New South Wales Medical Tribunal CITATION : HCCC v Dr Christopher Roberts [2007] NSWMT 15 revised - 14/08/2008 TRIBUNAL: Medical Tribunal PARTIES : Health Care Complaints Commission Dr Christopher Roberts FILE NUMBER(S) : 40037 of 2005 CORAM: Ainslie-Wallace, DCJ - Yeo, Dr G - Hely, Dr J - McNeil, P CATCHWORDS: Prescription of restricted substances and drugs of addiction - Failure to record diagnoses, medical treatment, particulars of clinical opinion and full particulars of prescribing Medical Practice Act 1992 LEGISLATION CITED: Medical Practice Regulations 1998 Poisons and Therapeutic Goods Act 1966 Poisons and Therapeutic Goods Regulations 1998 Briginshaw v Briginshaw (1938) 60 CLR 336; HCCC v Litchfield (1997) 41 NSWLR 630; CASES CITED: Law Society of NSW v Foreman (1994) 34 NSWLR 408; Craig v Medical Board of South Australia [2001]SASC 169; NSW Bar Association v Meakes [2006] NSWCA 340 DATES OF HEARING: 12.2.2007 to 15.2.1007, 2.3.2007 DATE OF JUDGMENT: 24 April 2007 LEGAL REPRESENTATIVES: AJ Katzmann of Senior Counsel for the complainant M Bozic of Senior Counsel with E Pike of Counsel for the respondent ORDERS: Orders:; The Tribunal accepts the undertaking of the respondent's solicitor that the respondent will cease practicing medicine and offering health services in the nature of counselling at 5.00 pm on Friday 27th April 2007; 1.order that the respondent's name be removed from the Register of Medical Practitioners on 21st May 2007.That he not apply to be re-registered for a period of five years from the date of these orders; 2. That until he is reregistered as a medical practitioner he not offer any health service in the nature of counselling; 3. Respondent to pay the costs of the action; Orders:; The Tribunal accepts the undertaking of the respondent's solicitor that the respondent will cease practicing medicine and offering health services in the nature of counselling at 5.00 pm on Friday 27th April 2007:; 1. order that the respondent's name be removed from the Register of Medical Practitioners on 21st May 2007.That he not apply to be re-registered for a period of five years from the date of these orders.; 2. That until he is reregistered as a medical practitioner he not offer any health service in the nature of counselling.; 3. Respondent to pay the costs of the action JUDGMENT: THE MEDICAL TRIBUNAL Tuesday 24th April 2007 OF NEW SOUTH WALES AT SYDNEY No. 40037 of 2005 BETWEEN Health Care Complaints Commission Complainant Dr Christopher Roberts Respondent Deputy Chair: Judge A M Ainslie-Wallace Members: Dr G Yeo Dr J Hely Associate Professor Paul McNeill Orders and Reasons for Determination Order: Pursuant to Clause 6 of Schedule 2 to the Medical Practice Act 1992 the Tribunal has made a Non Publication Order in respect of the names of the patients referred to in the proceedings. Introduction: The Health Care Complaints Commission (the "HCCC") alleges that the respondent, a medical practitioner is guilty of unsatisfactory professional conduct and/or professional misconduct within the meaning of sections 36 and 37 of the Medical Practice Act, 1992 in that he has: (i) demonstrated that the knowledge, skill or judgment possessed, or care exercised by him in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience; and/or (ii) contravened the Medical Practice Regulation 1998; and/or (iii) has engaged in improper or unethical conduct relating to the practice of medicine. There are 161 particulars of the complaint. [1] The particulars relate to 30 patients. Not every particular is alleged in relation to each patient. The particulars are conveniently summarised in two categories. Prescribing * That the respondent prescribed restricted substances [2] and drugs of addiction [3] when the practitioner knew or ought to have known that the patient was dependent or likely to become dependent on the restricted substances or drugs or addiction; * when the practitioner knew or ought to have known that the patient was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances for the patient; * when the practitioner knew or ought to have known that the patient was a participant in a methadone programme; * without exercising adequate medical judgment as to whether the prescribing of restricted substances and/or drugs of addiction was appropriate in the circumstances and/or in accordance with recognised therapeutic standards; * that he prescribed restricted substances in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances; [4] * that he prescribed restricted substances to patients without recording the directions for use, as shown in the prescription; [5] * that he recorded a date, other than the date of issue on prescriptions for restricted substances. [6] Records That the respondent failed to: * record information relevant to the patient's diagnosis and/or medical treatment; * record particulars of any clinical opinion he reached; * record treatment plans; * record full particulars of the medication prescribed; * record information or advice given to patients in relation to proposed medical treatment of them; * record his name as the practitioner who treated and prescribed the medication; * record sufficient and appropriate details about cases to allow other registered medical practitioners to continue the management of the patient; * clearly identify himself as the person who made entries in the patients' medical notes. [7] Each particular of each complaint was admitted and the respondent admitted that he was guilty of professional misconduct. Background 1 The respondent graduated MBBS in May 1975 from Sydney University. After graduating he completed an internship at Sydney Hospital and then worked in a number of hospitals in Sydney. He commenced private practice as a general practitioner in 1979. 2 In 1979 the respondent began the Holistic Medical Centre (the 'HMC') with a number of other doctors and at all relevant times he worked there for three days of each week. The HMC is a centre that includes Complementary and Alternative health practitioners, counsellors and general practitioners. He also worked in general practice in Campsie. 3 In 1987 the respondent joined two other doctors, Isaac Nadel and Steven Goodman who were practising together in the Redfern Street Medical Centre (the Redfern practice). 4 According to his curriculum vitae, the respondent has had an interest in counselling, natural therapies and dependency for some time. 5 He had pursued some counselling training in the USA in the model of co-dependency and addictions. The respondent said that the theory took into account the dynamic of the addict's family when dealing with addiction issues. [8] 6 When the respondent joined the Redfern practice, he described it as being a general practice with a mix of people with the usual ailments. Over time he noticed more and more drug-addicted people in the area were coming to the practice. He said that he tried to encourage the addicted patients to attend Narcotics Anonymous ("NA") and he would prescribe benzodiazepines for them if they would go. The respondent hoped that attendance at NA would help them overcome their addiction. In late 1997 he expanded this approach by having the patients enter into what he called "contracts" to attend NA, the reward being that if they agreed to attend at least three sessions each week, he would prescribe benzodiazepines on request. The respondent said that he also wished to encourage the patients not to go to other doctors for benzodiazepines but to attend the Redfern practice more frequently. As part of the treatment the respondent counselled the patients about the "nature of addiction and the drivers behind addiction". [9] By 1999 the respondent estimated that the practice saw about 700 patients all of whom were drug addicted. 7 The implementation of the respondent's theory resulted in him and his colleagues prescribing hundreds of tablets of benzodiazepines for drug-addicted patients who attended the Redfern practice. That conduct forms the basis of the complaint. 8 The respondent agreed that the cohort of thirty patients whose treatment comprise the particulars of the complaint were representative of his methodology of treatment of patients although, he said, that the 30 patients in the complaint received the most benzodiazepines. Of the 30 patients included in the complaint, two of them, patient DD and patient Z died of drug overdose while under the respondent's care. 9 The respondent left Australia in early March 1999 and returned in about May 1999. On his return he learned that the Pharmaceutical Services Branch of the NSW Department of Health (the 'PSB') had investigated his colleagues in relation to the level of prescribing of benzodiazepines in the Redfern practice. The respondent immediately wrote to the Minister for Health [10] asking for assistance in bringing the investigation to an end. 10 Mr Thompson, who investigated the other doctors at the Redfern practice for the PSB, attempted to interview the respondent but he declined to be interviewed. 11 The investigation by the PSB was not the first time that the respondent or the Redfern practice had been visited by the PSB about prescribing practices. In 1981 (when the respondent was practising at Campsie), he was spoken to about his prescription of Schedule 8 drugs. According to the note made by the PSB inspector[11], B. Darcy-Smith, following complaints from local pharmacists in Campsie that prescriptions for Endone and Ritalin were being issued to young people, an audit of prescriptions was conducted "with particular attention" to the prescriptions written by the respondent and his partners. After the audit, the respondent was interviewed. 12 The respondent was told during the interview that the patients under discussion were seeing each member of the practice in turn and obtaining regular quantities of narcotics. The respondent was urged to speak to his colleagues. At the conclusion of the interview the respondent was given a document which was entitled: "Recognising and Handling Addicts - Notes for General Practitioners". It dealt with how to recognise a drug-seeking person, consequences of prescribing for a drug-seeking patient and included a list of addresses and phone numbers of addict management facilities. The document pointed out that co-operation of doctors would not only assist the recovery of the patients but also minimise the diversion of the drugs to illicit channels. The respondent confirmed in writing that he had received and read the document. 13 In 1993, Dr Goodman was visited by Mr Thompson of the PSB in relation to the frequency with which he was prescribing benzodiazepines. Dr Goodman was given information of a similar kind to that given to the respondent in 1981. There was no dispute that the respondent knew of this visit. 14 In June 1999 a formal complaint about the respondent's conduct was made to the Medical Board and in September 1999 an inquiry pursuant to Section 66 of the Medical Practice Act was convened. At the conclusion of the inquiry, the Medical Board ordered that the respondent not be permitted to prescribe or otherwise deal with Schedule 4D and Schedule 8 drugs and ordered him to relinquish those rights. [12] 15 The Redfern practice was effectively closed within weeks of the orders of the Medical Board. From that time the respondent has been practising at the HMC. The Complaint 16 The respondent said that through his work in the co-dependency model of treating addictions, he embarked on the implementation of prescribing on request subject to an agreement to attend NA. The respondent said that at the time he was increasingly frustrated with the available alternatives for the treatment of drug addiction which was to refer patients to drug and alcohol experts and detoxification programs which he believed did not address the problem of the addiction. He devised a treatment strategy which would allow the patients to continue using large quantities of drugs while he counselled them and encouraged them to attend NA where, he hoped they could substitute "medication for people". [13] 17 Despite knowing that drug seeking patients could be manipulative and liars, the respondent maintained that he could detect those who were not serious about treatment and said he would send them away. He also said that he could tell if the patients were actually attending NA meetings by questioning them. 18 The Commonwealth Health Insurance Commission (the 'HIC') conducted what was called the "Doctor Shopper Programme". The programme monitored the number of doctors attended by drug seeking patients to try and reduce the amount of drugs received and the number of doctors prescribing for the patients. The programme was developed to stop patients obtaining benzodiazepines or opiates from many different doctors and then selling them or swapping them for other drugs. As part of the programme, patients were asked to enter into Voluntary Agreements in which they agreed that details of drugs prescribed to them could be made available to the HIC. A number of the patients referred to in the Complaint had entered into Voluntary Agreements with the respondent and the other practitioners at the Redfern practice. 19 At regular intervals, the HIC provided the respondent with a computer print out for each patient with a Voluntary Agreement. It showed the number of distinct prescribers, the numbers and types of drugs prescribed in the period and the daily average number of tablets prescribed for that patient. "The respondent said that he used the HIC information to "confront" his patients about their behaviour and the information gave him objective evidence by which to determine whether they were doing what they had agreed to." [14] 20 The respondent was of the opinion that all of his patients had psychiatric problems of which the predominant cause was emotional. Despite this, the respondent did not refer any patient to a psychiatrist because he felt that the co-dependency model that he had studied was: "...elegant in it's understanding of the cause of drug and alcohol. I felt that....I could show them something that perhaps the drug and alcohol experts could not." [15] The respondent conceded that he believed that he knew best how to treat the patient's psychiatric problems and said that he believed that he had adequate skills to counsel his patients and did not need to consult any other expert. [16] 21 The training in the co-dependency model, on which this method of treatment was based was conceded by the respondent to be outside the mainstream. The training was given by an American who certified that the respondent could be a counsellor in " Co-Dependency and Addictions ". The respondent agreed that this certificate was not recognised by the medical profession, the Psychologists Registration Board or any other relevant organisation in Australia. [17] 22 The respondent conceded during the hearing before the Tribunal that there is nothing in the co-dependency model which recommended or advocated prescribing on demand and said that it was an extrapolation by him from the model because he thought that: " it may work ". [18] Treatment Regime 23 During his treatment of the addicted patients, the respondent took minimal history from any patient, undertook no physical examination nor ordered any tests to diagnose or determine the effects on the patient of the proposed prescription of benzodiazepines. The respondent said that occasionally he would order a liver function test, not to monitor the effect of large quantities of benzodiazepines on any patient, but if the patient suffered from Hepatitis C. [19] 24 The vast majority of the respondent's patients were receiving Methadone. The respondent conceded that the doctor administering the Methadone would want to know that the respondent was prescribing benzodiazepines for the patient. He never contacted any Methadone prescribing doctor. The respondent did not regard this failure to notify the other doctors as possibly placing his patients at risk because, he said, the patients would obtain benzodiazepines from other practitioners in any event. [20] 25 The respondent said that he knew at the time that his treatment of these patients did not accord with the standards expected of an ordinary medical practitioner but said that at the time he did not see himself as being the patients "primary care practitioner". He said that he was seeing them for a very specific reason which was to get their drug taking under control and not attempt to get them physically well. He did agree that if a patient presented with a medical complaint which could be quickly attended to he would do it but he did not look at the whole patient. He saw his role as getting the patient off drugs. The respondent said that he did not regard himself as acting as a general practitioner during this time. [21] 26 The respondent maintained that he was medically supervising these patients. [22] He agreed that the usual medical supervision of a patient's intake of drugs would involve: "a doctor monitoring and keeping an eye with his clinical judgment on what he was prepared to let them have", and could involve routine blood tests. He did none of those things and said that his clinical judgment was that: "these people needed help to get to people, not to fix their bodies yet ... they needed something more important first, once their lives got in order then I would have started instituting some medical attention to their bodies". It was, he said, a matter of priorities. [23] The state of the respondent's knowledge 27 The respondent first said that at the time of the complaint, he was aware of: " some risks " attendant on prescription of benzodiazepines. [24] He agreed that he had had a keen interest in benzodiazepines and other drugs from the 1990s and in pursuit of this interest would read any articles on the subject which came up during his usual journal reading. The respondent said that until the complaint was made he regarded benzodiazepines as: "safe, people did not overdose on them". [25] Since the complaint the respondent said that he realised that what he was doing was potentially harmful to patients. 28 The respondent conceded that he had read MIMS many times over the years and that it sets out the adverse consequences of benzodiazepine use. He knew at the relevant time that addicts could inject temazepam and knew the potential physical risks which could arise from that practice. He knew that benzodiazepines could be abused by excess use, that there is a risk of dependency through excessive use and patients could abuse benzodiazepines by obtaining them from multiple prescribers. 