Civil and Administrative Tribunal New South Wales Medium Neutral Citation: Health Care Complaints Commission v Chong [2017] NSWCATOD 81 Hearing dates: 19 - 20 October 2016 Date of orders: 22 May 2017 Decision date: 22 May 2017 Jurisdiction: Occupational Division Before: Hon G Mullane ADCJ, Principal Member Dr L King, Professional Member Dr M Cox, Professional Member Associate Prof P MacNeill, Lay Member Decision: (1) The Respondent is guilty of professional misconduct. (2) The Respondent practitioner is reprimanded. (3) The Medical Council of NSW is the appropriate review body for the purposes of Part 8 Division 8 of the Health Practitioner Regulation National Law (NSW). (4) Sections 125 to 127 of the Health Practitioner Regulation National Law are to apply should the Respondent practitioner's principal place of practice be anywhere in Australia other than in New South Wales, so that the appropriate review body in those circumstances is the Medical National Board. (5) Not to possess, supply, administer or prescribe any 'drug of addiction' (Schedule 8 drug) as defined by the Poisons and Therapeutic Goods Act 1966 (NSW) except to prescribe to a patient in the following nursing home facilities: (a) W R – 3 Dalmar Place, Carlingford; (b) RE Tebutt Lodge – 40a Stewart St, Dundas; (c) BCS Yallambi Centre – 268 Pennant Hills Rd, Carlingford. (a) Order 5 is to remain in effect until the practitioner has provided documentary evidence to the Council that he has satisfactorily completed the following course "Issues in general practice prescribing" offered by Monash University. (6) To complete by 2 March 2018 the course "Issues in General Practice Prescribing" offered by Monash University. (a) Within one month of completing the abovementioned course, he is to provide documentary evidence to the Council that he has satisfactorily completed the course. (7) To nominate an experienced general practitioner to act as his professional mentor for approval by the Medical Council of NSW in accordance with the Medical Council of NSW Compliance Policy – Mentoring (as varied from time to time) and as subsequently determined by the appropriate review body: (a) To authorise the Council to provide proposed and approved mentors with a copy of the NCAT decision; (b) To meet with the mentor at least once each month; (c) Each mentoring meeting is to include discussion of the following; (i) Prescribing practices including prescribing of Schedule 8 and Schedule 4D drugs; (ii) Medical record keeping; (iii) The issues highlighted in this decision of the Tribunal; and (iv) Any personal and/or medical practice issues that may arise. (d) To authorise the mentor to report, in an approved format, to the Council every 6 months about the fact of contact, and to inform the Council if there is any concern about his professional conduct, or personal wellbeing; (e) To be mentored for a minimum period of 12 months and as subsequently determined by the Council. (8) To submit to an audit of his medical practice, of a random selection of this medical records by a person or persons nominated by the Medical Council of NSW and: (a) The audit is to be held by 2 March 2018 and subsequently as required by the Council; (b) The auditor(s) are to assess his compliance with good medical record keeping standards and legislative requirements and compliance with conditions; (c) The auditor(s) should pay particular attention to his assessment of patients, treatment plans and prescribing of medication, in particular of Schedule 8 and Schedule 4D drugs; (d) To authorise the auditor(s) to provide the Council with a report on their findings; (e) To meet all costs associated with the audit(s) and any subsequent reports. (9) To authorise and consent to any exchange of information between the Medical Council of NSW and Medicare Australia and Pharmaceutical Services for the purpose of monitoring compliance with these conditions. (10) The Respondent must pay the applicant's costs of or incidental to these proceedings as agreed or assessed. (11) Broadcast or publication without the leave of the Tribunal of the name or other identifying information of any patient referred to in these reasons is prohibited. Catchwords: Medical Practitioner – disciplinary proceedings- Professional misconduct - prescribing drugs of addiction- without authorisation, inadequate records, assessments, consideration of alternative pain options, strategies to deal with addicts seeking prescriptions of addictive drugs. Education, Strategies and other improvements already introduced by Practitioner. Reprimand, removal of conditions, restoration of prescribing rights, Legislation Cited: Health Practitioner's Regulation National Law (NSW) (2009 NO 86a); Poisons and Therapeutic Goods Act 1966 (NSW); Poisons and Therapeutic Goods Regulation 2008; Civil & Administrative Tribunal Act 2013; Cases Cited: Spicer v NSW Medical Council (unreported CA No 3 of 1981, 19 February 1981); Health Care Complaints Commission v Nemeth [2012] NSWMT4; Health Care Complaints Commission v Lo [2016] NSWCATOD 119; Health Care Complaints Commission v Suri [2016] NSWCATOD 54; HCCC v Dinkar [2009] NSWMT8; HCCC v Mazzaferro [2011] NSWMT 9 Texts Cited: Nil Category: Principal judgment Parties: Health Care Complaints Commissioner (Applicant) Peter Yoong-Keong Chong (Respondent) Representation: Counsel: A Britt (Applicant) C Magee (Respondent) Solicitors: Health Care Complaints Commission (Applicant) Avant Law Pty Limited (Respondent) File Number(s): 2016/00378652, 1620089 Publication restriction: Publication or Broadcast without the leave of the Tribunal of the name or other identifying information of a patient of the respondent mentioned in these reasons is prohibited ORDERS AMENDED: 18/09/2017 REASON FOR DECISION Introduction 1. These are disciplinary proceedings commenced by the applicant against the respondent medical practitioner for a complaint and application filed with the Tribunal on 8 April 2016. 2. A hearing under Section 150 of the Health Practitioner Regulation National Law (NSW) No. 86a ("The Act") in relation to the respondent's prescription of schedule 8 drugs allegedly, inappropriately and without authority was conducted on 7 October 2014. 3. The delegates appointed by the Medical Council of NSW to conduct the Section 150 hearing determined that the practitioner's registration be subject to practice conditions in the following terms: 1. Not to possess, supply, administer or prescribe any 'drug of addiction' (Schedule 8 drug) as defined by the Poisons and Therapeutic Goods Act 1966 (NSW) ("the PTG Act"). Except to prescribe to a patient in the following nursing home facilities: 1. Wesley Rayward - 3 Delmar Place, Carlingford 2. RE Tebutt Lodge - 40a Stewart St, Dundas 3. BCS Yallambi Centre - 268 Pennant Hills Rd, Carlingford 1. To provide written evidence to the Medical Council of NSW that he has attended the offices of the Pharmaceutical Services and consented to an Order being made under the Poisons and Therapeutic Goods Regulation 2008 ("the PTG Regulation") to prohibit him from possessing, supplying, administering or prescribing any Schedule 8 drug by 5:00pm 10 October 2014 in the terms of condition 1. 2. To authorise and consent to any exchange of information between the Medical Council of NSW and Medicare Australia and Pharmaceutical Services for the purpose of monitoring compliance with these conditions. 1. In his S40 Response letter of 21 September 2015 to the HCCC the Practitioner accepted the criticisms of the peer reviewer. He acknowledged his "ignorance of the statutory regime for obtaining authorities in relation to drug dependent patients meant that this cohort of patients were often receiving drugs of addiction without proper protection and oversight". 2. He said: "I also understand that decisions by other doctors in the practice can never be a replacement of my individual assessment of patients and my own responsibility for proper and safe prescribing. I continue to be disappointed in the poor decisions that I made and my treatment of certain patients, a vulnerable group; because of their varied and complex needs, well short of my own expectation. I accept that I was originally too easily manipulated and naïve in relation to patients I now recognise were drug seeking and I too easily placed reliance in some cases on the prescribing pattern of other doctors in the practice." 1. The Practitioner through his solicitors and counsel and in his oral evidence, admitted every complaint and the particulars of every complaint. The matter was heard on 19 and 20 October 2016 by the Tribunal, and the Tribunal made orders on 20 October determining the proceedings. 2. These are the reasons for those orders. The Evidence 1. Because of the respondent's admissions, it was necessary for the Tribunal to rely upon only 4 volumes of the 7 large volumes of material. 2. The evidence comprised: 1 Application and Complaint a Confirmation of Registration Status from AHPRA b Evidentiary Certificate from Medical Council of NSW 2 Letter to Commission from Medical Council of NSW - dated 1 October 2014 3 Outcome of s150 Proceedings - dated 14 October 2014 4 Written decision of s150 Proceedings - dated 21 November 2014 5 Transcript of s150 Proceedings - dated 7 October 2014 6 Letter of 27 August 2014 from PSU to MCNSW PSU Investigation report of 27 August 2014 with annexures: 7 Dispensing record from The Valley Pharmacy between 1/12/2012 and 1/12/2013 A Email from The Valley Pharmacy dated 25 March 2014 B Receipt for records from PSU to The Valley Pharmacy - dated 3 April 2014 C Letter dated 7 July 2014 to Dr Chong D Letter of 11 July 2014 from Avant to PSU E Copies of prescriptions referred to in Table 2 of PSU report. Patients whom Dr Lo prescribed without an authority F Copies of prescriptions referred to in Table 3 of PSU report. G Patients who were suspected to be drug dependent, whom Dr Lo prescribed to without an authority. H Prescriptions for Patient Q from Dr Chong req nesting Oxycontin to be issued in limited supply 8 Commission letter to Dr Andrew Patterson - dated 5 August 2015 9 Expert report from Dr Patterson - dated 28 August 2015 10 CV of Dr Patterson 11 Email from Commission to Dr Patterson seeking clarification on expert standard dated 3 September 2015 12 Final Report from Dr Patterson - dated 5 September 2015 13 Product information included by expert, with his report: A Endone B Fentanyl C Kalma D Mersyndol E Mogadon F MS Contin G Normison H NSW Health Opioid Treatment Program for methadone & buprenorphine I Ordine J OxyContin K OxyNorm L Panadeine Forte M Pethidine N Physeptone O Prodeine Forte P Ranzepam Q Temaze R Tramadol S Tramal T Vallium 14 Commission correspondence to Dr Chong - dated 14 November 2014 15 Response from Avant Law - dated 16 December 2014 16 S40 Commission correspondence - dated 21 September 2015 17 Response from Avant Law - dated 19 October 2015 18 CV of Dr Chong 19 NSW Health - Guide to Poisons and Therapeutic Goods legislation for medical practitioners - dated February 2014 20 NSW Health - Responsible °plaid prescribing - dated December 2008 21 Pharmaceutical Drugs of Addiction System - dated November 2013 22 Requirements for an authority to prescribe drugs of addiction under s28 - dated May 2009 23 Guide to Poisons and Therapeutic Goods legislation for medical practitioners - dated April 2009 24 Schedule 8 Drugs 25 Schedule 4 Appendix 0 Drugs 26 Section 27 Poisons and Therapeutic Goods Act 1966 27 Section 28 Poisons and Therapeutic Goods Act 1966 28 Poisons und Therapeutic Goods Regulation 2008 Division 3 (prescribing S4D) 29 Poisons and Therapeutic Goods Regulation 2008 Part 4 Division 3 (prescribing S8) 30 Statement of agreed facts 31 Undated letter from the respondent to the Health Care Complaints Commission responding to Health Care Complaints Commission letter of 21 September 2015. 