Health Care Complaints Commission v Golowenko

Civil and Administrative Tribunal New South Wales Amendment notes Medium Neutral Citation: Health Care Complaints Commission v Golowenko [2025] NSWCATOD 139 Hearing dates: 10 - 11 March 2025 Date of orders: 16 October 2025 Decision date: 16 October 2025 Jurisdiction: Occupational Division Before: Acting Judge Levy SC, Principal Member Dr G Yeo, Senior Member Dr M Walker, Senior Member S Lovrovich, General Member Decision: (1) Pursuant to s 64(1)(a) of the Civil and Administrative Tribunal Act 2013 (NSW), and clause 7 of Schedule 5D of the Health Practitioner Regulation National Law (NSW) 2009 (National Law), the disclosure to any person or entity of the name and the address of the person referred to as Patient A in the Schedule to the amended complaint and prohibition of the disclosure of the names of the persons who made notifications to the regulator is prohibited. For the avoidance of doubt this order does not preclude the disclosure or publication of the name of the respondent. (2) Pursuant to s 149C(1)(b) of the National Law, the medical registration of the respondent, Dr Alexander Robert Golowenko is cancelled, with a non-review period set at six months from today’s date. (3) Order (2) above is to take effect from the close of business hours on the 7th day following publication of these reasons. (4) Pursuant to s 175B of the National Law and clause 13 of Schedule 5D of

the National Law, the respondent must pay the costs of the Health Care Complaints Commission as agreed or assessed. Catchwords: OCCUPATIONS – medical practitioners – admitted allegations of unsatisfactory professional conduct and professional misconduct – boundary violation by general practitioner with vulnerable female patient – appropriate protective orders having due regard to the evidence – order for cancellation - non-review period of 6 months Legislation Cited: Civil and Administrative Tribunal Act 2013 (NSW), s 64(1)(a) Health Practitioner Regulation National Law (NSW) 2009, s 3A, s 3B, s 40, s 139B, s 139E, s 150, s 149C(1)(b), s 175B Health Practitioner (NSW) Regulation 2016, Schedule 4, s 2 Cases Cited: Briginshaw v Briginshaw (1938) 60 CLR 336 Bronze Wing International Pty Ltd v SafeWork NSW [2017] NSWCA 41 Chen v Health Care Complaints Commission [2017] NSWCA 186 Dawson v Law Society of NSW [1989] NSWCA 58 Director General, Department of Ageing, Disability and Home Care v Lambert [2009] NSWCA 102 Health Care Complaints Commission v Buys [2020] NSWCATOD 102 Health Care Complaints Commission v Do [2014] NSWCA 307 Health Care Complaints Commission v King [2013] NSWMT 9 Health Care Complaints Commission v Litchfield [1997] NSWSC 297; (1997) NSWLR 630 Health Care Complaints Commission v Schmaman [2019] NSWCATOD 82 House v The King [1936] HCA 40; (1936) 55 CLR 499 Lee v

Health Care Complaints Commission [2012] NSWCA 80 Kruger v The Commonwealth (1997) 190 CLR 1 Lucire v Health Care Complaints Commission [2011] NSWCA 99 Mooney v Medical Council of NSW [2024] NSWCATOD 24 Neat Holdings Pty Ltd v Karajan Holdings Pty Ltd (1992) 110 ALR 449 New South Wales Bar Association v Meakes [2006] NSWCA 340 Prakash v Health Care Complaints Commission [2006] NSWCA 153 Sabag v Health Care Complaints Commission [2001] NSWCA 411 Qasim v Health Care Complaints Commission [2015] NSWCA 282 Zepinic v Health Care Complaints Commission [2000] NSWSC 13 Texts Cited: Good Medical Practice: A Code of Conduct for Doctors in Australia, Medical Board of Australia & AHPRA, October 2020 Guidelines: Sexual Boundaries in the Doctor-Patient Relationship, Medical Board of Australia, 12 December 2018 Category: Principal judgment Parties: Health Care Complaints Commission (Applicant) Dr Alexander Robert Golowenko (Respondent) Representation: Counsel: O Jones (Applicant) Dr P Dwyer SC (Respondent) Solicitors: Health Care Complaints Commission (Applicant) Meridian Lawyers (Respondent) File Number(s): 2024/00354505 Publication restriction: Pursuant to s 64(1)(a) of the Civil and Administrative Tribunal Act 2013 (NSW), and clause 7 of Schedule 5D of the Health Practitioner Regulation National Law (NSW) 2009 (National Law), the disclosure to any person or entity of the name and the address of the person referred to as Patient A in the Schedule to the amended complaint and prohibition of the disclosure of the names of the persons who made notifications to the regulator is prohibited. For the avoidance of doubt this order does not preclude the disclosure or publication of the name of the respondent.

REASONS FOR DECISION Non-publication order Pursuant to s 64(1)(a) of the Civil and Administrative Tribunal Act 2013 (NSW), and clause 7 of Schedule 5D of the Health Practitioner Regulation National Law (NSW) 2009 (National Law), the disclosure to any person or entity of the name and the address of the person referred to as Patient A in the Schedule to the amended complaint and prohibition of the disclosure of the names of the persons who made notifications to the regulator is prohibited. For the avoidance of doubt this order does not preclude the disclosure or publication of the name of the respondent. Introduction These proceedings involve a combined Stage 1 and Stage 2 professional conduct inquiry concerning Dr Alexander Robert Golowenko, a general practitioner practising in Bowral, New South Wales. The jurisdictional focus of the proceedings is the paramount and guiding regulatory requirement of the protection of the health and safety of the public: s 3A and s 3B of the National Law. As was foreshadowed at the hearing, these reasons have been delayed by the untimely receipt of the transcript: T87.3. The proceedings These proceedings follow an investigatory hearing conducted on 24 August 2023 by the delegates of the Medical Council of New South Wales pursuant to s 150 of the National Law following notifications to the regulator by two mandatory reporters and by a relative of

Patient A. Complaints, responses and issues On 21 and 23 July 2023, the Australian Health Practitioner Regulation Agency (AHPRA) received complaints about the respondent from a relative of Patient A and from two mandatory reporters. Those complaints were passed on to the Medical Council of New South Wales for consideration. On 24 August 2023, pursuant to s 150 of the National Law, the Medical Council of New South Wales convened a hearing in relation to those complaints. At that time, the emergency power of suspension in that provision was considered but not invoked. Instead, a series of stringent conditions were placed on the respondent’s practice pending further investigations. On 18 September 2023, after the reasons for decision of the s 150 delegates became available, the Medical Council referred the factual circumstances of the notified complaints and the outcome of the s 150 inquiry to the Health Care Complaints Commission of New South Wales (HCCC) for investigation. On 25 September 2024, the HCCC filed an application to this Tribunal raising three particularised complaints concerning the professional conduct of the respondent concerning Patient A. In essence, those complaints concerned the respondent’s alleged failure to observe the universally understood ethical requirements for medical practitioners to maintain the required professional boundary between doctor and

patient, where those requirement precluded sexual and financial relationships, and allegations that the respondent failed to comply with professional standards regarding appropriate prescribing practices and record keeping with regard to his consultations with Patient A. On 20 December 2024, in response to those three complaints the respondent filed a reply to the complaints in which, with some minor exceptions as to detail, he admitted the substance of them. On 7 March 2025, following a consideration of the respondent’s reply, the HCCC filed an amended complaint which abandoned some of the details particularised in the original complaint. Those abandoned particulars related to Complaint 1, particulars numbered 4, 8(a), 8(b), 10(a), and 12(b) to which reference will be made at a later point in these reasons concerning the onus of proof of contested factual matters. The respondent has maintained his factual admissions regarding the remaining substance of the serious matters particularised against him in the amended complaint, and in doing so he has acknowledged that he has been guilty of unsatisfactory professional conduct and professional misconduct. The first two complaints allege that the respondent had engaged in unsatisfactory professional conduct in the practice of medicine within the meaning of s 139B of the National Law. The third complaint alleges the respondent was

guilty of professional misconduct by reason of the subject matter of the first two complaints, which involved matters of sufficient gravity concerning breaches of the professional boundary between doctor and patient which prohibited sexual and financial relationships such that the respondent’s admissions require a finding that he has engaged in professional misconduct within the meaning of s 139E of the National Law. Consequently, the HCCC seeks a finding of professional misconduct within the meaning of s 139E of the National Law, and pursuant to s 149C(1)(b) of the National Law. The HCCC also seeks the cancellation of the respondent’s registration as a medical practitioner with a non-review period of up to three years together with an order that the respondent pay the HCCC’s costs as agreed or assessed pursuant to clause 13 of Schedule D of the National Law. The respondent acknowledges that a period of cancellation if not suspension of his registration must necessarily follow these proceedings, however he seeks a lesser non-review period than the non-review period of between 2 and 3 years sought by the HCCC. He relies on evidence tendered on his behalf to support that outcome. The parties made focussed submissions on those matters. Factual background The respondent is presently aged 52 years. Before he qualified as a medical practitioner he had achieved other impressive

