Civil and Administrative Tribunal New South Wales Medium Neutral Citation: Health Care Complaints Commission v Arreza [2017] NSWCATOD 119 Hearing dates: 6 - 9 March 2017 Date of orders: 09 March 2017 Decision date: 09 March 2017 Jurisdiction: Occupational Division Before: Hon G Mullane ADCJ, Principal Member Dr S Howle, Professional Member Dr M Crawford, Professional Member Ms G Ettinger, General Member Decision: (1) The respondent practitioner is guilty of professional misconduct; (2) The practitioner is reprimanded; (3) The practitioner must: (a) complete within one year of today's date, the course "Difficult Patients Interactions Masterclass" as provided by the Cognitive Institute. (b) Provide to the Medical Council of NSW (the Council") within 6 months of today's date, evidence of enrolment in that course; (c) Provide the Medical Council with evidence of satisfactory completion of that course within 1 month of completion; and (d) If that course is not available, propose to the Council a similar course to be undertaken, and satisfactorily complete that course within 3 months of approval of the course by the Council. (4) The practitioner's registration as a medical practitioner is hereby subjected to the following conditions for a period of one year from today's date: Prescribing (a) 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) other than for palliative care patients (i.e. patients already under the management of a palliative care specialist), or if working as an employee of a hospital (other than as a Visiting Medical Officer); (b) Not to possess, supply, administer or prescribe any substance listed in Schedule 4 Appendix D of the Poisons and Therapeutic Goods Regulation 2008 (NSW) other than for palliative care patients (i.e. patients already under the management of a palliative care specialist) or if working as an employee of a hospital (other than as a Visiting Medical Officer); Obligations to Council (c) The Practitioner authorises and consents to any exchange of information between the Council and Medicare Australia where such exchanges are necessary to facilitate the monitoring of compliance with these conditions; (d) To obtain Council approval prior to changing the nature or place of his practice; (e) To advise the Council in writing at least 7 days prior to changing the nature or place of his practice; (f) To provide the Council within 14 days, evidence that he has provided a copy of all practice conditions to: (i) the practice manager of any general practice where he is employed; (ii) all other general practitioners working in the general practice where he is employed; and/or (iii) any other senior officer at any other place of his employment including public or private hospitals, nursing homes, medical centres or locum agencies; (g) To provide the Council within 14 days of publication of the Tribunal's decision, evidence that he has provided a copy of the tribunal decision to: (i) the practice manager of any general practice(s) where he is employed; and (ii) all other general practitioners working in the general practice where he is employed; and/or (iii) any other senior officer at any other place of employment including public or private hospitals, nursing homes, medical centres or locum agencies; (h) In the event that the practitioner changes his place of practice, provide the Council within 14 days, evidence that a copy of the conditions and the published Tribunal decision (if available) has been provided to: (i) the practice manager of any general practice where he is employed; and (ii) all other general practitioners working in the general practice where he is employed; and/or (iii) any other senior officer at any other place of employment including public or private hospitals, nursing homes, medical centres or locum agencies; Supervision (i) To practice under Level C supervision in accordance with the Council's Level C Supervision Policy as varied below: (j) within 14 days of these orders the practitioner is to nominate a proposed supervisor for approval by the council; (k) The Supervisor need not practice at the same location as the Practitioner; (l) During first 3 months of the period of supervision the approved Supervisor is to meet with the Practitioner for at least 2 hours each fortnight; (m) The Supervisor is to report to the Council every 3 months, and if required by the Council, on his supervision of the Practitioner, and is to raise any concerns with the Council which he/she may have about the Practitioner's capacity to practise medicine safely; (n) For the first 3 months of the supervision every second occasion of supervision is to include the Supervisor directly observing a sample of at least 8 consultations by the Practitioner with a patient (with the consent of each patient); (o) The Supervisor is to provide the practitioner oral feedback in relation to the Supervisor's observations of the Practitioner's patient consultations and his patient records and matters such as patient history taking, difficult patients, treatment plans, clinical decision making, clinical diagnoses, patient/doctor communications, prescribing and/or any other relevant issues that arise; (p) During the first 3 months of the supervision period the Supervisor is to conduct an audit and assess at least 25 of the Practitioner's patient medical records for the period since 1 January 2016 chosen randomly by the Supervisor; (q) The Supervisor is to include in his reports to the Council an audit assessing whether those records satisfy the statutory requirements under the National Law , the Regulation, and good medical record keeping, and whether they comply with the conditions of the Practitioner's registration; (r) After the first 3 months of supervision, the Supervisor is to meet with the Practitioner once every month for not less than 2 hours to discuss case studies, patient history taking, treatment plans, clinical decision making, , clinical diagnoses, record-keeping, patient/doctor communication, ,prescribing and any other issues raised by the Practitioner or the Supervisor. (s) If the approved Supervisor becomes unavailable to continue the supervision, the Supervisor must inform the Council in writing, and the Practitioner must nominate an different Supervisor within 14 days of becoming aware that the current arrangement cannot continue. Practice arrangements (t) If the practitioner is practising in general practice, he must practice only in a group practice approved by the Council. Expenses of Supervision (u) The practitioner is responsible for any costs arising out of compliance with the conditions. (5) The above conditions may be altered, varied or removed at the discretion of the Council and the Council is the appropriate body for the purposes of Division 8 of Part 8 of the National Law. (6) Sections 125 and 127 of the National Law are to apply while the Practitioner's principal place of practice is anywhere in Australia other than New South Wales, so that a review of these conditions can be conducted by the Medical Board of Australia. (7) The Respondent must pay the applicant's costs of or incidental to these proceedings, as agreed or as assessed under the Legal Profession Uniform Law Application Act (2014) NSW. (8) Publication or broadcast without the leave of the Tribunal of the name or other identifying information of any patient referred to in the evidence or the reasons for these orders is prohibited. Catchwords: Medical practitioner, disciplinary proceedings, prescribing drugs of addiction, inadequate patient assessment, inadequate patient records, inappropriate combination of medications, Prescribing excessive dosages and excessive frequency, Failing to properly consider alternatives to addictive drugs, failing to recognise and respond appropriately to indications of patient addictions and doctor shopping. Unsatisfactory professional conduct? Professional misconduct? Legislation Cited: Health Practitioner Regulation (NSW) Regulation 2010 Health Practitioner Regulation National Law NSW Legal Profession Uniform Law Application Act (2014) NSW Poisons and Therapeutic Goods Act 1966 (NSW) Cases Cited: HCCC v Lo [2016] NSWCATOD119; HCCC v Nemeth [2012] NSWMT 4; HCCC v Philipiah [2013] NSWCA 342; HCCC v Suri [2016] NSWCATOD54; Spicer v NSW Medical Council (unreported CA no.3 of 1981, 10 February 1981); Category: Principal judgment Parties: Health Care Complaints Commission (Applicant) Angelo Manuel Arreza (Respondent) Representation: Counsel: B O'Donnel (Applicant) M Lynch (Respondent) Solicitors: Health Care Complaints Commission (Applicant) TressCox Lawyers (Respondent) File Number(s): 2016/00378758, 1620197 Publication restriction: Publication or broadcast without the leave of the Tribunal of the name or other identifying information of any patient referred to in the evidence or the reasons for these orders is prohibited. This decision has been amended. Please see the end of the reasons for details of the amendment. reasons for decision Introduction 1. These were disciplinary proceedings against the respondent medical practitioner. 2. In December 2014, Pharmaceutical Services Unit ("The PSU") raised a complaint to the NSW Medical Council in relation to the practitioner's prescribing of drugs. 3. An investigation by the Applicant ("the HCCC") occurred. A Section 40 letter was sent by the HCCC to the practitioner on 17 November 2015 and his reply, by his solicitors, is dated 16 December 2015. 4. On 22 January 2015 the Practitioner consented to the imposition of Conditions on his registration as follows: 1. To obtain Medical Council of NSW approval prior to changing the nature or place of his practice. 2. To advise the Medical Council of NSW in writing at least seven days prior to changing the nature or place of his practice. 3. Not to possess, supply, administer or prescribe any 'drug of addiction' (Schedule 8 drug) as defined by Poisons and Therapeutic Goods Act 1966 (NSW). 4. 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 to prohibit him from possessing, supplying, administering or prescribing any Schedule 8 drug by 4 February 2015. 5. Not to possess, supply, administer or prescribe any substance listed in Schedule 4 Appendix D of the Poisons and Therapeutic Goods Regulation 2008 (NSW). 6. 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 act 1960 to prohibit him from possessing, supplying, administering or prescribing any Schedule 4 Appendix D drug by 4 February 2015. 7. To forward evidence to the Medical Council of NSW within 14 days of 22 January 2015, that he has provided a copy of the Practice Conditions to the; 1. Medical Director and/or; 2. Principal of Practice and/or; 3. Any other Responsible senior officer in any place that he works (including any locum agencies, Local Health District public and private hospitals, day procedures centre, medical centre or nursing home where he holds any appointments). 1. Within 14 days of a change in the nature or place of his practice, he is to forward 1. evidence to the Medical Council of NSW that he has provided a copy of the Practice Conditions to the; 2. Medical Director and/or; 3. Principal of Practice and/or; 4. Any other Responsible senior officer in any place that he works (including any locum agencies, Local Health District public and private hospitals, day procedures centre, medical centre or nursing home where he holds any appointments). 1. To authorise the Medical Council of NSW to notify current and future persons or organisations at places where he works as a medical practitioner in Australia, of any issues arising in relation to compliance with these Conditions. 2. To authorise and consent to any exchange of information between the Medical Council of NSW, Medicare Australia and Pharmaceutical Services for the purpose of monitoring compliance with these Conditions 1. After the investigation had been completed, the HCCC filed an application in the Tribunal alleging unsatisfactory professional conduct and professional misconduct in relation to his inappropriate prescription of drugs for patients, inadequate medical records by him for patients, unethical conduct, prescribing inappropriate combinations of medications, prescription of addictive drugs more frequently or in greater doses than therapeutic standards, failure to properly assess patients, failure to properly consider alternatives to prescription of addictive drugs, and other matters. 2. The proceedings were commenced on 12 August 2016 and the hearing occurred on 6, 7, 8, and 9 March 2017. The orders were made on 9 March and these are the reasons. The Application and Complaint 1. The application sought that there be a privacy order protecting the privacy of the patients referred to in the complaint by prohibiting publication or broadcast of their names or other identifying information. 2. It also sought an order for costs and orders "pursuant to s.149A (Powers to Caution, Reprimand, Imposed Conditions on Registration, etc); s.149B (Power to Impose a fine) and/or s.149c (Powers to suspend or cancel registration, make a prohibition order, etc) of the Health Practitioner Regulation National Law (NSW) ("The National Law")". 3. The complaints, as set out in the application, are as follows: COMPLAINT ONE The practitioner is guilty of unsatisfactory professional conduct under section 139B(1)(a) and/or (I) of the National Law in that the practitioner has: 1. engaged in conduct that demonstrates 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; 2. engaged in improper or unethical conduct relating to the practice or purported practice of medicine. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. BACKGROUND TO COMPLAINT ONE Patient A is a drug dependent patient with a history of depress ion and anxiety relating to domestic violence and a car accident in 2011 during which she fractured her thoracic spine. Patient A participated in the Opioid Treatment Program ("OTP") between 2007 and 2012. Patient A consulted with the practitioner between April 2013 and March 2014. PARTICULARS OF COMPLAINT ONE 1. The practitioner prescribed fentanyl, venlafaxine and diazepam to Patient A on the dates and quantities as set out in Schedule A: 1. without obtaining patient records from Patient A's prior general practitioner; 2. without conducting an adequate assessment of Patient A's pain in relation to her 2011 thoracic spine injury in that he did not undertake or make inquiries as to: 1. a psychological assessment; 2. length of time Patient A had been taking fentanyl, venlafaxine and diazepam; 3. when and in what circumstances she felt pain; 4. a pain assessment using a pain scale; 5. whether there was interruption of sleep, daily activities, relationships or sexual activity; 6. whether there was non-pharmaceutical steps taken to alleviate pain and anxiety; 7. a physical examination of her cervical thoracic and lumbar spine with assessments of mobility and power; 8. measurement of vital signs including weight 1. without referring Patient A to a: 1. psychologist; 2. pain management specialist; 1. for a purpose that does not accord with recognised therapeutic standards. 