VICTORI	AN CIVIL AND ADMINISTRATIVE TRIBUNAL
Administrative division
Review and Regulation List	
vcat reference No. Z531/2018	
CATCHWORDS	
Review and Regulation List – junior medical practitioner – professional misconduct and unprofessional conduct in relation to eight maternity patients – failures to provide clinically appropriate obstetric care and failures in her records – where systemic governance issues and critically inadequate supervision of international medical graduates at hospital – personal responsibility of medical practitioners to recognise and work within their competence and ensure their own practice is safe, no matter how junior –  appropriate determinations – delay in disciplinary proceedings – evidence of safe practice for over six years and insight – importance of general deterrence and protection of the reputation of and confidence in the medical profession – submission that suspending the practitioner would endanger the safety of the maternity service at Bacchus Marsh Hospital – Health Practitioner Regulation National Law (Victoria) s 196. 	

APPLICANT	Medical Board of Australia	
RESPONDENT	Dr Jocelyn Benedicto	
WHERE HELD	Melbourne	
BEFORE	Senior Member E Wentworth, Member A Williams and Member L Warfe	
HEARING TYPE	Videoconference Hearing	
DATE OF HEARING AND FINDINGS	22 November 2021	
Date of FINAL SUBMISSIONS	8 December 2021	
DATE OF ORDER AND REASONS	2 February 2022	
DATE OF CORRECTION	15 March 2022	
CITATION	Medical Board of Australia v Benedicto (Review and Regulation) (Corrected) [2022] VCAT 117	
Findings
1	With the agreement of the respondent and for the reasons given at the hearing, the Tribunal finds the allegations in the Amended Notice of Allegations proved, and appropriately characterised as follows:
[BL]
Allegation 1: Professional misconduct within paragraph (a) of the definition in s 5 of the Health Practitioner Regulation National Law (Victoria) (National Law) (professional misconduct (a)), in that on or about 3 November 2008, Dr Benedicto failed to provide clinically appropriate obstetric care to [BL] by her failure to identify that [BL]’s cardiotocography (CTG) trace was abnormal and to then take appropriate action. 
[BR]
Allegation 2: Unprofessional conduct within the definition in s 5 of the National Law (unprofessional conduct), in that on or about 25 November 2008, Dr Benedicto failed to provide clinically appropriate obstetric care to [BR] by her failure to adequately document her assessment of [BR]. 
Allegation 3A: Professional misconduct (a), in that on or about 25 November 2008, Dr Benedicto failed to provide clinically appropriate obstetric care to [BR] by failing to arrange an emergency caesarean section prior to her attempt at forceps delivery. 
Allegation 3C: Professional misconduct (a), in that on or about 25 November 2008, Dr Benedicto failed to provide clinically appropriate obstetric care to [BR] by applying traction with forceps an unacceptable number of times. 
Allegation 4: Unprofessional conduct, in that on or about 25 November 2008, Dr Benedicto failed to provide clinically appropriate obstetric care to [BR] by her failure to recognise and work within the limits of her competence and/or supervision. 
Allegation 5: Unprofessional conduct, in that on or about 25 November 2008, Dr Benedicto failed to make an appropriately comprehensive, clear and accurate medical record of the obstetric management of [BR].
[CA]
Allegation 6A: Professional misconduct (a), in that on or about 11 February 2009, Dr Benedicto failed to provide clinically appropriate obstetric care to [CA] by her failure to identify that the CTG trace of [CA]’s baby was abnormal and take appropriate action.
Allegation 6B: Unprofessional conduct, in that on or about 11 February 2009, Dr Benedicto failed to provide clinically appropriate obstetric care to [CA] by her failure to make appropriately comprehensive, clear and accurate medical records of the obstetric management of [CA].
[JM]
Allegation 8: Unprofessional conduct, in that on or about 17 and 18 February 2008, Dr Benedicto failed to make an appropriately comprehensive, clear and accurate medical record of her obstetric management of [JM].
[BE]
Allegation 9A: Professional misconduct (a), in that on or about 14 April 2009, Dr Benedicto failed to provide clinically appropriate obstetric care to [BE] by her failure to develop a suitable management and/or treatment plan in light of her placental abruption, as appropriate.
Allegation 9C: Unprofessional conduct, in that on or about 14 April 2009, Dr Benedicto failed to provide clinically appropriate obstetric care to [BE] by her failure to keep a clear and accurate patient record either contemporaneously or retrospectively.
[TH]
Allegation 10A: Unprofessional conduct, in that on or about 8 and 9 April 2010, Dr Benedicto failed to provide clinically appropriate obstetric care to [TH] by her failure to arrange necessary investigations of fetal wellbeing.
Allegation 10B: Unprofessional conduct, in that on or about 8 and 9 April 2010, Dr Benedicto failed to provide clinically appropriate obstetric care to [TH] by her failure to keep a clear and accurate patient record.
[AM]
Allegation 11: Unprofessional conduct, in that on or around 14 January 2014, Dr Benedicto failed to provide clinically appropriate obstetric care to [AM] by failing to appropriately assess [AM].
Allegation 12: Unprofessional conduct, in that on or around 14 January 2014, Dr Benedicto failed to keep a clear and accurate patient record by appropriately documenting investigations into the stillbirth of [AM]’s baby and/or by adequately documenting any counselling and explanation she gave to [AM].
[RI]
Allegation 14: Unprofessional conduct, in that on or around 28 and 29 September 2015, Dr Benedicto failed to keep a clear, accurate and legible patient record in respect of her obstetric care of [RI].
2	The Tribunal further finds that allegations 2, 5, 6B, 8, 9C, 10B, 12 and 14, which each concern inadequate record keeping, and which are each unprofessional conduct, considered together constitute one instance of professional misconduct under paragraph (b) of the definition in s 5 of the National Law.
Orders
1	The respondent is formally reprimanded under s 196 of the Health Practitioner Regulation National Law (Victoria).
2	No period of suspension is imposed under s 196 of the National Law for the reasons given.

E Wentworth
Senior Member and Presiding Member	Dr A Williams
Health Practitioner Member	Dr L Warfe
Health Practitioner Member	

APPEARANCES:		
For Applicant	Mr B Jellis of Counsel	
For Respondent	Ms E Gardiner of Counsel	

Note: Orders under the Open Courts Act 2013 (Vic) are in force
On 1 August 2018, the Tribunal ordered as follows:
2.	Any report of the whole of part of these proceedings, or information derived therefrom, that might enable the patients the subject of these proceedings, their families and/or the notifiers to be identified must not be published or otherwise disclosed, unless that disclosure is necessary for the preparation and conduct of the proceedings.
3.	This order applies throughout Australia on the basis that the Tribunal’s reasons for decision for final orders are published on AustLII and that website may be accessed throughout Australia.  The privacy of the patients, their families and that of the notifiers would be breached if persons living outside Victoria know or come to know their identity.
4.	This order operates until the later of the death of all of the relevant patients and their immediate family members.

Reasons
Introduction
1	These are professional disciplinary proceedings under the Health Practitioner Regulation National Law (Victoria) (National Law) brought by the Medical Board of Australia (the Board) against Dr Jocelyn Benedicto.  
2	This case is about the professional conduct of Dr Benedicto between 2008 and 2015, in her capacity as a junior doctor at the Djerriwarrh Health Service (DJHS, Djerriwarrh or Bacchus Marsh Hospital).  It concerns Dr Benedicto’s failure to provide clinically appropriate obstetric care or keep proper clinical records of care provided, in respect of eight patients who delivered their babies at Bacchus Marsh Hospital between 2008 and 2014.  In four cases, the babies were stillborn.  
3	And although she was a junior doctor under critically inadequate supervision at the time, this case is also about the personal responsibility every medical practitioner has, no matter how junior, to ensure that their own practice is safe, and consistent with the professional standards expected of them.
4	In 2018, the Board referred 16 allegations to the Tribunal, which Dr Benedicto admits, and which are set out in full in the Appendix to these reasons.  The parties provided agreed facts, which we set out below, and submissions before, at and after the hearing.  The agreed facts also include the expert evidence before us, which we accept.  We found the allegations proved at the hearing on 22 November 2021 and, with Dr Benedicto’s agreement, made findings about how the conduct should be characterised.  
5	We found that in respect of five allegations, Dr Benedicto’s conduct was properly characterised as professional misconduct, being conduct that is unprofessional and falls substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience.  We found that in respect of 11 allegations, Dr Benedicto engaged in unprofessional conduct, but that the conduct in respect of eight of those allegations, when considered together, constituted professional misconduct. 
6	These reasons focus on our consideration of the appropriate determinations (consequential orders under s 196 of the National Law). 
7	We respectfully acknowledge here, however, the impact on the eight patients of the events described in the allegations before us.  We have assigned pseudonyms to their names wherever they appeared and also made orders under the Open Courts Act 2013 (Vic) prohibiting publication of information derived from this proceeding and this decision which would identify the patients concerned. 
Preliminary remarks
8	As we explain below, with some reluctance we have not imposed one of the determinations we considered otherwise appropriate, and that the Board submitted should be imposed – a suspension of three months in addition to a reprimand – because of the evidence given on behalf of Dr Benedicto that doing so had the potential to endanger the safety and the continuity of care of current maternity patients at Bacchus Marsh Hospital.  We were told that:
•	Dr Benedicto continued to work at Bacchus Marsh Hospital after the conduct the subject of the allegations.  She is now a Resident Medical Officer (resident) and was described as the ‘backbone’ or ‘lynchpin’ of the maternity service.  She is one of only two residents, the only full-time resident, and the only full-time medical practitioner in the maternity service.
•	Bacchus Marsh Hospital has made no contingency plans for the prospect that the outcome of these proceedings might be a suspension of Dr Benedicto’s registration, despite the seriousness of the allegations she faced.
•	The maternity service at Bacchus Marsh Hospital is already understaffed, seriously stretched, and reliant on locums.  This is due not only to the extreme pressures caused by the COVID-19 pandemic, but also to the reputational issues Bacchus Marsh Hospital retains from the well-known failures to provide a safe maternity service in the period 2008-2015, which still make it difficult to recruit staff. 
