Civil and Administrative Tribunal New South Wales Medium Neutral Citation: Health Care Complaints Commission v Abdalla (Pharmacist) [2020] NSWCATOD 73 Hearing dates: On the papers Date of orders: 02 July 2020 Decision date: 02 July 2020 Jurisdiction: Occupational Division Before: The Hon F Marks, Principal Member R Samimi, Senior Member J Chen, Senior Member R Kusuma, General Member Decision: In consequence of our finding of professional misconduct we make the following orders; (1) if the respondent had remained registered as a pharmacist we would have cancelled his registration effective as at this date. (2) the respondent is disqualified from being registered as a pharmacist for a period of 3 years from this date (3) we ask the Registrar of this Tribunal to request the Pharmacy Board of Australia to record the fact that the Tribunal would have cancelled the respondent's registration in the National Register kept by the Board (4) costs are reserved with liberty to apply which must be exercised within one month of this date. Catchwords: PROFESSIONS AND TRADES – pharmacist also registered as medical practitioner proprietor of pharmacy adjoining medical practice – held conflict of interest with respect to circumstances of employed pharmacists dispensing prescriptions issued by respondent – held in circumstances where history of inappropriate filling of prescriptions for drugs of addiction respondent as proprietor was in breach of Guidelines issued by Pharmacy Board of Australia – finding of professional misconduct – finding that registration as a pharmacist would have been cancelled if the respondent had remained registered – consequential orders made – costs reserved Legislation Cited: Health Practitioner Regulation National Law (NSW) Poisons and Therapeutic Goods Regulation 2008 (NSW) Civil and Administrative Tribunal Act 2013 (NSW) Cases Cited: Health Care Complaints Commission v Abdalla [2020] NSWCATOD 20 Health Care Complaints Commission v Do [2014] NSWCA 307 Spicer v NSW Medical Council (unreported, CA No.3 of 1981, 19 February 1981) Category: Principal judgment Parties: Health Care Complaints Commission (Applicant) Dr Hany Abdalla (Respondent) Representation: Counsel: K Burke (Respondent) Solicitors: Health Care Complaints Commission (Applicant) Meridian Lawyers (Respondent) File Number(s): 2019/00388291 Publication restriction: The publication of the name of any person whose prescription was processed by the pharmacy formerly owned by the respondent which is the subject of these proceedings and any information which may tend to identify any such person is prohibited. REASONS FOR DECISION Background 1. In these proceedings the applicant, the Health Care Complaints Commission complains that the respondent Dr Hany Mahmoud Abdalla is guilty of unsatisfactory professional conduct and professional misconduct as those expressions are defined in the Health Practitioner Regulation National Law (NSW) ("the National Law)" in his capacity as a pharmacist. Relevantly, the application filed by the applicant is in the following terms The Health Care Complaints Commission of Level 12, 323 Castlereagh Street, Sydney NSW, having consulted with the Pharmacy Council of NSW in accordance with sections 39(2) and 90B(3) of the Health Care Complaints Act 1993 and section 145A of the Health Practitioner Regulation National Law (NSW) ("the National Law") HEREBY COMPLAINS THAT Dr Hany Mahmoud Abdalla ("the practitioner") of [address removed], Auburn NSW 2144 being a pharmacist registered under the National Law, COMPLAINT ONE The practitioner is guilty of unsatisfactory professional conduct under section 139B(1)(a) and/or (l) of the National Law in that the practitioner has: i. engaged in conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of pharmacy is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience; and/or ii. engaged in improper or unethical conduct relating to the practice or purported practice of pharmacy. BACKGROUND FOR ALL COMPLAINTS In 2000 the practitioner earned a Bachelor of Pharmacy degree from the University of Sydney. On 23 January 2002 he was first registered as a pharmacist. In June 2002 the practitioner purchased a 50% share in the Auburn Late Night Chemist located at 79 Auburn Rd, Auburn NSW 2144 ("the pharmacy"). Until late 2002 while completing his medical degree, the practitioner worked as a pharmacist at the pharmacy. From 2006 he became the sole proprietor of the Auburn Late Night Chemist but no longer worked as a pharmacist in the pharmacy. On 10 January 2015 the practitioner was first registered as a medical practitioner. From 2006 to September 2017 the practitioner worked as a general practitioner at the NAS Advanced Medical Centre, 79 Auburn Road, Auburn NSW 2144 ("the medical centre"). The pharmacy was adjacent to the medical centre. From 2006 to September 2017 the practitioner was both the proprietor of the pharmacy and a general practitioner at the medical centre. PARTICULARS OF COMPLAINT ONE 1. From 2006 until approximately September 2017, the practitioner failed to recognise and appropriately manage the conflict or potential conflict between his position as proprietor pharmacist of the pharmacy and his position as a general practitioner employed at the medical centre in circumstances where: a. the practitioner was aware that many of his patients would present prescriptions he had issued for dispensing by his employed pharmacists at the pharmacy due to its close proximity to the medical centre; b. the practitioner's patients may not have been aware of the practitioner's financial and professional relationship with and role as employer at the pharmacy and the practitioner took no steps to ascertain and inform his patients of this; c. the pharmacists he employed at the pharmacy may have felt constrained from scrutinising or questioning prescriptions written by the practitioner in fulfilment of their professional obligations because the practitioner was their employer and the practitioner failed to provide clarity and guidance to his employed pharmacists on this. 2. From 2006 – 2 June 2016 the practitioner failed to discharge his obligations as the proprietor of the Auburn Late Night Chemist, in that he did not: a. maintain an adequate awareness of the manner in which the pharmacy's dispensing practice was being conducted by his employed staff, and failed to intervene in the practice, when necessary; b. establish, implement and monitor adherence to systems and protocols for the safe and legal supply of schedule 4D and schedule 8 medications in compliance with regulations 39, 40(1), 54, 79, 80, 85, 87 and 109 of the Poisons and Therapeutic Goods Regulation 2008 (NSW); c. establish, implement and monitor adherence to systems and protocols to support staff to raise concerns or questions about unusual or unsafe prescribing with the prescribing doctor, colleagues or other external persons and bodies; d. establish, implement and monitor adherence to systems and protocols for his employed staff to raise concerns or questions about prescriptions written by the practitioner. 3. By his conduct in particular (2) from December 2010 to June 2016 the practitioner failed to comply with the Pharmacy Board of Australia's Guidelines on responsibilities of pharmacists when practicing as proprietors (December 2010) and Guidelines for proprietor pharmacists (September 2015). COMPLAINT TWO Is guilty of unsatisfactory professional conduct under section 139B(1)(c) and/or 139B(1)(l) of the National Law in that the practitioner has: i. contravened a condition to which the practitioner's registration was subject; BACKGROUND TO COMPLAINT TWO On 6 January 2017 the practitioner informed the Pharmacy Council of NSW ("the Council") by email that he would consent as a pharmacist to various conditions on his registration as a pharmacist. On 10 January 2017 the Council requested the practitioner sign a consent to conditions form. On 12 January 2017 the practitioner signed and returned his written consent to conditions form to the Council. The conditions the practitioner consented to included the following condition: Unless it has already occurred, must attend the offices of the Pharmaceutical Regulatory Unit of the NSW Ministry of Health by close of business on 13 January 2017 and surrender his drug authority under the provisions of the Poisons and Therapeutic Goods Regulation 2008 (NSW). ("Condition 6") PARTICULARS OF COMPLAINT TWO 1. On 18 April 2018 the practitioner surrendered his drug authority as a pharmacist to the Pharmaceutical Regulatory Unit of the NSW Ministry of Health. 2. Between 12 January 2017 and 18 April 2018 the practitioner failed to comply with Condition 6. COMPLAINT THREE The practitioner is guilty of professional misconduct under section 139E of the National Law in that the practitioner has: i. engaged in unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration, and/or ii. engaged in more than One instance of unsatisfactory professional conduct that, when the instances are considered together, amount to conduct of a sufficiently serious nature to justify the suspension or cancellation of the practitioner's registration PARTICULARS OF COMPLAINT THREE 1. Complaint One is repeated and relied upon individually. 2. Complaints One and Two are repeated and relied upon cumulatively. 1. With the consent of the parties the Tribunal has determined to deal with these proceedings on the basis of documentary evidence filed by the parties, and without the need for a hearing. In addition to this extensive evidentiary material the parties have filed written submissions. We proceed to deal with these proceedings on this basis. The issues for determination 1. In the course of providing submissions dated 1 May 2020 the applicant indicated that it no longer wished to rely on particular 1(b) of Complaint One. In a Response to the application the respondent made the following admissions; 1. with respect to Complaint One that his conduct was significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience and that his conduct amounted to unsatisfactory professional conduct 2. Particulars 1(c), 2 and 3 of Complaint One 3. with respect to Complaint Two that he contravened a condition of his registration 4. with respect to Complaint Two that he had consented to the condition particularised having been placed on his registration as a pharmacist. 5. both particulars of Complaint Three. 1. The respondent did not admit 1. with respect to Complaint One that he engaged in improper or unethical conduct as alleged and did not admit Particulars 1(a) and (b). 2. with respect to Complaint Two that his failure to comply amounted to unsatisfactory professional conduct "having regard to all of the circumstances leading to his failure to comply with the condition." 1. It follows that the areas of controversy are within a confined compass. However, it will be necessary for us to have regard, albeit more briefly, to those portions of the complaint admitted by the respondent to enable us to assess the nature and extent of the respondent's misconduct for the purpose of considering its gravity, any resultant findings which it is appropriate to make as to the characterisation of that conduct for the purpose of the National Law, and what appropriate consequential protective orders should be made. 2. We note for completeness that the applicant has previously brought complaint proceedings against the respondent arising out of his practice as a medical practitioner, the circumstances of which form the background against which these proceedings were instituted. As will have been observed from the contents of the application set out above, the complaints arise out of the respondent's proprietorship of a pharmacy which adjoined premises from which the respondent concurrently conducted a medical practice as a general practitioner. The proceedings were determined by this Tribunal in Health Care Complaints Commission v Abdalla [2020] NSWCATOD 20. In those proceedings the respondent admitted that he had inappropriately prescribed Schedule 8 drugs of addiction for 13 patients, that he had failed to keep appropriate and proper records and that he was guilty of professional misconduct. By order made on 9 March 2020 the Tribunal imposed a reprimand and suspended his registration as a medical practitioner for a period of 6 months. Significantly, delegates of the Medical Council of NSW had conducted proceedings referable to the respondent's medical practice under section 150 of the National Law in which the respondent was questioned about a perceived conflict of interest in conducting a medical practice next to a pharmacy of which he was a proprietor. The standard of proof 1. It is well-established and uncontroversial that although we are not bound by the rules of evidence, given the seriousness of the allegations made against the respondent and the gravity of the consequences of any protective order that we might make that we must be comfortably satisfied on the balance of probabilities that any factual matter alleged by the applicant has been made out. We shall proceed to deal with the necessary fact-finding tasks on this basis. Factual background 1. The narration which follows is based upon the evidentiary material filed in the proceedings. We shall deal with this evidence in connection with each of the factual issues where there is no agreement, and then deal more generally with the issues which were not contested by the respondent. Particular 1(a) the practitioner was aware that many of his patients would present prescriptions he had issued for dispensing by his employed pharmacists at the pharmacy due to its close proximity to the medical centre; 1. The controversy between the parties as raised by the respondent in written submissions revolved around the manner in which this particular was framed. It is preceded by a general assertion that from 2006 until approximately September 2017 the respondent failed to "recognise and appropriately manage the conflict or potential conflict" as proprietor of the pharmacy and his engagement as a general practitioner in the adjoining medical centre. The allegation is that the respondent was aware that many of his patients would present prescriptions that he had issued to the adjoining pharmacy to be dispensed by his employed pharmacists. The respondent submitted that it was "unclear what it is that the respondent failed to do or ought to have done" in order to appropriately manage the conflict. 2. This submission fails to address the manner in which Complaint One should be read as a whole. Particular 1(a) provides a circumstance which is to be read, relevantly, in conjunction with Particular 1(c), namely that the employed pharmacists may have felt constrained from scrutinising or questioning the respondent's prescriptions in fulfilment of their professional obligations because the respondent was their employer. The totality of this Particular is that the respondent issued scripts in the course of his practice as a general practitioner, he knew that some of his patients would have the scripts filled at the adjoining pharmacy, and the pharmacists he employed at that pharmacy may have felt constrained from scrutinising or questioning the scripts as they were obliged to do because the respondent was their employer. 