32 Statement of respondent dated 22 August 2016 33 Report of Dr Murray Wright, Consultant Psychiatrist, and letter from Avant Law dated 25 May 2016. 34 Reference by Dr Khaled Etri dated 19 august 2016 35 Reference of Dr Samuel Cheng 36 Reference to John MacIndoe dated 3 August 2016 37 Reference of Dr Simon A Collins dated 8 August 2016 38 Reference of Dr Manjula Rajaratnam dated 22 August 2016 39 Reference of Tracey Younie dated 30 September 2016 40 Reference of Dr Catherine Lip dated 30 August 2016 41 Respondent's document "Policy on Prescribing Drugs of Addiction" 42 Respondent's document "Benzodiazepines – Key Points for Initial Assessment" 43 Respondent's document "Patient Agreement for Drugs of Dependence Therapy" 44 Oral evidence of respondent on 19 October 2016 Statement of Agreed Facts 1. The statement of agreed facts stated as follows: 1. Dr Peter Yoong-Keong Chong (`the Respondent') qualified with a Bachelor of Medicine and Bachelor of Science from University of NSW in 2005. 2. The Respondent is a registered medical practitioner under Health Practitioner Regulation National Law (NSW) (`the National Law'). 3. The Respondent is a fellow of the Royal Australian College of General Practitioners. 4. In the period 2006-2007, the Respondent was a Junior Medical Officer (WO') employed at Hornsby Hospital. 5. In 2008 the Respondent worked for a period of 6 months in Paediatrics at Westmead Hospital. 6. In the period 2009-2012 the Respondent worked part-time undertaking his General Practitioner training. 7. In 2012, the Respondent commenced to work as a General Practitioner at the Dundas Valley Medical Centre (`the Practice'). 8. At the time of the matters the subject of the Complaints, the Respondent was the only General Practitioner working at the Practice on a full-time basis. There were a number of more senior General Practitioners who worked at the Practice on a part-time basis during that period. 9. Dr Kwong Yiu (Kelvin) Lo, a General Practitioner who worked in the Practice during the relevant period, has been the subject of an Application for Disciplinary Findings and Orders in the NSW Civil & Administrative Tribunal (`NCAT') in respect of complaints under the National Law. A decision of NCAT was published on 7 September 2016. 10. Dr Mengyi Chen, a General Practitioner who worked in the Practice during the relevant period, has been the subject of an Application for Disciplinary Findings and Orders in the NCAT in respect of complaints under the National Law. 11. On 7 October 2014 the Respondent attended a hearing at the Medical Council of NSW pursuant to s.150 of the National Law, in respect to the allegations the subject of the Complaints in these proceedings. 12. On 7 October 2014 the Medical Council of NSW imposed practice conditions upon the Respondent's registration. 13. In September 2015, the Respondent, with Dr Samuel Cheng ('Dr Cheng'), took over the management of the Practice. 14. In February 2016, Dr Cheng and the Respondent took over the management of a general practice in Lidcombe. 15. The Respondent is the subject of three Complaints under National Law. Complaints 1 & 2 allege that the Respondent is guilty of unsatisfactory professional conduct under the National Law. Complaint 3 alleges that the Respondent is guilty of professional misconduct under the National Law. 16. Complaint 1 alleges, inter alia, that the Respondent engaged in conduct which involved the inappropriate prescribing of Schedule 4D and Schedule 8 Drugs to 17 patients in the period August 2012 to June 2014. 17. Complaint 2 alleges a failure of the Respondent to maintain adequate medical records in relation to a number of patients, and in particular a failure to record information known to the Respondent relevant to his diagnosis and treatment of those patients including in sufficient details about a number of matters. 18. Complaint 3 alleges that the conduct which is the subject of the particulars of failure alleged in Complaints 1 & 2 constituted professional misconduct on the part of the Respondent 19. The Respondent admits all of the particulars to the complaints. Application and Complaints 1. The application sought the following orders: 1. An order pursuant to s64 of the Civil & Administrative Tribunal Act 2013 prohibiting the disclosure of the name of Patients A to Q in the attached Complaint dated 4 April 2016 in the event the complaints against the Respondent are proved or admitted: 2. Orders pursuant to s149A (powers to caution, reprimand, impose conditions on registration, etc); 31498 (power to impose a fine) and/or s149C (powers to suspend or cancel registration, make a prohibition order, etc) of the Health Practitioner Regulation National Law (NSW) (" the National Law') 3. Costs 1. The complaints are set out as follows in the application: Dr Peter Yoong-Keong Chong ("the practitioner") of Dundas Valley Medical Centre, Shop 9, Benaud Place TELOPEA NSW 2117 being a medical practitioner registered under the National Law, COMPLAINT ONE is guilty of unsatisfactory professional conduct under section 139B of the National Law in that the practitioner has engaged in conduct that demonstrates that the knowledge, skill or judgment possessed, or care exercised, 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. BACKGROUND TO COMPLAINT ONE At all relevant times Dr Chong was a registered medical practitioner practicing as a general practitioner at Dundas Valley Medical Centre in Telopea in the State of New South Wales. PARTICULARS OF COMPLAINT ONE PATIENT A 1. The practitioner prescribed the drugs Diazepam and Oxycodone hydrochloride, to Patient A on the dates and in the quantities set out in the schedule attached and marked A: 1. Without performing an appropriate medical assessment prior to issuing such prescriptions for the first time, 2. When it was not appropriate to prescribe a benzodiazepine, namely Diazepam in combination with a Schedule 8 drug namely Oxycodone hydrochloride. 1. The practitioner prescribed the drug Oxycodone hydrochloride to Patient A on the dates and in the quantities set out in the schedule attached and marked A: 1. Inappropriately in that he continued to prescribe the drugs in circumstances where the prescription was initiated by another practitioner; 2. Without firstly consulting with the practitioner who initiated the prescription, 3. Without making a timely referral to a specialist for treatment, review and/or advice. PATIENT B 1. The practitioner prescribed the drugs Diazepam and Oxycodone hydrochloride to Patient B on the dates and in the quantities set out in the schedule attached and marked B: 1. Without performing an appropriate medical assessment prior to issuing such prescriptions; and 2. When it was not appropriate to prescribe a benzodiazepine, namely Diazepam in combination with a Schedule 8 drug namely Oxycodone hydrochloride. 1. The practitioner prescribed the drug Oxycodone hydrochloride to Patient B on the dates and in the quantities set out in the schedule attached and marked B: 1. Inappropriately in that he continued to prescribe the drug in circumstances where the prescription was initiated by another practitioner; 2. In a quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the Poisons and Therapeutic Goods Regulation 2008 (" the PTG Reg"); 3. Without obtaining an authority to prescribe drugs of addiction to a drug dependent person (within the meaning of section 27 of the PTG Act), contrary to section 28(3) of the PTG Act in circumstances where the practitioner had formed, ought to have formed, or ought reasonably to have formed the opinion that the patient was a drug dependent person. PATIENT C 1. The practitioner prescribed the drug Oxycodone hydrochloride to Patient C on the dates and in the quantities set out in the schedule attached and marked C: 1. Without performing an appropriate medical assessment prior to prescribing for the first time; 2. Inappropriately in that he continued to prescribe the drug in circumstances where the prescription was initiated by another practitioner; 3. Without obtaining an authority to prescribe drugs of addiction to a drug dependent person (within the meaning of section 27 of the PTG Act), contrary to section 28(3) of the PTG Act in circumstances where the practitioner had formed, ought to have formed, or ought reasonably to have formed the opinion that the patient was a drug dependent person PATIENT D 1. The practitioner prescribed the drugs Diazepam, Nitrazepam, Oxycodone hydrochloride, Tramadol and Paracetamol + codeine to Patient D on the dates and in the quantities set out in the schedule attached and marked D: 1. When it was not appropriate to prescribe benzodiazepines, namely Diazepam and Nirazepam in combination with a Schedule 8 drug namely Oxycodone hydrochloride; 1. The practitioner prescribed the drug Oxycodone hydrochloride to Patient D on the dates and in the quantities set out in the schedule attached and marked D: 1. Without obtaining an authority to prescribe drugs of addiction to a drug dependent person (within the meaning of section 27 of the PTG Act), contrary to section 28(3) of the PTG Act in circumstances where the practitioner had formed, ought to have formed, or ought reasonably to have formed the opinion that the patient was a drug dependent person. PATIENT E 1. The practitioner prescribed the drugs Diazepam, Oxycodone hydrochloride, 1. Temazepam and Paracetamol + Codeine to Patient E on the dates and in the quantities set out in the schedule attached and marked E: 2. Without performing an appropriate medical assessment prior to issuing such prescriptions for the first time; 3. Without making timely referrals of Patient E to specialists for treatment, review and/or advice; and 4. When it was not appropriate to prescribe benzodiazepines, namely Diazepam and Temazepam in combination with a Schedule 8 drug namely Oxycodone hydrochloride. 