Civil and Administrative Tribunal New South Wales Medium Neutral Citation: Health Care Complaints Commission v Carayannis [2021] NSWCATOD 81 Hearing dates: 31 May – 1 June 2021 Date of orders: 15 June 2021 Decision date: 15 June 2021 Jurisdiction: Occupational Division Before: Balla ADCJ, Principal Member Dr M Cooper, Senior Member Dr G Dore, Senior Member D Telford, General Member Decision: The orders we make are the following: (1) Dr Carayannis is reprimanded. (2) The following conditions are placed on Dr Carayannis' registration: Practice Conditions 1. To obtain Medical Council of New South Wales' approval prior to changing the nature or place of his practice; 2. Not to undertake locum positions; 3. Not to participate in any on-call rosters; 4. Not to participate in retrieval medicine; 5. Not to prescribe, possess, supply, administer, handle or dispense any Schedule 8 drug as defined by the Poisons and Therapeutic Goods Act 1966 (NSW), except in a hospital where he is working. Dr Carayannis is permitted to prescribe, administer, handle or dispense Schedule 8 drugs only in a hospital to inpatients during the practice of anaesthesia, or on a hospital medication chart, or as patient discharge prescriptions; 6. Not to possess, supply, administer or prescribe any Schedule 4 drug listed in Appendix D to the Poisons and Therapeutic Goods Regulation 2008 (NSW), except in a hospital where he is working. Dr Carayannis is permitted to prescribe, administer, handle or dispense Schedule 4 Appendix D drugs only in a hospital to inpatients during the practice of anaesthesia, or on a hospital medication chart, or as patient discharge prescriptions; 7. To practise under category C supervision in accordance with the Medical Council of New South Wales' "Compliance Policy – Supervision" (as varied from time to time) and as subsequently determined by the appropriate review body; (a) The terms of the Council's "Compliance Policy – Supervision" are varied so that the practitioner is to: (i) have review meetings with his Council-approved supervisor(s), fortnightly, for a period of three months and monthly thereafter; (ii) authorise the Council-approved supervisor(s) to provide reports to the Council (in a Council-approved format) on a monthly basis; (b) At each supervision meeting the practitioner is to review and discuss his practice with his Council-approved supervisor with a particular focus on: (i) Clinical management; (ii) Documentation; (iii) Doses of opioid analgesia used during procedures in relation to accepted standards; (iv) Post-operative pain management; (c) The Council-approved supervisor is to conduct a random audit of the practitioner's: (i) Schedule 8 and Schedule 4 Annexure D drugs signed out during an operation; (ii) Drugs recorded as administered and drug discard witnessed; (iii) Recovery room analgesia required; (d) The Council-approved supervisor is to conduct a random audit of five of the practitioner's cases fortnightly, ensuring that at least one case is from each workplace; (e) Not to practise until a supervisor has been approved by the Council; (f) To authorise the Council to provide proposed and approved supervisors with a copy of the decision that imposed this condition; 8. To nominate an experienced anaesthetist to act as his professional mentor for approval by the Medical Council of New South Wales in accordance with the Council's "Compliance Policy – Mentor" (as varied from time to time) and as subsequently determined by the appropriate review body; (a) The terms of the Council's "Compliance Policy – Mentor" are varied so that the practitioner is to meet with the mentor on a monthly basis; (b) At each mentoring meeting the practitioner is to include discussion of the following: (i) Issues raised in supervision meetings; (ii) Challenges related to working with conditions on his registration; (iii) Career planning; (c) To authorise the mentor to report, in an approved format, to the Council every three months about the fact of contact, and to inform the Council if there is any concern about his professional conduct, health or personal wellbeing; 9. To forward evidence to the Medical Council of New South Wales, within 14 days of the making of these orders, that he has provided a copy of the full conditions to the head of the Anaesthetic Department at all places of practice; 10. Within 14 days of a change in the nature or place of his practice, he is to forward evidence to the Medical Council of New South Wales that he has provided a copy of the full conditions to the head of the Anaesthetic Department at all places of practice; Health Conditions 11. Further to the requirements of Condition 8, the practitioner is also required to discuss with his mentor at each mentoring meeting: (a) Work/life balance; (b) Progress with regard to his treatment; 12. Not to prescribe for self-medication; 13. To attend for treatment by a general practitioner of his choice. The frequency of treatment is to be determined by the treating practitioner. The practitioner: (a) is to authorise the treating practitioner to inform the Medical Council of New South Wales of any of the following: (i) Failure to attend for treatment; (ii) Termination of treatment; (iii) A significant change in health status (including a significant temporary change); (b) must provide the Council with the professional details of the treating practitioner; 14. To attend for treatment by a drug and alcohol clinician of his choice. The frequency of treatment is to be determined by the treating practitioner. The practitioner: (a) is to authorise the treating practitioner to inform the Medical Council of New South Wales of any of the following: (i) Failure to attend for treatment; (ii) Termination of treatment; (iii) A significant change in health status (including a significant temporary change); (b) must provide the Council with the professional details of the treating practitioner; 15. To attend for treatment by a psychiatrist of his choice. The frequency of treatment is to be determined by the treating practitioner. The practitioner: (a) is to authorise the treating practitioner to inform the Medical Council of New South Wales of any of the following: (i) Failure to attend for treatment; (ii) Termination of treatment; (iii) A significant change in health status (including a significant temporary change); (b) must provide the Council with the professional details of the treating practitioner; 16. To attend for treatment by a psychotherapist of his choice. The frequency of treatment is to be determined by the treating practitioner. The practitioner: (a) is to authorise the treating practitioner to inform the Medical Council of New South Wales of any of the following: (i) Failure to attend for treatment; (ii) Termination of treatment; (iii) A significant change in health status (including a significant temporary change); (b) must provide the Council with the professional details of the treating practitioner; 17. To take any medication as prescribed by his treating practitioners; 18. To comply with the Medical Council of New South Wales' "Drug Screening Policy" and "Participant Procedure: Drug Screening" (as varied from time to time) and attend for: (a) Urine drug screening three times a week; and (b) Quarterly hair drug screening; 19. To attend for review by a Council-appointed psychiatrist on a three-monthly basis or as otherwise directed by the Medical Council of New South Wales. 20. To attend a Medical Council of New South Wales' Review Interview on a three-monthly basis, or as otherwise directed by the Council. 21. To authorise the Medical Council of New South Wales to forward copies of the s 150 and s 150A written reasons, any subsequent Council Review Interview or other report, and any other information relevant to his health and treatment, to the Council-appointed practitioners and to his treating practitioners. 22. The Medical Council of New South Wales is the appropriate review body. (3) Dr Carayannis is to pay the costs of the Health Care Complaints Commission of the proceedings, as agreed or assessed. Catchwords: HEALTH — professional registration and discipline — unsatisfactory professional conduct – professional misconduct Legislation Cited: Health Practitioner Regulation National Law (NSW) Cases Cited: Briginshaw v Briginshaw (1938) 60 CLR 336; [1938] HCA 34 Clyne v The New South Wales Bar Association (1960) 104 CLR 186; [1960] HCA 40 Health Care Complaints Commission v Do [2014] NSWCA 307 Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630 Qidwai v Brown [1984] 1 NSWLR 100 Texts Cited: Medical Board of Australia, "Good Medical Practice: A Code of Conduct for Doctors in Australia" (March 2014) Category: Principal judgment Parties: Health Care Complaints Commission (Applicant) Daniel Carayannis (Respondent) Representation: Counsel: D New (Applicant) S Barnes (Respondent) Solicitors: Health Care Complaints Commission (Applicant) Unsworth Legal (Respondent) File Number(s): 2020/00281761 Publication restriction: Pursuant to s 64(1)(a) of the Civil and Administrative Tribunal Act 2013 (NSW), publication of the names of Person A and Person B is prohibited. REASONS FOR DECISION 1. This is an application for disciplinary findings and orders under the Health Practitioner Regulation National Law (NSW) (the National Law) by the Health Care Complaints Commission against Dr Daniel Carayannis. Background 1. Dr Carayannis is an anaesthetist. He graduated as a doctor in 2010 and then worked at Prince of Wales Hospital, firstly as an intern, then as a Resident Medical Officer and later as a Senior Resident Medical Officer. From 2014 to 2018 he worked there as an accredited anaesthetic registrar and was also seconded to Sutherland Hospital, Wollongong Hospital and the Royal Hospital for Women. 