3. Particular 1(a) also needs to be read against concessions made by the respondent that he did not dispute Particulars 1(c) or 2. The essence of Particular 2 is that pharmacists are obliged under Guidelines published by the Pharmacy Board of Australia inter alia to Take reasonable steps to ensure that the dispensing of the medicine in accordance with a prescription or order is consistent with the safety of the person named in that prescription or order In dispensing a prescription, a pharmacist has to exercise an independent judgement to ensure the medicine is safe and appropriate for the patient, as well as that it conforms to the prescriber's requirements. If there is any doubt, the prescriber is to be contacted. In conforming to the above principle, dose, frequency and route of administration, duration of treatment, the presence or absence of other medicines, the patient's illness, medication history, and other relevant circumstances need to be taken into account. 1. Pharmacists employed in the respondent's pharmacy were bound by the above Guidelines in considering the filling of scripts issued by him to patients. 2. In evidence given by the respondent to delegates of the Medical Council of NSW in the course of a hearing under section 150 of the National Law the respondent said that he was aware that many of the prescriptions issued by him to patients were filled at his pharmacy next door. He also conceded that if a pharmacist employed in his pharmacy had concerns about his prescribing practices, it would be difficult for his employee to either refuse to prescribe the medication or report him to the Pharmaceutical Investigation Unit. He said that he did not think that an employee would report him, but that he had not realised that his employees could find themselves in the situation where they might feel that they could not talk to him about any concerns they had with his prescribing practices. He said "I see now that because of the power imbalance this could have created difficulties for (the employees) and I am disappointed in myself for not realising this issue at the time." 3. When considered in context, Particular 1(a) plays a part in the narrative contained within Complaint One. We are satisfied to the requisite standard that there is an appropriate evidentiary basis to establish the elements of this Particular, and we find that it is proven. Failure to comply with condition requiring surrender of drug authority 1. This was the subject of Complaint Two. The respondent admitted that he had contravened this condition, but said that his failure occurred because he had "an honest belief" that it was not necessary for him to physically attend and surrender his drug authority because he had already surrendered the authority which he held as a medical practitioner to prescribe Schedule 8 drugs on 24 May, 2016 and for Schedule 4D drugs on 8 August, 2016. He said he did not know that there was a difference between authorities held by a medical practitioner and those held by a pharmacist. 2. On 21 March 2018 the Pharmacy Council of NSW wrote to the respondent informing him that he had breached this condition. A letter of 9 April 2018 from the Council to the respondent indicates that the respondent had been informed in a telephone conversation on 9 April, 2018 that separate drug authorities were issued to medical practitioners and to pharmacists. The respondent was given additional time in which to surrender his authority as a pharmacist. 3. In submissions the respondent emphasised that the Council amended Condition 6 in its letter of 9 April 2018 by requiring that the respondent surrender the authority "as a pharmacist." 4. We accept that at the time the condition was imposed the respondent was ignorant of the fact that he had possessed two separate authorities to prescribe and to supply drugs of addiction, and genuinely believed that when he had surrendered his authority as a medical practitioner that this was in compliance with the condition imposed on his registration as a pharmacist. However, ignorance of these matters does not necessarily excuse non-compliance by the respondent. At all times the respondent was aware that he was first registered to practice as a pharmacist, and later as a medical practitioner. We conclude that he must have known and been aware of the need for separate registration. We further conclude that the respondent must have been aware that medical practitioners and pharmacists have different functions in connection with the supply of drugs of addiction to patients. Medical practitioners issue prescriptions which are then dispensed by pharmacists. In the circumstances, ignorance of the fact that he possessed two separate authorities does not constitute an excuse for having failed to surrender the authority issued to him as a pharmacist. 5. The respondent submitted that we should not find that by reason of the breach which is the subject of Complaint Two that he was guilty of unsatisfactory professional conduct. We shall discuss what constitutes unsatisfactory professional conduct later in these reasons. The evidence relating to Particular 2 of Complaint One 1. The respondent admitted Particular 2. However we nevertheless need to refer to the evidentiary basis relevant to this Particular, firstly to assess the gravity of the misconduct, secondly whether to characterise the misconduct as unsatisfactory professional conduct or professional misconduct under the National Law and thirdly to determine what protective orders may be appropriate. 2. The bases for the allegations contained in these Particulars consist of several Guidelines and Codes of Conduct issued by the Pharmacy Board of Australia. By section 41 of the National Law these Guidelines and Codes may provide evidence of what constitutes appropriate professional conduct or practice 41 Use of registration standards, codes or guidelines in disciplinary proceedings An approved registration standard for a health profession, or a code or guideline approved by a National Board, is admissible in proceedings under this Law or a law of a co-regulatory jurisdiction against a health practitioner registered in a health profession for which the Board is established as evidence of what constitutes appropriate professional conduct or practice for the health profession. 1. In September 2015 the Pharmacy Board of Australia issued Guidelines for proprietor pharmacists. Relevantly this document contained the following A registered pharmacist who is a proprietor of, or who has a pecuniary interest in, a pharmacy business, must: • maintain, and be able to demonstrate an awareness of, the manner in which that pharmacy business is being conducted, and • where necessary, intervene to ensure that the practice of pharmacy is conducted in accordance with applicable laws, standards and guidelines. Responsibilities of proprietor pharmacists For the purposes of these guidelines, ensuring the pharmacy business is conducted properly includes: • assuring themselves that the pharmacists they employ are complying with and adhering to the Board's registration standards and guidelines, and where applicable, make any necessary arrangements that facilitate the pharmacists meeting these requirements, for example: - proprietors who arrange professional indemnity insurance (PII) cover for an employed pharmacist should ensure that sufficient evidence of currency of PII cover is available to the employed pharmacist - ensuring that their employed pharmacists have ready access to the list of essential references specified by the Board in Guideline 1 of its Guidelines on practice-specific issues • ensuring compliance with any state or territory legislation regarding facilities and equipment required for the types of services delivered at the pharmacy • ensuring appropriate risk management procedures are in place for the operation of the pharmacy, including all types of services delivered at that pharmacy • ensuring that confidential patient information is appropriately stored and accessed • having an awareness and understanding of the range of goods sold and services provided at the pharmacy, including non-traditional and novel goods and services, and their associated liabilities • ensuring that the pharmacy is suitably resourced, and that staff members are suitably trained and appropriately supervised to provide services in accordance with their position descriptions • maintaining an awareness of and responsibility for the services being provided including unregulated services, and goods being sold, particularly those known to be subject to abuse or misuse and those not regulated through the Therapeutic Goods Administration (TGA) or the pharmacy premises registering authorities • ensuring that business procedures, policies and protocols are developed, implemented and routinely followed for all services delivered at the pharmacy, and • ensuring that advertising of services and/or products sold at the pharmacy is carried out in accordance with applicable legislation and guidelines. The vigilance of the practice described in these guidelines includes on-site visits and attendance at staff meetings at a frequency that ensures that the proprietor is able to fulfill the above responsibilities at all times. The proprietor/owner or partner-in-ownership pharmacist must ensure that procedures and policies for all services provided by the pharmacy, as well as those relating to occupational health and safety, are documented and available within the pharmacy for all staff to access and follow. 1. In the course of giving evidence in the section 150 proceedings related to his medical practice on 1 August 2016, the respondent informed the delegates that he purchased the pharmacy practice in 2002 in partnership and became the sole proprietor in 2006. He commenced practising as a general practitioner in 2008. (We note that the Application incorrectly refers to the respondent as having first been registered as a medical practitioner on 10 January 2015). When asked by the delegates about his involvement in the pharmacy on a day-to-day basis the respondent replied that it was "mostly administration, things like paying for stock, wages, superannuation. Generally is making sure that everything is running smoothly." The respondent also said that he had spent some time organising accreditation for the employed pharmacists for the Pharmacy Guild. He said that he did not want to work in the pharmacy because of his role as medical practitioner next door. 2. The respondent advised the delegates that he employed a senior pharmacist in charge. 3. The applicant obtained an expert opinion from Mr Jack Leigh, an experienced pharmacist who provided a detailed and comprehensive report dated 22 June 2019. Mr Leigh had been provided with a number of background documents including reports of the PRU Investigation Report and transcript of the PRU interview with the respondent. Mr Leigh's report was tendered before us without objection by the respondent. Mr Leigh had an opportunity of perusing the prescribing records of the respondent which were filled by the pharmacy which he owned, and to consider whether the conduct of the employed pharmacists in filling those prescriptions provided evidence that the respondent had failed to comply with his obligations as proprietor under the Guidelines extracted above. 4. In dealing with this evidentiary material, Mr Leigh said that if the respondent had been aware of the Guidelines and the need to comply with them the respondent would, by way of summary ….. Also have been aware of the need to ensure risk management procedures were in place and that they were documented and available in the pharmacy (Guidelines on responsibilities of pharmacists when practising as proprietors (January 2013). Also the need for him to conduct regular on-site visits and regular staff meetings to ensure that these procedures and policies were being followed by the pharmacy (Guidelines on responsibilities of pharmacists when practising as proprietors January 2013 p.2) These risk management procedures would include raising concerns about risks to patients as well as the pharmacy working within systems to reduce error and improve the safety of patients plus supporting colleagues who raise concerns about the safety of patients (The code of conduct for registered health practitioners 27th July 2012 Section 6.2e). Also the pharmacy should have had a system in place to document each intervention (The standard and guidelines for pharmacists performing clinical interventions March 2011, paragraph 4.1) in which methods of documentation are recommended (paragraph 4.2). Maintaining clear and accurate health records is essential for the continuing good care of patients and involves keeping up to date and legible records that report details of clinical history, clinical findings, investigations and information given to patients (The Code of conduct for registered health practitioners 27th July 2012 Section 8.4) This conflict was shown throughout the patient cases noted above, where the pharmacist should have questioned Dr Abdalla about the prescriptions being written including appropriateness of supply, and their concerns about risks to patients. This is because, in dispensing a prescription, a pharmacist has to exercise independent judgement to ensure the medicine is appropriate for the patient and if there is any doubt the prescriber contacted (Guidelines for dispensing of medicines August 2010 p.1) In cases where the pharmacist is not happy with the outcome of the discussion he should refuse to dispense the prescription. I believe this created a conflict of interest by putting the employee in an invidious position as they may have assumed that this action could put their employment at risk. Furthermore, if a similar incident was repeated on subsequent occasions as also occurred in the patient cases above, then the pharmacist would need to consider taking steps to protect patients from being placed at risk of harm by a colleagues practice (The code of conduct for registered health practitioners 27th July 2012 Section 6.3d) This would include seeking advice from an experienced colleague, the employer, practitioner health advisory services, professional indemnity insurers or the boards of a professional organisation. To follow this advice would entail the employee reporting his employer to the appropriate authorities, again putting the employee in an invidious position. The regular onsite visits and staff meetings would have provided an avenue for discussion between the pharmacy employees and Dr Abdalla as the proprietor and prescribing doctor which may have helped prevent many of the issues that have been raised. In fact discussion with the pharmacists may have helped Dr Abdalla to reflect on his own skill level and appropriateness of prescribing. (Code of Conduct for pharmacists March 2014) I therefore believe that the conflict of interest was not appropriately handled by Dr Abdalla because he did not instigate the above policies and procedures. As Dr Abdalla stated in his interview with the PRU (28th April 2016 p.73 paragraph 40), he only did some administration such as payments and superannuation in terms of the day to day running and therefore no management of the pharmacy. From the above I consider that Dr Abdulla did not recognise, nor appropriately manage, the conflict of interest and therefore this caused his conduct to fall significantly below the standard reasonably expected of a practitioner of an equivalent level of training and experience and invites my strong criticism. 