1. The practitioner prescribed the drug Oxycodone hydrochloride to Patient E on the dates and in the quantities set out in the schedule attached and marked E: 1. Without obtaining an authority to prescribe drugs of addiction to a drug dependent person (within the meaning of section 27 of the PTG Act), contrary to section 28(3) of the PTG Act in circumstances where the practitioner had formed, ought to have formed, or ought reasonably to have formed the opinion that the patient was a drug dependent person . PATIENT F 1. The practitioner prescribed the drugs Morphine to Patient F on the dates and in the quantities set out in the schedule attached and marked F: 1. Without obtaining an authority to prescribe drugs of addiction to a drug dependent person (within the meaning of section 27 of the PTG Act) from the NSW Health Department, contrary to section 28(3) of the PTG Act. PATIENT G 1. The practitioner prescribed the drug Oxycodone hydrochloride to Patient G on the dates and in the quantities set out in the schedule attached and marked G: 1. Without performing an appropriate medical assessment prior to issuing such prescriptions for the first time; 2. Inappropriately in that he continued to prescribe the drug in circumstances where the prescription was initiated by another practitioner; 3. When such prescribing was contraindicated as the practitioner knew or ought to have known that the drugs so prescribed were being, or were likely to be, abused; 4. In a quantity and/or for a purpose that does not accord with the recognised therapeutic standard of what is appropriate in the circumstances contrary to clause 79 of the PTG Regs; 5. Without obtaining an authority to prescribe drugs of addiction to a drug dependent person (within the meaning of section 27 of the PTG Act) from the NSW Health Department, contrary to section 28(3) of the PTG Act. PATIENT H 1. The practitioner prescribed the drugs Diazepam, Temazepam, Paracetamol + Codeine, Oxycodone hydrochloride and Tramadol Hydrochloride to Patient H on the dates and in the quantities set out in the schedule attached and marked H: 1. Without performing an appropriate medical assessment prior to issuing such prescriptions for the first time ; 2. Without making timely referrals to specialists for treatment, review and/or advice; 3. Inappropriately in a quantity and/or for a purpose, that does not accord with the recognised therapeutic standard of what is appropriate in the circumstances contrary to contrary to clause 34 of the PTG Reg 2008; and 4. When it was not appropriate to prescribe benzodiazepines, namely Diazepam and Temazepam in combination with a Schedule 8 drug namely Oxycodone hydrochloride. 1. The practitioner prescribed the drugs Diazepam, Temazepam, Paracetamol + codeine and Tramadol hydrochloride to Patient H in a quantity and/or for a purpose that does not accord with the recognised therapeutic standard of what is appropriate in the circumstances contrary to clause 34 of the PTG Reg. 2. The practitioner prescribed the drug Oxycodone hydrochloride to Patient H in a quantity and/or for a purpose that does not accord with the recognised therapeutic standard of what is appropriate in the circumstances contrary to clause 79 of the PTG Reg. PATIENT I 1. The practitioner prescribed the drug Oxycodone hydrochloride and Fentanyl to Patient I on the dates and in the quantities set out in the schedule attached and marked 1. Without obtaining an authority to prescribe drugs of addiction to a drug dependent person (within the meaning of section 27 of the PTG Act), contrary to section 28(3) of the PTG Act. 1. The practitioner prescribed the drug Oxycodone hydrochloride to Patient I on the dates and in the quantities set out in the schedule attached and marked I: 1. When such prescribing was contraindicated as the practitioner knew or ought to have known that the drugs so prescribed were being, or were likely to be, abused. PATIENT J 1. The practitioner prescribed the drug Oxycodone hydrochloride to Patient J on the dates and in the quantities set out in the schedule attached and marked J; 1. Without performing an appropriate medical assessment prior to prescribing the medication for the first time; 2. Inappropriately in that he continued to prescribe the drug in circumstances where the prescription was initiated by another practitioner; 3. Without first consulting with the practitioner who initiated the prescription about any referral, and then making a timely referral to a specialist for treatment, review and/or advice; 4. Inappropriately in a quantity and/or for a purpose, that does not accord with the recognised therapeutic standard of what is appropriate in the circumstances contrary to clause 79 of the PTG Regs; 5. Without obtaining an authority to prescribe drugs of addiction to a drug dependent person (within the meaning of section 27 of the PTG Act), contrary to section 28(3) of the PTG Act in circumstances where the practitioner had formed, ought to have formed, or ought reasonably to have formed the opinion that the patient was a drug dependent 6. When such prescribing was contraindicated as the practitioner knew or ought to have known that the drug so prescribed was being, or was likely to be, abused. PATIENT K 1. The practitioner prescribed the drug Alprazolam to Patient K on the dates and in the quantities set out in the schedule attached and marked K without obtaining an authority to prescribe drugs of addiction to a drug dependent person (within the meaning of section 27 of the PTG Act), contrary to section 28(3) of the PTG Act. PATIENT L 1. The practitioner prescribed the drugs Physeptone and Diazepam to Patient L on the dates and in the quantities set out in the schedule attached and marked L: 1. Without performing an appropriate medical assessment prior to issuing such prescriptions for the first time; 2. When it was not appropriate to prescribe a benzodiazepine, namely Diazepam in combination with a Schedule 8 drug namely Physeptone. 1. The practitioner prescribed the drug Diazepam to Patient L on the date set out in the schedule attached and marked L: 1. Inappropriately for a purpose, that does not accord with the recognised therapeutic standard of what is appropriate in the circumstances contrary to clause 34 of the PTG Reg. 1. The practitioner prescribed the drug Physeptone to Patient L on the dates and in the quantities set out in the schedule attached and marked L: 1. Without obtaining an authority to prescribe drugs of addiction to a drug dependent person (within the meaning of section 27 of the PTG Act) , contrary to section 28(3) of the PTG Act. PATIENT M 1. The practitioner prescribed Morphine hydrochloride and Paracetamol + Codeine + Doxylamine to Patient M on the dates and in the quantities set out in the schedule attached and marked M without performing an appropriate medical assessment prior to issuing such prescriptions for the first time 2. The practitioner prescribed Paracetamol +Codeine + Doxylamine to Patient M on the dates and in the quantities set out in the schedule attached and marked M in a quantity that does not accord with the recognised therapeutic standard of what is appropriate in the circumstances contrary to clause 34 of the PTG Reg. 3. The practitioner prescribed the drugs Pethidine hydrochloride and morphine hydrochloride to Patient M on the dates and in the quantities set out in the schedule attached and marked M: 1. Without obtaining an authority to prescribe drugs of addiction to a drug dependent person (within the meaning of section 27 of the PTG Act) from the NSW Health Department, contrary to section 28(3) of the PTG Act; 2. In a quantity that does not accord with the recognised therapeutic standard of what is appropriate in the circumstances contrary to clause 79 of the PTG Reg. 1. The practitioner prescribed the drug Morphine hydrochloride to Patient M on the dates and in the quantities set out in the schedule attached and marked M when such prescribing was contraindicated as the practitioner knew or ought to have known that the drugs so prescribed were being, or were likely to be, abused. PATIENT N 1. The practitioner prescribed the drug Oxycodone hydrochloride to Patient N on the dates and in the quantities set out in the schedule attached and marked N: 1. Without performing an appropriate medical assessment prior to prescribing the medication for the first time; 2. Without obtaining an authority to prescribe drugs of addiction to a drug dependent person (within the meaning of section 27 of the PTG Act) from the NSW Health Department, contrary to section 28(3) of the PTG Act in circumstances where the practitioner had formed, ought to have formed, or ought reasonably to have formed the opinion that the patient was a drug dependent 3. When such prescribing was contraindicated as the practitioner knew or ought to have known that the drugs so prescribed were being, or were likely to be, abused. PATIENT 0 1. The practitioner prescribed the drugs Fentanyl, Diazepam and Temazepam to Patient 0 on the dates and in the quantities set out in the schedule attached and marked 0: 1. When it was not appropriate to prescribe benzodiazepines, namely Diazepam and Temazepam in combination with a Schedule 8 drug namely Fentanyl. 1. The practitioner prescribed the drug Temazepam to Patient 0 on the dates and in the quantities set out in the schedule attached and marked 0 1. Without performing an appropriate medical assessment prior to issuing such prescriptions. 1. The practitioner prescribed the drug Fentanyl to Patient 0 on the dates and in the quantities set out in the schedule attached and marked 0: 1. When such prescribing was contraindicated as the practitioner knew or ought to have known that the drugs so prescribed were being, or were likely to be, abused; 2. Inappropriately in a quantity that does not accord with the recognised therapeutic standard of what is appropriate in the circumstances contrary to clause 79 of the PTG Regs; and 3. Without obtaining an authority to prescribe drugs of addiction to a drug dependent person (within the meaning of section 27 of the PTG Act), contrary to section 28(3) of the PTG Act in circumstances where the practitioner had formed, ought to have formed, or ought reasonably to have formed the opinion that the patient was a drug dependent . PATIENT P 1. The practitioner prescribed the drugs Oxycodone hydrochloride, Diazepam and Morphine to Patient P on the dates and in the quantities set out in the schedule attached and marked P: 1. Without performing an appropriate medical assessment prior to issuing such prescriptions for the first time; 2. Without making timely referrals of Patient P to a pain specialist for treatment, review and/or advice; 3. When it was not appropriate to prescribe a benzodiazepine, namely Diazepam in combination with Schedule 8 drug namely Oxycodone hydrochloride and Morphine. 1. The practitioner prescribed the drug Oxycodone hydrochloride to Patient P on the dates and in the quantities set out in the schedule attached and marked P: 1. a. Inappropriately in that he continued to prescribe the drugs in circumstances where the prescription was initiated by another practitioner. 