The sorry story of Dr Teo is not isolated (ST,9710), with the Health Care Complaints Commission receiving up to 7000 annual complaints. A very busy, under-resourced organisation will show delays in its procedures. There are in-built failings in the system which must be addressed, even though achieving fairness is unlikely in a process that has become part of the legal system (which is renowned for delivering process rather than Justice). Often senior doctors referring colleagues to the HCCC are known consultant members of that organisation, biasing the defence of the referred doctor. The HCCC punishes “risky behaviour” even if there is no adverse outcome, which surely suggests that the clinical decision-making was not so bad in retrospect. Doctors have been condemned by the HCCC without adverse clinical outcomes, but because their judgment created suspicion. In a modem operating theatre where most decisions are collaborative, isolating one individual for blame would sound odd, yet it occurs. Reform of the HCCC is obstructed when many doctors have left hospitals in disgust, signing non-disclosure agreements on departure. The complexity of practice results in loss of skills during suspension. This is toxic when delays in HCCC procedure extend up to five years. If Dr Teo has been sidelined from practice, the irreparable damage to his future legacy may already have been done. Alan Sexton, North Parramatta. 16Oct2022.