2. Between February 2018 and February 2019, Dr Carayannis was employed as a provisional fellow at Royal Prince Alfred Hospital. 3. Relevantly for these proceedings, between 3 February 2019 and 3 August 2019 Dr Carayannis worked as an anaesthetic registrar at the CareFlight Rapid Response Helicopter Hanger at Westmead and the CareFlight Sydney Jet Operations Base at Mascot, after which he was awarded Fellowship of the Australian and New Zealand College of Anaesthetists. 4. From May 2019, he was a Visiting Medical Officer in anaesthetics at Royal Prince Alfred Hospital and returned to work there after his contract with CareFlight ended. Outline of the Application 1. The conduct underlying the Complaint is: 1. That between May and August 2019, Dr Carayannis inappropriately tampered with and misappropriated 29 ampoules of the Schedule 8 drug of addiction fentanyl at CareFlight Westmead for his own use by boring a small hole in the base of the ampoules with a Kincrome engraving tool and extracting the contents of the ampoules using a needle and syringe, refilling the ampoules with saline and sealing them with Loctite 60 Second Universal Glue or Loctite Easy Repair Rapid 60 Seconds. He then returned the ampoules for future use on patients, without disclosing to his employer that they had been tampered with, and consumed the contents of the syringes (Complaint One particulars 1–3). Dr Carayannis admits the conduct but says it occurred between June and July 2019. 1. That between May and August 2019, Dr Carayannis also inappropriately tampered with and misappropriated nine ampoules of fentanyl at CareFlight Mascot in the same way and then consumed the contents of the syringes (Complaint One particulars 4–6). Dr Carayannis admits the conduct but says it occurred in July 2019. 1. That between May and August 2019, Dr Carayannis also inappropriately tampered with and misappropriated seven ampoules of the Schedule 8 drug of addiction morphine at CareFlight Mascot in the same way and then consumed the contents of the syringes (Complaint One particulars 7–9). Dr Carayannis admits the conduct but says it occurred in July 2019. 1. That during August 2019, while working at Royal Prince Alfred Hospital, Dr Carayannis anaesthetised patients with drugs of addiction, including oxycodone, hydromorphone, fentanyl and IV methadone, and, instead of disposing of the unused portion of the drugs, inappropriately placed the unused portion of the drugs either in his top pocket or in his bag for his own use. He misappropriated these drugs of addiction from the operating theatre on almost every shift he worked, which was approximately three days a week for three weeks, or around nine occasions. He later consumed the drugs either sublingually, intranasally, or, on two occasions, intravenously (Complaint Two). Dr Carayannis admits the conduct but says he consumed the drugs at night and at home. 1. That between May and August 2019, Dr Carayannis failed to notify any professional medical or heath practitioner authorities of his drug use and the risk he may have posed to himself or his patients in contravention of section 9.2 of the Medical Board of Australia's "Good Medical Practice: A Code of Conduct for Doctors in Australia" (March 2014) (Complaint Three). Dr Carayannis admits the conduct but says it occurred between May and August 2019. 1. That the conduct in Complaints One and Two, either separately or when considered together, constitutes professional misconduct (Complaint Four). Dr Carayannis admits Complaint Four. 1. That Dr Carayannis has an impairment within the meaning of s 5 of the National Law, which is defined as including a substance abuse disorder or dependence which detrimentally affects or is likely to detrimentally affect his capacity to practise the profession of medicine. The Health Care Complaints Commission says Dr Carayannis suffers from an opiate use disorder — moderate type — in short-term remission, which began in early 2019 and has been in remission since September 2019 (Complaint Five). Dr Carayannis admits Complaint Five subject to the following: he says the opiate disorder began in May 2019, the conduct at CareFlight occurred between June and July 2019, and he consumed the drugs of addiction at night and at home. 1. Complaint Six was withdrawn by the Health Care Complaints Commission during the hearing. History 1. On 22 August 2019 a CareFlight Rapid Response Helicopter medical crew at the Westmead base started to prepare the pre-drawn drugs for the following day. After they removed a new ampoule of fentanyl from the S8 safe, they noticed there was fluid leaking from the bottom of the glass vial. They saw a small hole in the middle of the base of the ampoule. The hole appeared blocked by a clear glue or wax like material which had become dislodged, allowing a clear fluid to leak out. Another three ampoules of fentanyl were found to have been similarly tampered with. This led to an investigation across all the CareFlight operational sites. The investigation identified: 1. 29 tampered fentanyl ampoules at the Westmead base – total volume of 290ml; 2. 9 tampered fentanyl ampoules at the Mascot base – total volume of 90ml; 3. 7 tampered morphine ampoules at the Mascot base – total volume of 7ml. 1. The investigation identified Dr Carayannis as a "person of interest". On 27 August 2019 CareFlight informed various authorities including the Health Care Complaints Commission. 2. On 2 September 2019 the Health Care Complaints Commission sent Dr Carayannis the complaint it had received from CareFlight. The Evidence 1. The evidence from Dr Carayannis, family members and his treating general practitioner is that, in mid-2019, Dr Carayannis had been under a lot of stress and was suffering from back pain. This stress had a number of causes. 2. Dr Carayannis had a very close relationship with his father. In 2018 his father was diagnosed with cancer. He underwent treatment and was given a good prognosis. However in early March 2019 the cancer recurred and it was diagnosed as terminal. For the four weeks before Dr Carayannis' father died on 24 June 2019, Dr Carayannis took leave from work to spend time at the hospital. He witnessed his father suffering enormous pain before his death. He became concerned about a number of issues relating to the level of care being provided and the blurring of boundaries between him and the staff, such as staff asking for his advice on treatment. 3. In addition to this emotional stress, Dr Carayannis had been sleeping most of the time in the chair by the bedside. He initially slept there every second or third night but, towards the end, slept there every night. Dr Carayannis had a long-standing disc rupture in his low back for which he had undergone a procedure in 2015. Sleeping in the chair had caused a recurrence of his back pain. 4. In May 2019, Person A developed a neck growth and had a thyroidectomy. She did not want Dr Carayannis' father, who was then in hospital, to know of her condition, so Dr Carayannis took her to medical appointments and explained to her what was going on until she was diagnosed with, and underwent surgery for, thyroid carcinoma. That surgery occurred two days after Dr Carayannis was notified of the Complaint by the Health Care Complaints Commission. 5. In late 2018, Person B developed a rapidly progressive autoimmune condition and Dr Carayannis took him to, and supervised, his treatment throughout 2019. The treatment caused that person a lot of distress. Dr Carayannis said it was long and difficult for both of them. In 2019 that person was sexually assaulted. 6. In late 2018 Dr Carayannis had also taken on the co-ordination of the building of the family home. 7. Around mid-2019, Dr Carayannis did not feel overly supported by his partner who struggled to understand why he was spending so much time at the hospital and helping his relatives. 8. Dr Carayannis said he first took an opiate in May 2019 to relieve the acute back pain caused by sleeping in the chair at the hospital. He had about 18 Endone tablets at home which he had not used after his back procedure in 2015. He took most of those tablets. 9. In May 2019, his father, who was then in hospital, was being administered an opiate, hydromorphone, intravenously but at doses slightly less than was in the ampoules. This meant that some hydromorphone was left in each ampoule. Dr Carayannis said he saw the nurses place those ampoules into the sharps bin. 10. On one occasion in late May a used ampoule was left near the bed. Dr Carayannis took it and used it. After that he would extract the used ampoules with forceps from the sharps bin which had a broken lid. He said that he did this around 10 times. He used the hydromorphone at night to help him sleep and to relieve his back pain. 11. Dr Carayannis rapidly developed an opioid addiction and developed a tolerance to hydromorphone. 