Health Care Complaints Commission v Matta [2024] NSWCATOD 33
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Civil and Administrative Tribunal
New South Wales
Medium Neutral Citation: Health Care Complaints Commission v Matta [2024] NSWCATOD 33
Hearing dates: 6 March 2024
Date of orders: 19 March 2024
Decision date: 19 March 2024
Jurisdiction: Occupational Division
Before: G Blake AM SC, Senior Member
M Cross, Senior Member
H Dowling, Senior Member
B Seth, General Member
Decision: 1. The disclosure of the name of Patients A to I is prohibited.
2. The respondent is reprimanded.
3. The respondent is to pay the applicant's costs of the proceedings as agreed or assessed in accordance with the applicable costs legislation.
Catchwords: HEALTH — professional registration and discipline — pharmacist — where pharmacist is guilty of unsatisfactory professional conduct — what protective action should be taken
Legislation Cited: Civil and Administrative Tribunal Act 2013 (NSW), s 64
Evidence Act 1995 (NSW), s 140
Health Practitioner Regulation National Law (NSW), ss 3, 3A, 4, 39, 139B, 149, 149A, 150, 150A, 150D, 225, Sch 5D, cl 13
Poisons and Therapeutic Goods Act 1966 (NSW), s 28
Poisons and Therapeutic Goods Regulation 2008 (NSW), cll 54, 109
Cases Cited: Briginshaw v Briginshaw (1938) 60 CLR 336; [1938] HCA 34
Bronze Wing International Pty Ltd v SafeWork NSW [2017] NSWCA 41
Browne v Dunn (1893) 6 R 67; [1893] 1 WLUK 44
Gautam v Health Care Complaints Commission [2021] NSWCA 85
Ghosh v Medical Council of New South Wales [2020] NSWCA 122
Health Care Complaints Commission v A Medical Practitioner [2001] NSWCA 158
Health Care Complaints Commission v Do [2014] NSWCA 307
Health Care Complaints Commission v Elliott [2018] NSWCATOD 47
Health Care Complaints Commission v Fearon [2018] NSWCATOD 26
Health Care Complaints Commission v Haasbroek [2018] NSWCATOD 177
Health Care Complaints Commission v Khalighimonfared [2022] NSWCATOD 78
Health Care Complaints Commission v Lord [2019] NSWCATOD 182
Health Care Complaints Commission v Lu [2023] NSWCATOD 51
Health Care Complaints Commission v Meneghetti [2020] NSWCATOD 39
Health Care Complaints Commission v Neale [2024] NSWCATOD 16
Health Care Complaints Commission v Nguyen [2018] NSWCATOD 168
Health Care Complaints Commission v Philipiah [2013] NSWCA 342
Health Care Complaints Commission v Pickett [2019] NSWCATOD 53
Health Care Complaints Commission v Quan [2018] NSWCATOD 111
Health Care Complaints Commission v Sathiyapal [2024] NSWCATOD 14
Health Care Complaints Commission v Schmaman [2019] NSWCATOD 82
Health Care Complaints Commission v Tran [2024] NSWCATOD 1
Health Care Complaints Commission v Wilcox [2020] NSWCATOD 10
Healthcare Complaints Commission v Hollenbach [2019] NSWCATOD 118
Lee v Health Care Complaints Commission [2012] NSWCA 80
Neat Holdings Pty Ltd v Karajan Holdings Pty Ltd [1992] HCA 66; (1992) 67 ALJR 170
Texts Cited: None cited
Category: Principal judgment
Parties: Health Care Complaints Commission (Applicant)
Mina Matta (Respondent)
Representation: Counsel:
D Fuller (Applicant)
Dr P Dwyer SC (Respondent)
Solicitors:
E Martinkus (Health Care Complaints Commission) (Applicant)
Meridian Lawyers (Respondent)
File Number(s): 2022/00317612
Publication restriction: Pursuant to s 64(1)(a) of the Civil and Administrative Tribunal Act 2013 (NSW), the disclosure of the name of Patients A to I is prohibited.
REASONS FOR DECISION
Overview
1. In these proceedings the applicant, the Health Care Complaints Commission (which is also referred to as the HCCC), is seeking findings against the respondent, Mina Matta, a pharmacist (who is also referred to as the practitioner), that he is guilty of unsatisfactory professional conduct within the Health Practitioner Regulation National Law (NSW) (National Law), and the making of consequential protective orders.
2. We have decided to make:
1. the finding that the respondent is guilty of unsatisfactory professional conduct within s 139B(1)(a) and (l) of the National Law;
2. the following orders:
1. the disclosure of the name of specified patients of the respondent is prohibited;
2. the respondent is reprimanded;
3. the respondent is to pay the applicant's costs of the proceedings as agreed or assessed in accordance with the applicable costs legislation.
The factual background
1. Between October 2015 and August 2018, the respondent worked as a pharmacist at the Christopher Discount Chemist at West Gosford in New South Wales (the CDC Pharmacy).
2. During the period from July 2017 to the end of 2018, the following codes and guidelines had been approved by the Pharmacy Board of Australia (the Board) under s 39 of the National Law:
1. Code of conduct for pharmacists dated 17 March 2014 (the Code of Conduct);
2. Guidelines for dispensing of medicines dated 7 December 2015 (the Dispensing Guidelines).
1. On 17 October 2019, the Pharmacy Council of New South Wales (the Council) received a complaint from the Pharmaceutical Regulatory Unit (PRU) concerning the respondent's dispensing of Schedule 8 and Schedule 4 Appendix D drugs at the CDC Pharmacy (the PRU complaint).
2. On 12 November 2019, the delegates of the Council held a hearing under s 150 of the National Law in response to the PRU complaint.
3. On 17 December 2019, the delegates of the Council decided to suspend the registration of the respondent with effect from 12 November 2019 pursuant to s 150(1)(a) of the National Law and to refer the matter for investigation by the HCCC pursuant to s 150D of the National Law (the 17 December 2019 Council decision).
4. On 21 December 2019, the respondent made an application under s 150A of the National Law for a review of the 17 December 2019 Council decision.
5. On 13 January 2020, the delegates of the Council held a review hearing under s 150A of the National Law.
6. On 31 January 2020, the delegates of the Council pursuant to s 150A of the National Law set aside the 17 December 2019 Council decision and imposed the following conditions on the respondent's registration effective from 14 January 2020 (the 31 January 2020 Council decision):
"1. Not to work as the pharmacist in charge.
a) Upon entering the pharmacy premises in which he works, he must notify the pharmacist in charge."
1. On 21 February 2019, the respondent made an application under s 150A of the National Law for a review of the 31 January 2020 Council decision.
2. On 10 March 2020, the delegates of the Council held a review hearing under s 150A of the National Law.
3. On 2 April 2020, the delegates of the Council pursuant to s 150A of the National Law set aside the 31 January 2020 Council decision.
The proceedings
The procedural history
1. On 24 October 2022, the applicant commenced these proceedings against the respondent by filing an application for disciplinary findings and orders, which contained a complaint against the respondent in relation to his dispensing of Schedule 8 and/or Schedule 4D medicines (or drugs) for nine patients referred to as Patients A to I, and which relevantly provides:
"3. ORDERS SOUGHT
The Applicant seeks the following orders:
In the event the subject-matter of the complaint is proved or admitted, the Applicant seeks:
1. Conditions and/or a Reprimand of the Respondent's registration, pursuant to s 149A(1) of the National Law.
2. An order that the Respondent pay the Commission's costs under clause 13 of Schedule 5D of the National Law.
In the event that only some of the particulars of the complaint are proved, the Applicant may seek alternative protective orders under section 149A (caution, reprimand, counsel etc.), section 149B (fine), and/or section 149C (suspension) of the National Law.
GROUNDS FOR APPLICATION (INCLUDING PARTICULARS
The Director of Proceedings of the Health Care Complaints Commission has determined to prosecute the attached Complaint against the Respondent pursuant to section 90B(1) of the Health Care Complaints Act 1993 alleging that the Respondent has been guilty of unsatisfactory professional conduct within the meaning of section 139B(1)(a) and/or (I)."
1. On 29 June 2023, the applicant filed an Amended Complaint, in which it was no longer making a complaint against the respondent in relation to his dispensing of Schedule 8 and/or Schedule 4D medicines (or drugs) for Patients B and F.
2. On 21 July 2023, the respondent filed a Reply to the Amended Complaint.
3. On 5 March 2024, the applicant filed a Further Amended Complaint.
4. On 6 March 2024, the applicant with our leave filed a Second Further Amended Complaint.
5. On 6 March 2024, the respondent filed a Reply to the Second Further Amended Complaint.
The Second Further Amended Complaint
1. The Second Further Amended Complaint relevantly provides (omitting the strikethrough and bold text indicating amendments):
"Mr Mina Matta ("the practitioner") of CHARLESTOWN, New South Wales 2290, being a pharmacist registered under the National Law,
COMPLAINT ONE
i. is guilty of unsatisfactory professional conduct under section 139B(1)(a), and/or (I) of the National Law in that the practitioner has:
engaged in conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of pharmacy is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience; and/or
ii. engaged in improper or unethical conduct relating to the practice or purported practice of pharmacy.
Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified.