•	The maternity service is so dependent on Dr Benedicto that it would become ‘unsafe’ if she were suspended and might have to close.  Patient care would have to be transferred to the Joan Kirner Hospital, which itself is already stretched.  Continuity of care to current patients would be seriously affected. 
9	We regard it as a matter of concern that, despite the reforms implemented following the 2015 Wallace Report referred to below, the safety and continuity of the current maternity service at Bacchus Marsh Hospital depends, to the extent advised to us, on a still relatively junior practitioner whose conduct is the subject of serious allegations of professional misconduct.  
10	These proceedings were commenced in 2018, and DJHS has been aware for some time that it was possible that Dr Benedicto’s registration could be suspended: the suspension sought by the Board has been the only disputed matter for some time.
11	We understand the extreme pressures caused by the COVID-19 pandemic on all hospital services, which were acute at the time of the hearing in December and are even more so now at the time of writing.  Our role, however, in making appropriate determinations following serious findings of misconduct by a medical practitioner is to protect the public, including by deterring other practitioners from engaging in similar conduct, and to protect the reputation of and confidence in the medical profession.
12	In performing our role of protection of the public, we occasionally need to weigh competing priorities, and this is one such instance.  On the one hand, we recognise the requirement to send a clear message to the profession regarding the consequences should practitioners engage in such serious professional misconduct.  On the other, we recognise the potential for a negative impact on patient care and safety, and a detrimental impact on the well-being of maternity patients already under higher levels of stress because of the impact of COVID-19.  
13	We record that we regard a suspension as appropriate in this case, not because we consider that Dr Benedicto is currently an unsafe or incompetent medical practitioner – the evidence is otherwise – but primarily in the interests of general deterrence and to protect the reputation of and confidence in the profession.
14	We record that we have refrained from imposing a suspension, only because we do not want a decision of this Tribunal to have a potentially catastrophic impact on the safety and continuity of the care of maternity patients at Bacchus Marsh Hospital, because of the inability of DJHS to plan for or to cover any extended absence of Dr Benedicto.  We hope this will be the single instance of the Tribunal being put in a position where it must do so.
Background
15	As is now well-known, in the period 2008 to 2015, DJHS had a higher-than-normal perinatal mortality rate – babies who died immediately before or after birth – and a much higher rate than would be expected from a Level 3 maternity service.  The high mortality rate resulted in a review of the safety of the maternity service at DJHS led by Professor Euan Wallace, whose report identified catastrophic and unprecedented systemic governance failings with the obstetric services at DJHS, avoidable perinatal deaths and other adverse patient outcomes.
16	For most of the period covered by the Board’s allegations, Dr Benedicto, as an international medical graduate, had limited registration as a medical practitioner, requiring her to practise under supervision.  
17	Her supervisor was Dr Surinder Parhar, a senior doctor and the Director of Obstetrics at DJHS.  Dr Parhar’s own professional conduct during that period is the subject of another Tribunal decision, Medical Board of Australia v Parhar [2021] VCAT 1295 (Parhar).  In Parhar, the Tribunal made findings about the ‘serious failures in his supervision, assessment, and support of junior doctors, including those who were involved in perinatal deaths’.  
18	Dr Parhar’s failings were also referred to in the Tribunal’s decision in Medical Board of Australia v Lines [2021] VCAT 1394 (Lines), which concerned another international medical graduate under Dr Parhar’s supervision.  The agreed facts in this case also include details of the inadequacies evident in relation to Dr Benedicto.
19	The Tribunal has separately made adverse decisions about three senior nurses at DJHS, in proceedings brought by the Nursing and Midwifery Board of Australia.
20	Despite the supervision requirement and her junior status, Dr Benedicto was nevertheless on the frontline of the maternity service, frequently on call on her own, and in a service that was stretched by a rapidly increasing population in the Bacchus Marsh area, staff shortages, and unaddressed deficiencies in skills critical to the safe delivery of babies, including CTG skills.  There was, in addition, ‘an almost systemic complacency and misguided self-congratulation about the quality of the maternity service’.  
21	That ‘blindness’ on the part of those in charge extended to a failure to address what should have been obvious shortcomings in the professional performance of Dr Benedicto.  She continued to receive positive appraisals despite the adverse events occurring in deliveries undertaken by her.  She continued to be left relatively unsupervised or, at best, inadequately supervised.
22	Dr Benedicto remained at Bacchus Marsh Hospital after the reforms recommended by Professor Wallace were implemented, beginning in 2015.  She is one of the few medical practitioners to have done so.  Unlike others, she did not resign or retire.  Nor was her employment terminated.  
23	In the intervening years, she has taken steps to make sure she is up to date in her skills, and has practised safely and competently, according to the evidence of those to whom she currently reports.  She has shown insight into her own professional failings in the period in question by admitting the Board’s allegations.  
24	We record our concern, however, at a submission on her behalf that, because of the endorsement of her performance by her supervisor and others, she was ‘understandably oblivious’ to the true standard of her performance and could not be expected to be cognisant of her deficiencies.  
25	We agree with the Board’s submission that being let down by her supervisor and working in an environment where poor practices were normalised, does not absolve her from her own responsibility to ensure that her practice was safe and consistent with professional standards.  The finding of professional misconduct we have made in respect of five allegations take into account her level of training and experience in finding that she fell substantially short of the standards expected of her.  We say more about this later.
26	Dr Benedicto is now a full-time senior resident at Bacchus Marsh Hospital and is the only full-time resident in the maternity service there.  She is also, once again, on the frontline of a maternity service stretched by staff shortages, this time due in large part to the extreme pressures caused by the COVID-19 pandemic, but also due to difficulties in recruiting staff because of the residual reputational damage of the well-publicised failings in the previous era.
27	It was clear from the evidence given by witnesses called on her behalf that Dr Benedicto is an essential member of the maternity service staff, described as the ‘backbone’ of the maternity service by Dr Brown, as an ‘absolute rock’ by Dr Khot, and as the ‘cornerstone’ of the maternity service by Dr John Ferguson. 
28	While the regard in which Dr Benedicto is now held is to her credit, the degree of dependence on Dr Benedicto has raised serious issues in this case about the extent to which we are able to make the determinations we consider appropriate, without apparently endangering maternity patient safety at Bacchus Marsh Hospital.  We have outlined those concerns at the start of these reasons.
29	In the following sections, we set out first the agreed facts provided to us by the parties.  We then set out the general principles that guide determinations under the National Law, the application of the principles in this case and our conclusions. 
Agreed Facts and Proposed Findings
1.	Agreed Background Facts
Introduction
1.1	At all relevant times the respondent (Dr Benedicto) was employed by the Djerriwarrh Health Service (Djerriwarrh) and was registered as a medical practitioner under the Health Practitioner Regulation National Law (Victoria) Act 2009 (National Law).
1.2	Dr Benedicto was employed as a career medical officer (obstetrics and general).
1.3	Dr Benedicto was registered:
(a)	From 15 February 2008, under the Health Professions Registration Act 2005 (HP) Vic
(b)	From 1 July 2010 under the National Law with limited registration requiring her to practise under supervision
(c)	From 24 October 2014 under the National Law with general registration and continues to be so registered.
1.4	At all relevant times, Dr Benedicto’s conduct as a registered medical practitioner was governed by the:
(a)	Medical Practitioners Board of Victoria Good Medical Practice: Guidelines on Professional Conduct: December 2006 (MPBV Guidelines);
And from July 2010:
(b)	Medical Board of Australia, Good Medical Practice: A Code of Conduct for Doctors in Australia, July 2010 (MBA Code).
1.5	Attached to this Agreed Statement is an Amended Notice of Allegations.
1.6	The conduct the subject of the Notice of Allegations is covered by the period November 2008 to September 2015 (Relevant Period).
Previous Training and Experience
1.7	Dr Benedicto was born in 1973 and is currently 47 years of age. She undertook her primary medical training in the Philippines. She completed a Doctor of Medicine.
1.8	Dr Benedicto undertook an obstetrics-gynaecologist residency in 2003 at the Dr Pablo O Torre Memorial Hospital, Bacolod City in the Philippines and from 2004 to 2007 practised in the Philippines and the Maldives.
Experience at Djerriwarrh
1.9	Dr Benedicto commenced practising in Australia on or around 15 February 2008 at Djerriwarrh.
1.10	During the period in which Dr Benedicto practised under supervision, Dr Surinder Parhar, Director of Obstetrics was nominated by Dr Benedicto, in her applications for registration, as her supervisor.
1.11	Dr Parhar was highly experienced and had been practising at Djerriwarrh in excess of 30 years when Dr Benedicto commenced there immediately upon her arrival in Australia in 2008.
1.12	The position of career medical officer was identified in a role description document produced by Djerriwarrh as a ‘training position to assist in gaining experience and training towards the attainment of the AMC qualification’.
1.13	During the Relevant Period, in addition to her supervision by Dr Parhar, whilst working as a career medical officer at Djerriwarrh, Dr Benedicto reported to the Director of Medical Services, and in the absence of that person, the Executive Director of Nursing.
1.14	Dr Benedicto was initially provided with an employment contract by Djerriwarrh for her position of career medical officer for a period of three years. Via addendums to the employment contract, Djerriwarrh extended the contract on seven occasions between 2008 and early 2015. Dr Benedicto entered into new employment contracts with Djerriwarrh in 2015 and 2016 for her role as a Senior Medical Officer. The Clinical Appointments Committee at Djerriwarrh has confirmed Dr Benedicto’s clinical privileges in obstetrics as a Senior Medical Officer until October 2023.
1.15	Djerriwarrh’s Medical Credentialing and Scope of Practice Committee also approved Dr Benedicto’s re-credentialing in obstetrics at the time of the contract renewals.
1.16	Dr Benedicto has reflected on her experience at Djerriwarrh during the Relevant Period, she says that she:
(a)	Only had experiences working in the Philippines, and in the Maldives, which are less developed countries, before commencing practice in Australia supervised by Dr Parhar; and
(b)	Does not recall receiving any formal induction when she commenced working at Djerriwarrh.