12. At this time Dr Carayannis held the position at CareFlight, although he was on leave from work for a month before the death of his father. As a doctor, he had been given the access codes to the safes used by CareFlight to store S8 drugs and he knew that they contained fentanyl. 13. In mid-June he went to the Westmead base at a time when the facility was not being used. He extracted most of the fentanyl from ampoules using the method set out in the Complaint. His father had been a tradesman so Dr Carayannis had some experience of working with glass and he owned the tools he used to remove the fentanyl from the ampoule. After he had made the hole with the engraving tool, he removed 80-90% of the fentanyl with a syringe, refilled each ampoule with saline, sealed the hole with glue and put the ampoule back into the safe. He admits that he tampered with 29 x 500mcg/10ml ampoules of fentanyl in this way. He consumed the fentanyl either at the hospital when he was with his father, or at home at night, from mid-June until when his father died on 24 June 2019. 14. Dr Carayannis then had two weeks leave from 24 June 2019 during which he had no access to drugs. He went through a very severe withdrawal. 15. At the end of that leave Dr Carayannis returned to work at the CareFlight base at Mascot. He accessed the drugs safe and removed a total of 9 x 10mg/ml ampoules of fentanyl and 7 x 10mg/ml ampoules of morphine. He used the same technique as he had used at Westmead. He usually snorted the fentanyl but on two occasions he injected it intravenously. 16. The unused tampered ampoules of fentanyl and morphine discovered by CareFlight were sent for forensic examination to laboratories. The residual concentration of drug was <4% of expected concentration suggesting the entire contents had been removed and replaced with another liquid. 17. Dr Carayannis continued to use in this manner until around 3 August 2019 when his contract with CareFlight ended. 18. Dr Carayannis had an ongoing need for opiates when he then returned to work at Royal Prince Alfred Hospital. On occasions he would sign out more opiates than were required for an operation. A report from the hospital confirms that their investigations revealed that Dr Carayannis' practice involved the administration of oxycodone at higher doses than many of his colleagues. Dr Carayannis put the leftovers into his bag or top pocket instead of disposing of them. He later consumed them at night. He removed oxycodone, hydromorphone, fentanyl and IV methadone in this way on about nine occasions over three weeks. 19. Dr Carayannis said he made a conscious decision to wean himself off the use of opiates over the three weeks to 27 August 2019. He reduced his oral dose of oxycodone from 15mg to 5mg. When he stopped using drugs on 27 August 2019 he had only minor withdrawal symptoms. 20. Dr Carayannis then received the CareFlight complaint from the Health Care Complaints Commission. 21. On 10 September 2019, the matter came before a panel convened under s 150 of the National Law to decide whether any action should be taken to protect the public. The panel noted that Dr Carayannis had last used drugs only two weeks earlier, decided that Dr Carayannis was impaired, and took into account that Dr Carayannis was at the very beginning of a necessary period of rehabilitation. It imposed a condition on his registration that he was not to practise medicine and noted that he needed to demonstrate sustained abstinence from drug use before he could safely practise. 22. Dr Carayannis sought a review of the decision. A s 150A hearing took place on 7 February 2020. The delegates noted that six months had elapsed since the s 150 hearing during which Dr Carayannis had engaged actively in treatment and attended for thrice weekly urine drug screening, the results of which had all been negative. They concluded Dr Carayannis demonstrated a good degree of insight into his addiction and they saw encouraging indications of his recovery from a rapidly acquired addiction. On 7 April 2020 they removed the condition preventing him from practising and imposed 20 practice and health conditions on his registration. These included requiring him to obtain Medical Council of New South Wales' (the Medical Council) approval prior to changing the nature or place of his practice; not to undertake locum positions; not to participate in any on-call rosters; not to possess, supply, administer or prescribe any Schedule 8 or Schedule 4 drug of addiction except in defined circumstances; to practise under category B supervision; to have a mentor; to attend for treatment by a general practitioner, a drug and alcohol clinician, a psychiatrist and a psychotherapist of his choice; and to attend for urine drug screening three times a week and quarterly hair drug screening. The conditions are reproduced in full in Annexure "A". 23. Dr Carayannis then tried to organise a return to work at Royal Prince Alfred Hospital. While some staff were supportive of his return to practice at that hospital, there was a lengthy delay while he waited for approval from the Chief Executive Officer. Dr Carayannis said that despite several attempts by himself and his lawyers to contact her, they did not receive a response. 24. Dr Carayannis then obtained a position at two private clinics under his Council approved supervisor, Dr Stavrakis. 25. Dr Carayannis was reviewed by the Medical Council on 25 September 2020. He had recently commenced work at the two clinics and was organising a one day a week research role at Royal Prince Alfred Hospital. The reviewers recommended no changes to his conditions. 26. By the time Dr Carayannis was reviewed again by the Medical Council on 9 December 2020 he had also commenced work as a non-clinical research assistant at Royal Prince Alfred Hospital in early November 2020. The reviewers found Dr Carayannis to be very well both physically and mentally, showing good insight into his impairment. He had been enjoying his recent return to work which had been a very positive part of his recovery. The reviewers recommended no changes to the conditions on his registration. 27. Quite recently, Dr Carayannis was reviewed by the Medical Council on 26 March 2021. He had increased his clinical work and was doing a gastroenterology/bariatric list on alternate Tuesday and Monday afternoons, had a regular full day list at the other private clinic on Thursdays and Fridays and was working in the research position at Royal Prince Alfred Hospital on Wednesdays. In addition, Dr Carayannis believed he had been successful in securing a one day a week Visiting Medical Officer position at the Prince of Wales Hospital. 28. The reviewers said it was apparent that Dr Carayannis continued to function at a high level clinically, and that his return to work had been beneficial for his recovery. They remained impressed with the significant progress Dr Carayannis had made in a relatively short time. 29. Dr Carayannis gave evidence before the Tribunal. He is still working at the clinics, where patients undergo endoscopies and cosmetic surgery. He is also still working in the research position at Royal Prince Alfred Hospital. He has now obtained the approval of the Medical Council to start work at the Prince of Wales Hospital. He will work there one day a week, with a spinal surgeon. He believes working with more complex procedures is important for his skill retention. Steps taken to address issues 1. The evidence establishes that Dr Carayannis has, since almost immediately after receiving the Complaint in September 2019, engaged in various therapies and treatments to address his substance abuse issues, depression and back pain. 2. Dr Smith, who has been Dr Carayannis' treating general practitioner since 2016, has confirmed that in 2019 Dr Carayannis was under many stresses due to the medical conditions of his close relatives. Dr Carayannis had disclosed his use of unprescribed opiates on 6 September 2019 and appeared committed to engage with all treatment available. Dr Smith referred him to a psychologist, Mr Albert, an addiction psychiatrist, and a psychotherapist and suggested he attend a "Doctors in Recovery" support group. Dr Smith has continued to regularly review Dr Carayannis and has advised that he is continuing to improve, is motivated to return to practice and has engaged with treatment. 3. Mr Albert's area of expertise is acceptance-based psychotherapies. He first saw Dr Carayannis on 11 September 2019. Dr Carayannis had consulted with him initially weekly and now consults him fortnightly. Dr Carayannis has always been punctual and has never missed a planned session. Mr Albert has undertaken a thorough examination of the emotional and cognitive processes and combination of stressors underlying Dr Carayannis' substance misuse as well as clarifying early warning signs and establishing stress management and life balance strategies to deal with future challenges. Dr Carayannis has learned, consolidated and applied those skills so that he has faced later significant stressors without substance use and without urges to use. These later stressors have included these proceedings, not being able to work for six months, administrative difficulties returning to work at Royal Prince Alfred Hospital, his grandfather's death in December 2020, financial stressors and caring for close relatives who have ongoing medical conditions and personal issues. Mr Albert considers that Dr Carayannis is in long-term remission from substance abuse and can safely practise medicine with conditions on his registration. 