1. The practitioner prescribed the drug Oxycodone hydrochloride and Morphine to Patient P on the dates and in the quantities set out in the schedule attached and marked P: 1. Without obtaining an authority to prescribe drugs of addiction to a drug dependent person (within the meaning of section 27 of the Poisons and Therapeutic Goods Act 1966 (PTG Act, contrary to s28 (3) of the PTG Act). PATIENT Q 1. The practitioner prescribed the drugs Oxycodone hydrochloride to Patient Q on the dates and in the quantities set out in the schedule attached and marked Q: 1. Without performing an appropriate medical assessment prior to prescribing the medication for the first time; 2. Inappropriately in that he continued to prescribe the drugs in circumstances where the prescription was initiated by another practitioner; and 3. Without obtaining an authority to prescribe drugs of addiction to a drug dependent person (within the meaning of section 27 of the Poisons and Therapeutic Goods Act 1966 (PTG Act, contrary to s28 (3) of the PTG Act). COMPLAINT TWO Is guilty of unsatisfactory professional conduct under section 139B of the National Law in that the practitioner has contravened a provision of the Health Practitioner Regulation (NSW) Regulation 2010. BACKGROUND TO COMPLAINT TWO At all relevant times the practitioner was a registered medical practitioner practicing as a general practitioner at Dundas Valley Medical Centre in Telopea in the State of New South Wales. PARTICULARS OF COMPLAINT TWO 1. The practitioner failed to maintain adequate medical records in accordance with Sch 2 to the Health Practitioner Regulation (NSA° Regulation 2010 for each of Patients A to E and G, H, and J to M in that the practitioner failed to record: 1. Information known to the practitioner relevant to his diagnosis and treatment of patients including sufficient detail of: 1. the patient's medical history; 2. the results of any physical examinations of the patient; 3. details of any examination of the patient's mental state; 4. progress of the patient at each visit; and 5. diagnoses of the patient. 1. Particulars of any clinical opinion reached by the practitioner; 2. Plans of treatment for the patient (including recording the reasons for the practitioner's decision to prescribe particular medication); and 3. A level of detail appropriate to the patient's case and/or to the medical practice involved. COMPLAINT THREE 1. Is guilty of professional misconduct under section 139E of the National Law in that the practitioner has: 1. engaged in unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration, or 2. engaged in 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. The Respondent's reply to the complaints 1. The respondent admitted each and every one of the complaints and admitted the particulars of all the complaints. 2. The parties agreed on a "Statement of Agreed Facts" that was provided to the Tribunal at the hearing. 3. The complaints relate to alleged conduct in the period from about October 2011 to 24 July 2014. Unsatisfactory Professional Conduct 1. Para 139B (1) of the National Law defines "unsatisfactory professional conduct" of a registered health practitioner as including: 1. 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; and 2. Any other improper or unethical conduct relating to the practice or purported practice of the practitioner's profession. The Practitioner's Training and Experience 1. The practitioner obtained his Higher School Certificate from James Ruse Agricultural High School in 1999. He had a UAI score of 99.9. 2. In 1997 – 1998 he was a tutoring assistant at a coaching centre. 3. From 2000 – 2005 he tutored students in HSC mathematics. 4. In 2004 he undertook an Under-Graduate Elective Overseas Term in Taiwan. 5. He graduated MBS, BSc (Med) from the University of NSW in 2005. 6. He has had a strong interest in professional development. 7. He was a delegate the National PBEF in Adelaide in 2006. 8. From 2006 – 2007 he was a JMO at Hornsby Hospital. He was active in JMO education at Hornsby – Kuring-Gai Hospital and the co-ordinator and designer of the internal orientation program for 2007, which was an inter-active and creative program designed to introduced junior doctors to the hospital system, and orientate around the hospital, and development schools that junior doctors will require in various situations. 9. From 2007 he was part of a team that developed a proposal with a plan to institute a system within Hornsby Kuring-Gai Hospital involving PDA's aimed at improving junior doctor education and efficiency. 10. In 2008 he did a 6 month term in paediatrics at Westmead Hospital. 11. He was employed part-time by Pennant Hills Baptist Church and was co-ordinator and overseer of evening church. 12. During the period from 2009 to 2012 he did part time GP training with WestWest at North Richmond Family Practice, Hazelbrook General Practice, Priority Medical Centre at Harris Park, Rooty Hill Medical & Dental Centre, Locum work at various emergency departments, locum work at Blue Mountain's Hospital, and doing WorkCover pre-employments and immigration medical checks at Medibank Health Solutions, Parramatta. 13. He practiced as an employee in the Dundas Valley Medical Centre from 2012 to 2016 when he became a principal of that practice and a Medical Practice at Lidcombe, as a result of disciplinary proceedings against 3 more senior medical practitioners in the practice, including the 2 proprietors. 14. He has achieved 8th grade in Australian Music Examination Board (AMEB) exams, 5th musicianship examinations with honours. 15. He has achieved the Duke of Edinburgh Award and has been active in various Christian organisations. Expert Evidence of Dr Andrew Patterson 1. Dr Patterson is a General Medical Practitioner of more than 35 years. 2. Dr Patterson was instructed by the applicant and prepared a 73 page detailed report. It was supported also by extensive other documentation. 3. Dr Patterson also prepared a supplementary report of 5 September 2015. 4. There is no dispute that Dr Patterson has the necessary expertise to provide the opinions in the report. 5. Dr Patterson's opinion that the following conduct in the complaint was "conduct that demonstrates the knowledge, skill or judgment possessed or care exercised by the practitioner in the practice of the practitioner's profession, was significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience". 6. It was therefore considered to be unsatisfactory professional conduct. 7. The particulars that constituted unsatisfactory professional conduct and where it attracted strong criticism ("SC") is: Patient A particulars 1(a), 2(a), (b), & (c) SC: 1(b). Patient B particulars SC: 3 (b), 4(a), (b) & (c) Patient C particulars 5(b) & (c). SC: 5(a) Patient D particulars 7(a). SC 6(a) Patient E particulars 8(b) & 9(a). SC: 8(a) & (c) Patient F particulars 10(a). SC: Nil Patient G particulars 11(c) & (e). SC: 11(a) & (d) Patient H particulars 12(d). SC: 12(a), (b) & (c), 13 & 14 Patient I Particulars 15(a) & 14(a) SC: Nil Patient J particulars 15 (a), (b), (c), (d), (e), (f) &(g). SC 15(a) Patient K particulars 16. SC: Nil Patient L particulars 17(a), 18(a), 19(a). SC: 17(b) Patient M Particulars 20, 21, 22(a). SC: Nil Patient N Particulars 24(a), (b) & (c). SC: 22(b). Patient O particulars 25(a) SC: 24(a), 26(a), (b) & (c). Patient P particulars 27(a), (b) & (c), 28(a). SC: 29 Patient Q particulars 30(a). SC: 30(b) & (c) Complaint 2 Findings 1. Complaint 2 is that the practitioner failed to maintain adequate medical records in accordance with schedule 2 to the Health Practitioner Regulation(s) 2010 for each of patients A to E, G, H, and J to M, in the that the practitioner failed to record: 1. Information known to the practitioner relevant to his diagnosis and treatment of patients, including sufficient details of: 1. The patient's medical history; 2. The results of any physical examinations of the patient; 3. Details of any examination of the patient's mental state; 4. Progress of the patient at each visit; 5. Diagnoses of the patient 1. Particulars of any clinical opinion reached by the practitioner; 2. Plans for treatment for the patient (including recording the reasons for the practitioner's decision to prescribe particular medication); and 3. A level of detail appropriate to the patient's case and / or to the medical practices involved. 1. In accordance with the findings of Dr Patterson, the medical records of the patients G, K and L were not adequate and significantly below the standard required by Schedule 2. Of the records for the remaining nominated patients many were found to be adequate only if one accepted the fiction that the Practitioner said he did, that the patient was not "his patient" and Dr Patterson described the remainder as "barely adequate". But the medical record requirements of Schedule 2 applied to every one of the patients, even if they had only one consultation with the practitioner after another practitioner had prescribed an addictive drug. 2. The practitioner admitted, and the evidence established, that the records of patients A to E, G, H, and J to M did not meet the requirements of Schedule 2 of the Regulation. 3. Section 139B(1)(b) of the National Law provides that breach of the regulation is deemed to be unsatisfactory professional conduct. Accordingly, in regard to the 11 patients in respect to whom the Tribunal has found their records failed to comply with the regulation, there is a finding of unsatisfactory professional conduct. Professional Misconduct 1. Section 139 E of the National Law provides that the practitioner is guilty of professional misconduct if he has: 1. engaged in unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration, or 2. engaged in more than 1 instance of unsatisfactory professional conduct that, when the instances are considered together, amount to conduct of a sufficiently serious nature to justify the suspension of cancellation of the practitioner's registration. Complaint 3 Findings 1. The Tribunal has concluded that about 70 instances of unsatisfactory professional conduct under complaint 1 and 11 under Complaint 2 have been proved. The question that arises then is whether under Section 139E of the National Law, the practitioner has engaged in more than 1 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. 2. There are extensive authorities that where a medical practitioner prescribes and handles drugs of addiction recklessly and contrary to the law, that conduct constitutes professional misconduct (e.g. Spicer v NSW Medical Council (unreported CA No 3 of 1981, 19 February 1981); Health Care Complaints Commission v Nemeth [2012] NSWMT4; Health Care Complaints Commission v Lo [2016] NSWCATOD 119; and Health Care Complaints Commission v Suri [2016] NSWCATOD 54 at [88] – [89]). 3. The Tribunal is satisfied that the various findings of instances of unsatisfactory professional conduct are together sufficiently serious to justify a suspension or cancellation of the practitioners' registration. The practitioner himself admits the severity of his actions and that they together constitute professional misconduct. The Practitioner's Evidence 1. The practitioner filed a written statement of 12 pages. 