medical practice is economical, panoramic in philosophy, effective and safe. In comparison, orthodox medical practice is inordinately expensive, generally palliative, restrictive in philosophy and often dangerous."

21 The universal or ubiquitous illness for which this forceful spinal manipulation is the standard cure is, primarily, a spino-migraine illness (T 558), which is scan and blood test negative. According to the Respondent it has various interchangeable names (T 564):

"Well I'm - I'm - we're talking about my opinion. I - I think they're all - that all those names, the first one was railway brain, concussion of the spine, that was the first one. Then it became concussion of the brain. Then it became railway brain and railway spine because most of these patients litigated and the railways at that time were the fastest transport, so the whiplash injury was very likely to occur in railway accident. And then when those litigations went on, instead of talking about concussion of the spine, concussion of the spine, they took it into a litigation aspect and then they called it colloquially "railway brain" - "railway spine" first, and then they realised that it was a brain illness, so they called it railway brain.

And then by the 1890s it was being called traumatic neurasthenia because they'd gone off to thinking of it as being a psychiatric illness, and then in 1921 the researchers Barre-Lieou put forward the BarreLieou syndrome which was the same illness by another name and then about 1956, an orthopaedic surgeon at the University of Texas called it the cervical syndrome and she wrote the definitive tome on the illness at that time. Then the next one it was, of course, whiplash came up about that time and that was another name for it."

22 His therapy, consisting of forceful spinal manipulation is a 'rough procedure' designed to break any 'rigid end fields' encountered in the neck (T 555.37). The procedure is more fully described by him as follows (Exhibit 4 at p 89):

"Forced-thrust means a short, low amplitude manipulation directed to the spine in the end field of rotation or angulation. In the hands of chiropractors, this thrust is the key manoeuvre following 'taking up of the slack' until the rigid block to further movement is reached; then a high velocity, low amplitude force is applied...In my hands, the whole business of manipulation is a forceful continuous movement, which takes the joint, without pause, forcibly to the ultimate limit of its excursion - the aim to smash any obstructions, which limit full movement."

23 The Respondent has written a number of publications in support of his medical philosophy (see Exhibits 2, 3 and 4) and created a series of DVD's (see Exhibit 9) depicting his therapy in action. (One of these was written under the pseudonym Franz von Kurbel. As the Respondent explained, kurbel is a German word for 'crank' (T 362): Dr Milne and others sometimes affectionately referred to him as 'Frank the Crank'.) It is not the purpose of these reasons to analyse the totality of this material, but aspects and features from it will be referred to.

24 According to the Respondent, a cardinal feature of the ubiquitous illness is lowered sensitivity of vision, which reflects as a constriction of the visual fields towards the centre: tunnel vision (Exhibit 4 at p 89):

"On the 22 nd of June 1986, on the 60 Minutes program, in a segment entitled, " A Dangerous Twist ", I demonstrated that this visual abnormality: this migrainous, brain condition, recovered immediately when the spine was forcefully manipulated by Dr Milne's technique, while the patient was anaesthetised with full muscle relaxation..."

25 This phenomenon is the platform upon which the Respondent's medical philosophy rests. He contends that the scientific dimension of the recovery of vision as a result of spinal manipulation therapy is that it changes deficient capillary blood flow. In his final written submissions he said:

" Using my textbook: 'The Scientific Basis of Spinal Manipulation Therapy for Constitutional Illnesses' as a guide, I discussed the only logical hypothesis, which explains the scientific dimensions of the recovery of vision with spinal manipulation therapy.

In this discussion, I stressed that appreciation of the concepts of Interictal Migraine, the Ischemic Penumbra State, Watershed Ischemia and Intercapillary Watershed Ischemia were critical to comprehension of why vision improved when the spine was manipulated.

In my introduction to science in the 'Scientific Basis' book, I noted that interictal migraine, the ischemic penumbra state and the recovery of vision with spinal manipulation therapy all appeared as cast members on the stage of scientific discovery in the late 1970s.

I argued that, together, these three phenomena made the point that spinal manipulation changed deficient capillary blood flow for the better on most occasions."

26 Thus, a central tenet of the Respondent's medical philosophy is that the universal or ubiquitous illness, or interictal migraine, is related to diminished blood supply, or ischemia. Integral to his theory are his concepts of the 'osteopathic aura', the 'ischemic penumbra state', 'watershed tissue in penumbra' and the 'polynya concept', each of which he discusses at length in his publications: see in particular the booklet " The Scientific Basis of Spinal Manipulation Theory for Constitutional Illnesses " (Exhibit 4).

27 In Chapter 4 of the booklet which is Exhibit 4, the Respondent discusses his concept of 'the osteopathic aura' at pp 33 - 35:

"It has been left to me, by no means a scientist, to raise the concept of the 'osteopathic aura', which I see as a halo-like, quasi-electrical field, which occurs around joints, which are disturbed by trauma such that their kinetic mechanics (capacity to articulate) are impeded..."

"As a result of passing through this halo, blood vessels gain a pathological, vasomotor, constrictive influence; this vasospastic influence causes arterioles to constrict in a sporadic fashion in areas, which the influence can reach..."

"Gorman's rule: that is, my rule, states that any joint with abnormal kinetic mechanics for whatsoever reason, will generate an aura which will induce a voltage potential in the nervous systems of blood vessels, which lie adjacent to the abnormal joint..."

"Single arterioles can go into spasm anywhere in the body; but the result will not be a clear cut definition of the pathology so caused. We have to extrapolate from our knowledge of what happens in the optic nerve..."

"Thus, blood vessels which supply adjacent nerves, will be affected, causing their arterioles to contract; the subsequent restriction of blood flow to the nerve could cause a malfunction in nervous conduction..."

"When the kinetic mechanics are normalised by giving the joint a physical workout, the aura disappears..."

"My belief is that any joint can be affected by a 'subluxation', so to produce a 'subluxation complex'; thus it is possible to have ankle migraine, knee migraine, hip migraine and so on; any joint in the body can be involved in the migraine process..."

28 When the Respondent was cross-examined about his concept of the 'osteopathic aura', he acknowledged that it has not been verified scientifically, such that his theory explaining the phenomenon involves a 'leap of faith' (T 316 - 317 and 321).

29 The Respondent describes the link between spinal manipulation and migraine and interictal migraine as 'immensely important'. Dr Milne's discovery, in defining that there was a measurable abnormality in interictal migraine is the 'most significant medical discovery in the history of medicine', for which discovery Dr Milne should have been awarded a Nobel prize:

"Now the third reason why he (should get) a Nobel Prize is he defined that there was a measurable abnormality in interictal migraine, and that was this constriction of the visual fields. He measured - he and I found that and that was a coincidence, too, really. It wasn't a cleverness on our part. It was just so happens that I was an eye specialist and that part of my routine examination I examined the visual fields, and then we found these people with visual field abnormality. So that - he should have got a Nobel Prize for that because that is the most significant medical discovery in the history of medicine. "God, you're arrogant, Dr Gorman. You're such an arrogant person", but that's the reality. That's the link between spinal manipulation and migraine and interictal migraine. It's immensely important. That's why it so sad that the College of Ophthalmologists have been so foolish. They had it in their hands"

30 The Respondent says that the ubiquitous illness is hard for intelligent people to grasp. In fact, the less intelligent one is and the less educated, the more able one will be able to understand his medical philosophy:

"And what that's saying is that the more intelligent you are, the harder it is to understand this illness and this is what I refer to as the beautiful people" (T 407.25)

"And then we come to the picture on page 17, your Honour, where we've got orthodox medicine and unorthodox medicine or fanciful medicine, if you like. And orthodox medicine is known, definite, cut and dry, orthodox. It's something that can be measured.

And then there's - outside that, there's a vague cloud which some people can see and the more - in my opinion, the more intelligent you are, and the better educated you are, you'll have very great difficulty seeing that cloud. The people that see that cloud are weirdos, like me. They - they can see spiritual things, if you like. They - and - so there we go.

So the person who deals in that cloud and we can talk about it, acupuncturists, probably - probably they might be on the other side. But certainly, iridologists and certainly reiki. Reiki is when they do therapy by bringing the aura of the healer close to the person and - reflexology. Reflexology is when you massage the feet and that makes the patient better and - so - generally, orthodox medicine. "Oh, God, these people, they're conmen and they" - I use the word, "snake oil salesmen". You know, they are selling snake oil. But a lot of them are - in fact, very generally they really believe that what they're doing is doing something and that's a foible of human nature, if you like, that they can see this cloud so clearly.

Anyway, what happened was, that when we discovered that tunnel vision came to be part of the cloud and we were able to measure it, we moved it out of the cloud and moved it into the organic side. And at the same time as that happened, an illness appeared. A very vague nebulous, esoteric illness, called interictal migraine appeared in the literature, about the same time. We found tunnel vision in the late 1970s and interictal migraine appeared in the medical literature at the same time"

31 The proposition that tunnel vision can be cured by spinal manipulation is the cornerstone of the Respondent's medical philosophy.

32 He contends that all illnesses have to be challenged under the auspices of that discovery (T 825.17):

" Q. So you're saying this discovery that was made, was this the discovery about tunnel vision in the 70s?

A. That's right, about 78.

Q. Are you saying that that discovery is relevant to most of the illnesses or ailments that present to you in general practice?

A. Yes, that's totally correct. All illnesses have to be challenged under the auspices of that discovery. That's why it's so important. That's why they're trying to put me down so hard because it's so challenging that I'm saying to the tribunal you virtually - if you make a decision to exonerate me or allow me to continue, you're making a decision that, you know, says that my criticisms of the medical profession in Australia are valid ."

33 The Respondent considers that forceful spinal manipulation is the answer to patients complaining of a wide range of conditions, even where the patients have not in fact presented with loss of any vision. His medical philosophy, based on the 'leap of faith', is relevant to many if not most conditions encountered by him in general practice including allergic conditions, acne, dermatitis, arthritis, sinusitis, tonsillitis, colic, diarrhoea, influenza, glaucoma, pneumonia, autism, morning sickness, depression, hypertension and panic attacks. It is also relevant to the treatment of mental illness, suicide, and drug addiction. It could even be used to help the behavioural or cognitive function of prisoners, to reduce recidivism. Thus:

" Q. So is it the case it's not just relevant, it's the centrepiece of your philosophy? A. Yes, it is certainly the centre piece of my philosophy because it's a - an area of brain function that was previously not measured, now measurable and it's opened up tremendous doors and that's why it's been opposed so strongly by the HCCC and by the medical profession. "

Dr Beaumont's evidence as to the Respondent's medical philosophy

34 It is not the role of the Medical Tribunal to assess or determine the validity or otherwise of the Respondent's medical philosophy; its role is to consider and judge his professional conduct against the standard reasonably expected of a practitioner of an equivalent level of training and experience. It is, however, appropriate to observe that to the extent that the Respondent relies upon his medical philosophy to justify his care and treatment of the patients concerned, his philosophy has never been independently validated. Even the expert witness called in his case, Dr Beaumont, rejects the philosophy.

35 Dr Beaumont is an experienced ophthalmologist who has been involved in patient care, teaching and research for 30 years. He has a special interest in diabetic retinopathy, retinal venous occlusion, macular degeneration and neuroophthamology. The majority of his patients are referred from other eye specialists or optometrists due to his specialist expertise in medical retina. He has published over 70 articles in peer-reviewed journals, and is a frequently invited speaker at international meetings. He is a fellow of Royal Australasian and New Zealand College of Surgeons and Chairman of the New South Wales branch of the Royal Australian and New Zealand College of Ophthalmologists. He has other impressive qualifications and appointments as detailed in his curriculum vitae. He is clearly an expert in his field and an eminent practitioner, whose evidence before this Tribunal was articulate, forthright and dispassionate.

36 He was given the Respondent's three publications that are in evidence to read: "The Great Australian Medical Scientific Fraud" (Exhibit 2), "Chiropractic Medicine for Rejuvenation of the Mind" (Exhibit 3), and "The Scientific Basis of Spinal Manipulation Therapy for Constitutional Illnesses" (Exhibit 4). He read two of those publications (T 418.39). In his view it would take approximately three to six months to adequately discuss everything that is in those publications (T 418.33).

37 Accordingly, Dr Beaumont prepared a report dated 18 May 2011 (Exhibit 6) by way of a preliminary overview of the booklet "The Scientific Basis of Spinal Manipulation Therapy for Constitutional Illnesses" (Exhibit 4).

38 It is Dr Beaumont's view that a number of the theories and ideas postulated by the Respondent are very unlikely, that his philosophy is not 'evidence based' and that spinal manipulation is inappropriate therapy in most of the situations in which it has been employed by the Respondent.

39 As to the Respondent's concept of the "osteopathic aura", Dr Beaumont believes that the concept is highly unlikely, and says there is no evidence that there is a heightened electrical potential around joint derangements, nor that the arterioles are caused to constrict:

"...because I haven't read anything in the literature around this, that there are electrical impulses which occur when you move a joint a little bit, that then cause the vessels around it to go into spasm, I find it unlikely" (T 458.2).

40 As to the Respondent's theory that migraine illness is primarily a problem associated with any joint dysfunction (eg. "elbow-induced migraine"), Dr Beaumont describes that as "incredibly bizarre":

"They're not terms within the medical literature, and so he's got to postulate that there's electrical activity around the joint and that it's causing an elbow migraine. Well, the electrical activity around the joint was a bit unusual and then he's defined an entirely new thing called elbow migraine. I find that bizarre because I'm limited in my conservative approach to the medical language that migraine is a head phenomena" (T 458.39).

41 As to the Respondent's theory that bilateral altitudinal hemianopia occurs as a brain phenomenon and not as an optic nerve problem, Dr Beaumont believes that the theory is very unlikely (T 434.35).

42 While the Respondent would treat retinitis pigmentosa with spinal manipulation, Dr Beaumont expressed the view that he would not adopt such a treatment and would not send a patient with retinitis pigmentosa for manipulation.

43 In response to the suggestion that macular degeneration should be treated with spinal manipulation, Dr Beaumont responded:

"... in terms of macular degeneration I'd find it totally unacceptable to think that spinal manipulation would have anything to do with it, and yet you do" (T 503.23).

44 Dr Beaumont's rejects the theory that the explanation for the recovery of vision with spinal manipulation is a vascular hypothesis. The "vascular hypothesis", which is the central component of the Respondent's medical philosophy that justifies the extension of his use of manipulation to a wide variety of conditions, is "untenable" (T 454.18).

45 In his report Dr Beaumont discusses his involvement in the assessment of 12 patients presented by the Respondent exhibiting constricted visual fields, headaches and hypersomnolance. Dr Beaumont noted that the signs and symptoms of each subject had disappeared when evaluated after the Respondent performed forceful spinal manipulation therapy upon them. He considered that this intervention had a 'dramatic beneficial effect'. But in his view, it is not reasonable to use this evidence base to formulate the various postulates, hypotheses and proposals that are encompassed in the Respondent's medical philosophy as set out in his booklet "The Scientific Basis of Spinal Manipulation Therapy for Constitutional Illnesses" (Exhibit 4). Thus, Dr Beaumont is of the view that the Respondent's treatment of a wide range of 'constitutional illnesses' with spinal manipulation, the appropriateness of which is the central controversy in this proceeding, 'is not evidence based and is not reasonable' (at p 8).

46 Thus, in Dr Beaumont's opinion, the Respondent does not have enough evidence for what he does, such that it is to be classified as 'inappropriate and dangerous' (T 503.12). Accordingly, he said (T 441.06)

" One of the problems we have is Frank (the Respondent) wanting to extend it out into other areas before the area where it's fairly clear cut and works has been more rigorously evaluated."

47 As to the Respondent's contention that the therapy is safe, Dr Beaumont said (at p 8 of his report):

"The incidence of complication of spinal manipulation is unknown. There are no large prospective studies to shed light into this area. Evidence suggests that complications are grossly (nearly 100%) under reported. The true incidence therefore can't be estimated by the number of reports. The complications however include quadriplegia."

48 As to the existence of the "ubiquitous illness" Dr Beaumont said (T 426):

" Q. Good, so you're saying what I said in the first book which I wrote, "The Chiropractic Medicine for Rejuvenation of the Mind", that we're having to learn more and more about less and less and so that would you believe then that if there was a method whereby the brain's part in the management of the body could override the treatment of these illnesses down in the body, if there was a ubiquitous illness which was there that hadn't been recognised and if you treated that you didn't have to worry about what was down the body because you solved the problem at root source, can you comment on that?

A. That would be a wonderful situation if it existed.

Q. You don't think it exists?

A. Well, if it did, I think it would be implemented."

Background to the first Notice of Complaint (Complaint 1.1)

49 The procedural background to the first Notice of Complaint is set out in detail in the written submissions of Ms Richardson, counsel for the Commission. The following is a summary. The section references are from the Medical Practice Act 1992 (the MP Act):

(i) A Performance Review Panel was convened to be held on 4 January 2008 under s 86K to review the professional performance of the Respondent as a general practitioner.

(ii) The role of the Panel was to conduct a performance review in accordance with the performance assessment provisions set out in Part 5A and Part 13A.

(iii) The Panel made a finding that the professional performance of the Respondent was unsatisfactory:

"In accordance with s 86N of the MP Act, on 4 January 2008 the Panel finds that the professional performance of Dr Gorman is unsatisfactory in that the knowledge, skill and care possessed and applied by Dr Gorman in the practice of medicine is below the standard reasonably expected of a practitioner on an equivalent level of training or experience"

(iv) Section 86B defined the professional performance of a doctor as "unsatisfactory" if "it is below the standard reasonably expected of a practitioner of an equivalent level of training or experience".

(v) In accordance with the Panel's finding that the Respondent's professional performance was "unsatisfactory", it imposed the seven new conditions (numbered 2-7) on his registration in accordance with section 86N(2).

(vi) Condition 3 provided that within 3 months a performance assessment of the Respondent's practice of spinal manipulation be obtained by two health professionals with relevant experience. The rationale for Condition 3 was:

"The Performance Assessment undertaken prior to this hearing was not able to adequately assess Dr Gorman's practice of spinal manipulation, as this is not recognised part of general practice and was therefore outside the expertise of the Assessors. The Panel believes that this part of Dr Gorman's practice needs to be assessed by health practitioners who are appropriately trained and experienced. Such an assessment should include, but not be limited to, Dr Gorman's assessment of a patient's suitability for spinal manipulation, his method of spinal manipulation, the information he provides to patients and his process for obtaining informed consent. If Dr Gorman wishes to recommence spinal manipulation under general anaesthetic, the assessment should also include this, but only if the assessment of spinal manipulation without a general anaesthetic has not resulted in an adverse report."

(vii) On 28 August 2008, a Performance Assessment of the Respondent took place at the Bankstown surgery by Dr Ayscough and Mr Milazzo in accordance with condition 3 on registration - that is, to assess his spinal manipulation techniques.

(viii) Dr Ayscough is the President of the Australian College of Physical Medicine and Associate Professor of Musculoskeletal Medicine and Head of Discipline at the Australian School of Advanced Medicine at Macquarie University. Mr Milazzo is a physiotherapist and a physiotherapy lecturer. As a result of the Performance Assessment a Performance Assessment Report 29 August 2008 was prepared

(viii) During the Performance Assessment, Dr Ayscough and Mr Milazzo observed the Respondent carrying out a spinal manipulation on 5 patients. The first four of those patients were included in the Performance Assessment (Patients KS, MP, PD, and JE). The fifth patient observed (Patient CR) was observed receiving a spinal manipulation but was not included in the Report.