4. Dr D'Souza, a psychiatrist, has been treating Dr Carayannis since 19 September 2019. They meet weekly. He has been providing Dr Carayannis primarily with psychodynamic psychotherapy, which productively affects a person's emotions and cognition through increasing insight into relationship and developmental patterns, within the context of a therapist client relationship. He had also prescribed an antidepressant. Dr D'Souza described Dr Carayannis as sincere, curious and keen in doing the demanding emotional work required in therapy. He considers that Dr Carayannis' shock and remorse at his conduct and his realisation of how far gone his addiction had become, the depth of his isolation at the time and the reasons he sought to feed his dependency show that he has insight into his conduct. Dr D'Souza has diagnosed an Opioid Use Disorder which, in 2021, is in sustained remission. 5. Dr Sams is a psychiatrist, specialising in addiction psychiatry. He has provided reports and gave evidence. He has diagnosed an Opioid Use Disorder which is now in stable remission. He first saw Dr Carayannis on 17 September 2019. Dr Carayannis has continued to consult Dr Sams and now attends him every six to eight weeks. Dr Sams provides supportive psychotherapy, twelve step facilitation therapy and cognitive behavioural therapy. He considers that Dr Carayannis has expressed a high degree of insight into the seriousness of his conduct. Dr Sams believes the behaviours were out of character for Dr Carayannis and were the result of compulsion and desperation during a relatively brief period of physical dependence on opioids. He is of the view that Dr Carayannis can safely practise medicine with conditions on his registration. 6. Dr Carayannis also has a mentor. Initially his mentor was Professor Knoblanche who was formerly the Head of the Department of Anaesthesia at Royal North Shore Hospital. They first met in September 2019 and then continued to meet regularly. Professor Knoblanche considered that Dr Carayannis had acted on all his advice and counsel. Professor Knoblanche described Dr Carayannis as having made one substantial error in using narcotics and that all subsequent acquisitions, although totally unprofessional, were the result of narcotic addiction. 7. Professor Bennett, an anaesthetist, agreed to become Dr Carayannis' mentor in November 2020 when Professor Knoblanche was no longer able to continue in that role. Professor Bennett knew Dr Carayannis from when he had worked as a trainee in anaesthetics from February 2014 until February 2018. He then considered Dr Carayannis to be a conscientious, competent and keen trainee and well-respected among his colleagues and superiors. They met to discuss Dr Carayannis' professional activities, personal circumstances and ongoing efforts to overcome his history of misuse of opiate medication and falsification of medical records. Professor Bennett described his dealings with Dr Carayannis as positive. He believes he has reflected well on his own conduct, expressed sincere contrition and has a heartfelt desire to be the architect of his own recovery and rehabilitation. 8. Dr Carayannis has been attending Doctors in Recovery meetings weekly since September 2019 and has had a Narcotics Anonymous sponsor and attended Narcotics Anonymous meetings since October 2019. 9. Dr Carayannis has, since September 2019, been undergoing thrice weekly urine testing and quarterly hair testing. While the first hair test results on 5 September 2019 showed positive results for oxycodone, fentanyl, methadone and pseudoephedrine, there is no evidence before the Tribunal of any subsequent positive test result. 10. Dr Carayannis has also concentrated on his physical health by engaging in activities such as swimming and bicycling. He undertakes physiotherapy and Reformer Pilates to strengthen his back. He finds mindfulness and meditation of great benefit, particularly in managing insomnia. 11. Dr Carayannis has continued to undertake ongoing education in relation to anaesthesia, ethics and prescribing. In 2021 he enrolled in two courses dealing with Addiction Medicine offered online by the University of British Columbia and the British Columbia Centre on Substance Abuse. He said that he had decided to undertake the two courses as part of his ongoing recovery, and also so that one day he might be able to assist others. 12. Dr Stavrakis, anaesthetist, is Dr Carayannis' category B supervisor. He provided a statement and gave evidence. He has known Dr Carayannis since Dr Carayannis was a resident at Prince of Wales Hospital in 2013. He was then conscientious, keen to learn and respectful to patients and staff. 13. Dr Carayannis told him about the events giving rise to these proceedings in 2020. He knew that this was significantly out of character. Dr Stavrakis describes him as an outstanding gentleman, an affable and kind practitioner who treats his patients with respect and empathy. He is respectful of staff and he is diligent with his care of anaesthesia. He has become reflective and insightful to not only himself but also to others. 14. In 2019 Dr Stavrakis suggested Dr Carayannis apply for accreditation to work at the two clinics with him and offered to become Dr Carayannis' Medical Council approved supervisor. This led to Dr Carayannis working with Dr Stavrakis at the clinics. In his opinion Dr Carayannis responds to clinical emergencies with ease and competence. He has observed him closely as his supervisor and seen no cause for concern. 15. Dr Stavrakis believes that Dr Carayannis acted out of character in 2019 and his behaviour would not recur as there have been significant and life changing behaviours and insights, he has a strong support network and an impressive mentor in Professor Bennett. 16. Dr Stavrakis also works at Prince of Wales Hospital. Depending on the level of supervision required, he has offered to be Dr Carayannis' supervisor in his new position at that hospital. He thinks that Dr Carayannis will thrive on the challenges of working on more complex procedures with a multidisciplinary team. 17. Dr Carayannis has also been reviewed by the Medical Council appointed psychiatrist Dr Atherton. In June 2020 Dr Atherton considered that Dr Carayannis was making excellent progress and appeared to be well engaged with his treating specialist and was establishing a good recovery program. 18. In March 2021, Dr Atherton diagnosed Dr Carayannis as having an Opioid Use Disorder of severe type, which was in long-term remission. He considered that Dr Carayannis had developed an extremely strong, impressive recovery network, resulting in excellent self-awareness and a good understanding of addiction and the need for long-term support and engagement with his recovery plan. He had undertaken personal growth and development and had actively involved his other psychological supports if he felt anxious. He showed good insight into the need for his support network. 19. Dr Atherton described Dr Carayannis' slide into opioid addiction as rapid and profound, taking place on a background of significant stress. In all other respects Dr Carayannis had demonstrated dedication to the profession and to an honest life. He considered that his recovery seemed solid. He had no concerns about his return to work with conditions. 20. Dr Atherton gave evidence before the Tribunal. He agreed there is still a high risk of relapse and Dr Carayannis should be monitored for three to five years. He felt that Dr Carayannis understood that recovery will be a life-long journey; he has gone "above and beyond" and has shown himself willing to make changes in accordance with his recovery-based program. The Law 1. At the commencement of the hearing an order was made for the Tribunal to make findings in relation to the Complaint and then move on to determine the appropriate protective orders after a single hearing. 2. The onus is on the Health Care Complaints Commission to establish that one or more of the events pleaded in the Complaint occurred. To make any such finding we must be "comfortably satisfied" that the matter has been established on the balance of probabilities: Briginshaw v Briginshaw (1938) 60 CLR 336; [1938] HCA 34. Findings on the Complaint Complaint One 1. We find that the evidence establishes, and Dr Carayannis admits that, at CareFlight at Westmead he removed almost all of the fentanyl from 29 ampoules into a syringe, refilled each of those ampoules with saline, leaving the tampered ampoules for use on patients, and later consumed the contents of the syringes. We accept the evidence of Dr Carayannis that it occurred between June and July 2019, and we were not taken to any evidence by counsel for the Health Care Complaints Commission supporting the longer period set out in the Complaint. 2. We find that the evidence establishes, and Dr Carayannis admits that, at CareFlight at Mascot he removed almost all of the fentanyl from nine ampoules into a syringe, refilled each of those ampoules with saline, leaving the tampered ampoules for use on patients, and later consumed the contents of the syringes. We accept the evidence of Dr Carayannis that it occurred in July 2019, and we were not taken to any evidence by counsel for the Health Care Complaints Commission supporting the longer period set out in the Complaint. 