2. He said in that: As indicated in my s40 response forwarded to the HCCC on 19 October 2015 (see Tab 17 of HCCC documents) I unreservedly accept the criticisms made by the peer reviewer In relation to the treatment I provided to the patients referred to in the complaint and do not challenge the peer opinion. In particular I acknowledge that I did not conduct an appropriate assessment of the patients prior to prescribing drugs of addiction. I acknowledge that I failed to exercise my professional obligations and apply an independent mind to each of the patients prescribing needs. I understand that I ought to have undertaken a more thorough and detailed assessment of the patients' history of complaints, their specific symptoms, their duration and intensity, any possible causes or any factors that were contributing to their complaints prior to making any decision as to the appropriateness or otherwise of prescribing drugs of addiction. I accept that such an assessment should have included consideration of any other medication that the patient may have been taking at the time, because of the possibility of serious side effects and drug interactions. I agree that because of my lack of proper assessment of the patients prior to prescribing drugs of addiction my conduct fell significantly below the standard reasonably expected of a practitioner of my level of training and experience. Further, I accept that my clinical decisions to continue prescribing and/or maintaining the prescription of drugs of addiction in circumstances where the prescription was initiated by another practitioner in the practice was also inappropriate. I understand that it is not a reasonable excuse for my conduct that I had not initiated the prescribing regime for the majority of the patients in the complaint. I acknowledge that I should have given greater consideration to whether the behaviour of the patients in those circumstances reflected 'drug seeking' behaviour. I acknowledge that my conduct in this regard fell significantly below the standard reasonably expected of a practitioner of my level of training and experience. I also understand that I failed to make appropriate referrals for specialist assistance for patients to whom I was prescribing drugs of addiction. I understand that this step was an important part of formulating a treatment plan that addressed the patient's problems in a global fashion. I again acknowledge that my conduct in this regard fell significantly below the standard reasonably expected of a practitioner of my level of training and experience. I also accept that it was important that I carefully considered whether the prescription of drugs of addiction were being prescribed for an appropriate therapeutic purpose. I understand that I should have had greater regard to the clinical indications for prescribing S8 drugs. I accept that I ought to also have had greater regard to contraindications to the prescription of S8 drugs and in particular the risk associated with prescribing such drugs in circumstances where the patients were also prescribed other drugs which could have adverse interactions. I acknowledge that I did not adequately consider this issue and that my conduct fell below the standard reasonably expected of a practitioner of my level of training and experience. I also acknowledge that there were inadequacies in my prescription of the appropriate quantity of drugs of addiction to patients. I understand that I should have had greater regard to the therapeutic standards in terms of dosage and duration for prescribing S8 drugs. In particular I acknowledge that on occasions I authorised supplies greater than were necessary for the particular time interval for which they were prescribed. I understand that in doing so my conduct fell below the standard reasonably expected of a practitioner of my level of training or experience. I also now understand that in respect to some of the patients it was not appropriate for me to prescribe S8 drugs to those patients without an authority under section 28 of the Poisons and Therapeutic Goods Act, 1996, as I should have known that the patient was or had been drug dependent. I accept that my ignorance at the time of the statutory regime for obtaining authorities for drug dependent patients meant that this cohort of patients were prescribed drugs of addiction without proper assessment nor approval. I acknowledge that it was naïve of me to accept patient's statements in relation to their use of drugs of addiction and their reasons for requiring further prescriptions, without proper critical analysis and investigation. I accept that I failed to recognise drug seeking behaviours. I understand that I should have at least checked with the patient's usual treating practitioner in circumstances where I was concerned that there were indications that the patient was drug dependent. I accept that my failure in those circumstances were significantly below the standard reasonably expected of a practitioner of my level of training and experience. I agree that it was not appropriate for me to prescribe some drugs, such as benzodiazepines in combination with S8 drugs, because of the risk of serious, possibly fatal, drug interactions. I accept that my conduct in that regard fell significantly below the standard reasonably expected of my level of training and experience. I also agree that my clinical records in relation to these patients, and in particular in relation to the clinical indications for prescribing those drugs, and my assessment of the patients were deficient or at best barely adequate. I accept that it was not a reasonable excuse for not making adequate records that I did not regard the patient as mine, but as the patient of another practitioner in the practice. I understand the importance of good clinical record keeping. I accept that in respect to some of these patients that my conduct in relation to record keeping fell below the standard reasonably expected of a practitioner of my level of training and experience. I acknowledge and accept that my conduct in relation to my prescribing as alleged to the patients referred to in the complaint filed amounts to unsatisfactory professional conduct and professional misconduct. I have not addressed the circumstances of my prescribing in respect to each of the patients in the Complaint filed, as I anticipate that an Agreed Set of Facts will be provided to the Tribunal. I unreservedly apologise to the Tribunal, the medical profession and the patients for my conduct at the time. I accept that my conduct did not adequately serve the therapeutic needs of the patients in the circumstances. I understand that such conduct could bring the reputation of the medical profession into disrepute. Without excusing my behaviour I will attempt to briefly explain how this conduct came about and the steps I have taken to assure all that this conduct has ceased and will never occur again. 1. This evidence was reinforced by the practitioner's oral evidence and in his cross-examination. 2. In September 2015, he and Dr Samuel Cheng became the proprietors of the Dundas Valley Medical Centre and a practice at Lidcombe. There were 5 general practitioners in the Dundas practice when they took over. Of those, 3 doctors came to the attention of the PSU in relation to prescribing and are no longer in the practice. The registration of 2 of them was cancelled. 3. The practitioner now works 4 days a week (Monday to Thursday) from 9:00am to 12:30pm, and 2:00pm to 6:00pm, and also undertakes some home visits. He does not work on Wednesdays and he works every second Saturday of each month from 9:00am to 12:30pm. 4. The practitioners in the practice have now initiated a number of changes regarding prescribing to avoid the problems that occurred in the past. They have a sign at the reception desk advising of the practice policy of not prescribing drugs of addiction / dependency. They have a permanent sign on the shop front stating that drugs of addiction will not be prescribed in the surgery. They have an online template for reviewing patients for opioid addiction based on a RACGP document. The Benzodiazepine document was prepared in about October 2015. 5. His evidence was that only one of the subject patients was first prescribed an addictive medication by him. The others had already had such a prescription from one of the older practitioners in the practice. When he discussed the represcribing of addictive medications for patients with the 2 most senior practitioners, they told him that was their approach and advised him to do likewise. One of them had 30 years of experience and the other had many more years in practice than he did, so he deferred to their advice. He also said that although he had described his naivety as leading him to error, "but maybe I was lazy and unwilling to confront the doctors or the patients. My judgment was clouded." When asked whether he saw his conduct as an abdication of his responsibility and he replied 'certainly' " But he said he was able eventually get the more senior doctors to agree to not prescribe opioids long term. 6. In his oral evidence and cross examination the practitioner was direct and did not avoid questions. He presented as open, frank, caring and honest. He presented as a very reliable witness. 7. The practitioners in the practice have clinical practice meetings once a month, and during these meetings they discuss issues that include: "issues in relation to patients seeking prescriptions for S8 drugs or any imitation of prescription of S8 drugs the practitioners (who have such prescribing rights) or specialist, etc. This includes an assessment of Risk Factors, "Red Flags", or other concerns regarding these patients to ensure appropriate prescribing. They have put in place policies and procedures in relation to imitating or continuing prescription of S8 drugs to patients of the practice (for those probationers who have such prescribing rights) which include: 1. Taking a detailed clinical history and examination, including the use of an 'Opioid Risk Assessment Tool' form; 2. In respect to new patients, there must be contact made with the previous General Practitioner to find our when the last script was written and to verify their clinical condition; 3. Formulating a detailed pain management plan in conjunction with the patient; 4. Contracting with the patient that only 1 prescriber is allowed and advising them of outcomes if they appear to be becoming drug dependent; 5. Contacting the PSU to ensure there is no history of methadone treatment evident, of if any that an authority permit is in place; 6. Contacting the Doctor – Shopper line; 7. Contacting the liaising with pain specialists prior to prescribing; 8. Regular review with a pan specialist who is to provide guidance as to the long term management of the analgesia; 9. Regular reviews of the patient's condition and recording of such; 10. Call in the 'Drug and Alcohol Services" (DAAS) for advice if needed (this service is managed by St Vincent's Hospital Alcohol and Drug Service in Sydney); and 11. The practitioner is aware of the requirements for adherence and accountability to goals that the prescription of Opioids to non-cancer suffering patients be limited to short term use in light of the limited evidence for long term efficacy and safety of Opioid use. 1. The practice has a policy that if a patient becomes aggressive to a practitioner who has refused to prescribe S8 drugs or other drugs (or for other reasons) then the practitioner will terminate the doctor / patient relationship. In such circumstances the practice will also send a letter to the patient explaining the decision that the practice will no longer treat them. 2. After the complaint was received from the PSU, the practitioner contacted the medical defense organization AVANT. He took advice there and has since undertaken the following courses: 1. Effective pain management in general practice – RACGP course; 2. Opioid Risk Management in Chronic Pain - RACGP course; 3. Prescription Drugs Misuse – RACGP course 4. On the record: "Medical Records and Documentation" – AVANT course. 