(ix) The assessors did not include a specific reference to the fifth patient (Patient CR). Both Mr Milazzo and Dr Ayscough confirmed that their role at the August 2008 assessment was to assess the Respondent's skills and standard of care in relation to spinal manipulations and that each of the five patients they observed were manipulated in exactly the same way. The two assessors made comments in their report on patients one to four and both confirmed in their evidence before the Tribunal that the fifth patient (Patient CR) would have made no difference to their comments. This was because she was manipulated in exactly the same fashion as the first four patients. Indeed, a key concern of the assessors was the fact that all five patients were manipulated in exactly the same way regardless of their presenting symptoms.

(x) After observing the Respondent carry out the spinal manipulations on these patients, the Performance Assessors formed the following views:

(a) In Dr Ayscough's opinion, as a musculoskeletal physician, the Respondent's standard of care in carrying out spinal manipulations was unsatisfactory.

(b) In Mr Milazzo's opinion, the Respondent's method of manipulation was below the standard used by physiotherapists when carrying out spinal manipulations.

(xi) On 28 October 2008, following consideration of the Performance Assessment Report by Dr Ayscough and Mr Milazzo, the Medical Board's Performance Committee resolved that a complaint should be made to the Commission under s 86J(2).

(xii) The Medical Board suspended the Respondent on 5 December 2008 under s 66. An appeal against that suspension was upheld by a separate Medical Tribunal on 2 July 2009 (the appeal).

(xiii) The Commission received a letter of complaint from the NSW Medical Board (now the NSW Medical Council) on 26 November 2008. That letter stated that on 28 October 2008, the Board's Performance Committee resolved that a complaint should be made to the Commission under s 86J(2).

(xiv) On 30 June 2010, the Commission commenced the first complaint against the Respondent as set out in the First Notice of Complaint.

50 None of the five patients referred to in the First Notice of Complaint were called to give evidence in the proceeding. The Tribunal accepts that the nature of the allegations made in relation to each of those patients arises from:

(a) the observation of the performance assessors on 29 August 2008 (both of whom gave evidence);

(b) the peer expert evidence of Dr Young (who gave evidence);

(c) the clinical notes prepared by the Respondent in relation to the 5 patients;

and other documents. The presenting symptoms of the five patients and the treatment they were given was not in dispute.

Overview of the evidence of Dr Ayscough and Mr Milazzo

51 The Commission alleges, in relation to each of the first four of the patients in the First Notice of Complaint, that:

(a) the Respondent did not perform an adequate re-assessment of their clinical symptoms or impairments; and

(b) the spinal manipulation undertaken by the Respondent was unsafe by current manipulative standards.

52 The evidence is that among health care practitioners who do use spinal manipulation as a treatment - relevantly, musculoskeletal physicians, physiotherapists and chiropractors - each undertakes extensive pre-manipulation assessments in order to determine whether or not a manipulation is likely to be safe. It is accepted practice that there are provocation tests employed to demonstrate a contra-indication to manipulation. For example, in modern medicine theory, health care practitioners practice under the principle that vascular insufficiency to the brain is a contra-indication for spinal manipulation.

53 The Respondent, however, eschews these safeguards. In his view, such tests are actually done in order to identify that manipulation is indeed indicated. He believes that spinal manipulation actually resolves the risk of having a stroke (T 849.50).

"I do very minimal investigation of these people because, first of all, illness is scan negative. I've explained that, why the illness is scan negative. So it's no good looking for hard evidence of as [sic] are scan negative so that's the first thing. The second thing is about it, I don't - if we could go to the provocation test. The provocation tests are useless, because what I am looking for is the provocation test to be positive, and that for me is an indication to manipulate" (T 752.29 of the appeal hearing).

54 Furthermore, the Respondent's approach was that "one size fits all", hence his pre-manipulation assessment is the same for each patient, irrespective of their individual presentation. Mr Milazzo, for example, observed that the Respondent's manipulation technique used on each of the four patients described in the report was identical. Mr Milazzo was particularly concerned that the Respondent manipulated areas of the spine that did not appear to require manipulation.

55 The two skills assessors concluded that the Respondent's treatment of all four of the patients was significantly below the standard to be expected of a medical practitioner practising spinal manipulation techniques.

56 Specifically, Dr Ayscough and Mr Milazzo considered it inappropriate that the Respondent:

(a) did not perform spinal articular assessment;

(b) did not palpate the area to be manipulated;

(c) holds the view that the only contra-indications for spinal manipulation are a patient taking warfarin or aspirin;

(d) does not follow an accepted clinical standard of normal orthopaedic physical assessment, let alone apply the detailed assessment considered to be necessary prior to utilising spinal manipulation techniques;

(e) does not perform any screening tests for the risks of possible adverse effects;

(f) holds the view that established contra- indications for spinal manipulation are in fact indications.

57 The Respondent's attitude to the two skills assessors was that they are incompetent (T 550.8). They subscribe to a different philosophy that doesn't apply to him (T 77.29). So far as chiropractors are concerned, The Respondent's view is that the training they receive is useless (T 356.30), and the treatment they administer is different from his technique (T 555.50 - 556.35):

"Q. Well, what I'm putting to you is that in the skills assessment of you in 2008, the skills assessors - that the practice that was revealed by you is that it's not your practice to test for barriers. Do you accept that?

A. What barriers are you referring to...the barriers that I'm referring to--

Q. Barriers as to a range of movement.

A. Well, that's what I said. There's - I have a very significant barrier. I'm looking for what the end field does. They're looking for where - they're looking for where that barrier is in the spine. They check each one and then they - "not going to do this" and "do that" and fiddle about--

Q. And what are you doing by contrast?

A. I'm doing by contrast - I find there is a barrier but I'm not interested in where the barrier is. It's not relevant, really.

Q. Why isn't it relevant?

A. Well, it's just not relevant. It doesn't make - tell you anything about the function of the vertebral artery. It doesn't tell you anything about the danger of the - of the treatment. It just...there are so many bones there. It's really immaterial which one is blocking the movement. So long as the danger bit is - you're covering the danger bit, basically and you - you - there is no real relationship between the actual appearances and locks and things between that and danger. There's no direct connection.

Q. So is that another aspect where you're at issue with the practice of chiropractors?

A. Yeah, of course.

Q. That's not part of what you smash through, though, is it? Those barriers?

A. Yeah - that's it, your Honour. You've got these end field blocks where there's a bit of osteofibre going between--

Q. So that's part of the smash through technique?

A. That's so - and you just - you've got - you found the end field is limited, that they doesn't - can't move around and if you can correct that end field abnormality, you'll give the patient relief from migraine and things like that.

The evidence of Professor Bonello in the appeal hearing

58 Dr Ayscough is a musculo-skeletal physician. Mr Milazzo is a physiotherapist. Professor Bonello, who was called by the Respondent in the appeal hearing, is a chiropractor. He was, at the time, an Associate Professor in chiropracty at Macquarie University. His evidence at the appeal hearing was relied upon by the Respondent before this Medical Tribunal. It is not clear why, because, as Ms Richardson submitted, Professor Bonello's evidence made plain that the Respondent's practices in relation to pre-manipulation investigation, and his method of spinal manipulation, was below the standard expected of chiropractors:

"First, Professor Bonello confirmed that an extensive history-taking from the patient is an important part of good practice prior to doing a manipulation. By contrast, it is apparent that Dr Gorman's practice is not to take a detailed history but is rather to primarily rely on the Milne Score checklist...

Secondly, Professor Bonello's evidence was that the appropriate standard of care requires pre-manipulation assessment and testing as a layer of safety. It is apparent from Dr Gorman's own evidence that he does not carry out what are considered standard pre-manipulation assessments..."

59 As Ms Richardson submitted, Professor Bonello confirmed that a whole series of matters were potential or likely contra-indicators to manipulation, such as excessive weight loss, symptoms indicating a progressive neurological disorder, cancer, tumours, elderly patients, osteoporosis, steroids and so on. He referred also to a series of medications that are seen as contra-indicators. By contrast, the assessment of the Respondent revealed that he sees very few contra-indications to spinal manipulation.

60 Professor Bonello's view was that a responsible competent chiropractor would always take an appropriate history and carry out a pre-manipulation assessment, including a physical examination. This includes assessing the joint system and the muscle system. It also includes tests to determine vascular insufficiency. For example, Professor Bonello's considered it important before carrying out a manipulation to do an articular assessment to determine the barriers as to the range of movement of the particular patient.

61 These pre-manipulation precautions are an important part of good practice prior to undertaking a manipulation. A failure to undertake them would be sub-standard practice.

62 The need for pre-manipulation testing and investigation is equally important even when a person is returning for a repeat manipulation, to monitor the patient's current state.

63 By contrast, the Respondent does not consider it necessary to carry out what are considered standard pre-manipulation assessments (T 553.05 and 554.15), even on the first occasion he sees a patient, let alone by way of re-assessment (T 559.14). In particular, it is not his practice to test for barriers prior to carrying out a manipulation. His practice is to carry out minimal investigation. Indeed, in the case of the 200 to 250 care plan patients involved in repeat manipulations, the 'rule' was that it took one minute (T 585 - 589), with no discussion or assessment (T 554.15):

"Q. So you would agree that you do not do the pre-manipulation assessment and testing that chiropractors consider is necessary?

A. Yeah, well - I would say yes, to that, really. I don't - no, I don't do it.

DEPUTY CHAIRPERSON: He goes further than that, he says--

DEPUTY CHAIRPERSON: I said you go further than that. You say doing those things contra-indicates the type of treatment that you want to give. Because it limits them.

WITNESS: That's--

RICHARDSON: Well, I think Dr Gorman's evidence is that the type of pre-manipulation assessment and testing - that if it produced a particular result, might mean it's a contra-indication for a chiropractor. In most instances--

DEPUTY CHAIRPERSON: And he doesn't want a contra-indication. RICHARDSON: In most instances--

DEPUTY CHAIRPERSON: Because it inhibits the sort of treatment that he wants to give.

WITNESS: Exactly.

Q. Is that correct?

A. That's exactly right. What your Honour said - his Honour said.

Q. So, as an example of that, where a chiropractor can see if they produced dizziness as part of a pre-assessment technique, if the person became dizzy, the standard chiropractor would see that as a contra-indication but you would see that as expressly an indication for manipulation?

A. I love your word "expressly". Yes.

Q. That's correct?

A. Of course."

64 Dizziness in a patient when in the pre-manipulation position, in Professor Bonello view, is an important indicator of the need for further investigation. If further investigation revealed that the cause of dizziness was vascular, rather than mechanical, this would be a contra-indication to a manipulation being performed, due to the risk of a stroke following the manipulation.

65 Professor Bonello was also critical of the Respondent's 'one size fits all ' manipulation technique. In the Professor's view the type of manipulation a practitioner should do depends "absolutely" on the particular patient and on what the particular problem is:

"Well, every patient is different in that some people are very loosely jointed. For example, a younger female patient who did gymnastics would be a very mobile person. The tall slender person has a very - has typically a more mobile body than a short stocky person. Overweight people versus very thin people. These people have different needs in terms of physical medicine, and so when manipulation is applied to them one needs to be cognisant of what their body can withstand and be judicious in applying that, in the same way as delivering a dose of drug...

If the technique was executed in exactly the same fashion, then in my view... sometimes the treatment would be too weak and other times too strong, or sometimes inappropriate..."

66 The Respondent described Professor Bonello's evidence that it's important not to adopt a 'one size fits all' manipulation technique as immature. He applies a standard technique for all cases involving the ubiquitous illness.

67 His view is that all musculoskeletal physicians, physiotherapists and chiropractors are "ignorant" and are trying to make him "fit into their lowest common denominator". The Respondent's assertion is that "all these practitioners around the world are getting away with this really inferior type of spinal manipulation".

Background to the second Notice of Complaint (Complaints 2.1, 2.2 and 2.3)

68 The procedural background to the second Notice of Complaint is set out in detail in the written submissions of Ms Richardson, counsel for the Commission. The following is a summary. The section references are from the Medical Practice Act 1992 (the MP Act):

(i) On 4 December 2008, delegates of the NSW Medical Board (now the NSW Medical Council) decided that the Respondent would be suspended under s 66, with effect from 9 am on 5 December 2008.

(ii) When such an action is taken, the Board must refer the matter to the Commission for investigation. Under s 66B(2), the matter is to be dealt with by the Commission as a complaint made against the practitioner concerned.

(iii) The Commission thus received a letter of complaint from the NSW Medical Board on 9 January 2009. That letter referred to the Council's letter dated 9 December 2008 advising the Commission of the suspension order imposed by the Board on the Respondent under s 66 and enclosed a copy of the delegates' reasons for decision date 9 January 2009.

(iv) After investigation of the matter, the Commission commenced the second Notice of Complaint against the Respondent on 17 March 2011. This second Notice of Complaint is brought under the Health Practitioner Regulation National Law (NSW) (the National Law ) and was heard concurrently with the first Notice of Complaint. Complaints 2.1 and 2.2 in the second Notice of Complaint relate to alleged deficiencies in the care and treatment a further 8 patients. Complaint 2.3 relates to the alleged incompetence of the Respondent to practise medicine.

The Commission's case

69 By Complaint 1.1 the Commission asserts that the Respondent has engaged in:

(a) unsatisfactory professional conduct within the meaning of section 36 of the Medical Practice Act 1992 ; and/or

(b) professional misconduct within the meaning of section 37 of that Act

in that he has demonstrated that the knowledge, skill or judgment possessed, or care exercised, by him in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience and has contravened the Medical Practice Regulation.

70 Complaint 1.1 relates to the first set of 5 patients. There are comprehensive particulars setting out the detail of the conduct complained about. The Commission relies principally on the evidence of the two skills assessors, Dr Ayscough and Mr Milazzo, the evidence of Professor Bonello given at the appeal hearing in 2009, and the peer expert evidence of a general practitioner, Dr Young.

71 Dr Young provided a written report dated 9 September 2009, in which he deals with each of the 5 patients the subject of Complaint 2.1 in some detail, aspects of which will be referred to later in these reasons. Dr Young also made some global assessments of the Respondent's practice. He said (at p 14):

"Although 5 patients are only a 'snapshot' of a practitioner's practice, I believe that there are enough patterns in the cases and other documents examined to be able to make global assessments."

72 Dr Young then went on to express the following opinion as to the Respondent's clinical judgment:

"Dr Gorman appears to have a belief system in the applicability of his form of manipulation to a wide range of conditions that departs significantly from conventional assessment and treatment opinions in a General Practice setting. As can be seen ...he single-mindedly sticks to this treatment modality despite lack of longitudinal clinical improvement (as in Patient 3 and CR) or when the patient is requesting other treatments (as in Patient 4). As also mentioned in the specific cases, performing manipulation to patients who are acutely febrile or after administering IM narcotic medication also places Dr Gorman's clinical judgement in doubt.

It is my opinion that Dr Gorman's clinical judgement is significantly below the standard expected of a practitioner of an equivalent level of training and experience. This departure invites my strong criticism."

73 In respect of the Respondent's patient management skills, Dr Young concluded:

"The cornerstone of good patient management in the General Practice setting is continuous and comprehensive patient centred care. As I have outlined in detail... Dr Gorman's management of these patients primarily with spinal manipulation obstructs more comprehensive care of their conditions. While continuous care is displayed in patients 1,3 and CR, their care is by no means comprehensive.

Most GPs of Dr Gorman's level of training and experience use a safe diagnostic strategy in their initial and ongoing management of their patients. As outlined in my detailed discussion, Dr Gorman did not demonstrate such a strategy in diagnosing patient complaints. Dr Gorman's broader management skills display serious deficiencies and errors, as highlighted above.

His belief system in spinal manipulation and its application mean that his management is not patient centred.

It is my opinion that Dr Gorman's management skills are significantly below the standard expected of a practitioner of an equivalent level of training and experience. This departure invites my strong criticism."

74 Finally, Dr Young commented on the respondent's concept of a ubiquitous illness:

"I note Dr Gorman's statement in his letter to the HCCC dated 4.1.09 "that interictal migraine is presently the most serious and most rampant illness affecting mankind." This statement is clearly discordant with current medical opinion and supports my concerns about Dr Gorman's clinical judgement."

75 By Complaint 2.1 the Commission asserts that the Respondent has been guilty of unsatisfactory professional conduct within the meaning of section 139B of the National Law in that he has demonstrated that the knowledge, skill or judgment possessed, or care exercised, by him in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience and has contravened the Medical Practice Regulation 2003 and 2008 (both repealed).

76 By Complaint 2.2 the Commission asserts that the Respondent has been guilty of professional misconduct within the meaning of section 139E of the National Law in that he has:

(a) engaged in unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of his registration; and/or

(b) has engaged in unsatisfactory professional conduct on a number of occasions which, when considered together, amount to conduct of a sufficiently serious nature to justify suspension or cancellation of his registration.

77 Complaints 2.1 and 2.2 relate to the second set of 8 patients. There are comprehensive particulars setting out the detail of the conduct complained about. The Commission relies principally on the expert evidence of a general practitioner, Dr Jammal, and the evidence of Dr Susan Ieraci, the Senior Staff Specialist at the Bankstown Hospital Emergency Department.

78 Dr Jammal provided a written report dated 12 September 2010, in which he deals with each of the 8 patients the subject of Complaint 2.1 and Complaint 2.2 in some detail, aspects of which will be referred to later in these reasons. He did, however, express some global opinions.

79 On the question of the Respondent's overall clinical judgment and reasoning, Dr Jammal said:

"The process of clinical judgement and reasoning is a complex one, and is influenced by a number of factors, Judgement and reasoning involves a process of analysing and comprehending data (history, examination findings, test results), reconciling this with knowledge and experience, and then synthesising and evaluating a judgment.

The final two steps are also influenced by factors such as the patient's demeanour and emotion, the doctor's emotion, level of fatigue, concentration, and also the doctor's belief or preconceived ideas on the value of the individual parts of the data. It takes insight into these issues to understand the effect of these factors on judgement...

Dr Gorman stated that he would always consider the spinal neurological syndrome first, manipulate the spine, and if it doesn't work refer on.

His view is that spinal manipulation should be used as a first-line treatment for a wide range of conditions that present in general practice.

In my opinion, Dr Gorman's views and theory so radically depart from generally accepted medical practice that it borders on being more than just a theory, but a belief, of (for the lack of a better word) a religion. Furthermore, Dr Gorman displays a lack of insight into the manner in which his views affect his judgement, by simply stating that anyone who disagrees with him is ignorant or 'inadequate'. These comments ignore all essential features of rational clinical reasoning. In doing so, it is my opinion that Dr Gorman's clinical judgement is no longer that of a conventional general practitioner (or conventional medical practitioner), and this lack of clinical judgement depart significantly from the standard expected of a practitioner equivalent level of training and experience. This departure attracts my strong criticism."

80 In relation to the question of informed consent, in Dr Jammal's opinion, the Respondent failed at a number of levels:

i. He did not take an adequate history or undertake an adequate examination of the patients.

ii. He did not reach a diagnosis that reasonable medical practitioners would reach, supported by the information available.

iii. He did not document that he had given enough information to patients that would allow them to reach an informed decision regarding both the conventional and complementary treatment he was offering.

81 Furthermore, in his opinion, this lack of information may have misled patients into believing that the Respondent's views on their illness were widespread conventional knowledge.

82 By Complaint 2.3 the Commission asserts that the Respondent is not competent to practise medicine within the meaning of section 139 of the National Law in that he does not have sufficient physical capacity, mental capacity, knowledge and/or skill to practise medicine.

83 Complaint 2.3 relates to both the first set of 5 patients and the second set of 8 patients. In addition the Commission has particularised the following further matters (Particular 3):

"The practitioner gave evidence and made submissions before the Medical Tribunal in May 2009 (the appeal hearing) which demonstrate that he holds the following rigid and firmly-held views in relation to medical practice as a result of which there is a real risk that the practitioner:

[1] .will fail to correctly diagnose a patient's medical condition, and

[2] is unlikely to give impartial advice to patients to enable them to give informed consent."