3. We find that the evidence establishes and Dr Carayannis admits that, at CareFlight at Mascot he removed almost all of the morphine from seven ampoules into a syringe, refilled each ampoule with saline, left the tampered ampoules for use on patients, and later consumed the contents of the syringes. We accept the evidence of Dr Carayannis that it occurred in July 2019, and we were not taken to any evidence by counsel for the Health Care Complaints Commission supporting the longer period set out in the Complaint. 4. Section 139B(1)(l) of the National Law defines unsatisfactory professional conduct as any improper or unethical conduct relating to the practice of the practitioner's profession. We are satisfied that our findings establish improper and unethical conduct in Dr Carayannis' practice of his profession and find that the Health Care Complaints Commission has established Complaint One. Complaint Two 1. We find that the evidence establishes, and Dr Carayannis admits, that in August 2019, while working at Royal Prince Alfred Hospital, he anaesthetised patients with drugs of addiction, including oxycodone, hydromorphone, fentanyl and IV methadone and, instead of disposing of the unused portion of the drugs, he inappropriately placed the unused portion of the drugs either in his top pocket or in his bag for his own use. He misappropriated these drugs of addiction from the operating theatre approximately three days a week for three weeks, or around nine occasions. He later consumed the drugs at night and at home either sublingually, intranasally, or, on two occasions, intravenously. 2. As we have said, s 139B(1)(l) defines unsatisfactory professional conduct as any improper or unethical conduct relating to the practice of the practitioner's profession. We are satisfied that our findings establish improper and unethical conduct in Dr Carayannis' practice of his profession and find that the Health Care Complaints Commission has established Complaint Two. Complaint Three 1. The Health Care Complaints Commission asserts, and Dr Carayannis admits, that between May and August 2019 he did not notify any professional medical or heath practitioner authorities of his drug use and the risk he may have posed to himself or his patients, in contravention of section 9.2 of the Medical Board of Australia's "Good Medical Practice: A Code of Conduct for Doctors in Australia" (March 2014). 2. As we have said, s 139B(1)(l) defines unsatisfactory professional conduct as any improper or unethical conduct relating to the practice of the practitioner's profession. We are satisfied that our findings establish improper and unethical conduct in Dr Carayannis' practice of his profession and find that the Health Care Complaints Commission has established Complaint Three. Complaint Four 1. The Health Care Complaints Commission says that the conduct in Complaints One and Two either separately or when considered together amounts to professional misconduct. Dr Carayannis admits Complaint Four. 2. Section 139E of the National Law defines professional misconduct 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. To constitute professional misconduct, it has been held that the conduct the subject of the complaint must be of such a departure from the accepted standards of the profession as would reasonably incur the strong reprobation of professional colleagues of good repute and competence: Qidwai v Brown [1984] 1 NSWLR 100 at [105] (Priestley JA). 2. The Tribunal finds Dr Carayannis' conduct is of a very serious nature and demonstrates a departure from the accepted standards of the profession so that it would reasonably incur the strong reprobation of professional colleagues of good repute and competence. In particular: 1. Initially Dr Carayannis' conduct was opportunistic. However, as Dr Carayannis admits, the removal of the drugs from the two CareFlight bases involved planning. He deliberately went to the Westmead base intending to tamper with the ampoules when he knew it was unlikely he would be seen by others. He deliberately remained at work at the Mascot base after all the other employees had left work intending to tamper with the ampoules knowing this meant it was unlikely he would be seen by others. He worked out how to remove the drugs using his own equipment which he took with him to each base. In addition there was some planning when he removed drugs from the operating theatres at Royal Prince Alfred Hospital as he deliberately over-ordered the quantity of the drugs he needed so that he could use the leftovers. 2. The removal of the drugs from the ampoules at the CareFlight bases led to a number of potential risks to patients. There is no evidence of any adverse event having occurred. Dr Carayannis acknowledges that he put patients at risk for which he is deeply sorry. The incidents were extensively investigated by CareFlight. It identified 63 patients (with 64 episodes as one patient had been treated twice) from the Westmead base and 9 patients from the Mascot base who had been administered fentanyl or morphine and who could have been administered the contents of a tampered ampoule. Their records were reviewed and no adverse event was clearly identified. Dr Carayannis has conceded that it is possible that when he was drilling a hole some of the glass would go into the ampoule but he said he never saw that happen. The saline in the ampoules was analysed. No organisms were identified and there was no human blood detected in the samples, thereby ruling out the potential for the transmission of blood-borne virus. Dr Carayannis has acknowledged that the glue he used was not clinically sterile so that there was a risk of infection to the patient who was administered a tampered ampoule. The drugs were used for analgesia. The CareFlight helicopter is regularly used to retrieve patients with a traumatic injury. The consequence of Dr Carayannis' conduct was that a clinician could administer a drug from a tampered ampoule thinking they were administering a certain dose but the patient would actually be receiving a much smaller dose. Accordingly there was a risk of a patient being unnecessarily in pain. Further to this risk, Dr Carayannis agreed that there was a risk that, if the clinician administered a tampered ampoule and did not get the expected response, it was usual to give the patient some more of the drug. If they then used an untampered ampoule there was a risk they could over-sedate or overdose an opioid. Dr Carayannis also agreed that, as the patient usually was in a highly stressed situation, the opioids would be given to calm the central nervous system. If the patient was under-sedated there was a chance that someone's life was put at risk, if they had an underlying heart problem for example. 1. While there is no evidence that Dr Carayannis consumed any of the drugs during working hours, he conceded, and we find, that there were occasions where it was possible he could have been impaired when working the following day. 2. The report from CareFlight dated 19 November 2019 shows that significant work was done by CareFlight in investigating Dr Carayannis' conduct by examining their own records and dealing with, inter alia, the NSW Ministry of Health, Health Protection Branch and the Pharmaceutical Regulatory Unit, the Clinical Excellence Commission, NSW Health Pathology, Illicit Drugs Analysis Unit, Forensic & Analytical Science Service, the Westmead Microbiology Unit, NSW Ambulance and NSW Police. A letter from Sydney Local Health District also details their investigations into the drugs taken by Dr Carayannis while working at Royal Prince Alfred Hospital. We take into account that considerable resources of CareFlight and Royal Prince Alfred Hospital would have been taken up by these investigations. 1. We are satisfied that the conduct in Complaints One and Two, either separately or together, amounts to conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration. We find, and Dr Carayannis admits, that the Health Care Complaints Commission has established Complaint Four. Complaint Five 1. The Health Care Complaints Commission says that Dr Carayannis has an impairment within the meaning of s 5 of the National Law, which is defined as including a substance abuse disorder or dependence which detrimentally affects or is likely to detrimentally affect his capacity to practise medicine. 2. The disorder in this case is defined as an Opiate Use Disorder — moderate type — in short-term remission which began in early 2019 and has been in remission since September 2019. 3. We are satisfied that the Health Care Complaints Commission has established (and Dr Carayannis has admitted) the use of drugs underlying the disorder being: 1. The taking of Endone tablets in May 2019. 2. The consumption of the hydromorphone he took from his father's bedside. 3. The consumption of the drugs he misappropriated from his employer, CareFlight. 4. The consumption of the drugs he misappropriated from Royal Prince Alfred Hospital. 