1.17	In November 2008, there was no mandatory competency level in existence at Djerriwarrh regarding fetal surveillance.
1.18	Dr Benedicto completed the RANZCOG Fetal Surveillance Education Program (FSEP) on 28 April 2008 and scored 62.5% (where the average score was 68%). The correspondence accompanying the FSEP score noted in substance that the score should not be considered in isolation and should be considered in conjunction with a practitioner’s clinical skills and experience.
1.19	No member of staff at Djerriwarrh, including Dr Parhar, raised any concern with her regarding her competency in cardiotocography (CTG) interpretation.
1.20	In so far as formal evaluations and performance assessments were conducted at Djerriwarrh, such evaluations and assessments did not raise any concerns in relation to Dr Benedicto’s professional performance. Similarly, Dr Benedicto was not informally advised or counselled about such concerns. There was no recommendation that she engage in further training to improve her professional skills during the Relevant Period.
1.21	Dr Benedicto continues to be employed by the Djerriwarrh as a Senior Medical Officer, practising in obstetrics.
1.22	Dr Benedicto has not been the subject of any other notifications to AHPRA or disciplinary findings prior or subsequent to the matters the subject of the Amended Notice of Allegations, despite continuing to work in full-time practice at Djerriwarrh.
1.23	Dr Benedicto has provided the Board with positive testimonials relevant to her professional performance from:
(a)	The Associate Nurse Unit Manager at Djerriwarrh;
(b)	The Clinical Director of Maternity Services at Djerriwarrh;
(c)	A Consultant Obstetrician/Gynaecologist at Djerriwarrh; and
(d)	The Clinical Services Director for Women’s and Children’s Services at Western Health.
Subsequent Training
1.24	Dr Benedicto passed the Australian Medical Council Limited examinations on 15 August 2014.
1.25	Dr Benedicto completed the RANZCOG FSEP Full Program on 27 August 2019 where she obtained a test score of 91.7% which equates to that expected of a level 3 practitioner.
1.26	As part of her professional development, Dr Benedicto participated in the RANZCOG Fetal Surveillance Education Program in 2008, 2010, 2015, 2016, 2017, 2018, 2019 and 2020, the Practical Obstetric Multi-Professional Training (PROMPT) Obstetrics Emergencies Course in 2016, 2017, 2018 and 2020, and the Maternity and Newborn Emergencies (MANE) Program in 2019.
Djerriwarrh and the reports of Professor Wallace and Dr Duckett
1.27	The reports of Professor Wallace and Dr Duckett identified catastrophic systemic governance failings with the obstetric services at Djerriwarrh including during the Relevant Period. From these reports, it was understood that the governance framework did not ensure proper evaluation of cases and assessment of professional competency and it did not ensure the identification of issues, investigation of suboptimal performance and appropriate outcomes, including limitations on scope of practice and training.
1.28	Professor Wallace’s report of an Investigation into Perinatal Outcomes at Djerriwarrh, noted the misinterpretation of CTG’s was a recurrent issue which was suggestive of a workforce that was inadequately skilled in fetal surveillance.
1.29	As a consequence of the issues identified by the Professor Wallace and Dr Duckett reports, Djerriwarrh has been the subject of radical reform and is now rigorously oversighted and audited.
Report from Associate Professor Edward Weaver regarding Dr Surindar Parhar
1.30	The Board obtained an expert report from Obstetrician and Gynaecologist, Associate Professor Edward Weaver OAM dated 20 September 2018 on the performance of Dr Surindar Parhar, during his employment at Djerriwarrh as a consultant between 2008 and 2014. Amongst other matters, the report of Associate Professor Weaver made observations about Dr Parhar’s discharge of his responsibilities pertaining to three junior practitioners (the practitioners) who were subject to his supervision, including Dr Benedicto. Relevantly and in summary, on the basis of the documentary evidence summarised in pages 3-16 & 51 of his report, Associate Professor Weaver observed as follows:
Supervision by Dr Parhar generally
(a)	there was little, if any evidence, that Dr Parhar monitored or assessed the performance of the practitioners;
(b)	there was no evidence of any systematic appraisal or assessment of the practitioners and no sign off on any competency of clinical privilege;
(c)	Dr Parhar’s approach to supervising junior doctors, especially overseas trained doctors, who were attempting to pass the Australian Medical Council entrance examination was unsatisfactory and below the standard Dr Weaver would expect;
(d)	there was no evidence of any systematic approach to the appraisal and assessment of the practitioners and no sign off of any process to determine if they were sufficiently skilled to work on call;
(e)	there was no evidence that Dr Parhar discussed with the practitioners when they should or must contact the consultant.
Credentialing at Djerriwarrh
(a)	there was no evidence that Dr Parhar verified the practitioners’ credentials in any way or clarified what clinical privileges they had;
(b)	Dr Parhar should have individually credentialed each practitioner and articulated clearly what their clinical privileges were;
(c)	Dr Parhar’s failure to review and update the practitioners’ credentials represents a failure in supervision and Dr Parhar’s practice was substandard in that regard.
Supervision in relation to specific cases by Dr Parhar
1.31	Associate Professor Weaver also expressed the opinion that Dr Parhar did not discharge his duty as a consultant in a number of cases the practitioners were involved in. Such cases included those of [BR], [AM], [CA] and [BE].
1.32	Associate Professor Weaver observed that Dr Parhar’s supervision of the practitioners was deficient, and his overall supervision, with the conduct of appraisals, assessments, sign off on competency in various procedures, updating of clinical privileges, de-briefing and support of the practitioners was sub-standard.
Capabilities and policies at Djerriwarrh
1.33	Dr Weaver was of the view that the lack of policies or procedures relevant to the capabilities of the service, the management and transfer of patients who fell outside the capabilities of the service and consultation and referral pathways was a serious omission and that Dr Parhar must take some responsibility for that failure.
Fetal surveillance
1.34	Dr Weaver noted there was a systemic problem in the use and interpretation of CTG traces as part of fetal assessment antenatally and intrapartum in the cases analysed by him. He considered the practitioners should have had their interpretations of CTG traces scrutinised by a more experienced practitioner to ensure they were sufficiently skilled in CTG interpretation. Further, Dr Weaver opined that Dr Parhar was deficient in skills in CTG interpretation.
Documentation
1.35	Dr Weaver considered that Dr Parhar had overall responsibility to ensure suitable medical records were kept. The fact that did not appear to happen was construed by Dr Weaver as another failure of clinical leadership by Dr Parhar.
AHPRA Investigation
1.36	Between October 2015 and May 2017, on its own motion under section 160(1)(b)(ii)(A) of the National Law, the Board decided to investigate Dr Benedicto’s performance as follows:
(a)	[AM] on 15 October 2015;
(b)	[BR] and [BE] on 10 November 2016;
(c)	[BL] on 24 November 2016;
(d)	[JM] on 30 March 2017; and
(e)	[CA] on 26 May 2017.
1.37	Following receipt of notifications, the Board decided to investigate Dr Benedicto’s performance for [TH] and [RI] on 26 May 2016 and 1 September 2016, respectively.
1.38	On 9 November 2017, the Board decided to refer the matter covered by the period from November 2008 to September 2015 to VCAT and AHPRA’s referral to VCAT was filed on 28 June 2018.
1.39	At no stage, whilst investigating Dr Benedicto’s professional conduct from 2015 to 2017, did the Board formally propose or take immediate action against her.
1.40	Dr Benedicto has co-operated fully in relation to the investigation by AHPRA and the Board’s referral to VCAT and she has made significant concessions and acknowledgments in relation to her professional performance.
2.	Agreed Facts
[BL]
Allegation 1
2.1	[BL] was a gravida 2 para 1 woman who received her antenatal and perinatal care at Djerriwarrh. Her estimated due date was 31 October 2008.
2.2	She presented at Djerriwarrh on 3 November 2008 at 40.3 weeks’ gestation.
2.3	[BL] attended an antenatal appointment which included CTG monitoring. [BL] was initially assessed by a midwife who completed a handwritten form with her interpretation of the CTG trace and other observations.
2.4	The CTG exhibited a baseline of 150 beats per minute, reduced variability, no accelerations and some variable decelerations.
2.5	[BL] was then seen by Dr Benedicto. Dr Benedicto reviewed the CTG trace and incorrectly failed to assess the CTG trace as abnormal.
2.6	Dr Benedicto has undertaken further FSEP training, including RANZCOG training. She would now interpret the results of [BL]’s CTG as non-reassuring due to the reduced variability and would continue the CTG.
2.7	Had she assessed the trace as abnormal she says that, at the time: (a) she would have contacted Dr Parhar; (ii) consistent with her understanding of usual practice at Djerriwarrh in 2008, subject to any direction from Dr Parhar, she would have repeated the CTG three days later.
2.8	Had the CTG trace been assessed as abnormal it should have led to further intervention by or at the direction of Dr Benedicto: continuing the trace, repositioning the mother, stimulating the fetus and, if the trace failed to normalise, considering the induction of labour. The conduct described in Allegation 1 was in breach of paragraphs 1aDP1, 1bDP2, 1aDP2, and 1aDP3 of the MPBV Guidelines.
[BR]
Allegation 2
2.9	[BR] was a gravida 1 para 0 woman who received her antenatal and perinatal care at Djerriwarrh. Her estimated due date was 23 November 2008.
2.10	[BR] presented to Djerriwarrh at approximately 1835 hours on 25 November 2018 at 40.2 weeks’ gestation. [BR] was in established labour, 7cm dilated, with a history of spontaneous rupture of membranes at around 1500 hours. CTG monitoring was commenced and ceased at around 2000 hours.
2.11	At approximately 2205 hours CTG monitoring was recommenced. Dr Benedicto was asked to review [BR] because of variable decelerations and meconium stained liquor.
2.12	Dr Benedicto did not document having undertaken the following assessments or procedures at around 2230:
(a)	Vaginal examination (other than recording that the patient was 9cm dilated) and assessment of fetal presentation, station, position or degree of caput and moulding;
(b)	Abdominal examination to check for fetal head still palpable above the pelvic brim;
(c)	Urinary catherization and consent for the procedures.
2.13	This conduct was in breach of paragraph 1bDP3 of the MPBV Guidelines.
Allegation 3A
2.14	At about 2235 hours Dr Benedicto attempted to deliver [BR]’s baby by forceps delivery on the labour ward without first arranging for the theatre to be opened in the event that the forceps delivery was unsuccessful.
