Medical Board of Australia v Tausif  ACAT 4 raises significant issues about the extent to which a Tribunal addressing public protection and safety should consider not just the conduct of a registered practitioner but also the nature of the system in which he or she practises, including that system’s levels of training, supervision, mentorship and quality control: .
At  the Tribunal observed that that the respondent’s professional problems appeared to have gone undetected, uncorrected and unreported in the two practices in which she worked for approximately three years (seeing 40 – 50 patients per day, with a contractual obligation to work 45 hours per week for 48 weeks per year) and said:
….it was relevant for the Tribunal to consider whether she received adequate mentoring and supervision in those practices, so that she could most effectively provide medical services to the public in a way that could (as required by the relevant legislation) guarantee their protection and safety.
At  the Tribunal found that the doctor’s professional misconduct was substantially contributed to by the lack of clinical supervision and mentorship she experienced the practices where she worked.
…This lack of supervision and mentorship was not due to any fault by …(the lead clinicians at the practice) . Rather, it was due to the contractual organisation of the relationships of doctors with the management of the practices. Specifically, it appears to have been due in large part to a failure of the leadership of …(the practices)… to engage properly in its governance arrangements with the requisite professional standards required for public protection and safety.
Protective orders were made which included future work being at a place where the doctor would be supervised by a Board-approved supervisor prepared to comply with Level 2 Supervision requirements as contained in the Board’s Guidelines for Supervision.