84 In respect of these allegations, the Commission particularised a series of assertions (a) to (l) and set out the evidence upon which it relies to prove that the Respondent does indeed hold such rigid and firmly-held views in relation to medical practice as set out below. The Respondent specifically agreed with the assertions (T 826.19 and 827.35ff).

85 The Commission relies upon the opinion of the experts to establish that in holding these views, and adhering to them so rigidly, in conjunction with the Respondent' express disdain for aspects of conventional medical practice, and his lack of insight, he presents an unacceptable risk of misdiagnosis, delayed diagnosis, and an inherent inability to obtain informed consent.

86 These are themes to which these reasons will return.

87 The specific matters upon which the Commission relies as matters in respect of which the Respondent has rigid and firmly-held views in relation to medical practice are:

(a) there is a ubiquitous illness affecting all of mankind that can be treated by the very simple and safe treatment of spinal manipulation (T 647.40). Interchangeable names for this ubiquitous illness are whiplash, spinal arthritis, cervical syndrome, spine-induced neurological syndrome and interictal migraine (T 648.03);

(b) the ubiquitous illness manifests itself in different conditions, such as acne, panic attacks, lower back pain, tonsillitis and viral infections (T 648.15).

(c) spinal manipulation should be used as a firstline treatment for a wide range of conditions that present in general practice (and this is the approach he in fact takes to general practice) ( T 645.36 - 45);

(d) all pathologies can be challenged by spinal manipulation before recourse is had to orthodox treatment (T 645.09);

(e) every single patient who walks in the door of a general practice is likely to respond beneficially to spinal manipulation (T 648 - 649);

(f) the reason why every single patient who walks in the door of a general practice is likely to respond beneficially to spinal manipulation is that there is a ubiquitous illness that affects all of mankind (T 649.27);

(g) any illness whatever it is will be better after spinal manipulation ( T 629.41);

(h) spinal manipulation is appropriate virtually always ( T 696.27);

(i) general practitioners practising in accordance with accepted general practice are the lowest common denominator and are conducting inferior practices ( T 706.30, T 731.21-731.34);

(j) the accepted principles and framework of general practice are held in disdain by the practitioner ( T 706.30);

(k) the Respondent would be unlikely to talk to patients about treatments other than spinal manipulation because he does not see any point in advising patients to have inferior treatments (T 743.10 - 40);

(l) on being instructed in the philosophy of spine-induced neurological syndromes by the Respondent, most patients proceed to have spinal manipulation performed by him (the Amended Notice of Appeal in the appeal hearing at paragraph 4.6.1).

Some common themes

88 Before turning to consider the Commission's case as it relates to the individual patients the subject of the complaints it is appropriate to examine some of the common themes that the Commission asserts arise from an examination of the evidence relating to the Respondent's treatment of these patients. The common themes are set out under a series of headings.

89 These reasons draw upon the detailed written submissions of Ms Richardson, in particular her submissions in relation to the second Notice of Complaint at paragraphs [257] - [393].

90 These reasons seek only to summarise illustrative aspects of the themes addressed in the submissions.

Most illnesses respond beneficially to spinal manipulation

91 The first common theme is the Respondent's view that the entire "universe of patients" presenting to a GP in general practice would be likely to respond beneficially to spinal manipulation. Any illness, whatever it is, will be better after manipulation. Hence, the Respondent believes:

"...it's really quite reasonable to treat a patient with sore eyes or whatever - doesn't really matter, any brain function is liable, you improve if you do it. So over the course of 20 years, I've been challenging all the norms and I'm very, very satisfied that my theory about brain function is totally okay. Yes, you can treat someone's back and their whole function will improve, so their illness - whatever it is - will be better."

92 Thus, all pathologies can be challenged by spinal manipulation without recourse to orthodox treatment. There is no need to consider alternative diagnoses. The best approach is to challenge the condition with spinal manipulation as a first-line treatment and see if it works.

Spinal manipulation should be the first-line treatment

93 A second, related, common theme is the Respondent's view that spinal manipulation should be the first-line treatment for a wide range of conditions that present in general practice. He says you should "Do the brain first before you start trawling about the body" .

94 In response to criticism by Dr Young the Respondent said:

"The assessor advocates vague, complicated management, while ignoring a direct path to a likely diagnosis, for which the treatment is simple, safe, expeditions and totally inexpensive."

95 If spinal manipulation is ineffective the first time, you do it again in a month's time.

96 If it still doesn't work, only then would you resort to conventional medicine, because " you haven't got any penumbric tissue" (T 354.12) :

"Q. Just to go back to what you said, it takes one minute and if it doesn't cure the problem then do it again in a month and if that doesn't work there are no penumbra. So what do you do then?

A. They'll start--

Q. They'll go back to conventional medicine?

A. Yeah, whatever you like, your Honour. I mean, you've got to give them the chance. You've got to say well this is very safe, let's do it."

Disdain for the accepted principles of general practice

97 Another common theme in the respondent's approach to his patients is his disdain for the accepted principles and framework of general practice. In his opinion conventional general practice is inferior, incompetent and involves "the lowest common denominator".

98 The Respondent said, for example:

"Let there be no confusion - it is my sincere opinion that orthodox medical practitioners potentially injure patients at every consultation. This is because they do not recognise, as a result of inferior training, the existence of the "Traumatic Cervical Spine Syndrome".

"... current medical opinion does not have a clue about interictal migraine. As a result, patients are potentially being injured in every doctor-patient interaction under the prevailing, incompetent and incomplete medical philosophy."

"Of course I don't do what a doctor with good standing would do. I think that they are doing such harm. Why would I want to be associated with them?"

99 It was submitted that the Respondent made numerous grandiose statements that reveal he thinks he is superior to every other medical practitioner and that he is the only person who can make patients better (T 370.50). There is no other practitioner in the world with an equivalent level of training and experience, hence he should not be judged by such a standard (T 830.25):

"I don't think these ordinary general practitioners are competent, and when they say that I don't come up to their standards, I'm thinking, 'Well, God, this is strange. I am so far ahead of them it's ridiculous'."

Inflexibility and rigidity

100 The next common theme pointed to by the Commission is the Respondent's inflexibility and rigidity. It was submitted that although he is completely at odds with (and denigrates) the entire medical profession (and with the physiotherapy and chiropractic professions), and can identify no health care professional to support his theory or approach, he has no ability to reflect on why this might be the case or whether he might be wrong (T 371.30):

" Well, I'm not a good general orthodox practitioner. I'm a madman..."

101 This mindset reflects his approach to practice, an approach that Dr Beaumont described as bizarre (T 463).

102 The concern for the Commission is that the Respondent's rigid medical philosophy and faith in spinal manipulation as a treatment means that he would be mostly unlikely to alter his course and investigate alternative diagnoses if manipulation did not work after two or three treatments. Thus there are risks of failing to diagnose the actual problem, and risks that a patient, convinced by the Respondent's diagnosis, will not return for further treatment so the "red flag" (and the opportunity to explore alternative diagnoses) never arises.

103 Dr Young gave evidence of the risk of setting up patients with wrong expectations (T 151.30):

" Of one size fits all? Well that you - that you miss other things, that you set up a state of possible expectation of the patient, at best collusion at worst of continuing a certain style of treatment with the patient."

104 Dr Beaumont also gave evidence of the risks, in particular the risk of a missed diagnosis (T 490 492):

" Q. And would you agree with me that if a doctor has such a medical philosophy or has extended his medical philosophy from the core group or the first postulate to this wide variety of conditions that present in general practice, that there is a very real risk that he will fail to diagnose the obvious or fail to diagnose what's really wrong with a particular patient? Do you agree with that?

A. I think he's coming at it with such a biased point of view there is a risk he will miss a diagnosis of an illness but exactly how high that risk will depend on the ability of the practitioner..."

" Q. ...if you could put to one side what chiropractors do and focus on Dr Gorman as a general practitioner, holding himself out as a general practitioner, my proposition to you is that if Dr Gorman approaches medical practice with such a rigid and biased medical philosophy, that there is a very real risk that he will fail to diagnose the patient's medical condition in accordance with generally accepted principles?

A. Yes, I think if you come at it with a rigid paradigm then you may miss the obvious..."

" Q. So if you have an unorthodox approach to what's causing the symptoms it's obviously going to affect the treatment that you think is appropriate?

A. Yeah."

105 Dr Ieraci also gave evidence as to the risks associated with the Respondent's rigid approach (T 643.21 and T 637.10):

" Q. Are you able to express a view, one way or the other, on how that medical philosophy manifests itself in treatment and can you talk, in particular, about these four patients? How that philosophy manifests itself in terms of diagnosis.

A. The evidence I've seen here reflects a tendency to attribute the same physical or pathophysiological cause to a wide range of presentations and within this group, almost the same pathophysiological cause to an enormous range of ages and pathologies which would suggest both a lack of acceptance of orthodox medical understanding and also a tendency to use a blanket explanation for a range of different pathologies.

Q. What, in your professional opinion, is the risk of a medical practitioner who is applying the same explanation or pathophysiological explanation to a wide variety of conditions? What sort of risk does that present?

A. There are two main risks. The first would be a failure to effectively diagnose and treat both the cause and the effects of the pathology. And the second would be the potential risks of treatment by manipulation."

" Q. What do you see as the particular risk if a practitioner were applying a particular type of treatment to a symptom that might be caused by various different conditions? What do you see as the risk?

A. The main risk would be failure to either diagnose the root cause or to give effective treatment for that condition."

Inadequate assessment and clinical note taking

106 The Commission next submitted that the Respondent's medical philosophy translates into inadequate assessment and clinical note taking. It points to the evidence that his clinical notes do not accord with accepted general medical practice, and are generally inadequate.

107 The Respondent acknowledges the criticism, but seeks to justify it by reference to his medical philosophy. Referring to Patient KS, he said, for example (T 582.47):

" ... I'm looking at her from a different point of view and you know, I just don't hold with orthodox medicine's point of view and I don't hold it in any respect in this regard...I don't conform and I don't approve of orthodox general practice..."

108 The Commission similarly pointed to the Respondent's disparagement of standard pathology and diagnostic imaging (T 564.01):

" Q. What do you think is the explanation for the fact that compared to other general practitioners, the amount of pathology and diagnostic imaging ordered by you is a tiny fraction of what other general practitioners do? What do you say would be the explanation?

A. Well, first, I've got practitioners that have got nowhere to go. They're - they're stuck with finding something physically wrong with the patient before they can move on to give him treatment. I don't have that problem because I'm dealing in an illness that doesn't have very - there's a scan and blood test negative, so that I don't need to do those tests for the type of patient that consults me."

109 Accordingly, the Respondent spurns the conventional use of scans as a diagnostic tool (T 566.45):

" So to take a scan, you just get no information at all. And that's a very important part of this thing because with millions of scans being done looking for negativity - we say, "Do a scan just to make sure you're okay". Now, those scans cost money, maybe $400 each and if you've got a mentality that says, "Well, most of these scans area going to negative and really the best way to check whether this is a polynya or not is to do a manipulation and if the patient gets better, you don't have to do the scan."

Failure to obtain informed consent

110 Finally, but perhaps most importantly, is the common theme that the Respondent' does not obtain informed consent for the application of his therapy. As Dr Beaumont said, the Respondent's rigid and firmly-held views creates a real possibility that patients will not give informed consent for his therapy, and will be misled where the Respondent is practising as a general practitioner, not as a chiropractor. Dr Beaumont agreed (T 63.28):

"...it come[s] down to a question of informed consent in relation to a strange philosophy".

111 Hence, Dr Beaumont believes that patients or parents of young patients attending at a multi-doctor clinic (T 478):

(a) would trust the doctor they see in that context as being someone who is practicing general practice;

(b) would trust that the doctor is practising evidence-based medicine;

(c) would be likely to trust the advice they get because of the context in which it is given; namely, by a general practitioner in a multi-doctor clinic.

112 When patients come to the Respondent in general practice, most of them are instructed on his medical philosophy of "spine-induced neurological syndromes". As a result his patients almost invariably proceed to have a spinal manipulation. The Respondent gives patients this advice even when they have "inadvertently" come to him for ailments "not usually considered treatable by spinal manipulation".

113 Such conditions include conditions such as acne, dermatitis, panic attacks, flu, hay fever, sore eyes, sore backs, autism and developmental delay (T 640.14 of the appeal hearing).

114 The Commission submitted that the Respondent convinces patients to undergo his spinal manipulation by telling them they have a "syndrome" (T 642.24 of the appeal hearing):

"Q. ...So you agree with me that it is your practice to instruct patients who inadvertently come to you for ailments not usually considered treatable by spinal manipulation in the philosophy of spineinduced neurological syndromes, and after you've instructed them, most patients then proceed to spinal manipulation. Does that reflect your general practice?

A. The question is "most". I would think - I must be very convincing or something like that, because a terrible lot of them do. And I just say, these people are sensible. They understand what I'm saying..."

115 Thus, submitted the Commission, the particular risk is that patients treated by the Respondent will trust him as a GP in circumstances where it is apparent that his practice is actually inconsistent with accepted general practice. Further, the level of trust afforded by patients will affect whether they are in fact giving informed consent to being treated by spinal manipulation.

116 The Respondent has his own views on what informed consent involves. The Commission submitted that he believes it is for a patient to specify whether they prefer orthodox treatment to his particular therapy (T 640.45 of the appeal hearing):

"If the patient indicates to me that they want orthodox treatment I'm very happy to give them orthodox treatment. But I wouldn't be encouraging them to come back to me, because they really want some other doctor, not me."

117 Unfortunately, as Dr Beaumont points out, such patients don't know that the Respondent's therapy is not orthodox treatment, and the Respondent does little to enlighten them.

118 The Respondent does not explain to his patients that his treatment is not in accordance with accepted practice for a particular condition, or that other conventional treatments are available. He agreed that (T 820.37):

"I wouldn't normally do that."

119 In fact, the Respondent deliberately avoids advising patients about orthodox alternatives:

"I just don't see that it is in my interest to advise patients to have those inferior treatments."

120 The Respondent also fails to properly inform his patients about the risks associated with forceful spinal manipulation. In his opinion, the risks are so small that they don't warrant frightening the patient and thereby unnecessarily deterring the patient from undergoing the procedure (T 849.43). He considers that if a patient gets up on the bench and lets him manipulate them, that is sufficient consent (T 734.50).

121 The Commission also complains that the Respondent misleads patients into believing that his procedure has a scientific basis, without making it clear that his theory is not accepted by conventional practitioners. In fact, it is widely regarded as resting on a "shaky foundation". Even on his own exposition of the theory, it involves a "leap of faith".

122 The Commission submitted that these factors operate to vitiate the consent the Respondent relies upon to treat his patients with his therapy:

" First , any consent is not informed consent where the patient gives consent on the basis a doctor has convinced them they have a syndrome - such as "spine-induced neurological syndrome" or "dorsal spine syndrome" - these being conditions which are not accepted by general practice as existing." [363]

" Secondly , any consent is not informed consent where the patient gives consent on the basis a generalised diagnosis of a "brain failure" or a lack of blood flow to the brain - in circumstances where there is no clinical findings or assessment in relation to that patient to support such a diagnosis." [366]

" Thirdly , any consent is not informed consent where the patient is not informed of the risks associated with the spinal manipulation procedure (and in particular where, not only is there no explanation of the risks, the patient is positively told the procedure is "safe")." [369]

" Fourthly , any consent is not informed consent where the doctor provides the patient with materials which leads the patient to believe that there is a scientific basis for use of this treatment in relation to a particular condition (in circumstances where there is no such scientific basis)." [371]

" Fifthly , any consent is not informed consent where the doctor does not explain to the patient that the treatment he is recommending is not in accordance with accepted general practice (or at the very least is not the treatment that the majority of general practitioners would recommend for this condition)." [375]

" Sixthly , any consent is not informed consent where the doctor does not explain to the patient that other treatment options (which are consistent with accepted general practice) are available to treat the patient's condition." [381]

123 Thus, not only does the Respondent not obtain informed consent, his mindset is such that it would be impossible for him to ever obtain it.

124 The Tribunal will consider the circumstances surrounding the individual patients the subject of the first and second Notices of Complaint against the background of these themes.

The patients - Some general observations

125 The Commission alleges that the skill or judgment possessed, or care exercised, by the Respondent in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience, and that he does not have sufficient physical capacity, mental capacity, knowledge and/or skill to practise medicine. These allegations are particularised in detail in two Notices of Complaint. As already discussed above, the Commission relies principally on the evidence of the various medical practitioners to make out its case.

126 Each of the matters complained about by the Commission was the subject of specific criticism by these witnesses. The Respondent sought to dismiss the evidence of these witnesses on the basis that they were ignorant of his medical philosophy and the scientific basis by which he says it is supported. In his written submissions he said:

"In cross examination, the underlying theme was that my methods did not have the respect of my peers of good repute.

To this contention, I responded, again and again, that practitioners such as Dr. Ieraci, Dr. Simon Young, Dr. Walid Jammal, Dr. Rodney Ayscough and Mr. Gaetano Milazzo are not my peers by virtue of their manifest ignorance of the principles of cerebrovascular insufficiency as it appears in stroke, migraine and spinal derangement."

127 In respect of Dr Young, the Respondent submitted:

"Dr. Young was ignorant of the recovery of vision with spinal manipulation; the ischemic penumbra state; interictal migraine and watershed infarcts. These defects in his knowledge annihilated his credibility in his criticism of my medical practice."

128 In respect of Dr Ayscough, the Respondent submitted:

"Dr. Ayscough was ignorant of the recovery of vision with spinal manipulation; the ischemic penumbra state; interictal migraine and watershed infarcts. These defects in his knowledge annihilated his credibility in his criticism of my medical practice."

129 In respect of Dr Jammal, the Respondent submitted:

"Dr. Jammal was ignorant of the recovery of vision with spinal manipulation; the ischemic penumbra state; interictal migraine and watershed infarcts. These defects in his knowledge annihilated his credibility in his criticism of my medical practice."

130 In respect of Mr. Milazzo, the Respondent submitted:

"Mr. Milazzo was ignorant of the recovery of vision with spinal manipulation; the ischemic penumbra state; interictal migraine and watershed infarcts. These defects in his knowledge annihilated his credibility in his criticism of my medical practice."

131 In respect of Dr Ieraci, the Respondent attacked not only her expertise, but also her credit. He submitted:

"Dr. Ieraci was ignorant of the recovery of vision with spinal manipulation; interictal migraine and watershed infarcts. Dr. Ieraci had a vague appreciation of the Ischemic Penumbra State and its significance in the management of stroke. These defects in her knowledge annihilated her credibility in her criticism of my medical practice."

"I have no doubt that she perjured herself when asked whether she had had conversations at the Medical Board in which she was incited to protect Orthodox Medicine by complaining about this whistleblower."

132 It was on this basis that the Respondent submitted:

"Beautifully composed, the HCCC's protracted submissions suffer from reliance on the false premise that so-called orthodox medicine is competent and complete, to the exclusion of other forms of therapy.

In general, the HCCC's offering assumes that the opinions of its witnesses are still valid despite the fact that all its witnesses have admitted ignorance of the fundamental principles of modern medical practice: namely, the recovery of vision with spinal manipulation therapy, the ischemic penumbra state, interictal migraine and watershed infarcts."

133 Thus, the Respondent relied upon his own medical philosophy to justify his failure to apply the standards expected of a practitioner of an equivalent level of training and experience. There was no evidence that this philosophy is evidence based, or scientifically valid. It was universally rejected by all the witnesses. Dr Beaumont, who regarded the majority of the Respondent's theories as bizarre, gave some qualified support for a narrow evidence base in respect of the treatment of tunnel vision by forceful spinal manipulation. But even that evidence was likened by him to the process of rebooting a computer (T 454.31):

"If pushed to propose a mechanism, I would suggest spinal manipulation causes a massive neurological shock that results in a mechanism similar to that of resetting the computer."

