Medical Tribunal New South Wales Medium Neutral Citation: Health Care Complaints Commission v Dr Riju Ramrakha [2013] NSWMT 8 Hearing dates: 4, 5, 6 and 7 February 2013 Decision date: 12 April 2013 Before: Judge P Lakatos SC Dr Susan Messner Dr Saw-Hooi Toh Ms Geri Ettinger Decision: Respondent reprimanded and subjected to conditions. See paragraph [110] for orders. Catchwords: MEDICAL PRACTITIONER - alcohol abuse by practitioner - inappropriate sexual comments in presence of patients - violent, aggressive or threatening behaviour to staff and patients - conducting consultations whilst under influence of alcohol - practice of inappropriate prescription of restricted Schedule 4D and Schedule 8 drugs - adequacy of records kept by practitioner - protective orders and practice conditions. Legislation Cited: Health Practitioner Regulation National Law (National) - Sections 139B, 139B(1), 139E and 139E. Medical Practice Regulation 2003 (repealed) - Schedule 2. Medical Practice Regulation 2008 (repealed) - Schedule 1. Cases Cited: Briginshaw v Briginshaw [1938] HCA 34; (1938) 60 CLR 336 HCCC v Litchfield (1997) 41 NSWLR 630 Spicer v New South Wales Medical Board and Others (unreported, 19 February 1981), HCCC v Karalasingham [2007] NSWC 267 A Solicitor v Council of the NSW Law Society [ 2004] HCA 1 Lee v HCCC [2012] NSWCA 90 King v HCCC [2011] NSWCA 253 Category: Principal judgment Parties: Health Care Complaints Commission (Applicant) Dr Riju Ramrakha (Respondent) Representation: L Fernandez for the Applicant M Lynch for the Respondent Health Care Complaints Commission (Applicant) Holman Webb Lawyers (Respondent) File Number(s): 40004/12 Publication restriction: Restriction on publication of any material that could identify the complainants Judgment 1The Health Care Complaints Commission (the HCCC), by Notice of Complaint alleges that Dr Riju Ramrakha (the respondent) is guilty of unsatisfactory professional conduct and professional misconduct under sections 139B and 139E respectively, of the Health Practitioner Regulation National Law (the National Law). 2Leave was granted for the HCCC to proceed on an Amended Complaint. The HCCC firstly alleges that the respondent: i. engaged in conduct that demonstrates that the knowledge, skill judgment possessed, or care exercised by him in the practice of medicine is significantly below the standard reasonably expected of a practitioner of equivalent level of training or experience; and/or ii. contravened a provision of the Medical Practice Regulation 2008 (now repealed); and/or iii. engaged in improper or unethical conduct relating to the practice or purported practice of medicine. 3The second complaint alleges that the respondent engaged in unsatisfactory professional conduct either in one instance or more than one instance, and that conduct is sufficiently serious to justify suspension or cancellation of his registration. 4The conduct is particularised in paragraphs 1 - 36 of the particulars, as follows: i. the respondent prescibed excessive quantities of addictive drugs (Valium or diazepam, oxazepam, Endone, OxyContin and oxycodone, Panadeine Forte, tramal or tramadol, Panamax, MS Contin, and Xanax or alprazolam) in the treatment of nine patients (Patients A to I) between November 2005 to November 2008 (paragraphs 1 to 31 of the complaint). Although the particularised conduct varies in minor respects as to each of the patients, it is generally alleged that the respondent's conduct was deficient in that: * he failed to exercise responsible medical judgment as to whether it was appropriate to issue such prescriptions; * he prescribed medication for a duration in excess of recognized therapeutic standards as to what is medically appropriate; * he failed to have appropriate consultations with the patients; * he prescribed for a purpose not in accordance with recognized therapeutic standards as to what is medically appropriate; * he did so when he ought to have known that the drugs prescribed were being or were likely to be abused; * he prescribed these drugs when this was contraindicated as it was known or should been known to the respondent that the patient was on a methadone program (Patients A and B); * the respondent prescribed specified drugs to Patients B and C for a period exceeding two months without obtaining the requisite authority, contrary to section 28 of the Poisons and Therapeutic Goods Act 1966; * the respondent failed to adequately manage Patient D's anxiety condition and insomnia; ii. the respondent failed to keep proper records in respect of 10 specified patients in accordance with the requirements of Schedule 2 of the Medical Practice Regulation 2003 (now repealed) and of Schedule 1 of the Medical Practice Regulation 2008 (now repealed) (paragraph 32); iii. between July 2005 and 18 December 2008, the respondent consumed alcohol or illicit substances in a manner which affected his mental health and behaviour (paragraph 34 a.); used illicit substances on his professional premises during consulting hours while patients were present on the premises (paragraph 34 b.); made inappropriate comments of a sexual nature in the presence of patients (paragraph 34 c.) and behaved in a violent, aggressive or threatening manner to staff and/or patients (paragraph 34 d.); iv. the respondent failed to observe professional boundaries in that he accompanied patients from his surgery to a local public bar and consumed alcohol and socialised with them during consulting hours (paragraph 35); v. between July 2005 and 18 December 2008, the respondent made inappropriate comments of a sexual nature to his receptionist on several occasions (paragraph 36 a.); shouted and used abusive or offensive language in the presence of patients and two members of staff (paragraph 36 b.); consulted with patients, whilst under the influence of alcohol or illicit substances (paragraph 36 c.) and accessed adult websites on computers in his practice and responded to messages received from those websites during consultations with patients (paragraph 36 d.). 5At the outset of the hearing, counsel indicated that the respondent admitted paragraphs 1 to 32 of the amended complaint (there being no paragraph 33). As the proceedings progressed, the respondent admitted all the remaining complaints save for paragraph 34 b. and d. and paragraph 36 d. In some cases, there were areas of contest about some of the facts which the HCCC led in support of the admitted complaints, but the area of dispute was not extensive. Consequently, the respondent accepted that by reason of his conduct, he was guilty of unsatisfactory professional conduct and professional misconduct. Background 6The respondent is nearly 54 years of age, having been born in Newcastle and raised in Sydney. After a distinguished high school career, he attended at the University of Sydney, completing his medical degree in 1983 and graduating in 1984. The respondent completed an internship at St Vincent's Hospital in Darlinghurst, New South Wales and became the Resident Medical Officer at St Vincent Hospital, being seconded to other suburban hospitals during the same period. After a short stint as Resident Medical Officer at Prince of Wales Hospital, in 1986, the respondent became a partner at the general practice owned by his father in Balmain. The respondent continues to run that practice to the present day. 7The respondent says that he was a moderate but regular consumer of alcohol up until the year 2000. He was a victim of an assault in September 2000, which resulted in pain and disabilities to his left leg, groin and back. The continuing symptoms left him depressed. The respondent brought legal proceedings against his assailant, which proceedings concluded in early 2007 adversely to him. The respondent dealt with the consequences of stress by drinking to excess. Furthermore, the respondent reported that from about 2004 onwards, his father and his uncle (both general practitioners at the subject practice), retired for various reasons. This had the effect of dramatically increasing the respondent's workload at the practice, which then had rooms at Balmain, Pyrmont and Drummoyne. Additional stressors for the respondent about this period were the deaths of two uncles, which affected him significantly. 