PARTICULARS OF COMPLAINT ONE
1. On the highlighted dates set out in Schedule 2 to the Complaint with reference to the initials MB, the practitioner inappropriately dispensed Schedule 8 and 4D drugs, in various strengths to Patient A in circumstances where:
a. the dispensing was contrary to Clause 54 and/or 109 of the Poisons and Therapeutic Goods Regulation ("PTGR") in that, it was in a quantity that does not accord with a recognised therapeutic standard;
b. the dispensing intervals and/or frequency did not accord with a recognised therapeutic standard; and
c. the practitioner should have had regard to the dispensing history of the Patients and did not have sufficient regard to that dispensing history.
2. On the highlighted dates as set out in Schedule 2 to this Complaint with reference to the initials MB, the practitioner inappropriately dispensed Schedule 8 drugs, in various strengths to Patients C, D, E, G and H, in circumstances where:
a. the dispensing was contrary to Clause 109 of the PTGR in that, it was in a quantity that does not accord with a recognised therapeutic standard;
b. the dispensing intervals and/or frequency did not accord with a recognised therapeutic standard; and
c. the practitioner should have had regard to the dispensing history of the Patients and did not have sufficient regard to that dispensing history.
3. On the highlighted dates as set out in Schedule 2 to this Complaint with reference to the initials MB, the practitioner inappropriately dispensed Schedule 4D drugs, in various strengths to Patient I, in circumstances where:
a. the dispensing was contrary to Clause 54 of the PTGR in that, it was in a quantity that does not accord with a recognised therapeutic standard;
b. the dispensing intervals and/or frequency did not accord with a recognised therapeutic standard; and
c. the practitioner should have had regard to the dispensing history of the Patients and did not have sufficient regard to that dispensing history."
1. Schedule 2 sets out the dispensing history for Patients A to I by pharmacists including the respondent at the CDC Pharmacy.
2. Schedule 2 includes the following dispensing of Schedule 8 and Schedule 4D medicines (or drugs) by the respondent to Patient A which had been prescribed by a named doctor and were dispensed on the same day as they had been prescribed:
Dispensed S8 Drug S4D Drug
2/08/2017 Oxycodone SNZ Tabs SR 40mg 28
2/08/2017 Oxycodone SNZ Tabs SR 80mg 28
12/08/2017 Oxycodone SNZ Tabs SR 80mg 28
12/08/2017 Oxycodone SNZ Tabs SR 40mg 28 Antenex tablets 5mg 50
1. Schedule 2 includes the following dispensing of Schedule 8 and Schedule 4D medicines (or drugs) by the respondent to Patient C which had been prescribed by a named doctor and were dispensed on the same day as they had been prescribed:
Dispensed S8 Drug S4D Drug
9/08/2017 Oxycodone SNZ Tabs SR 80mg 28
9/08/2017 Targin Tabs SR 40mg-20mg 28
30/08/2017 OxyNorm Capsules 20mg 20
30/08/2017 Oxycodone SNZ Tabs SR 80mg 28 Antenex tablets 15mg 25
1. Schedule 2 includes the following dispensing of Schedule 8 medicines (or drugs) by the respondent to Patient D which had been prescribed by a named doctor and were dispensed on the same day as they had been prescribed:
Dispensed S8 Drug
19/08/2017 Oxycodone SNZ Tabs SR 40mg 28
19/08/2017 Oxycodone SNZ Tabs SR 80mg 28
23/08/2017 Oxycodone SNZ Tabs SR 80mg 28
8/11/2017 Oxycodone SNZ Tabs SR 80mg 28
8/11/2017 Oxycodone SNZ Tabs SR 40mg 28
27/12/2017 Oxycodone SNZ Tabs SR 80mg 28
27/12/2017 Oxycodone SNZ Tabs SR 40mg 28
1. Schedule 2 includes the following dispensing of Schedule 8 medicines (or drugs) by the respondent to Patient E which had been prescribed by a named doctor and were dispensed on the same day as they had been prescribed:
Dispensed S8 Drug
12/08/2017 Oxycodone SNZ Tabs SR 40mg 28
12/08/2017 Oxycodone SNZ Tabs SR 80mg 28
1. Schedule 2 includes the following dispensing of Schedule 8 medicines (or drugs) by the respondent to Patient G which had been prescribed by a named doctor and were dispensed on the same day as they had been prescribed:
Dispensed S8 Drug
29/11/2017 Oxycodone SNZ Tabs SR 40mg 28
29/11/2017 Oxycodone SNZ Tabs SR 80mg 28
7/03/2018 Oxycodone SNZ Tabs SR 20mg 28
7/03/2018 OxyContin Tabs SR 30mg 28
1. Schedule 2 includes the following dispensing of Schedule 8 medicines (or drugs) by the respondent to Patient H which had been prescribed by a named doctor and were dispensed on the same day or within a few days as they had been prescribed:
Dispensed S8 Drug
9/08/2017 OxyContin Tabs SR 80mg 28
9/08/2017 OxyContin Tabs SR 40mg 28
6/12/2017 OxyContin Tabs SR 80mg 28
6/12/2017 OxyContin Tabs SR 40mg 28
16/12/2017 OxyContin Tabs SR 40mg 112
27/12/2017 OxyContin Tabs SR 80mg 28
30/12/2017 OxyContin Tabs SR 40mg 28
1. Schedule 2 includes the following dispensing of Schedule 4D medicines (or drugs) by the respondent to Patient I which had been prescribed by a named doctor and were dispensed on the same day as they had been prescribed:
Dispensed S4D Drug
4/04/2018 Antenex tablets 30mg 25
4/04/2018 Antenex tablets 5mg 50
The Reply to the Second Further Amended Complaint
1. The Reply to the Second Further Amended Complaint provides (omitting the underlining):
"Complaint One
1 The Respondent admits he is guilty of unsatisfactory professional conduct under Section 139B(1)(a) of the National Law.
2 The Respondent does not admit that he is guilty of unsatisfactory professional conduct under Section 139B(1)(l) of the National Law.
Particulars of Complaint One
Particulars, Complaint One (1)
3 With respect to patient A, the Respondent admits the facts of Particulars 1(a) and (b).
4 With respect to the Particular 1(c), the Respondent says:
(a) The patients' dispensing history was considered and vetted.
(b) He would contact the prescribing doctors for their input in circumstances where the patients' dispensing history was concerning.
(c) With the benefit of hindsight, he accepts that he did not have sufficient regard to the dispensing history.
Particulars, Complaint One (2)
5 With respect to Patients C, D, E, G and H, the Respondent admits the facts of Particulars 2 (a) and (b).
6 With respect to the Particular 2(c), the Respondent says:
(a) The patients' dispensing history was considered and vetted.
(b) He would contact the prescribing doctors for their input in circumstances where the patients' dispensing history was concerning.
(c) With the benefit of hindsight, he accepts that he did not have sufficient regard to the dispensing history.
Particulars, Complaint One (3)
9 With respect to Patient I, the Respondent admits the facts of Particulars 3 (a) and (b).
10 With respect to the Particular 3 (c), the Respondent says:
(a) The patients' dispensing history was considered and vetted.
(b) He would contact the prescribing doctors for their input in circumstances where the patients' dispensing history was concerning.
(c) With the benefit of hindsight, he accepts that he did not have sufficient regard to the dispensing history."
The hearing
1. On 6 March 2024, the hearing took place. Mr D Fuller of counsel represented the applicant. Dr P Dwyer of counsel represented the respondent.
2. At the request of the applicant and with the consent of the respondent, we agreed to make an order prohibiting the disclosure of the name of Patients A to I pursuant to s 64(1)(a) of the Civil and Administrative Tribunal Act 2013 (NSW).
3. The applicant relied on the following documents which were admitted into evidence without objection:
1. the documents filed on 31 October 2023 other than the application for disciplinary findings and orders, which were marked as exhibit A1 and includes the report of Alexandra Torrens (Ms Torrens) dated 21 October 2020 (the Torrens report);
2. the documents filed on 29 January 2024, which were marked as exhibit A2;
3. the Certificate of Registration Status dated 30 January 2024 of the Council, which was marked as exhibit A3;
4. the certificate of the Australian Health Practitioner Regulation Agency (AHPRA) dated 29 February 2024, which was marked as exhibit A4.
1. The respondent relied on the following documents which were admitted into evidence without objection:
1. the documents filed on 21 July 2023 other than the Reply, which were marked as exhibit R1 and include the following documents:
1. the statement of the respondent dated 21 July 2023 (the Matta statement);
2. the reference of Susan Van (Ms Van) dated 14 January 2023 (the Van reference);
3. the reference of Fr John Ghandour (Fr Ghandour) dated 2 March 2022 (the Ghandour reference);
4. the undated reference of David North OAM (Mr North or the North reference according to the context);
5. the reference of Mark Davis (Mr Davis) dated 10 May 2023 (the Davis reference);
1. the document entitled "CPD Plan 2024 – Mina Matta", which was marked as exhibit R2;
2. the tax invoice dated 16 February 2024 and course "Working with Substance Use Disorders" of Mental Health Academy, which were marked as exhibit R3;
3. the document entitled "PDL Practice Alert", which was marked as exhibit R4.
1. The parties relied on the Statement of Agreed Facts and Admissions, which was admitted into evidence and marked as exhibit J1.
2. The respondent gave oral evidence.
3. The applicant relied on its written submissions dated 6 March 2024 (the HCCC submissions), and counsel for the applicant made oral submissions.
