'Woefully inadequate' - NZ Dr can practise here but not in Australia

Dr Kate Taylor, Waikato Sexual Assault Assessment and Treatment Service lead clinician.

A Waikato gynaecologist who gave what he called a ‘date rape’ drug for pain to a woman he met on a sugar daddy website has been suspended for three months in New Zealand but is suspended indefinitely from practising in Australia.

A doctor who reported Nalendra Appanna to authorities in 2019 says a three-month suspension from practise is “woefully inadequate and disproportionate to the seriousness of the findings” of the New Zealand Health Practitioners Disciplinary Tribunal (HPDT), which found his behaviour amounted to professional misconduct.

In a decision released on December 22, the HPDT found Nalendra Appanna, a specialist obstetrician and gynaecologist, who met a woman in her 20s on a ‘sugar daddy’ website in May 2019, had blurred professional boundaries by offering and providing health services to someone with whom he was sexually intimate over the course of several months.

Appanna asked her to undergo a sexually transmitted infection (STI) test before they engaged in sexual activity, and then took her to his clinic where he performed the test himself. He also gave her a class C controlled drug when she complained of pain during a meeting between the pair.

He was suspended for three months in New Zealand but is indefinitely suspended from practising in Australia, where he was also registered as a health practitioner, despite attempts to appeal the Australian suspension.

Appanna was found, among other things, to have provided medical services directly linked to the initiation of a sexual encounter. He also videoed for his benefit, the sexual encounters he had with her and refused to delete them completely at her request as the video included her consent to their activity. Police became involved, but didn’t lay charges.

‘Woefully inadequate’ penalty

The doctor who reported Appanna to the New Zealand Medical Council - Sexual Assault Assessment and Treatment Service lead clinician Dr Kate Taylor - told 1News the woman involved, referred to in the HPDT decision as Ms Y, initially approached the MSASS (Midlands Sexual Assault Support Service) for support.

“Once they were aware of what she was saying had occurred, a meeting was arranged with Ms Y, the police and myself (as a doctor involved in supporting victims of sexual assault).

Taylor said “having heard from Ms Y’s report of the events that had taken place between her and Dr Appanna, I was sufficiently concerned that there may have been a significant breach of professional conduct to warrant Medical Council involvement".

“All members of the medical profession have a duty to maintain high levels of professional behaviour; we have a social contract with the community that in return for their trust we are held to act under ethical codes to protect patients. When there is a possibility there has been a significant breach of those codes it is important in order for the public to be able to maintain their faith in the profession that it is looked into, and the person held to account were deemed appropriate.”

Taylor said she is concerned that the outcome in this case was the suspension was reduced to three months from a 12-month starting point.

In determining the suspension, the HPDT noted a number of factors – that it had been some three years since the incidents in question, the hearing had been adjourned twice due to Covid restrictions, Appanna had provided favourable references, and he had been practising with a chaperone in the meantime.

“It seems to be woefully inadequate and disproportionate to the seriousness of the findings. Covid slowed everything down. There wasn’t an industry/workforce in the country that wasn’t impacted. It doesn’t make sense that he should get to have a reduction in his suspension because of that. The victim doesn’t get a swifter recovery because of Covid,” Taylor said.

“She has had the process drawn out for over three years, hindering her recovery. During that time Dr Appanna was able to continue practising and had [interim] name suppression. He now has three months suspension from 5 December 2022, effectively giving him an extended summer break (during a time when a high proportion of medical specialists in New Zealand are also off work).”

Taylor said it is important not to judge Appanna for his lifestyle choices.

“The problem lies with his merging of his professional and private lives. By seeing people in his clinic rooms for sexual encounters, by giving medications and taking intimate medical swabs in the context of a sexual encounter he has very clearly failed to separate one from the other.

“Of substantial concern is that now a precedent has been set of a three-month suspension in cases such as this. It is hard to see a situation in which a victim would willingly step up to participate in a lengthy traumatising process to find at the very end of it all the doctor gets is a three-month suspension. And that will not serve the New Zealand public well.

“We owe Ms Y a huge debt of gratitude for having the courage to stay the course for the length of time required in order for a light to be shone on his behaviour. It is now the responsibility of our system to keep the public safe, to reassure them that they can trust the medical profession, that their concerns will be taken seriously and to the medical community that they will do their utmost to ensure that the standards of ethical care we agree to are being upheld.”

Sedation drug ‘extremely concerning’

Prescription medication.

Ms Y suffers from a chronic health condition which Appanna was aware of. After a complaint about being too sore to do anything with Appanna, Appanna gave her a tablet of midazolam which he told the HPDT “he considered would help her by taking the edge off her pain”. He also offered to refer her to a pain clinic.

Taylor said midazolam is given in the context of unpleasant surgical/medical procedures, as it is sedating, and is extremely concerned that it was provided to Ms Y.

“Midazolam is not an analgesic and should not be given solely for pain relief.”

The Tribunal found that Appanna was negligent in providing the drug to Ms Y as there was no record of the medication being prescribed and he did not monitor Ms Y after she went home as she was still unwell.

In the Australian proceedings where Appanna was attempting to appeal the suspension of his Australian medical registration, Appanna admitted he told Ms Y the tablet was a ‘date rape’ drug, but that it was given after, not before, sexual activity.

In an interview submitted in the Supreme Court of Victoria, Ms Y described this as having been "a scary thing to say to someone" and said that she had been "weirded out" by it and had only taken half of the Midazolam tablet provided.

Appanna’s actions

 Doctor’s examination room, file.

The HPDT decision noted, between May and July 2019, Ms Y and Appanna, who has been in medical practice for at least 36 years, would meet at his clinic.