134 Apart from Dr Beaumont's evidence, no independent evidence was led by the Respondent to challenge these witnesses. To the extent that the Respondent sought to rely on Dr Beaumont, that witness expressly distanced himself from the relevant aspects of the Respondent's treatment of the patients, and the medical philosophy upon which it rests. Specifically, Dr Beaumont was critical of the Respondent's failure to obtain informed consent (T 470.16).

135 The Tribunal rejects the Respondent's posit that the Commission witnesses are not qualified to express their opinions about his treatment of the patients and his treatment of them. Clearly, each of them is well qualified and experienced, and possesses the necessary expertise to express the views they did. The Tribunal expressly rejects the unnecessary imputation that Dr Ieraci was somehow incited to protect orthodox medicine by complaining about the Respondent. The Tribunal is satisfied that Dr Ieraci is a doctor of integrity who acted entirely from genuine motives and concerns in respect of the Respondent's medical activities.

136 For these reasons, and having regard to the general absence of professional support for the Respondent's medical philosophy and the appropriateness of his therapy, the Tribunal prefers the evidence of the Commission's witnesses to that of the Respondent.

The Respondent's "bargain" with his patients

137 Another feature of the Respondent's practice that emerged during cross-examination was the system he had put in place with a large number of patients to allow them to 'jump the queue' at the clinic on the basis that they came in to receive spinal manipulation but would not waste time discussing their condition. He described the system as follows (T 591.15):

" Their part of the bargain was they'd come in, they wouldn't be asking any questions and they'd go out. ... this was a multi-doctor clinic. There were always six doctors. If they wanted to get some other treatment for something else, they went and saw them... But if they did come and see me, I'd presume that they were following our agreement... That they came in and they didn't bother me with problems that weren't relevant to what was needed for and on that occasion."

138 The Respondent practised in a multi-doctor "first-in first-served" clinic where patients might suffer long waits. The purpose of this system was to create an incentive for patients to not discuss their condition and on the basis that there would not be any monitoring or assessment of them, but a streamlined process whereby they simply attended, underwent a spinal manipulation, then left (T 584.49ff):

"Okay, so one of the - some patient who's really satisfied with my treatment comes in and he wants to - all he wants - he knows the spinal manipulation fixes him. All he wants is a spinal manipulation and out the door. So what - my plan was, I said, "Well, I can't solve this. I don't know" - I couldn't - I'm working for a clinic where I'm expected to take care of the bulk of work that comes through. Dr Bateman, the boss there, he, you know, wants patients to be moved. He doesn't want them hanging around.

So what I did was, I said, "Well, what I'll do is that I'll make it a deal with you as a patient. If you come back and you want a - just a manipulation and I see on the notes" - say, look, the girls at the front desk - to note out the people that are just coming in for manipulation and I can see that on my computer screen, you can come in here in front on the queue - we can bump the queue for you provided you don't talk to me about your illness, just get up on the bench, let me manipulate, then out the door because that would be fair to the patients who are waiting in the - in the line."

139 It emerged that the Respondent had over 200 patients on this system, all of whom had care plans in which arthritis was nominated as the chronic condition, which was his way of describing the ubiquitous illness.

140 The Commission submitted that to impose such a regime of "rules" or to strike such a " bargain" with patients is extremely inappropriate. It inverts the very essence of being a general practitioner. On any view it increases the risk of failing to diagnose a patient's true condition.

Patient KS

141 Patient KS, a female patient, was born on 13 July 1983. She is Patient No 1 referred to in the Performance Assessment Report dated 29 August 2008 prepared by Dr Ayscough and Mr Milazzo. She first consulted the Respondent at the Bankstown Medical Centre on 27 July 2008, aged 25.

142 She presented with symptoms of flu, with a temperature of 38.2 C, and of a panic attack (dyspnoea and palpitations). She told the Respondent she was having panic attacks and had an associated neck rash. He didn't record that in the notes as he saw it as "irrelevant" to his treatment of her. Nor did he examine her ears, nose and throat, chest or cardiovascular systems, which Dr Young regards as standard practice for a patient with flu-like symptoms. The Respondent completed what he refers to as a "Milne Score" complaint survey, in which she made other complaints including insomnia, tiredness, anxiety, poor concentration, poor memory and a sore neck. The Respondent examined her neck.

143 The Respondent formed the view that Patient KS had "cervical spine syndrome" or "dorsal spine syndrome". He then performed a spinal manipulation on her, even though she was in a febrile state, and without doing any pre-assessment.

144 He did not adequately document a history, or any examination, nor did he set out any management plan for Patient KS in the medical record. In particular, there is no record in the notes of arrangements for follow-up or patient education about her current illness. He issued Patient KS with a Medical Certificate stating that she was " suffering from influenza".

145 In his view, her flu was caused by the cervical spine syndrome and it is appropriate to treat "influenza illnesses" with spinal manipulation. He considered that she had "very considerable cerebral symptoms", that is, a non-specific brain abnormality.

146 The Respondent subsequently saw Patient KS on 1 August 2008 when she consulted him in connection with a laryngeal cough. He performed a spinal manipulation, but the clinical notes do not make clear why that treatment was performed. He formulated a Management Plan Authority for Patient KS that listed the principal diagnosis as "arthritis". No such diagnosis, nor any evidence to support such a care plan, was recorded in the clinical notes. The "care plan" does not refer to spinal manipulation. Notwithstanding this, Dr Gorman continued to treat Patient KS with spinal manipulation under that care plan.

147 The clinical notes relating to the consultation on 1 August 2008 demonstrate that the Respondent did not document an examination or the taking of a history on that occasion.

148 In Dr Beaumont's view, spinal manipulation is not a generally accepted approach to the treatment of laryngeal cough by a general practitioner. Nor was there a basis for a diagnosis of arthritis.

149 According to the Respondent, as previously discussed, "arthritis" is an interchangeable term for the ubiquitous illness that is central to his medical philosophy. The Tribunal, however, is satisfied that such a view does not accord with accepted conventional medical practice.

150 Patient KS again consulted the Respondent on 10 August 2008. Again, the clinical notes do not document any symptoms, a history, or any examination. A further spinal manipulation was performed. According to the Respondent, Patient KS came in for a spinal manipulation pursuant to her "care plan". In those circumstances there was no need for any of those standard procedures.

151 Dr Young was critical of the fact that the Respondent only recorded in the clinical notes that a "care plan spinal manipulation had been done" (which care plan referred to "arthritis" but not to spinal manipulation).

152 The Respondent's explanation was that he instituted a care plan in which he undertook to care for the patient's chronic condition, which was best classified as a form of arthritis, the definition of arthritis being 'inflammation of a joint', a condition about which Dr Young is ignorant.

153 The next consultation upon which the Commission relies occurred on 29 August 2008, when the Respondent performed a further spinal manipulation on Patient KS in the presence of Dr Ayscough and Mr Milazzo as part of their Performance Assessment of the Respondent at the Bankstown surgery.

154 The Commission asserts, again, that the clinical notes demonstrate the Respondent failed to document a history or an examination for Patient KS in the medical record. It also asserts that there was no adequate management plan put in place for Patient KS.

155 In response to the criticism of these failures the Respondent said those rules don't apply to him:

"It's not an inadequate plan if you deal with a different philosophy to me... if you're criticising some other doctor that lives by this religion, and it is a religion, or general practice the way you want me to fit in, that would be inadequate, but when you come from me, who works by a totally different religion, a totally different set of values, then you know, it's okay what I do."

156 The assessors, Dr Ayscough and Mr Milazzo, were critical of the Respondent's performance on this occasion, including his failure to perform any adequate reassessment of clinical symptoms or impairments of Patient KS. They were also critical of the manipulative technique, describing it as generalised, non-specific, involving "large range procedures with high force and high velocity". The techniques employed were not known to be used in common manipulative therapy practice. Large range manipulations in the cervical spine are not employed because of concern for adverse effects from potential vascular damage.

157 Furthermore, in their opinion, the spinal manipulation performed was unsafe by current manipulative standards.

158 The final consultation upon which the Commission relies in relation to Patient KS occurred on 7 September 2008 when the Respondent again performed a spinal manipulation on her. The clinical notes record that this was done under her care plan arrangements. Again, there was no history documented, and no examination undertaken prior to the manipulation.

159 In Dr Young's opinion, the management of Patient KS by the Respondent on each of these occasions was significantly below the standard expected of a practitioner of an equivalent level of training and experience. In his view, spinal manipulation was not an appropriate treatment for the symptoms with which the patient presented.

160 The Commission submitted that the evidence demonstrates that the Respondent's treatment of Patient KS was significantly below the appropriate standard. It relies upon the particulars set out in the first Notice of Complaint.

161 Specifically, the Commission says, first, that the Respondent failed to adequately document a history or examination, and failed to formulate an adequate management plan in the record. Secondly, he failed to perform adequate clinical assessments or reassessments; in particular he failed to properly assess the patient for risk prior to carrying out spinal manipulation, and failed to obtain her informed consent. Thirdly, the spinal manipulation performed before the assessors on 29 August 2008 was unsafe by current manipulative standards. The Commission further alleges that the Respondent failed to provide Patient KS with appropriate treatment. The Management Plan Authority he formulated listed "arthritis" as the principal diagnosis, in circumstances where he had not recorded such a diagnosis or recorded any evidence in the clinical notes to support the diagnosis. Nor did the care plan refer to spinal manipulation.

162 The Respondent submitted that Patient KS came to no harm as a result of his treatment, which was appropriately directed to the problem of her nervous system and not primarily to the peripheral results of that problem.

163 He further contended that Patient KS returned for more treatment and that she provided informed consent for the treatment. As a health care professional with qualifications in acupuncture and Chinese medicine she would have been well aware of the other modalities of treatment that would have been available to her. Patient KS required spinal manipulation for a non-spinal, neurological problem. Given the ignorance of the spinal manipulation assessors, Dr Ayscough and Mr Milazzo, of the fundamental precepts underlying a spinal manipulation approach to such neurological problems, it must be accepted that their criticisms of the spinal manipulation method, which have been shown to be effective in resolving spine-based neurological problems, are both immature and spurious.

164 The Respondent chose not to deal with the matter of the panic attacks about which the patient complained, on the basis that at no time during the consultations did she exhibit signs of the 'panic attack' syndrome: agitation, hyperpnoea and mental obfuscation.

165 The Commission's allegations were clearly made out. The witnesses were critical of the Respondent on each of the matters about which it complains and, for the reasons already given, the Tribunal prefers those witnesses to the Respondent. That the patient came to no harm and returned for more treatment is not to the point. As already discussed, the risks associated with the Respondent's rigid approach are unacceptable.

166 The Tribunal finds that the Respondent failed to adequately document a history or examination, and failed to formulate an adequate management plan in the record, and he failed to perform adequate clinical assessments or reassessments.

167 The Tribunal also finds that the Respondent failed to properly assess the patient for risk prior to performing the spinal manipulations, and that the spinal manipulation performed on 29 August 2008 was unsafe by current manipulative standards.

168 The Respondent did not inform Patient KS that cervical spine syndrome and dorsal spine syndrome are not conditions that are accepted by general medical practice, or that spinal manipulation was not orthodox treatment for her condition. Nor did he explain to her the risks associated with forceful spinal manipulation. The fact that she was a health care professional did not relieve him of the need for full and proper disclosure.

169 In these circumstances, the Tribunal finds that Patient KS did not give informed consent to the Respondent for the spinal manipulations he carried out.

170 Accordingly, the Tribunal is satisfied that the Respondent's clinical assessment of Patient KS was significantly below the standard expected of a practitioner of an equivalent level of training and experience.

Patient MP

171 Patient MP, a female patient born on 12 December 1974) is Patient No 2 referred to in the Performance Assessment Report dated 29 August 2008 prepared by Dr Ayscough and Mr Milazzo. She was a sufferer of Hashimoto's disease. She first consulted the Respondent at the Bankstown Medical Centre on 7 August 2008, then aged 33, complaining of ear pain. He performed a spinal manipulation. The Respondent performed a further spinal manipulation in the presence of Dr Ayscough and Mr Milazzo as part of their Performance Assessment of the Respondent on 29 August 2008. On this occasion she had complained of neck pain and head aches.

172 The Commission submitted that the Respondent's explanation for performing a manipulation was inadequate.

173 In his final written submissions, the Respondent asserted that Patient MP was "competently treated for neurologic distress". The clinical notes, however, failed to adequately document a history, an examination or a management plan for Patient MP in the medical record.

174 In addition to the spinal manipulation, the Respondent was criticised by Dr Young for providing the patient with a repeat script for Oroxine without adequately assessing previous medications, and for failing to order a TSH blood test, even though her TSH levels had last been done more than 6 months before. The Respondent was dismissive of these omissions. He described Dr Young's criticism as "nit-picking comment."

175 The assessors, Dr Ayscough and Mr Milazzo, were critical of the Respondent's performance, in particular his failure to properly assess the patient's suitability for spinal manipulation. Also, in their view, the spinal manipulation performed was unsafe by current manipulative standards.

176 In Dr Young's opinion, the management of Patient MP by the Respondent was significantly below the standard expected of a practitioner of an equivalent level of training and experience.

177 The Commission submitted that the evidence demonstrates that the Respondent's treatment of Patient MP was significantly below the appropriate standard. It relies upon the particulars set out in the first Notice of Complaint.

178 Specifically, the Commission says, first, that the Respondent failed to adequately document a history or examination, and failed to formulate an adequate management plan in the record.

179 Secondly, he failed to perform an adequate clinical reassessment; in particular he failed to properly assess the patient for risk prior to carrying out spinal manipulation.

180 Thirdly, the spinal manipulation performed before the assessors on 29 August 2008 was unsafe by current manipulative standards.

181 The Commission further alleges that the Respondent failed to perform an adequate assessment of previous medications prescribed before providing a repeat script, and that he failed to order a TSH blood test.

182 In his final written submissions, the Respondent asserted that Patient MP was "competently treated for neurologic distress".

183 The Commission's allegations were clearly made out. The witnesses were critical of the Respondent on each of the matters about which it complains and, for the reasons already given, the Tribunal prefers those witnesses to the Respondent.

184 The Tribunal finds that the Respondent failed to adequately document a history or examination, and failed to formulate an adequate management plan in the record, and he failed to perform an adequate clinical reassessment.

185 The Tribunal also finds that the Respondent failed to properly assess the patient for risk prior to performing the spinal manipulations, and that the spinal manipulation performed on 29 August 2008 was unsafe by current manipulative standards.

186 Accordingly, the Tribunal is satisfied that the Respondent's clinical assessment of Patient MP was significantly below the standard expected of a practitioner of an equivalent level of training and experience.

Patient PD

187 Patient PD, a female patient, was born on 12 June 1978. She is Patient No 3 referred to in the Performance Assessment Report dated 29 August 2008 prepared by Dr Ayscough and Mr Milazzo. She consulted the Respondent at the Bankstown Medical Centre on 29 August 2008, then aged 30. Her symptoms included headaches, forgetfulness, moodiness, tension, tiredness, nausea, dizziness and pins and needles in both hands as well as poor sleep pattern.

188 A spinal manipulation was performed by the Respondent in the presence of Dr Ayscough and Mr Milazzo as part of their Performance Assessment of the Respondent. The Respondent did not record any diagnosis or assessment or reason for giving her a spinal manipulation on that day. She had been attending him regularly over the previous few years for spinal manipulation in relation to her many problems, as a result of an assessment made by the Respondent that the patient needed spinal manipulation treatment for the whole of her life. On one occasion a spinal manipulation was performed when she was pregnant, to help her with morning sickness.

189 In relation to the spinal manipulation performed on 29 August 2008 there is no record of re-assessment, of any detail taken by the Respondent as to the patient's progress or her current health, nor was any assessment undertaken to determine her suitability for spinal manipulation. The clinical notes failed to adequately document a history, an examination or a management plan.

190 In Dr Young's view, the patient's wide-ranging symptoms would need a lot more exploration and teasing out to differentiate physical from psychological symptoms. He criticised the Respondent for failing to properly investigate the patient's complaints, but looking for indicators to suit his theory, and thus missing other relevant symptoms.

191 The Respondent rejected this criticism as "vague, complicated management, while ignoring a direct path to a likely diagnosis, for which the treatment is simple, safe, expeditious and totally inexpensive".

192 In Dr Young's opinion, the management of Patient PD by the Respondent was significantly below the standard expected of a practitioner of an equivalent level of training and experience.

193 The assessors, Dr Ayscough and Mr Milazzo, were critical of the Respondent's performance, in particular his failure to properly assess the patient's suitability for spinal manipulation. Also, in their view, the spinal manipulation performed was unsafe by current manipulative standards.

194 Patient PD again consulted the Respondent on 4 October 2008. He again failed to adequately document a history, examination and management plan for Patient PD in the medical record. He formulated a Management Plan Authority for her that listed the principal diagnosis as "arthritis", however he had not recorded such a diagnosis or recorded any evidence in the clinical notes to support such a care plan.

195 There were further consultations on 5 October 2008, 29 October 2008 and 14 November 2008 when the Respondent treated Patient PD with spinal manipulation.

196 On each occasion he performed the manipulations under a "care plan" in circumstances where he had not documented a history or examination, nor a management plan, and where the care plan did not refer to spinal manipulation.

197 Dr Young concluded that the Respondent's treatment of Patient PD in these subsequent consultations was also significantly below the standard reasonably expected of a practitioner of an equivalent level of training and experience.

198 The Commission submitted that the evidence demonstrates that the Respondent's treatment of Patient KS was significantly below the appropriate standard. It relies upon the particulars set out in the first Notice of Complaint.

199 Specifically, the Commission says, first, that the Respondent failed to adequately document a history or examination, and failed to formulate an adequate management plan in the record.

200 Secondly, he failed to perform an adequate clinical reassessment; in particular he failed to properly assess the patient for risk prior to carrying out spinal manipulation. Thirdly, the spinal manipulation performed before the assessors on 29 August 2008 was unsafe by current manipulative standards.

201 The Commission further alleges that the Management Plan Authority the Respondent formulated listed "arthritis" as the principal diagnosis in circumstances where he had not recorded such a diagnosis or recorded any evidence in the clinical notes to support the diagnosis. Nor did the care plan refer to spinal manipulation.

202 In his final written submissions, the Respondent asserted that Patient PD was "competently treated for neurologic distress".

203 The Commission's allegations were clearly made out. The witnesses were critical of the Respondent on each of the matters about which it complains and, for the reasons already given, the Tribunal prefers those witnesses to the Respondent.

204 The Tribunal finds that the Respondent failed to adequately document a history or examination, and failed to formulate an adequate management plan in the record, and he failed to perform an adequate clinical reassessment.

205 The Tribunal also finds that the Respondent failed to properly assess the patient for risk prior to performing the spinal manipulations, and that the spinal manipulation performed on 29 August 2008 was unsafe by current manipulative standards.

206 Accordingly, the Tribunal is satisfied that the Respondent's clinical assessment of Patient PD was significantly below the standard expected of a practitioner of an equivalent level of training and experience.

Patient JE

207 Patient JE, a male patient, was born on 3 February 1960. He is Patient No 4 referred to in the Performance Assessment Report dated 29 August 2008 prepared by Dr Ayscough and Mr Milazzo. He first consulted the Respondent at the Bankstown Medical Centre on 28 August 2008, then aged 48, after he had bent down to pick up a baby and his back "went out". He was given a spinal manipulation.

208 He returned the following day, 29 August 2008, when a second spinal manipulation was performed by the Respondent in the presence of Dr Ayscough and Mr Milazzo as part of their Performance Assessment.

