Civil and Administrative Tribunal New South Wales Medium Neutral Citation: Health Care Complaints Commission v Ragavan [2018] NSWCATOD 67 Hearing dates: 23 - 24 April 2018 Date of orders: 10 May 2018 Decision date: 10 May 2018 Jurisdiction: Occupational Division Before: D A Cowdroy ADCJ, Principal Member Dr M Cohen, Senior Member Dr K McCarthy, Senior Member M Kelly, General Member Decision: 1 The Tribunal orders that the practitioner be reprimanded pursuant to s 149A(1)(a) of the National Law. 2 The Tribunal orders that conditions be imposed upon the registration of the practitioner as follows. (1) Education (a) The practitioner shall within 12 months: (i) Undertake a course held by the University of Sydney headed "Opioid Treatment Accreditation Course" and provide evidence in writing to the Council of his successful completion of the course. (ii) Complete the E-Learning module E-Learning: E&5558 AVANT WEBINAR: Proscribing Perils – Opioids, polypharmacy and Medication Errors. (iii) Complete a course offered by the Chapter of Addiction Medicine (RACP) through the elearningracp.edu.au website entitled "Opioid Risk Management in Chronic Pain" comprising of two modules, namely: 1. Minimising Risk when Prescribing Opioids; and 2. Structuring Opioid Therapy. (iv) Complete the E-learning modules 1-12: Better Pain Management Complete Program offered by the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists. (v) Complete a course in the keeping of medical records. (b) If any course specified in this condition is unavailable, then the practitioner is to complete an equivalent course as approved by the Medical Council of NSW ("the Council"). (2) Prescribing restriction (a) The practitioner shall not possess, supply, administer or prescribe any "drug of addition" (Sch 8 drug) as defined by the PATG Act. (b) The practitioner shall provide written evidence to the Council that he has attended the offices of the Pharmaceutical Services Branch 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 Sch 8 drug within 14 days of these orders. (c) The practitioner shall not reapply to the Pharmaceutical Services Branch for a new authority to possess, supply, administer or prescribe any "drug of addition" (Sch 8 drug) as defined by the PATG Act ("a new authority") at least until he has successfully completed the education courses required by condition (1). (3) Audits (a) To submit to an audit of his medical practice by a random selection of his medical records by a person or persons nominated by the Council to be held during the 12-month period from the date of these orders or as required thereafter by the Council. The auditor is to assess his compliance with good medical record keeping standards and legislative requirements. (b) To submit to an audit of his medical practice by a random selection of his medical records by a person or persons nominated by the Council to be held within 6 months from the grant of a new authority and subsequently as required by the Council. The auditor is to assess his compliance with appropriate prescribing of Sch 8 drugs and legislative requirements. (c) To authorise the auditor to provide the Council with a report on his/her findings. (4) Review (a) 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. (b) 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. (5) Expenses (a) The practitioner is responsible for any costs arising out of compliance with these conditions. 3 The Tribunal orders that the costs of the HCCC of these proceedings be paid by the practitioner as agreed. Catchwords: PROFESSIONS AND TRADES – Medical Practitioner – practitioner prescribing opiates without obtaining details of patient's psychosocial history specifically of previous drug use – inadequate record keeping – failure of practitioner to make holistic assessment of medical needs of patients – prescribing Sch 8 drugs without comprehensive assessment. Legislation Cited: Health Practitioner Regulation National Law (NSW) Health Practitioner Regulation (New South Wales) Regulation 2010 Poisons and Therapeutic Goods Act 1966 (NSW) Category: Principal judgment Parties: Health Care Complaints Commission (Applicant) Dr Rajen Ragavan (Respondent) Representation: Counsel: S Maybury (Applicant) M Fordham SC (Respondent) Solicitors: Health Care Complaints Commission (Applicant) Meridian Lawyers (Respondent) File Number(s): 2017/00215151 Publication restriction: An order is made under s 64 of the Civil and Administrative Tribunal Act 2013 (NSW) prohibiting publication of the name of the patients set out in the Schedule to the complaint. REASONS FOR DECISION 1. By Third Amended Application filed on 23 April 2018, the Applicant (HCCC) applies for disciplinary findings and orders pursuant to the Health Practitioner Regulation National Law (NSW) ("National Law") against the Respondent (the practitioner). 