accomplishments. He first obtained the degree of Bachelor of Information Technology (Computer Science) from the University of Wollongong and then a Diploma in Education from the University of New South Wales. For a short time, he worked as a high school teacher, and he has also operated a small business. Between 2003 and 2013 the respondent served his country as a commando in a special forces unit of the Australian Defence Force. In that capacity he saw active service in two tours of duty in Afghanistan, during which he encountered some dangerous and traumatic circumstances which have led to a diagnosis of post-traumatic stress disorder (PTSD). The respondent qualified in medicine after completing his military service and became a later age entrant into medical practice. In 2013, the respondent graduated with honours from the University of Sydney with the degrees of Bachelor of Medicine and Bachelor of Surgery and became registered as medical practitioner. In 2017, after completing the required periods of internship and further training, he became a Fellow of the Royal College of General Practitioners. In 2019, he commenced working as a general practitioner in a group practice at the Eastbrooke Medical Centre in Bowral. The evidence discloses that practice was not a particularly supportive collegiate environment for the respondent. That observation is a relevant factor to be

considered in our deliberation of the issues raised in these proceedings. The fact of the respondent’s military service has been raised in these proceedings as a matter of relevance, in that he claims his professional failings the subject of these proceedings has been in part influenced by his PTSD which was undiagnosed at the time of his impugned conduct. The respondent was aged between 48 and 49 years when his sexual and financial relationship with a vulnerable female patient took place. The patient is identified in these proceedings as Patient A. She was then aged between 30 and 31 years. She identifies as indigenous, and she has had an unfortunate and troubled family background. Patient A prepared a factual statement dated 2 June 2023, which was included as part of the applicant’s tender bundle of documents. Patient A was not called to give oral evidence. The ensuing summary of the factual background draws upon the unchallenged portions of the of Patient A’s statement and the related tendered records. In 2015, the respondent first met Patient A at [NOT FOR PUBLICATION]. At that time, her ambition was [NOT FOR PUBLICATION]. On 2 September 2020, a doctor and patient relationship was established between them when Patient A attended at the respondent’s clinic for treatment of a minor injury comprising a graze to her buttock. Thereafter, from time to time, until 14 December

2021, the respondent continued to see Patient A as her general practitioner. Patient A has stated, without challenge, that at her first consultation with the respondent, on 2 September 2020, she told him that she was seeing a psychologist, and a psychiatrist, Dr Adnan Younes, and that she needed to consult a new doctor for prescriptions of psychotropic medications. She told him of some traumatic experiences in her childhood. She also related to him some details of the trauma she experienced [NOT FOR PUBLICATION], her family history of opioid abuse, and of wanting to improve her life and her mental health. She said the respondent told her that he thought she might have complex PTSD, the treatment of which he would leave to her psychologist. She felt she had established a sympathetic rapport with him. In the course of the professional relationship the respondent became aware of Patient A’s mental health diagnoses, which included depression, insomnia, complex PTSD, generalised anxiety, and a borderline personality disorder. It appears that the respondent had underestimated Patient A’s vulnerability as a result of those conditions. In the course of their professional relationship the respondent gave Patient A some Botox treatment as a continuum of cosmetic intervention treatment she had been having since her early 20’s due to her feelings of insecurity. He also gave her his mobile

telephone number and suggested she could call if she experienced any difficulty with the Botox treatment. This was a departure from the standard of practice that was expected of the respondent in those circumstances. A flirtatious texting relationship between them soon commenced and continued. Hundreds of text and other messages passed between them. A large bulk of those messages are in evidence in these proceedings. Patient A described how the flirting continued in their appointments and this soon turned to kissing, hugging and touching. After a few further appointments, a full sexual relationship commenced and continued at the times of booked appointments in the respondent’s consulting room at his clinic. Those appointments were bulk billed to Medicare even though no medical services were provided on those occasions. It is unnecessary to identify the dates of those events other than to describe them as frequent occurrences. Ultimately, the doctor patient relationship ceased on 14 December 2021, but the personal and intimate relationship continued, with greater frequency of sexual encounters, until it ceased on 5 June 2022. It is undisputed that Patient A had a troubled background, and the respondent must be taken to have known that she was a vulnerable patient due to her disclosed mental health diagnoses and her indigeneity. In the circumstances, the respondent must also be

taken to have known that the relationship he was pursuing with her was improper, professionally inappropriate, and psychologically harmful to her as his patient. As the respondent has admitted that he had misconducted himself in a manner that constitutes professional misconduct it is unnecessary to further describe the intricacies and intimacies of the relationship. Apart from some matters of disagreement which will be outlined at a later point in these reasons, those matters are more fully described in Patient A’s evidentiary statement, and in the numerous messages, notes and other communications that passed between them, copies of which are in the documentary evidence before the Tribunal. The fact that a personal relationship had developed and continued between the respondent and Patient A has attracted strong peer professional criticism by an expert witness engaged by the HCCC, Dr Michael Golding, a general practitioner. The respondent’s conduct also attracted strong professional comments of ostracism from the Medical Council delegates who conducted the inquiry convened pursuant to s 150 of the National Law. After the HCCC obtained Dr Golding’s expert report, on 1 February 2024, a 13-page letter was emailed to the respondent, enclosing a copy of that report. That letter informed him of grounds of a proposed disciplinary action that might be taken against him, and it invited

him to take the opportunity of making submissions on the proposed action within 28 days, a time frame provided by statute: s 40 of the National Law. On 26 February 2024, the respondent replied to that letter confirming he had carefully read Dr Goldings’ report. Whilst stating that there were some factual matters that he did not entirely agree with, and which he said were ultimately inconsequential, he admitted that his “conduct relating to his treatment and care of [Patient A] and his conduct to her was significantly below the standard expected of [him] as a registered practitioner” and he admitted that “this may amount to unsatisfactory professional conduct or professional misconduct”. In that letter, the respondent also admitted that some of his patient record keeping was below the professional standard expected of him, and that this too may amount to unsatisfactory professional conduct or misconduct on his part. The respondent’s letter of response went on to state that at the time he was treating Patient A he was “burnt out” and “suffering with PTSD” from his experiences relating to his military service, and from his professional involvement in responding to bushfires, floods, and the Covid-19 pandemic. He admitted Patient A was a vulnerable patient and that he had not been taking care of his own mental health, and he had been seeing too many patients. He disclosed that he

had begun seeing a psychiatrist, Dr Robert Gordon, and a psychologist, Mr David Patton, for professional consultations and treatment, and that in those sessions, he was being provided with an opportunity to reflect on his professional failings. The respondent’s letter concluded with the statement: “I truly regret any harm I may have caused [Patient A], and regret failing my obligations as a registered practitioner”. It is salient to read that statement of regret alongside Patient A’s rationale for pressing the complaint against the respondent when she wrote: “I don’t want this to happen to anyone else. [The respondent] is still practising and I’ve lost everything”. [NOT FOR PUBLICATION]. Patient A’s statement dated 2 June 2023 sets out the unchallenged detail of the evolution of the relationship which developed between them. It is clear from her statement that she had an underlying vulnerability due to her experience of childhood trauma, a traumatic experience with the birth of her child, a problematic relationship with her fiancée, and she was taking a range of prescribed psychotropic medications in conjunction with her history of anxiety and depression. A statement from Patient A’s relative, another notifier, has charted the changes seen in Patient A during the time of her relationship with the respondent. In that time it came to notice that she had increased her medication

usage, she had undergone significant weight loss, she had a relationship breakdown with her fiancée, she had increased her alcohol consumption, and there was a general impression that she was increasingly stressed and that her life was spiralling out of control in the lead up to the termination of the relationship with the respondent. In light of those observations, Patient A's relative assisted her in achieving a termination of her relationship with the respondent, as it was thought to be an unhealthy situation for her. The s 150 findings On 21 September 2022, in the s 150 proceedings, the Medical Council delegates published their reasons for decision in which they were united in expressing their strongest condemnation of the respondent’s actions, based on the following findings: “In his evidence during the hearing, Dr Golowenko admitted to having sex with a vulnerable patient for about 10 months, at times in his office, a car, a motel and at her home. He also provided her cosmetic and other treatment and prescribed various medications, including drugs of addiction. In addition, in conjunction with these “consultations”, he charged Medicare for consultations during which he had sex with the patient. In our view, Dr Golowenko’s actions constitute flagrant and deplorable violations of the Code and the Guidelines. …” The s 150 Delegates gave consideration as to whether, in the

interests of public health and safety, the respondent’s medical registration should be suspended or whether conditions should be imposed on his practice whilst the HCCC continued its investigation as precursor to these proceedings. In their deliberations, the delegates noted the following matters: “We note that there is no evidence of previous history or complaints of boundary violations. Given that Dr Golowenko admitted to the sexual relationship with [Patient A], demonstrated insight and contrition, recognising that the relationship was unethical and unprofessional, is currently seeing a psychologist and a marriage guidance counsellor, we were not satisfied that there was a risk to the public interest, such that should take immediate action. …” [Emphasis added] Consequently, and significantly, notwithstanding the admitted misconduct, the respondent was not suspended. Instead, stringent restrictive conditions were placed on his practice pending these proceedings. The full details of those conditions are replicated in Appendix A to these reasons. Evidence overview The HCCC relied upon a comprehensive and detailed evidence bundle marked Exhibit “A”, pp 1 - 988, an evidentiary certificate setting out the details of the respondent’s registration and conditions of practice (Exhibit “B”), and the CV of Dr Michael Golding, the peer general practitioner expert retained by the HCCC:

Exhibit “C”. The respondent relied upon an evidence bundle marked Exhibit “1”, pp 1 – 52, comprising his evidentiary statement, a reply to the complaint filed, a series of references, and reports from his own treating and assessing practitioners. In addition to his own oral evidence, the respondent called oral evidence from Dr Robert Gordon, a psychiatrist, and Mr David Patton, a clinical psychologist. The CVs of those witnesses were marked Exhibit “2”. The respondent’s supplementary evidentiary statement was marked Exhibit “3”. Review of evidence adduced by HCCC Our review of relevant aspects of the evidence adduced by the HCCC now follows. The HCCC bundle of papers The material sections of the HCCC bundle of evidence comprised the evidentiary statements of Patient A and Person A, Patient A’s medical records, the transcript of the s 150 proceedings before the Medical Council delegates, the decision of the delegates, copies of the numerous messaging records and other notes that passed between the respondent and Patient A, the expert report of Dr Michael Golding, and annexed publications defining the appropriate standards of practice applicable to medical practitioners. Expert evidence – Dr Michael Golding Dr Michael Golding, the peer general practitioner engaged by the HCCC to provide an expert analysis and opinion on the respondent’s actions, was asked to consider the evidence

presented to him in relation to the respondent and Patient A and to provide opinions on whether the respondent had departed from the standard of care that was expected of a practitioner of similar training and experience, and if so, to indicate whether such departures fell significantly below the expected standard. In response, Dr Golding issued a report dated 23 December 2023, in which he identified a series of instances where in his opinion the respondent’s professional conduct critically fell significantly below the standard expected of a practitioner of his standing and training. Dr Golding’s comments made frequent reference to Good Medical Practice: A Code of Conduct for Doctors in Australia published by Medical Board of Australia and AHPRA, October 2020, and Guidelines: Sexual Boundaries in the Doctor-Patient Relationship, published by the Medical Board of Australia, 12 December 2018, respectively referred to as the Code and the Sexual Boundaries Code. Dr Golding’s peer criticisms of the respondent relate to two principal categories, first, his therapeutic management of Patient A, and secondly, the sexual relationship which had developed, and which was maintained between them in the period 2 September 2021 to 5 June 2022. The following summaries of Dr Goldings opinions exclude references to the particulars of complaint deleted from the original complaint when it was

replaced by the amended complaint. Reference will be made to those matters in the course of our consideration. As to the therapeutic aspect of the doctor and patient relationship, relevant to the final version of the amended complaint, Dr Golding expressed the opinion that, with the exception of the first two consultations with Patient A on 12 August 2020 and 2 September 2020, the respondent’s conduct involving Patient A should be seen to have fallen significantly below the expected standard in the following respects: The respondent continued to provide medical services to Patient A between 2 July 2021 and January 2022 whilst having a sexual relationship with her, and in that time, he inappropriately prescribed benzodiazepines, clonidine, and opioid medications: Exhibit “A”, pp 231 – 232; Exhibit “A”, pp 232 – 235; The respondent gave Patient A advice concerning psychoactive medications that was inconsistent with the opinion of her treating psychiatrist without consulting that practitioner: Exhibit “A”, pp 232 – 235; The respondent gave Patient A an iron infusion, being a second infusion, without contemporary laboratory evidence of an existing iron deficiency: Exhibit “A”, pp 254 – 255; The respondent issued Schedule 4 and Schedule 8 prescriptions for Patient A, namely benzodiazepines, nitrazepam, diazepam, alprazolam quetiapine, in excessive quantities. In that context he did

not follow the advice of Patient A’s treating psychiatrist to up-titrate quetiapine to an effective dose and he did not follow advice concerning the prescribing of clonidine; and he prescribed quetiapine in larger quantities than were required for the recommended dosing regime: Exhibit “A”, pp 236 – 247; The respondent issued Patient A with prescriptions for fluoxetine, tapentadol, codeine, paracetamol and promethazine hydrochloride without making appropriate notes in his patient records as to the clinical indications for those prescriptions: Exhibit “A”, pp 247 – 254; The respondent failed to appropriately consider Patient A’s family history of substance abuse and her psychosocial circumstances which represented risk factors for addiction, whilst also being aware that Patient A was taking medication at a greater rate than was being prescribed for her: Exhibit “A”, pp 255 – 256; The respondent inappropriately advised Patient A as to the combined use of the medications Palexia and Valium; withdrawal issues; provided her with unmarked boxes of Panadeine Forte; and provided her with a syringe of Maxolon for treatment of a hangover for the use of another person he had not seen: Exhibit “A”, pp 256 – 260; The respondent issued a prescription to Patient A for the management of a Bipolar condition when he ought to have known from specialist communication that Patient A did not have

that diagnosis: Exhibit “A”, pp 260 – 261. As to the sexual aspect of the doctor and patient relationship, relevant to the final version of the amended complaint, Dr Golding expressed the opinion that the respondent’s conduct involving Patient A should be seen as having fallen significantly below the expected standard in the following respects: The respondent seriously breached the expected standard of trust required of him as a cornerstone of the doctor and patient relationship with Patient A in breach of s 1.1 of the Sexual Boundaries Code: Exhibit “A”, pp 262 – 263; The respondent’s actions in providing Patient A with his mobile telephone number and engaging in a range of flirtatious communications with her, including by numerous messaging, were in breach of s 4, s 4.2.6, and s 10.2.1 of the Sexual Boundaries Code, which respectively flagged the propositions that the start of a sexual relationship between doctor and patient may not always be immediately obvious to either the doctor or the patient; where boundaries are being or are about to be crossed; where it is the responsibility of the practitioner to be alert to the warning signs which were present regarding Patient A; where the practitioner ought to have recognised that the inherent power imbalance in his relationship with Patient A could lead to physical, emotional and sexual exploitation of the patient: Exhibit “A”,

pp 265 – 263; The respondent’s actions in using humorously suggestive language and innuendos that might reasonably be interpreted as being designed or intended to arouse sexual interest, and his actions in kissing, hugging and touching Patient A during medical appointments in a non-therapeutic manner, were in breach of s 3.1 of the Sexual Boundaries Code: Exhibit “A”, pp 262 – 268; The respondent breached s 3.1 the Sexual Boundaries Code by engaging in and continuing to engage in a sexual relationship with Patient A, where engaging in or seeking to engage in a sexual relationship with a patient irrespective of whether the doctor believed there was consent for the relationship constitutes a breach of that Code: Exhibit “A”, pp 262 – 266; The respondent, by bulk billing Medicare for appointments on multiple occasions where medical services were not provided, where instead, sexual intercourse took place in his consulting rooms, failed to meet the professional standard of s 2.1 of the Good Medical Practice Code which calls for practitioners to act with honesty, integrity and truthfulness: Exhibit “A”, pp 263 – 264; The respondent’s documentation of his treatment of Patient A was deficient and in breach of s 10.5.1 and 10.5.4 of the Good Medical Practice Code requiring him to keep clear, up to date, legible and accurate medical records as an essential element of good patient care

that were sufficient to facilitate continuity of patient care: Exhibit “A”, pp 269 – 272; The respondent was in breach of s (2) of Schedule 4 of the Health Practitioner (NSW) Regulation 2016, which required him to maintain Patient A’s medical records in such way that included any relevant information known to him, the particulars of any clinical opinion he had reached, and the particulars of any medication prescribed to the patient: Exhibit “A”, pp 270 – 271; The respondent, by continuing his inappropriate sexual relationship with Patient A after her medical care had been transferred to another medical practitioner in his practice, was in breach of s 5 of the Sexual Boundaries Code which identified such conduct as unethical, unprofessional, and a misuse of the power imbalance between doctor and patient: Exhibit “A”, pp 264 – 265; The respondent, failed to recognise, as was required by s 4.9.6 of the Good Medical Practice Code, that Patient A had additional needs that placed her at greater risk: Exhibit “A”, pp 271 – 272; The respondent, by conducting a sexual relationship with Patient A, (knowing she was a vulnerable patient who had been diagnosed with depression, insomnia, complex PTSD, generalised anxiety, and a borderline personality disorder, who also identified as indigenous, raised additional issues of burden for her concerning social and health inequality), was in breach