1. Dr Carayannis admits Complaint Five subject to the following: he says the conduct at CareFlight occurred between June and July 2019 and that he consumed the drugs of addiction at night and at home. 2. All of the health care professionals, including the Medical Council appointed practitioner, Dr Atherton, agree that Dr Carayannis has an Opiate Use Disorder. They all agree that it is currently in remission. 3. We find that the Health Care Complaints Commission has established Complaint Five. Protective Orders 1. As we have said, an order was made for this matter to proceed as a combined hearing — that is, that this Tribunal is to make protective orders after making findings in relation to the various grounds of the Complaint. 2. Section 3A of the National Law provides: 3A Objective and guiding principle [NSW] In the exercise of functions under a NSW provision, the protection of the health and safety of the public must be the paramount consideration. 1. A finding of professional misconduct means that Dr Carayannis engaged in sufficiently serious conduct which could justify suspension or cancellation of his registration. It does not mean his registration must be suspended or cancelled. 2. The legislation provides that, on a finding of professional misconduct, the Tribunal may suspend or cancel Dr Carayannis' registration, impose a fine, caution or reprimand him, impose conditions, order him to undergo treatment or counselling, order him to complete an educational course, order him to report on his practice and/or order him to seek and take advice in relation to the management of his practice. 3. The orders are not intended to punish the practitioner, but to protect the public: Clyne v The New South Wales Bar Association (1960) 104 CLR 186; [1960] HCA 40; Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630. 4. The underlying principles are discussed by Meagher JA in Health Care Complaints Commission v Do [2014] NSWCA 307 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 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." 1. In determining the appropriate protective orders we have taken a number of matters into account. 2. Having an opioid dependence is of itself very serious. As Dr Carayannis now says, his thinking was overridden by his desire to obtain the drug. 3. We have already made findings in relation to the very serious potential risks which flowed from Dr Carayannis' behaviour. These underline the seriousness of the misconduct. 4. While there is no justification for Dr Carayannis' conduct, we accept it was precipitated by the unfortunate confluence of significant family upheaval which caused him great emotional distress and physical pain, resulting in a severe Opiate Use Disorder. He now acknowledges that he did not have the skills to appropriately manage the situation nor the insight to realise that he needed help. 5. We further accept that, since September 2019, Dr Carayannis has engaged with an appropriate and wide-ranging support network, some on a weekly basis. We have set out above the details of the steps he has taken and the universal support he has from his treating health care practitioners, his current supervisor, his mentor and Dr Atherton. The Health Care Complaints Commission concedes that Dr Carayannis has done everything that could be expected of him to effect reformation of his character. 6. His treating health care practitioners, his current supervisor, his mentor and Dr Atherton all describe Dr Carayannis as having excellent insight into his behaviour and its causes, and are of the view that it is safe for him to practise subject to conditions. 7. These observations are consistent with the results of the thrice weekly urinary drug screens and hair tests. The reviewers on 26 March 2021 noted that all of the urine and hair samples had tested negative for any licit and illicit drugs and Dr Carayannis had been fully compliant with the monitoring process. 8. We also accept Dr Carayannis' expressions of remorse to us and to others. He says he is incredibly sorry, embarrassed and ashamed about what he did. He said he has worked very hard to change his life because he is passionate about being a doctor and has a lot to offer patients. He intends to never let it happen again. He believes this occurred because of his major personality vulnerabilities as he had always fended for himself, never asked for help, was unable to open up to others, took on too much and had bereavement issues. He has explored this with therapists. He is doing all he can to protect himself and others from a relapse. He takes comfort from the Medical Council program which he sees as a support. 9. Dr Carayannis says he intends to continue with all of his supports and expects he will consult an addiction specialist for the rest of his life. 10. Dr Carayannis acknowledges significant reputational damage was done to CareFlight by his actions. He has apologised to the two paramedics he worked closely with at CareFlight and expressed remorse. He said that they were very supportive and understanding of the illness. He has also contacted his mentor at CareFlight and apologised to him. He has apologised in writing to CareFlight and received a positive response. He also understands that his actions caused an enormous strain on the resources of Royal Prince Alfred Hospital in conducting audits and he has apologised in person to the CEO and a Director of Royal Prince Alfred Hospital. 11. Dr Carayannis also relies on a number of statements tendered in evidence. 12. Dr McNamara is an anaesthetist. She is a friend and colleague of Dr Carayannis. They met in 2018 while working at Royal Prince Alfred Hospital. Dr McNamara said he contributed greatly to the department whilst employed at the hospital and he was regarded as a role model for junior staff. 13. Dr McNamara has always found Dr Carayannis to be professional, genuine, dependable, measured and calm with an easy-going nature, which makes him a joy to work with. His composure, good judgment and highly analytical nature make him an excellent ally in any crisis. He has approached his recovery methodically and diligently. She believes the experience has shocked him and has led him to address his vulnerabilities in a way that now leaves him galvanized and strengthened. 14. Dr Turner is a non-executive director of CareFlight and the Administrative Head of Anaesthesia at Prince of Wales Hospital. During his time at Prince of Wales Hospital, Dr Carayannis had an unblemished record. He was an above average registrar and was reliable, polite and personable. He treated his patients with respect and compassion. He was a very good training anaesthetist, and his clinical outcomes were excellent. 15. Dr Turner described Dr Carayannis' subsequent problems involving narcotic drug misappropriation and self-administration as being out of character. He has supported Dr Carayannis in his application for an appointment at Prince of Wales Hospital for the purpose of assisting with his return to work and rehabilitation. 16. Dr Saric is a doctor and is undergoing psychiatry training with the Royal Australian and New Zealand College of Psychiatry. He has known Dr Carayannis since 2004 when they met while doing their undergraduate degree. They have remained close friends. 17. Dr Saric said that Dr Carayannis told him about his conduct with a heavy heart, genuine remorse, and overwhelming guilt. He had suffered greatly with his personal and professional reputations damaged, and he feels ashamed and disgraced amongst his community. Dr Saric has seen Dr Carayannis grow mentally and emotionally, and that he has taken the opportunity to develop himself to the fullest. 18. Dr Saric does not believe his behaviours are indicative of Dr Carayannis' character overall — as he is a kind, caring and compassionate person, becoming an excellent and well-respected doctor. 19. There is a statement from Dr Carayannis' partner. They met in March 2018 when she was working as a Clinical Nurse Consultant at Royal Prince Alfred Hospital. In her opinion Dr Carayannis demonstrated high levels of professionalism, interest in the field and dedication to the education and mentorship of junior staff, excellent patient care and highly developed skills within his clinical work. 20. She said that during his father's illness Dr Carayannis found it difficult to share his emotions or rely on others. His father's prolonged hospital admission was fraught with multiple complications, procedures and worsening symptoms. Dr Carayannis was dedicated to his father's care both psychologically and physically. He was heavily relied upon by his family as a medical professional and consulted on his father's care by the treating teams regularly, and was asked to make many of the clinical decisions. She described the stress, responsibility, constant presence at the hospital and uncertainty as incredibly challenging and consuming. His father grew increasingly anxious about his care and was incredibly weak which furthered his dependence on Dr Carayannis. 21. She became aware of his drug use shortly after it occurred. She observed his dedication to his recovery, acceptance of the consequences, his ownership of his actions and his determination to make things right. He takes every opportunity to safeguard himself against anything like this ever happening again. They have had counselling as a couple which established an honest and supportive environment for their relationship. 