2. Eleven complaints are raised against the practitioner, each alleging that the practitioner is guilty of unsatisfactory professional conduct under s 139B(1)(a) and/or (l) of the National Law in respect of 10 patients. Such breaches are claimed to have resulted from the practitioner engaging in conduct that demonstrates the knowledge, skill or judgement 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; and/or that the practitioner has engaged in improper or unethical conduct relating to the practice of medicine. 3. The practitioner specialises in rehabilitation medicine. The practitioner has admitted unsatisfactory professional conduct ("UPC") in respect of several of the complaints on the occasions specified in Sch A attached to the Third Amended Complaint, the Particulars of which are now considered hereunder. For convenience, the practitioner's response in summary form is included immediately after each complaint. The full reply follows the last complaint. THE COMPLAINTS Complaint One [UPC admitted] Particulars of Complaint One 1. Between 13 October 2011 and 2 April 2015 on the occasions set out in Sch A, the practitioner prescribed oxycodone, hydromorphone, morphine and fentanyl, each being drugs of addiction within the meaning of Sch 8 of the NSW Poisons List proclaimed under s 8 of the Poisons and Therapeutic Goods Act 1966 (NSW) ("PATG Act"), for Patient A and failed to conduct an appropriate assessment of Patient A before prescribing. 2. On and after 29 May 2014 on the occasions set out in Sch A, the practitioner prescribed fentanyl on the occasions set out in Sch A and failed to respond appropriately to drug seeking behaviour exhibited by Patient A, in circumstances where Patient A was wearing two fentanyl 100mg patches on 29 May 2014. 3. On and after 29 May 2014 on the occasions set out in Sch A, the practitioner failed to comply with s 28(3) of the PATG Act, by prescribing fentanyl and oxycodone, both Type C drugs of addiction within the meaning of that Act, for Patient A: 1. When the practitioner knew or should have known that Patient A was a drug dependent person; and 2. Without the proper authority of the Secretary of the Ministry of Health. Complaint One A [UPC admitted] 1. In the period specified in Complaint One, on the occasion set out in Sch A to the complaint, the practitioner contravened clause 7(1) and Sch 2 of the Health Practitioner Regulation (New South Wales) Regulation 2010, ("the Regulation"), in respect of his medical records for Patient A in that he failed to record a comprehensive assessment of the patient. The background to Complaint One A are the same as for Complaint One. Complaint Two [UPC admitted] 1. The practitioner is guilty of unsatisfactory professional conduct under s.139B(1)(a) and/or (l) of the National Law as aforesaid. The particulars of such complaint are as follows. Particulars of Complaint Two 1. Between 26 October 2010 and 6 January 2014 on the occasions set out in Sch B, the practitioner prescribed buprenorphine, fentanyl, hydromorphone, morphine and oxycodone, each being drugs of addiction within the meaning of Sch 8 of the NSW Poisons List proclaimed under s 8 of the PATG Act, for Patient B and failed to conduct an appropriate assessment of Patient B before prescribing. 2. Between 26 October 2010 and 6 January 2014 on the occasions set out in Sch B, the practitioner failed to comply with s 28(3) of the PATG Act, by prescribing buprenorphine, fentanyl, hydromorphone, morphine and oxycodone, each Type C drugs of addiction within the meaning of that Act, for Patient B: 1. When the practitioner knew or should have known that Patient B was a drug dependent person; and 2. Without the proper authority of the Secretary of the Ministry of Health. 