1. The practitioner inappropriately prescribed fentanyl and venlafaxine on the dates and in the quantities set out in Schedule A in a dose that is in excess of the recognised therapeutic standard. 2. The practitioner prescribed fentanyl on the dates and in the quantities set out in Schedule A without obtaining an authority to prescribe the medication from the Secretary of the Ministry of Health contrary to section 28 of the Poisons and Therapeutic Goods Act 1966 (PTG Act). 3. The practitioner inappropriately prescribed diazepam to Patient A in combination with fentanyl on the dates and in the quantities as set out in Schedule A. COMPLAINT 1A is guilty of unsatisfactory professional conduct under section 139B(1)(b) of the National Law in that the practitioner has contravened a provision of the Health Practitioner Regulation (NSW) Regulation 2010 ("the Regulation"). Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background of Complaint 1A The background to Complaint 1 is relied on. PARTICULARS OF COMPLAINT 1A 1. The practitioner failed to maintain adequate medical records for Patient A in accordance with the requirements of the Regulation Schedule 2 Clauses 1 and 2 in that the records failed to include sufficient details as to Patient A's: 1. weight; 2. alcohol intake; 3. age-related related health checks including pap smears and skin checks. COMPLAINT 2 Is guilty of unsatisfactory professional conduct under section 139B(1)(a) and/or (I) of the National Law in that the practitioner has: 1. engaged in conduct that demonstrates 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; 2. engaged in improper or unethical conduct relating to the practice or purported practice of medicine Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 2 Patient B is a drug dependent patient with a number of issues relating to right knee pain. Patient B consulted with the practitioner between April 2013 and March 2014. PARTICULARS TO COMPLAINT 2 1. The practitioner prescribed fentanyl, oxycodone hydrochloride and temazepam to Patient B on the dates and quantities as set out in Schedule B: 1. without conducting an adequate assessment of Patient B in that he did not undertake or make inquiries as to: 1. a psychological assessment; 2. a pain assessment; 3. how the pain affected his work or daily activities; 4. how the medication affected his body and/or mind; 5. whether he experienced any side effects from the medication; 6. whether a plan ought to be developed to decrease fentanyl dose; 1. without referring Patient B to a pain specialist; 2. without recommending non pharmaceutical approaches to patient B for pain relief including: 1. hydrotherapy; 2. physical therapy; 3. sports physiology. 1. for an inappropriate therapeutic purpose; 2. without responding appropriately to Patient B's drug-seeking behaviour. 1. The practitioner prescribed fentanyl and oxycodone hydrochloride to Patient B on the dates and in the quantities set out in Schedule B without obtaining an authority to prescribe the medication from the Secretary of the Ministry of Health contrary to section 28 of the PTG Act. 2. The practitioner inappropriately prescribed temazepam to Patient B in combination with fentanyl and oxycodone hydrochloride on the dates and in the quantities as set out in Schedule B. 3. The practitioner failed to identify Patient B's drug-seeking behaviour until March 2014 because he failed to review Patient B's earlier medical records before that time. COMPLAINT 2A is guilty of unsatisfactory professional conduct under section 13913(1)(b) of the National Law in that the practitioner has contravened a provision of the Regulation. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 2A The background to Complaint 2 is repeated. PARTICULARS TO COMPLAINT 2A 1. The practitioner failed to maintain adequate medical records for Patient B in accordance with the requirements of the Regulation Schedule 2 Clauses 1 and 2 in that the records failed to include sufficient details as to Patient B's: 1. weight; 2. alcohol intake; 3. age-related related health checks including and skin checks; 4. mental health. COMPLAINT 3 is guilty of unsatisfactory professional conduct under section 139B(1)(a) and/or (I) of the National Law in that the practitioner has: 1. engaged in conduct that demonstrates 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; 2. engaged in improper or unethical conduct relating to the practice or purported practice of medicine Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 3 Patient C is a drug dependent patient who suffered in a motor vehicle accident sometime in 2003. Patient C consulted with the practitioner between January 2014 and March 2014. PARTICULARS TO COMPLAINT 3 1. The practitioner prescribed fentanyl and MS Contin to Patient C on the dates and quantities as set out in Schedule C: 1. without obtaining a copy of the opinion of Medical Practitioner A; 2. without undertaking a pain assessment; 3. without liaising with Medical Practitioner A as to the level of medication that ought to be prescribed prior to Patient C's admission to the Hunter Pain Clinic; 4. without arranging referral to a rehabilitation physician. 1. The practitioner prescribed fentanyl and morphine to Patient C on the dates and in the quantities set out in Schedule C: 1. in a dose that is in excess of the recognised therapeutic standard; 2. for an inappropriate therapeutic purpose. 1. The practitioner prescribed fentanyl and morphine to Patient C on the dates and in the quantities set out in Schedule C without obtaining an authority to prescribe the medication from the Secretary of the Ministry of Health contrary to section 28 of the PTG Act. 2. 14. On 10 March 2014 the practitioner failed to contact the Prescription Shopping Information Service prior to re-issuing prescriptions to Patient C for fentanyl and morphine in the quantities as set out in Schedule C. COMPLAINT 3A is guilty of unsatisfactory professional conduct under section 139B(1)(b) of the National Law in that the practitioner has contravened a provision of the Regulation. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 3A The background to Complaint 3 is repeated. PARTICULARS TO COMPLAINT 3A 1. The practitioner failed to maintain adequate medical records for Patient C in accordance with the requirements of the Regulation Schedule 2 Clauses 1 and 2 in that the records failed to include sufficient details as to Patient Cs: 1. general health; 2. vital signs; 3. age-related related health checks including and skin checks; 4. management of his left arm; 5. mental health. COMPLAINT 4 is guilty of unsatisfactory professional conduct under section 139B(1)(a) and/or (I) of the National Law in that the practitioner has: 1. engaged in conduct that demonstrates 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: 2. engaged in improper or unethical conduct relating to the practice or purported practice of medicine. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 4 Patient D is a drug dependent patient with a history of depression, anxiety and panic attacks as a result of domestic violence and childhood sexual abuse by family members. Patient D participated in the OTP between 1994 and 2000. Patient D consulted with the practitioner between December 2013 and November 2014 PARTICULARS TO COMPLAINT 4 1. The practitioner prescribed fentanyl, morphine and alprazolam to Patient D on the dates and in the quantities set out in Schedule D: 1. without undertaking an assessment of: 1. daily functioning; 2. pain levels; 3. assessment of side effects; 4. use of any other medication; 1. without referring Patient D to a pain specialist; 2. for an inappropriate therapeutic purpose; 3. in a combination which encouraged dependence and put Patient D at an increased risk of overdose; 4. without responding appropriately to Patient D's drug-seeking behaviour. 1. The practitioner prescribed fentanyl, morphine and alprazolam to Patient D on the dates and in the quantities set out in Schedule D without obtaining an authority to prescribe the medication from the Secretary of the Ministry of Health contrary to section 28 of the PTG Act. 2. The practitioner prescribed aiprazolam to Patient D on the dates and in the quantities set out in Schedule D in quantities in excess of recognised therapeutic standards of what is medically appropriate. COMPLAINT 4A is guilty of unsatisfactory professional conduct under section 139B(1)(b) of the National Law in that the practitioner has contravened a provision of the Regulation. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 4A Background to Complaint 4 is repeated. PARTICULARS TO COMPLAINT 4A 1. The practitioner failed to maintain adequate medical records for Patient D in accordance with the requirements of the Regulation Schedule 2 Clauses 1 and 2 in that the records failed to include sufficient details as to Patient D's: 1. mental health; 2. clinical indicators for pain relieving medication. COMPLAINT 5 is guilty of unsatisfactory professional conduct under section 139B(1)(a) and/or (I) of the National Law in that the practitioner has: 1. engaged in conduct that demonstrates 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; 2. engaged in improper or unethical conduct relating to the practice or purported practice of medicine. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 5 Patient E is a drug dependent patient with a history of depression, anxiety and insomnia. Patient E has suffered from Hepatitis C, a range of gynaecological issues and chronic back pain. Patient E participated in the OTP between 2008 and 2009. Patient E consulted with the practitioner between August 2013 and July 2014. PARTICULARS TO COMPLAINT 5 1. The practitioner prescribed fentanyl, morphine, oxycodone, diazepam, temazepam and panadeine plus codeine to Patient E on the dates and in the quantities set out in Schedule E: 1. without conducting an assessment of: 1. pain levels; 2. sleep; 1. without referring Patient E to a psychologist; 2. without responding appropriately to Patient E's drug seeking behaviour. 1. The practitioner prescribed diazepam and temazepam in an inappropriate combination with fentanyl, morphine and oxycodone on the dates and in the quantities set out in Schedule E. 2. The practitioner prescribed fentanyl, morphine, oxycodone on the dates and in the quantities set out in Schedule E without obtaining an authority to prescribe the medication from the Secretary of the Ministry of Health contrary to section 28 of the PTG Act. COMPLAINT 5A is guilty of unsatisfactory professional conduct under section 139B(1)(b) of the National Law in that the practitioner has contravened a provision of the Regulation. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 5A Background to Complaint 5 is repeated. PARTICULARS TO COMPLAINT 5A 1. The practitioner failed to maintain adequate medical records for Patient E in accordance with the requirements of the Regulation Schedule 2 Clauses 1 and 2 in that the records fail to include sufficient details as to Patient E's: 1. mental health; 2. sleeping habits; 3. use of medication following the physical assault; 4. management of daily living; 5. back pain. COMPLAINT 6 is guilty of unsatisfactory professional conduct under section 139B(1)(a) and/or (I) of the National Law in that the practitioner has: 1. engaged in conduct that demonstrates 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; 2. engaged in improper or unethical conduct relating to the practice or purported practice of medicine. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 6 Patient F is a drug dependent patient with a history of chronic back pain as a result of a car accident in 2006. Patient F was a participant of the OTP from May 2014. Patient F consulted with the practitioner between January 2014 and April 2014. PARTICULARS TO COMPLAINT 6 1. The practitioner prescribed fentanyl, oxycodone, and pregabalin to Patient F on the dates and in the quantities set out in Schedule F: 1. without conducting an assessment of: 1. back pain; 2. mental health; 3. daily functioning; 1. without ensuring he received relevant correspondence from Medical Practitioner A; 2. without referring Patient F for non-pharmacological pain relief options; 3. for an inappropriate therapeutic purpose; 4. in an inappropriate combination; 5. without responding appropriately to Patient F's drug seeking behaviour. 1. The practitioner prescribed fentanyl and oxycodone to Patient F on the dates and in the quantities set out in Schedule F without obtaining an authority to prescribe the medication from the Secretary of the Ministry of Health contrary to section 28 of the PTG Act. COMPLAINT 6A is guilty of unsatisfactory professional conduct under section 139B(1)(b) of the National Law in that the practitioner has contravened a provision of the Regulation. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 6A The background to Complaint 6 is repeated PARTICULARS TO COMPLAINT 6A 1. The practitioner failed to maintain adequate medical records for Patient F in accordance with the requirements of the Regulation Schedule 2 Clauses 1 and 2 in that the records failed to include sufficient details as to Patient F's: 1. weight; 2. physical examination; 3. routine age related checks including skin checks; 4. mental health. COMPLAINT 7 is guilty of unsatisfactory professional conduct under section 139B(1)(a) and/or (I) of the National Law in that the practitioner has: 1. engaged in conduct that demonstrates 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; 2. engaged in improper or unethical conduct relating to the practice or purported practice of medicine, Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 7 Patient G is a drug dependent patient with a history of anxiety, depression and a range of gynaecological issues. Patient G participated in the OTP between 1998 and 2000 and again from 2014. Patient G consulted with the practitioner between January 2014 and October 2014. PARTICULARS TO COMPLAINT 7 1. The practitioner prescribed buprenorphine, oxycodone and oxycodone plus naloxone to Patient G on the dates and in the quantities set out in Schedule G: 1. without conducting an assessment of or making inquiries as to: 1. Patient G's pain; 2. the difference the medication made to Patient G's daily living; 3. the side effects of the medication; 4. any other medications being taken. 1. The practitioner prescribed buprenorphine, oxycodone and oxycodone plus naloxone, and to Patient G on the dates and in the quantities set out in Schedule G without obtaining an authority to prescribe the medication from the Secretary of the Ministry of Health contrary to section 28 of the PTG Act. COMPLAINT 7A is guilty of unsatisfactory professional conduct under section 139B(1)(b) of the National Law in that the practitioner has contravened a provision of the Regulation. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 7A Background to Complaint 7 is repeated. PARTICULARS TO COMPLAINT 7A 1. The practitioner failed to maintain adequate medical records for Patient G in accordance with the requirements of the Regulation Schedule 2 Clauses 1 and 2 in that the records failed to include sufficient details as to Patient G's mental health. COMPLAINT 8 Background to Complaint 8 Patient H has multiple sclerosis and depression. Patient H consulted with the practitioner between November 2013 and October 2014. PARTICULARS TO COMPLAINT 8 1. The practitioner prescribed oxycodone, amitriptyline and pregabalin to Patient H on the dates and in the quantities set out in Schedule H: 1. without conducting an assessment of or making inquiries as to: 1. Patient H's pain; 2. the difference the medication makes to Patient H's daily living; 3. the side effects of the medication; 4. any other medications being taken. COMPLAINT 8A is guilty of unsatisfactory professional conduct under section 139B(1)(b) of the National Law in that the practitioner has contravened a provision of the Regulation. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 8A PARTICULARS TO COMPLAINT 8A 1. The practitioner failed to maintain adequate medical records for Patient H in accordance with the requirements of the Regulation Schedule 2 Clauses 1 and 2 in that the records failed to include sufficient details as to Patient H's mental health. COMPLAINT 9 is guilty of unsatisfactory professional conduct under section 139B(1)(a) and/or (I) of the National Law in that the practitioner has: 1. engaged in conduct that demonstrates 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; 2. engaged in improper or unethical conduct relating to the practice or purported practice of medicine. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 9 Patient I suffered chronic back pain after a work injury. Patient I consulted with the practitioner between February 2013 and August 2014. PARTICULARS TO COMPLAINT 9 1. The practitioner prescribed fentanyl and hydromorphone to Patient I on the dates and in the quantities set out in Schedule I: 1. without conducting an assessment of Patient l's: 1. neck; 2. back; 3. vital signs including weight; 4. liver functioning; 1. without requesting details from Patient I in relation to: 1. the causative history of his back injury; 2. duration and type of treatment for his back injury; 3. other medical conditions; 4. other medications; 5. alcohol intake; 1. without referring Patient I to a rehabilitation specialist in an appropriate timeframe; 2. for an inappropriate therapeutic purpose; 3. in quantities in excess of recognised therapeutic standards of what is medically appropriate; 4. without responding appropriately to Patient I's drug seeking behaviour. 1. The practitioner prescribed fentanyl and hydromorphone to Patient I on the dates and in the quantities set out in Schedule without obtaining an authority to prescribe the medication from the Secretary of the Ministry of Health contrary to section 28 of the PTG Act. COMPLAINT 9A is guilty of unsatisfactory professional conduct under section 139B(1)(b) of the National Law in that the practitioner has contravened a provision of the Regulation. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 9A Background to Complaint 9 is repeated. PARTICULARS TO COMPLAINT 9A 1. 34. The practitioner failed to maintain adequate medical records for Patient I in accordance with the requirements of the Regulation Schedule 2 Clauses 1 and 2 in that the records fail to include sufficient details as to Patient I's: 1. alcohol intake; 2. physical examinations; 3. consult with Medical Practitioner A. COMPLAINT 10 is guilty of unsatisfactory professional conduct under section 139B(1)(a) and/or (I) of the National Law in that the practitioner has: 1. engaged in conduct that demonstrates 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; 2. engaged in improper or unethical conduct relating to the practice or purported practice of medicine. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 10 Patient J has a history of depression and chronic back pain. In October 2013 Patient J was diagnosed with lung cancer. Patient J consulted with the practitioner between February 2013 and January 2015. PARTICULARS TO COMPLAINT 10 1. The practitioner prescribed diazepam to Patient J on the dates and in the quantities set out in Schedule J: 1. without conducting an assessment of the: 1. reason for the prescription; 2. effect of the medication; 3. effect of the combination of diazepam with other prescribed medications. 1. The practitioner prescribed valproate to Patient J on the dates and in the quantities set out in Schedule J in quantities in excess of recognised therapeutic standards of what is medically appropriate. 2. The practitioner prescribed methadone and oxycodone to patient J on 6 November 2013 in the quantities set out in Schedule J without obtaining an authority to prescribe the medication from the Secretary of the Ministry of Health contrary to section 28 of the PTG Act. 3. The practitioner prescribed diazepam and temazepem to Patient J on the dates and in the quantities set out in Schedule J with adequately assessing the effect of the medications on Patient J. COMPLAINT 11 is guilty of unsatisfactory professional conduct under section 139B(1)(a) of the National Law in that the practitioner has engaged in conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 11 Patient K has a history of anxiety, chronic back pain and Crohn's disease. Patient K consulted with the practitioner between April 2013 and January 2015. PARTICULARS TO COMPLAINT 11 1. The practitioner prescribed diazepam and endone to Patient K on the dates and in the quantities set out in Schedule K: 1. without conducting an adequate assessment of Patient K's: 1. blood pressure; 2. pulse; 3. abdomen. 1. The practitioner prescribed pregabalin to Patient K on the dates and in the quantities set out in Schedule K without conducting an examination of Patient K's right arm. 2. The practitioner prescribed diazepam to Patient K on the dates and in the quantities set out in Schedule K: 1. for an inappropriate therapeutic purpose; 2. without attempting to decrease Patient K's dependence on this medication. 1. The practitioner prescribed pregabalin to Patient K on the dates and in the quantities set out in Schedule K in quantities in excess of recognised therapeutic standards of what is medically appropriate. COMPLAINT 11A is guilty of unsatisfactory professional conduct under section 13913(1)(b) of the National Law in that the practitioner has contravened a provision of the Regulation. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 11A Background to Complaint 10 is repeated. PARTICULARS TO COMPLAINT 11A 1. The practitioner failed to maintain adequate medical records for Patient K in accordance with the requirements of the Regulation Schedule 2 Clauses 1 and 2 in that the records failed to include sufficient details as to: 1. Patient K's Mental health; 2. the reason for Patient K's referral to a physiotherapist. COMPLAINT 12 is guilty of unsatisfactory professional conduct under section 139B(1)(a) and/or (I) of the National Law in that the practitioner has: 1. engaged in conduct that demonstrates 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; 2. engaged in improper or unethical conduct relating to the practice or purported practice of medicine. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 12 Patient L has brain surgery in 1996 to remove a cancerous tumour. The surgery resulted in a long history of sleeping difficulties and epileptic seizures. Patient L also had a history of depression and anxiety. Patient L passed away after a seizure in October 2014. Patient L consulted the practitioner between August 2013 and October 2014. PARTICULARS TO COMPLAINT 12 1. The practitioner prescribed phenytoind sodium to Patient L on the dates and in the quantities set out in Schedule L: 1. without making relevant inquiries including: 1. results of recent EEG assessments; 2. how the medication was being taken; 3. whether there were any drug interactions; 1. without referring Patient E for neurosurgical opinion. 1. 45. The practitioner prescribed diazepam to Patient L on the dates and in the quantities set out in Schedule L: 1. without making relevant inquiries including: 1. the effect of the medication; 2. any side effects; 3. any drug interactions; 4. the reason for the prescription; 5. an alternative medication that does not interact with opiates; 1. for an inappropriate therapeutic purpose. 1. The practitioner prescribed oxycodone to Patient L on the dates and in the quantities set out in Schedule L: 1. with greater frequency than accords with recognised therapeutic standards of what is medically appropriate; 2. without responding appropriately to Patient L's drug-seeking behaviour. 1. The practitioner prescribed oxycodone to Patient L on the dates and in the quantities set out in Schedule L without obtaining an authority to prescribe the medication from the Secretary of the Ministry of Health contrary to section 28 of the PTG Act. COMPLAINT 12A is guilty of unsatisfactory professional conduct under section 139B(1)(b) of the National Law in that the practitioner has contravened a provision of the Regulation. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the • alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 12A Background to Complaint 12 is repeated. PARTICULARS TO COMPLAINT 12A 1. The practitioner failed to maintain adequate medical records for Patient L in accordance with the requirements of the Regulation Schedule 2 Clauses 1 and 2 in that the records fail to include sufficient details as to Patient L's: 1. headaches; 2. sleep disturbance; 3. reason for chronic diazepam prescriptions; 4. mental health issues. COMPLAINT 13 is guilty of unsatisfactory professional conduct under section 139B(1)(a) of the National Law in that the practitioner has engaged in conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 13 Patient M had chronic lung disease and suffered lower back pain. Patient M consulted with the practitioner between February 2013 and December 2014. PARTICULARS TO COMPLAINT 13 1. The practitioner prescribed salbutamol to Patient M on the dates and in the quantities set out in Schedule M: 1. without assessing the use and value of the medication; 2. with greater frequency than accords with recognised therapeutic standards of what is medically appropriate. 1. The practitioner prescribed oxycodone to Patient M on the dates and in the quantities set out in Schedule M: 1. without assessing Patient M's back pain; 2. without assessing the effectiveness of combining this medication with norspan; 3. without warning Patient M of the risk of respiratory depression; 4. with greater frequency than accords with recognised therapeutic standards of what is medically appropriate. 1. The practitioner prescribed morphine to Patient M on the dates and in the quantities set out in Schedule M with greater frequency than accords with recognised therapeutic standards of what is medically appropriate. COMPLAINT 13A is guilty of unsatisfactory professional conduct under section 1398(1)(b) of the National Law in that the practitioner has contravened a provision of the Regulation. Each particular in itself justifies a finding of unsatisfactory professional conduct. In the alternative, when two or more of the particulars are taken together, a finding of unsatisfactory professional conduct is justified. Background to Complaint 13A Background to Complaint 13 is repeated. PARTICULARS TO COMPLAINT 13A 1. The practitioner failed to maintain adequate medical records for Patient M in accordance with the requirements of the Regulation Schedule 2 Clauses 1 and 2 in that the records failed to include sufficient details as to Patient M's: 1. pain levels; 2. mental state; 3. daily functioning; 4. exercise tolerance; 5. inadequate influenza vaccination; 6. reason for increasing opiate medication. COMPLAINT 14 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 the suspension or cancellation of the practitioner's registration. Background to Complaint 14 The background for Complaints 1 to 13 is repeated. PARTICULARS TO COMPLAINT 14 1. 1. Complaints 1, 1A, 2, 2A, 3, 3A, 4, 4A, 5, 5A, 6, 6A, 7, 7A, 8, 8A, 9, 9A, 10, 10A, 11, 11A, 12, 12A, 13, 13A and the particulars thereof are repeated and relied upon both individually and cumulatively. The Practitioner's Reply to the grounds alleged in the application 1. The Practitioner's Reply was filed on 20 December 2016, more than 4 months after the application. 2. In the reply the practitioner admitted complaints 1 to 13(A) inclusive, except particular 32(b)(i). 3. In relation to complaint 14, the practitioner admitted the conduct that he had admitted in respect to complaints 1 to 13(A) constitute professional misconduct under Section 139E of the National Law. 4. The extensive evidence before the Tribunal supports findings in accordance with those matters alleged in respect to the complaints admitted. 5. The allegation in paragraph 32(b)(i) is an allegation in relation to Patient I that the practitioner prescribed fentanyl and hydromorphone to the patient on the dates and in the quantities set out in schedule 1 to the application without requesting details from Patient I in relation to the cause or the history of his back injury. 6. The practitioner gave evidence in his affidavit that on 21 February 2013 Patient I informed him that he had chronic upper back pain after falling from a scaffold and had injured his T1 vertebra. "I recorded this history in the medical records for Patient I". This evidence was not contradicted. Accordingly particular 32(b)(i) was not established. The Evidence 1. The evidence comprised: 1. Application and Complaint dated 11 August 2016 2. Certificate of Registration Status from Medical Council of NSW 3. Certificate of Registration Status from AHPRA 4. Notification to the Medical council from Pharmaceutical Services Unit (the PSU) dated 24 December 2014; 5. Complaint referral from the MCNSW to the Commission under s150D dated 2 February 2015. 