Civil and Administrative Tribunal New South Wales Medium Neutral Citation: Health Care Complaints Commission v Rahman (No 2) [2021] NSWCATOD 65 Hearing dates: 5 – 6 May 2021 Date of orders: 18 May 2021 Decision date: 18 May 2021 Jurisdiction: Occupational Division Before: Cowdroy AO QC ADCJ, Principal Member Associate Prof M Hooper, Senior Member J Fogarty, Senior Member J Barker, General Member Decision: (1) The registration of the respondent as a medical practitioner is cancelled with effect from seven days after the date of these orders; (2) Pursuant to s 149C(7) of the Health Practitioner Regulation National Law (NSW), an application for review of these orders may not to be made during the period of 12 months commencing on the date of these orders; (3) The respondent is to pay the costs of the applicant as agreed or assessed in default of agreement. Catchwords: HEALTH — professional registration and discipline — complaints — inappropriate prescribing of Schedule 4 and Schedule 8 drugs — prescribing without authority — continued prescribing in circumstances where no clinical need existed for drug — drugs prescribed without assessment — drugs prescribed in grossly excessive quantities in unexplained circumstances — prescribing to patients with history of drug dependence — failing to maintain proper clinical records — poor referral practices — self-prescribing — failure to heed warnings concerning prescribing practices Legislation Cited: Health Practitioner Regulation National Law (NSW) Poisons and Therapeutic Goods Act 1966 (NSW) Poisons and Therapeutic Goods Regulation 2008 (NSW) Cases Cited: Bronze Wing International Pty Ltd v SafeWork NSW [2017] NSWCA 41 Health Care Complaints Commission v Brush [2015] NSWCATOD 120 Health Care Complaints Commission v Do [2014] NSWCA 307 Health Care Complaints Commission v Dr Mohammed Sadiq Asar [2016] NSWCATOD 157 Health Care Complaints Commission v Philipiah [2013] NSWCA 342 Hughes and Vale Pty Ltd v The State of New South Wales (No 2) (1955) 93 CLR 127; [1955] HCA 28 Lee v Health Care Complaints Commission [2012] NSWCA 80 Prakash v Health Care Complaints Commission [2006] NSWCA 153 Spicer v New South Wales Medical Board (Court of Appeal (NSW), 19 February 1981, unrep) Texts Cited: Nil Category: Principal judgment Parties: Health Care Complaints Commission (Applicant) Bassel Abdul Rahman (Respondent) Representation: Counsel: P Aitken (Applicant) S Barnes (Respondent) Solicitors: Health Care Complaints Commission (Applicant) Unsworth Legal (Respondent) File Number(s): 2019/00293287 Publication restriction: Publication of the names of the patients set out in the schedule to the Complaint is prohibited pursuant to an order made on 11 March 2021. REASONS FOR DECISION Introduction 1. These reasons for decision should be read with the Stage One decision in these proceedings: Health Care Complaints Commission v Rahman [2021] NSWCATOD 25. Respondent's evidence 1. The respondent has provided a statement which provides detailed information concerning his background. 2. The respondent graduated with a MBBS from the University of New South Wales in 1999 and in that year and in 2000 was employed at Wollongong and Concord hospitals as an intern and thereafter as a resident medical officer. 3. In 2001 the respondent commenced general practice and in 2005 he passed the fellowship examinations of the Royal Australian College of General Practitioners (RACGP). In 2005 he commenced practice at the Cheso Family Medical Practice in Chester Hill. 4. In November 2012 he commenced practice at Primary Health Care Medical and Dental Centre, Bankstown. In January 2016 he commenced practice at the Miranda Medical Centre where he continues to practise. 5. The respondent states at the time of prescribing various medications the subject of the Complaint he was suffering from an autoimmune condition for which he is being treated. The condition manifests as extreme pain in the abdomen and joints requiring him to take rest and medication including steroids and analgesia. At the time, his treating practitioners were unable to offer a diagnosis for the condition. 6. The respondent also states that at that time he was being treated for post-traumatic stress disorder arising from an attack upon him in 2014 by a patient/stranger who was wielding an axe. 7. The respondent states that he considers these two conditions significantly impaired his capacity with difficult patients who attended seeking medications and that he felt overwhelmed. Further, the working conditions were such that his room was noisy, being close to a waiting area, and patients outside would walk in and demand particular medications. 8. The respondent accepts that his knowledge surrounding the medications in question was lacking and he did not appreciate all the serious consequences his prescribing might have and he accepts that, because of his own health circumstances, he did not seek advice concerning the medications and appropriate prescribing. 9. The respondent states that in relation to obtaining human growth hormones for patients, the company providing them did not offer any advice or education with respect to their use. 10. The respondent accepts that his conduct in prescribing was inappropriate in many instances and was excessive, especially in relation to anabolic steroids and Schedule 4D and Schedule 8 drugs. 