of 4.2.6 of the Good Medical Practice Code which required practitioners to recognise the existence of a power imbalance in the doctor and patient relationship when interacting with patients: Exhibit “A”, pp 265 – 263; The respondent has not challenged those aspects of Dr Golding’s peer criticisms of his admitted misconduct. Review of evidence adduced by the respondent Our review of relevant aspects of the evidence adduced by the respondent now follows. Respondent’s evidence The respondent’s evidentiary statement dated 20 December 2025, and his supplementary statement dated 3 March 2025, were reviewed alongside his oral evidence: T13 – T44. The respondent’s statement dated 20 December 2025 recounted the history of his professional practice. He also described the commencement of his professional relationship with Patient A. In brief terms, he confirmed that he had engaged in an intimate relationship with Patient between July 2021 and May 2022, and he expressed his sincere regret at having harmfully failed in his professional obligations to her by having engaged in that relationship. In that statement, the respondent identified as part of his background a series of his traumatic experiences whilst he was engaged in special forces commando duties in Afghanistan and his subsequent involvement in treating his community for the stresses associated with bushfires in his area and in

relation to the Covid-19 pandemic and the effect those matters had on him. The respondent’s supplementary statement dated 3 March 2025 was more expansive and set out the details of a series of professional consultations that preceded the intimate relationship with Patient A. This statement took issue with aspects of the terms of Patient A’s stated recollections of some of the exchanges that took place between them in the course of their personal relationship, but he nevertheless expressed his deep regret at harming Patient A by his acknowledged professional failings as her health practitioner without seeking to minimise the harm so caused. In the respondent’s supplementary statement, following some deep reflections on the events in question, he set out further details of some of the traumatic and stressful experiences that had affected him to explain the context of his professional offending. These included an excessive workload, marital stresses in a chaotic family situation, professional burnout, trauma management, and responding medically to an extremely challenging fatality which occurred at an equestrian event. He emphasised that he had set out that commentary in order to explain the factors that were influential in the shortcomings in his professional behaviour without seeking to minimise or excuse the harm he had caused to Patient A. In that supplementary statement the

respondent also provided details of some significant remedial steps he had been pursing since the events in question came to light, namely therapy to assist in dealing constructively with his marital separation, and his consultations with a treating psychologist and a treating psychiatrist since recognising that he has PTSD. In his oral evidence, the respondent confirmed the content of his evidentiary statements and confirmed the beneficial effects of the psychological therapy and the benefits of the professional supervision he has been receiving in his practice since 2022. The following matters of significance emerged from his evidence: He acknowledged that following the insights he has developed since the events in question, a cancellation if not suspension of his registration was necessary because his admitted professional conduct, which was serious, horrendous, and unacceptable. He acknowledged the detail of his professional offending with Patient A included sexual encounters with her in his consulting rooms on multiple occasions, for which he wrongfully bulk-billed Medicare, thereby profiting from those payments; He acknowledged his completely inappropriate prescribing in relation to psychoactive prescriptions he had issued to Patient A, along with his inadequate and poor record keeping contrary to accepted standards in relation to those matters, thereby placing her at

risk of exacerbating an already established dependency and placing her psychological state at risk; He did not seek to justify those shortcomings in his professional conduct, and acknowledged the harm he had occasioned to Patient A, and to his own family without seeking to attribute blame to Patient A for his professional shortcomings; He explained that his insight into his misconduct started from a baseline of zero at the time, and had developed into a very clear understanding through the “painful process” of therapy; He convincingly explained that as a result of therapy, the shame he has experienced, and the insights he has gained into his unacceptable misconduct, are sincere. He also stated that as a result of his understanding on how PTSD has manifested itself in his case, his professional offending is unlikely to recur; He became profoundly visibly distressed in explaining his circumstances to the extent that the Tribunal was left in no doubt that he was involuntarily displaying a behavioural manifestation of his PTSD when under the pressure of uncomfortable questioning: T27 – T29; He stated that he has come to realise that in taking on an excessive workload to the point of workaholism, that in pushing himself forward, without thought of rest breaks for self-care, he had been drawing upon his commando training in a way which was, in that setting, in hindsight,

“ridiculous”, and not appropriate for his own wellbeing or to good medical practice; He has been open about his impugned conduct and embarrassingly, he has made relevant disclosures to his practice manager, his medical colleagues and the specialists with whom he works in a variety of settings, including to several colleagues when he has been a regular surgical assistant. He has described having undertaken appropriate courses aimed at reinforcing a proper understanding of the professional boundaries that must be maintained between doctor and patient, and of the need to keep proper records and notes; He has been engaging appropriately with recommended treatments and therapies; In seeking to explain that he did not at the time understand how he could have let the events in question occur, gave the following evidence in emotional terms: Q. Does that mean in summary that you were blinded to the process at the time it was occurring? A. During the time that this was occurring I was blinded to what was happening. [Patient A] had been a patient of mine for nearly 12 months, about nine months prior to this occurring and this was something that had built up during this time. At this time, and I think as noted by both Dr Gordon, Dr Patton and Dr Roche(?), my treating doctors, I was, as hard as it is to accept, I was suffering from severe PTSD and burnout. Part of the nature of, from what I

understand now of combat-related PTSD and particularly in the counterinsurgency operations in Afghanistan, it's not the traditional Hollywood version of nightmares and flashbacks and the craziness that occurs but it seems that fighting an embedded and hidden enemy, embedded within a civilian population creates an element of hypervigilance and hyperarousal and severe risk-taking. From discussions I've had with my peers and fellow veterans at this time most of them have experienced this and it's not until there is a crisis that on reflection you can see how out of control you were and that this diagnosis or this illness creates vulnerability within myself as it does with any veteran and unfortunately being a doctor, it doesn't make me immune to this vulnerability and there was a PTSD risk-taking, adrenalin-seeking component potentially to how this occurred. Q. The tribunal understands that process well and your exposure to combat and trauma can produce these feelings. I want to come back to the question of being blindsided to the process and what was happening between you and Patient A. Did you ever along the timeline of your intimate relationship pause and recognise that what was happening was both - was deleterious to both you and to her? A. At this time, speaking honestly, I was in love with Patient A. I felt that, that t[h]ere was a future together. I felt a very strong

connection to her. I felt she was understanding or sympathetic to who I was at that time. I felt that, that we were - that there was a future for us and that our feelings for each other was (as said) get use through any of the hard times. So, I think I was vulnerable, and I feel in love with Patient A, and that I felt that she was going to be the one and that we'd have a future together. Which completely clouded and changed every from my usual practice; how I would ever treat anyone else, and again, this wasn't - didn't occur over a matter of weeks, this was a matter of months. Q. In that process did you ever pause to analysis (sic for analyse) whether this evolving relationship was based on equality or involved a power imbalance? A. Yes. There's a power imbalance between - in any doctor/ patient relationship. At the time of the affair the relationship developed with Patient A, I felt we were more friends and potentially developing feelings for each other rather than doctor/patient., Q. But in that process did you not recognise that because of the age difference and the status difference and the socioeconomic difference that there was a power imbalance between you? A. I did recognise there was a power imbalance. Q. And was that not accentuated by your knowledge of her underlying vulnerability due to the factors that have been identified such as her family background, her trauma

history, her anxieties and which Dr Unis (sic for Younes) identified as her borderline personality diagnosis? A. This adds to the vulnerability it was something that I was aware of. Again, there was a risk-taking element to what was occurring as well. Umm, this was exciting, and adrenaline based which now I know was just fuelling the PTSD demon which was giving me an outlet for something that had been going on for, since my service in Afghanistan in 2008, 2009.” [T23.40 – T25.1] [Emphasis added] In the course of cross-examination, it was initially suggested to the respondent that he had given untruthful evidence, a proposition which he denied. However, it was later noted that after reflecting on the evidence, counsel for the HCCC later withdrew that assertion: T35.17. Associate Professor Vincent Roche’s evidence The respondent relied upon a report dated 30 December 2024 provided by Associate Professor Vincent Roche, his treating general practitioner whom he had known since about 2015 during his time as a registrar. A/Professor Roche had been provided with a copy of the original complaint filed by the HCCC along with Dr Golding’s report (with which he was in general agreement), the NCAT Procedural Direction concerning the requirements of expert evidence, and he consulted his own medical records concerning the respondent: Exhibit “1’, pp 1 – 23. A/Professor Roche related his