2.15	Dr Benedicto says that such a practice was not required at Djerriwarrh at the time and that forceps deliveries were frequently undertaken in the maternity suite on the ward.
2.16	This conduct is in breach of paragraphs 1aDP1, 1aDP2, 1aDP3, and 1bDP8 of the MPBV Guidelines.
Allegation 3B
[Allegation 3B is not pressed]

Allegation 3C
2.17	When attempting a forceps delivery of [BR]’s baby, Dr Benedicto made five pulls on the forceps, which involved applying traction with forceps an unacceptable number of times.
2.18	The procedure should have been abandoned after no more than three pulls because no (or no material) descent of the fetal head occurred.
2.19	The conduct was in breach of paragraph 1aDP2 of the MPBV Guidelines.
Allegation 4
2.20	Dr Benedicto should have, but failed to inform her supervisor, Dr Parhar, about [BR]’s clinical situation before the attempted forceps delivery.
2.21	Dr Benedicto should have but failed to ask her supervisor Dr Parhar to attend for the attempted forceps delivery and the emergency caesarean section.
2.22	After the attempted forceps delivery, Dr Benedicto informed Dr Parhar that she was going to undertake the emergency caesarean section in circumstances where there had been an unsuccessful attempt at a forceps delivery. Dr Parhar lived close to Djerriwarrh and did not suggest that he should attend to assist her.
2.23	The conduct was in breach of paragraphs 1bDP2 of the MPBV Guidelines.
Allegation 5
2.24	Dr Benedicto did not record sufficient information about her assessment of [BR], her attempted forceps delivery and emergency caesarean section, including:
(a)	the fetal head’s situation, urinary catheterisation, analgesia, consent, episiotomy;
(b)	the strength used to exert traction.
2.25	Dr Benedicto did not record a legible operation note of the emergency caesarean section.
2.26	Dr Benedicto did not record a full and accurate explanation to her patient of the circumstances of the labour, delivery and the outcome.
2.27	Dr Benedicto signed a Confidential Medical Report on Perinatal Death, relating to [BR]’s baby, on or around 25 November 2008 and incorrectly recorded that the time to actual caesarean section from the time of deciding a caesarean section was about 20 minutes, when the time between deciding to perform a caesarean section and starting the caesarean section was 42 minutes.
2.28	The inaccurate recording of the time of deciding a caesarean section was an inadvertent error by Dr Benedicto and was not deliberate.
2.29	Dr Benedicto did not document the fact of and content of her discussion with Dr Parhar after the attempted forceps delivery.
2.30	The conduct was in breach of paragraph 1bDP3 of the MPBV Guidelines.
[CA]
Allegation 6A
2.31	[CA] was a gravida 2 para 1 woman who had an expected due date of 17 March 2009.
2.32	On 19 January 2009, at 32 weeks’ gestation, [CA] was concerned about strong sharp pains in her abdomen. [CA] attended Djerriwarrh, CTG monitoring was conducted and recorded as satisfactory.
2.33	On 21 January 2009 an ultrasound was performed to check if a low lying placenta had resolved. The placenta was clear of the internal os but the scan showed that fetal maturity was measuring approximately one week behind.
2.34	On 3 February 2009, [CA] was reviewed by a midwife at an antenatal clinic and it was noted that she had not gained any weight in the last two weeks.
2.35	On 11 February 2009, at 35 weeks gestation, [CA] called Djerriwarrh concerned about reduced fetal movements. [CA] attended Djerriwarrh for CTG monitoring.
2.36	The CTG trace was initially assessed by a midwife who completed a handwritten CTG monitoring form with her interpretation of the CTG trace and other observations.
2.37	Dr Benedicto then reviewed the CTG trace and recorded her assessment on the same form the midwife had used. Dr Benedicto assessed the results of the CTG for herself and did not contact, or otherwise seek any assistance from her supervisor, Dr Parhar. Dr Parhar’s signature is also on the trace results, which suggest that he agreed with Dr Benedicto’s interpretation of the CTG trace.
2.38	Dr Benedicto incorrectly assessed and documented the CTG trace as normal.
(a)	The CTG trace was abnormal within the meaning of the RANZCOG Intrapartum Fetal Surveillance Guidelines (Second Edition) because it showed reduced variability and a deceleration at around 1320.
(b)	Dr Benedicto noted ‘N’ for normal on the CTG monitoring form.
2.39	In 2009, the practice at Djerriwarrh was, if there was reduced fetal movements and the CTG was normal, or reassuring, repeat CTG monitoring was then scheduled for three days later. As a consequence of Dr Benedicto’s incorrect interpretation of the CTG trace, [CA] was told to return to Djerriwarrh in 3 days’ time for a repeat CTG.
2.40	Had the CTG trace been assessed as abnormal it should have led Dr Benedicto to:
(a)	arrange for the CTG trace being reapplied and/or continued for a longer period of time
(b)	require a bedside scan for liquor volume
(c)	consider fetal wellbeing and induction of labour.
2.41	The conduct was in breach of paragraphs 1aDP1, 1aDP2 and 1aDP3 of the MPBV Guidelines.
Allegation 6B
2.42	At the time of reviewing her CTG trace, Dr Benedicto assessed and formally reviewed [CA] by considering her presentation in light of her antenatal history and risk factors for pregnancy, including that she was a smoker;
2.43	Dr Benedicto did not document her assessment and review of the patient.
2.44	The conduct was in breach of paragraphs 1bDP3 of the MPBV Guidelines.
[JM]
Allegation 7
[Allegation 7 is not pressed]
Allegation 8
2.45	[JM] was a gravida 1 para 0 woman who had an expected due date of 11 February 2009.
2.46	During an antenatal appointment on 12 February 2009, at 40.1 weeks gestation, [JM] was examined by Dr Benedicto. [JM] was advised by Dr Benedicto to attend the hospital at around 1930 hours on 17 February 2009 for application of prostin gel (if labour had not started).
2.47	In the evening of 17 February 2009, at 40.6 weeks’ gestation, [JM] attended Djerriwarrh as advised. CTG monitoring was undertaken. At 2115 hours Dr Benedicto reviewed [JM] and conducted a vaginal examination.
2.48	At around 0700 hours on 18 February 2009, at 41 weeks gestation, [JM] attended Djerriwarrh. CTG monitoring was commenced.
2.49	[JM] was reviewed by Dr Benedicto, who performed a vaginal examination and, at 0720, an artificial rupture of membranes (ARM). Also at around 0720, Dr Benedicto ordered a syntocinon drip for the induction [JM]’s labour.
2.50	CTG monitoring ceased shortly after the ARM.
2.51	At around 0830 hours, [JM] went into labour spontaneously. The Syntocinon drip that had been ordered was therefore not administered.
2.52	The next record of a medical practitioner reviewing [JM] as at around 1400 hours when a GP anaesthetist inserted an epidural and CTG monitoring commenced.
2.53	At 1938 hours [JM]’s baby was delivered by forceps following a failed vacuum attempt after staff identified that the CTG trace showed reduced variability and a rising baseline.
2.54	In relation to the consultations on 17 February 2009 and 18 February 2009, Dr Benedicto failed to document any discussion with [JM] about the risks and benefits of induction of labour and the use of Syntocinon at the antenatal consultation.
2.55	This conduct was in breach of paragraph 1bDP3 of the MPBV Guidelines.
[BE]
Allegation 9A
2.56	[BE] was a gravida 2 para 0 woman, with an expected due date of 13 May 2009.
2.57	On 14 April 2009, at 35 weeks gestation, [BE] presented at Djerriwarrh in significant distress and pain. [BE] was examined and Dr Benedicto diagnosed probable fetal death in utero secondary to placental abruption. She decided to perform an emergency caesarean section.
2.58	Dr Benedicto made the decision to perform an emergency caesarean section without informing her supervisor Dr Parhar and obtaining his opinion or assistance. Dr Parhar was notified by the nurse unit manager of the fetal death in utero shortly after it was diagnosed and Dr Benedicto spoke with Dr Parhar once [BE] was anaesthetised and in the operating theatre. She provided Dr Parhar with accurate and appropriate information. She acknowledges that her contact with Dr Parhar was not timely and should have occurred earlier.
2.59	[BE] was taken for an emergency caesarean section for a probable fetal death in utero secondary to suspected placental abruption. Dr Benedicto did the operation which started at 1036 hours and finished at 1120 hours.
2.60	Dr Benedicto did not document any discussions with [BE] about a management plan, in light of her placental abruption.
2.61	Dr Benedicto did not document what blood products she ordered for the emergency caesarean section.
2.62	Dr Benedicto should have made and documented post-operative	orders regarding:
(a)	management in a high dependency area for additional and specified monitoring
(b)	checking for developing coagulopathy, oxytocin infusion 	and its continuance
(c)	hourly measures of urine output
(d)	emergency checking of haemoglobin level to guide blood replacement;
(e)	regular review of the patient; and
(f)	involvement of her supervisor or a senior consultant.
2.63	This conduct was in breach of paragraphs 1bDP3 and 1bPD4 of the MPBV Guidelines.
Allegation 9B
[Allegation 9B is not pressed].
Allegation 9C
2.64	Dr Benedicto’s progress and operation notes about [BE]’s treatment on 14 April 2009, consisted of those notes recorded at pages 164 & 169 of [BE]’s clinical records, parts of which are not legible.
2.65	Dr	Benedicto’s notes did not record sufficient information about her assessment, management plan and treatment of [BE], including:
(a)	A detailed management plan;
(b)	The reason for emergency caesarean section;
(c)	The details of any discussion with [BE];
(d)	Any concerns about [BE]’s blood loss, the need for transfusion, the possibility of administering un-cross matched o-negative blood for the patient rather than waiting for cross matched blood and the need for other blood products; and
(e)	What blood products had been ordered.
2.66	Written progress notes, a referral to the Royal Women’s Hospital and a Confidential Medical Record on Perinatal death conflict with one another and the Birth Record. The records are inconsistent with respect to the time of contractions and bleeding, the amount of blood loss, the time of admission, and type of anaesthesia. This occurred in circumstances where the respondent was attending to multiple tasks, including managing [BE]’s condition and arranging for her transfer to a tertiary facility. The inaccurate recording was an inadvertent error by Dr Benedicto and was not deliberate.