11. Since October 2015, when the respondent appeared before the Medical Council of New South Wales ("the Council"), the respondent has sought to improve his performance and has undertaken a number of educational courses related to dealing with anxiety disorders, including Managing Anxiety Disorders in Primary Care (the University of Sydney Centre for Continuing Education), Pain Management Master Class – A Practical Approach to Chronic Pain Management (RACGP), Alcohol and Other Drugs GP Education Program (RACGP) and Reflection: Pain Management Master Class. 12. In January and February 2016 the respondent completed an educational program offered by "GP Training" based in Melbourne to address legislative and regulatory obligations concerning prescribing S4 and S8 drugs, drug seeking patients and demanding patients, and "off label prescribing: treating self, relatives and friends". 13. The respondent stated that he has carefully reviewed the provisions of the Poisons and Therapeutic Goods Act 1966 (NSW) and the Poisons and Therapeutic Goods Regulation 2008 (NSW) relating to prescribing Schedule 4D and Schedule 8 medications. 14. The respondent states that he has reviewed the Guidelines published by the RACGP entitled "Prescribing drugs of dependence in general practice"; and information provided by the NSW Ministry of Health entitled "Guide to Poisons and Therapeutic Goods Legislation for Medical, Nurse and Midwife Practitioners and Dentists" and "Prescribing of Benzodiazepines, Alprazolam and Flunitrazepam". 15. As to medical records, the respondent states that one of the conditions imposed on his registration following the s 150 proceedings required him to undergo an audit of his medical records. He subsequently underwent four audits and while there had been improvement in record keeping such records remained inadequate. Accordingly, the Council determined that a further performance assessment be carried out on 26 August 2019. As a result, the records were found to be appropriate and the assessors recommended to the Council that no further action was required and such recommendation was accepted. The respondent has a supervisor, Dr Mary Joseph, who has not raised any issues of concern. 16. The respondent stated that he has not prescribed any medications for himself since the s 150 proceedings. He continues to attend upon Dr Robert Fisher, psychiatrist who was first consulted in 2017. With regard to prescribing for his immediate family the respondent acknowledges that he now understands that it is inappropriate to prescribe for them and he has not done so. Medical evidence Associate Professor Sean Riminton 1. Associate Professor Sean Riminton was first consulted by the respondent on 10 March 2014. Professor Riminton diagnosed a hereditary periodic fever syndrome, subject to qualifications, namely the initial episode commenced quite late at the age of 35, and secondly hypocomplementaemia was present. In the preceding 3 to 4 years, the respondent had experienced between 6 and 10 attacks of the syndrome, lasting in duration 3 to 4 days, up to 7 to 8 days. The symptoms included fevers, rigors, abdominal pain, chest pain and diarrhoea. Between the attacks there may be three to four months of no symptoms at all. 2. Professor Riminton also recorded in the report of 13 February 2017 certain medications which had been prescribed for the respondent but were unsuccessful in managing his illness. He recommended referral to an international immunologist and also that the respondent attend a multidisciplinary periodic fever syndrome clinic overseas. He considered that the respondent's syndrome "is either very rare or has not been previously described". 3. Professor Riminton provided a report of 1 April 2020. He states that he has seen the respondent once every three to six months since 10 March 2014 and more frequently by phone and email. He confirmed that the respondent has a significant chronic medical disorder "best described as a periodic fever syndrome… Treatment has been provided which is ongoing". Professor Riminton states that the respondent's condition was a "significant psycho-social stressor, and in his case diagnostic uncertainty and lack of clarity with respect to prognosis are undoubted additional concerns". His findings were confirmed by his oral evidence. Dr Robert Fisher 1. Dr Robert Fisher, psychiatrist, has provided a report dated 8 April 2020 and provided oral evidence. He was first consulted by the respondent on 4 August 2017 and has seen the respondent intermittently since then. Initially the appointments were about every two weeks, when the respondent was still "stressed about his traumatic experience with the axe wielding patient outside the clinic" and then by "accusations of sexually inappropriate behaviour which have subsequently been dismissed in Court". A schedule of appointments shows that consultations took place mainly in 2018, with one appointment on 31 May 2019 and another on 20 March 2020. 2. Dr Fisher considers that the respondent's psychiatric condition is best described as a phase of post-traumatic stress disorder symptoms following the axe attack; in addition he has suffered from an adjustment disorder with anxious depressed mood. The respondent has received medication for his conditions. 3. Dr Fisher considered that the respondent had only limited insight into the inappropriateness of his prescribing until he undertook various courses following the s 150 hearing in 2015. Thereafter, the respondent appears to have developed insight, has engaged in further education regarding prescribing practices, and has committed to not reoffending. 