1. It is alleged that each particular justifies a finding of UPC or alternatively, two or more of the particulars, taken together, constitutes UPC: "the Combined Particulars Claim." Complaint Two A [UPC denied] 1. The practitioner is guilty of unsatisfactory professional conduct under s 139B(1)(b) of the National Law by contravening the regulations under such law. The background to complaint is the same as for Complaint Two. 2. The particulars of Complaint Two A are that in the period 26 October 2010 to 6 January 2014, on the occasions set out in Sch B to the complaint, the practitioner contravened clause 7(1) and Sch 2 of the Regulation in respect of the medical records for Patient B by failing to record a comprehensive assessment of the patient. Complaint Three [UPC admitted] 1. This complaint alleges unsatisfactory professional conduct, particulars of which are as follows. Particulars of Complaint Three 1. On 4 October 2013 and 18 October 2013 as set out in Sch C, the practitioner prescribed fentanyl, being a drug of addiction within the meaning of Sch 8 of the NSW Poisons List proclaimed under s 8 of the PATG Act, for Patient C and failed to conduct an appropriate assessment of Patient C before prescribing. 2. On 4 October 2013 and 18 October 2013 as set out in Sch C, the practitioner prescribed fentanyl for Patient C: 1. The practitioner failed to respond appropriately to drug seeking behaviour exhibited by Patient C, in circumstances where the practitioner was told on 4 October 2013 by Patient C that he had been wearing 75 µg per hour fentanyl patches given to him by a friend for about one month. 1. On 4 October 2013 and 18 October 2013 as set out in Sch C, the practitioner failed to comply with s 28(3) of the PATG Act, by prescribing fentanyl, a Type C drug of addiction within the meaning of that Act, for Patient C: 1. When the practitioner knew or should have known that Patient C was a drug dependent person; and 2. Without the proper authority of the Secretary of the Ministry of Health. 1. The Complaint repeats the combined particulars claim. Complaint Three A [UPC Denied] 1. It is alleged that the practitioner is guilty of unsatisfactory professional conduct. The background for this complaint is the same as for Complaint One. The particulars are as follows. Particulars of Complaint Three A 1. On 4 October 2013 and 18 October 2013 as set out in Sch C, the practitioner contravened clause 7(1) and Sch 2 of the Regulation, in respect of his medical records for Patient C in that he failed to record a comprehensive assessment of the patient. Complaint Four [UPC admitted] 1. This complaint alleges unsatisfactory professional conduct, the particulars of which are as follows. Particulars of Complaint Four 1. On 16 July 2013 as set out in Sch D, the practitioner prescribed fentanyl and morphine, each being drugs of addiction within the meaning of Sch 8 of the NSW Poisons List proclaimed under s 8 of the PATG Act, for Patient D and failed to conduct an appropriate assessment of Patient D before prescribing. 2. On 16 July 2013 as set out in Sch D, the practitioner prescribed fentanyl and morphine for Patient D and failed to respond appropriately to drug seeking behaviour exhibited by Patient D, in circumstances where the drug seeking behaviour of Patient D was noted on 23 May 2013 and the practitioner was told by Patient D on 16 July 2013 that he was running out of medications. 3. On 16 July 2013 as set out in Sch D, the practitioner failed to comply with s 28(3) of the PATG Act, by prescribing fentanyl and morphine, each Type C drugs of addiction within the meaning of that Act, for Patient D: 1. When the practitioner knew or should have known that Patient D was a drug dependent person; and 2. Without the proper authority of the Secretary of the Ministry of Health. Complaint Four A [UPC not admitted] 1. The background for this complaint is the same as for complaint one. The particulars allege. Particulars of Complaint Four A 1. On 16 July 2013 as set out in Sch D, the practitioner contravened clause 7(1) and Sch 2 of the Regulation, in respect of his medical records for Patient D in that he failed to record a comprehensive assessment of the patient. Complaint Five [UPC admitted] 1. It is alleged that the practitioner is guilty of unsatisfactory professional conduct. The background of the complaint is the same as that for Complaint One. The particulars are as follows. Particulars of Complaint Five 1. On the occasions between 10 April 2014 and 19 January 2015 as set out in Sch E, the practitioner prescribed fentanyl, being a drug of addiction within the meaning of Sch 8 of the NSW Poisons List proclaimed under s 8 of the PATG Act, for Patient E and failed to conduct an appropriate assessment of Patient E before prescribing. 