29 The respondent agreed that he knew at the time that by prescribing benzodiazepines he could be contributing to the risk of death in a patient, to the release of drugs onto the street and that he was prescribing in a quantity and for a purpose that did not accord with the recognised therapeutic standard. Despite that knowledge, he continued to prescribe on demand for patients. [26] 30 He agreed that he knew that in prescribing benzodiazepines, there was a risk of dependence and if a doctor encouraged patients to only attend one general practitioner this allowed their intake and potential for dependence to be monitored. [27] 31 The respondent conceded that at the time he was prescribing, he was well aware of the risks to the patients from using large amounts of benzodiazepines and he well knew that what he was doing was not in accordance with the proper exercise of skill and judgment expected of a practitioner. [28] After acknowledging that he was aware of the risks in pregnancy of high doses of benzodiazepines, the respondent said that he did not warn patients because they would not listen. [29] He did not counsel or warn patients about the risks inherent in taking large amounts of benzodiazepines because he thought it would be futile - they would have laughed at him. [30] 32 The respondent said that at the time of prescribing he was familiar with the contents of publications such as that issued by the Royal Australian College of General Practitioners [31]which outline guidelines for practitioners in the prescribing of benzodiazepines. 33 The document published by the Royal Australian College of General Practitioners in January 1994- "Guidelines for the rational use of Benzodiazepines" contains the following points: (1) wherever possible avoid prescribing benzodiazepines especially to known polydrug users, including those with dependence; (2) reduction of benzodiazepines dose should be undertaken only with the patient's consent and co-operation; (3) all patients prescribed benzodiazepines should be advised of the risk of dependence associated with long-term use; (4) patients receiving prescriptions for benzodiazepines should be advised to obtain all such prescriptions from the same doctor, wherever possible, so that risk of dependence may be monitored; (5) medication review should be a part of every general practice consultation. Specifically this should include a review of the indication(s) for continued use, medication dose and possible adverse effects. For all patients receiving long term benzodiazepines this is particularly relevant; (6) Non-medication management for conditions such as anxiety and insomnia includes clarification of the problem, counselling and specific advice, with referral where the diagnosis is uncertain or where assistance in management is required; (7) detoxification from benzodiazepines may be facilitated by changing patients to long half-life medications eg diazepam and then slowly reducing the dose. One-to-one counselling may be supplemented by self-help support programmes during withdrawal; (8) management of anxiety and insomnia should rely largely on non-pharmacological interventions; (9) when benzodiazepines are prescribed, the lowest dose to achieve the desired outcome for the shortest duration necessary should be provided 34 Were those points not sufficiently clear, the document contains explanatory notes for each point, describes the reasons for the introduction of guidelines and the prevalence and patterns of drug use and misuse. 35 The respondent agreed that he did not prescribe benzodiazepines for the reasons for which they were meant to be prescribed. However he said he had a rationale for prescribing which was to use the issue of prescriptions for benzodiazepines as a "reward" to patients who promised to do what he invited them to do. [32] The respondent did not follow any of the guidelines in relation to any patient. 36 The respondent knew that repeat prescriptions of benzodiazepines should be limited because of the risk of people hoarding tablets and then taking a massive dose. [33] He denied that he had set out to subvert that by giving patients post-dated prescriptions and said that he was: "trying to make what I was doing work". The respondent would not agree that post dating prescriptions was dangerous but conceded that it was foolish. It was foolish because he said he did not think through what he was doing but was "overwhelmed" by the need to help these patients. He maintained that it was more dangerous not to post date prescriptions. [34] 37 He often wrote prescriptions for two different benzodiazepines for a patient at the same consultation. [35] Again, he denied that he was trying to subvert the prohibition on repeat prescriptions and when asked to explain why he prescribed two different benzodiazepines at the one time said: "I was trying to do something because I didn't feel people were getting well in our society". How prescribing two different benzodiazepines achieved that purpose was never made clear. [36] 38 In the light of this knowledge, the respondent embarked on this course of conduct knowing that there was no basis for it in the theory of co-dependency and no empirical evidence to support it. At best it was, as he described it: "an extrapolation" from the theory that "may" have worked. He spoke to no expert in the field of Drug and Alcohol Addiction, did no particular reading on the topic and at no time during this period did he discuss what he was doing with any colleague (other than those at the Redfern practice). He conceded that what he was doing between 1997 and 1999 was: "At best an experimentation with human lives". [37] 39 The Tribunal is satisfied that during the years 1997 to 1999 when the respondent was putting into practice his "theory" it was not only in the knowledge of the risks and dangers of prescribing large amounts of benzodiazepines to dependent people but was in deliberate defiance of what he knew to be the guidelines established by his professional body for the safe prescription of benzodiazepines. It was also illegal, a point which the respondent first admitted he knew and later qualified. 40 During the period in which the respondent was undertaking this conduct he was also practising in the HMC. He did not discuss what he was doing with those doctors (one of whom was a psychiatrist). He said that at the time he did not believe that he was acting in a way which would have incurred their disapproval. [38] However a short time later in his evidence the respondent said that at the time he was prescribing benzodiazepines he knew that what he was doing was unorthodox and flew in the face of everything he had learned in his medical training. The inconsistency between these two statements is obvious and, given the visit by the PSB in 1981 and 1993 and, for other reasons which appear later, the Tribunal is of the view that his statement that he did not believe his conduct would meet with disapproval simply cannot be accepted. 41 Not only did the respondent not discuss his theory with his colleagues at the HMC (despite his assertion that he considered it "elegant" and that it provided something which was unknown to other drug and alcohol professionals), neither did he contact the Methadone providing practitioners for any of his patients. He said that he did not contact them because if he rang the practitioner and described what he was planning to do "they would not understand, they would not...want this happening...they would not approve". [39] In his evidence to the Section 66 Inquiry the respondent said that he did not contact the methadone prescribers because he was apprehensive that he would be told to stop. [40] 42 The Tribunal is satisfied that the respondent well knew that his conduct during this period was not only wholly inappropriate but involved significant risks to his patients and was outside the standard of treatment expected of a medical practitioner. Case studies 43 It is illustrative of the course of conduct engaged in by the respondent at the Redfern practice, to examine a handful of the patients referred to in the complaint. 44 Patient DD had been a patient of the practice since July 1998. [41] On 8th September 1998 the notes record: "abusing Pan Forte. Takes 10 at once". The preceding notes for this patient show that on each visit she was prescribed Panadeine Forte x 20 tablets. The visit immediately after this on 12th September 1998 was with the respondent and he prescribed Panadeine Forte x 20 tablets. On 2nd October 1998 the respondent prescribed Panadeine Forte and Valium plus gave her two post-dated prescriptions for the same amount apparently because of a long weekend. 45 On 10th October, the patient saw the respondent and told him that she was "feeling more emotional, looking at what is the point of her life etc, that is waking up". The respondent prescribed 50 Valium and 20 Panadeine Forte tablets for her on that day because he said she asked for them. He knew that he had prescribed the same quantities two days before and that a colleague had prescribed the same quantities two days before that and regularly every two days in the past. [42] On that same day, the patient told the respondent that she wanted to cut down on her tablets. He recommended against that. He agreed that he devised no method or programme to assist her to reduce the numbers of tablets she was taking other than to encourage her to attend NA meetings. [43] 46 On 17th October 1998 the respondent noted that he confronted the patient about taking too many tablets. The patient had told the respondent that she had taken all of the tablets because she was depressed. The respondent advised her that it would make her more depressed and he told her that she must take less. He then prescribed her Panadeine Forte and Valium in the same quantities as before. 47 The respondent said that he was not worried that she might take her own life, either deliberately or accidentally although he conceded it was a possibility and counselled her against it. [44] 48 Despite telling the patient that she ought not take all of the tablets at once, the respondent prescribed the same quantity as before. He agreed that he could have prescribed less tablets and required her come back more often to receive the tablets but said that he did not do that because: "these people would not come back if you started to make things complicated and start to try to control them". [45] 49 The respondent said that he had the impression that this patient was "doctor shopping" [46] and he presumed that she was getting drugs from other doctors in addition to the 70 tablets that he was prescribing for her every other day. He said that he was "hoping" that she was not getting many tablets this way. He did not ask her to sign a Voluntary Agreement which would have provided him with the information rather than relying on hope. 50 Throughout the notes there are references to the patient's claimed attendances at NA meetings; at various times she told the respondent that she attended five to six meetings a week, and on one occasion had told him that she attended seven-plus meetings in a week. 51 The patient attended the practice and received repeat prescriptions every day or every second day. On 8th December the respondent prescribed Valium and Panadeine Forte for the patient and later that same day prescribed the same amount again and noted: "claims tabs stolen." On 23rd December 1998 the respondent gave her a prescription for Valium and Panadeine Forte plus post-dated prescriptions for 28th December, 30th December and 1st January. On 24th December he again saw her and gave her a prescription for that day and also for the 26th and 29th December. 52 On 18th January the respondent noted: "in tears, my life's not worth anything". He prescribed Serzone 200mg x 56 tablets, 50 tablets Valium and 20 tablets of Panadeine Forte. On the 20th January a colleague prescribed the same amount of Valium and Panadeine Forte. The respondent agreed that the patient had appeared to be severely depressed for some period of time and he agreed [47] that it had occurred to him that the tablets he was prescribing could be used by her to attempt suicide. 53 On 25th January the respondent noted that he had been contacted by a psychiatrist from RPA Hospital who told him that the patient had taken an overdose and had been admitted. The respondent did not ask for a report, discharge summary or a copy of the records of the admission to hospital because, after speaking to the psychiatrist he decided that the patient's motivation was a "cry for help". He did not recall whether he informed the psychiatrist of the amount of benzodiazepines he was prescribing for the patient. Although in the notes of this consultation are the words: "seriously considering detox" and the respondent said that he gave her a referral to the Langton Clinic for an in-patient detoxification programme, he was unaware whether she had been given advice in the hospital about detoxification nor did he enquire. 54 The respondent agreed that when administering Valium to patients who were addiction prone it is undesirable to write repeat prescriptions without adequate medical supervision. It was suggested that the respondent exercised no caution in issuing repeat prescriptions, and said that he exercised: "my sort of caution" when he told the patient not to take all the tablets at once. [48] When the respondent was asked to consider whether, in light of this patient's assertions that she was attending up to eight NA meetings a week yet still coming to the practice every second day for the same amount of Valium and Panadeine Forte, that his strategy of encouraging attendance at NA in return for prescriptions was not working, said: "No, it takes time. " [49] 55 Unfortunately for this patient, she did not have time. 56 The patient was seen on 30th January - the note reads: "says keen to live" and "( medication slowly". She was advised to attend daily NA and given her usual prescription. 1st February, she was seen by the respondent who noted that the: "OD was cry for help, not serious suicide attempt. Seriously consider detox". The respondent gave her the usual prescriptions. The notes of 3rd and 5th February record the same prescription and on the 3rd included the comment: "to cut down pan forte". The respondent prescribed for the patient on 8th and 10th February when he also gave her an extra prescription for Panadeine Forte. The respondent again prescribed for her on the 15th, 18th February and another day in February (the date is obscured) when he changed from Panadeine Forte to codeine phosphate. She then received codeine phosphate and Valium on 24th February, 27th February and 1st March from the respondent. She received those prescriptions on 3rd March, another date in March, 10th, 11th, 22nd, 26th (when she received a post-dated prescription for the 28th March), 29th March (plus a post dated prescription for 30th March) and 30th March (when she also received post dated prescriptions for 1st and 3rd April). 57 She continued to attend the practice and receive prescriptions for the same quantity of drugs. On 1st April she was noted to be confused, on 12th April the notes indicate that she had fallen down stairs on 8th April and been admitted to hospital. The notes also show: "Valium ( in hosp". On that day she received a prescription for Valium (which asked the chemist to dispense 12 tablets per day). The notes show that the patient was also receiving 13 tablets each day at the hospital. She was also given a prescription for codeine phosphate. The patient received Valium to be dispensed at the rate of twelve per day and codeine phosphate on 16th, 17th 19th, 21st and 24th April. 58 In April the notes record that the police rang to inform that patient DD had been found dead on 25th April. 59 In the month of February 1999 the patient received 220 tablets of Panadeine Forte or codeine phosphate. In the same period she received 550 tablets of Valium. Most of those prescriptions were written by the respondent. 60 The respondent said that at that time he did not believe that a person taking benzodiazepines in those quantities could suffer a fatal overdose and said that if he honestly had thought that a patient was suicidal he would not have prescribed those tablets. His judgment was that this patient was not suicidal at that time. 61 He did not refer her at any time to a psychiatrist and said: "Because I assessed that she was suffering a lot of dynamics that needed addressing and I didn't feel that those things could be necessarily addressed by sending her to a psychiatrist." 62 The respondent was asked: Q. "You took the view that you didn't need any advice from a psychiatrist or anyone else because you knew best? A. In this field, yes, at the time." [50] 63 Notwithstanding having been told in January 1999 that the patient had overdosed, he continued to prescribe for her the same drugs and in the same quantities as before. He did not see the need to alter his prescribing since he was of the view that it was not a suicide attempt. 64 After her admission to hospital for the overdose and when he and his colleagues continued to prescribe for this patient at the same levels as before, the respondent said that he considered that the quantity of drugs being prescribed for her were potentially contributing to another overdose. However, he believed at the time: "that the childhood trauma that people have was a much bigger factor contributing to aberrant behaviour and dangerous risk taking behaviour." [51] He said that he was counselling her and hoped that it would stop her taking the risk. 65 After being informed of her death when he returned from overseas in May 1999, the respondent did not change his prescribing patterns because he said that he did not realise her death was a result of the combination of benzodiazepines and opiates, even though the Coroner's report noted the direct cause of death as: "a combination of benzodiazepines and opiates". The respondent maintained: "I don't think it hit me, the significance, I still didn't get it, opioids and benzodiazepines could be lethal". [52] The respondent knew at the time that he was prescribing large quantities of benzodiazepines that one of the effects of them as central nervous system depressants was that they could exacerbate depression and that suicidal tendencies tended to go with depression. 66 The respondent did not conduct a physical examination of this patient. He agreed that: "any ordinary medical practitioner prescribing drugs ought to conduct a medical examination before doing so" and said: "I felt that I was trying to do something very specific for them and that I wasn't trying to be their primary care physician". [53] The autopsy report noted that the patient had: "numerous white scars on the fronts of her forearms consistent with previous suicide attempts". [54] The respondent said that he did not recall seeing those scars while treating the patient but said that he "imagined" that he would have seen them. He said they were common on people who were severely ill. He was aware at the time that she was quite capable of self harm and said: "I believed that she was at enormous risk before I ever saw her and that I was trying to do something I believed may actually stop the cycle for her." 67 He went on to say that he now realised that it was too risky but at the time: "I believed that I may make a difference". 