8In November 2007, the respondent was driving his motor vehicle and was stopped by police for random breath test. The ensuing drug test showed the presence of cannabis, ecstasy and amphetamines in the respondent's blood. In December 2007, the respondent consulted a psychiatrist for counselling, and in an attempt to reduce his alcohol intake. In early April 2008, the respondent was persuaded by his cousin (and mentor) Dr Sanjay Ramrakha and another relative to admit himself into a private hospital, due to the severity of his conditions and their observations that his personality had changed. On 3 April 2008, the respondent voluntarily admitted himself to St John of God Hospital in Burwood, under the supervision of psychiatrist Dr Selwyn Smith in relation to his depression and alcoholism. The respondent was discharged on 24 April 2008. 9The respondent stated that he has been entirely abstinent of alcohol since his admission and discharge from St John of God Hospital. The Tribunal notes that since approximately 2008 to the present time, the respondent has undergone a number of drug tests for alcohol and drugs, which have proved negative. 10In about April or May 1994, the respondent came to the attention of the Pharmaceutical Services Branch (PSB) in relation to the prescribing of Endone (oxycodone) to a patient known to be drug dependent. 11In August 1998, the respondent was interviewed by officers of the PSB in relation to prescribing Rohypnol (flunitrazepam) on two occasions in early 1998 to a patient who was a relative by marriage to the respondent. The respondent admitted that in each case, he did not consult with the patient in relation to those prescriptions, and he provided the prescriptions upon the request of a pharmacist, who was then under investigation by the PSB. The respondent was subject to action by the NSW Medical Board and was found guilty of unsatisfactory professional conduct. He was reprimanded and practice conditions relating to Schedule 8 drugs, were imposed upon his registration. The respondent was required to satisfactorily complete the "Issues in General Practice Prescribing" and "Ethics" courses and the PSB prescribing course, to ensure that he had a proper knowledge of prescribing procedures and requirements. In March 2003, the respondent satisfactorily completed those courses and the NSW Medical Board's Conduct Committee resolved to remove the practice conditions previously imposed. 12In January 2008, the respondent disclosed to the Medical Board that he had been charged with the driving under the influence of drugs offence in November 2007. Shortly thereafter, the Health Committee of the NSW Medical Board resolved that an Impaired Registrants Panel Inquiry be convened. In August 2008, the respondent consented to the imposition of Practice Condition 1 (that is that he is not to prescribe, supply, administer or dispense Schedule 8 drugs of addiction without prior written authority) and a number of Health Conditions. 13The current proceedings arise out of a complaint received by the PSB in August 2008 from a police officer that persons were provided with "prescriptions as a result of payment rather than medical need" and that such prescription drugs were resold into the broader community. The Tribunal notes that it is not suggested, nor is there any evidence, that the respondent was complicit in these alleged activities. However, as a result of that complaint, investigations were commenced, relating to the prescribing history of the respondent. In the event, nine patients were identified and their prescribing histories examined. In broad compass, the complaints which the respondent has admitted establish that between 2005 and 2008, he prescribed significant quantities of Schedule 4 and Schedule 8 drugs to those patients inappropriately. Complaints Paragraphs 1 to 29 - Inappropriate Prescribing 14These complaints are particularised in paragraphs 1 to 7; 9 to 16; 19 to 27 and 29 and were admitted by the respondent. The respondent admits prescribing excessive quantities and inappropriate drugs to nine patients (being identified as Patients A to I) over a period of time sometimes spanning up to three years. 15The evidence established that in relation to Patient A, between September 2007 and October 2008, the respondent prescribed a total of 20 prescriptions for Valium. The respondent accepted in his evidence that he knew that Patient A had a severely dysfunctional background. She had hepatitis C and had previously used benzodiazepines for anxiety, going back many years. She had also been prescribed Valium, had been charged with a serious criminal offence and drank alcohol very heavily. The respondent admitted that there was a real risk in mixing of benzodiazepines and alcohol so far as this patient was concerned. The patient stated that she could not take Valium due to severe adverse reactions. Against this background, the respondent conceded that the correct thing to do would have been not to prescribe Valium at all. He did not do so because he fallaciously thought that if he did not prescribe Valium, the patient would go doctor shopping and he wished to continue to manage her overall condition. 16The respondent admitted that he had no effective written plan for the management of Patient A but asserted that he had a mental plan. Furthermore, he conceded that prescribing Valium to a patient on the methadone program was something which fell significantly below the standard expected of a practitioner of his experience. 17In relation to Patient B, between March 2006 and May 2008 the respondent wrote a total of 60 prescriptions for diazepam, oxazepam, Endone, OxyContin and oxycodone and Panadeine Forte. 18The respondent accepted that Patient B had provided a history of having been on a methadone program at some stage in the past and he was mindful of the fact that prescription of serious drugs to such a patient may be problematic. Whilst the respondent accepted that he did not apply for authority to prescribe Schedule 8 medications to Patient B, he had some confusion concerning the rules and regulations about prescribing when an authority was required. 19The Tribunal has some concern about this evidence, given that by 2003 following earlier disciplinary proceedings, the respondent had undergone additional training courses relevant to prescribing such drugs. 20The respondent accepted that when he prescribed the multiple drugs to Patient B for a period of approximately 26 months, he should have had regard to the fact that there could be serious side-effects to the patient and that there was a risk of possible inappropriate disposal of those drugs by the patient to others. 21In addition, the respondent admitted failing to adequately or appropriately manage Patient B's medical conditions in that he concurrently prescribed multiple psycho-active drugs in a manner not in accordance with recognized therapeutic standards; that he prescribed narcotics to a patient with a history of intravenous drug use in circumstances where he knew or should have known that Patient B was on a methadone program and that he prescribed Endone, OxyContin or oxycodone for a period exceeding two months without obtaining the requisite authority from the Director-General of the New South Wales Department of Health. 22Between November 2005 and November 2008, the respondent admitted that on 315 occasions, he prescribed Patient C drugs, being diazepam, tramadol, oxycodone and Panadeine forte. 