209 The clinical notes failed to adequately document a history, an examination or a management plan. No examination was undertaken and no assessment was undertaken to determine his suitability for spinal manipulation.

210 In Dr Young's opinion, more conventional management would have been rest, pain relief and early physiotherapy involvement. He considered the Respondent's treatment of Patient JE was significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience.

211 The assessors, Dr Ayscough and Mr Milazzo, were critical of the Respondent's performance, in particular his failure to properly assess the patient's suitability for spinal manipulation. Also, in their view, as with other patients, the spinal manipulation performed was unsafe by current manipulative standards.

212 The Commission submitted that the evidence demonstrates that the Respondent's treatment of Patient JE was significantly below the appropriate standard. It relies upon the particulars set out in the first Notice of Complaint.

213 Specifically, the Commission says, first, that the Respondent failed to adequately document a history or examination, and failed to formulate an adequate management plan in the record. Secondly, he failed to perform an adequate clinical re-assessment; in particular he failed to properly assess the patient for risk prior to carrying out spinal manipulation. Thirdly, the spinal manipulation performed before the assessors on 29 August 2008 was unsafe by current manipulative standards.

214 In his final written submissions, the Respondent asserted that Patient JE was "competently treated for neurologic distress". He maintains that Patient JE had the "ubiquitous illness" that is central to his medical philosophy (T 712.8):

"Q. Why would you give him another spinal manipulation if he reports he's not better from the first one?

A. Well, because I'm a very experienced doctor in spinal replacing. I'm a very experienced doctor in this illness. That's why.

Q. So do you say you keep giving people spinal manipulation even if they're not reporting benefit from it?

A. Yes, of course because, you know, if you think that every illness is going to get better with one treatment, that's just ridiculous."

215 The Commission's allegations were clearly made out. The witnesses were critical of the Respondent on each of the matters about which it complains and for the reasons already given, the Tribunal prefers those witnesses to the Respondent.

216 The Tribunal finds that the Respondent failed to adequately document a history or examination, and failed to formulate an adequate management plan in the record.

217 The Tribunal also finds that the Respondent failed to properly assess the patient for risk prior to performing the spinal manipulations, and that the spinal manipulation performed on 29 August 2008 was unsafe by current manipulative standards.

218 Accordingly, the Tribunal is satisfied that the Respondent's clinical assessment of Patient JE was significantly below the standard expected of a practitioner of an equivalent level of training and experience.

Patient CR

219 Patient CR, a female patient, was born on 31 March 1982. She is Patient No 5 in the Performance Assessment though not included in the Report dated 29 August 2008 prepared by Dr Ayscough and Mr Milazzo. She consulted the Respondent on 7 March 2006, then aged 23 after she had injured an ankle in a fall and consulted the Respondent several days later after developing a sudden severe headache. She already had a history of pethidine use. The Respondent had previously seen her nearly two years earlier when he noted a warning about dependency. She did not complain of a migraine headache or any history of migraine, but did complain of some dizziness and tiredness. She had no vision impairments. Specifically, he tested her visual fields but found them to be "full". And yet he described her as having tunnel vision every time she saw him.

220 The Respondent explained his therapy of spinal manipulation to her and she agreed to undergo a manipulation. He also gave her a pethidine injection of 100 mgm. Over the next 6 days he gave her a further 6 pethidine injections.

221 Subsequent to the initial consultation, which concerned a minor ankle injury, Patient CR presented to the Respondent on multiple occasions over 2 years and on each occasion he treated her with pethidine or morphine, and on some of those occasions he also performed a spinal manipulation:

8 March 2006, 9 March 2006, 11 March 2006, 12 March 2006, 19 March 2006, 20 March 2006, 25 March 2006, 26 March 2006, 28 March 2006, 31 March 2006, 2 April 2006, 3 April 2006, 5 April 2006, 6 April 2006, 9 April 2006, 12 April 2006, 14 April 2006, 17 April 2006, 23 April 2006, 25 April 2006, 28 April 2006, 29 April 2006, 1 May 2006, 7 May 2006, 11 May 2006, 12 May 2006, 14 May 2006, 16 May 2006, 19 May 2006, 23 May 2006, 27 May 2006, 30 May 2006, 31 May 2006, 3 June 2006, 4 June 2006, 8 June 2006, 10 June 2006, 15 June 2006, 16 June 2006, 17 June 2006, 20 June 2006, 21 June 2006, 26 June 2006, 27 June 2006, 28 June 2006, 30 June 2006, 2 July 2006, 6 July 2006, 9 July 2006, 12 July 2006, 15 July 2006, 16 July 2006, 19 July 2006, 25 July 2006, 30 July 2006, 2 August 2006, 5 August 2006, 7 August 2006, 12 August 2006, 15 August 2006, 16 August 2006, 17 August 2006, 23 August 2006, 25 August 2006, 29 August 2006, 1 September 2006, 3 September 2006, 6 September 2006, 11 September 2006, 16 September 2006, 18 September 2006, 26 September 2006, 30 September 2006, 4 October 2006, 7 October 2006, 8 October 2006, 18 October 2006, 26 October 2006, 29 October 2006, 31 October 2006, 3 November 2006, 5 November 2006, 13 November 2006, 24 November 2006, 1 January 2007, 27 March 2007, 2 April 2007, 5 April 2007, 11 April 2007, 15 April 2007, 23 April 2007, 24 April 2007, 2 May 2007, 6 May 2007, 8 May 2007, 15 May 2007, 18 May 2007, 27 May 2007, 21 January 2008, 18 February 2008, 14 March 2008, 27 September 2008.

222 Thus, over a 2 year period the Respondent continued to administer Patient CR with opiate injections and spinal manipulations on a regular basis. He did so in the full knowledge that she was drug dependent. Indeed, he conceded that he started the process of her addiction. The Respondent also knowingly contravened s 28(2)(a) of the Poisons and Therapeutic Goods Act 1966 by supplying her with morphine and pethidine, being drugs of addiction, for a period exceeding two months. In this regard he admitted that he "arrogantly" defied the law.

223 Although the Respondent became the patient's primary GP over this 2 year period, he never once assessed her mental state, notwithstanding her addiction, and an evident psychological aspect in her presentation, which other practitioners had pointed out.

224 He ignored these matters, and other medical opinion, and chose instead to treat her according to his medical philosophy and administered drugs of addiction in conjunction with spinal manipulations that were not alleviating the symptoms about which she continued to complain.

225 There is no notation in the clinical notes that the Respondent ever explained the risks of spinal manipulation to Patient CR or explained that other treatments were available to her.

226 Dr Young concluded that the Respondent's overall management of Patient CR was significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience, and the departure invited his strong criticism. In particular, in his view, multidisciplinary care in the form of either a pain clinic or a drug and alcohol service should have been sought. The Respondent could, for example, have contacted the doctor shoppers' line. At no stage, however, did the Respondent develop any type of management plan to manage her condition.

227 The Commission submitted that some very clear patterns emerge from the evidence concerning the Respondent's treatment of Patient CR, which are set out in detail in the written submissions. These reasons will refer to some of these patterns.

228 It was submitted, for example, that there was a pattern involving a two-way relationship between a patient (engaging in drug-seeking behaviour) and a doctor (with a rigid medical philosophy), pursuant to which the patient rapidly adapts her drug-seeking behaviours. The notes reveal that Patient CR started to report visual field loss and other symptoms that would resonate with the Respondent's medical philosophy, even though none of those symptoms were reported when she first started presenting to him. She very quickly began to frame her complaints in a way that would fit in or resonate with the doctor's medical philosophy, knowing that if she submitted to a spinal manipulation she would be rewarded with an injection:

"Plainly Dr Gorman was unable to see clearly a very obvious pattern that has started very early on in the treatment relationship because he was blinded by his rigid medical philosophy." [170]

229 Similarly, it was submitted, there was a pattern involving the encouragement of Patient CR to adopt the medical philosophy, and to advocate it to others. For example, the Respondent tells the patient the reason the manipulations are not working is the fact that they were not done under anaesthesia. She then wrote to the Director of Health in the hope of having spinal manipulation done under anaesthesia. Instead of confronting the real problem, the Respondent seeks to cloud or excuse her addiction. [179]

230 Another matter of concern for the Commission was the Respondent's abandonment of Patient CR, after he cut her off cold without making any appropriate arrangements for her ongoing care (T 752.24ff).

231 The Commission submitted that the case of Patient CR demonstrates a distinct lack of insight and serious failings in judgment on the part of the Respondent, in that:

(a) the application of his rigid medical philosophy meant that Patient CR was not treated for either her underlying depression or her addiction; and

(b) he was blinded by his rigid medical philosophy into feeding the addiction of a pethidine addict.

"Of particular concern is Dr Gorman's frank admission that this would probably happen again. Dr Gorman is unable to reflect and unable to depart from his rigid medical philosophy - even given the very serious adverse consequences of the application of his rigid medical philosophy in this case." [198]

232 The Commission also contends that true informed consent for spinal manipulation cannot be given by someone such as Patient CR in circumstances where the ongoing and distinct pattern is that she is agreeing to it as the first step in a two-step process - where the second step is a pethidine injection. [173] - [175]. As Dr Beaumont agreed, the risk/benefit analysis for such a person means that they are not really considering the benefits of manipulation; they are considering the benefit of pethidine (T 485.10).

233 The Commission submitted that the evidence demonstrates that the Respondent's treatment of Patient CR was significantly below the appropriate standard. It relies upon the particulars set out in the first Notice of Complaint.

234 The Commission submitted that arising from these circumstances, the Respondent made a series of failures in respect of the management and treatment of Patient CR.

235 Specifically, the Commission says that the Respondent:

(a) failed to formulate a management plan to be administered at the Bankstown Medical Centre for the administering of narcotics to her,

(b) supplied her with drugs of addiction, namely injectable morphine and pethidine, for a period exceeding two months when he was of the opinion that she was a drug dependent person within the meaning of the Poisons and Therapeutic Goods Act 1966 , without obtaining an authority from the Department of Health, contrary to the requirements of s 28 of that Act,

(c) failed to instigate proper care for her narcotic addiction,

(d) failed to assess her mental state,

(e) failed to obtain informed consent to treatment by spinal manipulation in circumstances where she was seeking pethidine or morphine,

(f) failed to instigate or arrange for her care by another practitioner when he ceased treating her on 27 September 2008.

236 In his final written submissions, the Respondent conceded that he gave Patient CR too much pethidine, but remained otherwise unrepentant:

"I saw Patient CR as different from the usual group of addicts who doctor-shop for narcotic medications for personal, non- medical (as it were, recreational) use, and for financial benefit when the drugs are sold for considerable amounts of money."

237 It is evident that even now the Respondent continues to seek to justify his position in relation to Patient CR.

238 He seeks to attribute responsibility to others (at Page 14):

"...I should have approached the Premier of New South Wales (as I did when I approached Mr Morris Iemma about patient: 'Donny') again demanding that I be allowed to treat her spine under anaesthesia and full muscle relaxation according to the method taught to me by Dr. Eric Milne."

239 The Commission contends that this demonstrates the Respondent has still not appreciated the extent of his failures in relation to his management of Patient CR, and confirm the probability that he would do the same again:

"Thus, Dr Gorman gave her an excuse or raison d'tre for her problem, being the Department of Health and the fact that she cannot access spinal manipulation under anaesthesia, thus exacerbating the denial of the seriousness of her addiction." [180]...This exacerbation of her denial is particularly serious as, even when she did have spinal manipulation under anaesthesia, her condition did not improve. Rather, she presented immediately seeking more pethidine and, more importantly, presented with a "migraine" seeking pethidine. Notwithstanding her ongoing presentation with "migraines" after having had spinal manipulation under anaesthesia, Dr Gorman still thinks it cured her (and this is also notwithstanding that he had formed the view after 5 days that it was not a spine/migraine problem at all). Indeed, Dr Gorman describes the event of her having spinal manipulation under anaesthesia as a ' turning point '." [181]

240 His further written submissions demonstrate the rigidity of his views:

"My disgust in regard to the behaviour of some of the executive of the Royal Australian and New Zealand College of Ophthalmologists and the complicit behaviour of the executive of Bankstown Hospital and the New South Wales Department of Health, who effectively denied 'Donny' access to spinal manipulation under anaesthesia in the treatment of his drug addiction, added to my compassion for Patient CR.

I rail against the association of Patient CR with drug addicts generally - in my opinion, she did not 'make up' her pain: it was real, devastating on occasions and well worth a strong analgesic medication. I believe that I 'kept her together' during a time of temporary illness, when her responsibilities: the care of her two young children, were in jeopardy - temporary because she could have been abruptly put on the path to recovery but for the continuance of 'the Great Australian Medical Scientific Fraud'. Had my whistle blowing of the fraud been listened to in any section of the political establishment, which I had contacted over a period of greater than three decades, I allege that her outcome would have been vastly better. I imagine that she is still a pethidine addict; or, if she isn't, then her personal courage in her adversity must have been exceptional.

Suffice it to say that the continued opposition to the advent of a competent and complete treatment for the Cervical Spine Syndrome (Ictal and Interictal Migraine), as manifested by the no less than eight visits to the Medical Regulatory system by me since 1986 (Medical Board hearing in 1987, Professional Standards Committee circa 1988, Medical Tribunal 1989, 1998, 2002, 2009 and 2011), did not help Patient CR in her search for return of her good health, which was taken from her by a simple accident at a petrol service station. The year when this accident occurred is not apparent from the notes.

She had been warned about dependency in 2004 in a single notation in the history. However, the available notes do not record any injections between June 2003 and May 2004. This absence suggests that it was the injury at the petrol station, which so radically changed her life.

Patient CR certainly has a major case for compensation from numerous entities: the College of Ophthalmologists primarily, followed by the Universities of Sydney, New South Wales and Newcastle for ignoring the recovery of vision with spinal manipulation when it was categorically brought to their attention in 1986 and onwards."

241 The Commission's allegations were clearly made out. The witnesses were critical of the Respondent on each of the matters about which it complains and for the reasons already given, the Tribunal prefers those witnesses to the Respondent.

242 The Tribunal finds that the Respondent failed to formulate an appropriate management plan for Patient CR, failed to instigate proper care for her narcotic addiction, failed to assess her mental state, and failed to instigate or arrange for her care by another practitioner when he ceased treating her on 27 September 2008. The Tribunal also finds that Patient CR did not give informed consent to the Respondent for the spinal manipulations he carried out.

243 Finally, the Tribunal finds that the Respondent supplied Patient CR with drugs of addiction, namely injectable morphine and pethidine, for a period exceeding two months when he was of the opinion that she was a drug dependent person within the meaning of the Poisons and Therapeutic Goods Act 1966 , without obtaining an authority from the Department of Health, contrary to the requirements of s 28 of that Act.

244 Accordingly, the Tribunal is satisfied that the Respondent's management and treatment of Patient CR was significantly below the standard expected of a practitioner of an equivalent level of training and experience.

Patient NC

245 Patient NC, a male patient born on 15 April 1977, first consulted the Respondent at Bankstown on 30 November 2002, then aged 25, for abdominal pain and diarrhoea. A spinal manipulation was performed.

246 The patient next consulted the Respondent over two years later, on 6 October 2006, complaining of an eye irritation.

247 The Respondent told the patient that there was, in fact, nothing wrong with his eyes, but that his brain causing his symptoms, and that spinal manipulation would fix the problem. The Respondent said he went to great effort to explain the connection between brain failure and illnesses of the peripheral body, and that this patient "cottoned on" to the possible involvement of the brain in his eye condition.

248 The Respondent then treated Patient NC for his eye condition with a spinal manipulation. The therapy was ineffective and a short time afterwards the patient consulted an ophthalmologist who was diagnosed "chronic eye irritation" caused by allergic conjunctivitis. He was treated with Bion tears and Maxidex, which solved the problem within about one week. That diagnosis was reached after the patient had a skin test that determined the cause of the allergy was grass and pollen. Because he now knows the cause, Patient NC is able to manage the condition (for example by wearing goggles when mowing the lawn).

249 According to the Respondent, the diagnosis of allergic conjunctivitis was "an inferior diagnosis". He described it as "very conventional", the "approach that GPs would ordinarily take to such a problem". In his view, the patient's symptoms were the result of a brain condition. He reported to the referring doctor, Dr Sivarajah, that there was no abnormality in the patient's eyes, so the pain must be in the nervous system. The "commonest pathology in his age group with brain disability is migraine."

250 In Dr Beaumont's view, giving a spinal manipulation as first-line treatment to a presentation of irritated eyes in general practice was inappropriate.

251 The Commission's expert, Dr Jammal, holds the view that the Respondent's treatment of Patient NC was "markedly inadequate" and that it departed significantly from the standard expected of a practitioner of an equivalent level of training and expertise.

252 The Commission also contended that the Respondent did not give Patient NC sufficient information to consent to the treatment of his eye irritation with spinal manipulation. In fact, the information he gave the patient was actually misleading and incomplete. The patient said (T 175.20):

"He tried to explain it. I think he did. He tried to explain it and he pulled up some research and what he believed was correct, you know. So I probably believed it at that time. I'm a patient. I just wanted to get better."

253 It was submitted that it is not informed consent where the patient undergoes treatment on the basis that a doctor has convinced them they have a condition which is not accepted as existing or on the basis of a generalised diagnosis, such as here, of a "brain condition" or a "pain program" in the brain causing pain to the eyes, especially when the doctor has failed to explain to his patient that the diagnosis he has reached is not recognised in general practice, or that the proposed therapy is outside the parameters of mainstream health care and general practice. Dr Beaumont agreed. He went so far as to say the patient was in fact misinformed about the scientific "evidence" and could, therefore, only give "misinformed consent". (T 469.37)

254 The Commission submitted, in relation to patient NC:

"This is... an example where the risk to a patient is not only mis-diagnosis but also the distress of being given a worrying (and erroneous) diagnosis." [39]

"As a general matter, the case... reflects the fact that the Respondent approaches general practice with a presumption that nearly all people have a particular illness connected to the spine or the brain and he fits the diagnosis to meet that presumption or mindset. This is the "one size-fits all approach". [63]

255 The Commission submitted that the evidence demonstrates that the Respondent's treatment of Patient NC was significantly below the appropriate standard. It relies upon the particulars set out in the second Notice of Complaint.

256 Specifically, the Commission says that the Respondent wrongly diagnosed the patient's condition, provided inappropriate treatment, and failed to provide sufficient information such as to enable the patient to give informed consent for spinal manipulation.

257 In his written submissions, the Respondent defended his treatment:

"Patient NC's complaint about his treatment in my hands turned out to be spurious because it was made too early in the course of his illness.

When looked at from a long-term perspective, he achieved a very good result from brain-based, spinal manipulation treatment of his ocular irritation.

Apparently, once the known two months' recuperation period had passed, he has suffered minimal discomfort from his allergic conjunctivitis. His result from spinal manipulation treatment for his allergic conjunctivitis was excellent, based on his present state as he demonstrated in the Tribunal."

258 The Commission's allegations in respect of Patient NC were clearly made out. The witnesses were critical of the Respondent on each of the matters about which it complains and for the reasons already given, the Tribunal prefers those witnesses to the Respondent.

259 The Tribunal finds that the Respondent wrongly diagnosed the patient's condition, provided inappropriate treatment, and failed to provide sufficient information such as to enable the patient to give informed consent for spinal manipulation.

260 Accordingly, the Tribunal is satisfied that the Respondent's management and treatment of Patient NC was significantly below the standard expected of a practitioner of an equivalent level of training and experience.

Patient JEK

261 Patient JEK, a male patient born on 13 December 1991, first consulted the Respondent at Bankstown as a child, then aged 15, with his mother, on 17 September 2007, in connection with symptoms of a high fever, headaches, chest pain and productive cough.