4. Dr Fisher also said in oral evidence that he could not see a causal relationship between PTSD and inappropriate prescribing and that he did not believe the auto-immune disease was a causative factor. He said the respondent "would have known" that what he was doing was wrong. Dr Fisher further added there was no causal link between the respondent's psychological condition and inappropriate prescribing; it was "not exculpatory". Dr Stuart Saker 1. Dr Stuart Saker, consultant psychiatrist provided a report dated 12 May 2017. Dr Saker expressed the view that the plaintiff was suffering from post-traumatic stress disorder, following "an event which occurred in 2014–2015". As a result the respondent has been in a state of fear and was "terrorised into prescribing high potency [benzodiazepines] and [o]piates to his patients". Dr Saker was not called to provide oral evidence. Dr Abdullah Zobair 1. Dr Abdullah Zobair is a general practitioner conducting his practice at the Miranda Medical Centre. Dr Zobair considered himself to be the respondent's general practitioner. He provided a referral to the Emergency Department of Sutherland Hospital to enable the respondent to obtain treatment, and referrals to Dr Saker for psychiatric assistance and to Dr Fisher, and had generally cared for the respondent. Dr Mary Lynette Jayanti Joseph 1. Dr Mary Joseph, who provided statements and oral evidence on two occasions during the hearing, is a general practitioner, conducting her practice at the Miranda Medical Centre. She has been in practice for 30 years, and was nominated by the respondent to be his supervisor following the imposition of conditions in 2015 by the Council. The Tribunal has received in evidence supervision reports prepared by Dr Joseph from March 2016 to April 2020. The reports record that the respondent's notes were adequate and contained good detail, that he had participated in research and study through the University of Sydney, that patients were followed up promptly and recalled as appropriate, and that generally the respondent was performing well. The report dated 6 May 2020 states: "Dr Rahman continues to work well under his conditions. He is performing well clinically." 1. None of the reports, which were completed at three-monthly intervals, contains any adverse observations concerning the respondent's performance as a medical practitioner. 2. Dr Joseph states that she met with the respondent every two weeks for approximately one hour and prepared three-monthly supervision reports. She continues to supervise the respondent. She states that whilst his illness had caused him to take some days off work, he was able to return to work and had no issues once his illnesses subsided. 3. Dr Joseph was not aware of the respondent's history of prescribing inappropriately which resulted in the imposition of the conditions by the Council. She was unaware, prior to the Tribunal proceedings, of the conduct of the respondent in providing off-label drugs, human growth hormone and testosterone until about 2018, and was also unaware that the respondent had issued prescriptions without the authority to do so. She was not aware that the respondent provided drugs to addicted persons nor that his prescribing was inappropriate. Further, Dr Joseph had not read the Complaint upon which the present proceedings are based. 4. The respondent had stated that one of his areas of interest and specialty was men's health and hair loss. However, such interests had never been made known to Dr Joseph; although she was aware the respondent had completed a course in hair replacement therapy. Legal principles 1. Section 3A of the Health Practitioner Regulation National Law (NSW) ("the National Law") requires that the "protection of the health and safety of the public" be the paramount consideration when considering allegations of, inter alia, the practice of medicine which is deficient. The jurisdiction of the Tribunal is (generally) not punitive, but is protective: its role is to ensure that those who seek the services of medical practitioners are not exposed to inappropriate conduct. 2. The Tribunal must be satisfied that the respondent is a "fit and proper person" to be registered as a medical practitioner: see the observations contained in Health Care Complaints Commission v Brush [2015] NSWCATOD 120 at [72]–[73]. As has also been considered by the High Court of Australia in Hughes and Vale Pty Ltd v The State of New South Wales (No 2) (1955) 93 CLR 127 at 156 (Dixon CJ, McTiernan and Webb JJ); [1955] HCA 28, the term "fit and proper" is to be construed in light of the legislative context. 3. For observations to similar effect regarding the purpose of orders: see Prakash v Health Care Complaints Commission [2006] NSWCA 153 at [91] and Health Care Complaints Commission v Do [2014] NSWCA 307 where Meagher JA said (inter alia) at [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 conduct 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." 