understanding of the respondent’s background of military service and his exposure to stressors, and of having discussed those matters with him informally as a collegiate mentor rather than as a treating doctor. On 11 April 2023, A/Professor Roche formed the view that the respondent likely had PTSD, and referred him to Dr Robert Gordon, a consultant psychiatrist in the region. He has stated that the respondent seems to him to have acquired a growing awareness of the effects of PTSD on his life and on his professional life, and that he has enthusiastically embraced PTSD therapy. He expressed the opinion that the respondent has acquired significant insight into his admitted misconduct and in relation to the harm that he has likely caused to Patient A. A/Professor Roche was impressed by the fact that the respondent has been able to freely discuss his professional failures and admit that, unlike his earlier state of denial, he is now able to accept he has had severe PTSD. A/Professor Roche agreed with Dr Golding’s views that the respondent’s prescribing for Patient A was undertaken inadequately without consideration of possible side effects and complex drug interactions and without appropriate risk monitoring in view of the patient’s family history of drug abuse and her vulnerability. He was critical of the fact that a boundary violating sexual relationship had taken place. He also

agreed that the medical records kept by the respondent in relation to Patient A were inadequate. In expressing those views, he highlighted the obvious need for sanctions in view of the evident breaches by the respondent in relation to the required standard of practice. Dr Robert Gordon’s evidence Dr Robert Gordon, a consultant psychiatrist who also has specialist qualifications in general practice, has provided the respondent with a report dated 15 January 2025: Exhibit “1”, pp 34 – 40. The respondent first consulted Dr Gordon in April 2023, at which time he confirmed the respondent’s PTSD diagnosis stemming from his military service in Afghanistan. He also noted some catalytic family dynamics which have subconsciously activated the respondent’s PTSD symptoms. He concluded his report with the opinion that the respondent’s psychological condition remains unchanged despite his conscious attempts to at achieving some equilibrium. He said that in his view respondent has insight into the significant mistake he has made with regard to the management of Patient A. Dr Gordon gave oral evidence in these proceedings: T46 – T65. In that evidence, he made the following points of significance: The respondent’s symptoms of PTSD which he incurred in Afghanistan have never abated, and those symptoms are at times not apparent to him when they appear; they are extremely difficult to treat; the

success of the available treatments is very poor; the condition is ever present in the background and can flare according to triggering circumstances; The respondent appreciates that his impugned conduct, a major problem for him, was inappropriate, and he is in need ongoing treatment, preferably with a psychiatrist who is not involved in dealing with the family dynamics; The respondent’s insight into the events in question is still evolving, and because of his PTSD, whilst he is aware that logic usually does not play a significant part, there is a probability of a risk of a recurrence of the behaviour in question; The respondent would be advised to enter into lifelong psychotherapy with a therapist he can trust in order to have the ready facility for open discussion which would serve as mitigation against a risk or diminish the risk of a recurrence of the impugned behaviour; On the question of insight into the causes of the breach of the professional boundary between doctor and patient, he considered the respondent had underestimated the severity of Patient A’s underlying problems; He supported the suggestion that the respondent should have EMDR treatment for his condition; He said he valued and would defer to the treatment suggestions provided to the respondent by Mr Patton, the treating psychologist; He noted that an important mitigation strategy against a risk of recurrence

would be for the respondent to continue to accept his PTSD diagnosis and to continue with treatment for that condition. The overall impression gained from Dr Gordon’s evidence is that whilst the respondent’s PTSD is a lifelong condition, it could be managed with appropriate treatment, and of itself, it was not a barrier to future medical practice. Mr David Patton’s evidence Mr David Patton, a clinical psychologist, provided the respondent with a report dated 15 January 2025: Exhibit “1”, pp 24 – 33. The respondent first consulted Mr Patton in a professional capacity in March 2022 and since then there have been 21 consultations prior to the issue of the report. Mr Patton summarised the details of each of those consultations Beforehand, since 2017, they had a professional association through referrals, in that the respondent had been referring approximately 8 to 10 patients per year to him for psychological assistance. In July 2022, Mr Patton noted the respondent had felt lonely in his medical practice, the inference being he was not in an open or a supportive collegiate practising environment. By August 2022, Mr Patton recorded a history of the respondent feeling regret and remorse after an in-depth discussion on the inappropriateness of his relationship with his patient. In summarising subsequent consultations, Mr Patton recorded the respondent as having expressed self-blame,

taking personal responsibility for his untoward actions, feeling burnt out, continuing to exhibit hypervigilance, speaking about traumatic incidents in his deployment in Afghanistan, speaking about related distressing memories, discussing boundary issues, feeling stress from a pending civil law suit, being very reactive to situations, and requesting EMDR therapy, to which he was responding positively. Mr Patton described the applicant has having exhibited a high degree of compliance with psychological treatment and also exhibiting a high level of help seeking behaviour and openness about his aberrant and unacceptable conduct towards Patient A in having breached the doctor and patient boundary. Mr Patton recorded that the respondent was responding well to EMDR treatment for his PTSD symptoms, and was demonstrating willingness to adhere to treatment recommendations, and was also exhibiting an increasing self-awareness regarding his impugned behaviour and conduct. Mr Patton concluded his report by agreeing with Dr Golding’s opinion, and by saying that the respondent would benefit from ongoing peer support from medical practitioners. Mr Patton also gave oral evidence in the proceedings: T56 – T68. In that evidence, he made the following points of significance: He explained EMDR therapy as involving the identification of stressful memories or parts of memories associated with a

traumatic experience and desensitising such memories by bilateral stimulation through eye movements to achieve the desensitisation process; The timing of the respondent’s full disclosure of his boundary violation occurred in the third treatment session, and this was consistent with his growing awareness of the enormity of what he had done; The respondent’s insight into the events, although full, evidenced by a high degree of self-awareness, remains an ongoing process that will probably never cease to evolve because of his feelings of shame and regret that he continues to have over the events; The respondent has demonstrated a great willingness to engage in therapy and has shown a capacity to moderate his working hours and to accept professional supervision; His recommendation is for the respondent to continue to have treatment until the symptoms cease, and as such, treatment should be viewed as a work in progress, where there may be a range of potentially triggering circumstances that may be likely to evoke symptoms of reactivity and the associated behavioural pathologies; The respondent has developed a level of awareness about professional boundaries in the context of “not getting himself into that sort of situation again in the future”; He has been supporting the respondent through the Tribunal process in circumstances where the respondent realises that he will be suspended

(sic) from practice; The impression gained from Mr Patton’s evidence is that the respondent’s PTSD is a manageable condition that of itself was not inimical with future medical practice if supporting measures are in place. Dr Mark Wilson’s evidence Dr Mark Wilson, a general practitioner since 1994, has provided the respondent with a character reference dated 12 January 2025: Exhibit “1”, pp 39 – 41. He has known the respondent and has worked with him at the same practice between 2019 and 2021. He has been the respondent’s medical supervisor since May 2023 as required by the Medical Council as a result of the subject complaints. He made no negative comments on the respondent’s capacity and performance as a general practitioner. Dr Michelle Mulvihill’s evidence Dr Michelle Mulvihill, a senior practising psychologist who has had a professional referral relationship with the respondent who has been sending her patients since 2016, provided the respondent with a character reference dated 19 January 2025: Exhibit “1”, pp 44 – 48. Dr Mulvihill described the circumstances in which the respondent disclosed to her the nature of the complaints against him. She stated that he had expressed his extreme remorse, embarrassment, sorrow, distress, guilt and shame over those events. Apart from those events, she regarded him as a general practitioner of the highest standards, clinically

observant, always doing the right thing for his patients in helping them, and being a man of the highest character. She noted the complex trauma he might be carrying due to his time in Afghanistan. Dr Andrew Foote’s evidence Dr Andrew Foote, a consultant obstetrician, gynaecologist, and urogynaecologist, provided the respondent with a character reference dated 23 December 2024: Exhibit “1”, pp 49 – 52. His experience of the respondent has been in the context of the respondent having been his monthly surgical assistant since 2016 as well as being a source of patient referrals. He wrote positively about the respondent’s medical knowledge, abilities, and his efficiency in the work setting. He had not witnessed any unprofessional behaviour on the respondent’s part. He indicated he would be happy to have the respondent as his general practitioner of choice if his current general practitioner was unavailable. Dr Rui Niu’s evidence Dr Rui Nui, an orthopaedic surgeon, provided the respondent with a character reference letter dated 22 January 2025: Exhibit “1”, pp 51 – 52. He has known the respondent for 6 years as a professional colleague in Bowral. He considered the respondent’s misconduct to be incongruous with the professionalism and empathy he had observed in the respondent in multiple clinical settings, including as his surgical assistant. He formed the opinion that the respondent