23Patient C provided the respondent a history of serious injuries due to a road accident in 1985, and that he was already taking diazepam and Panadeine forte. Furthermore, he was drinking heavily and was suicidal. The respondent was aware that the patient had a number of dependency issues, and might be a person who went doctor shopping. In these circumstances, the respondent admitted that he was prescribed very high dosages of Valium, sometimes writing multiple prescriptions on the one day. The respondent accepted that the patient was a very difficult one. He agreed that he had no written management plan in relation to Patient C. 24Between February 2006 and October 2008, the respondent admitted prescribing Valium and Panadeine forte to Patient D on 145 occasions. The respondent was aware that Patient D had used amphetamines which she had ceased to do in 1998. She had also used heroin in 1986. Accordingly, the respondent was aware of the difficulties involved in her having an addiction. The respondent was also aware of the addictive qualities of benzodiazepines and accepted that he should not have in these circumstances, prescribed that drug or compound codeine to Patient D. 25In relation to Patient E, between August 2006 and November 2008 the respondent wrote a total of 52 prescriptions for Valium. The respondent was aware that this patient was severely unwell for much of the period that she was under his care. She complained of sleep and breathing difficulties. She also experienced severe pain. The respondent stated that he was attempting to wean Patient E off benzodiazepines, but he considered this a secondary matter to dealing with her immediate pain problems. He recognized the possibility that this patient was a doctor shopper. The respondent did not use pain scales and accepted that he did not monitor any tolerance the patient might have built up in relation to use of diazepam for pain management. 26In relation to Patient F, between July 2005 and November 2008 the respondent wrote 142 prescriptions for Valium and Panadeine forte. The petitioner was aware that Patient F had chronic pain issues. She had severe anxiety problems resulting from sexual abuse as a child. The patient had used Serepax very heavily in the past. Furthermore her child had died in 2000 and the respondent recognized that she had a real potential for dependence on drugs. The respondent admitted that despite him sending Patient F a letter in mid-August 2005, advising her to avoid taking Codalgin forte and Panadeine forte every day, in that period he regularly prescribed her Valium and Panadeine forte. The respondent accepted that he failed to keep written records in relation to this patient. 27Between December 2005 and November 2008, the respondent wrote 100 prescriptions for Patient G for Valium, Panadeine forte, and MS Contin. The respondent was aware that Patient G suffered from severe pain. He prescribed the patient MS Contin for a period in excess of a year, and never initiated a reduction of the dosage. The respondent said that this was because he thought the patient was seeing a specialist and he was awaiting the specialist's assessment. He accepted retrospectively that he should have reduced the medication himself. 28In relation to Patient H, between April 2007 and November 2008 the respondent wrote 66 prescriptions for Valium, Xanax and OxyContin (the complaint alleges over- prescription of the latter drug between 24 March 2006 and 4 May 2006). The respondent was aware that this patient was a person with severe psychological problems. He was also a person who had used recreational drugs in the past. The respondent acknowledged that he prescribed Patient H with diazepam and Xanax for a significant period of time. 29Finally, between January 2005 and January 2008, the respondent wrote 89 prescriptions for Patient I for Panadeine forte and Xanax. The respondent was aware that this patient had an extremely disturbed psychological background. Nevertheless for a period in excess of three years, the respondent prescribed the drugs to referred above. 30The respondent accepted that he was aware of the risks of prescribing the various drugs to Patients A to I. These risks were the potential misuse of those drugs, the risks associated with persons taking strong medication on a long-term basis and the actual risks inherent in relation to the drugs prescribed. He accepted that the quantities of the drugs he prescribed were in the most part very high and he had an awareness of the dangers of prescribing serious drugs to patients. 31The expert on behalf of the HCCC, Dr Chung was generally highly critical of the respondent's conduct as set out in these complaints. In most cases, he concluded that the conduct fell significantly below the standard reasonably expected of a practitioner of equivalent level of training or experience applicable at the time the conduct occurred. Generally, he disapproved or strongly disapproved of the respondent's treatment of the patients involved in these complaints. 32In the light of the respondent's admission of these complaints and Dr Chung's expert opinion about the lack of professional propriety of that conduct, the Tribunal is comfortably satisfied that each of the complaints has been established. In particular, the Tribunal accepts the submissions of the HCCC that the respondent's conduct was serious given the following features: each patient was a complex patient with complex personal history. The respondent prescribed serious drugs to each of them and he did so, over an extended period of time. There was an actual risk to each patient as a result of the drugs prescribed by the respondent and as a result of the period over which the drugs were prescribed. The respondent should have been aware of the dangers to the patients, including the potential for addiction or misuse of the drugs, or in which the prescriptions were contraindicated. The conduct involved nine patients in a period spanning 3 years and 10 months between January 2005 and November 2008. In these circumstances, the conduct cannot be characterised as an isolated lapse of judgment especially as the respondent was previously counselled for prescribing problems and his conduct took place after having done remedial courses. 33The Tribunal accepts the further contention that the respondent did not provide a satisfactory explanation as to why he prescribed medication to the patients in the ways described, but we have formed the view that the effect of his excessive alcohol intake and his psychological problems together, contributed to his extended lack of judgment in acting as he did. Paragraph 32 - Inadequate Record Keeping 34The respondent admitted this complaint and the Tribunal is comfortably satsified that this complaint is established. The evidence before the Tribunal shows that in the years since 2008, the respondent has taken proper steps to remedy this deficiency and to deal with other shortcomings in relation to his practice. 35In relation to the remainder of the complaints, the respondent admitted some of them but contested the detail of them as indicated below. He denied other complaints entirely. Generally, the HCCC relied upon the evidence of a number of patients, a former IT employee Mr Christopher Moloney and a medical student (now a qualified doctor), Dr Sukarma Tanwar, who was employed at the respondent's practice between June 2007 and July 2008. 36At the outset of the proceedings, counsel for the respondent indicated that Dr Tanwar's account was not disputed. Since many of the contested complaints are supported in many respects by that account, the Tribunal is relieved of the task of resolving issues of fact, where there is dispute between the respondent's evidence and the evidence of the HCCC witnesses, Dr Tanwar excluded. Paragraph 34 a. - Alcohol Use 37In his written statement to the Tribunal, the respondent stated that up until 2000, he drank alcohol in moderation. As a result of a number of traumatic events which occurred between September 2000 and approximately 2007, the respondent's alcohol consumption increased. The problem came to a head, according to the respondent in November 2007 when he was stopped whilst driving for a random breath test. 38Apart from a general description about his consumption, the statement did not specify the quantities of alcohol or the frequencies of his consumption. His evidence in these proceedings in this regard was not wholly satisfactory. He was asked by his counsel whether he admitted the allegation that he consulted with patients while under the influence of alcohol. His reply was in our view, somewhat guarded as follows: "There was alcohol in my blood stream, yes". That answer was not responsive to the question; it did not in terms, constitute an admission to the complaint and avoided the central issue of the impairment of the respondent's judgment. 