262 The clinical notes record that the Respondent considered the patient to have the flu plus neuropathic pain in the left shoulder region from neck problems, which "fitted in with dizziness at school on Thursday at the start of the illness". The Respondent manipulated the patient's neck.

263 When the patient did not respond to the "spinal interventions", the Respondent referred him to Bankstown Hospital. He was diagnosed with pneumonia, and spent 5 days in hospital recovering. Dr Ieraci wrote a letter of complaint to the NSW Medical Board detailing concerns about the Respondent's treatment of the patient.

264 In both his clinical notes and his referral letter to the Bankstown Hospital, the Respondent failed to note that the child had a history of asthma. As Dr Ieraci observed, asthma makes a patient more predisposed to have pneumonia because the mucus that is produced in an asthma attack blocks the airways, and breathing or respiratory reserve is lower:

"... so if they have two concurrent problems in their lungs then they potentially complicate each other...That's another concerning feature because the history of asthma is certainly significant in a boy presenting with another respiratory illness."

265 The Commission submitted that the medical records for Patient JEK reveal that the Respondent failed to adequately document a history, examination and management plan in the medical record. According to the Respondent, the failure to note a history of asthma was not important. Even if he had picked the probable diagnosis as pneumonia, he still would have given spinal manipulation as the treatment.

266 Dr Ieraci made the following observations regarding the Respondent's treatment of Patient JEK (T 632.47):

"Firstly, it suggests a lack of understanding of the pathophysiology of the illness, and by that, I mean the way orthodox medicine understands the way the body works. And then secondly, a lack of judgment about both severity and the time course of recovery of this illness."

267 In Dr Beaumont's opinion, treating the patient with cervical manipulation was "unacceptable" and "quite inappropriate" (T 471.12 and 472.47).

268 Dr Jammal concluded that the Respondent "missed a simple case of pneumonia". In his view the treatment of Patient JEK was a significant departure from the standard expected of a practitioner of an equivalent level of training and expertise. This departure invited his strong criticism; especially given the patient was a child.

269 The Commission submitted that the evidence demonstrates that the Respondent's treatment of Patient JEK was significantly below the appropriate standard. It relies upon the particulars set out in the second Notice of Complaint.

270 Specifically, the Commission says that the Respondent wrongly diagnosed the patient's condition, provided inappropriate treatment, and failed to adequately document a history or examination, and failed to formulate an adequate management plan in the record.

271 The Commission also submitted that the case of Patient JEK again reflects the fact that the Respondent approaches general practice with a presumption that nearly all people have a particular illness connected to the spine or the brain and he fits the diagnosis to meet that presumption or mindset.

272 The Respondent continues to maintain that his treatment of this patient was appropriate (T 763.45), and that the spinal manipulation was the treatment that resulted in his cure, not the antibiotics administered by the hospital (T 763.50ff). In his final written submissions he said:

"A complaint about the treatment of Patient JEK was unjustified because, in his case, the spinal manipulation treatment was remarkably effective.

From the time that the spinal manipulation was done early in the evening to the time that he was admitted to the ward from the Emergency Department (less than four hours), his illness changed from one that required hospitalisation to one that could be treated at home: in that time, his temperature normalised and he lost his sickness demeanour; these features were never to become abnormal again in this vicissitude of his life...

The patient's dramatic recovery following the spinal manipulation treatment was easy to demonstrate graphically. Although Dr. Ieraci attributed his recovery to the Amphicillin medication, which was given, the illness was better before the medication was started."

273 The Respondent then set out the graphs that were Exhibits 13A and 13B, which in his submission demonstrate his position that it was the spinal manipulation that caused the patient's temperature to drop from 39.0+ at the time of the manipulation treatment to 36.1 some four hours later in triage.

274 The Respondent's final written submissions continue:

"1. The first graph interprets what the temperature was, when the spinal manipulative treatment was given, in a way least beneficial to the respondent, because it suggests that the temperature was already falling before the manipulation was done.

2. The second graph interprets the temperature chart at the time when the spinal manipulation was performed. In this case, the fall in temperature commenced at the time of the manipulation.

3. It is not possible to determine which graph represented the truth of the matter, because the temperature was not taken at the time when the manipulation was done.

4. The second point to be noted that the antibiotic: Amphicillin, was not given as a bolus dose (all at once) so the amount of the drug which had been administered by the time that the temperature had normalised would have been relatively minuscule (the I.V. infusion would have gone on for some hours, so that the dose of antibiotic per minute would have been low, such that 20 minutes after the infusion was started: that is when the temperature normalised, the amount of antibiotic the patient received would not be expected to be therapeutic).

5. Suffice it to say that Dr. Ieraci's complaint about Patient JEK was spurious - the expected result of her lack of due diligence in confirming her facts and her deficiency in integrity.

6. In answer to the criticism, that I failed to diagnose pneumonia and Dr. Ieraci did do so, the fact, that she had an X ray to help her, was ignored in her complaint. The bald statement: 'that I had missed a pneumonic situation' was grossly unfair and a further criticism of Dr. Ieraci's integrity.

7. I had diagnosed a lung infection warranting admission to hospital; that was all that should have been expected of me as the doctor of first contact working in an after hours situation, outside the hospital, which was devoid of X ray assistance."

275 In the opinion of Dr Ieraci, the Respondent's proposition that the manipulation of the patient played a part in his immediate recovery is "inconceivable" (T 631.16):

"Q. In your opinion, could a spinal manipulation have some type of beneficial effect of bringing down a fever in a child?

A. Not that I'm aware of.

Q. Do you know of any evidence that would support that proposition?

A. Not at all.

Q. What is your response to a statement of Dr Gorman that "The manipulation was totally successful in resolving his pyrexia and played a part in his immediate recovery". What's your response to that?

A. I can't accept that that's true.

Q. Could you explain perhaps for my benefit what pyrexia is?

A. Pyrexia is fever.

Q. Fever, and what's your response to Dr Gorman's statement that "The spinal manipulation was effective in resolving his problem. All the hospital needed to do was manage him through his convalescence"?

A. It's inconceivable that that's an explanation of what actually happened.

Q. Is that inconsistent with the clinical notes of what was in fact happening in terms of treatment over the seven days in the hospital?

A. It is."

276 The Commission's allegations in respect of Patient JEK were clearly made out. The witnesses were critical of the Respondent on each of the matters about which it complains and for the reasons already given, the Tribunal prefers those witnesses to the Respondent.

277 It was not the spinal manipulation administered by the Respondent that resulted in the recovery of the patient. The Tribunal is satisfied that more probably the drop in the patient's temperature was due to antipyretics and the subsequent administration of antibiotics.

278 The Tribunal finds that the Respondent failed to adequately document a history or examination, and failed to formulate an adequate management plan in the record.

279 The Tribunal also finds that the Respondent wrongly diagnosed the patient's condition and that his initial treatment was inappropriate.

280 Accordingly, the Tribunal is satisfied that the Respondent's management and treatment of Patient JEK was significantly below the standard expected of a practitioner of an equivalent level of training and experience.

Patient CC

281 Patient CC was another young, male patient who was born on 13 October 2000. He presented to the Respondent at Primary Healthcare Bankstown as a 7 year old on 31 October 2007 complaining of abdominal pain, diarrhoea and vomiting. The Respondent diagnosed "spine induced neurological syndrome", and treated him with manipulation of the spine by a thoracic lift.

282 The patient was later admitted to Bankstown Hospital and treated for infective gastroenteritis and dehydration.

283 In a letter to the hospital, the Respondent wrote:

"...examination revealed no guarding or focal tenderness in the abdomen, but he did have positive skin rolling in the inter-scapular region on both sides. This would indicate a spine-induced neurological syndrome might be involving the bowel and producing inappropriate bowel hyper-activity..."

284 The Respondent said he would virtually always manipulate anybody with diarrhoea, including children as young as 6 months. In his view manipulation usually aborts abdominal pain and diarrhoea. Subluxation of the dorsal spine produces diarrhoea, which stops when the subluxation is repositioned.

285 In the view of Dr Ieraci, the Respondent's diagnosis and treatment of Patient CC was inconsistent with orthodox medicine. There was no basis for the carrying out of a skin-rolling test. That spinal manipulation could be an effective treatment for diarrhoea is not consistent with a conventional understanding of the human body. The risk of harm associated with spinal manipulation is not justified when no benefit from it could be expected:

"For this I'd make three separate points. One would be that there's no evidence that spinal manipulation is effective in the treatment of diarrhoea. The second point would be that there is a risk of harm, even though it's a small risk, that for an ineffective treatment the harm would outweigh any potential benefit. And the third concern would be that a single type of treatment could be applied throughout a range of potential illnesses. Diarrhoea isn't a single disease, it's a symptom, and it's not consistent with orthodox medical thinking, that you could apply a single type of treatment to a range of diseases of different causes."

286 Professor Bonello stated that if he took a history from a child of diarrhoea, and there was plainly no mechanical cause, he would not treat that child by way of manipulation under any circumstances.

287 In Dr Beaumont's opinion, a dehydrated child needs to be re-hydrated. To administer an alternative treatment such as a manipulation before re-hydrating the child is dangerous and inappropriate. The Respondent's approach to general practice, that anyone presenting with diarrhoea should " virtually always" be treated with spinal manipulation, is totally inappropriate by orthodox standards . His alternative diagnosis of a spine-induced neurological syndrome was, according to Dr Beaumont, inappropriate and bizarre.

288 Dr Jammal's view is that Dr Gorman's treatment of Patient CC departed significantly from the standard expected of a practitioner of an equivalent level of training and expertise. This departure, given the age of the child, attracted his strong criticism.

289 The Commission submitted that the evidence demonstrates that the Respondent's treatment of Patient CC was significantly below the appropriate standard. It relies upon the particulars set out in the second Notice of Complaint.

290 Specifically, the Commission says that the Respondent wrongly diagnosed the patient's condition, provided inappropriate treatment, and failed to provide appropriate treatment.

291 The Commission also submitted that the case of Patient CC again reflects the fact that the Respondent approaches general practice with a presumption that nearly all people have a particular illness connected to the spine or the brain and he fits the diagnosis to meet that presumption or mindset. This creates a risk of failure to either diagnose the root cause or to give effective treatment for the true condition.

292 The Respondent continues to maintain that his treatment of this patient was appropriate, and that his therapy cured his diarrhoea. The intravenous therapy given by the hospital was in fact unnecessary.

293 In his final written submissions the Respondent submitted:

"First, Dr. Ieraci's complaint about Patient CC railed on the fact that I manipulated the spine of a child with diarrhoea. Dr. Ieraci admitted ignorance of the ability to change brain function by spinal manipulation (change in the vision function); accordingly, her complaint, about resolution of a similar process elsewhere in the nervous system, is spurious and reflects that ignorance.

The second arm of her complaint about this patient hangs on the fact that I diagnosed a pericardial friction rub, when its presence was not confirmed when the child was examined in hospital. There is no question that the friction rub was loud because I offered a person who attended with Patient CC (his aunt) the opportunity to listen to it. (Not recorded in the clinical notes).

Dr. Ieraci's complaint about this patient would have had more moment if I had failed to diagnose a pericardial friction rub and one was later found to be present when the patient was examined in hospital. What the friction rub controversy does show, is that my examination of the patient extended beyond the abdomen, which was the focus of interest, when one considers that his complaint was of vomiting and diarrhoea. This fact indicates that my examination of the patient was comprehensive and competent."

294 The Commission's allegations in respect of Patient CC were clearly made out. The witnesses were critical of the Respondent on each of the matters about which it complains and for the reasons already given, the Tribunal prefers those witnesses to the Respondent.

295 The Tribunal is satisfied that it was not the spinal manipulation administered by the Respondent that resulted in the recovery of the patient. It finds that the recovery resulted from his subsequent treatment at Bankstown Hospital, including intravenous therapy.

296 The Tribunal also finds that the Respondent wrongly diagnosed the patient's condition and that his initial treatment was inappropriate.

297 Accordingly, the Tribunal is satisfied that the Respondent's management and treatment of Patient CC was significantly below the standard expected of a practitioner of an equivalent level of training and experience.

Patient DL

298 Patient DL was a female patient who was born on 22 June 1961. She first presented to the Respondent on 24 November 2007, then aged 46, with difficulties in breathing, chest pains, hand tremors and headache. The Respondent found her visual fields were restricted and formed the view she was suffering from "the dorsal spine syndrome" and "the cervical spine syndrome". He considered the right treatment would be spinal manipulation performed under anaesthesia, but because he was unable at that time to perform such a procedure, he referred her to Fairfield Hospital.

299 He wrote to the NSW Medical Board on 7 January 2008:

"My reasonable expectation was that Fairfield Hospital would treat this condition and make her well... Unfortunately, as you can imagine, she was "sloughed off" by the hospital: by her account the visual fields were not even examined and no treatment was instituted for the cervical syndrome illness..."

300 Patient DL went back to see the Respondent on 5 January 2008 in the midst of an acute mental health episode involving suicidal thoughts. His first-line assessment was to check her visual fields, which he found to be "quite narrowed as before". He asked her questions relating to the "Milne Score" test and told her she had a vascular illness and needed spinal manipulation performed under anaesthesia.

301 He could not treat her so he referred her to Dr Ieraci at the Fairfield Hospital, to whom he wrote as follows:

"Thank you for seeing Patient DL, who presented this afternoon with serious mental distress...

She has constricted visual fields which, as you know, is the key to her condition. This aspect of brain failure gets better when the spine is manipulated, presumably due to the effect of the treatment on the comfort of the vertebral arteries. Apparently she has a small cerebral tumour which does not require surgery.

In addition she has the dorsal spine syndrome, another spine induced neurological syndrome..."

302 Patient DL then presented At Bankstown Hospital in acute emotional distress, with depression and suicidal thoughts, and underwent an acute mental health assessment.

303 Dr Ieraci was critical of the Respondent's handling of Patient DL in a number of ways (T 637 - 640). She gave evidence that the assessment of visual fields, "because the presence of constricted visual fields indicates that the psychiatric illness is secondary to cerebral vascular hypoperfusion", is not consistent with an orthodox understanding of pathophysiology. Nor is the theory that "this aspect of brain failure" gets better when the spine is manipulated, "presumably due to the effect of the treatment on the comfort of the vertebral arteries". Of greater concern to Dr Ieraci was the possibility that this particular patient's condition may have been worsened by the lack of effective treatment of her depressive illness, given her background of psychiatric illness and use of marijuana, with an expression of suicidal intent. Not to address her psychiatric symptoms was not only inconsistent with orthodox medicine but it was potentially dangerous in a suicidal patient.

304 In Dr Beaumont's opinion, to inform the patient that her disease was vascular, and that the key was her constricted visual fields, which would get better with manipulation, was totally inappropriate, and "actually dangerous".

305 In Dr Jammal's view, the Respondent's treatment of Patient DL was a significant departure from the standard expected of a practitioner of an equivalent level of training and expertise. Given this potentially suicidal patient, the departure invited his strong criticism.

306 The Commission submitted that the evidence demonstrates that the Respondent's treatment of Patient DL was significantly below the appropriate standard. It relies upon the particulars set out in the second Notice of Complaint.

307 Specifically, the Commission says that the Respondent wrongly diagnosed the patient's condition, failed to provide her with appropriate treatment, recommended inappropriate treatment, and failed to adequately assess her mental state.

308 The Commission also submitted that the case of Patient DL further reflects the fact that the Respondent approaches general practice with a presumption that nearly all people have a particular illness connected to the spine or the brain and he fits the diagnosis to meet that presumption or mindset. This creates a risk of failure to either diagnose the root cause or to give effective treatment for the true condition.

309 The Respondent maintains that his treatment of this patient was appropriate. He contends that it was entirely appropriate to tell the patient she had a vascular illness. In his view, the cervical spine syndrome is a very serious illness when it affects the brain and it can make someone want to commit suicide. Her constricted visual fields was hard evidence that her condition was "cerebral vascular" and not intrinsically psychiatric.

310 In his final written submissions the Respondent submitted:

"Patient DL attended me on two occasions some months apart.

It would have been quite inappropriate for me to interfere with Patient DL's treatment other than to respond to her desire for 'a second opinion' and deal with any emergency need, which might be present at the time of each visit to me.

On the first visit to me, I addressed the major deficiency in her treatment; namely the failure to measure her visual fields, by drawing attention to the fact with her primary carer, the Fairfield Public Hospital. Further, because I saw a serious responsibility to do so, I 'whistleblew' this deficiency in her examination to the NSW Department of Health, which controlled the Fairfield Hospital.

On the second visit, I referred her to the Bankstown Hospital for psychiatric assessment and treatment, because such a referral is mandatory in patients who threaten suicide.

Accordingly Dr. Ieraci's complaints about Patient DL's care in my hands were vindictive and based on ulterior motives."

311 The Commission's allegations in respect of Patient DL were clearly made out. The witnesses were critical of the Respondent on each of the matters about which it complains and for the reasons already given, the Tribunal prefers those witnesses to the Respondent.

312 The Tribunal finds that the Respondent wrongly diagnosed the patient's condition, failed to adequately assess her mental state and failed to provide her with appropriate initial treatment. He then suggested inappropriate treatment in his referral letter to the hospital.

313 Accordingly, the Tribunal is satisfied that the Respondent's management and treatment of Patient CC was significantly below the standard expected of a practitioner of an equivalent level of training and experience.

Patient ZZ

314 Patient ZZ was a male patient who was born on 20 April 1968. He first presented to the Respondent on 11 October 2008, then aged 40, complaining of a sore neck and arm pain. He was given a spinal manipulation because the Respondent diagnosed the cervical spine syndrome and presumed the patient had a subluxation in his neck or dorsal spine.

315 The patient was a childhood polio sufferer. He had to get out of his wheelchair to have the spinal manipulation done. More force than usual was required due to a spasm. According to the Respondent's notes:

"It seemed to me that the arm pain could be explained by the neck condition and that treating his neck was the way to go despite the polio disability. Survey done. Spinal treatment done. This was a major effort ... The neck treatment was no fun due to the spasm. The Thoracic lift went well with a lot of disimpactions down his back..."

316 The patient returned the next day with pain and swelling in the wrists, and a high fever. On this occasion the Respondent referred him to Bankstown Hospital, where he was admitted and provisionally diagnosed with either a post infective syndrome or an autoimmune syndrome, causing inflammation of joints. He was put in the care of a specialist rheumatologist who dealt in joints and connective tissue, and remained in hospital for 9 days.

317 Dr Ieraci was highly critical of the Respondent's treatment of Patient ZZ with spinal manipulation.

318 She gave the following evidence:

"Q. What is your concern about the treatment with spinal manipulation - quite apart from the diagnosis but as a risk question, the treatment of someone with a history of polio with spinal manipulation?

A. There are several aspects here. One is that it's noted the patient had difficulty with movement, that patients with polio often have longstanding spasm in the muscles that remain, which would make manipulation require more force which would only increase the risk of neurological injury. The second concern there is that the term "subluxation" in the spine is not a concept that's consistent with orthodox medicine.

Q. What do you say to a view Dr Gorman has expressed, which is that polio is not a contraindication for spinal manipulation? What's your response to that?

A. I would say that in a patient who already has neurological impairment that adding another treatment which can cause further neurological impairment would only heighten the risk."

319 Her concern in relation to treatment with spinal manipulation of a patient with a history of polio was as follows:

"There are several aspects here. One is that it's noted the patient had difficulty with movement, that patients with polio often have longstanding spasm in the muscles that remain, which would make manipulation require more force which would only increase the risk of neurological injury. The second concern there is that the term "subluxation" in the spine is not a concept that's consistent with orthodox medicine."