6. PSU Investigation Report of 23 December 2014 attaching: 1. Appendix A: Media Release by the National Drug & Alcohol Research Centre dated 20 March 2013; 2. Appendix B: Pharmaceutical Drugs of Addiction System (PHDAS) - Six Individuals: Patient A, Patient B, Patient C, Patient D, Patient E & Patient F; 3. Appendix C: Therapeutic Guidelines Ltd. - A guide: 'Analgesics used in Chronic Non-malignant Pain' [Revised October 2012] 4. Appendix D: Pharmacy records relating to Patient B from 01/01/14 to 29/10/14 5. Appendix E: Pharmacy records relating to Patient D 6. Appendix F: Pharmacy records relating to Patient E from 01/01/14 to 29/10/14 7. Appendix G: Pharmacy records relating to Patient F from 01/01/14 to 29/10/14 8. Appendix H: Pharmacy records relating to Patient G 4 December 2014, Pharmacy records relating to Patient H dated 5 December 2014 9. Appendix I: Pharmacy records relating to Patient I from 01/01/14 to 29/10/14 10. Appendix J: Pharmacy records relating to Patient J from 01/01/14 to 29/10/14 11. Appendix K: Pharmacy records relating to Patient Z from 01/01/14 to 29/10/14 12. Appendix L: Drug interaction results 13. Appendix M: Pharmacy records relating to Patient K from 01/01/14 to 29/10/14 14. Appendix N: Pharmacy records relating to Patient L from 01/01/14 to 29/10/14 15. Appendix 0: Pharmacy records relating to Patient M from 01/01/14 to 29/10/14 1. Dispensing records for Patient C from Nabiac Pharmacy and Tuncurry Pharmacy 2. Dispensing records for Patient A from Tuncurry Pharmacy and Priceline Pharmacy Forster. 3. Full dispensing records from Tuncurry Pharmacy, between August 2013 and August 2014. 4. Expert request letter to Dr Linda Mann from the Commission dated 15 September 2015. 5. Expert report from Dr Mann dated 20 September 2015 6. Dr Mann's CV 7. Letter from the Commission to Dr Arreza, dated 29 January 2015 8. Letter from Dr Arreza to the Commission, dated 12 March 2015 9. Letter from the Commission to Dr Arreza, dated 15 May 2015 10. Letter from Dr Arreza to the Commission, dated 20 May 2015 11. S34A Notice to Dr Arreza, dated 22 May 2015 12. Letter from Dr Arreza to the Commission, dated 28 May 2015 13. Section 40 letter from the Commission to Dr Arreza, dated 17 November 2015. 14. Section 40 submissions from TressCox Lawyers on behalf of Dr Arreza, dated 16 December 2015 15. Dr Arreza's CV 16. Good Medical Practice: A Code of Conduct for Doctors in Australia (Medical Board of Australia, March 2014) — current version. 17. Good Medical Practice: A Code of Conduct for Doctors in Australia (Medical Board of Australia, July 2010) — repealed version 18. Guide to Poisons and Therapeutic Goods legislation for medical, nurse and midwife practitioners and dentists (NSW Health Pharmaceutical Services Branch, February 2014) —current version. 19. Guide to Poisons and Therapeutic Goods legislation for medical practitioners and dentists (NSW Health Pharmaceutical Services Branch, April 2006) — repealed version. 20. Requirements for an authority to prescribe drugs of addiction under s28 of the Poisons and Therapeutic Goods Act (NSW Health Pharmaceutical Services Branch, November 2013). 21. NSW Health Guidelines for recognising and handling drug dependant patients notes for medical practitioners, January 2006. 22. Guidelines for the management of patients with chronic non-cancer pain (NSW Health Pharmaceutical Services Branch, June 2006). 23. Guidelines for the prescribing of Flunitrazepam (NSW Health Pharmaceutical Services Branch, August 2000). 24. Prescribing of Benzodiazepines, Aiprazolam and Flunitrazepam (NSW Health Pharmaceutical Services Branch, November 2013). 25. RACGP Standards for General Practice (4th Edition) Criterion 5.3.1: Safe and quality use of medicines. 26. RACGP Standards for General Practice (4th Edition) Criterion 1.7.1: Patient health records. 27. RACGP Standards for General Practice (4th Edition) Criterion 1.7.2 Heath summaries. 28. RACGP Standards for General Practice (41h Edition) Criterion 1.7.3 Consultation notes 29. Medicare prescribing history for Dr Arreza from 01/04/10 to 09/03/15 for patients: 1. Patient M 2. Patient A 3. Patient Y 4. Patient B 5. Patient L 6. Patient C 7. Patient D 8. Patient G 9. Patient Z 10. Patient E 11. Patient J 12. Patient H 13. Patient K 14. Patient F 15. Patient I 1. Medicare service history for Dr Arreza from 01/04/10 to 09/03/15; 2. Statement of Mr Jonathan Du, Pharmacy Student, dated 26 August 2015; 3. Schedule of Dr Arreza prescribing to Patient A. 4. Medical records of Patient A 5. Schedule of Dr Arreza prescribing to Patient B. 6. Medical records of Patient B 7. Schedule of Dr Arreza prescribing to Patient C. 8. Medical records of Patient C 9. Schedule of Dr Arreza prescribing to Ms Howard. 10. Medical records of Patient D 11. Schedule of Dr Arreza prescribing to Patient E 12. Medical records of Patient E 13. Schedule of Dr Arreza prescribing to Patient F. 14. Medical records of Patient F 15. Schedule of Dr Arreza prescribing to Patient G. 16. Medical records of Patient G 17. Schedule of Dr Arreza prescribing to Patient H. 18. Medical records of Patient H; 19. Schedule of Dr Arreza prescribing to Patient I. 20. Medical records of Patient I; 21. Schedule of Dr Arreza prescribing to Patient J. 22. Medical records of Patient J 23. Schedule of Dr Arreza prescribing to Patient K. 24. Medical records of Patient K 25. Schedule of Dr Arreza prescribing to Patient L. 26. Medical records of Patient L 27. Schedule of Dr Arreza prescribing to Patient M. 28. Medical records of Patient M. 29. Reply dated 20 December 2016 to Application for Disciplinary Findings 30. Statement of Dr Angelo Manuel Arreza of 15 December 2016 31. 3 character references 32. Letter of instructions to Dr Sami Dayoub of 8 November 2016 33. Character reference of Dr Sami Dayoub of 18 November 2016 34. Letter of instruction to Dr John Olsen of 8 November 2016 35. Character reference of Dr John Olsen dated 25 November 2016 36. Letter of instruction to Dr Romney Newman of 8 November 2016 37. Character reference of Dr Romney Newman of 11 November 2016 38. Letter of instruction to Dr Gary Clemensen (mentor) of 15 November 2016 39. Report of Dr Gary Clemensen of 16 December 2016 40. Oral evidence of Dr Linda Mann on 6 & 7 March 2017 41. Oral evidence of Dr J Olsen on 6 March 2017 42. Oral evidence of Dr R A Newman on 7 March 2017 43. Oral evidence of the respondent practitioner on 7 & 8 March 2017 44. Oral evidence of Dr G Clemensen on 9 March 2017 45. Medical Council of NSW Compliance Policy – Supervision 46. Brochure of The Cognitive Institute "Difficult Patient Interactions Masterclass". Expert Evidence 1. Dr Linda Mann has been a registered Medical Practitioner in Australia since 1976. She is a general practitioner and has been a Fellow of the College of General Practitioners since 1992. She has a diploma from the Royal Australian New Zealand College of Obstetrics and Gynecology. She has worked as a general practitioner in various practices and has owned and worked in her present practice in a suburb of Sydney since 1987. She has been a Medical Educator and training provider in General Practice since 2005. She has been a visiting Medical Officer at Royal Prince Alfred Hospital in the Young Parent's Pregnancy Clinic since 2007. 2. She has held various other positions providing health services in rural areas. 3. She provided expert opinions in relation to the items in the complaint. There was no challenge to her expertise. 4. In cross-examination Dr Mann testified that she would not have gleaned from the records of the practice that Dr Hebbard, a principal in the practice, had been mentoring the practitioner. She said "from the documents given, she didn't provide any mentoring at all". She also said that a mentor would not be "his boss". 5. Dr Mann in cross-examination said that her understanding of a Rural Locum Relief Program was that the practice was required to have sufficient general practitioners to provide mentoring and training for the practitioner. From her experience of the practice at Nabiac, it appeared that there had been no orientation and very limited supervision. She said that although Dr Hebbard was supposed to be the practitioner's mentor, she could not have gleaned that from the records of the practice that she saw. 6. Dr Mann impressed the Tribunal members with her thoroughness and the strength of her expertise. In the course of her cross-examination she reinforced opinions that she had provided in her report and demonstrated considerable knowledge, care and thoroughness. 7. Her evidence in cross-examination also demonstrated in relation to some of the patients that the practitioner's conduct in prescribing addictive drugs for some of the 13 patients the subject of the complaints either fed an existing addiction or was likely to establish an addiction. 8. There were some situations where the practitioner repeated prescriptions previously issued by one or more of the principals of the practice at Nabiac. Dr Mann's approach was that the practitioner was responsible for his own conduct and could not rely on the prior conduct of other practitioners to avoid his responsibilities. She conceded, though, that a new employee doctor would be vulnerable to influence or prescribing conduct of more senior doctors who employed the practitioner, as was the case with his mentor, Dr Hebbard. 9. Dr Mann testified that in some situations involving difficult patients, the practitioner does not have to challenge the mentor, but he can say 'No. I can't deal with this patient'. 10. When asked whether it is responsible medical practice to cease a medication if the patient has developed a dependence on it, Dr Mann said "you have to know how the patient will react to the reduction". 11. She said that there needs to be some drug and alcohol expertise, and it is appropriate for a general practitioner to seek help from someone who has that expertise, and better to suggest a gradual reduction rather than just stopping the medication. 12. She conceded that it would be appropriate to refuse to supply an addictive medication where the doctor became aware that the patient was obtaining prescriptions from more than one practitioner. 13. In relation to continuing an inappropriate combination of four medications that had been previously prescribed by a doctor in the practice, Dr Mann said that there was only one consultation by the practitioner at which he continued that combination. She said that there was no evidence that he sought to establish whether the combination was appropriate. 14. Dr Mann conceded in cross examination that in respect to some patients, over time the practitioner reduced the dosage of an addictive drug. She said that unfortunately she could not tell from the clinical notes for the patients what effect it was having on the patient, and whether the patient was obtaining prescriptions for the drug elsewhere. She conceded that in one instance the practitioner had noted in the patient notes that a specialist had reviewed the patient and advised that the dosage of the addictive drug should be reduced. He acted on that advice. 15. Dr Mann conceded that some patient notes made by the practitioner in September 2013 showed a considerable improvement on his previous clinical notes, and better notes than the prior notes of the other doctors in the practice. 16. In response to a member of panel, Dr Mann said that the training relevant to GP work that would have been obtained by the practitioner when he was practicing in a hospital would be through involvement in medical meetings, and he would have been given time off to attend those. However, she said that the meetings would be "more about specialist areas, rather than GP work". 17. She said that they would probably not include "prescribing medications". She said that the practitioner's notes largely show a lack of recording of the effect of medications, effect of combinations, and concerns about patient medicines or combinations. 18. She said that the GP/patient situation is "very different" to the hospital doctor/patient situation. She said general practitioners are "often preyed on by patients after prescriptions". 19. She said that general practitioners need "inter-personal skills…". 20. She said that it was common for a mentoring program to be undertaken by an employer of the practitioner, because of the limited number of "options". She said "the mentor needs to be able to separate the employer and mentor roles. The employee may be reluctant to question or disagree with views of the employer or practices of the employer". She recommended a new mentor for the practitioner who was able to observe him doing consultations. 21. She said that she would not recommend the doctors in the practice to providing mentoring "given the patient notes that I have seen". 22. She said the doctors in the practice are not suitable for the mentoring role. 23. When asked by a panel member, Dr Mann said that the practitioner can obtain vocational registration without exams. She said he can choose to do the exams or to do further Continuing Medical Education. She also said that if mentoring is provided to a practitioner who is a member of a college, the college will pay for the mentoring. But otherwise the practitioner has to pay for it. Unsatisfactory Professional Conduct 1. The complaints relate to alleged conduct in the period from about February 2013 and about January 2015. 2. 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 judgement possessed, or care exercised by the practitioner in the practice of the practitioner's profession is significantly below the standard reasonably expected of the practitioner of an equivalent level of training or experience"; 2. A contravention by the practitioner (whether by act or omission) of a provision of this law, or the regulation under this law or under the NSW regulations whether or not the practitioner has been prosecuted for or convicted of an offence in respect of the contravention; …..and 1. (l) "Any other improper or unethical conduct relating to the practice or purported practice of the practitioner's profession". 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. Findings re Particulars 1 to 52 inclusive – except for particular 32(b)(i)) 1. These particulars are by the evidence (including the admissions of the practitioner) proved on the balance of probabilities. A summary of the findings of conduct proved and constituting unsatisfactory professional conduct in relation to the 13 patients referred to in the complaint is as follows: 1. Failure to conduct adequate assessment - 12 patients; 2. Failure to obtain records from prior medical practitioner - 5 patients; 3. Breaching Section 28 of the Therapeutic Goods Act 1966 by prescribing addictive drug without authority - 9 patients; 4. Failing to maintain adequate records for the patient in breach of clauses 1 & 2 of Schedule 2 to the Health Practitioner (NSW) Regulation 2010 - 12 patients; 5. Prescribing addictive drugs without recommending or referring patient to non-pharmaceutical approaches - 3 patients; 6. Prescribe inappropriate combination of medications - 5 patients; 7. Prescribe for an inappropriate therapeutic purpose - 10 patients; 8. Failed to respond appropriately to patient's drug seeking behaviour - 6 patients; 9. Failure to identify patient's drug seeking behaviour because failed to review earlier records - 1 patient; 10. Prescribe without appropriately referring patient to psychologist or pain management specialist - 4 patients; 11. Prescription of medication where frequency or dose was in excess of recommended therapeutic standards - 12 patients; 12. Prescribing addictive drugs without undertaking pain assessment - 1 patient; 13. Prescribing addictive drugs without referring patient to rehabilitation physician - 2 patients; 14. Failure to contact prescribing shopping information service when appropriate - 1 patient; 15. Prescribing addictive drugs without examining the right arm – 1 patient; 16. Prescribing without attempting to decrease the patient's dependence on the medication – 1 patient; 17. Prescribing without referring the patient for neurosurgical opinion – 1 patient; 18. Prescribing without adequately assessing the effect of the medications on the patient – 2 patients; 19. Prescribing without warning the patient of the risk of respiratory depression – 1 patient; 20. Failing to consider the effectiveness of combining the medication with neurospan – 1 patient; and 21. Prescribing in a combination that encouraged depression and increased the risk of overdose – 1 patient; 22. Prescribing without asking the patient relevant questions – 1 patient; 23. Prescribing without adequately assessing the effect of the medications on the patient – 2 patients. 