68 Patient Z was 16 years old when she first attended the Redfern practice. The first entry in the notes is on 4th December 1998 (made by a colleague of the respondent). It records that she was using heroin - $100 a day, trying to get on Methadone and wanted help with detoxification. She was prescribed Valium. The next day she returned and saw a colleague and received another prescription because she said the previous prescription had been stolen. This prescription was given notwithstanding that she is noted as appearing a: "bit dopey". 69 She first saw the respondent on 10th December. His note is: "normison 10(25). Won't put her on methadone. Min of 3 x NA if comes here". He saw her again on 17th December, noting that she was on 30mg Methadone and she received a prescription for Normison. The notes record that she would not receive tablets unless she does: "3 NA per week. She was encouraged to go to NA instead of receiving Methadone. 70 On 22nd December she was seen by a colleague who noted that her methadone had been increased to 40mg per day: "2 NA encouraged". She received the prescription for Normison. 71 She saw the respondent on 23rd December who wrote another prescription after being told her tablets were stolen. On 5th and 6th January, she received prescriptions because she said someone had torn hers up. On 7th January she saw the respondent who confronted her about the alleged destroyed prescriptions. He recorded that he told her that it was: "ok to get daily tabs + must do min of 3x NA". He prescribed Normison. She received the same prescription on the 9th, 11th, 12th and 14th January. 72 On the 16th January, the patient saw a colleague of the respondent. The note is "crying a lot ...cuts both wrists". She was prescribed the Normison and Zoloft. On 18th January she saw the respondent who continued the Normison and Zoloft. 73 She received Normison on the 18th, 19th, 20th, 21st, 22nd, 23rd, 25th, 27th, 28th and 30th January. The respondent's notes of the 21st January record that she was sometimes injecting the Normison which was being prescribed in capsule form. 74 On 30th January, her then boyfriend told one of the doctors at the practice that the patient had been anally raped the night before although there is no note of the patient mentioning it. The patient saw the respondent on 1st February and discussed the rape. She continued to receive regular prescriptions for Normison. 75 On 10th February, the notes record that the respondent: "pleaded with her to try and not shoot up Normison". She received a prescription for Normison on that day, and 11th, 12th, 13th even though she was observed to be: "a bit sleepy", told the doctor that she was prostituting herself and: "feels like killing herself". The respondent prescribed for her on 15th January. The patient continued to receive Normison which was later changed to Temaze. 76 On 24th February, the respondent noted that when the patient's boyfriend was shooting her up with Temaze, he hit an artery. The next prescription was issued on 26th February but in tablet form not capsule as before and there is a reference to her arm (presumably where she was injected). On 8th March there is a reference to her being off Methadone and using heroin. She is said to be depressed. 77 The patient continued to receive Temaze very frequently. On 30th March the notes are that she was using heroin daily. On 1st April she was given a prescription for Temaze plus two post-dated prescriptions for 3rd and 5th April. 78 The patient died sometime between 11 pm on the 7th May and 4 am on the 8th May 1999. The Coroner's report [55]noted: "This 16 year old girl was found dead in a bedroom of a boarding house... Empty bottles of Methadone, empty containers of Temazepam, Alepam and Diazepam as well as used syringes were seen in a small bin located in the room. The toxicological analysis revealed toxic blood levels of morphine and methadone and therapeutic blood levels of benzodiazepines." 79 The direct cause of death was recorded as: "the combined effects of opiate, methadone and benzodiazepine toxicity". 80 The respondent said that up to as late as June 1999 he believed that his treatment of this patient had nothing to do with her death. [56] He prepared a report dated 25th June 1999 for the Coroner on the death of this patient. [57] The respondent noted that he prescribed benzodiazepines at her request on her agreeing to attend three meetings of NA each week. The final paragraph of the report expressed the respondent's view; "I am of the opinion her internal shame, pain and fear were so overwhelming and her relationship skills so undeveloped and her acting out with drugs and prostitution so contributing to her ongoing damage that this tragic kid just could not reach out to the human race sufficiently to allow her enough succour to survive". 81 The deaths of these two patients and the clear expressions in the Coroner's reports about the causes of death being a combination of benzodiazepines and opiates, did nothing to change the respondent's prescribing pattern or cause him to rethink his theory. He agreed that he only stopped prescribing as he was after the PSB investigation. [58] 82 Patient P first attended the practice in June 1997. He was on methadone. Over the period of time he was a patient of the respondent and his colleagues, he received increasing doses of benzodiazepines. Between January and April 1999, he received a total of 3,225 tablets of benzodiazepines. 83 Patient W received 6,400 benzodiazepine tablets between January and April 1999; averaging about 50 tablets per day. The patient was on methadone and, according to the notes had been released from prison in December 1998. The expert reviewer, Professor Bell, [59] said that the patient could not have had an habitual intake of benzodiazepines of this magnitude within a month of being released from prison. Professor Bell regarded the pattern of prescribing for this patient as "giving the patient a habit". 84 Patient A . The HIC printout for Patient A shows that he was receiving Diazepam which neither the respondent nor the other doctors in the Redfern practice prescribed. There was no note of this in the patient's file. Professor Bell commented that the pattern of prescribing for this patient showed escalating doses to what he described as "massive" levels, to the extent that in December 1998 the respondent prescribed 300 Serepax and 200 Panadeine Forte tablets for this patient. Despite a note that "this guy lies" in June 1998, the respondent continued to prescribe for him and, presumably accepted his assurances that he was attending NA. Contracts 85 The respondent said that adherence to the contract to attend NA was a seminal part of his treatment theory. He said that he would send away any patient who was not anxious to engage in treatment. However, there were instances in the patient notes where it is clear that the respondent considered the patient to be a liar (Patient A) and on another occasion knew that the patient was not attending NA. For example, on 22nd December 1998 Patient Q's father rang to inform the practice that his son was injecting Normison, was behaving so erratically that he had taken an Apprehended Violence Order against him and said that his son never attended NA. This note was made by another doctor in the practice. At the bottom of that entry is a note drawing the next doctor's attention to that entry. The respondent was the next doctor to see Patient Q. The note was that he would get a privacy release (a Voluntary Agreement) form for the next visit and reminded himself to ask the patient about attending meetings. At the next visit, the respondent notes that the patient told him that his father was dead and a flat mate was impersonating his father (there is no indication that this was verified by the respondent). The patient told the respondent that he was attending three NA meetings a week. He was given a prescription for Normison and Serepax. The previous pattern of prescribing continued. 86 The respondent defended his continued prescription to these patients on the basis that in his clinical judgment, they were seriously trying to work at recovery. [60] He also maintained that he could tell whether a patient was, in fact, attending NA by asking questions about what had happened at the meeting. He persisted in this view despite acknowledging that drug-seeking patients were particularly manipulative and adroit liars who could easily discuss among themselves what to say to get a prescription. [61] 87 The respondent made no effort to verify independently whether the patients were attending NA, he never attempted to contact a nominated sponsor. [62] He agreed that it would be possible for a patient to gain enough information about NA either by going once or twice to a meeting or sharing information with another patient to make it appear that the patient was attending. Notwithstanding those possibilities he said that he was able to tell whether a patient was attending NA by "penetrating questioning". 88 The "reward" for entering into the contract to attend NA was that the patients would be prescribed benzodiazepines and other drugs at their request. In some cases it was not necessary for the patient to say that he or she was actually attending before the respondent would prescribe the benzodiazepines requested, agreeing to go in the future would result in a prescription. Counselling 89 Counselling was a critical part of the theory adopted by the respondent. The basis for the counselling sprang from the respondent's view that the addicts had psychiatric problems and, he said, 90% of them had experienced childhood abuse. There is little in the notes to support this assertion. 90 Despite this the respondent never referred any patient to a psychiatrist and when a patient (DD) was admitted to hospital with an overdose, the respondent spoke to the psychiatrist who treated her but he did not seek further information. 91 He agreed that neither Dr Goodman nor Dr Nadel had any qualifications in counselling. He said that it was only a small section of counselling training which was necessary at the Redfern practice and he tried to train his colleagues in the basics needed to implement the theory, including such matters as being able to recognise whether a patient was indeed attending NA. The other doctors apparently did not need to understand or explore: "…the childhood trauma which was in most of these people they weren't anywhere nearly ready to process that stuff. It was going to take years for them to get to the psycho-dynamics". [63]. 92 The respondent agreed, and it is starkly apparent from his entries in the patient notes, that Dr Nadel did little if any counselling. Often his notes simply record the repeated prescription of drugs already given. The respondent said that Dr Nadel "was not willing to go along with the way they'd said they would". Dr Goodman did more counselling but the respondent said he did not write extensive notes. [64] Successes 93 In his letter to the Minister for Health [65] and his submission to the Section 66 Inquiry, [66] the respondent claimed that he had had significant success with his patients through implementing his theory. To demonstrate this, he prepared a series of graphs that was provided to the Section 66 Inquiry and produced to this hearing. He also produced a list of patients whom he regarded as successes [67] and said that they were "patients that were tapering off their intake and their visits, by tapering off their intake they would have to be tapering off their visits". [68] 94 During the Tribunal hearing the respondent said that he no longer regarded these patients as having been successfully treated because of the risks that he had put them through. [69] He had claimed that they were successes because: "anecdotally and statistically ... they were showing signs of improvement". He said that he hoped he could show: "that there was some benefit to the patients by going to NA and coming down on scripts". [70] He said that this improvement was demonstrated for each patient by the reduction both in numbers of prescriptions written and distinct prescribers reflected in the HIC Doctor Shopper printouts. [71] The respondent said that the HIC printouts vindicated his claim to success. However he agreed that the printout also showed that while there may have been a reduction in the number of doctors visited, in most cases, the daily dose of benzodiazepines remained the same and in some cases, increased. In relation to many patients, the daily dose reduced only when Drs Goodman and Nadel had their prescribing rights withdrawn. 95 The respondent agreed that in judging success he had not taken into account the part of the print-out which listed the daily dose of tablets. Even while conceding that there had been an increase in the daily dose in relation to some patients whom he had claimed as a success, the respondent said that it (the success of his treatment) "takes time". [72] 96 The respondent's answer that he "never thought of looking at the daily dose" when claiming success is, in the Tribunal's view, completely disingenuous. 97 The respondent sent graphs to the Medical Board which he said supported his claimed success. He conceded before the Tribunal that he had included in those graphs information which post-dated, not only the withdrawal of Dr Goodman and Dr Nadel's rights to prescribe, but also the withdrawal of his own rights to prescribe that a decrease in daily dose was noted. 98 In nearly every case which the respondent claimed as a success, the patient continued to doctor shop. 99 The respondent still claimed a degree of success before the Tribunal. He referred to a number of patients and said that they were "anecdotal" successes based on his clinical impressions. For example, one patient was apparently taking Rivotril for which he had a medical need, according to directions and another said that he had found a sponsor at NA. Records 100 At the beginning of the hearing, the respondent conceded each particular of the complaint relating to his record keeping. 101 When asked about his medical records he said that he did not think that there was anything wrong with his clinical notes. He could not remember what information had to be recorded by a practitioner under the Medical Practice Act. [73] 102 The following evidence about his clinical records is illustrative of the respondent's attitude to his professional responsibilities: "... I know it was different to the average general practice where you would be seeing people in a general practice. Technically yes I breached the Medical Practice Regulations Act (sic) ..." He continued: "... our practice was a really special case where we were seeing some of the most difficult people and we were trying to get through it in a practical, pragmatic way." 103 Eventually, the respondent conceded that he had a "serious problem" with his clinical notes at the Redfern practice. [74] The respondent said that he now identifies himself on the notes and if he prescribes for his patients, he makes a note of the indication or dose. His present practice is almost entirely counselling. He has not done any course or reading on the proper method of record keeping for a medical practitioner. His notes are not seen by his colleagues. Dr Aitken, who works with the respondent at the HMC, said that if she sees one of his patients for a non-counselling consultation, she receives the patient's file but the counselling records are kept in a separate, confidential envelope within the file. The respondent has not asked her to look at his notes. Isolation 104 In his evidence before the Tribunal the respondent attributed his conduct to professional isolation. He said that there was no-one trained in the same counselling method as he who could look at what he was proposing to do. As a consequence, he said that he spoke to no one other than his colleagues at the Redfern practice before embarking on his treatment regime. 105 Despite adopting a theory of treatment of addiction which he described as "elegant", the respondent only applied it at the Redfern practice. He said that if drug seeking patients attended the HMC they would be turned away because: "it was a different practice". [75] Given that, according to the respondent, the other practitioners at the HMC were supportive of him and that he did not realise at the time that what he was doing at the Redfern practice would incur their disapproval [76] the Tribunal finds it difficult to understand why he made no mention of what he was doing. 106 The Tribunal is satisfied that the respondent did not tell his colleagues at the HMC about his practice at Redfern because he was well aware that it would not meet their approval. 107 The Tribunal finds that any isolation was self-imposed. The respondent knew from the literature he was given as early as 1981, the names and telephone numbers of Drug and Alcohol experts and treatment facilities. He contacted none of his own volition. On one occasion he referred a patient to Dr Alex Wodak, a well-known expert in this area. He did that not because he sought advice or assistance but because it was a condition of him being allowed to continue to prescribe a Schedule 8 drug to the patient. He said that he did not associate with drug and alcohol experts because he felt that they would not understand what he was doing. [77] 108 The isolation and the protestation that the respondent could not associate with any colleagues to discuss what he was doing because his method was unorthodox and would not be readily understood by those not trained in the co-dependency theory rings particularly hollow because the respondent knew at that time that there was nothing in the theory to support him. 109 The Tribunal finds that the respondent kept the implementation of the theory to the Redfern practice because he knew it was, in essence, an experiment. 110 The respondent said that since coming to the notice of the PSB and ultimately the Tribunal, he has adopted a system to prevent him from being professionally isolated again. 111 He said that he regularly speaks with two people who are trained in co-dependency counselling, neither of whom is a medical practitioner. In 2004 the respondent began meeting with a psychologist, Rosalyn Daymon, for what he termed "supervision". The purpose, he said, was to allow him to discuss his present case-load with her and for her to provide peer review for him. Ms Daymon is a long-standing friend of the respondent and had been a patient of his at both the Redfern practice and at the HMC. 112 Ms Daymon wrote a reference for the respondent and also gave evidence about her supervision of his work. Her note of their first meeting was: "spoke of Redfern ... the process of realising that prescribing benzos as he had been was wrong". Ms Daymon referred to this note (and others) as being a "prompt" to which she could refer at a later stage. She was asked what about the prescribing of benzodiazepines was wrong in the respondent's opinion but she could not amplify the conversation on which her note was based. Ms Daymon's answers to questions were often unresponsive. For example, she was asked whether she understood the respondent to be well aware of the dangers to his patients from prescribing large amounts of benzodiazepines. [78] In response, Ms Daymon outlined the respondent's theory of treatment. Eventually she said that he had not discussed the dangers to his patients with her. The Tribunal formed the view that Ms Daymon was being protective of the respondent in her evidence rather than attempting to assist the Tribunal. 