4. Counsel for the respondent made oral submissions.
5. At the conclusion of the hearing, we reserved our decision.
The issues
1. The following issues arise for determination:
1. issue 1: whether the respondent engaged in the conduct constituting complaint one, and any such proved conduct constitutes unsatisfactory professional conduct;
2. issue 2: whether any protective orders should be made against the respondent;
3. issue 3: whether the respondent should pay the applicant's costs of the proceedings.
1. Before considering these issues, it is appropriate to set out the applicable provisions of the National Law, the applicable legal principles as to the proof of facts and the Statement of Agreed Facts and Admissions.
The applicable provisions of the National Law
1. Part 1 (ss 1–10) contains provisions dealing with preliminary matters. Section 3 specifies the objectives and guiding principles of the National Law, and relevantly provides:
3 Objectives and guiding principles
(1) The object of this Law is to establish a national registration and accreditation scheme for—
(a) the regulation of health practitioners; and
…
(2) The objectives of the national registration and accreditation scheme are—
(a) to provide for the protection of the public by ensuring that only health practitioners who are suitably trained and qualified to practise in a competent and ethical manner are registered; and
…
1. Section 3A specifies the particular objective and guiding principle of the National Law in New South Wales, and 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. Section 4 specifies how functions under the National Law are to be exercised, and provides:
4 How functions to be exercised
An entity that has functions under this Law is to exercise its functions having regard to the objectives and guiding principles of the national registration and accreditation scheme set out in sections 3 and 3A.
1. Part 5 Division 3 (ss 38-41) contains provisions dealing with registration standards and codes and guidelines. Section 39 deals with codes and guidelines, and relevantly provides:
39 Codes and guidelines
A National Board may develop and approve codes and guidelines—
(a) to provide guidance to the health practitioners it registers; and
(b) about other matters relevant to the exercise of its functions.
1. Part 8 Division 1 (ss 138-139I) contains provisions dealing with preliminary matters in relation to health, performance and conduct. Section 139B contains a definition of unsatisfactory professional conduct of a registered health practitioner, and relevantly provides:
139B Meaning of "unsatisfactory professional conduct" of registered health practitioner generally [NSW]
(1) Unsatisfactory professional conduct of a registered health practitioner includes each of the following—
(a) Conduct significantly below reasonable standard
Conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of the practitioner's profession is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience.
…
(l) Other improper or unethical conduct
Any other improper or unethical conduct relating to the practice or purported practice of the practitioner's profession.
1. Part 8 Division 3 Subdivision 6 (ss 149-149E) contains provisions dealing with the disciplinary powers of the Tribunal. Section 149 specifies the circumstances in which these disciplinary powers may be exercised, and provides:
149 Powers may be exercised if complaint proved or admitted [NSW]
The Tribunal may exercise any power conferred on it by this Subdivision in relation to a registered health practitioner … if—
(a) it finds the subject-matter of a complaint against the practitioner … to have been proved; or
(b) the practitioner or student admits to it in writing to the Tribunal.
1. Section 149A specifies the general powers of the Tribunal to caution, reprimand, impose conditional and take other actions, and relevantly provides:
149A General powers to caution, reprimand, counsel etc [NSW]
(1) The Tribunal may do any one or more of the following in relation to the registered health practitioner—
(a) caution or reprimand the practitioner;
(b) impose the conditions it considers appropriate on the practitioner's registration;
…
1. Part 10 Division 3 (ss 221A-228) contains provisions dealing with registers in relation to registered health practitioners. Section 225 specifies the information to be recorded in National Register, and relevantly provides:
225 Information to be recorded in National Register
A National Register or Specialists Register must include the following information for each registered health practitioner whose name is included in the register—
…
(j) if the practitioner has been reprimanded, the fact that the practitioner has been reprimanded;
…
1. Schedule 5D contains provisions relevantly dealing with proceedings before the Tribunal. Clause 13 deals with the power of the Tribunal to award costs, and relevantly provides:
13 Tribunal may award costs [NSW]
(1) The Tribunal may order the complainant (if any), the registered health practitioner … concerned, or … to pay costs to another person as decided by the Tribunal.
…
(3A) The Tribunal may fix the amount of costs itself or order that the amount of costs be assessed by a costs assessor under the legal costs legislation (as defined in section 3A of the Legal Profession Uniform Law Application Act 2014) or on any other basis.
(4) This clause applies instead of section 60 (Costs) of the Civil and Administrative Tribunal Act 2013.
The applicable legal principles as to the proof of facts
1. In health practitioner disciplinary matters, the factual content of an allegation must be established on the balance of probabilities, and the question as to whether that level of proof has been reached is to be assessed having regard to all of the relevant evidence before the Tribunal: Health Care Complaints Commission v Wilcox [2020] NSWCATOD 10 at [52].
2. In Briginshaw v Briginshaw (1938) 60 CLR 336; [1938] HCA 34 (Briginshaw) at 362, Dixon J commented:
"The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding are considerations which must affect the answer to the question whether the issue has been proved ..."
1. In Neat Holdings Pty Ltd v Karajan Holdings Pty Ltd [1992] HCA 66; (1992) 67 ALJR 170 (Neat Holdings) at 171, the majority of the High Court (Mason CJ, Brennan, Deane and Gaudron JJ) said:
"[T]he strength of the evidence necessary to establish a fact or facts on the balance of probabilities may vary according to the nature of what it is sought to prove. Thus, authoritative statements have often been made to the effect that clear or cogent or strict proof is necessary 'where so serious a matter as fraud is to be found'. Statements to that effect should not, however, be understood as directed to the standard of proof. Rather, they should be understood as merely reflecting a conventional perception that members of our society do not ordinarily engage in fraudulent or criminal conduct and a judicial approach that a court should not lightly make a finding that, on the balance of probabilities, a party to civil litigation has been guilty of such conduct." [citations omitted]
1. Section 140 of the Evidence Act 1995 (NSW) (Evidence Act) provides that matters including the gravity of the matters alleged may be taken into account when making findings of fact.
2. In approaching the issue in these proceedings we have been conscious that, while the principle in Briginshaw supplemented by s 140 of the Evidence Act does not apply to fact finding in these proceedings to which the rules of evidence do not apply, what was said in Briginshaw and Neat Holdings reflects a more general approach to fact finding, which is applicable by analogy to the Tribunal: Bronze Wing International Pty Ltd v SafeWork NSW [2017] NSWCA 41 at [126]–[127] (Leeming JA, with Basten JA at [1] and Gleeson JA at [37] agreeing); Health Care Complaints Commission v Meneghetti [2020] NSWCATOD 39 at [14]; see also Gautam v Health Care Complaints Commission [2021] NSWCA 85 at [85]–[87] (Payne JA, with Leeming JA at [1] and Simpson AJA at [118] agreeing).
3. The second aspect of the rule in Browne v Dunn (1893) 6 R 67; [1893] 1 WLUK 44 is concerned with the weight to be afforded to evidence which has not been the subject of cross-examination, and is to the effect that evidence upon which there has been no relevant cross-examination should not usually be rejected by the tribunal of fact. It might be legal error not to accept unchallenged and uncontradicted evidence which is not inherently implausible: Ghosh v Medical Council of New South Wales [2020] NSWCA 122 at [69]–[70] (Brereton JA with Emmett AJA at [135] and Simpson AJA at [137] agreeing).
The Statement of Agreed Facts and Admissions
1. The Statement of Agreed Facts and Admissions, other than the Annexure which is identical to Schedule 2 to the Second Further Amended Complaint, relevantly provides:
"This document sets out facts that are agreed between the Applicant … and the Respondent (Practitioner). It also sets out admissions made by the Practitioner for the purposes of section 149(b) of the Health Practitioner Regulation National Law (NSW) (National Law).
The Practitioner
1. The Practitioner completed a pharmacy degree at Alexandria University, Egypt in 2005.
2. The Practitioner moved to Australia in 2009.
3. The Practitioner was first registered to practise as a pharmacist in Australia on 12 May 2011.
4. Between October 2015 and August 2018, the practitioner worked as a pharmacist at the Christopher Discount Chemist (the Pharmacy) in West Gosford, NSW.
5. The Pharmacy was located within a medical centre called the Reliance GP Super Clinic ….
6. The Practitioner worked at the Pharmacy on a casual basis, usually every Wednesday and every second Saturday, from 8am to 10pm.
7. During his shifts, the Practitioner was usually the sole pharmacist.
8. The Practitioner typically dispensed around 250 prescriptions per shift, and in some cases up to 300 or350.
9. During the period he worked at the Pharmacy, the Practitioner also worked:
(a) for two days a week at the Charlestown Pharmacy in Charlestown, NSW; and
(b) for two days a week at the Windale Pharmacy in Windale, NSW.
Schedule 8 drugs
10. Schedule 8 of the Poisons List proclaimed under section 8 of the Poisons and Therapeutic Goods Act 1966 (NSW) (PTGA) (Poisons List) contains substances which are addiction producing or potentially addiction producing. These are referred to as drugs of addiction or Schedule 8 drugs.