1. The tribunal is satisfied on the evidence that on the balance of probabilities : 1. The 21 instances in items (3), (4), each were instances of unsatisfactory professional conduct under para 139B(1)(b) of the National Law: and 2. The 11 instances in items (7) and (16) were unsatisfactory misconduct under para 139B(1)(l) as unethical and improper conduct; and 1. As regards the adequacy of the practitioner's patient records. Dr Mann's opinion was that only those for patient J were adequate. Those for the remaining 12 patients in the application were significantly below the reasonably expected standard. Six of these ( for A, B, C, E, F, and I) invited her strong criticism and the other 5 (G, H, K, L and M) did not. 2. With the remaining instances included in the list of instances (1) to (23), the occurrence for each patient and the opinion of Dr Mann as regards whether each instance was significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience and whether it attracts her strong criticism is as follows: Patient Category of complaint Below std Significantly Strong criticism A (1) X X X (6) X X X (10) X X X (11) X X X B (1) X X X (5) X X X (6) X X X (8) X X X C (1) X X X (5) X X X (6) X X X (8) X X X (9) X X NO (10) X X X (11) X X X D (1) X X NO (6) X X X (8) X X NO (10) X X X (21) X X X E (1) X X NO (6) X X X (8) X X NO (10) X X NO F (1) X X X (2) X X X (5) X X X (6) X X NO (8) X X X G (1) X X NO ( Patient G was in the late stage of terminal cancer and her medication regime was already established . Dr Mann's opinion was that the standard of the practitioner's records for patient G was also significantly below the reasonably expected standard, but did not invite her strong criticism. Otherwise the practitioner's conduct specified in the complaint was not below the reasonably expected standard.) H (1) X X NO I (1) X X NO (8) NO NO NO (11) X X X (13) NO NO NO (22) NO NO NO J (1) X X X (11) X X X (18) X X X K (1) X X X (11) X X X (15) X X X L (1) X X X (8) X X X (11) X X NO (17) X X X (18) X X X M (1) X X NO (11.1) X X X (11.2) X X X (18) X X NO (19) X X NO (20) X X NO 1. In respect of each of the 13 patients referred to in the complaint unsatisfactory professional conduct has been proved. The incidents of inadequate patient assessments for 12 and inadequate patient records for 12 each seriously threaten the future safety of the patients, as do the instances of inappropriately prescribing addictive drugs and prescribing inappropriate combinations of medications. There are authorities that where a medical practitioner prescribes drugs of addiction recklessly or contrary to the law, that conduct constitutes professional misconduct (e.g. Spicer v NSW Medical Council (unreported CA no.3of 1981, 10 February 1981); HCCC v Nemeth [2012] NSWMT 4; HCCC v Lo [2016] NSWCATOD 119; HCCC v Suri [2016] NSWCATOD54 at [88] – [89]) 2. Considered together the instances of unsatisfactory professional conduct proved are so serious that they amount to conduct of a sufficiently serious nature to justify the suspension or cancellation of the practitioner's registration and constitute professional misconduct under Section 139E of the National Law, as is admitted by the practitioner. Other Evidence in the Practitioner's Case His background 1. The practitioner had provided a statement dated 15 December 2016. In that statement he gave some history of his medical career. He completed his degree of Doctor of Medicine at a university in the Philippines in 1989. He completed a post graduate internship at a hospital in Manilla. He was licensed as a medical practitioner in 1990 after completing Physician Licensure examinations. 2. From January 1993 to December 1995 he trained in Internal Medicine at the Philippines General Hospital in Manilla. 3. From January 1996 to December 1997 he underwent some specialist Fellowship Training in Pulmonary Medicine at the same hospital. He became a Fellow of the Philippines College of Physicians in 1998. 4. From 1998 to February 2008 he was a Consultant Physician in Pulmonary Medicine and Internal Medicine at the University of Perpetual Help Hospital, an Associated Medical Centre and a Clinic, all located in Las Pinas City in the Philippines. 5. In 2006 he was inducted as a Fellow of the American College of Chest Physicians in Salt Lake City. 6. He became a Fellow of the Philippines College of Chest Physicians in Manilla in 2007. 7. He moved to Australia in March 2008 and initially worked as a Registrar at the John Hunter Hospital and other hospitals in the Hunter / New England Health Region. 8. In January 2001 he was awarded an Australian Medical Council Certificate and obtained general registration with AHPRA. 9. From August 2012 to October 2013 he was a Medical Officer at Forster Private Hospital in NSW and from February 2013 he has been a General Practitioner under the Rural Locum Relief Program based at the Nabiac Village Medical Centre. He worked there part time from February to October 2013 and then full time since October 2013. 10. He was sponsored under the Rural Doctors Network to work under the mentorship of Dr Hebbard at the practice. 11. The practitioner's evidence is that he has complied with the conditions since they were imposed on his registration in December 2015. He says in his statement: (31). I have carefully read the PSU Report dated 2 January 2015 and HCCC Expert Report dated 20 September 2015. I accept the criticisms contained in these reports. (32). I do accept that prior to being contacted by the PSU, I did not have adequate knowledge about how to appropriately prescribe drugs of addiction and I was not aware of the requirement to obtain an Authority to prescribe drugs of addiction from the PSU in similar circumstances. (33). I now understand that a doctor may only prescribe a drug of addiction to a patient when it is clinically appropriate and in the following circumstances a doctor must obtain an Authority from PSU: (a) When the patient is a drug dependant person; or (b) When the patient has been provided with the following drugs continuously for more than two months: (i) any injection form of any drug of addiction; (ii) Alprazolam; (iii) Buprenorphine (except transdermal preparation); (iv) Flunitrazepam; (v) Hydromorphone; and (vi) Methadone. (34). I have read the HCCC's Notice of Complaint dated 11 August 2016 (`the Notice of Complaint'). (35). Annexed hereto and marked Annexures "Al" to "Nl" are my specific responses to each complaint and the particulars of each complaint. (36). I do not wish to be in this position again and therefore, to address the deficiencies in my knowledge, I have participated in the following CPD activities: (a) 'Applying Best Practice in Chronic Pain: Taking Control of Chronic Pain' presented by Dr Rajen Ragavan on 17 February 2015; (b) 'Pain Management Masterclass: A Practical Approach to Chronic Pain Management presented by Drs Marc Russo, Anthony Schwartzer and Mike Shelley on 28 February 2015; (c) 'Challenges of Treating Chronic Pain in the Elderly by Dr William McClean on 4 March 2016; (d) 'Mental Health Skills Training for Rural Practitioners' starting on 18 May 2015 and consisting of 6 weekly sessions; (e) New South Wales RDN/RDA 2015 Summer Refresher Conference in Coffs Harbour on 27-29 March 2015. I attended a workshop on 'Pain Management and its Possible Abuse'; (f) Webinar on 'Prescribing Perils: °plaids, Polypharmacy and Medication Errors' on 31 May 2015 expert panel discussion; (g) Webinar on 'Prescribing Perils Part 2: Drugs of Dependence'. Expert panel discussion, speakers Professor Greg Whelan, Dr Heston Wilson, Dr Walid Jammal, Ms Sarah Spagnardi and Ms Georgie Hayson; (h) Webinar on 'Doctor Shoppers, the Law and Addiction: Prescribing Drugs of Dependence'; (i) Course on 'Mental Health Disorders Training for Rural Practitioners', completion date 30 June 2015; (j) Course on 'Managing mild-to-moderate osteoarthritic pain – when is paracetamol appropriate?, completion date 12 July 2016; (k) E-Learning: 'Prescribing Drugs of Dependence'; (l)New South Wales web site: 'Chronic Plain Management: Information for Medical Practitioners'; (m) Avant Risk IQ Course: 'Managing Difficult Patients' (3 hours); and (n) Avant Risk IQ Course: 'On the Medical Records and Documentation' (90 minutes). (o) Osteoarthritic Pain: Finding Management Options Close at Hand on 11 December 2015; (p) Effective Management of Low Back Pain with Neurological Component on 4 August 2016; and (q) Low Back Pain – A Practice Approach for GPs: Dr Charlotte Johnstone. The General Practice Education Day at Univesity of New South Wales on 27 August 2016. 1. He annexed to his statement certificates evidencing his attendance at those courses. 2. He has also completed the "Issues in General Practice Prescribing Course" conducted by the Department of General Practice at Monash University. 3. In his statement he also says that he has reviewed the following documents: 1. 'Legal Requirements for an Authority to Prescribe Drugs of Addiction Under Section 28 of the Poisons and Therapeutic Goods Act 1996' prepared by the NSW Ministry of Health; 2. Schedule 4 Appendix D Drugs (Prescribed Restricted Substances' prepared by the NSW Ministry of Health; 3. Chronic Pain Management — information for Medical Practitioners' prepared by the NSW Ministry of Health; 4. Recognising and Managing Drug Dependant Persons — Notes for Medical Practitioners' prepared by the NSW Ministry of Health; 5. Form 1: Application for Authority to Prescribe a Drug of Addiction' prepared by the NSW Ministry of-Health; 6. Guide to Poisons and Therapeutic Goods Legislation for Medical, Nurse and Midwife Practitioners and Dentists' prepared by the NSW Ministry of Health; 7. Responsible Opioid Prescribing: Identifying and Handling Drug-seeking Patients' prepared by NSW Ministry of Health. 1. He has also read 3 relevant decisions of this Tribunal, and 2 relevant decisions of the previous Medical Tribunal. 2. He says that reading those decisions "has assisted me in understanding what the acceptable standard is in relation to prescribing drugs of addiction" and "these decisions have also helped me to understand the risk posed to patients as a result of my inappropriate prescribing drugs of addiction along with the serious and professional consequences that can result from disciplinary proceedings". 3. Since the conditions were imposed he has developed a mentor relationship with Dr Garry Clemensen who works at the Forster/Tuncurry Medical Centre. He has attended on Dr Clemensen for discussions on a monthly basis since October 2015. 4. He said in his statement: "This mentor relationship with Dr Clemensen has allowed me to: a) Discuss with Dr Clemensen the PSU report and the expert report from the HCCC and what he would do if he was consulting with those patients; and b) Discuss with Dr Clemensen different issues, including, inter alia, the appropriate prescribing of drugs of addiction and managing difficult patients, and drug seeking patients". 1. He says that the mentoring process has provided him with opportunities to reflect on the care he provided to the patients referred to in the proceedings. 2. He said "I recognize and accept that my prescribing of drugs of addiction and maintaining adequate medical records was not appropriate. I am sorry that my conduct was not in my patient's best interests". 3. He also says in his statement: 51. I am relatively young and I hope to make a positive contribution in medicine over a long period of time. 52. My current Practice is a very supportive environment and I am building professional relationships with my colleagues. I would like to remain at this practice. 53. I have undertaken serious reflection in relation to the complaint and have given careful consideration as to how I can avoid making similar errors of judgement in the future. I do not want to be in the position that I currently find myself in. 54. I am deeply ashamed and embarrassed of the complaint has been brought against me and that I had a lack of understanding of the requirements surrounding the prescribing of drugs of addiction. I do not want to be in this position again and I have learnt from the whole experience. 55. I remain committed to my career as a general practitioner. 56. While I have found responding to this complaint to be extremely challenging, I believe that this reflection has made me a better doctor." 1. His evidence is that he is "very dedicated to my patients". He says "I understand that if I am allowed to continue to practice medicine I will continue to have conditions imposed on my registration and I am entirely agreeable with the current conditions remaining on my registration for the foreseeable future". 2. The practitioner provided a supplementary statement dated 2 March 2017. In that document he said that from February to August 2013 he was working full time at the private hospital and working one day a week at the Nabiac Practice, and from August to October 2013 he worked two days per week at the Practice, and continued to work full time at the private hospital. 3. He said in the supplementary statement that prior to working in the Nabiac Practice, he had no experience at all in general practice, and realizes that he was "ignorant of a number of obligations owed by general practitioners in relation to prescribing. I also had no experience in the ongoing prescribing of narcotics outside the hospital setting. I also had no experience in weaning patients off narcotics". 