22. She believes the period of time off work provided Dr Carayannis with a greater sense of work/life balance and he often speaks to her about his growth through this difficult time. 23. Family members have outlined their observations. During Dr Carayannis' childhood and adolescence one member of the family, for reasons which do not need to be disclosed, had greater needs than other family members including Dr Carayannis. As a consequence, Dr Carayannis was a quiet, very easy-going child who did not say much and was self-sufficient. He did well academically and was School Captain, head of the Cadet Corps and head of his debating team. 24. As an adult they observed him to be sensitive, very kind and thoughtful to others and averse to confrontation. He was highly compassionate, non-judgmental and self-sacrificing, often placing others' needs before his own. He had always wanted to be a doctor. 25. When Dr Carayannis told them in September 2019 of the conduct which is the subject of these proceedings, they described him as completely shattered. He said he was devastated for doing what he had done, how sorry he was, how he felt guilt and embarrassment and his concern at how his colleagues would perceive him. He felt worthless and ashamed. 26. Since Dr Carayannis has re-commenced work, they have seen a dramatic positive shift in his mood as he feels he is making a contribution to patient health and has been engaged in meaningful work. 27. They are certain Dr Carayannis has learnt lessons and skills that he will use in the future. The family will continue to support him in any way they can. 28. The Health Care Complaints Commission has asked us to suspend Dr Carayannis' registration for three to six months. It says that protective orders without suspension could not promote confidence in the profession. The suspension period, it says, strikes the appropriate balance between deterring others from similar misconduct, and recognising the considerable measures Dr Carayannis has taken to address his addiction, and that health practitioners endorse his continued practice. 29. Taking all of the above matters into account we do not think this is the appropriate order. 30. The orders we must make are not intended to punish the practitioner. One of the orders we can make is to reprimand Dr Carayannis. In our view such an order would achieve the balance described by the Health Care Complaints Commission as it would protect the health and safety of the public, uphold public confidence in the standards of the profession, act as a deterrent to both Dr Carayannis and the general body of practitioners, and takes into account his personal growth and abstinence. We propose to make this order. 31. We also propose to vary the conditions on Dr Carayannis' registration. In relation to the variation of conditions we find the following: 1. Dr Carayannis is currently subject to category B supervision, which is indirect, on-site supervision. A reduction from that level of supervision to category C (the effect of which would be that the supervisor would not have to be on the premises when Dr Carayannis was working) was recommended by the Medical Council panel who reviewed Dr Carayannis on 26 March 2021, based on Dr Carayannis' steady progress and the documentary evidence, and by both Dr Sams and Dr Stavrakis. We agree with this recommendation. 2. The Tribunal considers that Dr Carayannis should currently be precluded from working in the high stress environment of retrieval medicine, as he performed at CareFlight. 3. Dr Atherton in November 2020 said he would be comfortable with Dr Carayannis moving to six-monthly cycles of assessment and interview reports. However, as Dr Carayannis will soon be starting more complex work in a new work environment, a three-monthly review cycle with the Medical Council remains appropriate. 1. Dr Carayannis concedes that he should pay the costs of the Health Care Complaints Commission. 2. Accordingly the orders we make are the following: 1. Dr Carayannis is reprimanded. 2. The following conditions are placed on Dr Carayannis' registration: Practice Conditions 1. To obtain Medical Council of New South Wales' approval prior to changing the nature or place of his practice; 2. Not to undertake locum positions; 3. Not to participate in any on-call rosters; 4. Not to participate in retrieval medicine; 5. Not to prescribe, possess, supply, administer, handle or dispense any Schedule 8 drug as defined by the Poisons and Therapeutic Goods Act 1966 (NSW), except in a hospital where he is working. Dr Carayannis is permitted to prescribe, administer, handle or dispense Schedule 8 drugs only in a hospital to inpatients during the practice of anaesthesia, or on a hospital medication chart, or as patient discharge prescriptions; 6. Not to possess, supply, administer or prescribe any Schedule 4 drug listed in Appendix D to the Poisons and Therapeutic Goods Regulation 2008 (NSW), except in a hospital where he is working. Dr Carayannis is permitted to prescribe, administer, handle or dispense Schedule 4 Appendix D drugs only in a hospital to inpatients during the practice of anaesthesia, or on a hospital medication chart, or as patient discharge prescriptions; 7. To practise under category C supervision in accordance with the Medical Council of New South Wales' "Compliance Policy – Supervision" (as varied from time to time) and as subsequently determined by the appropriate review body; (a) The terms of the Council's "Compliance Policy – Supervision" are varied so that the practitioner is to: (i) have review meetings with his Council-approved supervisor(s), fortnightly, for a period of three months and monthly thereafter; (ii) authorise the Council-approved supervisor(s) to provide reports to the Council (in a Council-approved format) on a monthly basis; (b) At each supervision meeting the practitioner is to review and discuss his practice with his Council-approved supervisor with a particular focus on: (i) Clinical management; (ii) Documentation; (iii) Doses of opioid analgesia used during procedures in relation to accepted standards; (iv) Post-operative pain management; (c) The Council-approved supervisor is to conduct a random audit of the practitioner's: (i) Schedule 8 and Schedule 4 Annexure D drugs signed out during an operation; (ii) Drugs recorded as administered and drug discard witnessed; (iii) Recovery room analgesia required; (d) The Council-approved supervisor is to conduct a random audit of five of the practitioner's cases fortnightly, ensuring that at least one case is from each workplace; (e) Not to practise until a supervisor has been approved by the Council; (f) To authorise the Council to provide proposed and approved supervisors with a copy of the decision that imposed this condition; 8. To nominate an experienced anaesthetist to act as his professional mentor for approval by the Medical Council of New South Wales in accordance with the Council's "Compliance Policy – Mentor" (as varied from time to time) and as subsequently determined by the appropriate review body; (a) The terms of the Council's "Compliance Policy – Mentor" are varied so that the practitioner is to meet with the mentor on a monthly basis; (b) At each mentoring meeting the practitioner is to include discussion of the following: (i) Issues raised in supervision meetings; (ii) Challenges related to working with conditions on his registration; (iii) Career planning; (c) To authorise the mentor to report, in an approved format, to the Council every three months about the fact of contact, and to inform the Council if there is any concern about his professional conduct, health or personal wellbeing; 9. To forward evidence to the Medical Council of New South Wales, within 14 days of the making of these orders, that he has provided a copy of the full conditions to the head of the Anaesthetic Department at all places of practice; 10. Within 14 days of a change in the nature or place of his practice, he is to forward evidence to the Medical Council of New South Wales that he has provided a copy of the full conditions to the head of the Anaesthetic Department at all places of practice; Health Conditions 11. Further to the requirements of Condition 8, the practitioner is also required to discuss with his mentor at each mentoring meeting: (a) Work/life balance; (b) Progress with regard to his treatment; 12. Not to prescribe for self-medication; 13. To attend for treatment by a general practitioner of his choice. The frequency of treatment is to be determined by the treating practitioner. The practitioner: (a) is to authorise the treating practitioner to inform the Medical Council of New South Wales of any of the following: (i) Failure to attend for treatment; (ii) Termination of treatment; (iii) A significant change in health status (including a significant temporary change); (b) must provide the Council with the professional details of the treating practitioner; 14. To attend for treatment by a drug and alcohol clinician of his choice. The frequency of treatment is to be determined by the treating practitioner. The practitioner: (a) is to authorise the treating practitioner to inform the Medical Council of New South Wales of any of the following: (i) Failure to attend for treatment; (ii) Termination of treatment; (iii) A significant change in health status (including