was otherwise of good character. He said the respondent had demonstrated genuine remorse for his actions and has demonstrated understanding of the gravity of his impugned actions. Ms Katherine Armstrong’s evidence Ms Katherine Armstrong, the current practice manager of the Eastbrooke Medical Centre, provided the respondent with a character reference dated 8 January 2025: She wrote positively of the respondent’s medical interactions and professionalism. She has referred her own family members to him and felt comfortable working with him: Exhibit “1”, pp 42 – 43. Submissions of the parties The essential points made in the HCCC submissions, the respondent’s submissions, and the respondent’s submissions in reply, are summarised below. HCCC submissions The initial submissions by the HCCC were focussed on “penalty”: MFI ”1”, paragraph 2. In oral submissions this required refocus to the correct issue, namely protective orders: s 3B of the National Law: T69.37. The HCCC submitted that the cancellation of the respondent’s registration was required, with the imposition of a non-review period of 2 to 3 years in light of the extreme seriousness of the nature of the respondent’s departures from accepted standards of practice, which have been conceded as justifying findings of unsatisfactory professional conduct and professional misconduct. In making that submission, the HCCC pointed to the

following five uncontroversial factors of relevance The need to protect the public, and in particular future patients of the practitioner, against further misconduct by the practitioner; the need to protect the public for general deterrence of other practitioners; the need to protect the public by reinforcing high professional standards and denouncing transgressions; the maintenance of public confidence in the profession; the desirability of making available to the public any special skills possessed by the practitioner., In the course of oral submissions, the HCCC placed emphasis on the need for cancellation in cases of serious misconduct. The HCCC submitted that objectively very serious misconduct has been made out in this case by reason of the respondent’s reckless prescribing of drugs to Patient A, which created a dependence in his vulnerable patient, and this called for a general deterrence that required the denunciation of such conduct by cancellation rather than by means of a suspension. The HCCC also pointed out that whilst the respondent has expressed regret over his misconduct and is receiving appropriate treatment for his PTSD, a lifelong condition, that process still remains a journey for him in circumstances where the fact that diagnosis has been made does not necessarily mean the reactivity risks of aberrant behaviour associated with that condition are alleviated

and will not recur in the future. In those circumstances, the HCCC submitted public confidence requires that following cancellation, there should be a non-review period of between 2 to 3 years. The effect of that submission was that during that time the respondent would have the reflective opportunity to address the difficult issues he faces in his life with regard to the chaos in his family circumstances and consolidate his insights into the events in question. Respondent’s submissions The respondent’s submissions highlighted the fact that from an early stage, he had acknowledged his professional failings and has admitted the substance of the matters alleged against him concerning unsatisfactory professional conduct and professional misconduct save for a series of particulars relating to Complaint 1. Those exceptions respectively related to particular 4, alleged but disputed advice as to pregnancy termination; particular 8(a), a disputed lascivious comment; particular 8(b), a disputed conversation concerning Patient A’s appearance; particular 10(a), a disputed remark about another practitioner; and 12(b), a disputed assertion over drug dependency involving diazepam. In that regard, despite those disputed matters, the respondent submitted that he has not shied away from the serious substance of the complaints made against him, as can be seen from his answers to questioning at

the s 150 hearing, and from his early admissions concerning serious nature of his misconduct. In maintaining his denial of the matters raised by those particulars, reasonably, the respondent placed emphasis on the need for the HCCC to discharge its onus of proof in the face of such denials, where Patient A was not called to give oral evidence to dispute those denials. In those circumstances, it was submitted that the Tribunal would have no reason to dismiss the respondent’s denials on those limited matters, and that a finding should be made that those matters have not been proven to the required standard of comfortable satisfaction. As to the substantive matters which the respondent accepts as his professional failings and wrongdoings as being embarrassing, horrendous, and shameful, he accepts that these matters have had an untoward impact on Patient A and on the reputation of the medical profession. It was submitted that those failings were out of character and were influenced by his PTSD which stemmed from the traumatic experiences he incurred in the military whilst serving his country, and subsequently. The respondent’s submissions drew upon the supportive remarks from the practitioners and persons who provided references as to his professional skills, his otherwise good character, and his expressions of guilt, regret, shame and remorse, to argue that these factors suggest

that a pathway had been established working towards insight and the unlikelihood of a recurrence of his past aberrant behaviour in light of the insights he has gained from therapy, supervision, and reflection. Those submissions were made in the context of the unique and isolated practice circumstances of the offending conduct and the respondent’s PTSD, where his subsequent realisation of the latter factor was pointed to as having made him insightful, whilst also recognising a potential vulnerability for professional transgressions. On the question of protective orders, the respondent’s primary submission was to argue for a period of suspension rather than cancellation. On the alternative premise that a cancellation order would be made, the respondent’s submissions argued for a non-review period of between 6 and 12 months on the basis that it should be recognised that a renewal application involves an inevitable 6 month delay comprising an administrative time lag factor which should be added into the equation. HCCC’s submissions in reply The HCCC accepts that in such cases there are no pre-set tariff considerations that fetter the exercise of the discretion in relation to the setting a non-review period following a cancellation order: T86.28. That said, the respondent summitted that the respondent’s PTSD and volatile family environment, and the related triggers, continued to

pose risk factor such that public confidence required that there be an emphasis on the factor of general deterrence associated with cancellation in this case. Relevant principles for consideration of Stage 1 concerning disputed matters The applicant has admitted the substance of the misconduct complaints against him, save for Complaint 1, particulars numbered 4, 8(a), 8(b), 10(a), and 12(b) as detailed at paragraph [97] above. The HCCC referred to those matters of gravity in the course of submissions. Patient A was not called to elaborate on those allegations. Counsel for the respondent therefore did not have the opportunity to challenge and test those allegations. In the face of the respondent’s denials, those disputed matters stand to be determined according to which party bears the onus of proof on such matters. The onus of proof concerning such matters of gravity must be discharged by the HCCC on the balance of probabilities according to a state of comfortable satisfaction based on an actual persuasion, which may vary according to the nature and gravity of the alleged conduct: Neat Holdings Pty Ltd v Karajan Holdings Pty Ltd (1992) 110 ALR 449, at 450. In such cases the gravity of the conduct must be assessed according to the extent to which it departs from the proper standards of conduct, not according to comparisons with a worst-case scenario: Health Care Complaints

Commission v Litchfield [1997] NSWSC 297; (1997) NSWLR 630, at p 638. The decisions in Bronze Wing International Pty Ltd v SafeWork NSW [2017] NSWCA 41, at [126]-[128] and Lucire v Health Care Complaints Commission [2011] NSWCA 99, at [43] confirmed the limited applicability of the principle in Briginshaw v Briginshaw (1938) 60 CLR 336; [1938] HCA 34, also confirming that the rules of evidence do not strictly apply in this jurisdiction save for some limited and just exceptions. Those principles will be applied in determining our Stage 1 findings as identified below. Consideration: Stage 1 As to Complaint 1, particulars numbered 4, 8(a), 8(b), 10(a), and 12(b) as described at [97] above, on the state of the disputed evidence which has not been tested we are not persuaded or comfortably satisfied that the respondent has been guilty of the subject matter of those allegations either as to alleged unsatisfactory professional conduct or alleged professional misconduct. As the balance of the particulars of complaint, the respondent has properly admitted that he has been guilty of unsatisfactory professional conduct and professional misconduct, It is therefore sufficient for us to simply note that on the evidence presented, those admissions were appropriately made in circumstances where the respondent had the benefit of appropriately skilled legal advice. Accordingly, as to the balance

of the admitted matters, in our Stage 1 findings we are comfortably persuaded, satisfied, and find that the respondent has been guilty of unsatisfactory professional conduct and professional misconduct within the respective meanings of s 139B(1)(a) and s 139E of the National Law in respect of those admitted matters. Relevant principles for consideration of Stage 2 protective orders There is no dispute between the parties as to the relevant legal principles to be applied in relation to a Stage 2 consideration of appropriate protective orders. The paramount and guiding principle to be applied in determining the appropriate protective orders in this case is the protection of the health and safety of the public: s 3A and s 3B of the National Law. The application of those principles should not be punitive on the individual, although the effect of such orders may have a punitive effect: Lee v Health Care Complaints Commission [2012] NSWCA 80, at [21]. In identifying those principles, and in weighing the need to protect the public, there is scope to allow for the fact that the harrowing effect of the process of disciplinary proceedings and the threat of loss of a livelihood may have opened the eyes of the individual concerned to the seriousness of the subject matter of the conduct so as to, on balance, diminish significantly the likelihood of a repetition where a level of insight has