2. On the occasions between 10 April 2014 and 19 January 2015 as set out in Sch E, the practitioner failed to take appropriate action to determine whether Patient E was drug dependent and/or drug seeking before prescribing fentanyl. 3. On the occasions between 10 April 2014 and 19 January 2015 as set out in Sch E, the practitioner failed to comply with s 28(3) of the PATG Act, by prescribing fentanyl, being a Type C drug of addiction within the meaning of that Act, for Patient E: 1. When the practitioner knew or should have known that Patient E was a drug dependent person; and 2. Without the proper authority of the Secretary of the Ministry of Health. 1. The complaint repeats the combined particulars claim. Complaint Five A [UPC Denied] 1. It is alleged the practitioner is guilty of unsatisfactory professional conduct. The background is the same as for Complaint One. The particulars in support are as follows. Particulars of Complaint Five A 1. On the occasions between 10 April 2014 and 19 January 2015 as set out in Sch E, the practitioner contravened clause 7(1) and Sch 2 of the Regulation, in respect of his medical records for Patient E in that he failed to record a comprehensive assessment of the patient. Complaint Six [UPC admitted] 1. It is alleged the practitioner is guilty of unsatisfactory professional conduct. The background is the same as that for Complaint One. The particulars are as follows. Particulars of Complaint Six 1. On 25 July 2014 and 11 August 2014 as set out in Sch F, the practitioner prescribed fentanyl, being a drug of addiction within the meaning of Sch 8 of the NSW Poisons List proclaimed under s 8 of the PATG Act, for Patient F and failed to conduct an appropriate assessment of Patient F before prescribing. 2. On 25 July 2014, the practitioner prescribed fentanyl 12 mcg/hr patches, being a transdermal opioid, with tramadol 100mg capsules twice daily and Tramal 50mg capsules up to three daily, being oral opioids, without an appropriate therapeutic purpose. 3. The Complaint repeats the combined particulars Claim. Complaint Six A [UPC Denied] 1. It is alleged the practitioner is guilty of unsatisfactory professional conduct. The background is as for Complaint One. The particulars are as follows. Particulars of Complaint Six A 1. On 25 July 2014 and 11 August 2014 as set out in Sch F, the practitioner contravened clause 7(1) and Sch 2 of the Regulation, in respect of his medical records for Patient F in that he failed to record a comprehensive assessment of the patient. Complaint Seven [UPC Admitted] 1. It is alleged the practitioner is guilty of unsatisfactory professional conduct. The background is the same as Complaint one. The particulars are as follows. Particulars of Complaint Seven 1. On the occasions between 22 April 2013 and 6 June 2014 as set out in Sch G, the practitioner prescribed fentanyl and tapentadol, each being drugs of addiction within the meaning of Sch 8 of the NSW Poisons List proclaimed under s 8 of the PATG Act, for Patient G and failed to conduct an appropriate assessment of Patient G before prescribing. 2. On the occasions between 22 April 2013 and 6 June 2014 as set out in Sch G, the practitioner failed to comply with s 28(3) of the PATG Act, by prescribing fentanyl and tapentadol, each being Type C drugs of addiction within the meaning of that Act, for Patient G: 1. When the practitioner knew or should have known that Patient G was a drug dependent person; and 2. Without the proper authority of the Secretary of the Ministry of Health. Complaint Seven A [UPC admitted] 1. Unsatisfactory professional conduct as alleged against the practitioner. The background is as for complaint one. The particulars are as follows. Particulars of Complaint Seven A 1. On the occasions between 22 April 2013 and 6 June 2014 as set out in Sch G, the practitioner contravened clause 7(1) and Sch 2 of the Regulation, in respect of his medical records for Patient G in that he failed to record a comprehensive assessment of the patient. Complaint Eight [UPC admitted] 1. It is alleged the practitioner is guilty of unsatisfactory professional conduct. The background is the same as that for Complaint One. The particulars are as follows. Particulars of Complaint Eight 1. On the occasions between 7 May 2013 and 8 January 2014 as set out in Sch H, the practitioner prescribed buprenorphine, oxycodone and oxycodone plus naloxone, each being drugs of addiction within the meaning of Sch 8 of the NSW Poisons List proclaimed under s 8 of the PATG Act, for Patient H and failed to conduct an appropriate assessment of Patient H before prescribing. 