2.67	The conduct was in breach of paragraph 1bDP3 of the MPBV Guidelines.
Allegation 9D
[Allegation 9D is not pressed]
[TH]
Allegation 10A
2.68	[TH] was a gravida 4, para 1 woman with an expected due date of 16 April 2010.
2.69	At all relevant times Dr Benedicto was involved in and responsible for the obstetric care of [TH], save that she was not present for the birth of [TH]’s baby.
2.70	On 7 April 2010, [TH] presented at Djerriwarrh with reduced fetal movements and a bloody show. [TH] was assessed by a midwife who conducted a CTG and arranged for [TH] to be reviewed the following day. On that evening her vital signs were noted to be within normal limits and a CTG trace had been undertaken, which a midwife interpreted as normal.
2.71	On 8 April 2010, Dr Benedicto saw [TH]. As a result of [TH] reporting reduced fetal movements again on that day, Dr Benedicto ordered an ultrasound but did not order further CTG monitoring. The ultrasound was normal.
2.72	Dr Benedicto should have but did not arrange for a fetal CTG on this day.
2.73	It was not usual practice at Djerriwarrh at the relevant time to repeat CTG traces in circumstances where a trace had been undertaken the previous day and the results were interpreted as normal. Dr Benedicto’s clinical judgement at the time was that she did not perceive a CTG trace to be necessary.
2.74	[TH] gave birth to a son on 9 April 2010. The baby weighed 3.79 kg with a good APGAR score.
2.75	The conduct was in breach of paragraphs 1aDP2 of the MPBV Guidelines.
Allegation 10B
2.76	Dr Benedicto failed to keep a clear and accurate patient record by:
(a)	Failing to adequately document a follow up and/or management plan and her discussion with [TH] on 8 April 2010 about reduced fetal movements
(b)	Following the birth on 9 April 2010, failing to document sufficient information about the repair of [TH]’s perineal tear including
(i)	how she repaired the tear;
(ii)	what local anaesthetic she used;
(iii)	any advice to [TH] as to follow up including to re-present if her bleeding was too heavy or if she had other concerns;
(iv)	any discussion with [TH] about her incomplete placenta
2.77	The conduct was in breach of paragraph 1DP3 of the MPBV Guidelines.
[AM]
Allegation 11
2.78	[AM] was a gravida 4 para 3 woman with an estimated due date of 4 February 2014.
2.79	[AM] was referred to Djerriwarrh by her GP and had her first appointment at 29 weeks gestation.
2.80	[AM] had severe polyhydramnios. An ultrasound on 19 November 2013, at 31 weeks gestation, measured amniotic fluid index (AFI) at 40.7 cm and fetal weight in the 97th percentile. A follow up ultrasound on 19 December 2013, at 34 weeks gestation (reported as 36 weeks gestation) measured AFI at 33cm and fetal weight in the 97th percentile.
2.81	[AM] presented at Djerriwarrh by ambulance at around 0320 hours on 14 January 2014 at 36.6 weeks gestation. [AM] was assessed by midwifes and CTG monitoring was undertaken for approximately 25 minutes.
2.82	A midwife called Dr Benedicto at approximately 0347 hours with concerns about [AM]’s presenting part. Dr Benedicto asked the midwife to do an ultrasound to confirm the presenting part and, if unsure of position or if they required further assistance, to telephone her back. At that time, [AM] was 8-9 cms dilated and a previous CTG had returned normal results. Dr Benedicto expected [AM] would deliver her baby quickly.
2.83	The midwives caring for [AM] identified the presenting part was cephalic and continued to care for [AM].
2.84	At around 0632 hours midwives performed an ARM and at 0634 hours [AM] gave birth to a stillborn baby. Attempts at resuscitation were unsuccessful. Dr Benedicto subsequently attended [AM] to suture a second degree tear.
2.85	Dr Benedicto was the on-call medical officer and knew, or ought to have been aware that, [AM]:
(a)	was in premature labour at 36 weeks gestation;
(b)	that her pregnancy was complicated by polyhydramnios; and
(c)	the midwives caring for her could not ascertain which part of the fetus was presenting.
2.86	At approximately 0347 hours when Dr Benedicto was contacted by a midwife, Dr Benedicto should have, but failed to,
(a)	attend the hospital and adequately review [AM]; and
(b)	recommend and/or arrange continuous CTG monitoring.
2.87	The conduct was in breach of paragraphs 2.1.1, 2.1.2 and 2.1.3 of the MBA Code.
Allegation 12
2.88	On or around 14 January 2014, Dr Benedicto failed to keep a clear and accurate patient record by failing to document placental histology, placental swabs and a perinatal autopsy and other investigations as per the Perinatal Society of Australia and New Zealand Guideline and the explanation she gave to [AM] as to what had occurred, including the cause of death.
2.89	Dr Benedicto arranged for placental histology, external swabs of the fetus and external examination of the fetus, which was undertaken at Royal Children’s Hospital.
2.90	The conduct was in breach of paragraphs 2.2.3 and 8.4 of the MBA Code.
[RI]
Allegation 13
[Allegation 13 is not pressed]
Allegation 14
2.91	[RI] presented at Djerriwarrh on 28 September 2015. At all relevant times, Dr Benedicto was involved in and responsible for the obstetric care of [RI].
2.92	Dr Benedicto failed to record the following matters with respect to her treatment of [RI] on 28 & 29 September 2015:
(a)	The degree of caput and moulding of the fetal head as a result of the labour
(b)	Any changes to the vaginal examination from those recorded at 2200 hours
(c)	The detail of her findings of her vaginal examination at around 0042 hours
(d)	That she discussed with [RI] the manual adjustment of her cervix or the use of syntrometrine in third stage labour; and
(e)	Whether the patient had an indwelling catheter and whether it was removed or left in situ.
2.93	Dr Benedicto at around 2220 hours on 28 September 2010 incorrectly recorded that a vaginal examination had shown that [RI]’s cervix was fully dilated when in fact the anterior lip was oedematous and Dr Benedicto had pushed it away.
2.94	This conduct was in breach of paragraphs 2.2.3 and 8.4 of the MBA Code.
3.	The Allegations
3.1	On 28 June 2018, the Board filed and served the Notice which sets out 14 allegations (with some allegations divided into parts). The Board subsequently filed an Amended Notice of Allegations (the Amended Notice). The Amended Notice is exhibited as Appendix A to this Agreed Statement. The Amended Notice contains Allegations numbered 1 to 14, with allegations 3, 6, 9 & 10 divided into two parts.
4.	Admissions
4.1	Dr Benedicto admits that she engaged in the conduct described by the allegations in the Amended Notice and that the conduct was in breach of the MPBV Guidelines and MBA Code as agreed in part 2 of this document.
4.2	Dr Benedicto admits that:
(a)	The allegations numbered 1, 3A, 3C, 6A and 9A, constitute professional misconduct within the meaning of paragraph (a) of the definition of professional misconduct contained in s 5 of the National Law.
(b)	The allegations numbered 4, 10A, 11 constitute unprofessional conduct as defined in s 5 of the National Law.
4.3	Dr Benedicto does not admit that:
(a)	The allegations numbered 2, 5, 6B, 8, 9C, 10B, 12 & 14, when considered together, constitute professional misconduct within the meaning of paragraph (b) of the definition of professional misconduct contained in s 5 of the National Law.
5.	Submission on determinations
5.1	The Applicant submits that the appropriate determination is as follows:
(a)	That Dr Benedicto be reprimanded; and
(b)	That Dr Benedicto be suspended for a consecutive period of 3 months commencing on a date within two months of the date of this decision.
5.2	The Respondent submits that the appropriate determination is that Dr Benedicto be reprimanded.
Determinations: general principles
30	The principles underlying determinations in professional disciplinary cases are well-established.  Their primary purpose is protective.  The focus will be on protection of the public, maintaining standards, and the reputation of and public confidence in the profession concerned.  The principles are similar to principles of criminal sentencing in some but not all respects.
31	While the primary purpose of determinations is protective not punitive, sanctions which publicly condemn a practitioner’s conduct, such as a reprimand, or which remove them from practice for a period of time, such as a suspension or cancellation, will necessarily have a punitive effect on the practitioner, but one which is in aid of the protective purposes of determinations. 
32	With that protective focus in mind, the Tribunal considers a range of factors including the nature and seriousness of the conduct, any plea of guilty, insight and remorse, the relative importance in the case of specific deterrence and general deterrence, past disciplinary history, evidence of character, mitigating factors arising from the circumstances, medical or psychological evidence or delay, and any guidance provided by comparable cases.
33	In considering the importance of specific deterrence in any case – whether there is a need to deter the individual practitioner from repeating the conduct – the Tribunal assesses any ongoing risk posed by the practitioner taking into account factors such as: 
•	Whether they have demonstrated insight into the seriousness of the conduct and how and why it occurred; 
•	Whether they have shown genuine remorse and have taken independent steps to reduce the risk of repetition; 
•	Whether similar conduct has been repeated or there have been other professional transgressions; and 
•	Whether they have any past disciplinary history, which in turn may suggest that stronger penalties may be required to deter them in future.
34	In considering the importance of general deterrence, the Tribunal looks at:
•	The nature and seriousness of the conduct and the risk it poses to the public if engaged in by others; and 
•	The related question of whether there is therefore a need to deter other members of the profession from engaging in the same conduct by signalling that adverse consequences will follow such conduct.
35	This may mean that while the practitioner themselves no longer poses a risk, a sanction may be required that sends an appropriate message to other practitioners.  As the Tribunal observed in Little at [39]-[40]:
General deterrence requires consideration of whether there is a need to signal to other members of the profession that adverse consequences will follow such conduct, and thereby deter them from the same conduct, in the interests of maintaining professional standards and public confidence in the profession. In assessing the need for general deterrence, the Tribunal takes into account the nature and gravity of the conduct and the potential consequences of others engaging in similar conduct.