113 The respondent worked at the HMC with Dr Leonie Aitken. She gave evidence before the Tribunal. She said that since its inception the doctors at the HMC had regular meetings both formal and informal. At no time before the respondent was brought before the Medical Board had he told her of the way in which he was managing drug dependent patients at the Redfern practice neither did he discuss with her any problems which he might have had at the Redfern practice. Dr Aitken said that soon after the complaint was made, the respondent explained to her his rationale for treating addicted patients. In more recent times, she said, that he had said that he appreciated the risks to which he had exposed his patients. She did not approve of his treatment of the patients in the Redfern practice. Credit 114 The applicant submitted that there was much in the evidence of the respondent which was contradictory and evasive and would lead the Tribunal not to accept him as a truthful witness. 115 The respondent asserted that he was not aware when prescribing that there was a risk of overdose from benzodiazepine consumption and that it was not until after the complaint was laid that he realised that there were risks associated with prescribing benzodiazepines. That statement was demonstrably false. 116 The respondent was asked whether he was aware of a risk of overdose and he said: "I didn't think there was much risk and ... any risk was outweighed by the good I could do them". [79] 117 He agreed that an entry in Patient Q records of the 11th December 1998: "took some sleeping pills, some he found at home ... went stupid, was taken to psychologist hospital..." was strongly suggestive of an overdose on sleeping pills. The respondent then modified his earlier answer and said that he meant that he was unaware of death resulting from overdose. [80] 118 The respondent said that he was aware that death could follow overdose of benzodiazepines but said that it was "very rare ... an extraordinarily rare event". 119 Finally when asked about the two patients who had died of overdose while under his care, after being directed to the Coroner's report which, in each case, listed the direct cause of death as being the combined effects of opiate, methadone and benzodiazepine toxicity, he said that he did not think that it was the combination of the drugs which caused death but that it was the opiates which were the primary cause. 120 The shifting sand of the respondent's answers undermines his credibility. 121 There were other examples when the respondent contradicted his earlier evidence. Despite agreeing that his prescription of benzodiazepines was illegal, the respondent then resiled from that position [81] and said that he thought that to prescribe benzodiazepines as he had was "against the guidelines" and said that he did not know that it was illegal to prescribe benzodiazepines on request. 122 There were other obvious inconsistencies in the respondent's evidence, for example, when asked if he inquired of any patients whether they were pregnant and, if so, warned of the risks to a pregnant woman from benzodiazepine use, said that he knew of no risk to a foetus through the prescription of benzodiazepines. The following day the respondent said that he knew that there were risks to pregnant women. 123 The Tribunal accepts the submission of the applicant, that these contradictions together with the demeanour of respondent as observed during his evidence, leads to the conclusion that the respondent was not being frank. 124 There is support for that finding in the comments of the respondent to the Section 66 Inquiry and in the letter he wrote to the Minister for Health. 125 In the letter to the Minister the respondent claimed: "Since being approached by the Pharmaceutical Section of the NSW Department of Health, I've been guided by our lawyer to some tuition...I have discovered that there are proscribed guidelines for benzo prescribing to CDs". 126 The respondent referred to drug addicted patients as "CDs" being short for chemically dependent persons. 127 When it was suggested to him that that statement could not stand against his evidence to the Tribunal that he was well aware that it was "illegal" and later "against the guidelines", the respondent's answer was entirely unconvincing. He said: "I was trying to say that I knew that there were guidelines but that I hadn't you know specifically read them close enough like I was not trying to...the second half of the sentence was the things I didn't know about...but the actual guidelines I knew about just from talking to other people, from picking up from the other doctors..." 128 In the same letter to the Minister, at page 6, the respondent said; "While our practice was growing like topsy into a D&A practice, if we had received any official contact cautioning and explaining about our prescribing habits, we would have been only too happy to learn and change if necessary". 129 This paragraph must be considered in the light of his evidence about the visits from PSB in 1981 and 1993, when he was told of the dangers of over prescribing to patients. He explained this paragraph by saying that when he wrote the letter he knew what he was doing was: "against guidelines and orthodox medical thinking", but that he did not believe that what he was doing was wrong. In the Tribunal's view, this answer does not address the question asked and it is satisfied that the only reasonable reading of these two passages of the letter is that the respondent was (falsely) asserting that he was entirely unaware of any restrictions on prescribing benzodiazepines and was ignorant of any disapproval of over prescribing. 130 Such were the discrepancies in his evidence that the Tribunal is of the view that the respondent cannot be regarded as an honest witness. The lack of candour is relevant not only to the acceptance of the respondent's evidence but to the confidence which the Tribunal could hold for his future practice. Insight 131 The respondent's view of what he was doing at the Redfern practice is best illustrated by the following comment at page 278 line 16; "...I believed that I had the degrees and the power invested in me to make clinical decisions even though they weren't necessarily orthodox. There have been many examples through medicine where unorthodox decisions have been taken only to you know perhaps turn out to be worthwhile". 132 The respondent vigorously defended his position and maintained the correctness of his conduct well after the investigation by the PSB. His strident approach to the Minister in which he trumpeted the benefits of his treatment regime was repeated in the Section 66 Inquiry. In neither was there any concession of the possibility of error. 133 The respondent admitted the complaint and the particulars of it in November 2006. The respondent said that he had not been aware that he could have admitted professional misconduct earlier. It is clear that on a number of occasions after the Section 66 Inquiry, the HCCC had sought the respondent's views on the complaint. When the clear evidence of that; letters to the respondent's solicitor seeking his response were shown to him he finally conceded that he had, in fact, had many opportunities to concede the complaint. This is another example of his general want of frankness with the Tribunal. It is also relevant to a consideration of when the respondent arrived at the point at which he could concede that he was wrong. 134 The respondent prepared a written statement by way of response to the complaint. It is dated 25th July 2006. [82] He said this about his conduct: "I largely admit the complaint that has been made against me. I see that in retrospect, my conduct in relation to these patients was unwise, and while my motivation was good, I demonstrated poor judgment" 135 The respondent made no other concession about his conduct in that statement. He said that he thought it was "obvious" what, in his conduct, had been unwise and poor in his judgement. He also said that these words, chosen by him, embraced a concession that his conduct was improper and unethical. [83] The respondent expanded on his concession in evidence-in-chief. He said that his commitment to what he was doing stopped him looking at the risks and he now realised that what he was doing was dangerous for patients. He concluded by saying that he was sincerely trying to help the patients. [84] In cross-examination he explained that his conduct was "unwise" because he was: "giving out tablets freely and risking their lives with the papers that were coming out especially in the late nineties and early 2000's about the risks of benzos combined with methadone". [85] The obvious implication of this statement was that the respondent was unaware of the risks posed by supplying large quantities of benzodiazepines to patients. However, later the respondent said that he was aware of "some" of the risks. As later cross-examination proved, the respondent was well aware of all risks associated with the wholesale prescription of benzodiazepines. 136 As to his judgment, the respondent said that he weighed the risks to the patient of continuing to give them drugs to support their habits against what he was trying to do and came down on the side of his theory. 137 The issue of the respondent's motive in pursuing this theory was a prominent theme in the evidence. In evidence-in-chief, the respondent was taken to his comments about "unwise" and "poor judgment" and asked what his motivation was, he said that his motivation was: "... at all times to try and help my patients. I considered myself a sincere hardworking doctor who was really trying to help my patients". [86] When asked whether he placed his patients at risk he answered: "In hindsight, yes...but at the time my judgment was that the risk of allowing them to continue in the poly-drug abuse behaviour without any lasting healing...was less than the risk of trying to do what I was trying to do...". 138 The respondent said that he changed his opinion about the benefit of his theory through reflection, reading and speaking to colleagues. He could not say when he came to the view that he had been wrong. He referred often to the pain and shock he experienced after receiving the complaint and said that it was years before he could reflect on what he had done. 139 Shortly after the respondent's colleagues were interviewed by the PSB, on the advice of their lawyer, all three doctors attended on Dr Seidler who is experienced in Drug and Alcohol addiction. The respondent said that they visited Dr Seidler once and said: "When we first met him ... I started to explain why I practised the way I practised and he cut me off and said 'I've been in addiction treatment, don't tell me about addiction'. I didn't feel welcome to try and explain what I'd been doing. ... It was more getting our practice in order and telling us that ... we were cowboys, you can't do this sort of thing ... I didn't feel very welcome to continue with dialogue on why I did things" 140 Dr Seidler's comments apparently offended the respondent. The respondent said that he did not like Dr Seidler so did not go back and consult him again. [87] Bearing in mind that this visit was prompted by the PSB investigation and had been suggested by the respondent's lawyer and that the respondent wanted to use the meeting with an acknowledged expert in the area to talk about his method of treatment rather than trying to understand how he could avoid difficulties in the future, shows considerable arrogance and lack of insight. 141 Dr Seidler recommended that the doctors attend a lecture series on the topic. The respondent said that he considered the list of lectures and went only to one he "obviously approved of". [88] He said that he objected to the balance of the lectures because they made no mention of healing and counselling. [89] The respondent said that the lecture topics covered information he already knew and that his problem was that he had applied his methodology incorrectly. [90] 142 The Tribunal is satisfied that any realisation by the respondent that his conduct was wrong came very late in the day indeed. When it came the expression of it was hardly expansive. His evidence to the Tribunal while including more concessions than his written statement always bore the caveat that his motivation was good. 143 It may well be that his motivation was to help his patients, but considering that he had no objective basis on which to apply his theory and he knew all of the relevant risks to patients from large supplies of benzodiazepines, being well motivated does little to mitigate his conduct. 144 In the evidence both written and oral, there is no word of apology or sympathy for his patients. Even in relation to Patients DD and Z, the respondent was asked whether he accepted his treatment played any part in their deaths and he said: "I accept that it may have and I feel devastated if that is the case, absolutely devastated". Given that he had read the Coroner's report, which in the Tribunal's view clearly implicates benzodiazepines in combination with other drugs, it is hard to see why the respondent found it doubtful that he had. 145 If the respondent's expressions of regret given in his evidence are genuine, then in the Tribunal's view they are slight indeed. More particularly the Tribunal finds that the respondent has very little insight into the gravity of his conduct both for his patients and for the community. Gravity and duration of the conduct 146 Based on no empirical evidence, no data and without consultation with any other professional, the respondent embarked on an experiment using his drug addicted patients as guinea pigs. For more than two years he acted as a supermarket supplying drugs, offering the addicted patients the drugs that they wanted in the form that they asked. He said that it did not matter why the patient said he or she wanted the drug, so long as they agreed to attend NA, drugs were prescribed. 147 Not only was there no empirical or scientific basis for the regime of prescribing drugs on demand, at the time that he did, the respondent was well aware of the risks and dangers of prescribing large amounts of benzodiazepines not only to the patients themselves but as a conduit for the entry of those drugs into the illicit drug trade. At no time did the respondent inform any patient of the risks to his or her health from this course of prescribing. 148 The respondent knew at all relevant times that his method of prescribing was anathema to everything he had learned about the proper practice of medicine. He knew full well the proper approach to prescribing benzodiazepines. Rehabilitation 149 The respondent has done no course nor sought advice on handling difficult patients because it is not relevant to his present practice. [91] Equally he has had no counselling himself to address any personal issues which may have led to his conduct because, he said, there was no need. [92] 150 He said in his evidence that he could have done courses so that he had something objective to show the Tribunal but chose not to and preferred to read on the subject. He said he prefers to: [93] "Do it the way I do things, which is examine, talk to colleagues, examine myself, put some things into place to make sure that I don't get lost in the wilderness again. Attending lectures in and of themselves, to me its about interacting with people and having dialogue with them..." 151 He said that from time to time in his reading of journals if there is an article, about drug dependent patients, he will read it. He has no medically qualified supervisor because he sees his role as mainly counselling, he has made no enquiry as to whether there is a general practitioner who could supervise his practice as a counsellor. He has not spoken to any expert in the methadone programme because his reading about it had been sufficient to understand what was involved. [94] 152 He has put a system in place as a safeguard against a situation like the instant arising again. He said that he now talks to peers and has peer review. The peers are not medical practitioners, but people who support and apply the co-dependency model of addiction treatment. Ms Daymon, who the respondent indicated acted as his supervisor, speaks to him about his present case load and the process of counselling his patients. She offers no medical advice about his practice nor could she. 153 The respondent continues to work in the HMC. Dr Aitken was practising there when the respondent was practising at Redfern. He did not discuss with her what he was doing there. After the complaint he told her something about it but it was not until she received a copy of the complaint from the solicitors for the respondent that she realised the breadth of it. Since she has become aware of the complaint, the respondent has not sought and there is no formal system between them of consulting about his practice at the HMC. 154 The Tribunal is not persuaded that the respondent has in place any safeguard to prevent him from practising improperly in the future. 155 Further, the Tribunal is not satisfied that the respondent has any or any sufficient insight into the circumstances which led to his conduct which would persuade the Tribunal that he would not misbehave professionally in the future. Discussion 156 This matter concerns sections 36 and 37 of the Medical Practice Act 1992 (the Act). Those sections are in the following form: S 36(1) "For the purposes of this Act, unsatisfactory professional conduct of a registered medical practitioner includes each of the following: (a) Any conduct that demonstrates a lack of adequate knowledge, skill, judgement or care, by the practitioner in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience; (b) Any contravention by the practitioner (whether by act or omission) of a provision of this Act or the regulations; (c) Any other improper or unethical conduct relating to the practice or purported practice of medicine. S 37 "For the purposes of this Act, professional misconduct of a registered medical practitioner means unsatisfactory professional conduct of a sufficiently serious nature to justify suspension of the practitioner from practising medicine or the removal of the practitioner's name from the Register." 157 Section 64 of the Act provides for a range of orders which may be made by the Tribunal on making a finding of either unsatisfactory professional conduct or professional misconduct. 158 The concession of the respondent that he is guilty of professional misconduct is well made in the view of the Tribunal. Both a peer reviewer, Dr Chung, and an expert in Drug and Alcohol treatment, Professor James Bell, were scathing in their views about the respondent's conduct. 