39The respondent admitted that probably around 1999 or 2000, he commenced drinking heavily. His consumption escalated in periods of stress. The level of consumption was at least two beers in the evening and at least a bottle of wine. This occurred during the weekdays and possibly more on the weekends. 40When asked to describe his peak level consumption of alcohol, the respondent said that he rarely previously drank spirits but he started to drink vodka. He did not specify at this point the amount of vodka he consumed nor the circumstances in which that occurred. We note that he apparently told his psychiatrist, Dr Selwyn Smith in October 2012, that he had been consuming at least a half bottle of vodka every day. 41The respondent's admission concerning his driving whilst under the influence of drugs charge, was also guarded. When asked by his counsel what he had consumed leading up to that charge, the respondent said: "The analysis indicated cannabis, amphetamines and ecstasy" and when pressed as to whether that was what he had taken, he admitted that he had taken those drugs some hours before. He said that he was encouraged to engage in these drugs by a younger woman, whom he had met. 42His counsel returned to the issue of his drinking, asking how his excessive drinking would affect his mood. The respondent stated that he was irritable in the last hour before lunch, and then consumed two to three glasses of wine, adopting the "fallacious reasoning at that time ... that by four o'clock, I'd be under the legal limit". He admitted that at times he had more than three glasses of wine at lunch. Furthermore, he said that in last month before admission to hospital on April 2008, he woke up in the early hours of the morning and drank vodka to go to sleep. 43In cross-examination, the respondent stated that during 2005, he consumed a bottle of wine and at least two beers a day, although he said he could not say with any certainty. The respondent did not accept that he was intoxicated in 2004 to 2005 "for the very pragmatic and simple reason that I wanted to be able to drive a motor vehicle." The respondent stated that he had the erroneous thinking that if he was under .05 he would be okay. Even when he was asked to look back and reflect upon his state of intoxication, he continued to use the formulation: "I had alcohol in my blood". 44The respondent confirmed that by late 2007 that he consumed vodka in the early hours of the morning. When it was put to him that on those occasions from late 2007 onwards, he arrived at his practice intoxicated, the respondent answered in these terms: "It depends on one's definition of intoxication, but I admit there was alcohol at my bloodstream which there should not have been." The respondent accepted that some days he was intoxicated and others he simply had blood alcohol (both of which he thought were equally bad). He reluctantly conceded that his alcohol consumption "potentially" affected his performance as a doctor but he did not know "whether there was any particular adverse outcome on any particular day with any particular patient". The Tribunal accepts the respondent's thinking between 2000-2008 might well have been adversely affected by his alcohol intake. It is easy to understand that at that time he may have lacked insight into the effects of his abuse of alcohol. Given that he has admitted that in that period of time, he significantly over prescribed dangerous drugs to multiple patients, his statement that he was unaware of any particular adverse outcome is somewhat surprising and we consider lacks insight. 45The manner in which this evidence came out (noting that it was initially in response to questions asked by his own counsel) indicated to the Tribunal that notwithstanding his asserted present insight, the respondent has difficulty in making frank admissions in an unqualified way as to what he did, even though his position now is that he has been abstinent from alcohol and illegal drugs since April 2008. 46The respondent's case was put on the basis that his alcohol abuse, along with a major depressive disorder, were the precipitating causes of his lack of judgment in relation to his professional practice. It is not suggested that depression alone would have caused or precipitated such errors of judgment in the respondent. 47Consequently, the conundrum implicit in accepting the respondent's evidence about the effect on him of his excessive consumption of alcohol is self-evident: if his level of impairment was not significant, then his unsatisfactory professional conduct relating to overprescribing cannot be easily explained by reference to the effect of the alcohol. If on the other hand he was significantly affected - this would explain his unsatisfactory conduct but his failure to acknowledge this, reflects adversely on his insight. It is substantially for this reason that the Tribunal considers it necessary to continue the application of the restrictions which regulate the respondent's conduct at the present time. We recognize that the medical and psychological professionals whose reports are part of the materials before the Tribunal differ from this conclusion, but it does not appear that their opinions were based on the equivocal nature of the respondent's position as exhibited in his evidence. 48The effects of such alcohol consumption were well-documented in evidence. Patients J and B, each gave consistent evidence that they observed the respondent spraying Baygon on his skin, because he thought he had "bugs" on him. The credibility of those witnesses was attacked. However, Dr Tanwar confirmed their evidence in the following terms: Dr Ramrakha was obsessed with the thought that he had bugs crawling over his body. He used to spray Baygon on his skin for the purpose of removing the bugs which he believed were there. I didn't ever see any bugs on his skin, but he believed they were there. As a colleague, I checked his skin on two or three different occasions. I didn't see any bugs. I only saw scratch marks where he had been scratching. When he sprayed Baygon or eucalyptus oil on himself, the smell was strong. He often sprayed those things and it was not possible to smell alcohol after he had been drinking. 49The respondent himself gave evidence that he had sprayed his skin with Baygon, but did so only once out of desperation. This was at a time that he was using alcohol to excess. 50Furthermore, Dr Tanwar indicated that after the respondent returned from the hotel at lunchtime, he exhibited signs consistent with being affected by alcohol, namely, he would stare, walk differently, drag his feet and be agitated and speak to staff rudely. 51The Tribunal concludes that the evidence of Patients J and B added to the uncontested evidence of Dr Tanwar, together form a sufficient basis to be comfortably satisfied that this complaint has been established. 52The respondent has admitted that in that general time period, he had taken cannabis, ecstasy and amphetamines, but only on weekends in a social context. However, he denied that he indulged in illicit drugs at any time during surgery hours and at his surgery. 