11. At all relevant times, Schedule 8 drugs included:
(a) *alprazolam (sold under names including Kalma and Alprax);
(b) dexamphetamine;
(c) *fentanyl (sold under names including Durogesic);
(d) flunitrazepam (sold under names including Hypnodorm);
(e) hydromorphone (sold under names including Dilaudid);
(f) morphine (sold under names including MS Contin);
(g) *oxycodone (sold under names including Oxycontin, Oxynorm, Endone, Novacodone and Targin); and
(h) tapentadol (sold under names including Palexia).
*The asterisk indicates Schedule 8 drugs dispensed by the Practitioner to Patients.
12. Fentanyl, hydromorphone, morphine, oxycodone and tapentadol are opioids.
13. Alprazolam and flunitrazepam are benzodiazepines.
14. Use of opioids and benzodiazepines can lead to physical and psychological dependence, tolerance and misuse. They are also liable to be diverted for illicit use.
15. Administration of an opioid together with a benzodiazepine increases the risks of central nervous system and respiratory depression (including coma and death).
Schedule 4D drugs
16. Schedule 4 of the Poisons List contains substances which in the public interest should be supplied only upon prescription. These are referred to as restricted substances or Schedule 4 drugs.
17. Appendix D of the Poisons and Therapeutic Goods Regulation 2008 (NSW) (PTGR) contains Schedule 4 substances to which additional restrictions apply under the PTGA and PTGR, including a prohibition on their possession except for specified purposes under section 16 of the PTGA. These are referred to as prescribed restricted substances or Schedule 4D drugs.
18. At all relevant times, Schedule 4D drugs included:
(a) clonazepam (sold under names including Rivotril and Paxam);
(b) *diazepam (sold under names including Ranzepam, Antenex, Valium and Valpam);
(c) lorazepam (sold under names including Ativan);
(d) nitrazepam (sold under names including Alodorm and Mogadon);
(e) *oxazepam (sold under names including Alepam and Murelax);
(f) phentermine (sold under names including Duromine);
(g) temazepam (sold under names including Normison and Temaze); and
(h) testosterone except when included in Schedule 6 of the Poisons List (sold under names including Testogel).
*The asterisk indicates Schedule 4D drugs dispensed by the Practitioner to Patients.
19. Clonazepam, diazepam, lorazepam, nitrazepam, oxazepam and temazepam are benzodiazepines.
Relevant obligations
20. Clause 54 of the PTGR provides that an authorised practitioner or pharmacist must not supply any restricted substance [Schedule 4 drug] in a quantity, or for a purpose, that does not accord with the recognised therapeutic standard of what is appropriate in the circumstances.
21. Clause 109 of the PTGR provides that an authorised practitioner or pharmacist must not supply any drug of addiction [Schedule 8 substance] in a quantity, or for a purpose, that does not accord with the recognised therapeutic standard of what is appropriate in the circumstances.
22. At the relevant times, the following professional codes and guidelines for pharmacists made pursuant to section 39 of the National Law were in force:
(a) the Pharmacy Board of Australia 'Code of conduct for pharmacists' dated 17 March 2014 (Code of Conduct); and
(b) the Pharmacy Board of Australia 'Guidelines for dispensing of medicines' dated 7 December 2015 (Dispensing Guidelines).
23. The Code of Conduct relevantly provided that:
(a) practitioners must always act in accordance with the law (clause 1.1);
(b) practitioners have a duty to make the care of patients or clients their first concern and to practise safely and effectively, and a responsibility to protect and promote the health of individuals and the community (clause 1.2);
(c) practitioners must provide good care, including by:
(i) assessing the patient or client, taking into account their history, views and an appropriate physical examination where relevant (clause 2.1a));
(ii) formulating and implementing a suitable management plan (clause 2.1b));
(iii) ensuring that they maintain adequate knowledge and skills to provide safe and effective care (clause 2.2b));
(iv) considering the balance of benefit and harm in all clinical management decisions (clause 2.2f);
(d) when working with other practitioners to provide patient care, this does not alter a practitioner's personal accountability for professional conduct and the care provided (clause 4.4);
(e) practitioners must take all reasonable steps to address a risk issue if there is a reason to think that the safety of patients or clients may be compromised (clause 6.2f);
(f) practitioners must recognise and take steps to minimise the risks of fatigue, and endeavour to work safe hours where possible (clauses 6.3b), 9.2e)); and
(g) practitioners must take steps to protect patients or clients from being placed at risk of harm posed by a colleague's conduct, practice or ill health (clause 6.3d)).
24. The Dispensing Guidelines relevantly provided that:
(a) a pharmacist must take reasonable steps to ensure that the dispensing of a medicine in accordance with a prescription or order is consistent with the safety of the person named in that prescription or order, including exercising an independent judgment to ensure the medicine is safe and appropriate for the patient, having regard to the dose, frequency and route of administration, duration of treatment, the presence or absence of other medicines, the patient's illness, medication history, and other relevant circumstances (clause 1); and
(b) pharmacists should ensure that the individual workloads under which they operate are at reasonable and manageable levels to ensure the safety of the patient, provide an appropriate pharmaceutical service in an accurate, professional and timely manner, and cope with fluctuations in workload, with the Pharmacy Board recommending the following guidelines:
(i) if dispensing levels were in the range of 150 to 200 scripts per day, consideration needs to be given to the use of trained dispensary assistants and/or intern pharmacists to assist the pharmacist; and
(ii) if dispensing levels exceeded 200 scripts per day, additional pharmacists or dispensary assistants may be required to ensure adequate time is allowed to dispense properly every prescription in accordance with Pharmacy Board guidelines
(clause 11).
The Practitioner's dispensing
25. During the period from July 2017 to the end of 2018, practitioners at the Pharmacy dispensed Schedule 8 and Schedule 4D drugs to Patients A, B, C, D, E, F, G, H and I as set out in the Annexure to this statement of agreed facts.
26. The Practitioner dispensed Schedule 8 and Schedule 4D drugs to Patients A, B, C, D, E, F, G, H and I of the kinds, in the quantities and on the dates highlighted in yellow in the Annexure.
27. The Practitioner admits that in relation to his dispensing of Schedule 8 and Schedule 4D drugs to Patient A as identified in the Annexure:
(a) the dispensing of Schedule 8 drugs was contrary to clause 109 of the PTGR in that it was in a quantity that did not accord with a recognised therapeutic standard;
(b) the dispensing of Schedule 4D drugs was contrary to clause 54 of the PTGR in that it was in a quantity that did not accord with a recognised therapeutic standard;
(c) the dispensing intervals and/or frequency of Schedule 8 and Schedule 4D drugs did not accord with a recognised therapeutic standard; and
(d) the Practitioner was obliged to but did not have sufficient regard to the patient's dispensing history.
28. The Practitioner admits that in relation to dispensing of Schedule 8 drugs to Patients D and H as identified in the Annexure:
(a) the dispensing was contrary to clause 109 of the PTGR in that it was in a quantity that did not accord with a recognised therapeutic standard;
(b) the dispensing intervals and/or frequency did not accord with a recognised therapeutic standard; and
(c) the Practitioner was obliged to but did not have sufficient regard to the patient's dispensing history.
29. The Practitioner admits that in relation to his dispensing of Schedule 8 drugs to Patients C, E and G as identified in the Annexure:
(a) the dispensing was contrary to clause 109 of the PTGR in that it was in a quantity that did not accord with a recognised therapeutic standard;
(b) the dispensing intervals and/or frequency did not accord with a recognised therapeutic standard; and
(c) the Practitioner was obliged to but did not have sufficient regard to the patient's dispensing history.
30. The Practitioner admits that in relation to his dispensing of Schedule 4D drugs to Patient I as identified in the Annexure:
(a) the dispensing of Schedule 4D drugs was contrary to clause 54 of the PTGR in that it was in a quantity that did not accord with a recognised therapeutic standard;
(b) the dispensing intervals and/or frequency of Schedule 4D drugs did not accord with a recognised therapeutic standard; and
(c) the Practitioner was obliged to but did not have sufficient regard to the patient's dispensing history.
31. The Practitioner admits that with respect to each of Patients A, D and H, for the reasons set out in paragraphs 27 and 28 above, he:
(a) engaged in conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of pharmacy was significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience, within the meaning of section 139B(1)(a) of the National Law; and
(b) as a result, is guilty of unsatisfactory professional conduct."
Issue 1: whether the respondent engaged in the conduct constituting complaint one, and any such proved conduct constitutes unsatisfactory professional conduct
Introduction
1. The respondent has admitted that in his dispensing of Schedule 8 and/or Schedule 4D medicines (or drugs) for Patients A, D and H he engaged in unsatisfactory professional conduct within s 139B(1)(a) of the National Law.
2. The issue between the parties is whether the respondent in his dispensing of Schedule 8 and/or Schedule 4D medicines (or drugs) for Patients C, E, G and I engaged in unsatisfactory professional conduct within s 139B(1)(l) of the National Law.
3. It is appropriate to set out the relevant evidence of the respondent except in respect of the agreed facts and summarise the submissions of the parties before considering this issue.
The relevant evidence of the respondent
1. In the Matta statement, the respondent gave the following evidence ([21]):
"21. At the time of this dispensing, the relevant "Dispensing Practice Guidelines" from the Pharmaceutical Society of Australia were the 2017 Guidelines (attached). At page 14, there is reference to communicating with the prescriber. The document sets out useful advice but does not suggest that the pharmacist can decline the supply, once they have contacted the prescriber. In Dispensing Guidelines for pharmaceutical society of Australia 2019 (attached), on page 16 'communicating with the prescriber', there has been an amendment to advise pharmacists that they can decline supply. This amendment was introduced after the dates in the complaint, and it (is) a very useful guide to pharmacists like myself, who must respect the separate skill of the clinician, but also balance it against our independent duty."