1. He has also read the following: 1. Opioid Prescribing Pitfalls – Medico Legal and Regulatory Issues – Article by Dr Walid Jammal / Grace Gown, published in Australian Prescriber, September 2015; 2. Ministry of Health Guidelines entitled "Requirements from Authority to Prescribe Drugs of Addiction under Section 28 of the Poisons & Therapeutic Goods Act 1966"; 3. RACGP Benzodiazepine Guidelines; 4. NSW Health Guides for Medical Practitioners regarding handling drugs, including the prescribing and supplying of drugs of addiction; 5. NSW Health Guide lines – "Recognizing and Managing Drug Dependent Persons – Notes for Medical Practitioners"; 6. NSW Health Publication – "Prescribing a Schedule 8 Opioid or Benzodiazepine"; 7. NSW Health – Guide to Poisons and Therapeutic Goods Legislation for Medical, Nurse and Midwife Practitioners and Dentists; 8. AVANT Position Paper – Prescribing Drugs of Addiction. Linked from Australian Doctor Article "Confusing S8 Script laws gets GPs into trouble" dated 25 April 2015; 9. AVANT Risk IQ Webinar "Prescribing Perils: Opioids, Polypharmacy and medication errors". AVANT course; 10. AVANT Risk IQ Webinar " "Prescribing Perils Part 2: Drugs of Dependence". AVANT course 11. Medical Board of Australia "Code of Conduct"; 12. Regular discussion with my mentor – Dr Manju Rajaratnan about my prescribing and practice in general. 1. The practitioner has also had numerous conversations with Dr Walid Jammal seeking his advice regarding questions he had in relation to drugs of addiction. 2. In evidence before the Tribunal were: 1. Policy on prescribing drugs of addiction; 2. Benzodiazepine Key Points; 3. Patient Agreement for Drugs of Dependence therapy; 1. In the last of the 3 documents is a 4 page agreement which covers "my responsibilities as a patient", "my prescriptions", "taking my medications", "monitoring the effects of treatment", and "my behaviour". 2. The agreement provides conditions whereby the doctor / patient relationship will be terminated if a patient does not honour the conditions of the agreement. The document is very thorough. 3. In his statement of 22 August 2016, nearly 2 years after the Section 150 proceedings and the decision to impose conditions on his registration prohibiting him from prescribing or dealing with Schedule 8 of Schedule 4D substances, he said: "I have had considerable time to reflect on the circumstances which resulted in the complaints being brought against me. I understand that I placed myself in the position I am in now as a result of a combination of factors. These included my limited experience in respect of the prescription of S8 drugs and my inadequate knowledge of the requirements regarding prescribing Schedule 8 drugs. I accept that there was an obligation on me to have a proper understanding of the standards expected in relation to prescribing schedule 8 drugs patients with a history of drug dependence, the prescribing of benzodiazepines, and the prescribing of S8 drugs in combination with benzodiazepines, as well as prescribing narcotic analgesia to patients with a history of drug dependence. I understand that I too readily accepted and followed the long term existing practices for prescribing S8 drugs, benzodiazepines and narcotic analgesia that other doctors at the practice had adopted without exercising an independent mind. I also had an inadequate understanding of what a drug dependent patient was. I had incorrectly assumed that 'Dependency' was a term that applied to patients that were on methadone or an S8 drug that did not have a proper clinical indication for the prescription of such drugs, or where the dosage and duration of their use of such drugs was not consistent with their clinical indications but were a result of their addiction. The rationale behind my prescribing was that patients who I believed had a clinical indications for being prescribed such drugs were not classified as being drug dependent. I accept that my understanding of the concept of drug dependency was not consistent with the legal definition. I now understand for the purposes of compliance with the requirements of the Poisons and Therapeutic Goods Act that the definition of a 'drug dependent person' relies on Section 27 of the Act and as such, the specific wording 'an overpowering desire' for the continued administration of a drug. Medical Evidence 1. The practitioner also relied upon a report by a consultant psychiatrist engaged by the practitioner's solicitors to prepare a report for these proceedings. The psychiatrist was provided with various material including the reasons of the section 150 proceedings, the practitioner's response to the HCCC by his solicitors on 16 December 2014, the HCCC section 40 letter of 21 September 2015, and the practitioner's response of October 2015. 2. The psychiatrist's opinion is that the practitioner does not suffer from any psychiatric condition or disorder to preclude him from practicing medicine. She also formed an opinion that: "[The practitioner] was able to talk in depth about the situation when he joined the practice ….. He displayed significant insight into the environment at the time, the historical practices, and the advice he received from the senior doctors influenced him to make poor decisions. He did not, in my view, lay the blame on any other individuals, and accepted that he also had been more skeptical, and however had sought external advice at the earliest time. He subsequently sought that advice and completed several courses of education to improve his knowledge base". 1. The psychiatrist also concluded from her interview with the practitioner and the documents provided to her, that the practitioner is fit to practice medicine. 2. But she did say that she would support continuation of the restriction on his registration preventing him prescribing S8 drugs "for a period of time", but not permanently. Character Evidence 1. In evidence there were also character references. Dr Etri, General Practitioner and Fellow of the RACGP worked in the same medical practice as the practitioner for 18 months in 2011 / 2012. He had read the complaints by the HCCC against the practitioner and described them as "serious". 2. Notwithstanding that, he described the practitioner as "a person of excellent character and a dedicated medical practitioner". He impressed Dr Etri with his "genuine empathy for his patients" and described him as "guided by a desire to help and care for his patients as best he could". 3. He said in his reference that in his discussions with the practitioner about the complaints, the practitioner was "full of regret and embarrassment" and "He realizes fully that his actions fell short of the standard that the medical profession expects and just as importantly, what he expects of himself". 4. Dr Samuel Cheng, a general practitioner and Fellow of the RACGP has known the practitioner since 2011, worked with him in public hospitals, and has been a member of the same church as the practitioner since 2011, and is a close friend of the practitioner. They have been partners in the Dundas Practice and the Lidcombe practice since 2016. He referred to what he described as the practitioner's "passion for helping his patients by providing compassionate holistic care for all their medical and social needs over a long term period, outside the bounds of episodic hospital presentations". 5. They have a business partnership together which operates the 2 medical practices, and Dr Cheng described their "shared vision of ensuring that we maintain the highest professional standards in providing patient care in a compassionate manner". 6. He says that the ultimate intent of their business model is to direct company profits to charitable organisations. 7. He has had lengthy discussions with the practitioner about the complaints and the events that lead to them. He said the practitioner "has always shown deep remorse for his actions; whilst difficult circumstances existed at the time when these actions were from that may have contributed to what eventuated, he has always accepted full responsibility for what he did and has expressed sorrow that his actions did not satisfy the professional and ethical responsibilities expected of him". He also states that the practitioner has "also shown a commitment to correcting and improving his understanding of the professional standard expected in similar situations in the future, by completing appropriate continued education, including formal courses and regular literature / journal reading, and consulting his mentor, other medical professionals, and legal advisors on a regular basis". 8. There is also a reference from the lead pastor of the practitioner's church, who has known the practitioner for about 15 years. He describes him as a "devoted husband and father to his 3 young children, a hardworking General Practitioner with a big heart for the community he serves, a careful vision-minded businessman, a faithful Christian and a good friend of our family". 9. He praises the practitioner's integrity and compassion. 10. There is a reference by a specialist anesthetist, Dr Simon Collins, who has been a friend of the practitioner for nearly 20 years. They attended the same high school, studied medicine together, and after graduation were close colleagues as junior doctors working as Interns and Resident Medical Officers based at Hornsby / Kuring-Gai Hospital in 2006 to 2007 11. He expresses his opinion that the practitioner is "a man of well-formed ethical judgment and character". 12. Dr Collins is aware of the complaints against the practitioner and has discussed them with him. The practitioner expressed remorse for his conduct and "explained to me how his prescribing and record keeping practices have changed dramatically since the incidents in question". Dr Collins is of the view that the practitioner now has much greater insight into the need for adequate documentation as a result of one of the courses he has now attended and he has told Dr Collins how his involvement in the disciplinary process has given him greater insight into this prescribing practices, and the impact that this can have on both his patients and the wider community. 13. Dr Collins vouches for the practitioner's good character and says he has "a passion for mentoring, teamwork and community development which I have observed as I have seen his work as a junior doctor and heard of his involvement in his church". 