been reached, whereas beforehand, insight did not exist: Director General, Department of Ageing, Disability and Home Care v Lambert [2009] NSWCA 102; (2009) 74 NSWLR 523, at [83]-[84]. A decision to exercise the discretion to cancel the respondent’s registration on the ground of professional misconduct involves an assessment of matters of degree and judgment: Sabag v Health Care Complaints Commission [2001] NSWCA 411, at [82]. Decisions along those lines require that an assessment be made of the gravity of the proven professional misconduct and considerations of remorse and insight, if any, demonstrated by the practitioner, for example, as in Health Care Complaints Commission v King [2013] NSWMT 9, at [32]. Discretion of the kind conferred on the Tribunal with regard to protective orders must be exercised reasonably, in the sense that it must be appropriately reasoned, and it must proceed according to recognised principles of fairness to the persons affected, according to the justice of the case: House v The King [1936] HCA 40; (1936) 55 CLR 499, at pp 503; 505; Kruger v The Commonwealth (1997) 190 CLR 1 at 36; [1997] HCA 27; Chen v Health Care Complaints Commission [2017] NSWCA 186, at [15]. In cases such as this there is a need to appropriately denounce professional misconduct as a deterrence to others in the interest of maintenance of standards, public confidence and the

general standing of the profession in the eyes of the community: Health Care Complaints Commission v Do [2014] NSWCA 307, at [35]. The formulation of protective orders involves a discretionary consideration that recognises the potentially punitive effect of such orders so it is necessary to ensure that such orders are limited to providing the required level of public protection without imposing more serious consequences for the practitioner than is reasonably necessary: Prakash v Health Care Complaints Commission [2006] NSWCA 153, at [101]; New South Wales Bar Association v Meakes [2006] NSWCA 340, at [113]; Health Care Complaints Commission v Do, supra, at [34]; Health Care Complaints Commission v Schmaman [2019] NSWCATOD 82, at [88]. Absent the existence of distinguishing features in individual cases decided by differently constituted Tribunal members, there is a need, where reasonably possible, for consistency and comity in the Tribunal’s decisions. That said, in some extreme cases, where the offending conduct was deliberate and insightfully conscious, the harsh impact of protective orders on a practitioner and the practitioner’s family, and the potential for damage to the reputation of the practitioner, may require the characterisation that practitioners at fault should be seen as being the authors of their own misfortune: Health Care Complaints Commission v Buys [2020]

NSWCATOD 102, at [17]. In our view, that statement has only very limited application in this case because of the respondent’s undiagnosed PTSD and because of his related lack of insight which influenced his aberrant behaviours at the relevant time. Balanced against such factors is the rehabilitative consideration that in appropriate cases, the scope for a return of a denounced practitioner to the profession at a later point in time should be permitted as it is not in the public interest that a deregistered former practitioner be forever barred from reinstatement if it can be satisfactorily shown that there has been an insightful and redemptive acceptance of past flaws such that, on reinstatement, the health and safety of the public would be appropriately protected if a second chance to practise were to be afforded to the practitioner: s 3A and s 3B of the National Law: Mooney v Medical Council of NSW [2024] NSWCATOD 24, at [15], following Dawson v Law Society of NSW [1989] NSWCA 58, at p 7, lines 10-20; Zepinic v Health Care Complaints Commission [2000] NSWSC 13, at [85(5)]. In our view, on the facts of this case, without seeking to bind a subsequent Tribunal tasked with considering the merits of an application for re-registration, the door should be left open for such an application at the appropriate time. Those principles will guide our consideration of the required

protective orders in this case. Consideration: Stage 2 – cancellation of registration Our Stage 2 consideration, (in which we have concluded that cancellation rather than suspension of the respondent’s registration is the necessarily required outcome), proceeds according to the following structure: A preamble, emphasising the protective purpose of our consideration; A review of the material facts and consequences; Mitigatory factors; Balancing the relevant factors Determining the appropriate non-review period to follow cancellation. Preamble The primary focus of these proceedings is not concerned with concepts of harshness or leniency which may guide decisions in other jurisdictions. Similarly, although Patient A and those who support her might reasonably feel aggrieved because she has been the victim of the respondent’s professional misconduct, notions of retribution, compensation, punishment, or relative degrees thereof, are outwith the required consideration of the objectives required by the regulatory scheme with which we are concerned. Instead, we remind ourselves that the paramount focus and public interest objective of the regulatory scheme with which we are concerned is that of the protection of the health and safety of the public, and that the guiding operational principles of the scheme that must be borne in mind in making of decisions under the scheme include the

requirements of transparency, accountability and fairness: s 3A and s 3B of the National Law. The considerations of transparency and accountability are already evident in this process by reason of the public nature of the proceedings where the respondent’s conduct has been exposed and scrutinised from both peer and disciplinary perspectives and he has been denounced by our findings of unsatisfactory professional conduct and professional misconduct. A consideration of the justice of the case, here being the remaining issue of appropriately just protective orders, is not only concerned with justice to the complainants and to the respondent, but also with regard to the public interest, where it is known that appropriately skilled general practitioners in rural areas are in high demand and short supply. That consideration involves matters of discretion to be decided in accordance with a reasoned assessment of the justice of the case: House v The King [1936] HCA 40; (1936) 55 CLR 499,at pp 503; 505; Kruger v The Commonwealth (1997) 190 CLR 1 at 36; [1997] HCA 27; Chen v Health Care Complaints Commission [2017] NSWCA 186, at [15]. In that regard, Patient A has been heard in that the HCCC has ably represented both the public interest and her interests within the limited ambit of issues permitted to be raised within this regulatory scheme. Similarly, the interests of the respondent

have also been ably represented. Both parties have been heard on the issues calling for decision. Review of the material facts and consequences The details of the respondent’s professional shortcomings comprising his therapeutic mistakes and his ethical transgressions of the sexual boundary between doctor and patient, are set out in Patient A’s statement summarised at paragraphs [24] to [34] above. Those matters have also been critically examined by Dr Golding as summarised at paragraphs [49]to [56] above. As those matters have already been identified, they do not require further repetition at this point, other than to say that they represent egregiously significant shortfalls and departures by the respondent from the standards of practice that were expected of him according to the standard of a practitioner of similar training and experience. The respondent’s offending conduct, which also included making fraudulent financial claims on Medicare for sexual trysts where no medical services were provided, and which have ultimately caused harm to the health and well-being of Patient A, has resulted in the respondent being publicly denounced for such conduct. In our view, the necessary public interest consequence of those circumstances must be an order for the cancellation rather than the suspension of the respondent’s registration to satisfy the immediate expectation of the need

for the protection and the safety of the public and for the protection of the reputation of the medical profession. In that regard, the salutary need for the cancellation of the respondent’s registration serves several purposes, namely, protecting the health and safety of the public, the denunciation of the conduct as a professional rebuke to the respondent, a deterrent to other practitioners who may find themselves faced with the opportunity and inclination to similarly transgress, and to maintain public confidence in the high standards of medical practice expected of the profession. Mitigatory factors On reviewing the evidence as a whole, we consider that there are some significant mitigatory factors. In that regard, we record our impression that the respondent is an intelligent and otherwise good person who, in the informed eyes of his professional referral circle is regarded as having been a skilled general medical practitioner. We consider that the respondent’s inexcusable professional transgressions and poor professional judgments in relation to Patient A occurred under stressful conditions which included a chaotic domestic situation and his unrecognised and therefore unmanaged PTSD resulting from his military service. Relevantly, the respondent has from the outset and on successive occasions, expressed his regret, guilt, shame and remorse over his professional

transgressions, including an acquired insight relation to the harm incurred by his vulnerable patient as a consequence of his aberrant professional behaviours. He continues to reflect on this. In this case we advisedly use the expression acquired insight in light of the respondent’s candid concession that he had “zero” insight at the time of the events due to his PTSD, and in light of the professional assessments of his subsequently acquired insight, as remarked upon by Dr Gordon and Dr Patton. We interpret the question of insight as being a threshold issue in this case, in that at one point it did not relevantly exist, and at a later point it emerged, leading to the respondent’s expressions of remorse and regret: Director General, Department of Ageing, Disability and Home Care v Lambert, supra, at [83]-[84]. The respondent’s evidence has been consistent from the time he was first confronted over his professional wrongdoings, and we accept his expressions of guilt, regret, shame and remorse as being genuine, appropriate, and indicative of an acquired level insight into his professional wrongdoings. In reaching that conclusion we have not overlooked the effect of Dr Gordon’s view that the respondent’s insight has been evolving. We read that evidence as showing the respondent has reached the required level of insight and that as he continues to consider the ramifications of his

misconduct, his insight continues to evolve and consolidate in his thoughts in a positive way that will most likely act as a deterrent against a repeat of such misconduct, particularly as this process has been scarifying for him. To the respondent’s credit, he has been consistently candid and remorseful from the outset. He has accepted responsibility for his inappropriate actions without seeking to shift blame. His explanations for his aberrant behaviour did not extend to seeking to make excuses and he did not seek to justify his inappropriate actions. In our view, in summary, the following factors have operated to influence the respondent’s aberrant conduct: His underlying undiagnosed and unrecognised PTSD which had its origins in the traumatic experiences he encountered during his military service between 2008 and 2009 as a commando in the special forces the service of his country in Afghanistan; His chaotic and triggering domestic and family situation which has led to a marital separation and a pending divorce; The limited collegiate support in his medical practice; His previous coping mechanism of recourse, namely, his “can do” attitude ingrained from his military training when dealing with the stress of his day-to-day practice environment without due regard to his own mental health; His emotion driven belief that he was in love with Patient A, where he thought his future