The submissions of the parties
The submissions of the applicant
1. In the HCCC submissions, the applicant referred to several authorities and made the following submissions:
1. conduct that is 'contrary to some code of professional conduct' is properly characterised as unethical for the purposes of the National Law;
2. conduct has been characterised as improper for the purposes of the National Law when 'viewed objectively, [it] would be regarded by reasonable persons as falling below the standards of conduct to be expected of [the practitioner]';
3. despite the respondent's non-admission, the Tribunal should find that his dispensing to each of Patients C, E, G and I also amounted to unsatisfactory professional conduct.
1. In his oral submissions, counsel for the HCCC referred to various authorities including Health Care Complaints Commission v Sathiyapal [2024] NSWCATOD 14 (Sathiyapal) and Health Care Complaints Commission v Khalighimonfared [2022] NSWCATOD 78 (Khalighimonfared). He submitted that the Tribunal in Sathiyapal at [121] held that the practitioner by prescribing a particular drug without holding an authority under s 28 of the Poisons and Therapeutic Goods Act 1966 (NSW) engaged in improper conduct within s 139B(1)(l) of the National Law. He also submitted that Khalighimonfared was difficult to reconcile with a long line of cases and if there was an inconsistency it should not be followed.
The submissions of the respondent
1. In her oral submissions, counsel for the respondent made the following submissions:
1. while the respondent had a deficit in skill or knowledge, it was artificial to characterise his conduct as improper or unethical;
2. a breach of the Code of Conduct, the Dispensing Guidelines and PTGR did not of itself constitute improper or unethical conduct by the respondent;
3. the conduct in the authorities relied on by the HCCC could be distinguished;
4. the conduct in Khalighimonfared was far more serious than the conduct of the respondent.
Consideration
1. Having regard to the legal principles in [50] to [55] above, the agreed facts and the unchallenged evidence of Ms Torrens in the Torrens report, we are satisfied that the respondent:
1. in relation to Patient C - dispensed 20 OxyNorm 20 mg capsules and 28 oxycodone SR (slow release) 80 mg tablets, together with 25 Alepam 15 mg tablets (oxazepam, another benzodiazepine), five days after another pharmacist at the CDC Pharmacy had dispensed the same quantities of OxyNorm 20 mg capsules and oxycodone SR 80 mg tablets as well as 28 oxycodone SR 40 mg tablets, and where the supply of slow release tablets for Patient C would be expected to last 14 days at a dose of one tablet twice daily;
2. in relation to Patient E - dispensed 28 oxycodone SR 40 mg and 28 oxycodone SR 80 mg tablets five days after another pharmacist at the CDC Pharmacy had dispensed the same quantity of oxycodone SR 80 mg tablets together with 20 OxyNorm 20 mg capsules and 50 Ranzepam (diazepam) 5 mg tablets to Patient E, where the supply of 28 oxycodone SR tablets would be expected to last 14 days at a dose of one tablet twice daily;
3. in relation to Patient G - dispensed 28 oxycodone SR 20 mg and 28 OxyContin (oxycodone) SR 30 mg tablets one day after another pharmacist at the CDC Pharmacy had dispensed a total of 76 tablets or capsules of different strengths or forms of oxycodone (including slow release tablets);
4. in relation to Patient I - dispensed 25 tablets of Alepam (oxazepam) 30 mg and 50 tablets of Antenex (diazepam) 5 mg - both benzodiazepines - three days after another pharmacist at the CDC Pharmacy had dispensed 25 Alepam 30 mg tablets to Patient I, when Patient l's prescribed dose was one tablet in the evening, where a supply of 25 tablets would be expected to last 25 days.
1. We do not accept that the respondent had any relevant deficit in knowledge. In the Matta statement, he does not give any evidence of a lack of knowledge at the relevant time of the Code of Conduct, the Dispensing Guidelines or cll 54 and 109 of the Poisons and Therapeutic Goods Regulation 2008 (NSW) (PTGR). The Dispensing Practice Guidelines of the Pharmaceutical Society of Australia referred to by the respondent in the Matta statement at [21] do not have the status of guidelines approved by the Board under s 39 of the National Law.
2. In Health Care Complaints Commission v Nguyen [2018] NSWCATOD 168 (Nguyen) at [47], the Tribunal considered the meaning of "improper conduct" in s 139B(1)(l) of the National Law:
"[47] The second basis relied upon to establish unsatisfactory professional conduct, in the sense set out in s 139(1)(l), does not present similar difficulties. Under that provision, "unsatisfactory professional conduct" includes "[a]ny other improper … conduct relating to the practice or purported practice of the practitioner's profession". "Improper conduct" is not defined in the National Law. The High Court has noted that "improper" is not a term of art: The Queen v Byrnes (1995) 183 CLR 501 at 514, citing Grove v Flavel (1986) 43 SASR 410 at 420. In Byrnes at 514-5, Brennan, Deane, Toohey and Gaudron JJ explained the concept of impropriety as follows:
"Impropriety does not depend on the alleged offender's consciousness of impropriety. Impropriety consists in a breach of the standards of conduct that would be expected of a person in the position of the alleged offender by reasonable persons with knowledge of the duties, powers and authority of the position and the circumstances of the case.""
1. In Sathiyapal at [119]–[121], the Tribunal considered the meaning of s 139B(1)(l) of the National Law:
[119] In Health Care Complaints Commission v Liu [2016] NSWCATOD 133, the Tribunal said:
54. Decisions involving professional disciplinary proceedings have adopted as relevant the discussion of the term "impropriety" in R v Byrnes and Hopwood (1995) 183 CLR 501; [1995] HCA 1 as being a breach of the standards of conduct that would be expected of a person in the position of the alleged offender (see HCCC v Phung (No 1) [2012] NSWDT 1, Health Care Complaints Commission v Fisher [2016] NSWCATOD 62). The test of whether the conduct is improper is an objective one.
[120] In Health Care Complaints Commission v Sare [2018] NSWCATOD 190, the Tribunal said:
31. The Macquarie Dictionary defines "improper" as "not in accordance with propriety of behaviour, manners etc or abnormal or irregular" (see also R v Byrnes and Hopwood [1995] HCA 1; 183 CLR 501 at 514-515). Unethical is defined as "contrary to moral precept; immoral; in contravention of some code of conduct". As in Health Care Complaints Commission v Little [2016] NSWCATOD 146, we consider it appropriate to adopt the dictionary definition in construing these words as they appear in the National Law. We note that the words are to be read in the context of s 139B(1)(l), namely that the offending conduct is conduct relating to "the practice or the purported practice of the practitioner's profession".
[121] We adopt these descriptions of 'improper' and 'unethical'. …"
1. The Tribunal has adopted a similar approach to the meaning of s 139B(1)(l) of the National Law in other decisions: see, for example, Health Care Complaints Commission v Quan [2018] NSWCATOD 111 (Quan) at [55]–[56]; Khalighimonfared at [74]–[75]; Health Care Complaints Commission v Tran [2024] NSWCATOD 1 at [113]–[115].
2. We have adopted the descriptions of "improper" and "unethical" in s 139B(1)(l) of the National Law set out in Nguyen at [47] and Sathiyapal at [119]-[120].
3. We are satisfied that each of the following provisions set a standard of proper and ethical conduct relating to the practice of pharmacy:
1. clause 1 of the Dispensing Guidelines, by reason that it directly relates to the safety of the person named in the prescription;
2. clauses 54 and 109 of the PTGR, by reason that they create a mandatory statutory obligation for a pharmacist in the supply of Schedule 4D and Schedule 8 medicines (or drugs) respectively, the contravention is an offence punishable with a maximum penalty of a fine or imprisonment or both.
1. We are satisfied that the respondent breached clause 1 of the Dispensing Guidelines in dispensing Schedule 8 medicines (or drugs) to Patients C, E and G, and Schedule 4D medicines (or drugs) to Patient I. The respondent has admitted that dispensing Schedule 8 medicines (or drugs) to Patients C, E and G and I, and Schedule 4D medicines (or drugs) to Patient I, was contrary to cll 109 and 54 of the PTGR respectively.
2. We have not found Khalighimonfared helpful in considering whether the respondent's conduct in relation to Patients C, E, G and I is to be characterised as improper or unethical conduct relating to the practice of pharmacy within s 139B(1)(l) of the National Law. The complaint against the practitioner related to the prescribing of opioids to six patients over a period of approximately two years. The Tribunal at [85] held:
"[85] There is no doubt that the conduct of the practitioner, in relation to his treatment of the six patients, was significantly lacking and, by his own admission, sufficient to constitute unsatisfactory professional conduct and professional misconduct. We do not consider, however, that his conduct could properly be found to be 'improper or unethical relating to the practice or purposed practice of medicine'. In our view, his deficiencies in knowledge and practice do not include any element of 'unethical or improper conduct' for the purposes of section 139B. He lacked relevant knowledge and experience and acted in a manner which did not meet the best interests of his patients but, in our assessment, there was no 'unethical or improper element' to his conduct."