1. The Tribunal was satisfied to a high degree that the conduct complained of has been established on the evidence: see Bronze Wing International Pty Ltd v SafeWork NSW [2017] NSWCA 41. Practice restriction 1. On 30 October 2015 the Council imposed extensive conditions on the respondent's registration pursuant to s 150 of the National Law. Such conditions included a restriction on the respondent's right to practice to a group practice setting only; to treat no more than 30 patients a day; not to possess, supply, administer or prescribe any "drug of addiction" (Schedule 8 drug) as defined by the Poisons and Therapeutic Goods Act; not to possess, supply, administer or prescribe any substance listed in Schedule 4, Appendix D of the Poisons and Therapeutic Goods Regulation; to submit to audits and to report regularly. Such conditions were reviewed in December 2015 and again between 31 December 2015 and 8 January 2016. Further reviews took place between 14 March 2017 and 19 April 2018, between 19 April 2018 and 10 August 2018, between 10 August 2018 and 2 April 2019, and from 19 November 2019 to the present day. The final "Performance Assessment Summary" provided to the Tribunal is dated 26 August 2019. It concludes: "Conclusion The assessors believe that the professional performance of Dr Rahman is satisfactory in that it meets the standard reasonably expected of a practitioner of an equivalent level of training or experience. Recommendations In view of the conditions already in place on Dr Rahman's registration it is recommended that no further action be taken." References 1. During this Stage Two hearing references were provided by several medical practitioners and other health workers which testify of the high esteem in which they held the respondent. References were provided by Dr Carl James Allen, general practitioner, Dr Saima Khalid, general practitioner (who also provided oral evidence), Dr Goran Josifoski Stevans, psychiatrist (who did not treat the respondent) and Dr Joseph. Dr Joseph stated that she considered that the respondent had insight into his condition, was observing the prescribing requirements, was remorseful for his conduct and would not transgress again. 2. The Tribunal found such references to be of value to the extent they address the current practices of the respondent in the management of patients. They confirmed that the respondent's records and practising methods are satisfactory and that the respondent is hard-working. They did not specifically address the issues which this Tribunal has to consider concerning the inappropriate conduct of the respondent in medical practice. Observations 1. The conduct of the respondent includes the inappropriate prescribing of prescription drugs. The respondent acknowledged that his prescribing was "unscientific" and was also "reckless". The respondent acknowledged that his prescribing was below the standard expected of a medical practitioner. By way of explanation of his behaviour he referred to his own illness, his PTSD, which arose out of an axe attack in 2014 when he went to assist a stranger (though the respondent also describes this person as a patient) and was himself placed in danger; and the fact that the surgery where he conducted his practice made him feel exposed and vulnerable to belligerent members of the public who demanded that he issue prescriptions to them for the drugs they sought. 2. In many instances, prescriptions for drugs such as testosterone were issued without any adequate blood tests having been performed which indicated the necessity for such drugs. In another case, a test had been performed but the timing of the test was inappropriate and accordingly the result of the test which was relied upon by the respondent to issue such drugs was misleading because it was taken at the wrong time of day. 3. The respondent also acknowledged that he had prescribed inappropriately for members of his family, and had self-prescribed. 4. In other instances, the prescribing of drugs was carried out on a scale which the Tribunal finds was grossly excessive. For example, the respondent wrote prescriptions for one patient between 16 February 2015 and 7 April 2015 for 540 Endone tablets. There is no clinically legitimate reason for such an extraordinary quantity to be issued to a patient. The same patient, in the above period, consulted the respondent on 16 occasions and was also issued prescriptions for Lyrica, Tramal, Primoteston, Nexium, and Avanza. Overprescribing is also apparent in relation to the other patients referred to by the expert. 5. The respondent first came to the attention of the Council as a result of a complaint made against him in approximately 2007 and as a consequence an audit was conducted in 2008. Conditions of practice have repeatedly been imposed, restricting or prohibiting the respondent from prescribing certain drugs. Performance assessments have also been carried out on his practice and in as early as 2011 the assessors, in making their report, stated: "The Interview Panel examined the paper records and felt that little had changed since the 2009 Performance Interview in regard to record keeping. The progress notes were still scant in details of history, examination findings and management plan including details of discussions noted to have occurred. Dr Rahman agreed that his notes were inadequate and required more detail. … "The Interview Panel, however, felt that Dr Rahman needed to review the requirements for authority prescriptions and was critical that he still lacked the understanding of correct authority prescribing of S8 drugs. The Panel also felt that Dr Rahman needed to be more assertive in his role to guide patients