4. He also said in that supplementary statement: (4). My understanding whilst working at the Practice during the period of time referred to in the Notice of Complaint, was that each consultation had to be completed in a ten minute period unless the relevant patient had a double appointment booked. The appointments made by patients were arranged by the receptionist of the Practice who would decide the length of the appointment time and who would ordinarily book a patient in with me for a 10 minute appointment. I did not interfere with this process for booking patients and thought it was the policy of the Practice. (5). I understood that I had 10 minutes to consult with a patient. I recorded my medical records in relation to each consultation during the consultation itself. I did not take time at the end of each consultation to complete my medical records for the consultation or take steps at an appropriate time to ensure my medical records were adequately detailed. I now accept that I rushed my recording of medical records during the consultation with the patient and this contributed to the poor quality of my medical records. (6). When I commenced working at the Practice, I was not familiar with how to use the Medical Director software which was and is used at the Practice for medical record keeping. The first time I used Medical Director software was when I started working part-time at the Practice in February 2013. I think that my lack of confidence in using Medical Director software also contributed to the poor quality of my medical record keeping. I am now much more confident using the software and my medical record keeping is greatly improved. (7). Since this Complaint, I have changed how I consult with patients at the Practice and how I maintain my medical records. (8). I now consult with approximately 4 - 5 patients an hour. Each consultation on average lasts for approximately 15 minutes. I record my medical records both during and at the end of each consultation and I spend at least a few minutes ensuring the medical records are appropriately detailed. The quality of my medical record keeping has improved significantly and I understand it is important to maintain accurate and detailed medical records. (9). If a consultation requires me to spend a longer period of time with the relevant patient, I make my other patients wait for the consultation to be completed. This can result in my other patients having to wait for periods of time to see me or I arrange to return and set aside sufficient time for the return visit. 1. In oral evidence the practitioner reinforced evidence in his statements. 2. He said that the Nabiac practice had 3 doctors including him. He said that Dr Hibberd gave him training in only 2 areas; women's health and paediatrics. Neither she nor the other principal raised with him any concerns about his prescribing prior to the POSU alert. In that period there was an occasion where Dr Hibberd had referred one of her patients to him. The woman was difficult and aggressive and making demands for a particular medication. He said he asked Dr Hibberd if he could give her the patient back and she refused and said "She's so yours". 3. He said he had also expressed concerns about prescriptions for Diazepam. He told the Tribunal he wants to change his mentor as soon as possible. 4. When asked on cross-examination what he would do if a patient presented with a long history of other doctors prescribing addictive drugs and asking for a further prescription. He said he would: * do a complete history, identify the pain if involved and do a pain inventory. * ascertain how the patient says the pain affects his life. * not give a prescription on the first attendance. * not give a prescription on the first attendance, but make a second appointment. * before the next appointment, contact the previous doctor to discuss the pain history, whether the particular medication is appropriate, and whether the dose is appropriate, and he would need to assess for himself whether the medication and dose would be appropriate. 1. He said that if a patient is aggressive or threatens him, he would ask the patient to "calm down", if necessary say he would call the police, and tell the patient he would not give him a medication. He said he would need to decide whether the pain is genuine and that would require a comprehensive pain assessment and history. If there was a long history of prior prescriptions by another doctor or the patient was "passing through", he would suggest they get a repeat script from the previous prescriber. He said if he did prescribe the first prescription should be a trial to see if the medication is appropriate. 2. He said he had no objection to another doctor sitting in occasionally on consultations with patients seeking prescriptions for addictive medications. He said he would have no opposition to occasional audit of his patient records if done by someone nominated by him. Evidence of Dr John Olsen 1. Dr Olsen is the Director of Prevocational Education and Training at Belmont Hospital. In November 2016 the solicitors for the practitioner provided Dr Olsen with a copy of the Application and Complaints and informed Dr Olsen that the practitioner "admits almost the entirety of the complaint". A written character reference was sought. 2. Dr Olsen is a Medical Practitioner with General Registration. He was first registered at the commencement of his internship in October 1978 and fully registered in October 1979. He has no post-graduate clinical qualifications, but has a Masters Degree in Health Administration conferred in 1993. 3. He has worked in acute medicine for more than 35 years, always in teaching hospitals. During his career he has supervised hundreds of non-specialist doctors in Sydney and Newcastle. 4. Since mid-2010 he has been the Medical Superintendent and ED Director at Belmont Hospital. 5. Dr Olsen was the Clinical Superintendent in the Department of Medicine at John Hunter Hospital and Network Clinical Superintendent for the Hunter Region Basic Physician Training Program. 6. In the role as Clinical Superintendent he was the Medical Director of the Medical Assessment and Co-ordination Unit at John Hunter Hospital from its opening in April 2008 until early 2010. 7. He considers that his most important responsibility at John Hunter Hospital was the recruitment of capable non-specialist medical staff from overseas. That happened in the context of a severe shortage of medical practitioners in Australia. 8. During the period of the shortage he was directly responsible for importing and developing many international medical graduates to work and train with Hunter New England Health. 9. He met the practitioner in late 2007 and the practitioner became a Registrar as a trainee sponsored by the Royal Australian College of Physicians. The opinion of Dr Olsen and his colleagues was that the practitioner was "an excellent recruit because he would have the potential to progress to specialist recognition in Australia". 10. Dr Olsen encouraged the practitioner to pursue full registration through the Australian Medical Council and that was achieved in late 2011. This was achieved despite him having complex and intense responsibilities in his clinical role as Senior Medical Registrar. 11. Dr Olsen also hoped that the practitioner would satisfy the requirements of the Royal Australian College of Physicians and obtained recognition as a specialist physician. He needed to work in a supervised advanced training role, received positive appraisals from his supervising senior physicians, and pass a specialist level clinical assessment examination. He was well supported by the senior physicians at the hospital and they were confident that he was practicing at the required standard. 12. However, on two occasions the practitioner attempted a formal examination and assessment and was unable to satisfy the examiners of his level of knowledge and that his standard of clinical practice was equivalent to that of a Fellow of the College. 13. The practitioner then apparently determined not to make any further attempt to pass the FRACP credential. He then decided to pursue a career in general practice. 14. Dr Olsen's experience of the practitioner's personality is that he is a gentle and compassionate person. He said "he's a natural healer. He is very well informed in relation to pathology, disease processes, and therapeutic intervention. It is his life. In assessing the situation now, it is absolutely evident that Dr Arreza was not prepared for the type of patient who can threaten a novice in general practice, and that he was poorly informed in regard to the policies and regulations which are required to be met for community general practice". 15. He also said in his reference: 16. "Circumstances led him to an isolated GP position where he expected to be provided with training which would have facilitated his transition to a new professional career. What he experienced was something for which he was clearly unprepared. His sympathetic compassion exposed him to a type of 'patient' with which he had very little experience. His natural innocence and naïvety and his complete lack of exposure to conditions in Australian regional communities and the general practices which serve them, meant that it took him several months to realise that he was being duped and manipulated. He was well out of his depth in a clinical world which was really quite foreign to him. Review of the total concerns expressed in the complaints listed in the Application for Disciplinary Findings and Orders suggest that Dr Arreza was struggling on occasion with the nature of the work and with the record keeping aspects required for all patients, and particularly with difficult and complex patients". 17. Dr Olsen referred to the contrast between hospital practice and solo GP practice. The hospital environment is one where the use of drugs of addiction is relatively commonplace. Patients who attended hospitals tend to be among the sickest patients in our society. He said "they are people who suffer significant pain as a component of their condition. It is for these patients that the expanded range of opiate medication has been developed over the past 30 years. Whilst working in the acute hospital environment, Dr Arreza would have provided care for numerous patients, who were legitimate users of drugs of addiction, in a variety of departments within the hospitals. In these patients there is generally an emphasis on attempting to optimize the use of medication rather than on questioning the legitimacy of the use of the drug. Many of the patients have malignant disease and have limited life expectancy. However, unless a clinician is permanently attached to oncology or palliative care services, there is not a high level of acute awareness of the impending mortality. Medical registrars simply care for patients on the day and see that they are on opiates as part of their medication regime. I believe this hospital situation would be significantly different to general practice, where I would expect the presence of drugs of addiction within a patient's medication list would be relatively uncommon. I believe that Dr Arreza's failure to immediately detect that he was being subjected to fraudulent activity by patients was a reflection of his failure to understand that he was in a new practice model". 18. Because of the admissions made by the practitioner, Dr Olsen is of the view that the practitioner "understands that the complaint of events occurred when he was a registered medical practitioner, and that being a registered medical practitioner carries with it profound responsibilities which need to be honoured". 19. Dr Olsen considered the performance of the practitioner under his supervision in the services of Hunter New England Health Region to be "exemplary". 20. He said "his high standard of clinical practice was not surprising, given his previous practice for several years in the Philippines. In Australia, and very likely in the Philippines as well, Dr Arreza's practice involved patient population in an acute hospital service, with numerous clinicians from all disciplines supporting each other in an organised team-based model of care". 21. Dr Olsen testified that the practitioner never presented in his hospital position "as a doctor who would be negligent or incompetent in clinical practice. He was highly professional in his presentation and approach to the patients and staff, and always well informed in regard to evidence based practice". He said that, in moving from working in a public hospital to working in a rural general practice "Dr Arreza was moving from a world in which he had many years of experience to a world in which he was a complete novice". 22. He said his experience of the practitioner in the hospital environment was that he was thorough in his provision of care. Dr Olsen also said: 23. "I believe it needs to be emphasized that medication management is profoundly different in the hospital environment and the GP environment. Hospital pharmacists have a prominent role in the dispensing of medications on the basis of clearly defined policies and regulations. In the event of any deviation, the hospital pharmacy immediately calls the doctor involved or the clinical superintendent. Hospital pharmacy attracts professionals who are extremely capable and see themselves as important contributors to the patient care process". He also said "the dilemma in which Dr Arreza now finds himself is not reflective of devious or criminal or fraudulent current practice on his part. It is an indication that he embarked naïvely on a venture involving a substantial change in his practice circumstance, before arming himself with full information in regard to the relevant policies and regulations". 24. Dr Olsen has had discussions with the practitioner since the commencement of these proceedings. He said in his reference that he believes that the practitioner has "learnt a substantial lesson from the unfortunate events of the past 3 years. He is an intelligent cognition. While he may be quiet and unassertive, he is clever, with considerable current knowledge, and considerable capacity to learn". 25. Dr Olsen's prediction is that the practitioner is: 26. "unlikely to ever again misinterpret situations involving opiate and psycho-tropic drug use in any of his patients. He would have learnt in this country, and in contrast with the acute hospital in-patient setting, the world outside the protected hospital environment is full of hidden risks and traps for a practitioner who is practicing alone". 27. Dr Olsen's opinion is that the practitioner now understands that he needs to have a well-developed awareness of the applicable policies and regulations, a personal system for the detection of fraudulent patient presentations, and a capacity to respond quickly and assertively to threats to his clinical practice. 