1. Here the circumstances are different. There is no evidence that the respondent lacked knowledge of his obligation under clause 1 of the Dispensing Guidelines to exercise an independent judgment to ensure the medicine is safe and appropriate for the patient, having regard to the dose, frequency and route of administration, duration of treatment, the presence or absence of other medicines, the patient's illness, medication history, and other relevant circumstances. Further, the respondent by supplying the medicines (or drugs) in question contravened the statutory prohibition in cll 109 and 54 of the PTGR. These clauses of the PTGR each created a statutory prohibition which is relevantly similar to the statutory obligation the breach of which was found to be improper conduct in Sathiyapal at [121]. In view of the content of clause 1 of the Dispensing Guidelines and cll 109 and 54 of the PTGR, then, unlike the position in Khalighimonfared, there was both an unethical and improper element to the conduct of the respondent.
2. Accordingly, we are satisfied that the respondent engaged in improper and unethical conduct relating to the practice of pharmacy with respect to Patients C, E, G and I. It follows that we find that the respondent engaged in unsatisfactory professional conduct within s 139B(1)(l) of the National Law with respect to Patients C, E, G and I.
Issue 2: whether any protective orders should be made against the respondent
Introduction
1. The applicant and the respondent, while agreeing that protective orders should be made, disagree as to what protective orders are appropriate. The applicant seeks a reprimand, while the respondent seeks a caution.
2. Before considering this issue, it is appropriate to summarise the evidence of the respondent and the submissions of the parties.
The evidence of the respondent
The Matta statement
1. In the Matta statement, the respondent relevantly gave the following evidence:
1. he takes full responsibility for shortcomings in his practice of pharmacy over the relevant time, and has made every effort to take courses that sharpen up his understanding of when to refuse supply. Over the relevant time, he did understand that he needed to check a script or supply that he felt uncomfortable with, and he regularly did so, but he did not understand that he could refuse supply if a doctor told him that the medication should be dispensed. He does now ([52]);
2. he hopes that the Tribunal will take into account the following matters in understanding the circumstances ([53]):
1. he worked at the CDC Pharmacy between October 2015 and August 2018 on a casual basis every Wednesday and every second Saturday. The workload while he was working at the pharmacy was high (on average 250 scripts per day as a sole pharmacist without any dispensary technicians to assist). Although he brought his concerns about this to the owners at the time, no action was taken by them. When he realised that he could not provide the best service to customers, he left the pharmacy ([54]);
2. he did not have the same issues at the other pharmacy he worked at during that same time period ([55]);
3. most of the dispensing occurred at the beginning of the patient attending the pharmacy and there was little patient history to see clearly patterns of short supply. Hence, there was not firm evidence of diversion or misuse and most times he contacted the prescriber to verify the prescription if it was a concern ([56]);
4. since this complaint, he has taken a firmer position on contacting the prescriber to discuss any concerns regarding prescriptions or requests for early supply, and it is now his practice to refuse to dispense if he thinks the script is inappropriate after speaking with the doctor, or if he is not able to speak to the doctor. If he has any concerns, he will speak to a colleague or call the PRU for reassurance about the appropriate action to be taken. He is also now ensuring that he documents all communication between himself and the prescriber, and also documents key discussions with colleagues or the PRU ([57]);
5. the Council in its investigation into the PRU report considered that he was only a minor share of the CDC Pharmacy issues. Ms Torrens considered that his dispensing was significantly below (the standard reasonably expected of a practitioner of an equivalent level of training or experience) for only three patients (19 prescriptions in total) ([58]);
6. he appreciates that he did not always exercise his independent clinical judgment adequately in considering whether to refuse supply (particularly for later dispensing). He did exercise his clinical judgement on each occasion by assessing who the prescriber was and what was the prescribed dose. He thought he had a good relationship with the doctors at the medical centre next door and he trusted their expertise and integrity. He admits that his exercise of professional judgement was deficient on a number of occasions, based in part on his having placed too much trust and confidence in the competence and expertise of the doctors at the medical centre next door. He also agrees that he should have recorded all his contact with prescribers when he rang to verify prescriptions ([59]);
1. due to the pressures he felt at the CDC Pharmacy, in terms of the workload, failure to provide support for his two days of work per week and lack of professional assistance with his questions regarding dispensing, he left the pharmacy in August 2018 ([60]);
2. since 2016, he has been employed as a pharmacist at Windale Pharmacy and he has continued work there until today. He has had no issues and he thoroughly enjoys the enjoyable and supportive environment ([61]);
3. since the issues were drawn to his attention by the PRU, he has done the following to ensure that this situation is never repeated, and he will never face any other complaint:
1. he has completed extensive education about controlled medication and ethical practices when dispensing;
2. he has focused his learning on improving his knowledge and practice regarding chronic pain management, legislation, addiction and substance abuse and ethics;
3. he has worked extensively with his mentor in improving his knowledge of all areas and has reviewed and reflected on all relevant legislations, codes of conduct and guidelines relevant to his practice;
4. he has attended continuing professional development as required;
5. he concedes that he did not record his conversations with the prescribers as he should have done and he now records all such conversations in the pharmacy dispensary system, having reviewed all the legislation and guidelines that govern this ([62]);
1. he has undergone intensive investigation by the Council which, although was distressing for him, he welcomed ([63]);
2. he has worked now for three years with no conditions on his registration, as a pharmacist in charge, and has had no issues. He has thoroughly enjoyed his work as a pharmacist, ensuring that his learnings following the investigation into the CDC Pharmacy are well implemented in his day-to-day conduct ([64]);
3. he now fully appreciates, following the investigation by the PRU and subsequently by the Council, that he must exercise his own independent clinical judgment about the appropriateness of medication he is being asked to dispense. It is now his practice to refuse to dispense if he considers that prescribing is inappropriate, even after speaking with the prescriber. If the situation requires it, he will also speak with the pharmacist in charge or another pharmacist for reassurance about his concerns in relation to such dispensing ([65]);
4. he now appreciates that he has other resources available to him to ensure appropriate dispensing, such as calling the PRU and also accessing SafeScript and the Doctor Shopping Line ([66]);
5. although painful, the proceedings he has been though, and the additional learning it has prompted him to do, has made him a better pharmacist and he is committed to share his learning with other trainees ([67]).
The oral evidence of the respondent
1. In his examination in chief, the respondent gave the evidence as to the online course referred to in exhibit R3 and the practice alerts he received referred to in exhibit R4.
2. In cross-examination, the respondent gave the following evidence:
1. his understanding as to his obligation in dispensing Schedule 8 and Schedule 4D medicines (or drugs);
2. his practice in dispensing Schedule 8 and Schedule 4D medicines (or drugs) including maintaining records;
3. the circumstances in which he worked at the Pharmacy including the hours of work and number of prescriptions dispensed;
4. his current working circumstances;
5. the assistance he received from Mr North.
1. In re-examination, the respondent gave evidence that he had informed his other employer at Windale Pharmacy of the PRU complaint and offered to leave. He was put back on as a senior pharmacist at Windale Pharmacy as soon as the 31 January 2020 Council decision was set aside. He had also informed his other employer at a pharmacy at Newcastle of these proceedings after their commencement.
The Van reference
1. In the Van reference, Ms Van, who is a pharmacist, states that she is the proprietor of Windale Pharmacy where the respondent has worked since 2015. He always follows the rules and regulations that are put in place for the pharmacy industry.
The Ghandour reference
1. In the Ghandour reference, Fr Ghandour states that he is the Parish priest of St. Mary & St. George Coptic Orthodox Church at Newcastle. He has known the respondent for the last six years through church. He has found the respondent to be an honest and trustworthy person.
The North reference
1. In the North reference, Mr North, who is a pharmacist, states that he has offered guidance to the respondent. From December 2021 to February 2023, there have been 62 email communications in the order of 20 tasks sent by him, 20 replies in completion of tasks, and 20 comments and answers to questions posed by the respondent. He believes that the respondent deserves to be recognised for his motivation and effort he has put into reviewing his practice of pharmacy where gaps in his understanding have been identified.
The Davis reference
1. In the Davis reference, Mr Davis states that he is the owner and the pharmacist of a pharmacy at Newcastle. The respondent has been working in the pharmacy since September 2022. The respondent understands and works to deliver policies and procedures with a high level of integrity to ensure that the pharmacy maintains regulatory requirements, patient confidentiality, pharmacy confidentiality, and a high level of care to patients.