14. He said in his reference: "as a junior doctor [the practitioner] had a reputation for being clinically sensible and having excellent procedural skills. This reputation did not contribute to overconfidence or arrogance, but remained founded in a deep sense of compassion for patients. He was diligent to maintain and develop emergency and critical care skills, and did so with punctuality, humility and respect for colleagues of all kinds – doctors, nurses, allied health and support staff. Through our years of working together I was never aware of any performance issues or any professional inadequacies which may have given suspicion of character deficiency. He was always viewed as a reliable team member who worked hard and would not compromise patient care". 1. Dr Manjula Rajaratnam is a General Practitioner and a Fellow of the RACGP. He has practiced as a General Practitioner since about 1990. He has worked in several medical practices as a General Practitioner. 2. He has also been appointed to a position as the "Lead Independent Doctor" in his practice. That role is "to maintain high medical standards by overseeing a team of doctors through clinical meetings and discussions". 3. Dr Rajaratnam has been mentoring the practitioner since the Section 150 hearing in October 2014. 4. At the time of his reference in August 2016, they were meeting monthly. He describes the topics of their discussions as "his general health and wellbeing, any new insights into S4D and S8 medications…. his clinical notetaking, and any other general medical issues". 5. Dr Rajaratnam is familiar with the complaints by the HCCC. He discussed those issues with the practitioner. He said in his reference: "He clearly has insight in realising the error of his ways and is deeply embarrassed by the way that he has failed to maintain the standard that is expected of him as a doctor of his training and experience. He expressed a sincere regret in letting down the medical profession and putting the safety of the public due to his improper handling of these drugs. It has been a pleasure mentoring [the practitioner] and seeing how much this past situation has affected and changed him. I can testify that his knowledge of S4D and S8 drugs of addiction is now quite exceptional, and [he] has a very clear understanding of how and when to prescribe those medications appropriately. His medical records, from what I have seen, are extremely thorough and of a very high standard". 1. Dr Rajaratnam describes the practitioner as at August 2016 as "a good, high-quality caring doctor who wants to be as good a doctor as he can be and do what is best for his patients. He has a strong desire to create a high standard for himself as a general practitioner and to create a medical practice that reflects this, both now and in the future". 2. There is a character reference by Ms Tracey Younie, Care Manager of the RE Tebbutt Lodge, Wesley Mission, at Dundas. She has read the complaints. She says that the practitioner "has been an asset to our facility as a regular doctor who is currently looking after a number of residents. Doctors who are willing to come and see patients in nursing homes regularly are hard to find". She says that the practitioner is "always professional in the way he relates to his patients and to staff". She said "he genuinely cares for his patients and is willing to address their concerns in a professional and extremely caring manner, no matter how small the issue". She says "he has an excellent rapport with the residents, and his professionalism is evident". 3. She said there had been no prescribing or mis-management issues. His medication charts and clinical notes are also managed without any issues. 4. She also said "we are very fortunate and grateful for having a doctor like [the practitioner] at our facility. He is always willing to come to our facility as required, which is often many times a week – to see patients and to meet all of the requirements". 5. Dr Lip is a Fellow of the RACGP and also has a Diploma of Child Health and a Diploma of Obstetrics and Gynaecology. She has known the practitioner since they were childhood friends. She is the wife of Dr Cheng. Their 2 families have socialised considerably, especially since the business partnership formed by the practitioner and Dr Cheng. 6. She has been in discussions by the practitioner about the complaints and his responses. She says: "he has shown not only clear remorse for what happened, but also a strong desire to take every possible endeavour to improve his knowledge and understanding of safe prescribing and medical documentation to ensure that he would not put his patient's health at risk in this way again". 1. She too has worked in the practice with the practitioner since September 2015 and said that she observed from her very first day there the positive impression the practitioner had made on his patients, "and the good reputation he had formed by having worked 3 years in the area as a high quality and compassionate doctor". 2. She has been working alongside the practitioner and said she had observed "how proficient he has become in safe prescribing and documentation". 3. She also refers in her reference to the initiatives the practitioner has taken in the practice. She said "At a practice management level he has put safeguards in place for all doctors, regardless of their experience levels, to ensure the professional standard, especially for those relating to the areas of safe prescribing and appropriate record keeping can be met at the practices he manages. These include sending all doctors updates on safe prescribing and the latest / upcoming drugs of addiction, administering specific practice policies (eg not prescribing restricted medications to new patients, flagging patients with previous potential for medication misuse, establishing a standard policy for dealing with poorly behaved patients) and having a specific item on our monthly clinical meeting's agenda to discuss safe prescribing, to assist with enforcing the safety principals. Even after gaining such an increased knowledge around these issues, he maintains vigilance of the potential challenges that present themselves in future medical practices, and is therefore committed to ensuring that he and other doctors can be protected in as many ways as possible". Additional Policies 1. Some of the policies the practice now has governing the initiating and continuing of prescriptions of S8 drugs (for practitioners with such prescribing rights) are: 1. Taking a detailed clinical history and examination, including the use of an 'Opioid risk assessment tool' form; 2. In respect to new patients - there must be contact made with their previous General Practitioner to find out when last script was written and to verify their clinical condition; 3. Formulating a detailed pain management plan in conjunction with the patient; 4. Contracting with the patient that only one prescriber is allowed and advising them of outcomes if they appear to becoming drug dependant. 5. Contacting the PSU to ensure there is 110 history of methadone treatment evident or if an authority permit is in place. 6. Contacting the Doctor-Shopper line. 7. Contacting and liaising with pain specialists prior to prescribing. 8. Regular review with a pain specialist who is to provide guidance as to the long term management of their analgesia 9. Regular reviews of the patient's condition and recording of such 10. To call the 'Drug and Alcohol Service' (DASAS) for advice if needed. This service is managed by St Vincent's Hospital Alcohol and Drug Service in Sydney. 11. that the practitioner is aware of the requirement for adherence and accountability to goals that the prescription of opioids to non-cancer suffering patient be limited to short term use in light of the limited evidence for long term efficacy and safety of opioid use 1. The practitioner's evidence also is: "The practice also has a policy that if a patient becomes aggressive towards the practitioner in circumstances of the refusal to prescribe S8 drugs or other drugs (or for other reasons) then the practitioner shall terminate the doctor/patient relationship. In such circumstances the practice will send a letter to the patient explaining of the decision that the practice will no longer treat them" Complaint 3 - Consideration 1. The complainant alleges that the conduct of the practitioner the subject of complaints 1 and 2, together amount to professional misconduct. 2. The practitioner admits this. 3. The findings of unsatisfactory professional conduct include instances of inadequate assessment of patients, instances of inadequate record keeping, instances of breach of regulatory requirements, instances of prescribing addictive drugs without proper assessment or inappropriate dosages or inappropriate combination with other medications. 4. The inappropriate prescription of addictive drugs for serious social problems as it often involves medical practitioners prescribing addictive drugs to person who are already addicted to them. In that way it feeds addictions and the problems they involve for the users and the community. 5. Inappropriate prescriptions of addictive drugs and other prescription medications in inappropriate combinations or dosages are very serious incidents of unprofessional conduct and in many instances threaten the life of the patient for whom the drugs were prescribed. 6. Taken together, the instances of unsatisfactory professional conduct that have been proved are of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration. They therefore constitute professional misconduct. 7. Complaint 3 has been proved. Orders proposed 1. At the end of the hearing the Health Care Complaints Commission's submission was that the cancellation of the practitioner's registration pursuant to s 149C(1)(b) of the National Law is an option still available to the Tribunal. But the Health Care Complaints Commission proposed as follows: The suspension of the practitioner's registration for 3 months pursuant to s 149C(1)(b) of the National Law; A reprimand; and Conditions of the practitioner's registration as follows: Practice Conditions 1. Not to possess, prescribe, supply, dispense or administer any "drug of addiction" (Schedule 8 drug) as defined by the Poison's and Therapeutic Goods Act 1966 (NSW), except to prescribe to a patient in [any of 3 nominated nursing home facilities]; 2. (a) Wesley Rayward - 3 Delmar Place, Carlingford 3. (b) RE Tebutt Lodge - 40a Stewart St, Dundas 4. (c) BCS Yallambi Centre - 268 Pennant Hills Rd, Carlingford 5. Not to possess, prescribe, supply, dispense or administer Schedule 4 Appendix Drugs as defined by the Poison's and Therapeutic Goods Regulation 2008 (NSW), except to prescribe to a patient in any of the 3 nominated nursing home facilities; 6. To provide written evidence to the Medical Council of NSW that he attended the offices of the Pharmaceutical Services Unit of the NSW Ministry of Health "PSU" and consented to an order being made under the Poison's and Therapeutic Goods Act 1966 (NSW), to prohibit him from possessing, supplying, administering or prescribing any Schedule 4 Appendix D Drugs within 1 month of the NCAT decision; 7. Any future change to his Schedule 8 and Schedule 4D Drug authorities must be in accordance with the Medical Council of NSW protocol This includes consultation with the Council prior to the making of any application for variation to the PSU; 8. To only practice in a group practice approved by the Council where there are at least 2 registered medical practitioners (excluding the subject practitioner) and where the patients and patient records are shared between the medical practitioners; 9. If practicing in a general practice, to notify the owner/s and principal of the practice and any other practitioner, (including future practitioners), who may be working on site with Dr Chong of these conditions, and to forward to the Council, within 7 days, a copy of these conditions signed by each one of these practitioners; 10. To obtain approval from the Medical Council of NSW ("The Council") prior to changing his base of practice of the nature of his practice; 11. Not to treat more than an average of 155 patients in any 1 week, and an average of no more than 35 patients in any 1 day; 12. To authorise and consent to any exchange of information between the Council, Medicare Australia, and PSU for the purpose of monitoring compliance with these conditions. Mentoring 1. To nominate an experienced general practitioner to act as his professional mentor for approval by the Council in accordance with the Council's Compliance Policy – Mentoring (as varied from time to time) – and as subsequently determined by the appropriate review body: 2. To authorise Council to propose and approve mentors with a copy of the NCAT decision; 3. At each mentoring meeting the practitioner is to include discussion of the following: 1. Prescribing practices, including Schedule 8 and Schedule 4 D substances; 2. Medical record keeping; 3. The issues highlighted in this decision and then any personal and / or medical practice issues that may arise. 