320 In Dr Jammal's view, the treatment and clinical documentation of Patient ZZ involved significant departures from the standard expected of a practitioner of an equivalent level of training and expertise and invited his strong criticism.

321 The Commission submitted that the evidence demonstrates that the Respondent's treatment of Patient ZZ was significantly below the appropriate standard. It relies upon the particulars set out in the second Notice of Complaint.

322 Specifically, the Commission says that the Respondent wrongly diagnosed the patient's condition, failed to provide him with appropriate treatment, and provided inappropriate treatment. It further alleges he failed to adequately assess the patient's neurological state, or that he failed to adequately document a neurological assessment in the medical record.

323 The Commission also submitted that the case of Patient ZZ further reflects the fact that the Respondent approaches general practice with a presumption that nearly all people have a particular illness connected to the spine or the brain and he fits the diagnosis to meet that presumption or mindset.

324 The Respondent maintains that his treatment of this patient was appropriate. In his final written submissions he said:

"Again Dr. Ieraci complained about this patient; she complained that I manipulated his spine when he was a patient with a history of longstanding paralyses consequent on acute poliomyelitis, which he suffered in childhood decades earlier. Dr. Ieraci provided no evidence of why the spinal manipulation treatment would be dangerous - she spoke purely from conjecture. On the other hand, I have been instructed in spinal manipulation treatment by a meister in the art of spinal manipulation: Dr. Eric Milne, and I have had subsequent experience in the field, which is unrivalled worldwide in duration and extent.

At all times, my approach to the illness of Patient ZZ was professional and careful, as demonstrated by the fact that I sought a second opinion from a colleague: Dr. Umesh Kamkalker, to assist me with his management."

325 The Commission's allegations in respect of Patient ZZ were clearly made out. The witnesses were critical of the Respondent on each of the matters about which it complains and for the reasons already given, the Tribunal prefers those witnesses to the Respondent.

326 The Tribunal finds that the Respondent wrongly diagnosed the patient's condition, failed to provide him with appropriate initial treatment, and provided inappropriate treatment, namely spinal manipulation.

327 The Tribunal also finds that the Respondent failed to adequately assess the patient's neurological state, and that he failed to adequately document a neurological assessment in the medical record.

328 Accordingly, the Tribunal is satisfied that the Respondent's management and treatment of Patient ZZ was significantly below the standard expected of a practitioner of an equivalent level of training and experience.

Patient ST

329 Patient ST was a young female patient who was born on 22 November 1998. She first presented with her mother to the Respondent on 15 January 2006, then aged 7, with recurrent tonsillitis. He proceeded to spinal manipulation. He subsequently administered spinal manipulations on a regular basis over the next year when the patient presented with tonsillitis or high fevers.

330 The justification for the treatment was the Respondent's view that the patient was suffering from the cervical spine syndrome. In his view, her treatment was based on the principles brought forward by the recovery of vision when the spine is manipulated, that is, on his medical philosophy as already discussed. He said the best way of describing her condition was "arthritis" (T 800.40)

331 But Dr Beaumont's evidence was that there is no orthodox evidence to support the idea that spine manipulation is a treatment for recurrent tonsillitis.

332 In Dr Jammal's view, the Respondent's treatment of Patient ST departed significantly from the standard expected of a practitioner of an equivalent level of training and expertise. This departure attracted his strong criticism. In his view, the management of recurrent tonsillitis should involve referral to an Ear Nose and Throat specialist.

333 The Commission submitted that the evidence demonstrates that the Respondent's treatment of Patient ST was significantly below the appropriate standard. It relies upon the particulars set out in the second Notice of Complaint.

334 Specifically, the Commission says that the Respondent wrongly diagnosed the patient's condition, failed to provide her with appropriate treatment, and provided inappropriate treatment. It further alleges that he wrongly failed to refer the patient to an Ear Nose and Throat specialist.

335 The Respondent maintains that his treatment was appropriate, because the patient had some type of syndrome connected to her brain that was causing the repeat attacks of tonsillitis.

336 In his final written submissions, the Respondent pointed to the fact that according to his clinical notes it is completely clear that spinal manipulation treatment of Patient ST was remarkably effective in aborting attacks of acute tonsillitis:

"Patient ST: ...was brought to see me repeatedly by her mother: a very intelligent woman, who appreciated that spinal manipulation treatment aborted attacks of tonsillitis in this child who was prone to them."

337 The written submissions continue in this vein:

" No doubt this phenomenon of resolution of an acute infective illness would be totally incredible to the Tribunal had they not critically contemplated the remarkable temperature graph of Patient JEK who recovered in similar circumstances, (over a mere couple of hours), from acute pneumonia.... The case history of ST is very instructive, probably best demonstrated graphically as in the experience of Patient JEK.

Add to this, the evidence brought to the Tribunal's attention by my witness: Mr. Sullivan, in regard to the remarkable results recorded in the chiropractic treatment of the 'Spanish Flu' in 1917; chiropractic treatment was measurably better for that illness than the orthodox medical treatment, which was available in that era...

The HCCC complains that the treatment of acute infections by spinal manipulation is not recognised by my peers of good repute: the usual way of assessing inferior, medical practice. Needless to say, such a gauge of competency is not fair to practitioners with valid, dissenting philosophies based on scientific evidence.

Fortunately, this Tribunal does not need to accept 'recognition by peers of good repute' as the be all and end all in judgment of competence, because it has seen for itself the remarkable recoveries as a result of treatments which are not practised by these 'peers of good repute'.

At my instigation, the mother of Patient ST complained to the health care authorities that her daughter had previously received incompetent treatment at the hands of orthodox medical practitioners. Her complaint was not dealt with appropriately - she was another whistleblower, who blew in the wind, for all the attention that was paid to her concerns for her daughter and other children in similar situations of febrile illnesses."

338 The Respondent sets out in his written submissions a graph that was not in evidence, but which he says was constructed from the clinical notes. In his submission the graph demonstrates that not only did spinal manipulation result in rapid resolution of the attack of tonsillitis, but continued spinal manipulation treatment removed the 'root cause':

"...not only were the attacks of tonsillitis greatly reduced in frequency, but there are also other neurological improvements. For instance, after some months of treatment, Patient ST had improved from the lowest reading class to the top class."

339 The written submissions then conclude:

"There would be sympathy for sceptical persons, who have not had, like the Tribunal, intensive instruction in the recovery of vision with spinal manipulation (the multiple demonstrations in the video films provided); in the recovery from gaze abnormalities (Fred, Anthony and Corey in their respective video films); in the recovery from neuropathies of the arms (as seen in the '60 minutes' video film); and the dramatic recovery from a febrile illness as has been graphed in the case of Patient JEK.

Such scepticism could not be entertained in the case of the Tribunal, which has been bombarded with evidence that, what happened to Patient ST was to be expected on the basis of the photographic evidence which had been presented."

340 The Commission's allegations in respect of Patient ST, however, were clearly made out. The witnesses were critical of the Respondent on each of the matters about which it complains and for the reasons already given, the Tribunal prefers those witnesses to the Respondent.

341 The Tribunal has already rejected the Respondent's proposition that the graphs relating to Patient JEK were probative of his theories.

342 For the same reasons, the Tribunal rejects the proposition that the graph set out in his written submissions is probative of his theory that spinal manipulation is an appropriate treatment for recurrent tonsillitis.

343 The Tribunal finds that the Respondent wrongly diagnosed the patient's condition as cervical spine syndrome, failed to provide her with appropriate treatment, and provided inappropriate treatment, namely spinal manipulation.

344 The Tribunal also finds that the Respondent should have referred the patient to an Ear Nose and Throat specialist.

345 Accordingly, the Tribunal is satisfied that the Respondent's management and treatment of Patient ST was significantly below the standard expected of a practitioner of an equivalent level of training and experience.

Patient AT

346 Patient AT was a young male patient who was born on 24 December 2004. The child had been diagnosed as having developmental delay and autism. He was taken to see the Respondent by his parents in 2006, at the age of 5. The father had himself been treated previously by the Respondent for sleeping problems. The Respondent recommended spinal manipulation for the child:

"As usual I recommended spinal manipulation as the logic is so good and the treatment is easy and inexpensive."

347 The Respondent then proceeded to treat the child with spinal manipulation for his autism on a regular basis, as forcefully as possible. He was not easy to treat and the spinal manipulations often proved physically difficult, such that he often had to be held down and restrained (T 194.46).

348 Dr Jammal's report notes that the management of autism is multidisciplinary and complex and requires input from specialists. What was ultimately necessary was referral to a paediatrician.

349 The Respondent, however, actively sought to dissuade the parents of Patient AT from spending money on "high powered behavioural treatment", because, according to him, "the mental improvement must come from the inside".

350 He showed the parents diagrams of the spinal cord, which according to the father looked scientific such that he thought that the information the Respondent was giving him was "scientific proof", convincing him that spinal manipulation would be a good treatment.

351 Dr Beaumont did not consider that this was sufficient to enable the parents to give informed consent (T 479.36):

"...the patient has to be given what is an evidence base. They've got to be told "Look, there are studies" or "There are no studies", "I've done ten patients with autism and" - you know - "five out of ten have improved. It's not published in the literature. This is how I think it should be done." That would be informed consent. But to go in and say "Now, look, this is the disease and here's the mechanism" and show little diagrams of vessel spasming and things like that when there's no evidence for it, then that is misinformed consent. So I don't know what happened there but it's quite clear that if you were shown diagrams and it wasn't couched in the fact that "This is how I think it works and there's no evidence for it", then it would be misinformation."

352 Dr Beaumont went on to say that the parents of an autistic child are a particularly vulnerable group and that informed consent is particularly sensitive because they are so vulnerable (T 479.36).

353 Professor Bonello said that sometimes manipulation is used by some chiropractors to treat autism, but only where a mechanical cause of the problem is found. There is no evidence that Patient AT had a type of mechanical problem. The Respondent was not treating the patient for a mechanical problem. In his view, the patient would respond to manipulation because "he had a problem with his brain".

354 In Dr Jammal's view, the Respondent's treatment of Patient AT was a significant departure from the standard expected of a practitioner of an equivalent level of training and expertise. He said:

"As there is no documented proof that spinal manipulation is in any way helpful to children with autism, such treatment by Dr Gorman of this patient is somewhat disturbing, especially given that the child had to be restrained on occasions. In my opinion, this is a significant departure of the standard expected of a practitioner of the equivalent level of training and experience. This invites my strong criticism."

355 The Commission submitted that the evidence demonstrates that the Respondent's treatment of Patient AT was significantly below the appropriate standard. It relies upon the particulars set out in the second Notice of Complaint.

356 Specifically, the Commission says that the Respondent provided inappropriate treatment and failed to provide appropriate treatment. It also alleges that he failed to provide the parents with sufficient information to consent to the treatment of Patient AT with spinal manipulation.

357 The Respondent maintains that his treatment of Patient AT was appropriate and effective. He pointed to evidence from the father to the effect that the child's sleep pattern was greatly improved by the spinal manipulation treatment, and that since it has ceased, he has retrogressed in his every day performance.

358 The Respondent's final written submissions conclude:

"In terms of the life of Patient AT in the future, the casual way in which the 2009 Tribunal ignored his plight was an abomination in terms of compassion and fairness to both him and his parents - this is to say nothing of other autistic children and their parents, who could have greatly benefited from the path-finding element of the treatment."

359 The Commission's allegations in respect of Patient AT were clearly made out. The witnesses were critical of the Respondent on each of the matters about which it complains and for the reasons already given, the Tribunal prefers those witnesses to the Respondent.

360 The Tribunal finds that the Respondent provided Patient AT with inappropriate treatment, namely spinal manipulation.

361 The Tribunal also finds that the Respondent failed to provide the parents with sufficient information to consent to the treatment of Patient AT with spinal manipulation.

362 Accordingly, the Tribunal is satisfied that the Respondent's management and treatment of Patient AT was significantly below the standard expected of a practitioner of an equivalent level of training and experience.

Patient RP

363 Patient RP was a male patient who was born on19 January 1983 who was brought in to see the Respondent by his mother on 24 May 2008, when he was aged 25. The patient had a history of developmental delay, with depression and suicidal tendencies. The mother, who had herself previously been treated by the Respondent with spinal manipulation, brought the patient to see him to obtain a disability entitlement.

364 The Respondent noted that the patient had a "long story of brain problems" and had him complete the "Milne score" survey, from which he diagnosed the patient with the cervical spine syndrome. He told Patient RP that spinal manipulation would help his condition (T 203):

"I do remember he did explain that there was a blockage in my - in me? (My) vertebral artery was blocked and he said he needed to treat my back. Like to untwist my vertebral artery so it gets untwisted and my brain can get more blood into it... he said I was really intelligent and he was going to fix - make me better and I believed him because I felt I was getting better and - and - and I did. Well, compared to what I was before."

365 He then proceeded to treat Patient RP with spinal manipulations on a weekly basis up until November 2008, when he was suspended. He prepared a care plan for him that listed the chronic condition as "arthritis".

366 The patient subsequently went to see another chiropractor who refused to give him the same treatment that the Respondent had given him.

367 Dr Jammal was critical of the Respondent's treatment of Patient RP:

"Notwithstanding the fact that the patient seemed to support Dr Gorman's treatment, the treatment provided does not conform with any known treatment guidelines for this patient's medical problems. He required a multidisciplinary team approach to his problems."

368 The Commission complains that not only did the Respondent fail to give Patient RP appropriate treatment for his developmental delay and depression, he actively sought to dissuade him from seeking out, and was critical of, appropriate treatment (such as anti-depressants given by another health practitioner). The Respondent, however, considered that sending this patient to a psychologist would have been a waste of time and money (T 817.33ff).

369 The Commission also submitted that the issue of informed consent is of particular concern in the case of a patient with developmental delay and depression. According to Dr Beaumont Patient RP was a vulnerable patient in which case informed consent was a very serious and difficult issue.

370 The Respondent did not consider this patient vulnerable. But the patient himself said that he trusted the Respondent and he gave him hope (T 206.31):

"Because I didn't have any friends at the time, and he always gave me good advice and that - that I - that I was going to get better."

371 The Respondent showed the patient some diagrams that he said demonstrated that the brain was being suffocated from the lack of blood flow, causing it to shut down. But he failed to give the patient any information about the risks associated with spinal manipulation, particularly the forceful method he employed, which the chiropractor refused. Nor did he explain that there were any other forms of treatment that might be helpful to the patient.

372 Dr Jammal expressed the view that the Respondent did not give the patient enough information that would enable him to reach an informed decision, either as to the treatment he provided, or as to available conventional treatment, and may have misled him into believing that the Respondent's view on his condition was "widespread conventional knowledge".

373 The Respondent, however, seems to believe that informed consent is unimportant, and that the end justifies the means: (T 820.55ff):

"...it's silly to be fumbling around, worrying about whether he got consent, when there has been such a good result...".

374 In Dr Jammal's opinion, the Respondent's overall management of this patient departed significantly from the standard expected of a practitioner of equivalent level of training and experience. Given this patient's developmental delay, as well as the issue of lack of informed consent this departure from the standard invited his strong criticism.

375 Dr Beaumont's opinion was that there is no evidence that he knows of that an appropriate treatment for this patient's condition would be spinal manipulation.

376 The Commission submitted that the evidence demonstrates that the Respondent's treatment of Patient RP was significantly below the appropriate standard. It relies upon the particulars set out in the second Notice of Complaint.

377 Specifically, the Commission says that the Respondent provided inappropriate treatment and failed to provide appropriate treatment. It also alleges that he failed to provide the patient with sufficient information to enable him to consent to the treatment.

378 The Commission goes on to submit that the case of Patient RP demonstrates the Respondent's inability to give impartial advice and the risk he poses to patients of misdiagnosis, through misplaced trust. It pointed to evidence given by the patient of attempts to self-manipulate after the Respondent was suspended, because he could not find a chiropractor who would treat him in the same way as the Respondent had. The patient demonstrated the technique of self manipulation during the course of giving evidence, which he described as follows T 208.15ff):

"Q. So you would pull your head to one side?

A. I'd jerk it, but then I twist it at the same time. But I did it really softly and just a really fast jerk. I stopped doing it because I - I just don't want to get arthritis or - or something..."

379 Asked why he had manipulated his own neck at home, he said he felt like he had been robbed of his health (T 211.32):

"Q. Why did you feel you had been robbed of your health?

A. Because he...was the only person I knew that was helping me...and - and I had no - I still don't know who - who can help do what he did to me, so I felt as though it was - I felt I couldn't do anything, I had to try and do something."

380 Dr Beaumont was asked for his reaction:

"Q. What about if because he has had that diagnosis and he has been told that's what he needs when he can't get access to spinal manipulation, he's trying to manipulate his own neck at home?

A. I'd think that's very sad.

Q. It's also dangerous, isn't it?

A. Yes, I would think so. I - no, I don't know if it's dangerous because there's no evidence base for that, but, you know, it's really quite inappropriate when you have no evidence base for a treatment - a patient to be trying to self-treat with manipulation. It sounds absolutely bizarre. Dreadful."

381 The Respondent disagrees. He believes that Patient RP was actually doing the sensible thing, and posed no risk (T 819.09).

382 The Respondent seeks to justify his treatment of Patient RP on the basis that the Patient expressed the view he was much better for the first time in his life as a result of the spinal manipulation therapy. According to the Respondent, the therapy was appropriate because it was consistent with the principles brought forward by him pursuant to his discovery as to the recovery of vision in appropriate patients when the spine is manipulated (T 542.15).

383 The Commission's allegations in respect of Patient RP were clearly made out. The witnesses were critical of the Respondent on each of the matters about which it complains and for the reasons already given, the Tribunal prefers those witnesses to the Respondent.

384 The Tribunal finds that the Respondent provided Patient RP with inappropriate treatment, namely spinal manipulation, and failed to provide him with appropriate treatment.

385 The Tribunal also finds that the Respondent failed to provide him with sufficient information to give informed consent to spinal manipulation.

386 Accordingly, the Tribunal is satisfied that the Respondent's management and treatment of Patient RP was significantly below the standard expected of a practitioner of an equivalent level of training and experience.

The Respondent's submissions

387 The Respondent relies upon his medical philosophy to justify his conduct.

"There is no evidence that...my dissenting philosophy and practice has been proven to be incorrect or even misguided."

388 He submitted that his style of medical practice is economical, panoramic in philosophy, effective and safe. Hence, no patient came to any harm as a result of his treatment, apart from Patient CR, and the majority of his patients were satisfied with his treatment.

389 He submitted that the Tribunal should find that his medical actions do not warrant the criticisms of unsatisfactory professional conduct or professional misconduct. It should remove all conditions and return him to full medical practice with a record unblemished by any criticisms.

390 The Respondent contends that his spinal manipulation treatment is scientifically based. In comparison, orthodox medical practice is inordinately expensive, generally palliative, restrictive in philosophy and often dangerous. Once orthodox medical practice leaves the parameters of trauma, resuscitation, complicated obstetrics, pain relief and public health, it is incompetent and incomplete. The witnesses who criticised his medical behaviour, like most medical practitioners, are ignorant of the basic principles of neurovascular medicine. The Commission's case is based on ignorance:

"I submit that it was based on ignorance - this inference is based on the ignorance, as demonstrated by the HCCC's so-called, "expert witnesses"', of the recovery of vision with spinal manipulation, Interictal Migraine, the Ischemic Penumbra State and Watershed Infarction.

391 He criticised the Commission for the complaints made against him:

"I believe that, what the Health Care Complaints Commission wished to demonstrate, was that I had not enunciated the benefits of pharmacological (drug) medicine and surgical medicine.

If effective in producing a valid criticism of my medical practice, this ploy will have demonstrated the bias of the Tribunal - the Tribunal will have been shown to be the sycophant of 'Orthodox Medicine', which the medical practitioner, panel members had formally disavowed in their personal cases."