1. In his report Mr Leigh dealt at some length with the circumstances of 9 patients of the respondent and other medical practitioners whose prescriptions were filled by employed pharmacists at the adjoining pharmacy of which the respondent was the proprietor. We have previously noted the concessions by the respondent that he admitted Particulars 2 and 3 of Complaint One. On one view it is therefore not necessary to deal with the circumstances of these areas of misconduct in detail. However, the factual circumstances upon which these particulars are based as revealed in Mr Leigh's report paint a most disturbing picture of the operations of the pharmacy whilst the respondent was a proprietor, and which merely by their recitation cause concern for the health and safety of the public. These circumstances are so compelling and so graphic that we have reproduced those portions of it relevant to Particulars 2 and 3 of Complaint One as an appendix to these reasons for decision. They should be compulsory reading for every pharmacist and aspiring pharmacist because they demonstrate the severity of the breaches by the respondent (and pharmacists engaged to work in the pharmacy) of his responsibilities as revealed in Particulars 2 and 3 of Complaint One. The references to "clauses" is a reference to clauses of the Poisons and Therapeutic Goods Regulation 2008. 2. However, we do set out below an extract from Mr Leigh's report which contains a summary of his opinion concerning the proprietorship of the pharmacy by the respondent. Again, the reference to clauses is a reference to clauses of the Poisons and Therapeutic Goods Regulation 2008 As the same points need to be made for every patient, I have incorporated them below to prevent repetition. In each case a pharmacist should have observed the following safeguards in relation to the dispensing of prescriptions:- Dr Abdalla's lack of oversight prevented the following safeguards from being observed:- Clause 54 relates to restricted substances and Clause 109 relates to drugs of addition. Both state that an authorised practitioner or pharmacist must not supply any of these substances in a quantity, or for a purpose, that does not accord with the recognised therapeutic standard of what is appropriate in the circumstances. The pharmacist should have considered whether the use of the medicine was appropriate and not excessive (Code of Conduct for Health Practitioners March 2014 Paragraph 5.2) The pharmacist should have taken all reasonable steps to address the issue if reason to think that the safety of the patient could be compromised (Code of Conduct for Health Practitioners March 2014 Paragraph 6.2F). The pharmacist should have contacted the prescribing doctor to clarify the situation so that the pharmacist could ensure that the service provided was appropriate for the assessed needs of the patient (Code of Conduct for pharmacists March 2014 p.16 paragraph 5.2a). In dispensing a prescription, a pharmacist has to exercise independent judgement to ensure the medicine is appropriate for the patient and if there is any doubt the prescriber contacted (Guidelines for dispensing of medicines August 2010 p.1) If the pharmacist is not satisfied with the outcome of the discussion then supply should have been refused as the Code of Conduct for registered health practitioners July 2012 states that working as part of a team does not alter a practitioner's personal accountability for professional conduct and the care provided (p.9 paragraph 4.4). A pharmacy should have a system in place to document each intervention (The Standard and guidelines for pharmacists performing clinical interventions March 2011, paragraph 4.1) in which methods of documentation are recommended (paragraph 4.2). Maintaining clear and accurate health records is essential for the continuing good care of patients and involves keeping up to date and legible records that report details of clinical history, clinical findings, investigations and information given to patients (The Code of conduct for registered health practitioners 27th July 2012 Section 8.4) Furthermore, if the script was incorrectly written, this does not follow the Guide to poisons and therapeutic goods legislation for pharmacists November 2013 p.20 which states that dispensed medicines containing any drug of addiction should contain adequate directions for use as set out in the prescription. If a prescription for a drug of addiction does not include adequate directions for use then it is not considered a valid prescription and should not be dispensed (Guide to poisons and therapeutic goods legislation for pharmacists November 2013 p.15).As the prescription did not contain adequate directions then the pharmacy should not have dispensed the medicine. The pharmacy could have contacted the doctor to ask if the doctor was prepared to forward a new prescription or alter and return the correctly written script. (It is possible that the script was written correctly but incorrectly transcribed by the pharmacy) Dr Abdalla should have considered the code of conduct for registered health practitioners 27th July 2012 which states under Risk management p.10 6.2d that if a practitioner has management responsibilities then they need to make sure that systems are in place for raising concerns about risks to patients. Risk management also entails working within these systems to reduce error and improve the safety of patients and supporting colleagues who raise concerns about the safety of patients Section 6.2e. Section 6.3d Practitioner performance, states that a practitioner should take steps to protect patients from being placed at risk of harm by a colleagues practice. If a practitioner, in this case the duty pharmacist, is not sure what to do, a practitioner should seek advice from an experienced colleague, the employer, practitioner health advisory services, professional indemnity insurers or the boards of a professional organisation. Dr Abdalla's lack of oversight prevented the above safeguards from being observed. 1. We agree with the submissions of the applicant that the evidence of Mr Leigh demonstrates that the respondent's failure to manage his pharmacy permitted extremely poor dispensing practices to go unnoticed and unchecked and that by his conduct the respondent permitted such a culture and practice to be created. The respondent's evidence 1. The respondent relied upon an affidavit sworn by him on 2 April 2020. In it the respondent said that on 2 March 2020 he requested that his registration as a pharmacist be cancelled. By letter dated 1 April 2020 he was informed that his registration had been surrendered effective from 31 March 2020. 2. In his affidavit the respondent said that he had decided to concentrate on his medical career and that he had no desire to return to practising as a pharmacist or to hold any financial interest in a pharmacy "again in the future." He repeated an undertaking previously furnished in a Statutory Declaration that he would not attempt to seek registration as a pharmacist again in Australia, to practice as a pharmacist again in Australia and that he would not hold any financial interest in any pharmacy again in Australia. Furthermore, the respondent confirmed that he admitted that his conduct as a pharmacist "amounted to unsatisfactory professional conduct and professional misconduct." 3. The respondent explained that he did not intend to give evidence in the hearing of the matter, and wished to save costs in light of his surrender of his registration, and his undertaking not to return to pharmacy practice again in the future. 4. The respondent filed an expert report from Associate Professor Vincent Roche, a general practitioner which dealt with a number of issues being any obligation by the respondent as a medical practitioner to inform patients that he was the proprietor of the pharmacy, that he would receive a financial benefit from any scripts which were filled at the pharmacy, whether these matters brought about any conflict of interest and whether the respondent's conduct would be considered significantly below the standard reasonably expected of a medical practitioner. All of these matters go to the practice of the respondent as a medical practitioner, and not as a pharmacist. In the circumstances, it is not necessary that we have regard to the contents of this report. Is the respondent guilty of professional misconduct? 1. The applicant alleges that by reason of Complaints One and Two the respondent should be found guilty of unsatisfactory professional conduct and by reason of Complaint Three, the more serious form of misconduct, professional misconduct. We have determined to find that the respondent is guilty of professional misconduct as conceded by him, and we now set out our reasons for so finding. 2. Professional misconduct is defined in the National Law as follows: 139E Meaning of "professional misconduct" [NSW] For the purposes of this Law, professional misconduct of a registered health practitioner means— (a) unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration; or (b) more than One instance of unsatisfactory professional conduct that, when the instances are considered together, amount to conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration. 1. This definition in turn refers to the definition of unsatisfactory professional conduct which is found in section 139B of the National Law. We reproduce hereunder that part of that definition which is relevant to our consideration of these proceedings: 139B Meaning of "unsatisfactory professional conduct" of registered health practitioner generally [NSW] (1) Unsatisfactory professional conduct of a registered health practitioner includes each of the following— (a) Conduct significantly below reasonable standard Conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of the practitioner's profession is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience. (b) Contravention of this Law or regulations A contravention by the practitioner (whether by act or omission) of a provision of this Law, or the regulations under this Law or under the NSW regulations, whether or not the practitioner has been prosecuted for or convicted of an offence in respect of the contravention. … (l) Other improper or unethical conduct Any other improper or unethical conduct relating to the practice or purported practice of the practitioner's profession. 1. It is clear from the expert opinion of Mr Leigh, which we accept, that the conduct of the respondent constitutes unsatisfactory professional conduct. The conduct of the respondent which is the subject of each of the Particulars of Complaint One has been assessed by Mr Leigh as being significantly below the standard reasonably expected of a pharmacist of an equivalent level of training and experience of that of the respondent for the reasons which he has given. Each of these matters reflects upon the knowledge, skill and judgement of the respondent in his practice as proprietor of the pharmacy. We are comfortably satisfied that in the aggregate all of these matters constitute unsatisfactory professional conduct and we so find. 2. We add for completeness that the applicant relied on the provisions of section 139B(1)(l) of the National Law, asserting that the respondent was also guilty of other improper or unethical conduct relating to his practice as a pharmacist. The respondent resisted such a finding on the basis that by reason of the structure of section 139B improper or unethical conduct must be of a kind other than that referred to in section 139B(1)(a). It is not necessary that we determine this issue. There is substantial evidence that the respondent is guilty of the former subsection, compounded by the respondent's admissions. We are content to proceed on the basis that we find the respondent guilty of unsatisfactory professional conduct under section 139B(1)(a), for the reasons earlier advanced. 3. It is now necessary to determine whether the respondent is guilty of professional misconduct as asserted by the applicant. By reason of the definition contained in section 139E which we have set out above, it is necessary to determine whether the unsatisfactory professional conduct is of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration or there is "more than one instance of unsatisfactory professional conduct that, when the instances are considered together, amount to conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration." 4. This directs attention to a consideration of those circumstances which would justify suspension or cancellation of registration. Whilst this involves the exercise of a value judgement having regard to all of the relevant factual circumstances, it must be undertaken in the context of the statutory regime which applies to these proceedings. 5. It is well-established that the jurisdiction of this Tribunal is primarily protective in nature. In exercising this jurisdiction there are a number of matters to which we must have regard. They have been succinctly referred to in the judgement of Meagher JA in the New South Wales Court of Appeal in Health Care Complaints Commission v Do [2014] NSWCA 307 (Basten and Emmett JJA agreeing). At [35] and following his Honour said; 35. The objective of protecting the health and safety of the public is not confined to protecting the patients or potential patients of a particular practitioner from the continuing risk of his or her malpractice or incompetence. It includes protecting the public from the similar misconduct or incompetence of other practitioners and upholding public confidence in the standards of the profession. That objective is achieved by setting and maintaining those standards and, where appropriate, by cancelling the registration of practitioners who are not competent or otherwise not fit to practise, including those who have been guilty of serious misconduct. Denouncing such misconduct operates both as a deterrent to the individual concerned, as well as to the general body of practitioners. It also maintains public confidence by signalling that those whose conduct does not meet the required standards will not be permitted to practise. 36. In Law Society of New South Wales v Foreman (1994) 34 NSWLR 408 Mahoney JA described (at 441) the scope of the objective of protecting the public interest in the context of disciplinary proceedings against a solicitor as follows: "The protection of the public has been described as, for example, the primary purpose or primary object of such proceedings: ... In the relevant sense, the protection of the public is in my opinion not confined to the protection of the public against further default by the solicitor in question. It extends also to the protection of the public against similar defaults by other solicitors and has, in this sense, the purpose of publicly marking the seriousness of what the instant solicitor has done. But, in my opinion, it would be wrong to confine the objects of disciplinary proceedings and the purposes to be achieved by the orders made in them strictly to matters of this kind. Those purposes and objectives have traditionally been seen as having a wider operation. In the end, the question to be determined is whether the solicitor is a fit and proper person to be a solicitor of the Court and the orders to be made are to be directed to ensuring that, to the extent she is not, her practice is restricted." 37. In Herron v McGregor (1986) 6 NSWLR 246 McHugh JA referred more briefly to the same consideration (at 258): "It is, of course, of fundamental importance to bear in mind the public interest in disciplining doctors who are guilty of professional misconduct. In many cases the protection of the public and the maintenance of professional standards requires that the names of doctors be removed from the register. However, it is present fitness to practise which is the principal and ultimate issue of public interest." 1. We should make it clear that in determining whether the conduct of the respondent may be characterised as professional misconduct justifying cancellation or suspension of registration, such a characterisation is not necessarily determinative of any consequential appropriate protective orders. Our concern for present purposes is to determine whether or not the conduct is such that cancellation or suspension is warranted. In determining this matter we have regard to the protection of the public, the maintenance of public confidence in the integrity of the profession, and the deterrent effect both on the respondent and on other members of the pharmacy profession. 