53In summary, the Tribunal has reservations about some of the evidence that the respondent gave. In relation to the effect of his alcohol intake, the respondent tended to give qualified answers which in the view of the Tribunal, appeared to be an attempt to minimise or downplay the effects of the alcohol on his judgment and the extent of his misconduct. This led to a contradictory approach to the respondent's defence and/or explanation of the various complaints made against him. On the one hand, he relied upon the fact that he was "a terrible alcoholic" to provide an explanation for the over-prescribing complaints. On the other hand, he denied being under the influence of alcohol or being intoxicated. 54This is a matter which reflects adversely on his insight in relation to carrying on professional practice, whilst under the influence of alcohol. It also demonstrates his inability to view the problem of his alcohol addiction in terms of the potential harm it might do to his patients. Paragraph 34 b. - Using Illicit Subtances at Surgery during Consulting Hours 55Patient J provided a statement in which she stated that in early November 2007, she observed the respondent returning from the local hotel very intoxicated. She saw him going into one of the consultation rooms and shutting the door. Patient J opened the door and observed the respondent with "a thing like a bong, which had white crystals in the base." She asked the respondent whether it was ice, and he said that it was. Patient J confirmed this account in her oral evidence before the Tribunal, describing the bong as having bulbous bottom with plain water and white crystals on the bottom. There is some support in the respondent's own evidence for these allegations. He admitted that about this time he was using illicit drugs including methamphetamines or ice, but only away from the surgery and on weekends. 56The respondent denied the allegation of drug use at his surgery. His counsel robustly cross-examined Patient J about her memory, the circumstances in which she belatedly came before the Tribunal, and other matters relevant to her credibility. It is not necessary to repeat that evidence. 57Although, The Tribunal accepts Patient J as an honest witness, we considered that Patient J presented as a person with many medical difficulties. The evidence disclosed that she had been charged with perjury or false swearing. Furthermore, the evidence disclosed that she had on a number of previous occasions, made complaints against other people, which were subsequently either withdrawn or not proceeded with by the police. These raise significant questions about the reliability of Patient J's evidence. 58Given the seriousness of this allegation, the Tribunal is not comfortably satisfied that the evidence is sufficiently reliable to justify the conclusion that this complaint has been made out. Paragraph 34 c. - Inappropriate Comments of Sexual Nature in Presence of Patients 59Evidence was led from Patients J and B, Mr Moloney and Dr Tanwar in support of this complaint. None of these witnesses gives evidence about the same incident, but the various incidents they deposed to are similar. It is not necessary to refer in detail to the claims made by each of them. Suffice to say, they involved the respondent making personal comments about his sex life in front of patients, as well as making suggestive comments to his staff and making sexual gestures towards them. 60Whilst the respondent admitted the complaint, he gave a more benign complexion of his acts and words. He accepted that he had made inappropriate comments to female patients, but mainly to female staff members. Furthermore, the respondent admitted that the comments were made whilst patients were "probably within earshot". 61Dr Tanwar's evidence was as follows: I have witnessed Dr Ramrakha making horrible comments about his receptionist in front of patients. ... Dr Ramrakha would make dirty comments to her, he would say personal comments about his sex life in front of patients and other people. It was very embarrassing. 62The Tribunal is comfortably satisfied that the complaint that the respondent made inappropriate comments of a sexual nature in the presence of patients is made out by the evidence led by the HCCC. Paragraph 34 d. - Behaving Violently, Aggessively or Threateningly to Staff and/or Patients 63The respondent denied this complaint. Mr Moloney gave evidence that the respondent would call patients "stupid". He would scream in loud and bullying terms to staff in front of patients and would use foul language. Patient J also gave evidence of the respondent's conduct towards her, consistent with this manner of behaviour. 64Dr Tanwar stated in his statement that the respondent: "On a few occasions he used to be really crazy. He would shout at staff members and make bad comments like swearing at them. He would do this when patients were present in the surgery." 65The Tribunal accepts the evidence of the witnesses for the HCCC and is comfortably satisfied that this complaint has been established. Paragraph 35 - Failure to Observe Professional Boundaries 66This complaint is admitted by the respondent. Patient J stated that when she was at his surgery, the respondent invited her to the local hotel where they drank alcohol together. Dr Tanwar stated: " I have witnessed Dr Ramrakha offer patients alcohol. I have seen him in the surgery invite patients to go with him to the pub across the road. ... while we were having lunch at the pub we would be joined by patients who would sit down and drink with Dr Ramrakha. I have seen Patient J join him in the pub quite a number of times." The Tribunal is comfortably satisfied that this complaint has been established. Paragraph 36 a. - Inappropriate Sexual Comments to Staff 67Mr Moloney said that the respondent used to proposition his receptionist in front of patients. This had occurred on several occasions. Dr Tanwar gave substantial support to that version of events. The respondent admitted that complaint and the Tribunal is comfortably satisfied that the complaint has been established. Paragraph 36 b. - Abusive or Offensive Language in presence of Patients or to Staff 68There is a substantial overlap between this complaint and the complaint referred to above in paragraph 34 d., although the HCCC relies upon evidence from different sources. Based upon the evidence of Mr Moloney and Dr Tanwar, referred to above, at paragraphs 63 to 65, the Tribunal is satisfied that this complaint has been established. Paragraph 36 c. - Consulting with Patients whilst Under Influence of Drugs/Alcohol 69There is a substantial overlap between this complaint and the complaint referred to above in paragraph 34 a. The respondent admits so much of this complaint as alleges that he was under the influence of alcohol. The evidence of the patients, supported by Dr Tanwar's evidence, is conclusive of the fact that the respondent was significantly affected. 70The Tribunal is not persuaded that he was affected by drugs (a complaint which was substantially based upon the evidence of Patient J) but is otherwise satisfied that the complaint has been established. However, the level of his intoxication and his irrational behaviour, consequent upon it, render the distinction between the cause of the intoxication as alcohol or drugs, of little consequence. Certainly, the effect of his intoxication upon his professional capacity and judgment from the perspective of his patients, is not affected by this distinction. Paragraph 36 d. - Accessing Adult WebSites 71This complaint was denied by the respondent. This complaint relies on the evidence of Mr Moloney who was employed by the respondent for a short time. Mr Moloney left the employment of the respondent in unhappy circumstances, claiming that the respondent had not paid him his proper wages. Counsel for the respondent submitted that his evidence ought not to be accepted because he was a disgruntled employee with an axe to grind. The Tribunal rejects that submission, concluding that he was an honest witness. 