would be with her, which blindsided him in relation to his professional obligations to maintain the required professional boundary between doctor and patient, where he was otherwise required to be more vigilant and assiduous in relation to his prescribing and record keeping practices in relation to Patient A; The historical absence of insight regarding the inappropriateness and harmfulness of his boundary crossing behaviour. We consider that the confluence of those factors served to blindside the respondent and this led to him into a spiralling descent of offending professional misconduct, including to the misguided extent of making fraudulent claims on Medicare in circumstances where no medical services were involved. Balancing the relevant considerations In the HCCC submissions, attention was properly drawn to the seriousness of the respondent’s prescribing misconduct, and to the following longstanding observations in Spicer v New South Wales Medical Board & Ors, (unreported, New South Wales Court of Appeal, 19 February 1981) as apt concerning cases involving the prescription of drugs: “… it is clear beyond argument that the proper handling and prescribing of drugs by medical practitioners are of the greatest importance to the community. If a medical practitioner handles or carries out that very great responsibility in a way which is reckless and which shows a disregard to

the law it cannot be said that he is fitted at such a time to be a medical practitioner. In my opinion the view expressed by the Tribunal has implicit in it that not merely was he presently unfitted to treat those addicted or habituated to drugs but that that unfitness in itself demonstrated his present unfitness to be a medical practitioner.” In our view those remarks are distinguishable from the respondent’s present circumstances for several reasons. First, the respondent’s impugned behaviour occurred when he was blindsided by his relationship with Patient A, whilst he was significantly affected by his unmanaged PTSD, which fuelled his obsession with that relationship. Secondly, he has not only openly acknowledged his past failings once they were exposed, but he has disclosed and spoken about them freely to other practitioners in circumstances that indicate he now has the requisite insight into such issues. In those circumstances, following the respondent’s denunciation, we consider that it is unlikely that his problematic prescribing and inadequate record keeping will recur as he now clearly understands the likely severe consequences for him of a repetition of such prior inadequacies and misconduct. In our view, a similar assessment applies to the insight the respondent has gained into his boundary crossing behaviour with Patient A. In that regard, we consider that the

salutary scarifying and shaming experience of the exposure of that relationship has been harrowing for him and has made him vigilant to the risks of a repetition of that behaviour now that his PTSD diagnosis has been confirmed and he has been obtaining professional assistance in recognising and managing that condition. In those circumstances we consider that the respondent’s boundary crossing behaviour and misuse of the power imbalance between doctor and patient is unlikely to be repeated. Another factor that requires consideration is the fact of the respondent’s actions in wrongfully billing Medicare. This was a matter raised with counsel for the respondent’s counsel in submissions, where the non-repayment of the amounts billed could be seen as being a relevant character flaw. Having heard submissions on the administrative complexities of restitution of those amounts, we conclude that factor need not be weighed in exercising the discretionary fixing of a non-review period as the restitution of the sums in question involves a separate administrative pathway. Appropriate non-review period to follow cancellation The HCCC has called for a non-review period of two to three years whereas the respondent’s ultimate submission was for 6 months or a year. We consider that the factors pointing to an acceptance of the respondent’s submissions on fixing the non-review period are the

insight gained by the respondent in to his offending, the treatment and management of his PTSD as explained by Dr Gordon and Mr Patton, his otherwise acknowledged skills as a general practitioner and surgical assistant, and the shortage of general practitioners in rural practice. Having regard to those considerations, in this unusual case, we consider that a non-review period of 6 months would assuage the need for deterrence, acknowledge reputational harm to the profession, and at the same time provide the public with the required protection in the secure knowledge that a reregistration order would inevitably be subject to stringent conditions of practice involving supervision for a time, together with some necessary health conditions, along the lines imposed following the earlier s 150 inquiry pending these proceedings. Determination The respondent’s registration should be cancelled on account of his admitted unsatisfactory professional conduct and professional misconduct, with a non-review period set at 6 months. Costs As the HCCC has been successful in securing the orders it seeks, and absent any evidence of disentitling conduct on its part, costs must follow the event in the usual manner: Qasim v Health Care Complaints Commission [2015] NSWCA 282 at [85]. Orders The Tribunal makes the following orders: Pursuant to s 64(1)(a) of the Civil and Administrative Tribunal Act 2013

(NSW), and clause 7 of Schedule 5D of the Health Practitioner Regulation National Law (NSW) 2009 (National Law), the disclosure to any person or entity of the name and the address of the person referred to as Patient A in the Schedule to the amended complaint and prohibition of the disclosure of the names of the persons who made notifications to the regulator is prohibited. For the avoidance of doubt this order does not preclude the disclosure or publication of the name of the respondent. Pursuant to s 149C(1)(b) of the National Law, the medical registration of the respondent, Dr Alexander Robert Golowenko is cancelled, with a non-review period set at six months from today’s date. Order (2) above is to take effect from the close of business hours on the 7th day following publication of these reasons. Pursuant to s 175B of the National Law and clause 13 of Schedule 5D of the National Law, the respondent must pay the costs of the Health Care Complaints Commission as agreed or assessed. Appendix A - Conditions of practice following s 150 hearing 1. To obtain Medical Council of NSW approval prior to changing the nature or place of his practice.

2. To practise only in a group practice approved by the Medical Council of NSW where there are at least 2 practitioners (excluding the subject practitioner): • Where the patients and patient records are shared between the medical practitioners. • Where there is always one other registered medical practitioner on site. a) This condition does not preclude the practitioner from undertaking surgical procedures as a surgical assistant.

3. To practise under category C supervision in accordance with the Medical Council of NSW's Compliance Policy — Supervision (as varied from time to time) and as subsequently determined by the appropriate review body. a) The terms of the Council's Compliance Policy — Supervision are varied so that the practitioner is: i. To meet with the Council-approved supervisor on a fortnightly basis for the first 6 months, and monthly thereafter. ii. To authorise the Council-approved supervisor to provide reports to the Council in a Council-approved format on a 2-monthly basis for the first 6 months, and quarterly thereafter. b) At each supervision meeting the practitioner is to review and discuss his practice with his approved supervisor with particular focus on: • Medical record keeping • History taking • Clinical reasoning/diagnosis • Management including follow up and safety netting • Appropriate prescribing practices c) To authorise the Medical Council of NSW to provide proposed and approved supervisor with a copy of the decision which imposed this condition or any relevant decision or report. d) The practitioner must have a supervisor approved by the Medical Council of NSW within 3 months of 20 March 2023. The practitioner is not to practise after this date until a supervisor has been approved by the Council.

4. To complete within 6 months of 20 March 2023 the Health records eLearning module organised by MIGA. a) Within 2 months of 20 March 2023 he must provide evidence to the Medical Council of NSW of his enrolment in the abovementioned course. b) Within 1 month of completing the abovementioned course, he is to provide documentary evidence to the Council that he has satisfactorily completed the course. c) To bear responsibility for any costs incurred in meeting this condition. In the event that the Health records eLearning module is unavailable, he must propose to the Council for approval a similar course to be undertaken in accordance with the requirements of this condition no later than 2 months from date of conditions.

5. To submit to an audit of his medical practice, by a random selection of his medical records by a person or persons nominated by the Medical Council of NSW and: a) The audit is to be held within 12 months from 20 March 2023 and subsequently as required by the Council. b) The auditor(s) is to assess his compliance with good medical record keeping standards and legislative requirements and compliance with conditions. The auditor(s) should pay particular attention to: • Clinical reasoning/diagnosis • Management including follow up and safety netting • Appropriate prescribing practices c) To authorise the auditor(s) to provide the Council with a report on their findings. d) To meet all costs associated with the audit(s) and any subsequent reports.

6. These conditions may be altered, varied or removed by the Medical Council of New South Wales and the Medical Council is the appropriate review body for the purposes of Part 8 Division 8 of the Health Practitioner Regulation National Law (NSW).

7. Sections 125 to 127 of the Health Practitioner Regulation National Law are to apply whilst the practitioner's principal place of practice is anywhere in Australia other than New South Wales, so that a review of these conditions may be conducted by the Medical Board of Australia. ** I hereby certify that this is a true and accurate record of the reasons for decision of the Civil and Administrative Tribunal of New South Wales. Registrar Amendments 17 October 2025 - Paragraph 25 - redacted and marked [NOT FOR PUBLICATION] Paragraph 27 - redacted and marked [NOT FOR PUBLICATION] Paragraph 39 - redacted and marked [NOT FOR PUBLICATION] The word 'that' removed from Paragraph 64 (8) DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment or decision. The onus remains on any person using material in the judgment or decision to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court or Tribunal in which it was generated. Decision last updated: 17 October 2025