2. As has been endorsed often by this Tribunal, a medical practitioner who prescribes and handles drugs of addiction recklessly and contrary to the law engages in conduct which constitutes professional misconduct. In Spicer v NSW Medical Council (unreported, CA No.3 of 1981, 19 February 1981), Hope JA (Reynolds and Hutley JJA agreeing) said: In my opinion it is clear beyond argument that the proper handling and prescribing of drugs by medical practitioners are of the greatest importance to the community. If a medical practitioner handles or carries out that very great responsibility in a way that is reckless and which shows a disregard to the law it cannot be said that he is fitted at such a time to be a medical practitioner. In my opinion the view expressed by the Tribunal has implicit in it that not merely was he presently unfitted to treat those addicted or habituated to drugs but that that unfitness in itself demonstrated his present unfitness to be a medical practitioner 1. There is no reason why these comments made in Spicer should not apply equally in the case of pharmacists who are also given the privilege of supplying to the public restricted drugs, including drugs of addiction in response to a prescription issued properly and appropriately, and subject to the duty of care which is inherent in the exercise of their profession. 2. We have previously discussed the evidentiary material available to us in these proceedings. We have found that Particulars 1(a) and (c) of Complaint One have been proven. We regard the circumstances revealed in Particular 1(c) as being most serious. As the expert observations of Mr Leigh demonstrate, pharmacists have particularly onerous obligations when dealing with clients who have been prescribed or are seeking drugs of addiction. It is essential that employed pharmacists be able to interrelate with their employer and be in a position to receive the appropriate guidance in this difficult area. As the respondent readily conceded in giving evidence to the delegates in the section 150 hearing concerning his medical practice, he had not really considered the conflict of interest which he had created when seeking to practice concurrently both as a medical practitioner and the proprietor of a pharmacy next door to his medical practice. 3. However, in the circumstances the most serious area of misconduct is that which is described in Particular 2 of Complaint One. This Particular must be read in the context of the circumstances which prevailed in the pharmacy as revealed in the expert report of Mr Leigh. The circumstances outlined in that report are indicative of an egregious continuing and systematic failure by those involved in the operation of the pharmacy, of which the respondent was at all relevant times the proprietor, such as to cause a serious risk to the health and safety of the public. The potential destructive effects of exposure to drugs of addiction are notorious, as those involved in the operation of the pharmacy should have known. The misconduct of the respondent is so serious that not only does it indicate a disregard for the health and safety of the public, but is indicative that the respondent was not a fit and proper person to hold registration as a pharmacist. 4. We find that the respondent is guilty of professional misconduct. We add for completeness that in so finding we also take into account in the aggregate our finding that the respondent is guilty of the matters referred to in Complaint Two. 5. It follows that we find that Complaint Three has been proven. Protective orders 1. We now consider what protective orders should be made consequent upon the findings which we have made. The available protective orders are set out in section 149C of the National Law the relevant parts of which are 149C Tribunal may suspend or cancel registration in certain cases [NSW] (1) The Tribunal may suspend a registered health practitioner's registration for a specified period or cancel the registered health practitioner's registration if the Tribunal is satisfied— (a) the practitioner is not competent to practise the practitioner's profession; or (b) the practitioner is guilty of professional misconduct; or (c) the practitioner has been convicted of or made the subject of a criminal finding for an offence, either in or outside this jurisdiction, and the circumstances of the offence render the practitioner unfit in the public interest to practise the practitioner's profession; or (d) the practitioner is not a suitable person for registration in the practitioner's profession. … (4) If the person is no longer registered, the Tribunal may— (a) decide that if the person were still registered the Tribunal would have suspended or cancelled the person's registration; and (b) if the Tribunal would have cancelled the person's registration, decide that the person is disqualified from being registered in the health profession for a specified period or until specified conditions have been complied with; and (c) require the National Board with which the person was registered to record the fact that the Tribunal would have suspended or cancelled the person's registration in the National Register kept by the Board. 1. We note that as the respondent is not currently registered as a pharmacist, the provisions of section 149C(4) will apply. We have found the respondent is guilty of professional misconduct for the reasons earlier set out. We have also found that the misconduct is of a most serious kind. It is, in the circumstances, incompatible with entitlement to practice as a pharmacist. In all the circumstances it is appropriate that we conclude that if the respondent were still registered as a pharmacist that we would have cancelled his registration. In so concluding we take into account not only the serious misconduct which we have found and which we have earlier described but also the necessity to deter the respondent from conduct of this kind in the future, and to deter other proprietor pharmacists who might be tempted to engage in misconduct of a similar kind. We also take into account the need to enhance the reputation of the profession of pharmacy in the eyes of the public, so as to provide the public with confidence in the safe and professional care that they will be provided by pharmacists. 2. In so finding we note that the respondent properly conceded that it was appropriate that his registration as a pharmacist be cancelled. 3. Although the respondent has undertaken that he will not seek to practice as a pharmacist in the future, it is appropriate that we give consideration to the fixing of an appropriate period of disqualification for registration under section 149C(4)(b). Such a period is usually fixed by reference to such time during which the practitioner might have an opportunity to engage in an appropriate rehabilitation process designed to allow him or her to again apply for registration. On one view, given the respondent's undertaking it is unnecessary to fix a time period. However, lest the respondent change his mind, we agree with the applicant's submission that a period of 3 years would be appropriate in all the circumstances, to allow him to engage in an appropriate reflective process and demonstrate fitness and suitability to again be registered as a pharmacist. 4. We shall also, in compliance with section 149C(4)(c) require the Pharmacy Board of Australia to record the fact that the Tribunal would have suspended or cancelled his registration in the National Register kept by the Board. Costs 1. The applicant sought a costs order in its favour. The respondent sought to resist the costs order having regard to section 60(1) of the Civil and Administrative Tribunal Act. However, as the applicant correctly pointed out in submissions the question of costs is governed by clause 13, Schedule 5D of the National Law, which renders this as a costs jurisdiction. In the circumstances it is appropriate to grant liberty to apply in the event that the parties are unable to reach sensible agreement about a costs order, by reference to the applicable statutory basis. Orders 1. In consequence of our finding of professional misconduct we make the following orders; 1. if the respondent had remained registered as a pharmacist we would have cancelled his registration effective as at this date. 2. the respondent is disqualified from being registered as a pharmacist for a period of 3 years from this date 3. we ask the Registrar of this Tribunal to request the Pharmacy Board of Australia to record the fact that the Tribunal would have cancelled the respondent's registration in the National Register kept by the Board 4. costs are reserved with liberty to apply which must be exercised within one month of this date. APPENDIX extracts from the expert report of Mr Jack Leigh In my opinion, based on the dispensing history of Late Night Chemist Auburn, the supply of Fentanyl to Patient A does not accord with the recognised therapeutic standard of what is appropriate in the circumstances and I clarify this statement as follows:- From the dispensing record of Patient A, Zydol (Tramadol) SR 200mg 1 daily, was first dispensed on 17/11/2013 with a subsequent prescription dispensed almost a year later on 24/10/14 at the same dosing schedule. Next dispensing for an analgesic at this pharmacy was for Durogesic (Fentanyl) 50 patches which occurred Two months later on 17/12/14. Fentanyl is not considered first line treatment for opioid naive patients with chronic pain (Therapeutic Guidelines Analgesic Version 6 2012) and is not recommended for opioid naive patients with non-cancer pain due to cases of hypoventilation and death (Durogesic Product Information (PI) 15/01/14). Furthermore, in circumstances where it is considered appropriate for opioid naive patients to use Fentanyl, it is recommended that patients first be titrated with low doses of immediate release opioids to receive an equianalgesic dose of not more than Fentanyl 25mcg/hour before conversion to Fentanyl patches (Durogesic PI 2014). While Tramadol is classified as an opioid analgesic, it has relatively weak affinity to the mu opioid receptors and the misuse potential appears to be low (AMH 2012 p. 58). Also, Tramadol does not appear on the Equianalgesic table potency conversion table within the Durogesic Product Information (PI) 2014. From the above information a pharmacist, before dispensing the first Durogesic 50 script, should have known that this dose is reserved for opioid dependent patients and is considered a higher than normal initiating dose (Durogesic PI 2014) so a pharmacist should have considered whether the use of the medicine was appropriate and not excessive (Code of Conduct for Health Practitioners March 2014 Paragraph 5.2) This would have consisted of clarifying with the prescribing doctor whether the patient had been initiated with Fentanyl outside of the pharmacy and, if so, confirmed that the dosing schedule was correct. If no prior initiation of opioids then a pharmacist should have discussed the above information with the prescribing doctor to provide good care for the patient through shared decision making (Code of Conduct 2012 p.1, Overview). There was then a break in dispensing until 24th March 2015 when the next Durogesic 50 script was dispensed. Due to the three month time lag, the pharmacy should have treated the Patient A as a new patient and gone through the same procedure as above before dispensing the medication. There was a further break in dispensing until 6th May and again until the 3rd June. A further break occurred between the 9th December and 13th January 2015. On each occasion the above procedure should have been carried out. On 10th June 2015 and 15th September 2015 Sertraline 100mg, a SSRI, was dispensed. Fentanyl is a drug that may contribute to serotonin toxicity (AMH 2012 p.747) and the combination should be avoided or closely monitored (AMH 2012 p.750). The doctor should have been contacted for clarification. On two occasions the directions for use were not provided except for as directed. (see above) As a pharmacist and proprietor of the pharmacy since 2002, Dr. Abdalla should have been aware of the Guidelines on responsibilities of pharmacists when practicing as proprietors, 29th January 2013, which states that a proprietor pharmacist must maintain an awareness of the standards published by the profession. Therefore he should have maintained an active interest in the practice of pharmacy and known that he could not delegate his professional responsibility (Guidelines for proprietor pharmacists 2nd September 2015). However, as he stated in his interview with the PRU (28th April 2016 p.73 paragraph 40) he only did some administration such as payments and superannuation in terms of the day to day running. Each of the above occasions required the pharmacist to consider the safeguards above before dispensing to ensure good patient care and a clinical intervention noted. From the above, I consider that Dr Abdulla's lack of oversight caused his conduct as a pharmacist and proprietor of the pharmacy to fall significantly below the standard reasonably expected of a practitioner of an equivalent level of training and experience and invites my strong criticism. … Based on the dispensing history of Late Night Chemist Auburn, the supply of Fentanyl to Patient B does not accord with the recognised therapeutic standard of what is appropriate in the circumstances and I clarify this statement as follows:- First dispensing at this pharmacy for Durogesic (Fentanyl) 100 patches occurred on 28th April 2014. Fentanyl is not considered first line treatment for opioid naive patients with chronic pain (Therapeutic Guidelines Analgesic Version 6 2012) and is not recommended for opioid naive patients with non-cancer pain due to cases of hypoventilation and death (Durogesic Product Information (PI) 15/01/14). Furthermore, in circumstances where it is considered appropriate for opioid naive patients to use Fentanyl, it is recommended that patients first be titrated with low doses of immediate release opioids to receive an equianalgesic dose of not more than Fentanyl 25mch/hour before conversion to Fentanyl patches (Durogesic PI 2014). From the above information a pharmacist, before dispensing the first Durogesic 100 script, should have known that this dose is reserved for opioid dependent patients and is considered a higher than normal initiating dose (Durogesic PI 2014) so a pharmacist should have considered whether the use of the medicine was appropriate and not excessive (Code of Conduct for Health Practitioners March 2014 Paragraph 5.2) This would have consisted of clarifying with the prescribing doctor whether the patient had been initiated with Fentanyl outside of the pharmacy and, if so, confirming that the dosing schedule was correct. If no prior initiation of opioids then a pharmacist should have discussed the above information with the prescribing doctor to provide good care for the patient through shared decision making (Code of Conduct 2012 p.1, Overview). The next dispensing of Fentanyl 100 patches occurred over one year later on the 15th May 2015 and due to the long interval between scripts a pharmacist should have treated this dispensing as if for a new patient and a clinical intervention inserted to confirm that the patient had been continuing opioid treatment away from the pharmacy and therefore the prescription was appropriate. It