72There are two aspects to Mr Moloney's evidence, which potentially impact upon the respondent's professional integrity and competence. The first is his resorting to so-called "adult websites" during professional consultations and responding to messages; the second is the vulnerability of the system to outside hacking. The respondent himself gave evidence that during consultations, he sometimes took account of and responded to messages on a computer communication system, which was on his desk. However, he denied that he accessed adult i.e. in the sense of pornographic, websites at all. 73Mr Moloney, in his statement, described the websites as "adult websites", "live chat sites" and recalled the names of the sites as "Red Hot Pie (or similar)" and "Adult Friend Finder". He stated that the respondent was always waiting for new messages, which beeped when he was involved in consultations during consulting hours. In his evidence before the Tribunal, Mr Moloney agreed that the websites could be properly described as "dating websites", although he later described them as pornographic sites. He was clear that the respondent's access to these sites was during consultations. 74The respondent gave evidence that he did not consult pornographic websites during consulting hours; and only consulted dating websites like RSVP and eHarmony, on his home notebook computer. He denied that any of these websites were open on other computers in the surgery. 75The Tribunal accepts the main thrust of Mr Moloney's evidence. However, given his various descriptions of the relevant websites, we are not satisfied that they were "pornographic websites". Nevertheless, we consider that the main thrust of the complaint is that the respondent was engaging in personal interests, at a time when his sole focus should have been on his professional duties to the patients he was seeing. In so far as this aspect is concerned, we accept Mr Moloney's evidence. 76It follows that we are comfortably satisfied that this complaint has been established in the terms we have discussed. 77Without diminishing the seriousness of the conduct in the complaints particularised in paragraphs 34 to 36, the Tribunal considers that in most cases, they were manifestations of the underlying psychological and alcohol/drug abuse problems suffered by the respondent. We consider that if the underlying causes are effectively dealt with, a repetition of conduct of this kind by the respondent is unlikely. Principles 78The following statutory enactments and legal principles apply in proceedings of this kind. Section 139B(1) of the National Law defines "unsatisfactory professional conduct" as including: (1) "Unsatisfactory professional conduct" of a registered health practitioner includes each of the following- (a) Conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of the practitioner's profession is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience. ... (l) Any other improper or unethical conduct relating to the practice or purported practice of the practitioner's profession. 79Section 139E defines "professional misconduct" as: (a) unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration; or (b) more than one instance of unsatisfactory professional conduct that, when the instances are considered together, amount to conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration. 80The Tribunal accepts in accordance with the authorities that such complaints asserting serious improper conduct must be established on the balance of probabilities. But according to the standard expressed in Briginshaw v Briginshaw [1938] HCA 34; (1938) 60 CLR 336 i.e. on the balance of probabilities "subject only to the rule of prudence that any tribunal should act with much care and caution before finding that a serious allegation ... is established". 81In HCCC v Litchfield (1997) 41 NSWLR 630, the Court of Appeal stated that at p.637: Disciplinary proceedings against members of a profession are intended to maintain proper ethical and professional standards, primarily for the protection of the public, but also for the protection of the profession. 82The Court of Appeal in Spicer v New South Wales Medical Board and Others (unreported, 19 February 1981), Hope JA, (Reynolds and Hutley JJA agreeing) wrote as follows: Strict adherence to the statutory requirement relating to the use of drugs of addiction is required in medical practitioners ... any medical practitioner who prescribes drugs of addiction other than in accordance with the law is seriously misconducting himself in a professional respect. It is clear beyond argument that the proper handling and prescribing of drugs by medical practitioners is of the greatest importance to the community. If a medical practitioner handles or carries out that very great responsibility in a way that is reckless and which shows a disregard for the law, it cannot be said he is fitted at such a time to be a medical practitioner. 83Those principles remain as valid today as they were thirty years ago and the Tribunal is duty bound to apply them. 84The Tribunal accepts that its role is to protect the public by ensuring there is no repetition of misconduct, acknowledging that any decision will have a deterrent effect on others who might transgress against the high standards required, and will have the effect of encouraging the maintenance of high standards in medical profession, as well as maintaining public confidence in it. We also recognize the countervailing factor that any decision would not necessarily deprive the public of services of a medical practitioner. 85The Tribunal accepts that a finding of professional misconduct does not automatically lead to cancellation of a medical practitioner's registration - HCCC v Karalasingham [2007] NSWC 267 at [67]. 86Furthermore, the Tribunal accepts that normally a pre-requisite for making orders for the de-registration of a medical practitioner, is that it must find that he or she is currently probably permanently unfit to practise. It is fitness at the time of the hearing, which is of central importance - see A Solicitor v Council of the NSW Law Society [ 2004] HCA 1 at [21]. 87It is incumbent upon the Tribunal to recognize that the specific purpose for which orders are made is protective in the public interest and not punitive with respect to the individual. Nevertheless, it must recognize that such orders may be punitive in effect, and hence such punitive effects may be relevant in formulating a protective order. The Tribunal must also recognize in an appropriate case, that the "harrowing experience of disputed proceedings, together with the real threat of loss of livelihood, may have opened the eyes of the individual concerned to the seriousness of his or her conduct so as to diminish significantly the likelihood of its repetition, and to produce a level of insight into his or her own character or misconduct, which did not previously exist" - Lee v HCCC [2012] NSWCA 90 at [20]. 88In assessing the central question of the respondent's fitness to practice, it is important to have regard to the steps he has taken since this conduct occurred. Events after 2008 89The respondent was reviewed by a Review Panel on 12 June 2012. The report summarised the respondent's history with the Impaired Registrants Panel since approximately August 2008. It noted that on 28 April 2009, Section 66 proceedings were convened to investigate concerns about the respondent's prescribing. At that time, the delegates expressed a number of concerns about the respondent's practice in that he failed to request authority to prescribe drugs of addiction to patients, whom he was aware had a history of drug dependence; that he had been over prescribing for patients; and that he failed to keep adequate medical records. The delegates ordered a performance assessment which occurred in August 2009. The respondent's performance was assessed as satisfactory in all domains except as to the content of his records and his office facilities which were unsatisfactory. On 4 March 2010, a Performance Review Panel found the professional performance of the respondent was unsatisfactory in that his knowledge, skill and care in the practice of medicine were below the standard reasonably expected for a practitioner of equivalent level of training or experience in the area of medical records content and office facilities. 