1. On the occasions between 7 May 2013 and 8 January 2014 as set out in Sch H, the practitioner prescribed oxycodone (a short term opioid) as needed, oxycodone plus naloxone (a long term opioid plus opioid antagonist) twice daily and buprenorphine (a partial opioid agonist) for Patient H: 1. Without an appropriate therapeutic purpose; 2. In an inappropriate combination. 1. On the occasions between 7 May 2013 and 8 January 2014 as set out in Sch H, the practitioner failed to comply with s 28(3) of the PATG Act, by prescribing buprenorphine, oxycodone and oxycodone plus naloxone, each being Type C drugs of addiction within the meaning of that Act, for Patient H: 1. When the practitioner knew or should have known that Patient H was a drug dependent person; and 2. Without the proper authority of the Secretary of the Ministry of Health. 1. On 27 May 2013, the practitioner failed to respond appropriately to drug seeking behaviour exhibited by Patient H, in circumstances where the practitioner was told on 27 May 2013 by Patient H that she had developed a dependence on morphine and wants to get off morphine. 2. The Complaint repeats the combined particulars claim. Complaint Eight A [UPC Admitted] 1. It is alleged the practitioner is guilty of unsatisfactory professional conduct. The background is the same as that for Complaint One. The particulars are as follows. Particulars of Complaint Eight A 1. On the occasions between 7 May 2013 and 8 January 2014 as set out in Sch H, the practitioner contravened clause 7(1) and Sch 2 of the Regulation, in respect of his medical records for Patient H in that he failed to record a comprehensive assessment of the patient. Complaint Nine [UPC Denied] 1. It is alleged the practitioner is guilty of unsatisfactory professional conduct. The background is the same as that for Complaint One. The particulars are as follows. Particulars of Complaint Nine 1. On the occasions between 15 May 2014 and 26 November 2014 as set out in Sch I, the practitioner prescribed buprenorphine, fentanyl, oxycodone and tapentadol, each being drugs of addiction within the meaning of Sch 8 of the NSW Poisons List proclaimed under s 8 of the PATG Act, for Patient I and failed to conduct an appropriate assessment of Patient I before prescribing. Complaint Nine A [UPC Admitted] 1. It is alleged the practitioner is guilty of unsatisfactory professional conduct. The background is the same as that for Complaint One. The particulars are as follows. Particulars of Complaint Nine A 1. On the occasions between 15 May 2014 and 26 November 2014 as set out in Sch I, the practitioner contravened clause 7(1) and Sch 2 of the Regulation, in respect of his medical records for Patient I in that he failed to record a comprehensive assessment of the patient. Complaint Ten [UPC is admitted] 1. It is alleged the practitioner is guilty of unsatisfactory professional conduct. The background is the same as that for Complaint One. The particulars are as follows. Particulars of Complaint Ten 1. On the occasions between 18 July 2013 and 15 August 2013 as set out in Sch J, the practitioner prescribed fentanyl, hydromorphone, oxycodone and oxycodone plus naloxone, each being drugs of addiction within the meaning of Sch 8 of the NSW Poisons List proclaimed under s 8 of the PATG Act, for Patient J and failed to conduct an appropriate assessment of Patient J before prescribing. 2. On the occasions between 18 July 2013 and 15 August 2013 as set out in Sch J, the practitioner prescribed fentanyl, hydromorphone, oxycodone and oxycodone plus naloxone (all being long-term opioids) for Patient J: 1. Without an appropriate therapeutic purpose; 2. In an inappropriate combination. 