is noted that between the 15th May 2015 and 24th November 2015, Fentanyl appears to have been prescribed by five different doctors and in three different strengths. The pharmacist should have considered that it is better for the patient to have only one doctor responsible for prescribing and monitoring a patient's opioid use (Oxycontin PI 2011 p.4) There is also one occasion when the interval of repeat was only 4 days (31st August and 5th September 2015) and two occasions with 10 and 11 day intervals. The pharmacist should have considered the possibility that the patient was struggling with pain control or possibly abusing the opioid because Fentanyl has the potential to be abused by ingestion or injection and has led to deaths as a result (Durogesic PI 2012 p.7). Furthermore it is also known to have been diverted for sale on the street at a price of over $100 per patch (The Age 19/10/2012). On three occasions the directions for use were not provided except for apply as directed or simply as directed. Durogesic 50 was last dispensed on 24th November 2015 and there is a gap until 9th April 2016 when the patient presented with a prescription for Oxycontin MR 10mg with a dosing schedule of one daily when required. Due to the long interval between scripts a pharmacist should have treated the dispensing for the Oxycontin as if for a new patient especially as the patient had been prescribed Durogesic several months previously. The pharmacist would need to clarify with the prescribing doctor, who had previously supplied Patient B with Durogesic, whether the patient had been initiated with Oxycontin outside of the pharmacy because Oxycontin, as a controlled release tablet, is not recommended for initial stabilisation or acute pain (AMH 2012 p.56). The pharmacist should also have known that there is a significant difference in potency between the Two medications with Durogesic 50 being equivalent of 135-224mg of oral morphine per day as a recommended starting dose and with patients on stable and well tolerated opioid therapy this equivalence is still only reduced to 90-149mg of oral morphine per day. This compares with 10mg Oxycontin a day being equivalent to 15mg of daily oral morphine (Durogesic PI 15/01/2014 p.18). The pharmacist could also confirm that the strength and the unusual dosing schedule were correct as Oxycontin MR 10mg is usually used as a starting dose for opioid naive patients or patients presenting with severe pain uncontrolled by weaker opioids and the dosing schedule is twice daily, not on a once daily when needed basis (Oxycontin PI September 2014 p.12). On two occasions the directions for use were not provided except for as directed (see above) Each of the above occasions required the pharmacist to consider the safeguards above before dispensing to ensure good patient care and clinical interventions noted. As a pharmacist and proprietor of the pharmacy since 2002, Dr. Abdalla should have been aware of the Guidelines on responsibilities of pharmacists when practicing as proprietors, 29th January 2013, which states that a proprietor pharmacist must maintain an awareness of the standards published by the profession. Therefore he should have maintained an active interest in the practice of pharmacy and known that he could not delegate his professional responsibility (Guidelines for proprietor pharmacists 2nd September 2015). However, as he stated in his interview with the PRU (28th April 2016 p.73 paragraph 40) he only did some administration such as payments and superannuation in terms of the day to day running. From the above, I consider that Dr Abdulla's lack of oversight caused his conduct as a pharmacist and proprietor of the pharmacy to fall significantly below the standard reasonably expected of a practitioner of an equivalent level of training and experience and invites my strong criticism. … Based on the dispensing history of Late Night Chemist Auburn, the supply of Fentanyl, Buprenorphine and Oxycodone to Patient C does not accord with the recognized therapeutic standard of what is appropriate in the circumstances and I clarify this statement as follows:- First dispensing at the pharmacy for 28 Oxycontin 80mg tablets occurred on 13th September 2011. As Oxycontin 80mg should only be given to opioid dependent patients to prevent fatal respiratory depression in opioid naïve patients (Oxycontin PI 2011 p.10), a pharmacist, before dispensing this script, should have contacted the prescribing doctor to clarify whether the patient had been initiated with Oxycontin MR 80mg outside of the pharmacy. Dosing schedule of 12 hourly is normal (Oxycontin PI 2011 p.10). On the same day the patient was also prescribed 20 Tramal SR 200mg with a dosing schedule of one tablet twice daily when required. This is considered the maximum daily dose of Tramal (AMH 2012 p.58) Tramal controlled release tablets are not recommended for acute pain management as slow onset and offset make rapid and safe titration impossible (AMH 2012 p.58) so the discussion with the doctor would have clarified the need for the Tramal as well as the "when needed" dosing. In fact a trial of Tramal SR 200mg twice daily is recommended before trying other opioids (AMH 2012 p.58). If no prior initiation of opioids then a pharmacist should have discussed the above information with the prescribing doctor to provide good care for the patient through shared decision making (Code of Conduct 2012 p.1, Overview). This would also ensure that the service provided was appropriate for the assessed needs of the patient and not excessive (Code of Conduct for pharmacists March 2014 p.16 paragraph 5.2a) Two days after the initial dispensing on the 13th September 2011 a second prescription was dispensed for 28 Oxycontin 80mg and 20 Tramal SR 200mg. As the Oxycontin supplied 2 days earlier was a 14 day supply and the Tramal SR 200mg a minimum of 10 days' supply, a pharmacist should have immediately questioned the need for a second dispensing, especially as Oxycontin can cause physical dependence and was known to be drug of abuse (Oxycontin PI 2011 p.5 and p. 10) with a high street value (The Age 19/10/2012) Before dispensing either script a pharmacist should have contacted the prescribing doctor to clarify the reason for the second script and from the information obtained decide if the service provided by the doctor was appropriate. If not satisfied with the discussion then the pharmacy should refuse supply. Significantly early dispensing of Oxycontin 80mg occurred on 3 further occasions, between 20th December 2011 and 5th March 2012, but, as above, no clinical interventions have been provided to explain these anomalies. Ditto for the script for 40 Tramal SR 200mg on 11th October 2011 for $45 which was for a quantity that constituted a private script and more than 3 times the price for 2 lots of 20 Tramal SR 200mg on the PBS. This should have alerted the pharmacy to appropriate dispensing by the doctor and the appropriateness of supply by the pharmacy. On the 15th October 2012 the pharmacy dispensed a script for 28 Oxycontin 80mg as a private script, charging the patient $105.00 (this is about 20 times more than the patient would normally pay). Also the period of dispensing was 21 days after the previous dispensing for the normal 14 days' supply which doesn't match up to the patients usual dispensing timetable. As Oxycontin could cause physical dependence and was known to be drug of abuse (Oxycontin PI 2011 p.5 and p. 10) with a high street value (The Age 19/10/2012) the pharmacist should have contacted the prescribing doctor to clarify the long time frame between scripts and the reason for prescribing it as a private prescription. Again this should have alerted the pharmacy to appropriate dispensing by the doctor and the appropriateness of supply by the pharmacy The first script for 5 Fentanyl 50 patches was dispensed on 23rd February 2012 which was over three months after the final Oxycontin 80mg script had been dispensed and One day after a short acting Oxycodone (Endone) had been dispensed. Due to the long interval between the Oxycontin and Fentanyl scripts a pharmacist should have treated the dispensing on the 23rd February 2012 as if for a new patient and clarified with the prescribing doctor whether the patient had been continuing opioid treatment away from the pharmacy as a pharmacist should have known that this Fentanyl dose is reserved for opioid dependent patients and is considered a higher than normal initiating dose (Durogesic PI 2014). Two days later a script was dispensed for 2 Norspan 20mcg patches, another opioid analgesic, and four days later 5 Fentanyl 100 patches were dispensed. A pharmacist should have immediately contacted the prescribing doctor to clarify the reasons for the short time span between prescriptions and the mixing of these two opioids. The combination can not only increase the risk of respiratory depression (AMH 2014 p.950) but Norspan can block the therapeutic effects of other opioids which may reduce analgesia or precipitate withdrawal symptoms in opioid dependent people. It is advised to avoid this combination (AMH 2014 p.950). Furthermore a pharmacist should have considered the large difference in the potency of the Two opioids as a 20mcg/hr Norspan patch is less potent than a Fentanyl 12mcg/hr patch (AMH 2012 p.48) Furthermore the pharmacist should have checked with the doctor and the patient about the whereabouts of the remaining Durogesic 50 patches as two of these could have been used instead of one Durogesic 100 patch (Durogesic PI 2014 p.19).This is because Fentanyl patches have the potential to be abused by ingestion or injection and has lead to deaths as a result (Durogesic PI 2012 p.7). It is also known to have been diverted for sale on the street at a price of over $100 per patch based on the 2012 price (The Age 19/10/2012) Between 23rd February 2012 and 11th November 2015, Five Fentanyl patches, equal to fifteen days supply, were dispensed many times but with many anomalies. • On several occasions prescriptions were dispensed well before the due date, and example being on 28th November 2013 and 2nd December 2013, a gap of only 4 days and each occasion should have alerted the pharmacy to appropriateness of supply • Between 8th October 2014 and 28th January 2015 there was a three month gap in the dispensing history of Fentanyl patches • On four occasions Patient C was charged privately for Fentanyl scripts and each occasion should have alerted the pharmacy to appropriateness of supply • On approximately twenty occasions Fentanyl scripts were dispensed without adequate directions for use (see above) • On 14th May 2013 and 23rd August 2013 the pharmacy dispensed prescriptions for Antenex 5mg prescribed by another doctor. A pharmacist should have known that Fentanyl and Diazepam are not a recommended combination as Diazepam may also cause respiratory depression thereby exacerbating the effect from the Fentanyl. Antenex may also cause dependence (AMH 2012 p.778) • Tramal SR 200mg tablets were regularly dispensed yet Tramal controlled release tablets are not recommended for acute pain management as slow onset and offset make rapid and safe titration impossible (AMH 2012 p.58). • On three occasions the pharmacy dispensed prescriptions for Aurorix 300mg whilst the patient was taking Fentanyl patches. A pharmacist should have known that this combination is contraindicated due to the possibility of causing Serotonin toxicity (AMH 2012 p.909). Each of the above occasions required the pharmacist to consider the safeguards above before dispensing to ensure good patient care and clinical interventions noted. As a pharmacist and proprietor of the pharmacy since 2002, Dr. Abdalla should have been aware of the Guidelines on responsibilities of pharmacists when practicing as proprietors, 29th January 2013, which states that a proprietor pharmacist must maintain an awareness of the standards published by the profession. Therefore he should have maintained an active interest in the practice of pharmacy and known that he could not delegate his professional responsibility (Guidelines for proprietor pharmacists 2nd September 2015). However, as he stated in his interview with the PRU (28th April 2016 p.73 paragraph 40) he only did some administration such as payments and superannuation in terms of the day to day running. From the above, I consider that Dr Abdulla's lack of oversight caused his conduct as a pharmacist and proprietor of the pharmacy to fall significantly below the standard reasonably expected of a practitioner of an equivalent level of training and experience and invites my strong criticism. … However, based on the dispensing history of Late Night Chemist Auburn, the supply of other medicines to Patient D does not accord with the recognized therapeutic standard of what is appropriate in the circumstances and I clarify this statement as follows:- First dispensing of Diazepam occurred on the 20th June 2014 together with Mirtazapine. As both medications may cause sedation (AMH 2012 p.759 and p.779) a pharmacist should have contacted the prescribing doctor to clarify the prescriptions. On the 10th September 2014 the pharmacy dispensed 50 Diazepam 5mg with a dose of 2 twice daily when needed and 25 Oxazepam 30mg with a dose of 1 daily which from subsequent information is a night time dose. As both of these medications are benzodiazepines a pharmacist should have assessed the need for two medicines from the same class to be dispensed together, especially as the patient had also been dispensed Mirtazapine on the 29th August. Each of these three medications causes drowsiness and the patient could be adversely affected through the additive effect. They should also have taken into consideration the fact that although Oxazepam is classified as short acting, with a half life of 6-12 hours and Diazepam is classified as long acting, with a half life of greater than 24 hours, Diazepam has a rapid onset of action which again raises the question of the need for the two to be dispensed together (AMH 20012 p.779). Furthermore Mirtazapine has a sedative action which may be useful in depression where insomnia is a feature (AMH 2012 p.760) again raising questions about the need for another hypnotic. A pharmacist should have had strong reservations about dispensing these three medications at the same time so the prescribing doctor should have been contacted to clarify the prescriptions. If not satisfied with the outcome of the discussion with the doctor, a pharmacist should refuse supply. Subsequent Diazepam and Oxazepam scripts were dispensed nine days later by the same doctor, four days after that from another doctor (not known if from the same practice) and again seven days after that by the first doctor. All of these should again have raised a warning flag with the pharmacy about the interval of supply as Patient D should still have ample supplies of the above medicines. The pharmacist should have been aware that benzodiazepines have the potential to be abused and can cause dependency if used for more than 2-4 weeks (AMH 2012 p. 779). Furthermore they should be reserved for short term use, 2-4 weeks, and should be part of a broader treatment plan (AMH 2012 p. 779). The pharmacist should have considered whether Patient D fitted into this category. On each occasion the doctors should have been contacted as above including notification of possible doctor shopping, refusal of supply considered and a clinical intervention recorded. First dispensing at this pharmacy of Norspan 10mcg/hr patches occurred on 11th March 2015 a break of six months since the previous dispensing. A pharmacist should have considered the previous history of the patient with relation to