90The respondent was previously reviewed on 11 May 2011, at which time his sustained commitment to the rehabilitation were summarised as follows: Dr Ramrakha remains well and stable. He is committed to a comprehensive support programme of medical, psychological and professional follow-up to long-term sobriety and to an Alcoholics Anonymous approach to recovery. He has now been sober for over four years. His practice has successfully passed the accreditation process, he continued to maintain regular links with mentors and he has been able to respond to Council queries about prescribing in an organised way. 91The respondent was noted to have remained fully compliant with the conditions of his practice and was working towards a full practice accreditation. The Reviewers agreed with the Council appointed psychiatrist's view, that but for the HCCC enquiry, the respondent's conditions should be eased with a view towards exit. 92Since approximately 2008 or 2009, the respondent has been assessed by a psychiatrist on behalf of the Medical Council, Dr Anthony Samuels. The Tribunal was provided with reports from Dr Samuels, the most recent being dated April 2011, and 2 May 2012. In the earlier report, the respondent declined to disclose matters about the disciplinary proceedings, because the matter was "sub judice". He claimed that a person who performed volunteer work for him had made "a spurious complaint". He labelled the complaints "malicious", and somewhat "bizarre". He expressed concern about the adverse publicity. 93The respondent stated that he continued to see his psychologist on a regular basis. He regularly consulted his psychiatrist Dr Selwyn Smith and was on medication. He labelled himself "a celebrity", in his after-care group having been there for three years. 94Dr Samuels concluded: Dr Ramrakha seems to be very stable from a mood point of view. He certainly continues along the path of sobriety and he continues to access all the supports that are in place. He is very committed and enthusiastic about the changes he has made in his life. 95Dr Samuels conducted the respondent's routine annual review in May 2012, and his views were not materially different. Dr Samuels confirmed that the respondent continues to do very well and is compliant with all the conditions upon him. The report notes that he has been abstinent from alcohol for four years, things in his practice seem to be going well and the respondent continues to be well engaged with the support groups and his therapists. Dr Samuels saw no impediment to easing back on some of the conditions presently on him and moving the respondent towards exiting the Impaired Registrants Program, once these proceedings have concluded. 96The respondent relied upon a number of expert reports, in his own case, which it should be said, contained similar opinions to those already referred to immediately above. 97Dr Selwyn Smith psychiatrist, furnished a report dated 17 October 2012, in which he confirmed that the respondent is a patient under his clinical care. Dr Smith recorded that his progress to date included the following matters: the respondent has not consumed alcohol or drugs of addiction since his discharge from St John of God Hospital. He continued to attend Alcoholics Anonymous, as well as the after-care program at the hospital. He has had ongoing regular appointments with Dr Smith. The respondent has also undergone regular blood screening through a mandated program of the Medical Council of New South Wales. 98Dr Smith opines that the respondent experienced a major depressive episode associated with generalised anxiety to the point of panic. The report sets out the symptoms and Dr Smith's overall conclusion that the respondent had been decreasingly active, effective and productive. Dr Smith was of the view that the respondent had benefited considerably from his admission to hospital. He has been most compliant with treatment and attended at professionals and various programs as directed. Dr Smith was of the view that with further treatment, the likelihood of any relapse would be low. He found the respondent to be a genuine man who has displayed significant remorse, shame and humiliation for his conduct. Dr Smith remained optimistic in regard to an excellent prognosis. It was Dr Smith's opinion that the respondent is fit to continue to practise medicine. 99Ms Justine Corry, psychologist worked with the respondent on a weekly basis for approximately 23 months (and he consulted Ms Corry's colleague for 16 months previously). In that time he has been sober. The aim of the treatment was to maintain his sobriety, for the respondent to understand the triggers for his drinking and to improve his capacity to regulate negative emotions and to examine this interpersonal relationships to develop healthy boundaries. Ms Corry reports that the respondent has maintained his sobriety and reported no cravings to drink alcohol; his mood has been positive, and generally is better able to cope. She concluded that his prognosis was excellent, and he was committed to maintaining his sobriety. In Ms Corry's view, the respondent demonstrated all the characteristics of somebody who has made a full recovery, and his risk of relapse was negligible. Accordingly, she considered he posed no risk to the community as a medical practitioner. 100The respondent's mentor and cousin Dr Sanjay Ramrakha provided a similar opinion in his letter of 5 November 2012. Conclusion 101The Tribunal is comfortably satisfied that all the complaints (on the basis set out in the reasons above) have been established (with the exception of paragraph 34 b.). The Tribunal concludes that the respondent is guilty of unsatisfactory professional conduct. Furthermore, the Tribunal concludes that the conduct considered together, occurred over an extended period and was sufficiently serious to justify the respondent's registration being suspended or cancelled i.e. that the respondent is guilty of professional misconduct. 102Section 3A of the National Law provides that the protection of the health and safety of the public must be the paramount consideration. Section 149A of the National Law provides that the Tribunal in exercising its clearly protective and not punitive jurisdiction, may impose various sanctions including imposing conditions it considers appropriate on the doctor's registration - subparagraph (b). Furthermore, section 149C of the National Law provides that where the Tribunal finds a respondent guilty of professional misconduct, it may suspend his registration for a specified period or cancel his registration. 103The HCCC contended that suspension or registration was the appropriate protective order to be made. That submission is consistent with the principles we have referred to above concerning the serious nature of the respondent's misconduct over more than three years, and the potential harm that he exposed patients to in that period. 104However, almost five years have passed since that conduct last occurred. The evidence establishes that the respondent has undergone personal and professional assistance to address the underlying precipitating causes of his behaviour and according to the professional opinions of Drs Samuel and Smith, he has been successful in so doing. 105We have expressed reservations about aspects of the respondent's evidence in these proceedings, especially regarding the extent of his alcohol problems between 2000 and 2008. We recognize, however, that we have only had the opportunity to assess the respondent in a somewhat artificial and stressful process of a disciplinary hearing over some days. Drs Samuels and Smith (whom we regard as careful and competent psychiatrists) have assessed the respondent over a much longer period. We are reassured by their consistent opinions about the respondent's progress, and also by his unblemished professional history since 2008. The evidence suggests that since 2008, the respondent has continued to practise subject to conditions in a professional and competent fashion. 