In some cases, the Tribunal may decide that the particular practitioner no longer poses a risk, either because rehabilitation is complete with very little risk of offending or they have ceased practising, but that general deterrence requires an outcome that sends the appropriate signal to the rest of the profession.
36	We disagree with the submission on behalf of Dr Benedicto that sanctions are ‘to be aimed at regulating the professional performance of the particular individual under consideration’, and the suggestion that should be the focus.  The submission references only part of the observation in Honey v Medical Practitioners Board of Victoria [2007] VCAT 526 (Honey) that the Tribunal’s aim must be to protect the public:
and we achieve that aim by imposing sanctions aimed at regulating professional performance of the particular individual under consideration and also by way of general deterrence to the profession as a whole. [emphasis added]
37	Mitigating factors, and matters to the practitioner’s credit, such as an appropriate plea of guilty and an absence of any re-offending, will usually influence the penalty that might otherwise apply.  They may, for example, mean that the outcome is suspension rather than cancellation of the practitioner’s registration.
38	Contrary to the submission on behalf of Dr Benedicto, mitigating factors do not reduce the importance of general deterrence, which is an objective consideration, but may reduce the penalty ultimately imposed.  
39	As discussed below, in this case there were mitigating factors and matters in Dr Benedicto’s favour which have meant that cancellation of her registration was not required, and which have significantly reduced the period of suspension we considered appropriate.
40	Whilst the Tribunal may be assisted by submissions as to the appropriate sanction, it is ultimately in the discretion of the Tribunal as to the appropriate sanction in any given case.
41	Determinations in other cases of similar or analogous conduct will provide useful guidance.  Consistency and proportionality are important.  But every case is different, with its own combination of facts and relevant factors, including the degree of seriousness of the conduct, the length of time the practitioner engaged in the conduct, the number of patients or others impacted by the conduct, and the circumstances involved including any mitigating factors.
42	In Honey at [42]-[45], the Tribunal discussed the difference between the determinations of suspension and cancellation:
The major difference between a period of suspension and cancellation is that once the doctor’s registration is cancelled, he must reapply after the period specified. He is not guaranteed that he will be so re-registered. He must still satisfy the Board that registration is appropriate and that he fulfils the qualifications for general registration …
Cancellation of registration sends a clear message of unsuitability to practice. Suspension may be thought to indicate confidence in the doctor’s future ability to practice once the period of suspension is served. 
There are some cases in which it is abundantly clear that deregistration is the only option available to protect the public from a miscreant doctor.
This is apparent in situations in which the practitioner does not accept the inappropriateness of his conduct, or has been shown to be a serial offender.
Applying the principles
43	Both parties submitted that a reprimand is appropriate in this case.  We agree. 
44	The nature of a reprimand under the National Law is often misunderstood in the wider community as being like ‘telling off’ a child for misbehaviour.  In professional disciplinary cases, a reprimand is a serious form of censure and condemnation.  It has been observed that a reprimand will almost always follow a finding of professional misconduct.  And ‘[a] reprimand is a strong professional rebuke and indicates that the conduct is condemned by the profession’.
45	The dispute concerned whether the short suspension proposed by the Board was required.  
46	The Board submitted that it was required, principally in the interests of general deterrence, because of the nature and gravity of the conduct and the need to deter others by an appropriate signal, with the period reduced significantly to take into account the mitigating factors here.  
47	Dr Benedicto submitted, in essence, that it would serve no protective purpose and be punitive, taking into account matters such as:
•	Her junior role and the conditions she practised under, including lack of supervision and systemic failings;
•	The fact that deficiencies in her practice were not brought to her attention and she could not reasonably have been expected to have been aware of them;
•	The improvements to the quality and safety of patient care at DJHS since the Wallace Report;
•	Dr Benedicto’s participation in those quality improvement efforts;
•	Her status and authority compared to other practitioners at DJHS, who have been the subject of Tribunal findings and determinations, with the exception of Dr Lines, whose case was the closest but was nevertheless distinguishable;
•	The steps Dr Benedicto has taken to improve her skills and evidence of her safe practice since the events the subject of the allegations;
•	The delay since the events in question – Dr Benedicto has undergone six years of uncertainty and distress associated with the disciplinary investigation and action.  Of itself, this is likely to be a salutary warning to other practitioners; 
•	The risk that a suspension would deter other practitioners from diligently addressing the underlying causes of their misconduct; and
•	The potentially serious implications for the safety and continuity of maternity patient care at Bacchus Marsh Hospital because of increasing workload, staff shortages and the Hospital’s dependence on Dr Benedicto as one of only two registrars, the other being on rotation from Western Health.
48	Both the Board and Dr Benedicto submitted that specific deterrence has low importance in this case.  The following matters support that conclusion.
49	Although serious conduct extended over seven years, a fact which we do not downplay, the last of the allegations in time related to Dr Benedicto’s conduct in 2015.  
50	No further incidents have been reported.  Dr Benedicto has apparently practised well and safely, benefitting from a higher quality of supervision, and a reformed hospital governance structure.  It appears that she now appropriately seeks out supervision and consultation.  In the intervening years, she has also undertaken extensive education and improved her skills, most notably in FSEP. 
51	A table referred to in the submissions on her behalf shows that from October 2015 onwards, there has been significant improvement in the scores obtained and the level of skill indicated by the scores:
Date	FSEP score	Level	
28 April 2008	62.5 %	1	
2 June 2010	66.7 %	1	
12 June 2015	66.7 %	1	
20 August 2015	65.0 %	1	
19 October 2015	81.7 %	3	
3 November 2016	88.3 %	3	
15 September 2017	85.0 %	3	
7 June 2018	90.0 %	3	
22 August 2019	91.7 %	3	
15 March 2021	81.7 %	3	
 
52	Importantly, by her admissions in this proceeding, she has demonstrated insight into her own personal responsibility for the failures in the clinical care she provided and the inadequacy of the records she made.
53	One submission made about her personal responsibility concerned us, however, as we noted in the Background section of these reasons.  The submission was that the conduct occurred in circumstances where the deficiencies in her practice were ‘obscured’ from her; that she was not and could not reasonably be expected to be aware of those deficiencies.  This was said to be due to inadequate supervision and inappropriate endorsement of her performance by Dr Parhar and others.
54	Dr Parhar’s supervision was undoubtedly inadequate, and her performance reviews did not identify that anything was amiss.  She was working in an environment where those in a leadership position failed to ensure that adverse events including stillbirths were properly reviewed.  
55	These are mitigating factors which we take into account.  But the submission overlooks the fact that there were adverse outcomes, including four stillbirths, in the deliveries she undertook over a long period, which ought reasonably to have prompted, at the very least, some self-reflection.  
56	As example, early in the period under consideration, the allegations found proved in relation to one patient in 2008 were that Dr Benedicto:
•	Failed to adequately document her assessment of the patient;
•	Failed to arrange an emergency caesarean section prior to her attempt at forceps delivery;
•	Applied traction with forceps an unacceptable number of times;
•	Failed to work within the limits of her competence and/or supervision; and 
•	Failed to make an appropriately comprehensive, clear and accurate medical record of the obstetric management, of particular importance where, as in that case, the baby died.
57	To the extent that the submission seeks to absolve Dr Benedicto from any responsibility to make her own assessment of any deficiencies in her practice following adverse events and ensure that her practice was safe and consistent with professional standards, we reject it.  As the Tribunal observed in Lines, at [59-60]:
being registered as a doctor is a ‘privileged position’, but comes with responsibility in the sense that each and every practitioner ‘must ensure that they are able to and are practising in a safe manner’.
58	We regard the view expressed by the Tribunal in Lines at [57], in response to a similar submission, as apposite:
Nevertheless, it should have been obvious to Dr Lines in 2013 that it was unsafe for her to be the obstetrician on duty or on call when she did not have ready or reliable access to consult with Dr Parhar or another experienced obstetrician.  Even after she obtained unrestricted registration, she was a relatively junior doctor and should have known that she needed to consult with an experienced obstetrician before making critical decisions …
59	Associate Professor Weaver’s opinions on Dr Benedicto’s performance are also relevant in this context, including the following:
From the clinical material provided to me, I can say that Dr Benedicto’s performance in managing these cases was frequently associated with poor or absent documentation, with examples of poor clinical judgment, with lack of clinical skill and with repeated failures to escalate concerns or to notify her supervisor Dr Parhar. 
60	As submitted by the Board, Associate Professor Weaver repeatedly opined that Dr Benedicto’s performance was well below what would reasonably be expected of a practitioner of an equivalent level of education and training.  Her patients were entitled to expect better.
61	We recognise that international medical graduates often practice with limited registration and under visa conditions that can reduce their ability easily to move workplaces.  Any practitioner under supervision has a degree of dependence on the person who supervises them.  But every medical practitioner with registration that allows them to provide care to patients has the obligation stated in Lines.
62	Finally, poor working conditions do not absolve a practitioner, no matter how junior, from responsibility for incompetence or dangerous practice.  
63	The importance of specific deterrence is low, but not absent, in our view.
64	General deterrence has high importance in this matter.  The nature and breadth of the conduct is set out in the Notice of Allegations and recounted in the Agreed Facts.  The gravity of the conduct and the need for deterrence of others is obvious:
•	Failing to provide clinically appropriate obstetric care can potentially endanger the lives of two patients – the mother and the baby.  
•	Failing to make appropriately comprehensive, clear and accurate records of the obstetric management of maternity patients can likewise endanger them, if the records are inaccurate or incomplete, particularly if another practitioner has to step in.  As the Tribunal observed in Macrae at [67]:
Inadequate records significantly limit the ability of other practitioners to provide continuity of care, including in emergencies.  Poor documentation contributes to delays in recognising, managing, and providing urgent care to deteriorating patients.
•	Failing to recognise and work within the limits of one’s competence presents a danger in any field of patient care. 
65	As the Board submitted, when the nature and gravity of the conduct are considered, the obvious risk to patient care and safety if others were to engage in the conduct requires a strong message to be sent in this case.  Maintaining professional standards and public confidence in maternity services are also relevant considerations.
66	As stated, we reject the submission that Dr Benedicto in this case, and other practitioners in a similar situation, could not reasonably be expected to be aware of deficiencies in the standard of their practice (and so deterring them from the same conduct would be ‘illogical’).  We repeat our view that each and every practitioner bears personal responsibility for ensuring that they are able to practise in a safe manner and within the limits of their competence. 