benzodiazepine usage, the fact that Norspan is not considered a first line treatment for analgesia (AMH 2012 p.47) and that the commencing dose for Norspan in opioid naïve patients is 5mcg/hour patches. The prescribing doctor should have been contacted to clarify the prescription. On 24th March 2015, thirteen days later, the pharmacy dispensed Oxazepam and Diazepam scripts. From the past history of the patient concerning the same Two benzodiazepines and the fact that they and Norspan are not a recommended combination due to possible significant respiratory depression (Norspan PI 2014 p.7) the pharmacist should have been highly alert to the ramifications of dispensing these medications. The pharmacist should therefore have contacted the doctor to clarify the prescriptions and if not satisfied with the outcome of the discussion supply should have been refused. First dispensing of Durogesic (Fentanyl) 50 patches occurred on 3rd April 2015. This represented a three week gap in the dispensing history since the patient had received two weeks supply of the Norspan 10mcg/hr. The pharmacist should have contacted the doctor to clarify the reason for the gap and at the same time discussed the continuing use of the two benzodiazepines as well as the fact that the Durogesic 50 Patches constituted a substantial increase in strength of opioid over the Norspan 10mcg/hr (AMH 2012 p.48) and was considered a higher than normal initiating dose (Durogesic PI 2014). From 3rd April 2015 until 2nd September 2015 there was continued dispensing of the two benzodiazepines and the Fentanyl but with other anomalies as below:- • Short intervals of supply for the Durogesic especially on April 14th, 21st April, 1st , 8th, 12th May 29th May 5th June, 12th June • Short intervals of supply for the benzodiazepines especially on 3rd, 14th 21st April and 1st 8th May and 26th and 29th June The pharmacist should have been aware that Fentanyl patches have the potential to be abused by ingestion or injection and has lead to deaths as a result (Durogesic PI 2012 p.7). It is also known to have been diverted for sale on the street at a price of over $100 per patch, based on the 2012 price (The Age 19/10/2012). Also that benzodiazepines may cause dependence and may be abused (AMH 2012 p.779) On the 10th September 2015, five months on from receiving a regular supply of Durogesic 50 and 75 patches, the patient was dispensed 2 Norspan 10 patches only seven days after receiving 15 Durogesic 50 patches. This again should have raised questions with the pharmacist about the reason for the sudden change by the doctor especially because the Norspan was significantly weaker than the Durogesic and could precipitate opioid withdrawal symptoms (AMH 2012 p.48) Before dispensing the pharmacist should have contacted the doctor for clarification and if not satisfied with the discussion the pharmacist should have refused supply. Six days later on 16th September 2015 the pharmacy dispensed another script for Durogesic 50 which in light of the above would again have created doubts about the safety of the patient as above. The Antenex, Durogesic and Mirtazapine continued to be dispensed to the patient at regular intervals until 13th January 2016. On four occasions the directions for use were not provided except for apply as directed or simply as directed. Each of the above occasions required the pharmacist to consider the safeguards above before dispensing to ensure good patient care and clinical interventions noted. As a pharmacist and proprietor of the pharmacy since 2002, Dr Abdalla should have been aware of the Guidelines on responsibilities of pharmacists when practicing as proprietors, 29th January 2013 which states that a proprietor pharmacist must maintain an awareness of the standards published by the profession. Also Dr Abdalla should have maintained an active interest in the practice of pharmacy and known that he could not delegate his professional responsibility (Guidelines for proprietor pharmacists 2nd September 2015). However, as he stated in his interview with the PRU (28th April 2016 p.73 paragraph 40) he only did some administration such as payments and superannuation in terms of the day to day running. In addition, Dr Abdalla as proprietor of the pharmacy should have had systems in place for raising concerns about risks to patients (Code of conduct for health practitioners July 2012 p.10 paragraph 6.2d) From the above, I consider that Dr Abdulla's lack of oversight caused his conduct as a pharmacist and proprietor of the pharmacy to fall significantly below the standard reasonably expected of a practitioner of an equivalent level of training and experience and invites my strong criticism … Based on the dispensing history of Late Night Chemist Auburn, the supply of Fentanyl to Patient E does not accord with the recognized therapeutic standard of what is appropriate in the circumstances and I clarify this statement as follows:- From the dispensing record of Patient E, first dispensing at this pharmacy of Durogesic (Fentanyl) 75 patches occurred on 25th July 2014. Fentanyl is not considered first line treatment for opioid naive patients with chronic pain (Therapeutic Guidelines Analgesic Version 6 2012) and is not recommended for opioid naive patients with non-cancer pain due to cases of hypoventilation and death (Durogesic Product Information (PI) 15/01/14). Furthermore, in circumstances where it is considered appropriate for opioid naive patients to use Fentanyl, it is recommended that patients first be titrated with low doses of immediate release opioids to receive an equianalgesic dose of not more than Fentanyl 25mcg/hour before conversion to Fentanyl patches (Durogesic PI 2014). From the above information a pharmacist should have known that this dose is reserved for opioid dependent patients and is considered a higher than normal initiating dose (Durogesic PI 2014) so a pharmacist should have considered whether the use of the medicine was appropriate and not excessive (Code of Conduct for Health Practitioners March 2014 Paragraph 5.2) and taken all reasonable steps to address the issue if reason to think that the safety of the patient could be compromised (Code of Conduct for Health Practitioners March 2014 Paragraph 6.2F). As there was no previous dispensing history of analgesics to patient E a pharmacist, before dispensing the first Durogesic 75 script, should have clarified with the prescribing doctor whether the patient had been initiated with Fentanyl outside of the pharmacy and, if so, confirmed that the dosing schedule was correct. If no prior initiation of opioids then a pharmacist should have discussed the above information with the prescribing doctor to provide good care for the patient through shared decision making (Code of Conduct 2012 p.1, Overview). This would also ensure that the service provided was appropriate for the assessed needs of the patient and not excessive (Code of Conduct for pharmacists March 2014 p.16 paragraph 5.2a) In the dispensing history of Patient E there is a time period of three weeks between 8th and 29th August 2014 when no Fentanyl 75 was dispensed. As the normal length of supply is 15 days the pharmacist should have contacted the doctor to confirm continuity of supply outside the pharmacy or current status of the patient. There is a long gap between 30th January and 8th May 2015 when no dispensing of Durogesic 75 occurred. The pharmacist should have treated the dispensing on the 8th May 2015 as if for a new patient and clarified the appropriateness of the prescription as above. On one occasion the directions for use were not provided except for apply as directed or simply as directed. Each of the above occasions required the pharmacist to consider the safeguards above before dispensing to ensure good patient care and clinical interventions noted. As a pharmacist and proprietor of the pharmacy since 2002, Dr Abdalla should have been aware of the Guidelines on responsibilities of pharmacists when practicing as proprietors, 29th January 2013 which states that a proprietor pharmacist must maintain an awareness of the standards published by the profession. Also Dr Abdalla should have maintained an active interest in the practice of pharmacy and known that he could not delegate his professional responsibility (Guidelines for proprietor pharmacists 2nd September 2015). However, as he stated in his interview with the PRU (28th April 2016 p.73 paragraph 40) he only did some administration such as payments and superannuation in terms of the day to day running. In addition, Dr Abdalla as proprietor of the pharmacy should have had systems in place for raising concerns about risks to patients (Code of conduct for health practitioners July 2012 p.10 paragraph 6.2d) From the above, I consider that Dr Abdulla's lack of oversight caused his conduct as a pharmacist and proprietor of the pharmacy to fall significantly below the standard reasonably expected of a practitioner of an equivalent level of training and experience and invites my strong criticism … Based on the dispensing history of Late Night Chemist Auburn, the supply of Fentanyl to Patient F does not accord with the recognized therapeutic standard of what is appropriate in the circumstances and I clarify this statement as follows:- First dispensing at this pharmacy was for Durogesic (Fentanyl) 75 patches which occurred on 28th March 2014. Fentanyl is not considered first line treatment for opioid naive patients with chronic pain (Therapeutic Guidelines Analgesic Version 6 2012) and is not recommended for opioid naive patients with non-cancer pain due to cases of hypoventilation and death (Durogesic Product Information (PI) 15/01/14). Furthermore, in circumstances where it is considered appropriate for opioid naive patients to use Fentanyl, it is recommended that patients first be titrated with low doses of immediate release opioids to receive an equianalgesic dose of not more than Fentanyl 25mcg/hour before conversion to Fentanyl patches (Durogesic PI 2014). From the above information a pharmacist, before dispensing the first Durogesic 75 script, should have known that this dose is reserved for opioid dependent patients and is considered a higher than normal initiating dose (Durogesic PI 2014) so a pharmacist should have considered whether the use of the medicine was appropriate and not excessive (Code of Conduct for Health Practitioners March 2014 Paragraph 5.2) and taken all reasonable steps to address the issue if reason to think that the safety of the patient could be compromised (Code of Conduct for Health Practitioners March 2014 Paragraph 6.2f). As there was no previous dispensing history of analgesics to patient F a pharmacist would have clarified with the prescribing doctor whether the patient had been initiated with Fentanyl outside of the pharmacy and, if so, confirming that the dosing schedule was correct. If no prior initiation of opioids then a pharmacist should have discussed the above information with the prescribing doctor to provide good care for the patient through shared decision making (Code of Conduct 2012 p.1, Overview). There are four elongated gaps in the patients dispensing history between 10th April 2014 and 27th August 2014 where the patient has not received a script within a period of 15 days which is the length of time a prescription would last. This should have been discussed with the prescribing doctor to check if the patient had been receiving scripts and was having them dispensed elsewhere to ensure that supply was still appropriate. This would also act as an alert in case the doctor had not been prescribing the medication to the fact that the patient may have been getting prescriptions from elsewhere. On six occasions the directions for use were not provided except for as directed (see above) Each of the above occasions required the pharmacist to consider the safeguards above before dispensing to ensure good patient care and clinical interventions noted. As a pharmacist and proprietor of the pharmacy since 2002, Dr Abdalla should have been aware of the Guidelines on responsibilities of pharmacists when practicing as proprietors, 29th January 2013 which states that a proprietor pharmacist must maintain an awareness of the standards published by the profession. Also Dr Abdalla should have maintained an active interest in the practice of pharmacy and known that he could not delegate his professional responsibility (Guidelines for proprietor pharmacists 2nd September 2015). However, as he stated in his interview with the PRU (28th April 2016 p.73 paragraph 40) he only did some administration such as payments and superannuation in terms of the day to day running. In addition, Dr Abdalla as proprietor of the pharmacy should have had systems in place for raising concerns about risks to patients (Code of conduct for health practitioners July 2012 p.10 paragraph 6.2d) From the above, I consider that Dr Abdulla's lack of oversight caused his conduct as a pharmacist and proprietor of the pharmacy to fall significantly below the standard reasonably expected of a practitioner of an equivalent level of training and experience and invites my strong criticism … In my opinion, based on the dispensing history of Late Night Chemist Auburn, the supply of [Oxycodone and Temazepam] to Patient G does not accord with the recognised therapeutic standard of what is appropriate in the circumstances and I clarify this statement as follows:- First dispensing for Patient G occurred on 13th September 2011 for 28 Oxycontin CR 20mg with a dose of One twice daily when needed together with 50 Antenex 2mg one at night when needed. The pharmacist should have contacted the doctor to clarify whether the patient had been initiated with Oxycontin outside of the pharmacy because Oxycontin, as a controlled release tablet, is not recommended for initial stabilisation or acute pain (AMH 2012 p.56). The pharmacist could also confirm that the strength and the unusual dosing schedule were correct as Oxycontin MR 10mg is usually used as a starting dose for opioid naive patients or patients presenting with severe pain uncontrolled by weaker opioids and the dosing schedule is twice daily and not on a when needed basis (Oxycontin PI September 2014 p.12). At the same time the pharmacist should have discussed the fact that Oxycontin and diazepam are both CNS depressants and that concurrent use may result in increased respiratory depression, profound sedation and coma (Oxycontin PI September 2014 p.9). The above would ensure that the service provided was appropriate for the assessed needs of the patient On the 13th and 22nd September 2011 fourteen days' supply of Oxycontin CR 20mg were also dispensed with only a nine day interval and subsequently with an eight day interval on the 22nd and 30th September 2011. These shortened intervals should have alerted the pharmacist to the possibility that the patient may not be coping with his pain management and was taking additional tablets, and/or showing signs of dependency and possible abuse (Oxycontin PI 17th September 2014 p.5). A discussion should have been held with the doctor to clarify the situation so that the pharmacist could ensure that the service provided was appropriate for the assessed needs of the patient. If the pharmacist was not satisfied with the outcome of the discussion then supply should have been refused. On 22nd September 2011 and 18th October 2011 the pharmacy dispensed 20 Codapane forte with a dose of one or two tablets four times a day plus, on 16th October 2011, a script for Tramadol SR 150mg one twice daily when needed. The pharmacist should have considered that the need for breakthrough medication greater than twice a day would indicate that that