1. On the occasions between 18 July 2013 and 15 August 2013 as set out in Sch J, the practitioner failed to comply with s 28(3) of the PATG Act, by prescribing fentanyl, hydromorphone, oxycodone and oxycodone plus naloxone, each being Type C drugs of addiction within the meaning of that Act, for Patient J: 1. When the practitioner knew or should have known that Patient J was a drug dependent person; and 2. Without the proper authority of the Secretary of the Ministry of Health. 1. The Complaint repeats the combined particulars Claim. Complaint Ten A [UPC Admitted] 1. It is alleged the practitioner is guilty of unsatisfactory professional conduct. The background is the same as that for Complaint One. The particulars are as follows. Particulars of Complaint Ten A 1. The practitioner, on the occasions between 18 July 2013 and 15 August 2013 as set out in Sch J, contravened clause 7(1) and Sch 2 of the Regulation, in respect of his medical records for Patient J in that he failed to record a comprehensive assessment of the patient. Complaint Eleven [Professional Misconduct denied] 1. It is alleged the practitioner is guilty of professional misconduct. The background is the same as that for Complaint One. The particulars are as follows. Particulars of Complaint Eleven 1. Complaint One – particular 3, Complaint Two – particular 2, Complaint Three – particulars 2 and 3, Complaint Four – particular 3, Complaint Five – particular 3, Complaint Six – particular 2, Complaint Seven – particular 2, Complaint Eight – particulars 2 and 3 and Complaint Ten – particulars 2 and 3 are repeated and relied upon individually. 2. Complaints One, One A, Two, Two A, Three, Three A, Four, Four A, Five, Five A, Six, Six A, Seven, Seven A, Eight, Eight A, Nine, Nine A, Ten and Ten A and the particulars are repeated and relied upon cumulatively to allege professional misconduct. PRACTITIONER'S DETAILED RESPONSE 1. Complaint One: Unsatisfactory professional conduct ("UPC") is admitted. 2. The practitioner states that he contacted Patient A's general practitioner to advise what had occurred and made a plan to reduce the patient's dose of fentanyl. 3. Complaint One A: UPC is admitted. 4. Complaint Two: UPC is admitted. The practitioner denies he failed to conduct an appropriate assessment of Patient B before prescribing and relies upon medical records. 5. Complaint 2A: UPC is denied. 6. Complaint Three: UPC is admitted. The practitioner denies that he failed to conduct an appropriate assessment of Patient C before prescribing and relies upon medical records. The practitioner denies particular 2, namely that he prescribed fentanyl without appropriate therapeutic purpose and says that fentanyl was prescribed on 4 October and 18 October 2013 for chronic back pain and that on those dates the practitioner reduced the dose of fentanyl to wean Patient C off the medication while still controlling his pain levels. 7. Complaint Three A: UPC is denied and particular 1 is denied. 8. Complaint Four: UPC is admitted. 9. Complaint Four A: The practitioner admits the background but does not admit UPC. 10. Complaint Five: UPC is admitted. 11. As to particular 1, he admits the prescribing of fentanyl but denies that he failed to conduct an appropriate assessment of Patient E on each occasion. He relies upon the medical records. 12. As to particular 2, the practitioner denies such particular and says that he considered patient he was drug dependent; that he continued prescription of fentanyl for pain relief of Patient E's shoulder injury whilst trying to wean the patient off such drug. 13. Complaint Five A: UPC is denied but the background is admitted. 14. Complaint Six: UPC is admitted, as is particular 1. However with respect to particular 2 the practitioner admits that on 25 July 2014 he prescribed fentanyl without a therapeutic purpose. He denies that on the same day he prescribed tramadol and Tramal without an appropriate therapeutic purpose. He says he prescribed such medications for significant pain from moderate osteoarthritis from L 5/S 1 to L1/L2. 15. Complaint Six A: UPC is denied. 16. Complaint Seven: This complaint is admitted, including UPC. 17. Complaint Seven A: This complaint is admitted, including UPC. 18. Complaint Eight: UPC is admitted, together with the particulars. 19. Complaint Eight A: UPC is admitted. 20. Complaint Nine: UPC is denied. 21. The practitioner admits that on occasions between 15 May 2014 and 26 November 2014, he prescribed buprenorphine, fentanyl, oxycodone and tapentadol as alleged; but denies he failed to conduct an appropriate assessment of the patient before prescribing. 