67	We also disagree with the submission made that imposing a suspension on Dr Benedicto would deter others from diligently addressing their own deficiencies.  Practitioners have an absolute obligation to diligently address their own deficiencies.
68	As already stated, this is not a case where cancellation of registration (requiring Dr Benedicto to demonstrate to the Board in the future that she is suitable to be re-registered) is required.  It might have been otherwise if not for the length of time that has passed since the last of the conduct under consideration, which has given Dr Benedicto the opportunity over the past six years to demonstrate that she can practise safely and within the limits of her competence.  She is within the conditions for suspension rather than cancellation indicated in Honey.
69	Had it not been for the matters which are to her credit, referred to at the start of this section, and the delay, a period of suspension longer than the three months proposed by the Board might have been warranted.
70	We agree with the submission, made by both the Board and Dr Benedicto, that because Dr Benedicto was a junior practitioner, without leadership responsibilities or authority, her situation is very different to the DJHS practitioners in Little, Meek and Parhar.  In those cases, the outcome was a lengthy period of disqualification – 10, 10 and 12 years respectively – and would been cancellation if they had remained registered.  Such an outcome is not appropriate in the circumstances here. 
71	We consider that Dr Benedicto’s case is comparable to Dr Lines’, where a three-month disqualification was imposed.   Dr Lines was also an international medical graduate working with limited registration under the supervision of Dr Parhar, and in the dysfunctional environment of Bacchus Marsh Hospital.  
72	As submitted, the three-month disqualification imposed in Lines was jointly proposed to the Tribunal by the parties as appropriate and, unlike Dr Benedicto, Dr Lines did not contest it.  But a comparison of the conduct in question is not favourable to Dr Benedicto in our view:
•	In Lines, there were seven allegations proved, there are 16 here;
•	In Lines, the allegations concerned three patients, in this case eight; and
•	In Lines, the conduct occurred in the period March 2013 to August 2013, in this case the conduct extended from 2008 to 2015.
73	We also disagree with the submission that, unlike Dr Benedicto, Dr Lines did not have a substantial body of material attesting to her competence and improvement.  Although the evidence concerning Dr Benedicto is more current because she remains at Bacchus Marsh Hospital, and Dr Lines left practice in 2019, we note that the Tribunal in Lines had sufficient material to comment favourably on Dr Lines’ practice:
Dr Lines learnt from the unfortunate events that gave rise to these proceedings, and was able to resume safe practise in accordance with appropriate standards.
Conclusion
74	In our view, for the reasons above, the three-month suspension proposed by the Board appropriately balances the considerations relevant to determinations.
75	We refer to without repeating the evidence before us that suspending Dr Benedicto would have the stated adverse impact on the safety and continuity of maternity patient care at Bacchus Marsh Hospital.
76	We repeat the statement here that we have refrained from imposing a suspension, only because we do not want a decision of this Tribunal to have a potentially catastrophic impact on the safety and continuity of the care of current maternity patients at Bacchus Marsh Hospital, in a clinical setting where exceptional public health and workforce issues are playing a part, but also due to the inability of DJHS to plan for or to cover any extended absence of Dr Benedicto under circumstances which were largely foreseeable.  As stated, we hope this will be the single instance of the Tribunal being put in a position where it must do so.

E Wentworth
Senior Member and Presiding Member	Dr A Williams
Health Practitioner Member	Dr L Warfe
Health Practitioner Member	

Appendix: Amended Notice of Allegations
While working as a career medical officer (obstetrics and general) employed by Djerriwarrh Health Services (DJHS) and registered as a medical practitioner under the Health Professions Registration Act 2005 (Vic) (HP Registration Act) and/or the Health Practitioner Regulation National Law (Victoria) Act 2009 (National Law), Dr Jocelyn Benedicto:
1.1	engaged in professional misconduct as defined in s 5(a) and/or (b) of the National Law; and/or
1.2	engaged in unprofessional conduct as defined by s 5 of the National Law; and/or
1.3	engaged in unsatisfactory professional performance as defined by s 5 of the National Law –
by each of the acts or omissions as alleged in paragraphs 1-14 below.
[BL]
1.	On or about 3 November 2008, Dr Benedicto failed to provide clinically appropriate obstetric care to [BL] by her failure to identify that [BL]’s cardiotocography (CTG) trace was abnormal and to then take appropriate action.
Particulars
(a)	At all relevant times Dr Benedicto was a registered medical practitioner and working as a career medical officer (obstetrics and general) at DJHS.
(b)	Dr Benedicto was registered:
(i)	from 15 February 2008, under the HP Registration Act to undertake supervised training;
(ii)	from 1 July 2010, under the National Law with limited registration requiring her to practise under supervision;
(iii)	from 24 October 2014 under the National Law with general registration and continues to be so registered.
(c)	Dr Benedicto commenced practising in Australia on or after 15 February 2008. Dr Benedicto undertook a obstetrics-gynaecologist residency in 2003 at the Dr Pablo O Torre Memorial Hospital, Bacolod City in the Philippines and from 2004 to 2007 practised in the Philippines and the Maldives. She passed the Australian Medical Council Limited examinations on 15 August 2014.
(d)	At all relevant times, Dr Benedicto was involved in and responsible for the obstetric care of [BL].
(e)	Dr Benedicto incorrectly failed to assess the CTG trace as abnormal, in circumstances where it exhibited a baseline of 150 beats per minute, and showed reduced variability, no accelerations and some variable decelerations.
(f)	[Not pressed]
(g)	Dr Benedicto assessed the results of the CTG trace for herself and did not contact, or otherwise seek any assistance, from her supervisor Dr Parhar.
(h)	Had the CTG trace been assessed as abnormal it should have led to further intervention by or at the direction of Dr Benedicto: continuing the trace, re-positioning the mother, stimulating the fetus and, if the trace failed to normalise, considering the induction of labour.
(i)	The conduct was in breach of paragraphs 1aDP1, 1bDP2 1aDP2 and 1aDP3 of the Medical Practitioners Board of Victoria Good Medical Practice: Guidelines on Professional Conduct: December 2006 (MPBV Guidelines).
[BR]
2.	On or about 25 November 2008, Dr Benedicto failed to provide clinically appropriate obstetric care to [BR] by her failure to adequately document her assessment of [BR].
Particulars
(a)	It refers to and repeats the particulars in paragraphs (1)(a) and (c) above.
(b)	At all relevant times, Dr Benedicto was involved in and responsible for the obstetric care of [BR].
(c)	Dr Benedicto was asked to review [BR] because of variable decelerations and meconium stained liquour (the Emergency Presentation).
(d)	Dr Benedicto did not adequately document the following at both 22:30 and/or 22:35 hours:
(i)	vaginal examination (other than recording that the patient was 9cm dilated) and assessment of fetal presentation, station, position or degree of caput and moulding;
(ii)	abdominal examination to check for fetal head still palpable above the pelvic brim;
(iii)	urinary catherization, and consent for the procedure.
(e)	The conduct alleged in paragraph 2 was in breach of paragraph 1bDP3 of the MPBV Guidelines.
3.	On or about 25 November 2008, Dr Benedicto failed to provide clinically appropriate obstetric care to [BR] by:
3A	Failing to arrange an emergency caesarean section prior to her attempt at forceps delivery.
Particulars
(a)	It refers to and repeats the particulars in paragraphs 2(a)-(c) above.
(b)	[Not pressed]
(c)	At about 22:35 hours Dr Benedicto attempted to deliver [BR]’s baby by forceps delivery on the labour ward without first arranging for theatre to be opened in the event that the forceps delivery was unsuccessful.
(d)	The conduct alleged was in breach of paragraphs 1aDP1, 1aDP2, 1aDP3, and 1bDP8 of the MPBV Guidelines.
3B	[Not pressed]
3C	Applying traction with forceps an unacceptable number of times.
Particulars
(a)	It refers to and repeats paragraph the particulars in paragraph 3A(a) above.
(b)	Dr Ben[e]dicto made five pulls on the forceps, but the procedure should have been abandoned after no more than three pulls because no descent of the fetal head occurred.
(c)	The conduct was in breach of 1aDP2 of the MPBV Guidelines.
4.	On or about 25 November 2008, Dr Benedicto failed to provide clinically appropriate obstetric care to [BR] by her failure to recognise and work within the limits of her competence and/or supervision.

Particulars
(a)	It refers to and repeats the particulars to paragraphs 2 and 3 above, including the Emergency Presentation;
(b)	The emergency caesarean section was performed by Dr Benedicto in circumstances where [BR] was at full dilation and after a failed forceps delivery.
(c)	In the circumstances, Dr Ben[e]dicto should have but failed to:
(i)	tell her supervisor Dr Parhar about the clinical situation before the attempted forceps delivery;
(ii)	ask her supervisor Dr Parhar to attend for the attempted forceps delivery and the emergency caesarean section.
(d)	The conduct was in breach of paragraph 1bDP2 of the MPBV Guidelines.
5.	On or about 25 November 2008, Dr Benedicto failed to make an appropriately comprehensive, clear and accurate medical record of the obstetric management of [BR].
Particulars
(a)	It refers to and repeats particulars to paragraphs 2-4 above.
(b)	Dr Benedicto failed to record sufficient information about her assessment of [BR] and her attempted forceps delivery and emergency caesarean section including:
(i)	The fetal head’s station, urinary catheterisation, analgesia, consent, episiotomy;
(ii)	The strength used to exert traction.
(c)	Dr Benedicto failed, in whole or in part, to record a legible operation note of the emergency caesarean section.
(d)	Dr Benedicto failed to record in detail a full and accurate explanation to her patient of the circumstances of the labour, delivery and the outcome.
(e)	Dr Benedicto incorrectly recorded the ‘decision to incision time’ of the caesarean section on the Confidential Medical Report on Perinatal Death following the stillbirth of [BR]’s baby.
(f)	Dr Benedicto failed to document the fact of and content of her discussion with Dr Parhar following the unsuccessful forceps delivery of [BR]’s baby.
(g)	The conduct was in breach of paragraph 1bDP3 of the MPBV Guidelines.