the patient should be reassessed and if appropriate the Oxycontin dose increased (Oxycontin PI 17th September 2014). The doctor should therefore have been contacted to clarify the prescriptions and based on their discussions the pharmacy could decide if the service provided was appropriate. Between 18th October 2011 and 2nd July 2012 regular scripts were dispensed for Oxycontin CR 20mg together with Antenex 2mg and Tramadol SR 200mg together with an occasional prescription for 20 Codapane Forte and one script for 20 Endone 5mg with a dose of one three times daily when needed. All of these medications may have a sedative effect plus these scripts should have highlighted the need by the pharmacist to consider the pain management of the patient as per the recommendations of the Oxycontin PI 2014 plus the fact that Diazepam is only recommended as a short term treatment of two to four weeks (AMH 2012 p.779). Therefore the pharmacist should have been in regular contact with the doctor and constantly assessed if the service provided was appropriate for the assessed needs of the patient. If the pharmacist was not satisfied with the outcome of the discussion then supply should have been refused. On 16th July 2012 and 17th August 2012 25 Temazepam 10mg was dispensed together with 28 Oxycontin CR 20mg. As a benzodiazepine, the CNS depressant effects as above should again have been considered and the doctor contacted to clarify the prescription. On the 6th November 2012 28 Oxycontin 20mg were dispensed. The same medication was then dispensed again one day later plus the second script was charged as a private prescription at almost eight times the price of a PBS prescription. As the Oxycontin supplied the previous day was a 14 day supply, a pharmacist should have immediately questioned the need for a second dispensing and the reason for the private prescription status, especially as Oxycontin can cause physical dependence and was known to be drug of abuse (Oxycontin PI 2011 p.5 and p. 10) with a high street value (The Age 19/10/2012). Therefore, before dispensing this second script a pharmacist should have contacted the prescribing doctor to clarify the reason for the second script and from the information obtained decide if the service provided by the doctor and subsequently the pharmacist was appropriate for the assessed needs of the patient and not excessive. If not satisfied then the pharmacist should have refused supply. Between 7th November 2012 and 8th February 2013 there was a three month break in the supply of Oxycontin Cr 20mg and the first prescription dispensed was charged as a private prescription. The fact that the last prescription dispensed in November 2012 was also charged as a private prescription, plus the long delay between prescriptions, should again have alerted the pharmacist to question the prescribing doctor about the circumstances surrounding these scripts and from this discussion decide if the service provided by the doctor and subsequently the pharmacist was appropriate for the assessed needs of the patient and not excessive. If not satisfied then the pharmacist should have refused supply. Oxycontin 20mg and Diazepam 2mg and 5mg scripts then continued to be dispensed at regular intervals until 22nd October 2013 when a prescription for 28 Oxycontin CR 20mg was dispensed followed by a second prescription for 28 reduced strength Oxycontin CR 10mg three days later. The pharmacist should have taken into consideration the previous occurrence on 6th November 2012 and raised their concern with the prescribing doctor and refused supply if not satisfied with the outcome of the discussion. On 18th November 2013, after a further prescription of 28 Oxycontin CR 10mg was dispensed on 8th November, possibly indicating that the patient had reduced needs for opioid medication, the pharmacy dispensed a prescription for 5 Durogesic 50 patches with a dose of as directed. The pharmacist should have known that there is a great difference in potency between the two medications, with Durogesic 50 being equivalent of 90-149mg of oral morphine per day (patients on stable and well tolerated opioid therapy) versus 20mg Oxycontin a day being equivalent to 30mg of daily oral morphine (Durogesic PI 15/01/2014 p.18) and contacted the doctor about a possible over treatment leading to a possible opioid overdose and discussed the option of increasing the dose of Oxycontin as there is no ceiling dose unless adverse drug reaction occur (Oxycontin PI February 2011 p. 10) At the same time the pharmacist could have told the doctor that the script had inadequate instructions for dosing and needed to be corrected or re-written. Eight days later and again ten days after that, two further scripts for 5 Durogesic 50, 15 days supply each, were dispensed with one again having inadequate dosing instructions. In light of previous short intervals of supply the doctor should have been contacted before the pharmacist dispensed these prescriptions and refusal of supply considered if no acceptable reason supplied by the doctor. Six days later on 12th December 2013 the pharmacy dispensed 28 Oxycontin 20mg. The reduction in opioid dosage could lead to possible withdrawal symptoms and the fact that the patient would still have supply of Durogesic 50 patches in his possession would be grounds to contact the doctor before dispensing this script. Between 28th January 2014 and 10th April 2014 28 Oxycontin 20mg was dispensed eight times, enough for 112 days. However the period of dispensing is only 75 days. Again this should have raised issues with the pharmacist about the frequency of dispensing and possible overuse, abuse or diversion of this medication. There was then a gap of one month in opioid dispensing until 9th May which a pharmacist should have checked with the doctor closely followed by two 14 day scripts dispensed within a nine day period which again should have been checked by the pharmacist. This was followed in September 2014 with two Oxycontin scripts being dispensed within 3 days of each other which should have again alerted the pharmacist to over treatment and possible abuse and or diversion by the patient. During this whole period Diazepam 2mg or 5mg tablets were being dispensed which again should have been discussed with the doctor regarding prolonged usage and the possibly of additional CNS depression through the mixture of a benzodiazepine and an opioid. There was another gap in the dispensing history between 26th September 2014 and 18th November 2014 which would necessitate the pharmacist contacting the doctor to confirm whether opioid dosing had continued outside of the pharmacy. Oxycontin CR 20mg was regularly dispensed until 1st April 2016 with certain anomalies. These included short intervals between dispensing of both Oxycontin CR 20mg and Diazepam, a three month gap in Oxycontin dispensing between 7th December 2015 and 1st February 2016, a one month gap between 1st February 2016 and 7th March 2016 and ditto until 1st April 2016. All of which should have been checked by the pharmacy. On every occasion outlined above, the pharmacist should have contacted the prescribing doctor and to clarify the situation so that the pharmacist could ensure that the service provided was appropriate for the assessed needs of the patient. If the pharmacist was not satisfied with the outcome of the discussion then supply should have been refused. As a pharmacist and proprietor of the pharmacy since 2002, Dr Abdalla should have been aware of the Guidelines on responsibilities of pharmacists when practicing as proprietors, 29th January 2013 which states that a proprietor pharmacist must maintain an awareness of the standards published by the profession. Also Dr Abdalla should have maintained an active interest in the practice of pharmacy and known that he could not delegate his professional responsibility (Guidelines for proprietor pharmacists 2nd September 2015). However, as he stated in his interview with the PRU (28th April 2016 p.73 paragraph 40) he only did some administration such as payments and superannuation in terms of the day to day running. In addition, Dr Abdalla as proprietor of the pharmacy should have had systems in place for raising concerns about risks to patients (Code of conduct for health practitioners July 2012 p.10 paragraph 6.2d) From the above, I consider that Dr Abdulla's lack of oversight caused his conduct as a pharmacist and proprietor of the pharmacy to fall significantly below the standard reasonably expected of a practitioner of an equivalent level of training and experience and invites my strong criticism … In my opinion, based on the dispensing history of Late Night Chemist Auburn, the supply of [Fentanyl and Oxycodone] to Patient H does not accord with the recognized therapeutic standard of what is appropriate in the circumstances and I clarify this statement as follows:- The first dispensing for 28 Oxycontin 40mg occurred on 13th January 2012 after Two prescriptions for analgesics in December 2011. The pharmacy should have contacted the doctor to clarify whether the patient had been initiated with Oxycontin outside of the pharmacy because Oxycontin, as a controlled release tablet, is not recommended for initial stabilisation or acute pain (AMH 2012 p.56). The pharmacy could also confirm that the strength was correct as Oxycontin 10mg twelve hourly is the usual starting dose for opioid naive patients or patients presenting with severe pain uncontrolled by weaker opioids (Oxycontin PI February 2011 p.10). The dispensing of the Oxycontin 20mg ten days later on 23rd January 2012 could signify that the patient had reduced needs for opioid medication or that the 40mg dose was causing adverse reactions yet one day later by a script for 5 Durogesic 75mcg patches with a dose of apply three HOURLY as directed was dispensed The pharmacist should have known that there is a significant difference in potency between the two medications with Durogesic 75 being equivalent of 225-314 mg of oral morphine per day as a recommended starting dose. With patients on stable and well tolerated opioid therapy this equivalence is still only reduced to 150-209mg of oral morphine per day. This compares with 20mg Oxycontin a day being equivalent to 30mg of daily oral morphine (Durogesic PI 15/01/2014 p.18). The pharmacy should have contacted the doctor about a possible over treatment and at the same time this should have reminded the pharmacist that the correct dosing interval for Durogesic was one patch every three days not every three hours. In either case this could have prevented the incorrect labeling and possible overdosing which could have led to adverse effects for the patient. Finally, in this instance, the pharmacy should have clarified that the patient understood not to combine the Oxycontin and Fentanyl as this could lead to increased respiratory depression, hypotension, profound sedation and coma (Oxycontin PI 2011 p.7) and a clinical intervention noted. On 6th February 2012 the pharmacy dispensed a script for 5 Durogesic 100 patches followed ten days later by a script for only 14 Oxycontin 10mg and two days after that another script for Durogesic 100 with inadequate directions for use. Both of these dispensing should have been questioned by the pharmacy as the Oxycontin 10mg script is a substantial reduction in opioid strength (as above) followed by the much stronger opioid. The pharmacy should have known that If two opioids are used concurrently then additive CNS depression, respiratory depression and hypotension may occur (Oxycontin PI 2011 p. 8) adversely affecting the patient. Further, a pharmacist should have known that it is recommended to use small increments to titrate the correct dose (AMH 2012 p. 47) Nine days later, on 27th February 2012 the patient was dispensed 50 Coumadin 1mg. The pharmacy should have been aware that opioids may potentiate the anticoagulant activity of warfarin (Oxycontin PI 2011 p.7) and the doctor contacted to confirm that he was aware of this possibility. Between 6th February 2012 and 29th March 2012, a period of approximately 56 days Durogesic 100 was dispensed 6 times, equivalent to 90 days supply. This should have alerted the pharmacy to over prescribing by the doctor and the fact that the patient still required breakthrough analgesics on the 6th and 8th March should further have alerted the pharmacy to the fact that the patient was either struggling with pain control or possibly abusing the opioid because Fentanyl has the potential to be abused by ingestion or injection and has led to deaths as a result (Durogesic PI 2012 p.7). Furthermore it is also known to have been diverted for sale on the street at a price of over $100 per patch (The Age 19/10/2012). On four of the six occasions there was inadequate dosing instructions for the Durogesic and the same procedure as above should have occurred. The next dispensing of Durogesic 100 took place 6 months later on 28th September 2012. The pharmacy should have contacted the doctor to clarify the current opioid status of the patient and tell the doctor that there was inadequate dosing instructions. On the 19th October 2012 the next opioid dispensing was for 28 Oxycontin 80mg. The pharmacy should have been aware of the potency differential between Fentanyl and Oxycontin and that a conservative oxycodone dose of approximately 10mg every twelve hours should be initially substituted for each 25mcg Fentanyl patch (Oxycontin PI February 2011 p. 11). Because of this there is a potential overdose and the doctor contacted for clarification. A further cause to alert the pharmacy to reflect on whether this supply accorded with recognised therapeutic standards pursuant to Clause 109 of the Poisons and Therapeutic Goods Regulation 2008, especially in light of the past dispensing history of the patient, was the fact that the dispensing was done as a private prescription which was very unusual. The doctor should have been contacted to clarify the situation and if no satisfactory explanation received the pharmacy has the duty to refuse supply. There was then a further break in opioid dispensing until 8th March 2013 when the pharmacy dispensed a script for 28 Oxycontin 40mg with a dose schedule of one daily by an unknown doctor. Due to the previous dispensing history the doctor should have been contacted to confirm the opioid status of the patient and to discuss the dosing schedule as the total daily oral Oxycontin dose should be divided into two twelve hourly doses (Oxycontin Pi Feb 2011 p.11) On 24th March 2013 the pharmacy dispensed a script for 28 Oxycontin 80mg with the same dosing of one daily written by the same unknown doctor. Again the doctor should have been contacted to confirm change of strength and dosing schedule. Nine days later on 2nd April 2013 the pharmacy dispensed a script for Durogesic 100 by a third doctor. Again the pharmacy should have contacted the doctor to discuss the change of medication from the previous doctor due to the potency differential where even in patients on stable and well tolerated opioid therapy; Durogesic 100 is equivalent to 210¬269 mg/day of oral morphine against Oxycontin 80mg equivalency of 80mg/day of oral morphine (Durogesic PI 2014 p.18). Based on this evidence there is a possibility of an opioid overdose. There is a further break in the dispensing history until 28th May 2013 when a script for Durogesic 100 was dispensed from the original doctor. Between 28th May 2013 and the final dispensing shown on 14th December 2015, Durogesic 100 followed by Durogesic 75 from 28th January 2015 onwards was dispensed on many occasions with breaks occurring between June and July 2013, October and December 2013 and April and August 2014. At each resumption