The submissions of the parties
The submissions of the applicant
1. In the HCCC submissions, the applicant referred to several authorities and made the following submissions:
1. determining the appropriate protective orders requires balancing the seriousness of the respondent's conduct against other circumstances that serve to reduce the risk he poses to members of the public. Balancing those considerations, the appropriate protective order is a reprimand;
2. on the one hand, although the respondent's conduct is at the lower end of the range of seriousness, it is sufficiently serious as to warrant denunciation and a material protective response for reasons of general deterrence for the following reasons:
1. the respondent's conduct amounting to unsatisfactory professional conduct involved several occasions of inappropriate dispensing of dangerous drugs (or drugs of addiction: Schedule 8 and Schedule 4D medicines) to a range of patients over a not insignificant period of time. While the total number of occasions on which he engaged in inappropriate dispensing was relatively small, that is in the context of him only working at the CDC Pharmacy for one to two days per week. These instances of dispensing were sufficiently excessive that he admits they were contrary to recognised therapeutic standards. The medicines dispensed excessively were of a kind known to be liable to misuse or abuse by the patients themselves or, alternatively, illicit diversion into the community;
2. the observations in Health Care Complaints Commission v Fearon [2018] NSWCATOD 26 (Fearon) at [165], Health Care Complaints Commission v Elliott [2018] NSWCATOD 47 (Elliott) at [54]–[57] and Health Care Complaints Commission v Pickett [2019] NSWCATOD 53 (Pickett) at [61], indicate there is a strong need for denunciation to maintain public confidence in the regulatory regime around Schedule 8 and Schedule 4D medicines (or drugs), and for general deterrence in relation to contraventions of that regulatory regime;
3. to the extent the respondent relied on contact with prescribers to justify his dispensing, that does not mitigate the seriousness of that dispensing having regard to the professional standards described in the Code of Conduct and the Dispensing Guidelines and the matters explained in Elliott at [54]–[57]. His asserted lack of knowledge of the professional standards that did not permit him just to rely on verification by prescribers is not to his credit;
4. similarly, while the long hours worked by the respondent at the CDC Pharmacy and his high workload may go some way to explaining his conduct, they do not justify it: a pharmacist's responsibilities under the Code of Conduct and the Dispensing Guidelines include to manage the risks of fatigue and working unsafe hours, and to ensure they operate under reasonable and manageable workloads consistent with patient safety. He was not inexperienced: he had been working as a pharmacist in Australia for more than six years, and at the CDC Pharmacy for almost two years, when he engaged in the dispensing the subject of the Second Further Amended Complaint;
1. on the other hand, it acknowledges that:
1. the respondent did ultimately choose to leave the CDC Pharmacy of his own volition shortly after the last of those dispensing incidents (in August 2018), including because of the high workload;
2. the incidents in question occurred approximately six years ago;
3. since that time, the respondent has continued practising (apart from a period of approximately two months when his registration was suspended because of these events) without any recorded complaints, including for a period of approximately four years with no conditions on his registration and as a pharmacist in charge;
4. the respondent has acknowledged shortcomings in his previous practice and has taken steps to address those, including further education and (informal) mentoring and working more manageable hours;
5. the respondent has provided positive references from his current employers and from his mentor, who is an experienced pharmacist;
1. in these circumstances, a reprimand is appropriate to mark the seriousness of the respondent's shortfall from professional standards including to uphold public confidence in those standards as they apply to the dispensing of dangerous drugs (or drugs of addiction) such as opioids and benzodiazepines; but no further order is necessary for the protection of the public.
1. In his oral submissions, counsel for the applicant in substance repeated the HCCC submissions.
The submissions of the respondent
1. In her oral submissions, counsel for the respondent made the following submissions:
1. the Tribunal should accept the evidence of the respondent in the Matta statement;
2. the conduct of the respondent was relatively isolated and characterised by naivety, but not carelessness or recklessness;
3. relied on Quan where the Tribunal cautioned the practitioner whose conduct was arguably more serious than that of the respondent;
4. the respondent poses no risk to the public;
5. the respondent is supported by Mr North in the North reference, Ms Van in the Van reference, and Mr Davis in the Davis reference.
Consideration
1. The Tribunal has previously commented on the importance of pharmacists complying with their obligations in relation to drugs of addiction and prescribed restricted substances:
1. in Fearon at [165], the Tribunal relevantly said:
"[165] … The effectiveness of the statutory scheme governing the retail supply of prescribed substances and drugs of addiction requires pharmacists to act with integrity and to scrupulously adhere to the statutory requirements governing the supply of those drugs."
1. in Elliott at [54]-[57], the Tribunal relevantly said:
"[54] Mr Elliott was dispensing considerable quantities of Sch 8 drugs over a lengthy period, but especially in 2013 and 2014. In our view, in those circumstances any trained pharmacist operating at the general standard required of his or her profession would have become highly attuned and attentive to the potential risks of dispensing such quantities of drugs. In particular, it would be reasonable to expect an experienced pharmacist to be alert to the possibility – perhaps even the probability – that some of the patients were likely to be opioid-dependent and therefore more likely than other patients to simulate symptoms in order to obtain prescribed drugs, to involve themselves in "doctor shopping" or to misuse drugs.
[55] Pharmacists are gatekeepers with responsibility, among other things, for dispensing drugs of addiction. To assist them in that serious task, regulations and guidelines are imposed so that the very real risks involved in dispensing drugs of addiction can be managed and mitigated. As the National Law emphasises, the protection of the public is paramount. And some members of the public, such as drug dependent patients, need protection from themselves. Medical practitioners and pharmacists share significant responsibility and are required to exercise their individual clinical judgments to ensure that individual consumers and the public are protected. The more experienced a pharmacist becomes, the better that practitioner's judgment might be expected to be. A pharmacist's failure to be attentive, or sufficiently attentive to the self-evident risks of dispensing Sch 8 drugs, undercuts the protective structure which the regulations and guidelines are intended to erect for the benefit of individual patients and the community as a whole.
[56] When compounded by a pharmacist's effective failure to exercise clinical judgment by, for example, not raising appropriate concerns with prescribing doctors (who may themselves be falling short of professional standards), the protective structure is rendered virtually useless. This would reduce a pharmacy almost to a supermarket level where customers can help themselves to whatever they want, no questions asked. ...
[57] Although failure to comply with regulations and guidelines might well evidence a fall from appropriate standards, professional standards in the health professions are not to be measured merely by compliance. The ultimate benchmark against which the professional conduct of health practitioners will be measured is the protection of the public. If the relevant conduct of a health professional fails to protect the public, and falls significantly short of the standards required to do so, or poses a real risk to the health and safety of the public, it might well justify suspension or deregistration because the community ought not be exposed to the risk inherent in such failures. …"
1. in Pickett at [61], the Tribunal relevantly said:
"[61] A pharmacist occupies a position of trust in our community by virtue of having access to drugs of addiction. They are responsible for the secure storage and safe administration to patients of such medication. …"
1. In Health Care Complaints Commission v A Medical Practitioner [2001] NSWCA 158 at [47], Stein JA (with Powell JA at [1] and Rolfe AJA at [54] agreeing) explained the use that may be made of character evidence:
"[47] Nonetheless, it is plain that the Tribunal is not entitled to take character into account in considering whether a practitioner is guilty of unsatisfactory professional conduct. It is difficult to see, given the admission of careless conduct by the respondent, (which was accepted by the Tribunal) what probative force such evidence would have. It had no relevance to the consequences which might flow from the inadvertent error. It could, of course, be relevant to credit. But the mistake made by the practitioner involved no issue of credibility. The character evidence was, by its very nature, relevant to penalty, should the Tribunal get to that issue."
1. In Lee v Health Care Complaints Commission [2012] NSWCA 80 at [19]–[21] Barrett JA (with Macfarlan JA at [1] and Tobias AJA at [80] agreeing) set out the principles for the exercise of the disciplinary powers of the Tribunal under Pt 8 Div 3 Subdiv 6 of the National Law:
"[19] As Basten JA pointed out in Prakash v Health Care Complaints Commission [2006] NSWCA 153 at [85], the power of the Tribunal to make a disciplinary order is discretionary in nature. …
[20] Essential to a proper assessment of a tribunal's discretionary judgment in a disciplinary jurisdiction in accordance with these criteria is a clear understanding of the nature of the jurisdiction and an appreciation of the purpose of orders made in exercise of it. These matters were explained by Basten JA in Director-General, Department of Ageing, Disability and Home Care v Lambert [2009] NSWCA 102; (2009) 74 NSWLR 523 at [83]. His Honour made several important points:
1. The specific purpose for which orders are made is protective in the public interest and is not punitive with respect to the individual.
2. That is not to deny that such orders may be punitive in effect and that punitive effects may be relevant in formulating a protective order.
3. The punitive effects may be directly relevant to the need for protection so that, in a particular case, there may be a factual finding that the harrowing experience of disciplinary proceedings, together with the real threat of loss of a livelihood, may have opened the eyes of the individual concerned to the seriousness of his or her conduct so as to diminish significantly the likelihood of its repetition and to produce a level of insight into his or her own character or misconduct which did not previously exist.
[21] The task of the Tribunal … centres not on punishment as such but on the protection of the public and the maintenance of proper professional standards."
1. In Health Care Complaints Commission v Do [2014] NSWCA 307 at [35], Meagher JA (with Basten JA at [1] and Emmett JA at [60] agreeing) emphasised that protecting the health and safety of the public is not confined to protecting future patients from the risk of harm:
"[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. No order should be made which has more serious consequences for the practitioner than is reasonably necessary in execution of the protective purpose of the National Law: Health Care Complaints Commission v Schmaman [2019] NSWCATOD 82 at [88].