to wean them from the benzodiazepines and counselled him on the important role he plays in his patient's care." 1. When the respondent testified before the Council convened on 28 October 2015, he was asked questions concerning the fact that he didn't perform testosterone level tests for those patients who were asking for testosterone medication. The respondent replied: "They were asking for it but they previously would have had a blood test at some stage, but a lot of them did come and ask and I've had a lot of people asking (indistinct) but I got stuck with those ones for mostly my fault, but a lot of them have come and asked me. I just tell them, "No, I can't give it to you," because they obviously look like bodybuilders, like, most of them. These ones they don't. The ones I have at the moment are not bodybuilders, but the ones that are obvious I just tell them, you know, I can't give it." 1. In its determination as contained in the written reasons of the Council, the Council stated: "… The delegates were of the view that Dr Rahman had prescribed or supplied S8 and S4D drugs, growth hormones, steroids, and other substances for purposes that were not medically indicated, and in contravention of accepted standards and limitations. This was at considerable risk to some of his patients and to others who may be offered those drugs through trafficking. The delegates found that he had continued to do so over a long period of time, in spite of warnings he had received from the relevant authorities." 1. The Tribunal observes that the matters which have been the subject of the complaints focus upon continued inappropriate prescribing on a vast scale, prescribing without authority S8 and S4 drugs, and poor record keeping. It appears that the remarks of the Council in 2008 remain valid. Further, the need for proper prescribing was clearly brought to the attention of the respondent, as he acknowledged, in 2009, and on a recurring basis until 2015. 2. The Tribunal notes the observations of the New South Wales Court of Appeal in Spicer v New South Wales Medical Board (Court of Appeal (NSW), 19 February 1981, unrep) which are instructive. Hope JA, with whom Reynolds and Hutley JJA agreed, observed at 5–6: "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 which is reckless and which shows a disregard to the law it cannot be said that he is fit 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 unfit to treat those addicted or habituated to drugs but that unfitness in itself demonstrated his present unfitness to be a medical practitioner". Tribunal findings 1. The Tribunal refers to its findings set out in [157]–[171] of its reasons for decision in Stage One of these proceedings. The Tribunal considers that the respondent's conduct is strikingly similar to the factual circumstances which existed in Health Care Complaints Commission v Dr Mohammed Sadiq Asar [2016] NSWCATOD 157 ("Asar"), in which the Tribunal found: [79] The professional misconduct of the respondent which we have found following his admissions and our conclusions concerning those matters which were contested is of a most serious kind. With respect to Complaint One, the respondent has conceded that he engaged in conduct that demonstrated that his knowledge, skill or judgement which he possessed and the care which he exercised in the practice of medicine was significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience. This misconduct was not confined to a few cases. It extended to 26 patients over a considerable period of time. It persisted notwithstanding warnings received from the Pharmaceutical Services Unit. The respondent conceded that, in the bulk of the cases, he did not perform an appropriate medical assessment prior to issuing the scripts, he did not exercise responsible medical judgement as to whether it was appropriate to issue the scripts, he failed to refer the patients to a specialist for treatment, review or advice and he was aware that his conduct in prescribing drugs of addiction was contraindicated because of the likelihood of substance abuse. In effect, based on the evidence of the respondent himself, as well as the expert opinion of Dr Patterson, the respondent was in the same position as a drug supplier, dispensing drugs of addiction to persons who were, or might become, addicted and drug-dependent. In addition, as is clear from the expert opinion of Dr Patterson and as conceded by the respondent the fact that he prescribed Schedule 8 drugs in combination with a benzodiazepine created significant health risks for some of his patients. These included the possibility of respiratory depression with potentially fatal outcomes as well as the increased risk of benzodiazepine-dependence. [80] Furthermore, the respondent was aware that he required a relevant authority under the Poisons and Therapeutic Goods legislation to dispense such drugs, and that his misconduct was carried out in contumelious disregard for his lawful obligations. By reason of the matters referred to in Complaint Two, the respondent conceded that he had issued private scripts. Despite, and, relevantly, because of the respondent's inability to give any plausible explanation as to why he would do this, we infer that the private scripts were issued so that it was more likely that the respondent's misconduct would not come to the attention of the authorities. The misconduct of the respondent as we