of dispensing the same procedure of checking with the doctor should have been carried out and a clinical intervention noted. During the above period there were thirteen occasions when inadequate dosing instructions were added to the dispensing label. On every occasion outlined above, the pharmacist should have contacted the prescribing doctor and to clarify the situation so that the pharmacist could ensure that the service provided was appropriate for the assessed needs of the patient. As a pharmacist and proprietor of the pharmacy since 2002, Dr. Abdalla should have been aware of the Guidelines on responsibilities of pharmacists when practicing as proprietors, 29th January 2013, which states that a proprietor pharmacist must maintain an awareness of the standards published by the profession. Therefore he should have maintained an active interest in the practice of pharmacy and known that he could not delegate his professional responsibility (Guidelines for proprietor pharmacists 2nd September 2015). However, as he stated in his interview with the PRU (28th April 2016 p.73 paragraph 40) he only did some administration such as payments and superannuation in terms of the day to day running. In addition, Dr Abdalla as proprietor of the pharmacy should have had systems in place for raising concerns about risks to patients (Code of conduct for health practitioners July 2012 p.10 paragraph 6.2d) From the above, I consider that Dr Abdulla's lack of oversight caused his conduct as a pharmacist and proprietor of the pharmacy to fall significantly below the standard reasonably expected of a practitioner of an equivalent level of training and experience and invites my strong criticism. … In my opinion, based on the dispensing history of Late Night Chemist Auburn, the supply of Fentanyl to Patient I does not accord with the recognised therapeutic standard of what is appropriate in the circumstances and I clarify this statement as follows:- The first dispensing at this pharmacy for Patient I was for Durogesic (Fentanyl) 100 patches which occurred on 17th December 2013 Fentanyl is not considered first line treatment for opioid naive patients with chronic pain (Therapeutic Guidelines Analgesic Version 6 2012) and is not recommended for opioid naive patients with non-cancer pain due to cases of hypoventilation and death (Durogesic Product Information (PI) 15/01/14). Furthermore, in circumstances where it is considered appropriate for opioid naive patients to use Fentanyl, it is recommended that patients first be titrated with low doses of immediate release opioids to receive an equianalgesic dose of not more than Fentanyl 25mcg/hour before conversion to Fentanyl patches (Durogesic PI 2014). From the above product information a pharmacist, before dispensing the first Durogesic 100 script, should have known that this dose is reserved for opioid dependent patients and is considered a higher than normal initiating dose (Durogesic PI 2014). There the pharmacy should have clarified with the prescribing doctor whether the patient had been initiated with Fentanyl outside of the pharmacy and, if so, confirming that the dosing was correct. If no prior initiation of opioids then a pharmacist should have discussed the above information with the prescribing doctor to provide good care for the patient through shared decision making (Code of Conduct 2012 p.1, Overview). This would also ensure that the service provided was appropriate for the assessed needs of the patient and not excessive (Code of Conduct for pharmacists March 2014 p.16 paragraph 5.2a) As there was a gap in the patients dispensing history between 16th January 2014 and 26th May 2015, a period of over one year, the pharmacist should have treated the dispensing on the 26th May 2015 as if for a new patient and clarified the appropriateness of the prescription as above. It is further noted that on the 17th June and 6th July 2015 the pharmacy received prescriptions from Dr Abdalla for 10 patches of Durogesic 100 which equates to 30 days supply for each script. This is outside the concessional PBS limits and therefore converted the prescriptions into private scripts. Also the 6th July script was dispensed after 20 days when the patient should still have had 10 days' supply left. The fact that the patient was prescribed a larger than usual amount, was prepared to pay over ten times more for each script plus the requested early supply for the 6th July script should have immediately aroused the suspicion of the pharmacist because Fentanyl has the potential to be abused by ingestion or injection and has lead to deaths as a result (Durogesic PI 2012 p.7). It is also known to have been diverted for sale on the street at a price of over $100 per patch based on the 2012 price (The Age 19/10/2012) A pharmacist taking this information into consideration should have contacted the prescribing doctor to ascertain the reason for the large quantity of supply and again contacted the doctor about the reason for the need to supply the second prescription before the due time. If the pharmacist was not satisfied that the discussion with the doctor had provided a satisfactory explanation, he should have refused to dispense either or both the prescriptions. Each of the above occasions required the pharmacist to consider the safeguards above before dispensing to ensure good patient care and clinical interventions noted. As a pharmacist and proprietor of the pharmacy since 2002, Dr Abdalla should have been aware of the Guidelines on responsibilities of pharmacists when practicing as proprietors, 29th January 2013 which states that a proprietor pharmacist must maintain an awareness of the standards published by the profession. Also Dr Abdalla should have maintained an active interest in the practice of pharmacy and known that he could not delegate his professional responsibility (Guidelines for proprietor pharmacists 2nd September 2015). However, as he stated in his interview with the PRU (28th April 2016 p.73 paragraph 40) he only did some administration such as payments and superannuation in terms of the day to day running. In addition, Dr Abdalla as proprietor of the pharmacy should have had systems in place for raising concerns about risks to patients (Code of conduct for health practitioners July 2012 p.10 paragraph 6.2d) From the above, I consider that Dr Abdulla's lack of oversight caused his conduct as a pharmacist and proprietor of the pharmacy to fall significantly below the standard reasonably expected of a practitioner of an equivalent level of training and experience and invites my strong criticism. … The three forged prescriptions [for Fentanyl to patient AE] were dispensed in December 2014. The pharmacy had been dispensing regular quantities of opioid medication since at least 2011 from the records provided and therefore would have had lots of experience in dispensing these drugs of addiction. Furthermore they should have been aware that Fentanyl had the potential to be abused by ingestion or injection and had led to deaths as a result (Durogesic PI 2012 p.7) and was also known to have been diverted for sale on the street at a price of over $100 per patch (The Age 19/10/2012). Therefore all Fentanyl scripts should have been treated with extreme care. However, through the lack of Dr Abdalla's oversight of the pharmacy, drugs of addiction were dispensed on forged prescriptions. There did not appear to be a system in place to ensure that Clause 87 which states that a drug of addiction must not be supplied by a pharmacist unless they are familiar with the handwriting of the doctor, or knows the person for whom the drug is prescribed or has verified that the person who is purported to have issued the prescription had actually done so, had been followed. Further, it does not appear that that a system existed to consider when drugs of addiction were dispensed within short time intervals as the three prescriptions were, the last being dispensed only one day after the previous script. As stated in clause 109 of the Poisons and Therapeutic Goods Regulations 2008 an authorized practitioner or pharmacist must not supply any of these substances in a quantity, or for a purpose, that does not accord with the recognized therapeutic standard of what is appropriate in the circumstances. All of the above should have alerted the pharmacy to contact the prescribing doctor to verify the scripts so that the pharmacist could ensure that the service provided was appropriate for the assessed needs of the patient (Code of Conduct for pharmacists March 2014 p.16 paragraph 5.2a). If the pharmacy had a system in place to ensure that regulations were observed, none of these scripts would have been dispensed. Dr Abdalla should have been aware of the Guidelines on responsibilities of pharmacists when practicing as proprietors, 29th January 2013 which states that a proprietor pharmacist must maintain an awareness of the standards published by the profession. Also Dr Abdalla should have maintained an active interest in the practice of pharmacy and known that he could not delegate his professional responsibility (Guidelines for proprietor pharmacists 2nd September 2015). Dr Abdalla should also have considered the code of conduct for registered health practitioners 27th July 2012 which states under Risk management p.10 6.2d that if a practitioner has management responsibilities then they need to make sure that systems are in place for raising concerns about risks to patients. Risk management also entails working within systems to reduce error and improve the safety of patients and supporting colleagues who raise concerns about the safety of patients Section 6.2e. This would have included a system to document each intervention (The Standard and guidelines for pharmacists performing clinical interventions March 2011, paragraph 4.1) in which methods of documentation are recommended (paragraph 4.2) Had Dr Abdalla overseen the running of the pharmacy he would have ensured that such systems were in place. From the above, I consider that Dr Abdulla's lack of oversight caused his conduct as a pharmacist and proprietor of the pharmacy to fall significantly below the standard reasonably expected of a practitioner of an equivalent level of training and experience and invites my strong criticism. … The majority of [115] non-compliant prescriptions [of S8 drugs] were dispensed in 2015 when the pharmacy had been dispensing regular quantities of drugs of addiction since at least 2011 from the records provided. Dr Abdalla should have been aware that a proprietor pharmacist must maintain an awareness of the standards published by the profession (The Guidelines on responsibilities of pharmacists when practicing as proprietors, 29th January 2013). He should therefore have maintained an active interest in the practice of pharmacy and known that he could not delegate his professional responsibility (Guidelines for proprietor pharmacists 2nd September 2015). The quantity of non-compliant scripts shows a lack of knowledge in the pharmacy concerning Clause 80 of the Poisons and Therapeutic Goods Regulation 2008 which states the necessary information that must be on a prescription for a drug of addiction before it can be even considered for dispensing. He should have set in place risk management systems at the pharmacy which entailed working within systems to reduce errors (The code of conduct for registered health practitioners 27th July 2012 Section 6.2e) and maintained and developed his knowledge and skills as these are core aspects of good practice (The code of conduct for registered health practitioners 27th July 2012 Section 7.1). Through the lack of Dr Abdalla's oversight of the pharmacy no systems appeared to be in place to ensure that correct procedures were followed. This would have included a system to document each intervention (The Standard and guidelines for pharmacists performing clinical interventions March 2011, paragraph 4.1) in which methods of documentation are recommended (paragraph 4.2) Had Dr Abdalla had followed the above, non-compliant scripts would not have been dispensed. From the above, I consider that Dr Abdulla's lack of oversight caused his conduct as a pharmacist and proprietor of the pharmacy to fall significantly below the standard reasonably expected of a practitioner of an equivalent level of training and experience and invites my strong criticism. … [Re whether the Pharmacy's practice in the supply of S8 and S4D drugs was conducted in accordance with applicable laws, standards and guidelines]. Dr Abdalla should have been aware that a proprietor pharmacist must maintain an awareness of the standards published by the profession (The Guidelines on responsibilities of pharmacists when practicing as proprietors, 29th January 2013 (and should therefore have maintained an active interest in the practice of pharmacy and known that he could not delegate his professional responsibility (Guidelines for proprietor pharmacists 2nd September 2015). Had he maintained an active interest, he would have been able to ensure that the pharmacy's practice for the supply of the above drugs would have been carried out in accordance with the various laws standards and guidelines as stated previously. Further that as a practitioner with management responsibilities he needed to ensure that systems were in place for raising concerns about risks to patients (The code of conduct for registered health practitioners 27th July 2012 states under Risk management p.10 6.2d) which are outlined in the above case histories. He would have set in place risk management strategies at the pharmacy which entailed working within systems to reduce errors (The code of conduct for registered health practitioners 27th July 2012 Section 6.2e) and maintained and developed his (and his staffs) knowledge and skills as these are core aspects of good practice (The code of conduct for registered health practitioners 27th July 2012 Section 7.1) As maintaining clear and accurate health records is essential for the continuing good care of patients Dr Abdalla should have ensured that the pharmacy kept up to date and legible records that reported details of clinical history, clinical findings, investigations and information given to patients (The code of conduct for registered health practitioners 27th July 2012 Section 8.4). This would have included a system to document each intervention (The Standard and guidelines for pharmacists performing clinical interventions March 2011, paragraph 4.1) in which methods of documentation are recommended (paragraph 4.2). Through the lack of Dr Abdalla's oversight of the pharmacy no systems appeared to be in place to ensure that correct procedures were followed. Had he done so many if not all the incidents raised in the patient case histories above would not have occurred. From the above, I consider that Dr Abdulla did not take adequate steps to ensure that the pharmacy's practice in the supply of S4D and S8 drugs was conducted in accordance with applicable laws, standards and guidelines and this caused his conduct as a pharmacist and proprietor of the pharmacy to fall significantly below the standard reasonably expected of a practitioner of an equivalent level of training and experience and invites my strong criticism. ********** I hereby certify that this is a true and accurate record of the reasons for decision of the Civil and Administrative Tribunal of New South Wales. Registrar DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment or decision. The onus remains on any person using material in the judgment or decision to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court or Tribunal in which it was generated. Decision last updated: 02 July 2020