[CA]
6.	On or about 11 February 2009 Dr Benedicto failed to provide clinically appropriate obstetric care to [CA] by her:
6A	Failure to identify that the CTG trace of [CA]’s baby was abnormal and take appropriate action.
Particulars
(a)	It refers to and repeats the particulars in paragraphs 1(a) - (c) above.
(b)	At all relevant times, Dr Benedicto was involved in and responsible for the obstetric care of [CA].
(c)	On 11 February 2009, at 35 weeks gestation, [CA] called Melton Health and expressed her concern about reduced fetal movements (Reduced Fetal Movements).
(d)	[CA] then attended Bacchus Marsh Hospital for CTG monitoring and the CTG trace was initially assessed by a midwife.
(e)	Dr Benedicto reviewed the CTG Trace.
(f)	Dr Benedicto incorrectly assessed and documented the CTG trace as normal, when in fact it was abnormal within the meaning of the RANZCOG Intrapartum Fetal Surveillance Guidelines (Second edition) because it showed reduced variability and a deceleration at around 1320.
(g)	[Not pressed];
(h)	Dr Benedicto assessed the results of the CTG trace for herself and did not contact, or otherwise seek any assistance, from her supervisor Dr Parhar;
(i)	Had Dr Benedicto correctly assessed the CTG trace she ought to have:
(i)	arranged to reapply and/or continue the CTG trace for a longer period of time;
(ii)	required a bed side-scan for liquour volume;
(iii)	considered fetal well-being and induction of labour.
(j)	The conduct was in breach of paragraphs 1aDP1, 1aDP2 and 1aDP3 of the MPBV Guidelines.
6B	Failure to make appropriately comprehensive, clear and accurate medical records of the obstetric management of [CA].
Particulars
(a)	It refers to and repeats the particulars in paragraphs 6A(a)-(c) and (e) above, including the Reduced Fetal Movements.
(b)	Dr Benedicto failed to record any information regarding any assessment or review of [CA].
(c)	The conduct was in breach of paragraph 1bDP3 of the MPBV Guidelines.
[JM]
7.	[Not pressed]
8.	On or about 17 and 18 February 2008, Dr Benedicto failed to make an appropriately comprehensive, clear and accurate medical record of her obstetric management of [JM].
Particulars
(a)	It refers to and repeats the particulars in paragraphs 1(a) - (c) above.
(b)	At all relevant times, Dr Benedicto was involved in and responsible for the obstetric care of [JM].
(c)	On 17 February 2008, there was an antenatal consultation between Dr Benedicto and [JM].
(d)	Dr Benedicto failed to document any discussion with the patient about the risks and benefits of induction of labour and the use of syntocinon at the antenatal consultation.
(e)	The conduct was in breach of paragraph 1bDP3 of the MPBV Guidelines.
[BE]
9.	On or about 14 April 2009, Dr Benedicto failed to provide clinically appropriate obstetric care to [BE] by her:
9A	Failure to develop a suitable management and/or treatment plan in light of her placental abruption, as appropriate by:
(1)	Failing to document any discussions with [BE] about a management plan for her condition.
(2)	Failing to adequately discuss [BE]’s condition with her supervisor.
(3)	[Not pressed].
(4)	Making inappropriate and inadequate post-operative orders and management plan.

Particulars
(a)	It refers to and repeats the particulars in paragraphs 1(a) - (c) above.
(b)	At all relevant times, Dr Benedicto was involved in and responsible for the obstetric care of [BE].
(c)	[BE] was admitted on 14 April 2009 and had suffered an antepartum haemorrhage, she was assessed by Dr Benedicto who diagnosed probable fetal death in utero secondary to placental abruption.
(d)	Dr Benedicto decided to perform an emergency caesarean section, and made this decision without informing her supervisor and obtaining his opinion or assistance.
(e)	[Not pressed]
(f)	Dr Benedicto should have made and documented post-operative orders for management in a high dependency area/for additional and specified monitoring, to check for developing coagulopathy, oxytocin infusion, hourly measures of urine output, emergency checking of haemoglobin level to guide blood replacement, regular review of the patient and the involvement of her supervisor or a senior consultant.
(g)	[Not pressed]
(h)	The conduct was in breach of paragraphs 1bDP3 and 1bDP4 of the MPBV Guidelines.
9B	[Not pressed].
9C	Failure to keep a clear and accurate patient record by either contemporaneously or retrospectively:
Particulars
(a)	It refers to and repeats the particulars to paragraph 9A above;
(b)	Dr Benedicto failed to record sufficient information about her assessment, management plan and treatment of [BE], including:
(i)	a detailed management plan;
(ii)	the reason for emergency caesarean section;
(iii)	the detail of any discussion with [BE];
(iv)	In the alternative to 9A above, her concern about [BE]’s blood loss, the need for transfusion, the possibility of administering un-cross matched O Negative blood for the patient rather than waiting for cross matched blood and the need for other blood products;
(v)	what blood products had been ordered.
(c)	Failure to record legible progress and operation notes.
(d)	Writing progress notes, a referral letter to the Royal Women’s Hospital and a Confidential Medical Record on Perinatal Death which conflict with one another and the Birth Record.
(e)	Failure to adequately document any explanation after the caesarean section to [BE] of what happened.
(f)	The conduct was in breach of paragraph 1bDP3 of the MPBV Guidelines.
9D	[Not pressed].
[TH]
10.	On or about 8 and 9 April 2010, Dr Benedicto failed to provide clinically appropriate obstetric care to [TH] by her:
10A	Failure to arrange necessary investigations of fetal wellbeing.
Particulars
(a)	It refers to and repeats the particulars in paragraphs 1(a) - (c) above;
(b)	At all relevant times, Dr Benedicto was involved in and responsible for the obstetric care of [TH].
(c)	On about 7 April 2010, [TH] presented at Bacchus Marsh Hospital with reduced fetal movements and a bloody show at which time a CTG was conducted and arrangements were made for her to be reviewed the next day.
(d)	On about 8 April 2010, Dr Benedicto saw [TH] and should have but did not arrange for CTG monitoring.
(e)	The conduct was in breach of paragraph 1aDP2 of the MPBV Guidelines.
10B	Failing to keep a clear and accurate patient record by:
(1)	Failing to adequately document a follow up and/or management plan and her discussion with [TH] on 8 April 2010 about reduced fetal movements.
(2)	Following the birth on 9 April 2010, failing to document sufficient information about her repair of [TH]’s perineal tear including:
(i)	how she repaired the tear,
(iii)	what local anaesthetic she used;
(iv)	any advice to [TH] as to follow up including to re-present if her bleeding was too heavy or if she had other concerns;
(v)	any discussion with [TH] about her incomplete placenta.
Particulars
(a)	It refers to and repeats the particulars in paragraphs 10A(a) and (b) above.
(b)	The conduct was in breach of paragraph 1bDP3 of the MPBV Guidelines.
[AM]
11.	On or around 14 January 2014, Dr Benedicto failed to provide clinically appropriate obstetric care to [AM] by failing to appropriately assess [AM] by:
(1)	failing to review [AM] in the intrapartum period or perform any intrapartum assessment; and
(2)	failing to recommend and/or arrange continuous CTG fetal monitoring.
Particulars
(a)	It refers to and repeats the particulars in paragraphs 1(a) - (c) above;
(b)	At all relevant times, Dr Benedicto was, or ought to have been, involved in and responsible for the obstetric care of [AM].
(c)	On 14 January 2014, [AM] presented at Bacchus Marsh Hospital.
(d)	Dr Benedicto was the on-call medical officer and knew or ought to have been aware that: (i) the patient was in premature labour at 36 weeks gestation; (ii) that her pregnancy had been complicated by polyhydramnios (iii) the midwives caring for her could not ascertain which part of the fetus was presenting.
(e)	In the circumstances, Dr Benedicto should have, but failed to, attend the hospital and:
(i)	adequately review [AM];
(ii)	recommend and/or arrange continuous CTG fetal monitoring.
(f)	The conduct was in breach of paragraphs 2.1.1, 2.1.2 and 2.1.3 of the Medical Board of Australia Good Medical Practice: A Code of Conduct for Doctors in Australia (MBA Code).
12.	On or around 14 January 2014, Dr Benedicto failed to keep a clear and accurate patient record by appropriately documenting investigations into the stillbirth of [AM]’s baby and/or by adequately documenting any counselling and explanation she gave to [AM].
Particulars
(a)	It refers to and repeats the particulars in paragraphs 11(a) - (c) above.
(b)	[AM]’s baby was stillborn.
(c)	Dr Benedicto should have but failed to document: placental histology, placental swabs, a perinatal autopsy and other investigations as per the Perinatal Society of Australia and New Zealand’s Guideline and the explanation she gave to [AM] as to what had occurred including the cause of death.
(d)	The conduct was in breach of paragraphs 2.2.3 and 8.4 of the MBA Code.
[RI]
13.	[Not pressed].
14.	On or around 28 and 29 September 2015, Dr Benedicto failed to keep a clear, accurate and legible patient record in respect of her obstetric care of [RI].
Particulars
(a)	It refers to and repeats the particulars in paragraphs 1(a) - (c) above.
(b)	At all relevant times, Dr Benedicto was involved in and responsible for the obstetric care of [RI].
(c)	Dr Benedicto should have but failed to record:
(i)	the degree of caput and moulding of the fetal head as a result of the labour;
(ii)	any changes to the vaginal examination from those recorded at 2220 hrs;
(iii)	the detail of her findings of her vaginal examination at around 0042 hours;
(iv)	that she discussed with [RI] the manual adjustment of her cervix or the use of syntrometrine in third stage labour;
(v)	whether the patient had an indwelling catheter and whether it was removed or left in situ.
(d)	Dr Benedicto at around 2220 hrs on 28 September 2010, recorded that a vaginal examination had shown that [RI]’s cervix was fully dilated when in fact the anterior lip was oedematous and Dr Benedicto had pushed it away.
(e)	The conduct was in breach of paragraphs 2.2.3 and 8.4 of the Medical Board of Australia Good Medical Practice: A Code of Conduct for Doctors in Australia 2014 (the 2014 MBA Code).