159 Dr Chung said [95] that there were occasions "too numerous to mention" when the respondent breached the accepted standards for prescribing drugs, including the quantities, the times between prescribing, concurrent prescription of related drugs and drugs with potential for interaction, drugs prescribed not for the approved purpose and post dating prescriptions. Dr Chung strongly criticised the other aspects of the respondent's practice as demonstrated in the complaint and its particulars. In summary he said @ page 19; "I am very strongly critical of Dr Roberts in the extreme for his overall role in the prescribing behaviour of this practice. His conduct attracts my strongest and extreme disapproval and, in my opinion, his conduct would attract the strongest disapproval in the extreme of my peers of good repute and conduct." 160 Associate Professor James Bell is the Director of the Langton Centre which is a specialist facility for the treatment of addictive disorders. He said in general comments about the respondent's conduct: "It is apparent from a detailed investigation of the prescribing schedules, many of the patients under his care went into a progressive, prolonged escalation in their use of benzodiazepines. The clinical files lack systematic documentation - there is no assessment, no examination, almost no diagnoses, no treatment plan, no systematic monitoring of outcomes nor even any systematic monitoring of the amount of medication being prescribed." 161 Professor Bell said that using the prescription of drugs to persuade people to attend is not an acceptable rationale for prescribing and is not the basis for the maintenance of prescribing opioids. He said that the respondent has very limited understanding of a counselling relationship if he believed that by issuing prescriptions for drugs of abuse he can promote engagement in a proper counselling relationship. He strongly disapproved of the nature of the practice. 162 The Tribunal is satisfied that the conduct complained of amounted to an abandonment of all skill, judgment and care expected of a medical practitioner by the respondent. It is misconduct of the gravest kind, exacerbated by the respondent's persistence with it over a period of years before it was stopped by the PSB investigation. 163 Given the particulars which are voluminous and barely canvassed in this judgment but all of which are admitted, the Tribunal is satisfied to the requisite standard [96] that the respondent is guilty of professional misconduct. 164 The jurisdiction of the Tribunal is a protective not punitive one. [97] The purpose of disciplinary proceedings is to maintain proper ethical and professional standards in protection of the community and also to protect the good standing and reputation of the profession. The object of protecting the public includes deterring the practitioner from repeating his misconduct and deterring others who might be tempted to behave in a similar way. The role of the Tribunal is also to ensure that public and professional colleagues can place their confidence in the practitioner: "One element of deterrence is providing an assurance to the public that serious lapses in the conduct of....practitioners will not be passed over or lightly put aside, but will be appropriately dealt with." [98] 165 To give effect to the protective jurisdiction of the Tribunal, it may make orders which operate in a number of ways, by preventing the practitioner from practising or by deterring him from repetition of the conduct. [99] 166 In considering what orders to make it is important to have regard to the gravity of the conduct which comprises the professional misconduct. 167 The practice of the respondent in prescribing benzodiazepines on demand to drug addicted patients flew in the face of everything he had learned as a medical practitioner, was anathema to proper standards of professional medical practice and drew extreme disapproval from his peers. 168 Although the respondent asserted that his treatment of the patients was drawn from a theory of co-dependency in the treatment of addicted people, in the result he agreed that there was nothing in that theory or any training which he received which supported or provided any basis for treating addicted people by prescribing to them on demand. 169 The respondent preferred to see himself as a counsellor to these patients and in doing so abandoned his role as a medical practitioner. 170 This "experimentation" persisted for over two years in relation to the approximately 700 patients who attended the Redfern practice of which thirty provided the basis for the complaint. During the time of his implementation of his theory, two patients under the respondent's care died, one of whom was a child. 171 In the process of implementing this theory, the respondent repeatedly breached the Poisons and Therapeutic Goods Act and Regulations and the Medical Practice Act. 172 The respondent tendered a number of references attesting to his good character. Dr Aitken said that he was well regarded by his patients at the HMC and that she believed that he is honest and trustworthy. It is to be recalled that it was only when Dr Aitken received the complaint document from the solicitors acting for the respondent that she was aware of the extent of the complained conduct. She was not given that information by the respondent. 173 Dr Gutkin, a psychiatrist who had worked at the HMC at the same time that the respondent was working at the Redfern practice, said that he understands from patients that the respondent is well regarded and he had found him to be professional and caring in his work. 174 The respondent has practised medicine for many years. Letters of recommendation and reference attest to his commitment to the practice of medicine and to his desire to assist others in the community. 175 Evidence of good character is relevant to the determination of the issues before the Tribunal. It is only one factor to be considered and in this case is heavily outweighed by the evidence that the respondent apparently carried on two different practises - that in the Redfern practice and that in the HMC. It is also to be considered in the light of the evidence given by the respondent to the Tribunal. 176 Time has passed since the respondent behaved in the way complained of. The lapse of time can be relevant to the orders made by a Tribunal. For example, the time which has passed may persuade the Tribunal that the respondent has become a "changed person" since the conduct complained of. However as Walsh JA said in Ex Part Tziniolis: Re Medical Practitioners Act (1966) 67 SR (NSW) 448 at 461 ; "Reformations of character and of behaviour can doubtless occur but their occurrence is not the usual but the exceptional thing. One cannot assume that a change has occurred merely because some years have gone by and it is not proved that anything of a discreditable kind has occurred. If a man has exhibited serious deficiencies in his standards of conduct and his attitudes it must require clear proof to show that some years later he has established himself as a different man." 177 Lapse of time then may be relevant in determining whether the respondent has undergone a reformation of character or in whether the conduct complained of was an isolated or passing departure from proper professional standards. [100] 178 The passage of time and the evidence of the respondent as discussed in these reasons do not persuade the Tribunal that the respondent has reformed his character over the passing years nor could his conduct be seen as an isolated or passing departure from proper standards. 179 The Tribunal is satisfied that the only order which could give effect to its protective functions, to assure the public and the medical profession that this conduct is not taken lightly, is to order that the respondent's name be removed from the Register of Medical Practitioners. 180 In the time between the PSB investigation and the hearing, the respondent has done little, if anything to address the conduct which brings him to this point. The Tribunal will order that he not apply to be registered for a period of five years from the date of the orders. 181 By the Health Legislation Amendment (Unregistered Health Practitioners) Act 2006, section 64 of the Medical Practice Act was amended to allow the Tribunal, where it makes an order either suspending or deregistering a practitioner, to make an order prohibiting the practitioner from providing health services or may order that conditions be imposed on the provision of those services. A health service includes mental health services. 182 The order may be made if the Tribunal is satisfied that the person poses a substantial risk to the health of members of the public. 183 The applicant submitted that the respondent is a person who, notwithstanding deregistration or suspension, would continue to pose such a substantial risk. 184 If the respondent were to continue to practise as he presently does, by offering counselling, the Tribunal is satisfied that he would pose a substantial threat to the health of members of the public based on his past conduct. In the past he has acted in isolation, conducted a baseless experiment on vulnerable patients in the knowledge that it was outside the accepted standards for a medical practitioner coupled with his limited insight into the mechanisms by which he came to this position and his persistent view that he knew best, a view which obtained at least for some years after the Section 66 Inquiry. These matters satisfy the Tribunal that the respondent poses a substantial risk to the health of members of the public in offering any health service after de-registration. 185 The Tribunal will order that until he is re-registered as a medical practitioner, the respondent not offer health services in the nature of counselling. Orders: The Tribunal accepts the undertaking of the respondent's solicitor that the respondent will cease practicing medicine and offering health services in the nature of counselling at 5.00 pm on Friday 27th April 2007: 1. Order that the respondent's name be removed from the Register of Medical Practitioners on 21st May 2007. That he not apply to be re-registered for a period of five years from the date of these orders. 2. That until he is reregistered as a medical practitioner he not offer any health service in the nature of counselling. 3. Respondent to pay the costs of the action. Endnotes 1 Annexure A to the Reasons for Determination 2 Section 4(1) of the Poisons and Therapeutic Goods Act 1966 - "any substance specified in Schedule 4 of the Poisons List 3 Section 4(1) Poisons and Therapeutic Goods Act 1966 - "any substance specified in Schedule 8 of the Poisons List" 4 Clause 36 Poisons and Therapeutic Goods Regulation 1994 5 Clause 40(1) Poisons and Therapeutic Goods Regulation 1994 6 Clause 37(1)(a) Poisons and Therapeutic Goods Regulation 1994 7 Medical Practice Regulation 8 transcript page 23 line 25 ff 9 transcript page 25 line 40 10 Exhibit D tab 4 11 Exhibit A tab 4 12 Exhibit A tab 16 page 9 13 transcript page 28 line21 14 transcript page 29 line 15 15 transcript page 46 line 15 16 transcript page 160 17 transcript pages 52-54 18 transcript page 161 19 transcript page 45 20 transcript page 130 21 transcript page 65-66 22 transcript page 75 ff 23 transcript pages 174-175 24 transcript page 86 25 transcript page 90 line 46 26 transcript page 94 lines 5-35 27 transcript page 129 28 transcript pages 129-137 29 transcript page156 30 transcript 270 line 15 ff 31 Exhibit E tabs 5 and 7 32 transcript page 138 line 20 ff 33 transcript page 173 line 15 34 transcript page 279 line 20 ff 35 Patient A - Serepax and Valium - transcript page 174 36 transcript page 174 line 28 37 transcript page 138 line 56- 139 line 38 transcript 49 39 transcript page 130 line 15 ff 40 Exhibit A tab 16, report of Section 66 Inquiry 41 Exhibit B, tab DD 42 transcript page 166 line 15 ff 43 transcript page 167 line 18 44 transcript page 167 line 40ff 45 transcript page 168 line 18 46 attending on a number of general practitioners seeking prescriptions for benzodiazepines 47 transcript page 121 line 20 48 transcript page 172 line 55 49 transcript page 173 line 30 50 transcript page 122 line 29-35 51 transcript 123 line 38 ff 52 transcript page 140 line 52 53 transcript page 165 line 1-5 54 Exhibit A tab 27 55 Exhibit A tab 22 56 transcript page 140 line 20 57 Exhibit A tab 21 58 transcript page 140 line 1-5 59 Exhibit A tab 42 60 transcript page 188 61 transcript page 28 line 50, page 186 62 transcript page 320-324 63 transcript page 281 line 45 64 transcript page 282 line 11 to 25 65 Exhibit D tab 4 page 3 66 Exhibit A tab 13 page 7 67 Exhibit O 68 transcript page 192 line 15-20 69 transcript page 194 line 30 70 transcript page 194 line 15 71 transcript page 196 72 transcript page 210 line 30 73 transcript page 253 line 5 ff 74 transcript page 258 75 transcript page 133 76 transcript page 49 line 45 77 transcript page 106 78 transcript page 304 line 55 79 transcript page 93 line 55 80 transcript page 118 line 28-55 81 transcript page 113 82 Exhibit 1 tab 1 83 transcript pages 86-87 84 transcript page 39 line 15 85 transcript page 86 line 15 86 transcript page 26 line 17 87 transcript pages 246 and 247 88 transcript page 262 89 transcript 263 90 transcript page 263 line 28 91 transcript page 265 92 transcript 287 93 transcript page 263 line 48 94 transcript page 238 line 45 95 Exhibit A tab 39 page 5 and following 96 Briginshaw v Briginshaw (1938) 60 CLR 336 . "That is, that the Tribunal must be comfortably satisfied on the balance of probabilities but that having regard to the serious nature of the charge and the consequences that follow, the satisfaction cannot be produced by "inexact proofs, indefinite testimony or indirect references" 97 Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630 at 637D and F 98 Law Society of NSW v Foreman (1994) 34 NSWLR 408 at 441B, 471B . Also Craig v Medical Board of South Australia [2001] SASC 169 at [45]-[47] 99 NSW Bar Association v Meakes [2006] NSWCA 340 at [114] per Basten JA 100 Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630 at 637 ANNEXURE A To theReasons for Determination and Orders of the Medical Tribunal of NSW HCCC v Dr Christopher Roberts 40037 of 2005 AMENDED COMPLAINT MEDICAL PRACTICE ACT 1992 The Chairperson Medical Tribunal 86 - 90 Goulburn Street SYDNEY NSW 2000 The Health Care Complaints Commission of Level 13, 323 Castlereagh Street, Sydney, New South Wales, having consulted with the New South Wales Medical Board pursuant to Section 51 of the Medical Practice Act 1992 ("the Act") HEREBY COMPLAINS that Dr Christopher Roberts, Medical Practitioner of the Holistic Medical Centre, 1st Floor, 17 Randle Street, Surry Hills, New South Wales, 2010 ("the Practitioner"), being a medical practitioner registered under the Act:- COMPLAINT Has been guilty of unsatisfactory professional conduct within the meaning of section 36 of the Act and/or professional misconduct within the meaning of section 37 of the Act, in that the Practitioner has: (i) demonstrated that the knowledge, skill or judgment possessed, and/or the care exercised, by him in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience; and/or (ii) contravened the Medical Practice Regulation 1998; and/or (iii) engaged in improper or unethical conduct relating to the practice of medicine. PARTICULARS OF COMPLAINT Patient A 1. During the period 12 March 1998 to 25 February 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient A in the quantities and on the occasions shown in Schedule A: (a) when the Practitioner knew or ought to have known that Patient A was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient A was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances and/or drugs of addiction to Patient A; and/or (c) when the Practitioner knew or ought to have known that Patient A was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 2. During the period 29 October 1998 to 25 February 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient A's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient A; and/or (c) record a plan of treatment for Patient A; and/or (d) full particulars of the medication prescribed to Patient A; and/or (e) record information or advice given to Patient A in relation to medical treatment proposed by the Practitioner in relation to Patient A; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient A; and/or (g) record sufficient and appropriate detail as to Patient A's case so as to allow another registered medical practitioner to continue the management of Patient A; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient A's medical notes. 3. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient A during the period 12 March 1998 to 25 February 1999 (as shown in Schedule A) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 4. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient A as shown in Schedule A1. 5. During the period 12 March 1998 to 25 February 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient A (as shown in Schedule A) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient B 6. During the period 4 January 1998 to 1 March 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient B in the quantities and on the occasions shown in Schedule B: (a) when the Practitioner knew or ought to have known that Patient B was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient B was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient B; and/or (c) when the Practitioner knew or ought to have known that Patient B was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 7. During the period 30 November 1998 to 1 March 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient B's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient B; and/or (c) record a plan of treatment for Patient B; and/or (d) full particulars of the medication prescribed to Patient B; and/or (e) record information or advice given to Patient B in relation to medical treatment proposed by the Practitioner in relation to Patient B; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient B; and/or (g) record sufficient and appropriate detail as to Patient B's case so as to allow another registered medical practitioner to continue the management of Patient B; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient B's medical notes. 8. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient B during the period 4 January 1998 to 1 March 1999 (as shown in Schedule B) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 9. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient B as shown in Schedule B1. 