106Against that background, the Tribunal considers that the doubts it has about the respondent's evidence in attitude, can be accommodated in so far as the considerations set out in section 3A of the National Law are concerned, by the orders we propose to make. 107However, it it should be noted that the HCCC conceded that since 2008, the respondent has acted without blemish in a professional sense and has undertaken the necessary medical and professional assistance (including drug and alcohol testing and also a restriction on his prescribing schedule 8 drugs) required to ensure that his professional practice achieved the appropriate standard. That concession is well made. 108It was agreed between the parties that given the majority of the complaints and the fact that the respondent was guilty of professional misconduct were both admitted and all relevant material was before the Tribunal, it was unnecessary to have a separate hearing on the issue of consequential orders cf King v HCCC [2011] NSWCA 253. The parties were content to rely upon the evidence already before the Tribunal in this regard. 109The Tribunal has determined that it is appropriate that the respondent be allowed to continue to practise but subject to conditions, particularly as to having a mentor and subjecting himself to drug and alcohol testing. The respondent's present mentor is his cousin Dr Sanjay Ramrakha who has practised as an emergency physician at the Royal Prince Alfred Hospital since 1998. We do not doubt that Dr Sanjay Ramrakha is well qualified and enjoys a good reputation amongst his peers, but we consider it more appropriate that the respondent's mentor should be an independent, experienced and practising general practioner. Furthermore, we consider that the respondent should subject to a condition that he regularly submit himself to the EtG test. Orders 110The Tribunal makes the following orders: a. the respondent is reprimanded; b. the respondent complies with the conditions in Annexure A; c. the respondent pays the HCCC's costs less one day (consistent with the order made on 7 February 2013). ANNEXURE A DR RIJU RAMRAKHA Practice Conditions 1. Not to possess, prescribe, supply, administer or dispense Schedule 4 Appendix D drugs. Dr Ramrakha's Schedule 4 Appendix D drug authority is to remain withdrawn by the Pharmaceutical Services Unit. 2. Not to prescribe, supply, administer or dispense Schedule 8 drugs of addiction without the prior written authority of the Pharmaceutical Services Unit. 3. Any future change to his Schedule 8 and Schedule 4D authorities must be in accordance with the Council's protocol. This includes consultation with the Council prior to thesubmission of any variation application to the Pharmaceutical Services Unit. 4. To obtain approval of the Council prior to changing the nature or place of practice. 5. To authorise the exchange of information between the Pharmaceutical Services Unit, the Council and Medicare Australia in order to facilitate compliance with these conditions. 6. The Council may notify any employer/s of any issues arising in relation to compliance with these conditions. 7. To complete within 12 months of the date of this Decision and at his own expense the distance education course "Issues in General Practice Prescribing" conducted by the Department of General Practice, Monash University. a) Within one week of the date of enrolment he must provide evidence to the Council of enrolment in the Issues in General Practice Prescribing course. b) Within two weeks of completing the Issues in General Practice Prescribing course, he is to provide documentary evidence to the Council that he has satisfactorily completed the course. 8. To complete within 18 months of the date of this Decision and at his expense the course "Medical Ethics" conducted in distance mode by the Department of General Practice, Monash University. a) Within one week of the date of enrolment, the practitioner must provide evidence to the Council of enrolment in the Ethics course. b) Within two weeks of completing the Ethics course, the practitioner is to provide documentary evidence to the Council that he has satisfactorily completed the course. 9. To complete within 18 months of the date of this Decision and at his expense the course "Depression & Anxiety Disorders in General Practice" conducted in distance mode by the Department of General Practice, Monash University. a) Within one week of the date of enrolment, the practitioner must provide evidence to the Council of enrolment in the course. b) Within two weeks of completing the Depression & Anxiety Disorders in General Practice course, the practitioner is to provide documentary evidence to the Council that he has satisfactorily completed the course. 10. To complete within two years of the date of this Decision and at his own expense the course "Introduction to Pain Management" conducted in distance mode by the School of Medicine, Sydney University. a) Within one week of the date of enrolment, the practitioner must provide evidence to the Council of enrolment in the course. b) Within two weeks of completing the "Introduction to Pain Management" course, he is to provide the Council with documentary evidence of satisfactory completion. 11. Within twenty-one days, the respondent is to provide for approval by the Council the name and professional address of a registered medical practitioner specialising in general practice who has agreed to act as his professional mentor. The nature and frequency of contact with the mentor is to be determined by the mentor in accordance with the Council's Guidelines for Mentors. The mentor is to be provided with a copy of the Guidelines and a copy of the Medical Tribunal Decision upon which these conditions are based and these Orders. The respondent is to ensure that: (a)He and the mentor meet on a monthly basis for at least one hour, the first meeting to occur within one fortnight of being advised that his nominated mentor has been approved. (b)He is to authorise the mentor to report, in an approved format, to the Council every two months about the fact of contact, and to inform the Council if there is any concern about his professional conduct, health or personal wellbeing. (c)He is to authorise the mentor to notify the Council of any failure to attend, termination of the mentoring relationship against the advice of the mentor or any other matter the mentor considers appropriate. (d)In the event that the approved mentor is no longer willing or able to continue as mentor, he is to nominate another mentor for approval by the Council within 28 days of the cessation of the original mentor relationship. (e)He is to be responsible for any costs associated with the mentoring process. (f)The meetings should include discussion of the respondent's personal and professional development as a registered medical practitioner. Health Conditions (not for publication on the public register) Review Provisions The Medical Council of New South Wales is the appropriate review body for the purposes of Division 8 of Part 8 of the Health Practitioner Regulation National Law (NSW). In accordance with section 163 of the Health Practitioner Regulation National Law (NSW), the conditions may be reviewed by the Medical Council of New South Wales provided that the practitioner's principal place of practice is in New South Wales. However, sections 125 to 127 inclusive of the Health Practitioner Regulation National Law are to apply whilst the practitioner's principal place of practice is anywhere in Australia other than in New South Wales, so that a review of these Conditions can be conducted by the Medical Board of Australia. DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment or decision. The onus remains on any person using material in the judgment or decision to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court or Tribunal in which it was generated. Decision last updated: 07 May 2013