28. He also said in his report that he expects that the practitioner has learned "that there is a very clear distinction between compassion for patients who are legitimate sufferers of adversity and gullibility to people whose intention it is to defraud". 29. In his reference, Dr Olsen wrongly assumed that the practitioner had recognised the problems before the pharmaceutical services unit has raised them. In cross-examination he was asked whether his opinions would be different if that assumption was wrong. He said that his opinions would not be different. 30. Dr Olsen said that the practitioner has "a lot to offer in medical practice" and he would be "a good GP". He said that the practitioner needs "supervision, explanation and instructions". He said that the practitioner has a "great capacity to learn". 31. When asked whether he thought the practitioner would benefit from "an environment closely supervised", he said "I mean open communication, allowance to develop and guidance all the way". Evidence of Dr R Newman 1. Dr Newman provided a reference dated 11 November 2016. The solicitors for the practitioner previously provided Dr Newman with a copy of the Application and Complaints and instructed him that the practitioner had admitted "almost the entirety of the complaint". 2. Dr Newman had known the practitioner since he commenced working at Forster Private Hospital from August 2012. 3. Dr Newman is a Fellow of the Royal Australian College of Physicians. He was a member of the Medical Advisory Committee for the Hospital. 4. Dr Newman was not notified of any prescribing problems by nursing staff or other doctors. At no time did the Medical Advisory Committee receive any adverse reports regarding the practitioner. 5. Dr Olsen found the practitioner related well to nursing staff and patients. Dr Newman considered the practitioner's knowledge of cardiology, respiratory medicine, and his investigations and suggested treatments were appropriate. 6. In his practice as a consultant physician in diabetes Dr Newman received patient referrals by the practitioner, and in his opinion the referrals and the practitioner's knowledge were appropriate. 7. Dr Newman said that he believes the practitioner is of good character "and with further supervision in general practice he could continue to make a worthwhile contribution to medicine in this area". 8. In cross-examination Dr Newman said that he never saw the practitioner to be "assertive". He said he impressed as "competent, helpful, friendly and compassionate". 9. He expressed an opinion that the practitioner would benefit from a general practitioner "sitting in on his consultations and then reporting to him". He described the practitioner as "a well-trained hospital doctor with no deficiencies" Evidence of Dr G Clemensen 1. Dr Clemensen, the principal of the Forster Tuncurry Medical Centre. He graduated in Medicine and Surgery from the University of NSW in 1985 and has been a registered Medical Practitioner since 1985. He attained a diploma in obstetrics in 1988 and later accreditation as a methadone prescriber in about 1995. 2. He has worked as a full time general practitioner in Forster since 1990 and has been an accredited GP Registrar mentor/educator since 1998, as well as a mentor for overseas trained doctors to assist them to attain their GP Fellowship qualification. 3. In November 2016 he was assisting six GP Registrars in attaining their GP specialist qualifications. 4. He first met the practitioner in August 2012 when the practitioner was employed at the Forster Private Hospital, which is located opposite Dr Clemensen's medical practice. He said that the practitioner is "regarded highly by his peers at the hospital and related professionally well to all his patients". 5. They used to see each other professionally most days at the hospital and Dr Clemensen had offered to provide ongoing mentorship for the practitioner if he required it. There was some infrequent mentoring that he provided when they were both at the hospital and sometimes after work. 6. One of the particular problems that they discussed was strategies to cope with the heavy patient loads, specifically regarding limiting patient numbers. 7. In early October 2015, about 10 months after the conditions has been imposed on his registration, the practitioner sought monthly meetings with Dr Clemensen to discuss the problems he was experiencing. They commenced from 16 October 2015 and were still continuing at the time of the hearing. 8. Dr Clemensen said that the practitioner had "fully engaged in these mentoring sessions" and says that he believed the practitioner "is a much better general practitioner for taking up all of these educational supports so far". 9. Dr Clemensen said in his reference that the practitioner had him discuss all of the specific cases in the Notice of Complaint, discussed the issues relating to each of them. He said the points of concern raised in each case are similar to each other, "I feel they highlight Dr Arreza's number of areas of weakness that he needed to address, normally if he were a GP Registrar Training Program (which is normally a 2 year supervised training course where GP Registrars are continually assessed and given feedback regarding their strengths and weaknesses) and I feel these deficiencies would have been identified earlier. I know that Dr Arreza has attended structured educational courses as described in his personal statement, and specifically the Monash Course for "Issues in GP Prescribing", I feel he is better able to manage such patients." 10. He said in his statement that their discussions have included record keeping and using current GP software programs to improve record keeping. He said they have discussed issues relating to his "clinical naïvety of trusting of patients and processes in identifying and then managing drug seeking patients; we have discussed how these patients might use such medications inappropriately and the principle of 'harm minimization'; development of management plans or contracts; we have identified local community service providers, who could be recruited in assisting in the management of patients with chronic pain and psychological distress. Dr Arreza has taken this advice well and I believe he has made substantial changes to his clinical practice as a result". 11. Dr Clemensen supports the practitioner being allowed to continue to practice medicine and to continue to study to attain his specialist GP Fellowship qualification. 12. Dr Clemensen's opinion is, from his observations of the practitioner working as a medical officer at the Forster Private Hospital and also from their monthly meetings, that it would be appropriate for the practitioner to be able to prescribe opiate analgesia for at least his terminally ill patients. 13. He said in his report "I believe that Dr Arreza was guilty of naïvety and unfortunately trusted his patients at their word. He is truly remorseful and has learned a great deal from his experience, and I believe he is now a better doctor as a result. I do share patients with Dr Arreza and I know that they hold him in high esteem finding him a caring and compassionate doctor. It would be a terrible loss to the Nabiac community who are already lacking in medical manpower, if he was not allowed to continue to practice." Evidence of Dr Dayoub 1. Dr Dayoub is a surgeon. He was provided with the application and Complaints and the Expert's Code of Conduct and acknowledged having read them. He met the practitioner when he commenced working at the Forster Private Hospital and has since had dealings with the practitioner at the Private Hospital and also in the practitioner's work as a GP. 2. Dr Dayoub's evidence is "Dr Arreza has always conducted himself in a very professional manner and [I] have found him to be of good character." Orders Sought by HCCC 1. The Health Care Complaints Commission proposed that the following orders be made: 1. The respondent is to pay the applicant's costs of these proceedings. 2. In accordance with section 149A(1)(a) of the Health Practitioner Regulation National Law ("the National Law") the practitioner is reprimanded. 3. In accordance with section 149A(1)(d) of the National Law the practitioner is ordered to complete within 12 months of the date of the Tribunal decision the course "Difficult Patients Interactions Masterclass" organised by the Cognitive Institute: 1. Within six months of the date of the Tribunal decision he must provide evidence to the Medical Council of NSW ("the Council") of enrolment in the abovementioned course. 2. Within one month of completing the abovementioned course he must provide evidence to the Council that he has satisfactorily completed the course. 3. In the event that the abovementioned course is unavailable, he must propose to the Council a similar course to be undertaken and satisfactorily completed by him within three months of the date of the decision. 1. In accordance with section 149A(1)(b) of the National Law the practitioner's registration shall be subject to the following conditions: Prescribing 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). 2. Not to possess, supply, administer or prescribe any substance listed in Schedule 4 Appendix D of the Poisons and Therapeutic Goods Regulation 2008 (NSW). Council obligations 1. The practitioner authorises and consents to any exchange of information between the Council and Medicare Australia where such exchanges are necessary to facilitate the monitoring of compliance with these conditions. 2. To obtain Council approval prior to changing the nature or place of his practice. 3. To advise the Council in writing at least 7 days prior to changing the nature or place of his practice. 4. To forward evidence to the Council within 14 days of the date of the Tribunal decision that he has provided a copy of all practice conditions to: 1. The practice manager of any general practice where he is employed; and 2. All other general practitioners working at the general practice where he is employed; and/or 3. Any other senior officer at any other place of employment including: public/private hospitals, nursing homes, medical centres or locum agencies. 1. To forward evidence to the Council within 14 days of the date of the publication of the Tribunal decision that he has provided a copy of the Tribunal decision to: 1. The practice manager of any general practice(s) where he is employed; and 2. All other general practitioners working at the general practice(s) where he is employed; and/or 3. Any other senior officer at any other place of employment including: public/private hospitals, nursing homes, medical centres or locum agencies. 1. In the event that the practitioner changes his place of practice, within 14 days the practitioner shall forward to the Council evidence that a copy of the conditions and published Tribunal decision (if available) has been provided to: 1. The practice manager of any general practice, where he is employed; and 2. All other general practitioners working at the general practice where he is employed; and/or 3. Any other senior officer at any other place of employment including: public/private hospitals, nursing homes, medical centres or locum agencies. Supervision 1. The practitioner is to practice under Category B supervision in accordance with the Council's compliance policy (Supervision) (as varied from time to time) and as subsequently determined by the appropriate review body. 1. The practitioner is to nominate a supervisor for approval by the Council within 14 days of the date of the Tribunal decision. 2. The practitioner must provide the supervisor with a copy of all practice conditions and a copy of the Tribunal decision (once available). 3. The supervisor need not practice at the same location as the practitioner. 4. The supervisor is to directly observe the practitioner practicing in general practice for one full day per fortnight for a six month period. 5. The supervisor is to provide oral feedback and as appropriate written feedback to the practitioner relating to his observations as to the practitioner's performance and/or areas for improvement regarding: patient history-taking; how to handle difficult patients; patient treatment plans; clinical decision-making; clinical diagnoses; record-keeping; patient-doctor communication; prescribing and/or any other relevant issues that arise. 6. Following the six month period of fortnightly observation, the supervisor is to meet in person with the practitioner for at least 2 hours per fortnight to discuss case studies, patient history-taking; patient treatment plans; clinical decision-making; clinical diagnoses; record-keeping; patient-doctor communication; prescribing and any other issues raised by the practitioner or supervisor, until such a time that the Council decides that supervision is no longer necessary. 7. The supervisor is to report to the Council every three months as required by the Council. 8. If the approved supervisor becomes unavailable to continue acting as a supervisor, they supervisor must inform the Council in writing and the practitioner must nominate an alternate supervisor within 14 days of becoming aware that the current supervision arrangement cannot continue. Audit 1. To submit to an audit of his general medical practice, by a random selection of his medical records by a person or persons nominated by the Council and: 1. An audit is to be held within 3 months from the date the Tribunal hands down its orders and a second audit is to be conducted within 6 months of the first audit and then any further audits as required by the Council. 2. The auditor(s) is to assess his compliance with good medical record keeping standards, legislative requirements and compliance with conditions. 3. To authorise the auditor(s) to provide the Council with a report on their findings. Review 1. These conditions may be altered, varied or removed at the discretion of the Council and the Council is the appropriate body for the purposes of Part 8 Division 8 of the National Law. 2. Sections 125 and 127 of the National Law are to apply while the practitioner's principal place of practice is anywhere in Australia other than New South Wales so that a review of these conditions can be conducted by the Medical Board of Australia. Practice arrangements 1. If the practitioner is working in general practice, the practitioner is to practice only in a group practice approved by the Council. 1. The practitioner is responsible for any costs arising out of compliance with conditions. Orders Proposed by Respondent 1. The Respondent proposed the following orders: 2. (1) In accordance with section 149A(1)(a) of the Health Practitioner Regulation National Law (the National Law) the Practitioner is reprimanded. 