10. During the period 4 January 1998 to 1 March 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient B (as shown in Schedule B) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient C 11. During the period 7 January 1997 to 7 December 1998 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient C in the quantities and on the occasions shown in Schedule C: (a) when the Practitioner knew or ought to have known that Patient C was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient C was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient C; and/or (c) when the Practitioner knew or ought to have known that Patient C was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 12. On 7 December 1998 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient C's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient C; and/or (c) record a plan of treatment for Patient C; and/or (d) full particulars of the medication prescribed to Patient C; and/or (e) record information or advice given to Patient C in relation to medical treatment proposed by the Practitioner in relation to Patient C; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient C; and/or (g) record sufficient and appropriate detail as to Patient C's case so as to allow another registered medical practitioner to continue the management of Patient C; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient C's medical notes. 13. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient C during the period 7 January 1997 to 7 December 1998 (as shown in Schedule C) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 14. During the period 7 January 1997 to 7 December 1998 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient C (as shown in Schedule C) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient D 15. During the period 21 June 1998 to 25 February 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient D in the quantities and on the occasions shown in Schedule D: (a) when the Practitioner knew or ought to have known that Patient D was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient D was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient D; and/or (c) when the Practitioner knew or ought to have known that Patient D was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 16. The Practitioner contravened clauses 13(1) and 14(1) of the Medical Practice Regulation 1998 by failing to make contemporaneous entries in Patient D's medical notes with respect to medical treatment or services provided to Patient D on 22 December 1998. 17. During the period 10 September 1998 to 25 February 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient D's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient D; and/or (c) record a plan of treatment for Patient D; and/or (d) full particulars of the medication prescribed to Patient D; and/or (e) record information or advice given to Patient D in relation to medical treatment proposed by the Practitioner in relation to Patient D; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient D; and/or (g) record sufficient and appropriate detail as to Patient D's case so as to allow another registered medical practitioner to continue the management of Patient D; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient D's medical notes. 18. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient D during the period 21 June 1998 to 25 February 1999 (as shown in Schedule D) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 19. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient D as shown in Schedule D1. 20. During the period 21 June 1998 to 25 February 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient D (as shown in Schedule D) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient E 21. During the period 18 June 1998 to 25 February 1999 the Practitioner prescribed restricted substances and drugs of addiction (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient E in the quantities and on the occasions shown in Schedule E: (a) when the Practitioner knew or ought to have known that Patient E was dependent or was likely to become dependent on the restricted substances and/or drugs of addiction prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient E was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances and/or similar drugs of addiction to Patient E; and/or (c) when the Practitioner knew or ought to have known that Patient E was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances and/or drugs of addiction was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 22. During the period 14 September 1998 to 25 February 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient E's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient E; and/or (c) record a plan of treatment for Patient E; and/or (d) full particulars of the medication prescribed to Patient E; and/or (e) record information or advice given to Patient E in relation to medical treatment proposed by the Practitioner in relation to Patient E; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient E; and/or (g) record sufficient and appropriate detail as to Patient E's case so as to allow another registered medical practitioner to continue the management of Patient E; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient E's medical notes. 23. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient E during the period 18 June 1998 to 25 February 1999 (as shown in Schedule E) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 24. During the period 18 June 1998 to 25 February 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient E (as shown in Schedule E) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. 25. The Practitioner contravened clause 81 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for drugs of addiction (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient E during the period 11 July 1998 to 25 February 1999 (as shown in Schedule E) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what is appropriate in the circumstances. 26. During the period 11 July 1998 to 25 February 1999 the Practitioner contravened clause 84(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing drugs of addiction (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient E (as shown in Schedule E) and failing to record the particulars of: (a) the name, strength and quantity of the drug prescribed; and/or (b) the maximum number of times the drug may be supplied on the prescription; and/or (c) the directions for use as shown on the prescription. 27. The Practitioner contravened section 28(a) of the Poisons and Therapeutic Goods Act 1966 by prescribing, otherwise than in accordance with an authority given to the Practitioner, Proladone Suppositories, being a drug of addiction (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient E during the period 11 July 1998 to 25 February 1999 (as shown in Schedule E) resulting in the drug of addiction being prescribed for continuous therapeutic use by Patient E for a period exceeding 2 months. 28. The Practitioner contravened section 28(b) of the Poisons and Therapeutic Goods Act 1966 by prescribing Proladone Suppositories, being a drug of addiction (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient E during the period 11 July 1998 to 25 February 1999 (as shown in Schedule E) otherwise than in accordance with an authority given to the Practitioner, when the Practitioner knew or ought to have known that Patient E was during that period of time an addict (as defined by section 27 of the Poisons and Therapeutic Goods Act 1966). Patient F 29. During the period 25 March 1997 to 1 March 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient F in the quantities and on the occasions shown in Schedule F: (a) when the Practitioner knew or ought to have known that Patient F was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have that known Patient F was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient F; and/or (c) when the Practitioner knew or ought to have known that Patient F was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 30. During the period 30 November 1998 to 1 March 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient F's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient F; and/or (c) record a plan of treatment for Patient F; and/or (d) full particulars of the medication prescribed to Patient F; and/or (e) record information or advice given to Patient F in relation to medical treatment proposed by the Practitioner in relation to Patient F; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient F; and/or (g) record sufficient and appropriate detail as to Patient F's case so as to allow another registered medical practitioner to continue the management of Patient F; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient F's medical notes. 31. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient F during the period 25 March 1997 to 1 March 1999 (as shown in Schedule F) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 32. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient F as shown in Schedule F1. 33. During the period 25 March 1997 to 1 March 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient F (as shown in Schedule F) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient G 34. During the period 30 November 1998 to 19 February 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient G in the quantities and on the occasions shown in Schedule G: (a) when the Practitioner knew or ought to have known that Patient G was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient G was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient G; and/or (c) when the Practitioner knew or ought to have known that Patient G was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 35. During the period 30 November 1998 to 19 February 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient G's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient G; and/or (c) record a plan of treatment for Patient G; and/or (d) full particulars of the medication prescribed to Patient G; and/or (e) record information or advice given to Patient G in relation to medical treatment proposed by the Practitioner in relation to Patient G; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient G; and/or (g) record sufficient and appropriate detail as to Patient G's case so as to allow another registered medical practitioner to continue the management of Patient G; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient G's medical notes. 36. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient G during the period 30 November 1998 to 19 February 1999 (as shown in Schedule G) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 37. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient G as shown in Schedule G1. 38. During the period 30 November 1998 to 19 February 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient G (as shown in Schedule G) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient H 39. During the period 15 June 1998 to 1 March 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient H in the quantities and on the occasions shown in Schedule H: (a) when the Practitioner knew or ought to have known that Patient H was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient H was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient H; and/or (c) when the Practitioner knew or ought to have known that Patient H was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 40. During the period 15 October 1998 to 1 March 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient H's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient H; and/or (c) record a plan of treatment for Patient H; and/or (d) full particulars of the medication prescribed to Patient H; and/or (e) record information or advice given to Patient H in relation to medical treatment proposed by the Practitioner in relation to Patient H; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient H; and/or (g) record sufficient and appropriate detail as to Patient H's case so as to allow another registered medical practitioner to continue the management of Patient H; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient H's medical notes. 41. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient H during the period 15 June 1998 to 1 March 1999 (as shown in Schedule H) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 42. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient H as shown in Schedule H1. 43. During the period 15 June 1998 to 1 March 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient H (as shown in Schedule H) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient I 44. During the period 21 December 1998 to 1 March 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient I in the quantities and on the occasions shown in Schedule I: (a) when the Practitioner knew or ought to have known that Patient I was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient I was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient I; and/or (c) when the Practitioner knew or ought to have known that Patient I was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 45. During the period 21 December 1998 to 1 March 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient I's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient I; and/or (c) record a plan of treatment for Patient I; and/or (d) full particulars of the medication prescribed to Patient I; and/or (e) record information or advice given to Patient I in relation to medical treatment proposed by the Practitioner in relation to Patient I; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient I; and/or (g) record sufficient and appropriate detail as to Patient I's case so as to allow another registered medical practitioner to continue the management of Patient I; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient I's medical notes. 46. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient I during the period 21 December 1998 to 1 March 1999 (as shown in Schedule I) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 47. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient I as shown in Schedule I1. 48. During the period 21 December 1998 to 1 March 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient I (as shown in Schedule I) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient J 49. During the period 30 November 1998 to 1 March 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient J in the quantities and on the occasions shown in Schedule J: (a) when the Practitioner knew or ought to have known that Patient J was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient J was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient J; and/or (c) when the Practitioner knew or ought to have known that Patient J was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 50. During the period 30 November 1998 to 1 March 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient J's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient J; and/or (c) record a plan of treatment for Patient J; and/or (d) full particulars of the medication prescribed to Patient J; and/or (e) record information or advice given to Patient J in relation to medical treatment proposed by the Practitioner in relation to Patient J; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient J; and/or (g) record sufficient and appropriate detail as to Patient J's case so as to allow another registered medical practitioner to continue the management of Patient J; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient J's medical notes. 51. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient J during the period 30 November 1998 to 1 March 1999 (as shown in Schedule J) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 52. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient J as shown in Schedule J1. 53. During the period 30 November 1998 to 1 March 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient J (as shown in Schedule J) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient K 54. During the period 12 July 1997 to 1 March 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient K in the quantities and on the occasions shown in Schedule K: (a) when the Practitioner knew or ought to have known that Patient K was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient K was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient K; and/or (c) when the Practitioner knew or ought to have known that Patient K was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 55. The Practitioner contravened clauses 13(1) and 14(1) of the Medical Practice Regulation 1998 by failing to make contemporaneous entries in Patient K's medical notes with respect to medical treatment or services provided to Patient K on 15 December 1998. 56. During the period 27 September 1998 to 1 March 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient K's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient K; and/or (c) record a plan of treatment for Patient K; and/or (d) full particulars of the medication prescribed to Patient K; and/or (e) record information or advice given to Patient K in relation to medical treatment proposed by the Practitioner in relation to Patient K; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient K; and/or (g) record sufficient and appropriate detail as to Patient K's case so as to allow another registered medical practitioner to continue the management of Patient K; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient K's medical notes. 57. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient K during the period 12 July 1997 to 1 March 1999 (as shown in Schedule K) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 58. During the period 12 July 1997 to 1 March 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient K (as shown in Schedule K) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient L 59. During the period 23 July 1998 to 25 February 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient L in the quantities and on the occasions shown in Schedule L: (a) when the Practitioner knew or ought to have known that Patient L was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient L was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient L; and/or (c) when the Practitioner knew or ought to have known that Patient L was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 60. The Practitioner contravened clauses 13(1) and 14(1) of the Medical Practice Regulation 1998 by failing to make contemporaneous entries in Patient N's medical notes with respect to medical treatment or services provided to Patient N on the following occasions: (a) 23 October 1998; and/or (b) 5 December 1998; and/or (c) 12 December 1998. 61. During the period 12 September 1998 to 25 February 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient L's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient L; and/or (c) record a plan of treatment for Patient L; and/or (d) full particulars of the medication prescribed to Patient L; and/or (e) record information or advice given to Patient L in relation to medical treatment proposed by the Practitioner in relation to Patient L; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient L; and/or (g) record sufficient and appropriate detail as to Patient L's case so as to allow another registered medical practitioner to continue the management of Patient L; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient L's medical notes. 62. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient L during the period 23 July 1998 to 25 February 1999 (as shown in Schedule L) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 63. During the period 23 July 1998 to 25 February 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient L (as shown in Schedule L) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient M 64. During the period 22 October 1998 to 15 February 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient M in the quantities and on the occasions shown in Schedule M: (a) when the Practitioner knew or ought to have known that Patient M was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient M was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient M; and/or (c) when the Practitioner knew or ought to have known that Patient M was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 65. During the period 22 October 1998 to 15 February 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient M's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient M; and/or (c) record a plan of treatment for Patient M; and/or (d) full particulars of the medication prescribed to Patient M; and/or (e) record information or advice given to Patient M in relation to medical treatment proposed by the Practitioner in relation to Patient M; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient M; and/or (g) record sufficient and appropriate detail as to Patient M's case so as to allow another registered medical practitioner to continue the management of Patient M; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient M's medical notes. 66. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient M during the period 22 October 1998 to 15 February 1999 (as shown in Schedule M) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 67. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient M as shown in Schedule M1. 68. During the period 22 October 1998 to 15 February 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient M (as shown in Schedule M) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient N 69. During the period 18 January 1997 to 2 March 1999 the Practitioner prescribed restricted substances and drugs of addiction (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient N in the quantities and on the occasions shown in Schedule N: (a) when the Practitioner knew or ought to have known that Patient N was dependent or was likely to become dependent on the restricted substances and/or drugs of addiction prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient N was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances and/or similar drugs of addiction to Patient N; and/or (c) when the Practitioner knew or ought to have known that Patient N was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances and/or drugs of addiction was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 70. The Practitioner contravened clauses 13(1) and 14(1) of the Medical Practice Regulation 1998 by failing to make contemporaneous entries in Patient N's medical notes with respect to medical treatment or services provided to Patient N on the following occasions: (a) 29 October 1998; and/or (b) 21 November 1998; and/or (c) 25 January 1999. 71. During the period 5 September 1998 to 2 March 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient N's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient N; and/or (c) record a plan of treatment for Patient N; and/or (d) full particulars of the medication prescribed to Patient N; and/or (e) record information or advice given to Patient N in relation to medical treatment proposed by the Practitioner in relation to Patient N; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient N; and/or (g) record sufficient and appropriate detail as to Patient N's case so as to allow another registered medical practitioner to continue the management of Patient N; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient N's medical notes. 72. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient N during the period 18 January 1997 to 2 March 1999 (as shown in Schedule N) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 73. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient N as shown in Schedule N1. 74. During the period 18 January 1997 to 2 March 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient N (as shown in Schedule N) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. 75. The Practitioner contravened clause 81 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for Proladone Suppositories, being a drug of addiction (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient N during the period 18 January 1999 to 24 February 1999 (as shown in Schedule N) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what is appropriate in the circumstances. 76. The Practitioner contravened clause 82(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for drugs of addiction (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient N as shown in Schedule N2. 77. During the period 18 January 1999 to 24 February 1999 the Practitioner contravened clause 84(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing Proladone Suppositories, being a drug of addiction (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient N (as shown in Schedule N) and failing to record the particulars of: (a) the name, strength and quantity of the drug prescribed; and/or (b) the maximum number of times the drug may be supplied on the prescription; and/or (c) the directions for use as shown on the prescription. 78. The Practitioner contravened section 28(b) of the Poisons and Therapeutic Goods Act 1966 by prescribing Proladone Suppositories, being a drug of addiction (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient N during the period 18 January 1999 to 24 February 1999 (as shown in Schedule N) otherwise than in accordance with an authority given to the Practitioner, when the Practitioner knew or ought to have known that Patient N was during that period of time an addict (as defined by section 27 of the Poisons and Therapeutic Goods Act 1966). Patient O 79. During the period 13 November 1997 to 1 March 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient O in the quantities and on the occasions shown in Schedule O: (a) when the Practitioner knew or ought to have known that Patient O was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have that known Patient O was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient O; and/or (c) when the Practitioner knew or ought to have known that Patient O was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 80. During the period 8 October 1998 to 1 March 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient O's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient O; and/or (c) record a plan of treatment for Patient O; and/or (d) full particulars of the medication prescribed to Patient O; and/or (e) record information or advice given to Patient O in relation to medical treatment proposed by the Practitioner in relation to Patient O; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient O; and/or (g) record sufficient and appropriate detail as to Patient O's case so as to allow another registered medical practitioner to continue the management of Patient O; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient O's medical notes. 81. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient O during the period 13 November 1997 to 1 March 1999 (as shown in Schedule O) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 82. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient O as shown in Schedule O1. 83. During the period 13 November 1997 to 1 March 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient O (as shown in Schedule O) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient P 84. During the period 1 July 1997 to 2 March 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient P in the quantities and on the occasions shown in Schedule P: (a) when the Practitioner knew or ought to have known that Patient P was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient P was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient P; and/or (c) when the Practitioner knew or ought to have known that Patient P was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 85. The Practitioner contravened clauses 13(1) and 14(1) of the Medical Practice Regulation 1998 by failing to make contemporaneous entries in Patient P's medical notes with respect to medical treatment or services provided to Patient P on 23 November 1998. 86. During the period 5 September 1998 to 2 March 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient P's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient P; and/or (c) record a plan of treatment for Patient P; and/or (d) full particulars of the medication prescribed to Patient P; and/or (e) record information or advice given to Patient P in relation to medical treatment proposed by the Practitioner in relation to Patient P; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient P; and/or (g) record sufficient and appropriate detail as to Patient P's case so as to allow another registered medical practitioner to continue the management of Patient P; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient P's medical notes. 87. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient P during the period 1 July 1997 to 2 March 1999 (as shown in Schedule P) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 88. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient P as shown in Schedule P1. 89. During the period 1 July 1997 to 2 March 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient P (as shown in Schedule P) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient Q 90. During the period 31 October 1998 to 8 March 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient Q in the quantities and on the occasions shown in Schedule Q: (a) when the Practitioner knew or ought to have known that Patient Q was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient Q was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient Q; and/or (c) when the Practitioner knew or ought to have known that Patient Q a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 91. During the period 31 October 1998 to 8 March 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient Q's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient Q; and/or (c) record a plan of treatment for Patient Q; and/or (d) full particulars of the medication prescribed to Patient Q; and/or (e) record information or advice given to Patient Q in relation to medical treatment proposed by the Practitioner in relation to Patient Q; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient Q; and/or (g) record sufficient and appropriate detail as to Patient Q's case so as to allow another registered medical practitioner to continue the management of Patient Q; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient Q's medical notes. 92. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient Q during the period 31 October 1998 to 8 March 1999 (as shown in Schedule Q) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 93. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient Q as shown in Schedule Q1. 94. During the period 31 October 1998 to 8 March 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient Q (as shown in Schedule Q) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient R 95. During the period 25 April 1998 to 30 January 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient R in the quantities and on the occasions shown in Schedule R: (a) when the Practitioner knew or ought to have known that Patient R was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient R was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient R; and/or (c) when the Practitioner knew or ought to have known that Patient R was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 96. During the period 5 September 1998 to 30 January 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient R's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient R; and/or (c) record a plan of treatment for Patient R; and/or (d) full particulars of the medication prescribed to Patient R; and/or (e) record information or advice given to Patient R in relation to medical treatment proposed by the Practitioner in relation to Patient R; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient R; and/or (g) record sufficient and appropriate detail as to Patient R's case so as to allow another registered medical practitioner to continue the management of Patient R; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient R's medical notes. 97. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient R during the period 25 April 1998 to 30 January 1999 (as shown in Schedule R) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 98. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient R as shown in Schedule R1. 99. During the period 25 April 1998 to 30 January 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient R (as shown in Schedule R) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient S 100. During the period 15 May 1997 to 17 December 1998 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient S in the quantities and on the occasions shown in Schedule S: (a) when the Practitioner knew or ought to have known that Patient S was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient S was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient S; and/or (c) when the Practitioner knew or ought to have known that Patient S was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 101. The Practitioner contravened clauses 13(1) and 14(1) of the Medical Practice Regulation 1998 by failing to make contemporaneous entries in Patient S's medical notes with respect to medical treatment or services provided to Patient S on 17 September 1998. 102. During the period 10 September 1998 to 17 December 1998 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient S's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient S; and/or (c) record a plan of treatment for Patient S; and/or (d) full particulars of the medication prescribed to Patient S; and/or (e) record information or advice given to Patient S in relation to medical treatment proposed by the Practitioner in relation to Patient S; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient S; and/or (g) record sufficient and appropriate detail as to Patient S's case so as to allow another registered medical practitioner to continue the management of Patient S; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient S's medical notes. 103. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient S during the period 15 May 1997 to 17 December 1998 (as shown in Schedule S) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 104. During the period 15 May 1997 to 17 December 1998 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient S (as shown in Schedule S) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. 105. The Practitioner contravened clause 57 of the Poisons and Therapeutic Goods Regulation 1994 by supplying restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient S during the period 10 September 1998 to 7 December 1998 (as shown in Schedule S) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. Patient T 106. During the period 29 August 1998 to 24 February 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient T in the quantities and on the occasions shown in Schedule T: (a) when the Practitioner knew or ought to have known that Patient T was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient T was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient T; and/or (c) when the Practitioner knew or ought to have known that Patient T was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 107. During the period 5 September 1998 to 24 February 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient T's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient T; and/or (c) record a plan of treatment for Patient T; and/or (d) full particulars of the medication prescribed to Patient T; and/or (e) record information or advice given to Patient T in relation to medical treatment proposed by the Practitioner in relation to Patient T; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient T; and/or (g) record sufficient and appropriate detail as to Patient T's case so as to allow another registered medical practitioner to continue the management of Patient T; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient T's medical notes. 108. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient T during the period 29 August 1998 to 24 February 1999 (as shown in Schedule T) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 109. During the period 29 August 1998 to 24 February 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient T (as shown in Schedule T) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient U 110. During the period 3 January 1997 to 1 March 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient U in the quantities and on the occasions shown in Schedule U: (a) when the Practitioner knew or ought to have known that Patient U was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient U was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient U; and/or (c) when the Practitioner knew or ought to have known that Patient U was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. (e) The Practitioner contravened clauses 13(1) and 14(1) of the Medical Practice Regulation 1998 by failing to make contemporaneous entries in Patient U's medical notes with respect to medical treatment or services provided to Patient U on 11 February 1999. 111. During the period 5 September 1998 to 1 March 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient U's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient U; and/or (c) record a plan of treatment for Patient U; and/or (d) full particulars of the medication prescribed to Patient U; and/or (e) record information or advice given to Patient U in relation to medical treatment proposed by the Practitioner in relation to Patient U; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient U; and/or (g) record sufficient and appropriate detail as to Patient U's case so as to allow another registered medical practitioner to continue the management of Patient U; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient U's medical notes. 112. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient U during the period 3 January 1997 to 1 March 1999 (as shown in Schedule U) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 113. During the period 3 January 1997 to 1 March 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient U (as shown in Schedule U) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient V 114. During the period 7 August 1997 to 15 February 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient V in the quantities and on the occasions shown in Schedule V: (a) when the Practitioner knew or ought to have known that Patient V was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient V was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient V; and/or (c) when the Practitioner knew or ought to have known that Patient V was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 115. During the period 19 September 1998 to 15 February 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient V's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient V; and/or (c) record a plan of treatment for Patient V; and/or (d) full particulars of the medication prescribed to Patient V; and/or (e) record information or advice given to Patient V in relation to medical treatment proposed by the Practitioner in relation to Patient V; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient V; and/or (g) record sufficient and appropriate detail as to Patient V's case so as to allow another registered medical practitioner to continue the management of Patient V; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient V's medical notes. 116. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient V during the period 7 August 1997 to 15 February 1999 (as shown in Schedule V) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 117. During the period 7 August 1997 to 15 February 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient V (as shown in Schedule V) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient W 118. During the period 7 January 1999 to 1 March 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient W in the quantities and on the occasions shown in Schedule W: (a) when the Practitioner knew or ought to have known that Patient W was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient W was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient W; and/or (c) when the Practitioner knew or ought to have known that Patient W was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 119. During the period 7 January 1999 to 1 March 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient W's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient W; and/or (c) record a plan of treatment for Patient W; and/or (d) full particulars of the medication prescribed to Patient W; and/or (e) record information or advice given to Patient W in relation to medical treatment proposed by the Practitioner in relation to Patient W; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient W; and/or (g) record sufficient and appropriate detail as to Patient W's case so as to allow another registered medical practitioner to continue the management of Patient W; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient W's medical notes. 120. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient W during the period 7 January 1999 to 1 March 1999 (as shown in Schedule W) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 121. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient W as shown in Schedule W1. 122. During the period 7 January 1999 to 1 March 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient W (as shown in Schedule W) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient X 123. During the period 27 August 1998 to 1 March 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient X in the quantities and on the occasions shown in Schedule X: (a) when the Practitioner knew or ought to have known that Patient X was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient X was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient X; and/or (c) when the Practitioner knew or ought to have known that Patient X was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 124. During the period 24 September 1998 to 1 March 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient X's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient X; and/or (c) record a plan of treatment for Patient X; and/or (d) full particulars of the medication prescribed to Patient X; and/or (e) record information or advice given to Patient X in relation to medical treatment proposed by the Practitioner in relation to Patient X; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient X; and/or (g) record sufficient and appropriate detail as to Patient X's case so as to allow another registered medical practitioner to continue the management of Patient X; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient X's medical notes. 125. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient X during the period 27 August 1998 to 1 March 1999 (as shown in Schedule X) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 126. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient X as shown in Schedule X1. 127. During the period 27 August 1998 to 1 March 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient X (as shown in Schedule X) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient Y 128. During the period 11 December 1997 to 7 December 1998 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient Y in the quantities and on the occasions shown in Schedule Y: (a) when the Practitioner knew or ought to have known that Patient Y was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient Y was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient Y; and/or (c) when the Practitioner knew or ought to have known that Patient Y was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 129. During the period 5 September 1998 to 7 December 1998 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient Y's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient Y; and/or (c) record a plan of treatment for Patient Y; and/or (d) full particulars of the medication prescribed to Patient Y; and/or (e) record information or advice given to Patient Y in relation to medical treatment proposed by the Practitioner in relation to Patient Y; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient Y; and/or (g) record sufficient and appropriate detail as to Patient Y's case so as to allow another registered medical practitioner to continue the management of Patient Y; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient Y's medical notes. 130. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient Y during the period 11 December 1997 to 7 December 1998 (as shown in Schedule Y) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 131. During the period 11 December 1997 to 7 December 1998 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient Y (as shown in Schedule Y) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. 132. The Practitioner contravened clause 57 of the Poisons and Therapeutic Goods Regulation 1994 by supplying restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient Y during the period 5 September 1998 to 9 December 1998 (as shown in Schedule Y) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. Patient Z 133. During the period 10 December 1998 to 1 March 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient Z in the quantities and on the occasions shown in Schedule Z: (a) when the Practitioner knew or ought to have known that Patient Z was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient Z was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient Z; and/or (c) when the Practitioner knew or ought to have known that Patient Z was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 134. During the period 10 December 1998 to 1 March 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient Z's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient Z; and/or (c) record a plan of treatment for Patient Z; and/or (d) full particulars of the medication prescribed to Patient Z; and/or (e) record information or advice given to Patient Z in relation to medical treatment proposed by the Practitioner in relation to Patient Z; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient Z; and/or (g) record sufficient and appropriate detail as to Patient Z's case so as to allow another registered medical practitioner to continue the management of Patient Z; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient Z's medical notes. 135. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient Z during the period 10 December 1998 to 1 March 1999 (as shown in Schedule Z) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 136. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient Z as shown in Schedule Z1. 137. During the period 10 December 1998 to 1 March 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient Z (as shown in Schedule Z) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient AA 138. During the period 7 November 1998 to 25 February 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient AA in the quantities and on the occasions shown in Schedule AA: (a) when the Practitioner knew or ought to have known that Patient AA was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient AA was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient AA; and/or (c) when the Practitioner knew or ought to have known that Patient AA was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 139. During the period 7 November 1998 to 25 February 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient AA's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient AA; and/or (c) record a plan of treatment for Patient AA; and/or (d) full particulars of the medication prescribed to Patient AA; and/or (e) record information or advice given to Patient AA in relation to medical treatment proposed by the Practitioner in relation to Patient AA; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient AA; and/or (g) record sufficient and appropriate detail as to Patient AA's case so as to allow another registered medical practitioner to continue the management of Patient AA; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient AA's medical notes. 140. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient AA during the period 7 November 1998 to 25 February 1999 (as shown in Schedule AA) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 141. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient AA as shown in Schedule AA1. 142. During the period 7 November 1998 to 25 February 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient AA (as shown in Schedule AA) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient BB 143. During the period 10 January 1997 to 25 February 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient BB in the quantities and on the occasions shown in Schedule BB: (a) when the Practitioner knew or ought to have known that Patient BB was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient BB was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient BB; and/or (c) when the Practitioner knew or ought to have known that Patient BB was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 144. The Practitioner contravened clauses 13(1) and 14(1) of the Medical Practice Regulation 1998 by failing to make contemporaneous entries in Patient BB's medical notes with respect to medical treatment or services provided to Patient BB on 11 September 1998. 145. During the period 11 September 1998 to 25 February 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient BB's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient BB; and/or (c) record a plan of treatment for Patient BB; and/or (d) full particulars of the medication prescribed to Patient BB; and/or (e) record information or advice given to Patient BB in relation to medical treatment proposed by the Practitioner in relation to Patient BB; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient BB; and/or (g) record sufficient and appropriate detail as to Patient BB's case so as to allow another registered medical practitioner to continue the management of Patient BB; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient BB's medical notes. 146. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient BB during the period 10 January 1997 to 25 February 1999 (as shown in Schedule BB) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 147. During the period 10 January 1997 to 25 February 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient BB (as shown in Schedule BB) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient CC 148. During the period 16 January 1997 to 2 March 1999 the Practitioner prescribed restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient CC in the quantities and on the occasions shown in Schedule CC: (a) when the Practitioner knew or ought to have known that Patient CC was dependent or was likely to become dependent on the restricted substances prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient CC was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances to Patient CC; and/or (c) when the Practitioner knew or ought to have known that Patient CC was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 149. The Practitioner contravened clauses 13(1) and 14(1) of the Medical Practice Regulation 1998 by failing to make contemporaneous entries in Patient CC's medical notes with respect to medical treatment or services provided to Patient CC on 21 November 1998. 150. During the period 5 September 1998 to 2 March 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient CC's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient CC; and/or (c) record a plan of treatment for Patient CC; and/or (d) full particulars of the medication prescribed to Patient CC; and/or (e) record information or advice given to Patient CC in relation to medical treatment proposed by the Practitioner in relation to Patient CC; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient CC; and/or (g) record sufficient and appropriate detail as to Patient CC's case so as to allow another registered medical practitioner to continue the management of Patient CC; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient CC's medical notes. 151. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient CC during the period 16 January 1997 to 2 March 1999 (as shown in Schedule CC) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 152. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient CC as shown in Schedule CC1. 153. During the period 16 January 1997 to 2 March 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient CC (as shown in Schedule CC) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. Patient DD 154. During the period 5 September 1998 to 1 March 1999 the Practitioner prescribed restricted substances and drugs of addiction (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient DD in the quantities and on the occasions shown in Schedule DD: (a) when the Practitioner knew or ought to have known that Patient DD was dependent or was likely to become dependent on the restricted substances and/or drugs of addiction prescribed; and/or (b) when the Practitioner knew or ought to have known that Patient DD was under the care of other medical practitioners who were also concurrently prescribing similar restricted substances and/or similar drugs of addiction to Patient DD; and/or (c) when the Practitioner knew or ought to have known that Patient DD was a participant in a methadone program; and/or (d) without exercising adequate medical judgment as to whether the prescribing of the restricted substances and/or drugs of addiction was appropriate in the circumstances and/or in accordance with recognised therapeutic standards. 155. During the period 5 September 1998 to 1 March 1999 the Practitioner contravened clause 13(1) of, and clauses 1(2)(a) to (d), 1(3), 1(4)(c), 2(1), 2(2) and 3(2) of Schedule 2 to, the Medical Practice Regulation 1998 by failing to: (a) record information relevant to Patient DD's diagnosis and/or medical treatment; and/or (b) record particulars of any clinical opinion reached by the Practitioner in relation to Patient DD; and/or (c) record a plan of treatment for Patient DD; and/or (d) full particulars of the medication prescribed to Patient DD; and/or (e) record information or advice given to Patient DD in relation to medical treatment proposed by the Practitioner in relation to Patient DD; and/or (f) record the name of the person, being the Practitioner, who treated and prescribed medication to Patient DD; and/or (g) record sufficient and appropriate detail as to Patient DD's case so as to allow another registered medical practitioner to continue the management of Patient DD; and/or (h) clearly identify the Practitioner as being the person who made entries in Patient DD's medical notes. 156. The Practitioner contravened clause 36 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for restricted substances (as defined by section 4 of the Poisons and Therapeutic Goods Regulation 1994) to Patient DD during the period 5 September 1998 to 1 March 1999 (as shown in Schedule DD) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what was appropriate in the circumstances. 157. The Practitioner contravened clause 37(1)(a) of the Poisons and Therapeutic Goods Regulation 1994 by recording a date, other than the date of issue, on prescriptions for restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) issued to Patient DD as shown in Schedule DD1. 158. During the period 5 September 1998 to 1 March 1999 the Practitioner contravened clause 40(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing restricted substances (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient DD (as shown in Schedule DD) and failing to record the particulars of: (a) the name, strength and quantity of the substance prescribed; and/or (b) the maximum number of times the substance may be supplied on the prescription; and/or (c) the directions for use, as shown on the prescription. 159. The Practitioner contravened clause 81 of the Poisons and Therapeutic Goods Regulation 1994 by issuing prescriptions for drugs of addiction (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient DD during the period 22 February 1999 to 1 March 1999 (as shown in Schedule DD) in quantities and/or for purposes not in accordance with recognised therapeutic standards of what is appropriate in the circumstances. 160. During the period 22 February 1999 to 1 March 1999 the Practitioner contravened clause 84(1) of the Poisons and Therapeutic Goods Regulation 1994 by prescribing drugs of addiction (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient DD (as shown in Schedule DD) and failing to record the particulars of: (a) the name, strength and quantity of the drug prescribed; and/or (b) the maximum number of times the drug may be supplied on the prescription; and/or (c) the directions for use as shown on the prescription. 161. The Practitioner contravened section 28(b) of the Poisons and Therapeutic Goods Act 1966 by prescribing Codeine Phosphate, being a drug of addiction (as defined by section 4(1) of the Poisons and Therapeutic Goods Act 1966) to Patient DD during the period 22 February 1999 to 1 March 1999 (as shown in Schedule DD) otherwise than in accordance with an authority given to the Practitioner, when the Practitioner knew or ought to have known that Patient DD was during that period of time an addict (as defined by section 27 of the Poisons and Therapeutic Goods Act 1966). _____________________________ Karen Mobbs Director of Proceedings Health Care Complaints Commission 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.