392 The Respondent defended his conduct in respect of the criticism that he failed to obtain informed consent for his spinal manipulation treatment. Firstly, he submitted that the patients were not denied information on which they could give informed consent. Second, he submitted that it was not necessary for his patients to be instructed in the mores of health care in Australia in order to give informed consent to his treatment.

393 His final written submissions continue:

"As a subheading, was my decision: not to canvass other forms of treatment with the patient, a medical crime at all; and if it were a crime, is it a crime, which warrants the penalty of suspension or deregistration?

In this regard, 'omission of discussion' of which available, alternative (meaning other) treatments, made the omission so offensive, such that the omission warrants suspension or deregistration?"

394 He went on to discuss this issue in terms of the placebo effect:

"This is not to say that I would not have fully discussed the advantages and disadvantages of any of the above forms of therapy, with any patient who sought such a discussion.

A main reason for not raising alternatives therapies to replace my projected therapy is the nullification of the 'placebo response'. Essentially this means that the more committed that the practitioner is to the therapy, which is recommended, the more likely that it will be successful. The placebo effect is a very powerful therapeutic tool, which requires an aura of confidence in the therapy, which is being promoted, to be exuded by the practitioner who seeks to add 'the placebo effect' into the therapeutic mix.

Adding 'the placebo effect' to a therapy such as spinal manipulation, which has scientific merit in its own right, is an advantageous 'double whammy' in healing the patient, such that it should not be neglected.

The criticism of such sentiments is that a practitioner might persist with the invocation of the placebo effect for too long, leading to denial of the patient to more effective therapy from other therapeutic modalities as outlined above.

For such a criticism to be justly applied in my case, the Health Care Complaints Commission must specify that such damage to patients had occurred - it is not enough to insinuate that it might occur.

This is a particularly obligatory, legal factor in considering my case, given my level of general medical education based on a lifelong connection with medical practice, my personality in terms of apprehension of error and medical misadventure, and my post graduate training."

395 The Respondent contends that he is an extraordinary whistleblower. He submitted:

" In this Tribunal hearing, the Respondent has brought to the fore allegations of medical corruption in Australia, which have injured countless millions of persons worldwide.

The main focus of the corruption was the decision of the then executive of the Royal Australian and New Zealand College of Ophthalmologists to 'bury' the recovery of vision, which occurs when the spine was manipulated in appropriate patients. 'Appropriate patients', are patients who have a correctable form of vision loss.

Unfortunately for Australia's reputation as a first world country of impeccable dedication to human rights and democracy, this fraud has continued to the present day, coming to a focus when I 'whistleblew' the malevolent process worldwide in my book : 'The Great Australian Medical Scientific Fraud'... With the publication of this book, the fraud is out in the open - in full view of other nations. Australia must now make corrective measures to right the wrong to patients and to regain its reputation for integrity after more than three decades of pursuit of the Respondent in the medical regulatory system, which, in part, had been frustrated by the wisdom of Judge Bell in the Medical Tribunal in 1989; and by the NSW Supreme Court of Appeal in later decisions.

What must Australia do to regain its reputation?

Further turning of a 'blind eye' to the whistleblowing as foreshadowed in this Tribunal by a completely incredible, judicial refusal to acknowledge that the Respondent was a whistleblower on legal grounds, certainly will not lift Australia's reputation - it did not augur that the Tribunal would take seriously its responsibilities to citizens of Australia and to those of other countries worldwide.

It was completely immaterial whether the said whistleblowing reflected the reality, or, alternatively, was misapprehension on my part... Australia must search out the truth of the matter: namely, does vision improve in appropriate patients when the spine is manipulated by the technique of Dr Eric Milne?

Further turning of a 'blind eye' to the whistleblowing as foreshadowed in this Tribunal by a completely incredible, judicial refusal to acknowledge that the respondent was a whistleblower on legal grounds, certainly will not lift Australia's reputation - it did not augur that the Tribunal would take seriously its responsibilities to citizens of Australia and to those of other countries worldwide.

It was completely immaterial whether the said whistleblowing reflected the reality, or, alternatively, was misapprehension on my part - in fairness to those entities, which have possibly been detrimentally affected, and might be affected in the future, not only in Australia but worldwide, Australia must search out the truth of the matter: namely, does vision improve in appropriate patients when the spine is manipulated by the technique of Dr Eric Milne?

Australia has to go back to the categorical demonstration of the phenomenon in the 'Dangerous Twist', 60 Minutes television segment which 'went to air' on the 22 nd of June 1986...

This process must start in this Medical Tribunal; otherwise it is unlikely to start at all - to the progressive worsening of Australia's reputation for fair play as the years pass...

Such a course will require courage and pragmatism by the Tribunal Panel, because it will be intensely resented by the NSW Medical Council and the Health Care Complaints Commission, which, for some unexplainable reason, have joined as a disreputable duo, to put the agenda of orthodox medicine far ahead of their duty to the community."

396 The Respondent placed significant reliance upon the asserted cost effectiveness of his treatment. He called as a witness Mr Jim Sullivan to give evidence concerning "the totally unsustainable cost of ambient health care". Mr Sullivan is the Chairman of the Rural Branch of the Liberal Country Party in the Northern Territory and a member of the Board of Katherine Hospital: see Exhibit 8.

397 The Respondent summarised the important features of Mr Sullivan's evidence upon which he relies as follows:

" Mr Sullivan provided a graph from the Congressional Budget Office of the United States Government which depicted that overall health care expenditure in that country would reach 99% of that country's gross national product by 2082, if the cost of health care kept rising at the present rate of rise.

Mr Sullivan provided a solution in his 'Innovations Clinic', which he aspired to trial at the Katherine Hospital, where he is a Member of the Board. Mr Sullivan testified that the theme of the 'Innovations Clinic' was to be the medical philosophy as espoused by Dr Gorman but not limited to that style of treatment. He advocated wider choice for patients: access to other forms of health care, such as, for instance, acupuncture and naturopathy, if only to apply the 'placebo effect', which is known to be very effective.

Mr Sullivan described the dire situation of patients waiting for specialist consultation at Katherine Hospital and lamented that many would never consult the specialist whose care had been projected. He intimated that benefit could be obtained by approaching their problems by an alternative route: by giving patients access to alternative health care philosophies."

398 Accordingly, submitted the Respondent:

" Mr Sullivan's testimony makes the point that serious ramifications for patients, who attend the Katherine Hospital, will follow if the HCCC's recommendations in regards to Dr Gorman are adopted."

399 The Respondent also relied upon evidence from Mr Sullivan in connection with the issue of informed consent, and to suggest that the Commission seeks to ask the Tribunal to apply a double standard in respect of the requirements for informed consent:

" Mr Sullivan gave evidence concerning informed consent based on his experiences as a parent of five children and his own personal experience. In the latter experience, he described how he nearly bled to death after taking anti-inflammatory medications prescribed by a medical practitioner who did not warn him of potential, life-threatening, gastro-intestinal haemorrhage. As a result, when be became weak and sick within a day or so after commencing the medication, he lay in bed all day not knowing what was wrong with him. Thus, his medical management was delayed; this precarious situation could have been avoided had he been warned of possible haemorrhagic complications, when the tablets were ordered.

From his experience in taking his children to the doctor, Mr Sullivan expressed the opinion that medical practitioners generally did not seek to gain informed consent to the prescription of medications by describing the dangers inherent to their use. Mr Sullivan suggested that a double standard of informed consent was applied in Dr Gorman's case."

400 Accordingly, submitted the Respondent:

" In terms of informed consent, much more is expected of Dr Gorman compared with that expected of other medical practitioners - a double standard is being applied, which is inappropriate; it reflects badly on the District Court of New South Wales."

401 Finally, the Respondent submitted that the Tribunal should accept his evidence, and his medical philosophy, which has been suppressed, and reject the medical opinion of his peers of good repute as fundamentally unsound:

" The HCCC's submissions arrogantly presume that the bias of the Medical Tribunal will favour so-called 'Orthodox Medical Practice'...

... the removal and burial of the significant evidence that vision improves in appropriate patients when the spine is manipulated, has converted the world of health care into 'Fantasy Land'.

The 'Fantasy Land' of health care is a place where the solid buttresses of reality have been removed: a place of virtual reality where there are no penalties for error...

... competence to be judged by the opinion of peers of good repute, is only reasonable if the said 'opinion' is fundamentally sound.

Obviously, it is the last of these incongruous perceptions which is pertinent to this case - the opinion of my peers of good repute is fundamentally unsound because, for more than thirty years, they have been denied cogitation of critical scientific information by medical academics in Australia, in particular those of the Royal Australian and New Zealand College of Ophthalmologists."

Findings in relation to conduct

402 For all the reasons set out above, the Tribunal makes the following findings in respect of the complaints brought against the Respondent in the first Notice of Complaint and the second Notice of Complaint arising out of his treatment of the patients concerned, in accordance with the findings made in respect of each and all of the patients.

403 In respect of Complaint 1.1, the Tribunal is satisfied that the Commission has proved to the requisite standard of proof that the Respondent has engaged in:

(a) unsatisfactory professional conduct within the meaning of section 36 of the Medical Practice Act 1992 ; and

(b) professional misconduct within the meaning of section 37 of the Medical Practice Act 1992 .

in that he has demonstrated that the knowledge, skill or judgment possessed, or care exercised, by him in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience and he contravened the relevant Medical Practice Regulation .

404 In respect of Complaint 2.1, the Tribunal is satisfied that the Commission has proved to the requisite standard of proof that the Respondent has been guilty of unsatisfactory professional conduct within the meaning of section 139B of the National Law in that he has demonstrated that the knowledge, skill or judgment possessed, or care exercised, by him in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience and he contravened the relevant Medical Practice Regulation .

405 In respect of Complaint 2.2, the Tribunal is satisfied that the Commission has proved to the requisite standard of proof that the Respondent has been guilty of professional misconduct within the meaning of section 139E of the National Law in that he has:

(a) engaged in unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of his registration; and

(b) has engaged in unsatisfactory professional conduct on a number of occasions which, when considered together, amount to conduct of a sufficiently serious nature to justify suspension or cancellation of his registration.

Findings in relation to competence

406 The Commission is satisfied that the Respondent has rigid and firmly-held views in relation to medical practice arising from his medical philosophy, as discussed. These views relate to and include his theory that there is a ubiquitous illness affecting all of mankind that can be treated by the very simple and safe treatment of spinal manipulation, for which illness he has used other interchangeable names including whiplash, spinal arthritis, the cervical syndrome, spine-induced neurological syndrome and interictal migraine. This ubiquitous illness manifests itself in multiple different conditions as already discussed. His views include the proposition that spinal manipulation should be used as a firstline treatment for a wide range of conditions that present in general practice. Virtually all pathologies can be challenged by spinal manipulation before recourse is had to orthodox treatment, such that the majority of patients who walk in the door of a general practice is likely to respond beneficially to spinal manipulation, due to the fact that the ubiquitous illness that affects all of mankind.

407 Thus, the Respondent has rigid and firmly-held held views that nearly every illness, whatever it is will be better after spinal manipulation, such that it is virtually always appropriate. He holds the accepted principles and framework of general practice in disdain, and considers that general practitioners practising in accordance with accepted general practice are the lowest common denominator, conducting inferior practices.

408 The Tribunal is further satisfied that the Respondent would be unlikely to talk to patients about treatments other than spinal manipulation because he does not see any point in advising patients to have inferior treatments; and, that on being instructed in the philosophy of spine-induced neurological syndromes by the Respondent, most patients would proceed to have spinal manipulation performed by him. He is inflexible. His spinal manipulation technique has not been adapted in 30 years, and he rejects out of hand any modification to it, or any supervision.

409 These concerns are amply demonstrated in the findings set out above in respect of the patients.

410 In particular, the Tribunal is satisfied that in the examples discussed, the Respondent not only did not obtain informed consent, rather he obtained what Dr Beaumont described as "misinformed consent".

411 The Tribunal is also concerned by the numerous examples of a lack of insight displayed by the Respondent and the attitude aptly described by the Commission as "grandiosity". Of particular concern is his disdain for conventional medical practice, his peers, the rules, and indeed, the law. These elements were displayed in the case of Patient CR, and the episode in which he involved his neighbour, who he improperly taught his manipulation technique, knowing he was not legally permitted to perform cervical spine manipulations. His care plans, in which he described the chronic illness as "arthritis", but rarely expressly articulated the treatment as spinal manipulation, also involved a factitious element.

412 His rigidity also inhibits the Respondent's ability to take on new information. His fixed belief that others are responsible for the failure of the promulgation of his medical philosophy is an example of his firmly-held views. Dr Beaumont repeatedly pointed out to the Respondent in his evidence what was required for the validation and acceptance of his medical philosophy by the wider profession, but he stubbornly refused to accept the reality of the situation, choosing instead to assert it was for others to disprove his theory.

413 A further concern for the Tribunal is the Respondent's dismissive attitude to the risks associated with his technique of spinal manipulation. Contrary to the Respondent's asserted position that the therapy is safe, which he seems to base on the historical basis of an absence of problems to date, for the reasons already discussed, the Tribunal is satisfied that the technique of spinal manipulation employed is inherently and unpredictably risky, to a substantial degree, in the ways described in detail above by the experts, particularly his spurning of the contra-indicators employed by conventional manipulative therapists.

414 The Tribunal finds that the risk associated with the Respondent's method of spinal manipulation is not supported by currently accepted standards, particularly in the case of vulnerable patients, such that express, careful and precise information would be required to be given to patients in the manner and with the content described by the experts, as set out above.

415 For these reasons, the Tribunal is, therefore, satisfied that the Commission has proved to the requisite standard of proof that as a result of the Respondent's rigid and firmly-held views there is a real risk that he:

[1] will fail to correctly diagnose a patient's medical condition, and

[2] is unlikely to give impartial advice to patients to enable them to give informed consent.

416 Having regard to its findings in respect of the patients, individually and collectively, and the risks associated with and arising out of Respondent's rigid and firmly-held views, as discussed, the Tribunal finds that the Commission has clearly made out its allegations in Complaint 2.3.

417 In respect of Complaint 2.3, therefore, the Tribunal is satisfied that the Commission has proved to the requisite standard of proof that the Respondent is not competent to practise medicine within the meaning of section 139 of the National Law in that he does not have sufficient physical capacity, mental capacity, knowledge and/or skill to practise medicine.

Disposition

418 The Commission seeks a de-registration order and a prohibition order. It also seeks orders that the Respondent be prevented from making an application for review of the Tribunal's orders until after a period of 3 to 5 years.

419 The Tribunal has determined that the Respondent's conduct amounted to unsatisfactory professional conduct and professional misconduct, and that he does not have sufficient physical capacity, mental capacity, knowledge and/or skill to practise medicine.

420 The Tribunal exercises its jurisdiction for the protection of the public and of the medical profession. Deregistration may be required in serious cases of misconduct in order to adequately achieve those objectives by minimising the risk of recurrence, by deterring other practitioners from engaging in such conduct, and by maintaining public confidence in the profession.

421 This jurisdiction is protective rather than punitive. The discretion of the Tribunal is at large and depends upon the circumstances of the individual case: HCCC v Karalasingham [2007] NSWCA 267 at [67].

422 Having regard to the totality of the Respondent's conduct, and its cumulative effect, in particular his rigid and deeply-held views and his disdain for conventional general practice, the Tribunal is deeply concerned as to the serious nature of Respondent's misconduct, and as to the risk of recurrent misconduct, including the improper administration of drugs of addiction. As the Commission submitted, the Respondent has effectively "checked out of general practice." The Tribunal therefore considers that the only appropriate order is for the deregistration of the Respondent with a significant period restricting his ability to make an application for restoration of his name to the Register.

423 The Respondent's name should be removed from Register. The Tribunal considers that a period of 3 years restricting him from applying for restoration of his name to the Register is appropriate.

Prohibition order

424 In addition to deregistration and cancellation of registration, the Commission seeks a Prohibition Order under s 64(2A) of the Medical Practice Act 1992 and/or s 149(C)(5) of the National Law . The terms of the order sought are as follows:

"That the Respondent is prohibited from providing the following health services:

(a) performing spinal manipulation;

(b) educating (including instructing or supervising) other persons in the performing of spinal manipulation,

until at least such time as the Respondent is re-registered as a medical practitioner by the Medical Tribunal.

425 Not unexpectedly, the Respondent rigorously opposes the making of any such order.

426 The pre-conditions to the making of such an order are that there have been findings of professional misconduct and incompetence for practice. The Tribunal must also be satisfied that there is a "substantial" risk to the health of the members of the public. The Tribunal has already made sufficient findings to satisfy these pre-conditions. The issue for determination is whether it should make such an order.

427 The Commission submitted that a probation order should be made, principally due to the risk that the Respondent:

(a) will offer spinal manipulation services in an allied health or other context; and

(b) will teach others how to carry out his spinal manipulation technique.

428 It points to the evidence that the Respondent has previously indicated a wish to do manipulations as a naturopath (if he were prevented from doing so by suspension) (T 704.37); and that he has already instructed his neighbour in his spinal manipulation technique and thus encouraged his neighbour to break the law. It also points to the fact that the method the Respondent adopts in carrying out spinal manipulations falls well below the standard adopted by practitioners who do use spinal manipulation as a treatment for particular conditions; namely, the standards of chiropractors, musculoskeletal physicians and physiotherapists.

429 The Tribunal is concerned about the width of the orders proposed.

430 Firstly, it does not see the justification for preventing the Respondent from continuing to advocate his theory.

431 Second, in the light of his deregistration, it does not see a necessity for a blanket prohibition against the Respondent from performing spinal manipulation.

432 Contrary to the Commission's submission, the Tribunal considers that the prohibition under s 123 of the National Law provides sufficient protection of the public. The section provides that a person must not perform manipulation of the cervical spine unless the person is registered in an appropriate health profession. That means a medical practitioner, a chiropractor, an osteopath or a physiotherapist.

433 Accordingly, the Respondent will be precluded, by law, from performing cervical manipulations. Otherwise, as a deregistered practitioner, the risk associated with the Respondent performing other forms of manipulation is minimal. The Tribunal is concerned not to place the Respondent in a worse position than any other citizen, or to prohibit the Respondent from advocating his theory in a controlled environment, such as Mr Sullivan's vision for an 'Innovations Clinic' at the Katherine Hospital. Obviously, in such a situation, the Respondent, as a de-registered practitioner, would undoubtedly be required to operate under controlled and supervised circumstances, including strict requirements for the full and genuine provision of information sufficient to satisfy the requirements for true informed consent to be provided.

434 For these reasons, the Tribunal is not persuaded that it should exercise its discretion to make a prohibition order.

Costs

435 The usual order in respect of Medical Tribunal proceedings is that costs follow the event: Ohn v Walton (1995) 36 NSWLR 77 at 79; Lucire v Health Care Complaints Commission (No 2) [2011] NSWCA 182 at [48]. The Commission has succeeded on the substantive complaints and in the interlocutory applications. The power to award costs is, however, discretionary. But there is nothing in the present matter that militates against the making of the usual order.

Orders

436 The Tribunal orders that:

(1) The Respondent is to be deregistered under s 64(1) of the Medical Practice Act 1992 .

(2) The Respondent's registration is to be cancelled under 149C(1) of the National Law .

(3) The Respondent is prevented from making an application for review of the Tribunal's orders for a period of three years from the date of the orders.

(4) The Respondent is to pay the costs of the Commission in respect of the proceedings arising as a result of the two Notices of Complaint, including the interlocutory applications.

(5) The Medical Board of Australia is to effect the necessary administrative action to implement these orders.

437 Tribunal also made non-publication orders in respect of the names of the patients referred to in these proceedings.

Decision last updated: 22 August 2011