1. In accordance with section 149A(1)(b) of the National Law, the Practitioner's registration shall be subject to the following orders and conditions:- 1. To obtain Medical Council ('the Council') approval prior to changing the nature or place of his practice 2. To advise the Council in writing at least 7 days prior to changing the nature or place of his practice; 3. Not to possess, supply, administer or prescribe any 'drug of addiction' (Schedule 8 drug) as defined by the Poisons & Therapeutic Goods Act 1966 (NSW) other than for palliative care patients (i.e. patients already under the management of a Palliative Care Team) or if working as an employee of a hospital (other than as a VMO); 4. Not to possess, supply, administer or prescribe any substance listed in Schedule 4, Appendix D of the Poisons & Therapeutic Goods Regulation 2008 (NSW) other than for palliative care patients (ie patients already under the management of a Palliative Care Team) or if working as an employee of a hospital (other than as a VMO); 5. The Practitioner is to forward to the Council within 21 days of the date of the Tribunal's decision a copy of his disclosure of these Practice Conditions to: 1. The Medical Director of the place of his practice and/or; 2. The Practice Manager of any general practice where he is practising and/or; 3. Any other responsible senior office in any place that he works (including any locum agencies, Local Health District, public or private hospitals, day procedure centre, medical centre or nursing home where he holds any appointments). 1. In the event the Practitioner changes his place of practice, within 14 days tie Practitioner shall forward to the Council a copy of his disclosure of these Practice Conditions to: 1. The Medical Director of the place of his practice and/or; 2. The Practice Manager of any general practice where he is practising and/or; 3. Any other responsible senior officer in any place that he works (including any locum agencies, Local Health District, public or private hospitals, day procedure centre, medical centre or nursing home where he holds any appointments). 1. To practise medicine under Level C supervision (in accordance with the Council's Supervision Policy, a copy of which is annexed hereto and marked "A") as varied below: 1. The Practitioner is to nominate a supervisor for approval by the Council within 14 days of the date of this decision; 2. The approved supervisor is to meet with the Practitioner, on a fortnightly basis for at least 2 hours; 3. The supervisor is to report monthly to the Council on his supervision of the Practitioner and is to raise any concerns with the Council which he/she may have about the Practitioner's capacity to practice medicine safely; 4. As part of his/her initial supervision, the supervisor is to directly observe consultations by the Practitioner with a sample of at least 8 of his patients each month with the said patient's consent on at least a monthly basis for an initial period of 3 months; 5. After the initial period of 3 months, unless the supervisor has raised a concern about the Practitioner's capacity to practice medicine safely, the supervision shall revert to Level C supervision in accordance with the terms of the council's supervision Policy; 6. The initial supervision period of 3 months shall be extended by a further 3 months in the event that the supervisor notifies the Council of any concerns as to the Practitioner's capacity to practice medicine safely; 7. During the first 3 months of the Practitioner's supervision, the supervisor is to assess a random selection chose by the supervisor of at last 25 of the Practitioner's patient's medical records for the period from 1 January 2016 and to include in the monthly reports to the Council, his / her assessment as to whether the said records satisfy the statutory requirements under the National Law and Regulation thereto; and 8. Any costs of the Practitioner's supervision are to be borne by the Practitioner; 1. The Practitioner authorises the Council to notify current and future persons or organisations at places where he works as a medical practitioner in Australia, of any issues arising in relation to compliance with these Practice Conditions; 2. The Practitioner authorises and consents to any exchange of information between the Council and Medicare Australia for the purpose of monitoring compliance with these Practice Conditions Conclusions 1. The culpability of the practitioner in respect of his professional misconduct is less for this practitioner than one might expect of someone with the prior years of practice he had, particularly because of: 1. his lack of prior experience of prescribing in general practice; 2. The very different experience he had in prescribing in hospitals; 3. The relative absence in hospitals of the experience of 'doctor shoppers' and other addicted patients attending to obtain scrips for addictive drugs; and 4. The lack of supervision, training, mentoring, and collegiality he experienced in the practice at Nabiac from when he commenced in 2012. 1. There are other factors that persuade the Tribunal that the practitioner is unlikely to, in the future, be guilty of unsatisfactory professional conduct or professional misconduct, which include: 1. His present insight into what was wrong about his conduct the subject of the complaint; 2. His prior unblemished professional record; 3. His genuine commitment to his career as a medical practitioner; 4. The very extensive courses he has now undertaken in relation to making proper clinical records and prescribing (particularly prescribing addictive drugs, and alternative therapeutic options for pain sufferers); 5. The extensive reading he has undertaken in those areas; 6. The extensive changes he has made to his procedures for consultations with patients; 7. The mentoring he has had from Dr Clemensen since October 2015; 8. The experience he has had of the restrictive conditions on his registration for more than two years; 9. His experience of the investigations by PSU and HCCC and these proceedings and the expenses he has incurred; and 10. The positive opinions of Doctors Olsen, Newman, and Clemensen; 1. The Tribunal concludes that this is not a situation where protection of the public or the reputation of the profession or any other relevant matter requires that the practitioner's registration should be suspended or cancelled. 2. However, the Tribunal has decided that the protection of the public does require that: 1. The practitioner be ordered to complete the course conducted by the Cognitive Institute called "Difficult Patient Interactions Masterclass"; 2. His registration be subject to a condition that if the practitioner practices in general practice it must be only in a group practice approved by the Council; 3. That registration conditions and associated conditions and orders restricting the practitioner's involvement with Schedule 8 and Schedule 4D substances and associated conditions apply for one year from 9 March 2017 and limit his involvement to palliative care patients and patients in a hospital if he is working as an employee of the hospital; 4. The practitioner have the benefit of Level C supervision for one year and there be the appropriate conditions on his registration for that and to ensure that the Supervision provides him an audit of medical records and includes assistance in specific areas of general practice; and 5. The conditions should include that the practitioner is responsible for payment of the expenses of the supervision. Costs of These Proceedings 1. The Applicant has succeeded in establishing numerous instances of serious unsatisfactory professional conduct and also professional misconduct. In accordance with the decided cases (see HCCC v Philipiah [2013] NSWCA 342), in the absence of some contrary factor, the Respondent should be ordered to pay the Applicant's costs. Orders 1. Therefore the orders made by the Tribunal on 9 March 2017 are as follows: 1. The respondent practitioner is guilty of professional misconduct; 2. The practitioner is reprimanded; 3. The practitioner must: 1. complete within one year of today's date, the course "Difficult Patients Interactions Masterclass" as provided by the Cognitive Institute. 2. Provide to the Medical Council of NSW (the Council") within 6 months of today's date, evidence of enrolment in that course; 3. Provide the Medical Council with evidence of satisfactory completion of that course within 1 month of completion; and 4. If that course is not available, propose to the Council a similar course to be undertaken, and satisfactorily complete that course within 3 months of approval of the course by the Council. 1. The practitioner's registration as a medical practitioner is hereby subjected to the following conditions for a period of one year from today's date: Prescribing 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) other than for palliative care patients (i.e. patients already under the management of a palliative care specialist), or if working as an employee of a hospital (other than as a Visiting Medical Officer); 2. Not to possess, supply, administer or prescribe any substance listed in Schedule 4 Appendix D of the Poisons and Therapeutic Goods Regulation 2008 (NSW) other than for palliative care patients (i.e. patients already under the management of a palliative care specialist) or if working as an employee of a hospital (other than as a Visiting Medical Officer); Obligations to Council 1. The Practitioner authorises and consents to any exchange of information between the Council and Medicare Australia where such exchanges are necessary to facilitate the monitoring of compliance with these conditions; 2. To obtain Council approval prior to changing the nature or place of his practice; 3. To advise the Council in writing at least 7 days prior to changing the nature or place of his practice; 4. To provide the Council within 14 days, evidence that he has provided a copy of all practice conditions to: 1. the practice manager of any general practice where he is employed; 2. all other general practitioners working in the general practice where he is employed; and/or 3. any other senior officer at any other place of his employment including public or private hospitals, nursing homes, medical centres or locum agencies; 1. To provide the Council within 14 days of publication of the Tribunal's decision, evidence that he has provided a copy of the tribunal decision to: 1. the practice manager of any general practice(s) where he is employed; and 2. all other general practitioners working in the general practice where he is employed; and/or 3. any other senior officer at any other place of employment including public or private hospitals, nursing homes, medical centres or locum agencies; 1. In the event that the practitioner changes his place of practice, provide the Council within 14 days, evidence that a copy of the conditions and the published Tribunal decision (if available) has been provided to: 1. the practice manager of any general practice where he is employed; and 2. all other general practitioners working in the general practice where he is employed; and/or 3. any other senior officer at any other place of employment including public or private hospitals, nursing homes, medical centres or locum agencies; Supervision 1. To practice under Level C supervision in accordance with the Council's Level C Supervision Policy as varied below: 2. within 14 days of these orders the practitioner is to nominate a proposed supervisor for approval by the council; 3. The Supervisor need not practice at the same location as the Practitioner; 4. During first 3 months of the period of supervision the approved Supervisor is to meet with the Practitioner for at least 2 hours each fortnight; 5. The Supervisor is to report to the Council every 3 months, and if required by the Council, on his supervision of the Practitioner, and is to raise any concerns with the Council which he/she may have about the Practitioner's capacity to practise medicine safely; 6. For the first 3 months of the supervision every second occasion of supervision is to include the Supervisor directly observing a sample of at least 8 consultations by the Practitioner with a patient (with the consent of each patient); 7. The Supervisor is to provide the practitioner oral feedback in relation to the Supervisor's observations of the Practitioner's patient consultations and his patient records and matters such as patient history taking, difficult patients, treatment plans, clinical decision making, clinical diagnoses, patient/doctor communications, prescribing and/or any other relevant issues that arise; 8. During the first 3 months of the supervision period the Supervisor is to conduct an audit and assess at least 25 of the Practitioner's patient medical records for the period since 1 January 2016 chosen randomly by the Supervisor; 9. The Supervisor is to include in his reports to the Council an audit assessing whether those records satisfy the statutory requirements under the National Law , the Regulation, and good medical record keeping, and whether they comply with the conditions of the Practitioner's registration; 10. After the first 3 months of supervision, the Supervisor is to meet with the Practitioner once every month for not less than 2 hours to discuss case studies, patient history taking, treatment plans, clinical decision making, , clinical diagnoses, record-keeping, patient/doctor communication, ,prescribing and any other issues raised by the Practitioner or the Supervisor. 11. If the approved Supervisor becomes unavailable to continue the supervision, the Supervisor must inform the Council in writing, and the Practitioner must nominate an different Supervisor within 14 days of becoming aware that the current arrangement cannot continue. Practice arrangements 1. If the practitioner is practising in general practice, he must practice only in a group practice approved by the Council. Expenses of Supervision 1. The practitioner is responsible for any costs arising out of compliance with the conditions. 1. The above conditions may be altered, varied or removed at the discretion of the Council and the Council is the appropriate body for the purposes of Division 8 of Part 8 of the National Law. 2. Sections 125 and 127 of the National Law are to apply while the Practitioner's principal place of practice is anywhere in Australia other than New South Wales, so that a review of these conditions can be conducted by the Medical Board of Australia. 3. The Respondent must pay the applicant's costs of or incidental to these proceedings, as agreed or as assessed under the Legal Profession Uniform Law Application Act (2014) NSW. 4. Publication or broadcast without the leave of the Tribunal of the name or other identifying information of any patient referred to in the evidence or the reasons for these orders is prohibited. ******** 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 04 September 2017 - Typographical error in orders 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: 04 September 2017