2. In Health Care Complaints Commission v Lord [2019] NSWCATOD 182 (Lord) at [41]–[42], the Tribunal considered the difference between a caution and a reprimand:
"[41] In Health Care Complaints Commission v Dowla (No 2) [2019] NSWCATOD 156 (Dowla (No 2)), the Tribunal considered at [42] the difference between a caution and a reprimand under s 149A(1)(a) of the National Law and cited with approval the decision of the Victorian Civil and Administrative Tribunal in Psychologists Registration Board of Australia v Coleman (Review and Regulation) [2013] VCAT 738 (Coleman), in which the Tribunal explained at [14]:
[T]he ordinary meaning of the words leads to the conclusion that a reprimand is an official rebuke for past wrongful conduct whereas a caution is a reminder to take care in the future and avoid repetition. Of the two, we consider a reprimand provokes more serious consequences. In Peeke v Medical Board of Victoria (unreported, Marks J. 19 January 1994). His Honour commented on a view that had been expressed to the effect that to impose a reprimand was to trivialise a serious lapse in professional standards. His retort was succinct -
I am not able to agree with the Board that a reprimand is a trivial penalty. It may be inappropriate or inadequate in many circumstances, but a reprimand, to a professional person, has a potential for serious adverse implications.
[42] As noted by the Tribunal in Dowla (No 2) at [44], a reprimand, if imposed, will appear on the record of a practitioner's registration maintained by the Australian Health Practitioner Regulation Agency (AHPRA): s 225(j). In contrast, the National Law does not require AHPRA to record a caution on practitioner's record."
1. The Tribunal has held that the concept of general deterrence and the need to uphold public confidence in the standards of the profession in an appropriate case will be adequately addressed if the misconduct of the practitioner is denounced, in the sense of being openly condemned, by reprimanding him: Health Care Complaints Commission v Haasbroek [2018] NSWCATOD 177 at [94]–[95]; Healthcare Complaints Commission v Hollenbach [2019] NSWCATOD 118 at [553]; Health Care Complaints Commission v Lu [2023] NSWCATOD 51 at [60].
2. We accept that the respondent was an honest witness and demonstrated insight as to the nature and extent of his departure from the applicable standards in clause 1 of the Dispensing Guidelines and cll 54 and 109 of the PTGR. We are satisfied that he is genuinely remorseful for his actions and there is little risk that he will ever repeat his conduct.
3. We have not found Quan helpful in considering the appropriate protective action to be taken against the respondent. The practitioner was a medical practitioner with a high reputation in the medical and general community, and until the proceedings, had an unblemished record as a general practitioner for over thirty years. The complaint against the practitioner relevantly involved the improper prescribing on two days. The Tribunal at [80]–[81] expressed the following conclusion:
"[80] We considered the range of orders open to us under s 149A and s 149B of the National Law including issuing a reprimand to the practitioner or imposing a fine on him. On careful reflection, having regard to our assessment of the practitioner, the isolated nature of the conduct, and the fact we are confident the practitioner will not present a risk to patients in the future by like conduct, we conclude the appropriate order is that the practitioner be cautioned rather than reprimanded or fined.
[81] That caution, the fact the practitioner was subject of these disciplinary proceedings and our reasons, which will be publicly available on NSW Caselaw, will serve as a deterrent to like conduct and uphold the standards of the profession."
1. Here the circumstances are different. The conduct of the respondent was not of an isolated nature, and the dispensing of Schedule 8 and/or Schedule 4D medicines occurred over a period of eight months.
2. Having regard to ss 3, 3A and 4 of the National Law, the legal principles in [88] to [94] above, the evidence of the respondent, and the character evidence on behalf of the respondent, we are satisfied that the appropriate protective order is to reprimand the respondent pursuant to ss 149 and 149A(1)(a) of the National Law. The public nature of a reprimand will be recorded on his practitioner's registration pursuant to s 225(j) of the National Law, which is accessible to the public on the AHPRA's website and this decision, which is accessible to the public on the NSW Caselaw website, will be a sufficient general deterrence and will uphold public confidence in the standards of the profession of pharmacy. There is no need for the imposition of any conditions on the respondent's registration pursuant to ss 149 and 149A(1)(b) of the National Law.
Issue 3: whether the respondent pay the applicant's costs of the proceedings
Introduction
1. The applicant and the respondent disagree as to what costs orders is appropriate. The applicant seeks an order that the respondent pays the whole of is costs, while the respondent seeks an order that he pays 50% or some lesser percentage of the applicant's costs.
2. Before considering this issue, it is appropriate to summarise the submissions of the parties.
The submissions of the parties
The submissions of the applicant
1. In the HCCC submissions, the applicant referred to an authority and submitted that it has conducted itself in a proper manner such that there is no reason why the usual order that costs follow the event should not be made.
2. In his oral submissions, counsel for the applicant referred to Health Care Complaints Commission v Neale [2024] NSWCATOD 16 (Neale) at
[9]–[12], [14].
The submissions of the respondent
1. In her oral submissions, counsel for the respondent made the following submissions:
1. there was no complaint of the conduct of the applicant in conducting the proceedings;
2. a proportional costs order should be made as was done in Quan.
Consideration
1. In Health Care Complaints Commission v Philipiah [2013] NSWCA 342 (Philipiah) at [42]–[46], Emmett JA (with Meagher JA at [1] and Beech-Jones J at [50] agreeing) set out the principles relevant to the exercise of the power of the Tribunal to award costs under cl 13 of Sch 5D of the National Law:
"[42] As a general rule, costs of proceedings before the Tribunal should follow the event and mere impecuniosity is not a justifiable reason for departing from that rule. However, there are factors that might militate against the recovery by the Commission of all of its costs in particular proceedings. For example, one factor might be that the Commission failed to obtain findings of professional misconduct alleged, even though it obtained findings of unsatisfactory professional conduct. Another factor might be that the Commission failed to establish all of the particulars of professional misconduct alleged. Where discrete elements of the conduct complained of are not established, that may be relevant. A third factor might be oppressive conduct by the Commission in the way in which it prosecuted the proceedings before the Tribunal, such as taking procedural steps that gave rise to unnecessary expense in preparing for the hearing (see Lucire v Health Care Complaints Commission (No 2) [2011] NSWCA 182 at [48]-[52]). It has not been suggested by the Doctor that any of those factors applied.
[43] As the Tribunal observed in its reasons, the question of costs is discretionary. However, the discretion is a judicial one and must be exercised according to proper fixed principles and rules of reason and justice, not according to private opinion. While it is not easy to state the precise principles that are to guide a court in exercising the discretion over costs, the discretion is only to be exercised where there are materials upon which to exercise it (Williams v Lewer (1974) 2 NSWLR 91 at 95).
[44] It is important when exercising the discretion to bear in mind that costs are intended to compensate a successful party. Costs are not intended to penalise an unsuccessful party. It is not an appropriate basis for the exercise of the discretion that an order for costs may cause hardship to the party against whom the order is made.
[45] The Doctor could have made admissions as to professional misconduct and as to the degree of impairment immediately after he was notified of the complaints. However, he chose not to do so. The normal price to be paid for a practitioner's disputing a complaint and losing is that, unless some disentitling conduct be established on the part of the Commission, the practitioner should bear the Commission's costs, not by way of penalty, but to compensate the Commission for the costs that it has incurred in prosecuting the proceedings in the public interest, over the opposition of the practitioner.
[46] The fact that the Doctor has made, and continues to make, an effort to overcome personal difficulties is not a rational basis for excusing him from the normal consequences of disputing allegations that are ultimately made out against him. …"
1. In Neale at [8]–[10], the Tribunal relevantly said:
"[8] In its submissions with respect to costs dated 4 August 2023 the Applicant identified the relevant statutory provisions with respect to costs and a number of the principles relevant in that regard. As is not in doubt, costs are awarded to compensate a successful party, rather than punish an unsuccessful party and, as a general rule, follow the event (HCCC v Philipiah [2013] NSWCA 342).
[9] The presumption that a successful party is entitled to receive its costs is generally only displaced where there has been some disentitling conduct by the successful party (Oshlack v Richmond River Council (1998) 193 CLR 72 [1998] HCA 11, Health Care Complaints Commission v CSM [2016] NSWCATOD 125, Health Care Complaints Commission v Brush (No. 2) [2015] NSWCATOD 154).
[10] A respondent bears the onus of establishing a basis for any departure from the general rule (Health Care Complaints Commission v Livermore [2021] NSWCATOD 115). If the successful party is found to have engaged in disentitling conduct the general rule may be departed from."
1. We have not found Quan helpful in considering the appropriate costs order. The Tribunal at [84] expressed the following conclusion:
"[84] While these proceedings had their genesis in the practitioner's conduct, we find there are circumstances why it is appropriate in this case to depart from "the general rule". The practitioner made early admissions of his conduct. Further the HCCC has not been successful in establishing to the requisite standard the complaint of professional misconduct. In these circumstances we find a fair and proportionate response is to order that the practitioner pay 50 per cent of the HCCC's costs as agreed and failing agreement as assessed."
1. Here the circumstances are different. While the respondent made a substantial number of admissions, the character of part of his conduct and the appropriate protective action against him remained in dispute. The applicant was successful on issues 1 and 2.
2. Having regard to the principles in Philipiah at [42]–[46] and Neale at [8]–[10], it is appropriate to order the respondent to pay the applicant's costs of the proceedings pursuant to Sch 5D cl 13 of the National Law as agreed or assessed in accordance with the applicable costs legislation.
Orders
1. We make the following orders:
1. the disclosure of the name of Patients A to I is prohibited;
2. the respondent is reprimanded;
3. the respondent is to pay the applicant's costs of the proceedings as agreed or assessed in accordance with the applicable costs legislation.
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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
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Decision last updated: 19 March 2024