have described it, which involved him in engaging in the unlawful and inappropriate distribution of drugs of addiction was compounded by his failure to maintain adequate and proper medical records as set out in Schedule 2 to the Health Practitioner Regulation (NSW) Regulation, 2010 for each of the patients. [81] It is a trite observation that comprehensive record-keeping is essential to assist a medical practitioner in affording proper and appropriate treatment to patients. A history of reported symptoms, diagnoses, tests and procedures, medication, and referrals amongst other matters are necessary tools in the practice of medicine. It is important also that another medical practitioner who may be required to afford treatment to the patient, be able to become informed about the patient as quickly as possible by reference to existing medical records. A failure to keep and maintain necessary and appropriate records may not only constitute a breach of the statutory requirements referred to above, but may, in appropriate cases per se be characterised as constituting unsatisfactory professional conduct and professional misconduct," 1. The Tribunal in Asar determined that cancellation of the practitioner's registration was warranted and that the practitioner not be eligible to apply for renewal of his registration for a period of 24 months from the date of the orders. 2. The Tribunal is mindful that the respondent has not infringed any restriction on prescribing for at least five years. This is no doubt due to the imposition of the conditions pertaining to his practice. However, he has successfully conducted his practice and not come under notice for any recent transgressions. The Tribunal is also mindful that the respondent is performing a valuable community service as a medical practitioner and has expressed remorse for his conduct. The Tribunal also notes that the respondent's conduct largely occurred during a period when he was suffering from a mental condition. However, the Tribunal notes the opinion of Dr Fisher, the respondent's psychiatrist, that the respondent's illness does not explain his behaviour. 3. The Tribunal is also mindful of the extensive delays that have occurred in the institution of these proceedings. Though this was not the fault of the applicant, the fact remains that there has been an extensive delay between when the offending conduct ended and the matter being brought before this Tribunal. 4. The mere fact that a complaint may be old does not diminish its seriousness: Prakash v Health Care Complaints Commission at [52] per Santow JA. In Lee v Health Care Complaints Commission [2012] NSWCA 80 Barrett JA referred, at [72], to Walsh JA's observation in Ex parte Tziniolis; Re Medical Practitioners Act (1956) 67 SR (NSW) 448 at 461 that: "… One cannot assume that a change has occurred merely because some years have gone by and it is not proved that anything of a discreditable kind has occurred. If a man has exhibited serious deficiencies in his standards of conduct and his attitudes it must require clear proof to show that some years later he has established himself as a different man". At [73] Barrett JA concluded that "a finding of reformation thus cannot be made by reference merely to the passage of time without renewed misconduct." 1. Despite the delay, the Tribunal considers that disqualification is necessary in view of the gross overprescribing referred to in the Tribunal's decision; the respondent's practice of purchasing and reselling off-label drugs including Somatropin, which is frequently used for bodybuilding and known to have black market appeal; his failure to heed warnings over many years, and out of a concern which the Tribunal has that the respondent may again lapse into wrongful prescribing. 2. The Tribunal is also concerned that the respondent does not comprehend the ethical requirements necessary for appropriate practice, as is also demonstrated by his past history of prescribing, particularly with respect to Somatropin, and by his pursuing unproven hair loss therapies, in which he has taken a keen interest. The respondent does not seem to appreciate that such therapies, until tested, remain novel. Further, the respondent's prior history has demonstrated a disregard for authority. Costs 1. The applicant seeks an order that the respondent pay its costs of the proceedings. Such application is not opposed. In accordance with the principles established by the New South Wales Court of Appeal in Health Care Complaints Commission v Philipiah [2013] NSWCA 342 at [42]–[46], costs will be awarded in favour of the applicant. The applicant has been successful in its application in that the Tribunal considers there is no basis to depart from the provisions of cl 13 of Sch 5D to the National Law. Orders 1. The Tribunal makes the following orders consequent upon its findings of professional misconduct: 1. The registration of the respondent as a medical practitioner is cancelled with effect from seven days after the date of these orders; 2. Pursuant to s 149C(7) of the Health Practitioner Regulation National Law (NSW), an application for review of these orders may not to be made during the period of 12 months commencing on the date of these orders; 3. The respondent is to pay the costs of the applicant as agreed or assessed in default of agreement. ********** 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: 18 May 2021