1. To authorise the mentor to report, in an approved format to the Council, every 3 months about the fact of contact, and to inform the Council is there is any concern about his professional conduct or personal wellbeing; 2. To be mentored for a minimum period of 12 months and as subsequently determined by the Council. Medical Records Audit 1. To submit to an audit of his medical practice, of a random selection of his medical records by a person or persona nominated by the Council and: 2. The audit is to be held within 6 months from the NCAT decision, and subsequently as required by the Council; 3. The auditor(s) are to assess his compliance with good medical record keeping standards and legislative requirements and compliance with conditions. The Auditor(s) are to pay particular attention to his assessment of patients, treatment plans and prescribing of medication. 1. To authorise the auditor(s) to provide the Council with a report on their findings; and 2. To meet all costs associated with the audit(s) and any subsequent reports. Note re Conditions The Tribunal to include in the decision the following orders in relation to any conditions imposed. 1. Under Section 163(1)(a) of the National Law the Medical Council of NSW is the appropriate review body for the review of the conditions; 2. The Tribunal is also to make an order if the practitioner is anywhere else in Australia other than NSW, Sections 125-127 inclusive of the National Law are to apply; 3. A review of these conditions may be conducted by the Medical Board of Australia; (These above orders should only relate to conditions.) 1. On behalf of practitioner, his counsel opposed any order for a suspension of the practitioner's registration. The Tribunal was reminded that at the time of the hearing it was 2 years since the practitioner had prescribed or had anything to do with Schedule 8 or Schedule 4D substances. 2. It was proposed for the Practitioner that he be reprimanded and permitted to continue to practice, but subject to the existing conditions on his registration. Conclusions 1. The powers of the Tribunal in disciplinary proceedings such as these are set out in sub-division 6 and 7 of Part 8 of the National Law. 2. They include powers to order suspension or cancellation of the practitioner's registration, powers to caution, reprimand, or counsel the practitioner, and power to impose fines. 3. They also include a power to impose or alter conditions of the practitioner's registration. 4. The purpose of the disciplinary proceedings is the protection of the public, not punishment of the practitioner. 5. There are many proceedings against practitioners who are found to have inappropriately prescribed drugs of addiction to their patients. Many of them also have not done proper assessments of the patient and have not kept proper records. 6. The practitioner in this case amongst that group is exceptional. He has made outstanding efforts to better understand what his patients and the public are entitled to expect from him by way of protection. 7. He has undertaken extensive course and reading for that purpose and also for the purpose of equipping his practice to achieve a level of excellence in its treatment in this area of general medicine. 8. The Tribunal is satisfied that this is not a situation where the public interest requires that there by any suspension or cancellation imposed. 9. The Tribunal is satisfied that in terms of protection of the public the outcome should be that there is a finding of professional misconduct, the practitioner is reprimanded, the practitioner continues being mentored for at least 12 months, and any conditions currently on the practitioner's registration are to be removed upon him producing to the Medical Council evidence that he has completed the 4 courses listed on page 6 of his statement in the proceedings and the course provided by the Medical Faculty of Monash University called "Issues In General Practice Prescribing". 10. The Tribunal is satisfied that subject to proof of his attendances at those courses, protection of the public does not require the current conditions on his registration and he should have prescribing rights for Schedule 8 and Schedule 4D drugs. 11. There should also be an authorisation by the practitioner for the PSU to monitor his prescribing of Schedule 8 drugs and Schedule 4D drugs for 2 years from the date of these orders. 12. In addition, there should be a medical records audit condition on his registration with the audit to be held within 6 months from this decision. Costs 1. Given the findings of unsatisfactory professional conduct and professional misconduct, the applicant has succeeded in its application and should succeed on its application for costs (HCCC v Dinkar [2009] NSWMT8; HCCC v Mazzaferro [2011] NSWMT 9 at [67]). There should be an order for the practitioner to pay the costs of the Health Care Complaints Commission. Privacy 1. To protect the privacy of patients referred to in the proceedings there should be an order prohibiting the publication or broadcast of the name or other identifying information of any patient, except by leave of the Tribunal. Orders 1. Accordingly the Orders made on 20 October 2016 were (as amended 18 September 2017 by consent): 1. The Respondent is guilty of professional misconduct. 2. The Respondent practitioner is reprimanded. 3. The Medical Council of NSW is the appropriate review body for the purposes of Part 8 Division 8 of the Health Practitioner Regulation National Law (NSW). 4. Sections 125 to 127 of the Health Practitioner Regulation National Law are to apply should the Respondent practitioner's principal place of practice be anywhere in Australia other than in New South Wales, so that the appropriate review body in those circumstances is the Medical National Board. 5. Not to possess, supply, administer or prescribe any 'drug of addiction' (Schedule 8 drug) as defined by the Poisons and Therapeutic Goods Act 1966 (NSW) except to prescribe to a patient in the following nursing home facilities: 1. W R – 3 Dalmar Place, Carlingford; 2. RE Tebutt Lodge – 40a Stewart St, Dundas; 3. BCS Yallambi Centre – 268 Pennant Hills Rd, Carlingford. Order 5 is to remain in effect until the practitioner has provided documentary evidence to the Council that he has satisfactorily completed the following course "Issues in general practice prescribing" offered by Monash University. 1. To complete by 2 March 2018 the course "Issues in General Practice Prescribing" offered by Monash University. 1. Within one month of completing the abovementioned course, he is to provide documentary evidence to the Council that he has satisfactorily completed the course. 1. To nominate an experienced general practitioner to act as his professional mentor for approval by the Medical Council of NSW in accordance with the Medical Council of NSW Compliance Policy – Mentoring (as varied from time to time) and as subsequently determined by the appropriate review body: 1. To authorise the Council to provide proposed and approved mentors with a copy of the NCAT decision; 2. To meet with the mentor at least once each month; 3. Each mentoring meeting is to include discussion of the following; 1. Prescribing practices including prescribing of Schedule 8 and Schedule 4D drugs; 2. Medical record keeping; 3. The issues highlighted in this decision of the Tribunal; and 4. Any personal and/or medical practice issues that may arise. 1. To authorise the mentor to report, in an approved format, to the Council every 6 months about the fact of contact, and to inform the Council if there is any concern about his professional conduct, or personal wellbeing; 2. To be mentored for a minimum period of 12 months and as subsequently determined by the Council. 1. To submit to an audit of his medical practice, of a random selection of this medical records by a person or persons nominated by the Medical Council of NSW and: 1. The audit is to be held by 2 March 2018 and subsequently as required by the Council; 2. The auditor(s) are to assess his compliance with good medical record keeping standards and legislative requirements and compliance with conditions; 3. The auditor(s) should pay particular attention to his assessment of patients, treatment plans and prescribing of medication, in particular of Schedule 8 and Schedule 4D drugs; 4. To authorise the auditor(s) to provide the Council with a report on their findings; 5. To meet all costs associated with the audit(s) and any subsequent reports. 1. To authorise and consent to any exchange of information between the Medical Council of NSW and Medicare Australia and Pharmaceutical Services for the purpose of monitoring compliance with these conditions. 2. The Respondent must pay the applicant's costs of or incidental to these proceedings as agreed or assessed. 3. Broadcast or publication without the leave of the Tribunal of the name or other identifying information of any patient referred to in these reasons is prohibited. These orders were amended by consent 18 September 2017. ********* I hereby certify that this is a true and accurate record of the reasons for decision of the Civil and Administrative Tribunal of New South Wales. Registrar Amendments 18 September 2017 - Orders of 24 October 2016 amended by consent DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment or decision. The onus remains on any person using material in the judgment or decision to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court or Tribunal in which it was generated. Decision last updated: 18 September 2017