Appanna also performed a vaginal swab on the woman in his examination room, to detect any sexually transmitted infections before exchanging in sexual activity. Details were entered into his computer, but the (negative) results were not sent to her GP, on her request.

Despite not having the results, Appanna, on that same occasion tied Ms Y to a chair next to the bed and engaged in sexual activity with her.

Appanna gave her $100, to help her with food and other expenses as she was struggling financially.

The HPDT noted Appanna printed a contract which contained all the rules that he expected of a [sexual] “subordinate.” The contract was never signed by Ms Y.

Appanna filmed their sexual activity on a tripod that he had at his clinic. At the beginning of each recording, he would get Ms Y to state that she consented to the sexual acts that he was doing. After filming, Appanna would then put the video on his work computer and would play it back.

After Ms Y said she was too sore to do anything with Appanna, she claims he said, “You know I’m a doctor, I can prescribe you anything you want aye?”. Ms Y said that it was “like him flaunting his doctor’s powers to her, telling her how powerful or important he was and what he could do for her if they stayed “friends”.”

Ms Y told the HPDT that she did not accept that the offer of midazolam was a genuine attempt to try to help her with her pain. She thought that it was so that she would be well enough to do what he wanted her to do.

After the last meeting with the woman, Appanna travelled to Australia and performed locum duties in a rural location. He sent Ms Y a photograph of a patient taken after a delivery, and claims it was with the permission of that patient.

Less than a month later, the woman asked Appanna to delete the videos he had taken of their sexual activity at his clinic. He refused to, but offered to edit the video to retain the sound only. It was revealed in the HPDT that Appanna wanted to keep an audio recording because it included Ms Y’s consent to the sexual activity.

Concerned about this, Ms Y went to the Midland Sexual Health Support Services, which led to a meeting with her, the police and Dr Taylor, who made a complaint about Appanna to the Medical Council on behalf of Ms Y. No charges were laid.

The HPDT decision

Appanna was suspended indefinitely from practising in Australia in 2021, a decision upheld in two proceedings in Victorian courts. However, he was still allowed to practise in New Zealand while under investigation by the Professional Conduct Committee (PCC), appointed by the Medical Council, albeit with a chaperone.

The HPDT said in its decision, it found Ms Y to be “a fair and articulate witness. Although somewhat diffident in her examination-in-chief, and more forthright under cross-examination, there was little attempt to claim naivete or being a victim”.

In its decision, the HPDT found, among other things, that:

- There was a blurring of boundaries as Appanna provided medical care to someone he had a close personal relationship with, and he engaged in sexual activity at his clinic;

- Providing the STI test was contrary to the standards expected of a reasonable medical practitioner;

- Providing midazolam with no record keeping or follow-up was negligent; and

- Sending the photograph of the patient in Australia was unprofessional and negligent.

It reached the conclusion that a period of suspension of up to 12 months was warranted to “make it clear to Dr Appanna and the profession that behaviour such as his will not be tolerated”.

But the penalty was reduced to three months.

Appanna was ordered to pay $74,296 in costs and work under supervision for one year.

Appanna’s suspension began on December 5 and will lapse on March 5 when he can practise again. His interim name suppression also lapsed on December 5 as he dropped his application for permanent name suppression.

“Dr Appanna’s decision not to pursue [permanent] name suppression is a relevant factor. This gives women some information upon which to base their choice of gynaecologist,” the Tribunal said.

For a period of three years Appanna has to inform any employer, practice partner or health care provider to whom he contracts his medical services of the Tribunal’s decision.

In a statement to 1News, a Medical Council spokesperson said its role is to ensure public health and safety is protected by using the processes available to it.

“The Council immediately considered what steps it needed to take to protect and assure the safety of the public and made a decision to suspend Dr Appanna from practising in New Zealand.

“The District Court ordered a stay of his suspension and that the Council and Dr Appanna agree to a voluntary undertaking. This undertaking required Dr Appanna to observe various requirements in his practise, including requiring a chaperone be present for examinations and procedures. The Council is aware Dr Appanna is suspended from practising in Australia.”

The spokesperson said it’s the Tribunal (not the Medical Council) that hears and determines disciplinary proceedings brought against health practitioners. This includes deciding what the appropriate sanctions should be.

“We operate under different laws to the Medical Board of Australia. Dr Appanna’s suspension in Australia is an interim suspension, and not the result of a completed disciplinary process. The Medical Council of New Zealand suspended Dr Appanna on similar grounds. This was overturned by the District Court.”

The Australian Courts’ decision

Supreme Court of Victoria.

Appanna was suspended in Australia in March 2021, nearly 18 months before the HPDT decision in New Zealand. He appealed his suspension to the Victoria Civil and Administrative Tribunal (the Victoria Tribunal) where they upheld the suspension, finding there was a “reasonable belief” that he posed a serious risk and immediate action was needed to protect the public or public confidence.

The Tribunal did not make findings of fact against him. However, it did find that he had a “disturbing lack of insight into the nature of what he did and the problems with it,” and that he posed a risk of misusing his position as a medical practitioner to women he might meet out of hours.

While he was allowed to practise with a chaperone while under investigation in New Zealand, the Australia authorities determined a chaperone wouldn’t address the risk in Australia as the concerns were with his conduct outside of hours.

Appanna sought leave to appeal the Victoria Tribunal’s decision to the Supreme Court of Victoria. It was heard in October 2021 before Judge O’Meara and was again, unsuccessful for Appanna.

In refusing Appanna’s application, Judge O’Meara noted the “absence of any proper insight into the nature of his actions and the risk that they could present”.

“Aspects of the applicant’s material are, in my view, of considerable concern; especially coming from a senior medical practitioner of long experience whose specialty is obstetrics and gynaecology. Indeed, some of it is downright alarming,” Judge O’Meara noted.