a significant temporary change); (b) must provide the Council with the professional details of the treating practitioner; 15. To attend for treatment by a psychiatrist of his choice. The frequency of treatment is to be determined by the treating practitioner. The practitioner: (a) is to authorise the treating practitioner to inform the Medical Council of New South Wales of any of the following: (i) Failure to attend for treatment; (ii) Termination of treatment; (iii) A significant change in health status (including a significant temporary change); (b) must provide the Council with the professional details of the treating practitioner; 16. To attend for treatment by a psychotherapist of his choice. The frequency of treatment is to be determined by the treating practitioner. The practitioner: (a) is to authorise the treating practitioner to inform the Medical Council of New South Wales of any of the following: (i) Failure to attend for treatment; (ii) Termination of treatment; (iii) A significant change in health status (including a significant temporary change); (b) must provide the Council with the professional details of the treating practitioner; 17. To take any medication as prescribed by his treating practitioners; 18. To comply with the Medical Council of New South Wales' "Drug Screening Policy" and "Participant Procedure: Drug Screening" (as varied from time to time) and attend for: (a) Urine drug screening three times a week; and (b) Quarterly hair drug screening; 19. To attend for review by a Council-appointed psychiatrist on a three-monthly basis or as otherwise directed by the Medical Council of New South Wales. 20. To attend a Medical Council of New South Wales' Review Interview on a three-monthly basis, or as otherwise directed by the Council. 21. To authorise the Medical Council of New South Wales to forward copies of the s 150 and s 150A written reasons, any subsequent Council Review Interview or other report, and any other information relevant to his health and treatment, to the Council-appointed practitioners and to his treating practitioners. 22. The Medical Council of New South Wales is the appropriate review body. 1. Dr Carayannis is to pay the costs of the Health Care Complaints Commission of the proceedings, as agreed or assessed. Annexure A Conditions imposed at s 150A hearing Practice Conditions: 1. To obtain Medical Council of NSW approval prior to changing the nature or place of his practice. 2. Not to undertake locum positions 3. Not to participate in any on-call rosters 4. Not to possess, supply, administer or prescribe any "drug of addiction" (Schedule 8 drug) as defined by Poisons and Therapeutic Goods Act 1966 (NSW), other than to issue a prescription to inpatients on a hospital medication chart or as patient discharge prescriptions. 5. Not to possess, supply, administer or prescribe any Schedule 4 drug listed in Appendix D to the Poisons and Therapeutic Goods Regulation 2008 (NSW) other than to issue a prescription to inpatients on a hospital medication chart or as patient discharge prescriptions. 6. To practise under category B supervision in accordance with the Medical Council of NSW's Compliance Policy – Supervision (as varied from time to time) and as subsequently determined by the appropriate review body. (a) The terms of the Council's Compliance Policy – Supervision are varied so that the practitioner is to: (i) have review meetings with his Council-approved supervisor each week for a period of 3 months and fortnightly thereafter. (ii) authorise the Council-approved supervisor(s) to provide reports to the Council (in a Council-approved format) on a monthly basis (b) At each supervision meeting the practitioner is to review and discuss his practice with his approved supervisor with a particular focus on: (i) Clinical Management (ii) Documentation (iii) Doses of opioid analgesia used during procedures in relation to accepted standards (iv) Post-operative pain management (c) The approved supervisor is to conduct a random audit of the practitioner's: (i) Schedule 8 and Schedule 4 Annexure D drugs signed out during an operation (ii) drugs recorded as administered and witnessed drug discard (iii) recovery room analgesia required The random audit should be conducted by the Council approved supervisor initially weekly reviewing 5 cases per week for a period of 4 weeks and a random audit of 5 cases each month thereafter (d) Not to practice until a supervisor has been approved by the Medical Council of NSW. (e) To authorise the Medical Council of NSW to provide proposed and approved supervisors with a copy of the decision which imposed this condition. 7. To nominate an experienced Anaesthetist to act as his professional mentor for approval by Medical Council of NSW in accordance with the Medical Council of NSW's Compliance Policy - Mentoring (as varied from time to time) and as subsequently determined by the appropriate review body. (a) The terms of the Council's Compliance Policy - Mentor are varied so that the practitioner is to meet with the mentor on a monthly basis. (b) At each mentoring meeting the practitioner is to include discussion of the following: (i) Issues raised in supervision meetings (ii) Challenges related to working with conditions on his registration (iii) Career planning (c) To authorise the mentor to report, in an approved format, to the Council every three months about the fact of contact, and to inform the Council if there is any concern about his professional conduct, health or personal wellbeing. 8. To forward evidence to the Medical Council of NSW within 14 days of 30 March 2020, that he has provided a copy of the full conditions to the head of the Anaesthetic Department at all places of practice 9. Within 14 days of a change in the nature or place of his practice, he is to forward evidence to the Medical Council of NSW that he has provided a copy of full conditions to the head of the Anaesthetic Department at all places of practice Health Conditions: 10. Further to the requirements of Condition 7, the practitioner is also required to discuss with his mentor at each mentoring meeting: (i) Work/Life balance (ii) Progress with regards to his treatment 11. Not to prescribe for self-medication. 12. To attend for treatment by a general practitioner of his choice. The frequency of treatment is to be determined by the treating practitioner. The practitioner: (a) is to authorise the treating practitioner to inform the Medical Council of NSW of any of the following: (i) Failure to attend for treatment; (ii) Termination of treatment; or (iii) A significant change in health status (including a significant temporary change). (b) must provide the Council with the professional details of the treating practitioner. 13. To attend for treatment by a drug and alcohol clinician of his choice. The frequency of treatment is to be determined by the treating practitioner. The practitioner: (a) is to authorise the treating practitioner to inform the Medical Council of NSW of any of the following: (i) Failure to attend for treatment; (ii) Termination of treatment; or (iii) A significant change in health status (including a significant temporary change). (b) must provide the Council with the professional details of the treating practitioner. 14. To attend for treatment by a psychiatrist of his choice. The frequency of treatment is to be determined by the treating practitioner. The practitioner: (a) is to authorise the treating practitioner to inform the Medical Council of NSW of any of the following: (i) Failure to attend for treatment; (ii) Termination of treatment; or (iii) A significant change in health status (including a significant temporary change). (b) must provide the Council with the professional details of the treating practitioner. 15. To attend for treatment by a psychotherapist of his choice. The frequency of treatment is to be determined by the treating practitioner. The practitioner: (a) is to authorise the treating practitioner to inform the Medical Council of NSW of any of the following: (i) Failure to attend for treatment; (ii) Termination of treatment; or (iii) A significant change in health status (including a significant temporary change). (b) must provide the Council with the professional details of the treating practitioner. 16. To take any medication as prescribed by his treating practitioners. 17. To comply with the Medical Council's Drug Screening Policy and Participant Procedure: drug screening (as varied from time to time) and attend for: (a) Urine drug screening 3 times a week and (b) quarterly hair drug screening. 18. To attend for review by a Council-appointed psychiatrist on a 3 monthly basis or as otherwise directed by the Medical Council of NSW. 19. To attend a Medical Council of NSW's Review Interview on a 3 monthly basis, or as otherwise directed by the Council. 20. To authorise the Medical Council of NSW to forward copies of the s150 and s150A written reasons and any subsequent Council Review Interview or other reports and any other information relevant to his health and treatment to the Council-appointed practitioners and to his treating practitioners. ********** 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 Amendments 15 June 2021 - Counsel details corrected on cover sheet 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: 15 June 2021