22. Complaint Nine A: UPC is admitted. 23. Complaint Ten: UPC is admitted. 24. Complaint Ten A: This complaint is admitted, including UPC. 25. Complaint Eleven: The practitioner denies that he is guilty of professional misconduct but admits the background to this complaint. The practitioner repeats and relies upon his responses to Complaints One to Ten. THE EVIDENCE 1. The HCCC relies upon an investigation report. Such report was commissioned to establish whether the apparent increase in the supply of fentanyl patches and other drugs prone to misuse was reflective of a failure by the practitioner to comply with the requirements of the PATG Act. 2. As part of the investigation, the records of numerous pharmacies in the area of Tuncurry-Foster, Nabiac and Taree were examined. 3. The report concluded that the practitioner appears to have issued prescriptions for a drug of addiction within close proximity to the same or similar prescriptions having been issued by certain patients' regular prescribers. In particular, eight patients, known as Patients A, B, C, D, E, F, G and H were identified. 4. The details investigations were referred to Professor Hugh Dickson for expert opinion. Professor Dickson provided his report, in which he considered the 10 patients before arriving at his opinion. Subsequently he provided a supplementary report dated 12 December 2016. Such reports relate to the administration of opioids, risks associated with prescribing such medication and incidental issues. 5. In respect of Dr Ragavan's prescription of opioids, Professor Dickson states: "Dr Ragavan's standard of medical practice is significantly below the accepted standard reasonably expected of a practitioner of his level of training and experience. His departure from the standard attracts my criticism but not my strong criticism." 1. Professor Dickson continued: "Dr Ragavan has provided no justification for the use of two long-acting narcotics simultaneously. I do not withdraw my criticism of him about this issue, which should be noted is not strong criticism." 1. In respect of any drug seeking behaviour of a patient, Professor Dickson agreed that the practitioner's standard was not significantly below the accepted standard. 2. As to record keeping, Professor Dickson said: "In fact that he [the practitioner] uses an electronic system does not relieve him of the responsibility to make an assessment of a patient at an appropriate standard and to keep a record of this." 1. Professor Dickson continued: "He does keep a record of his prescriptions of s8 drugs within the electronic system. This information, however, does not appear in the record of the clinical interaction, the letter which he sends to the referring general practitioner, though he might mention that the dosage of a drug has changed or the drug has been discontinued or another commenced. The general practitioner therefore usually has no knowledge of the fact that the prescriptions might have been written for narcotics for the patient and might unwittingly write additional prescriptions for the patient." 1. As to patient assessment, Professor Dickson said: "As regards assessments of patients, I still consider, on the basis of the records of the consultations that have been supplied to me that Dr Ragavan's standard of medical practice is significantly below the accepted standard reasonably expected of a practitioner of his level of training and experience. His departure from the standard attracts my strong criticism. His level of inquiry into the education level, work history, current source of income, debt level, living conditions, social relationships, psychological factors such as depression, usual daily activities and so on is non-existent in the correspondence supplied to me." Medical Council of NSW 1. The Tribunal notes that the Medical Council of NSW ("Medical Council") investigated complaints against the practitioner and held a hearing pursuant to s150 of the National Law on 21 August 2015. The practitioner was present and provided his explanations. On 31 August 2015, the Medical Council, after considering all the material before it, was not satisfied that it was appropriate to suspend or impose conditions upon the practitioner's registration. The Practitioner's Background 1. The practitioner practices as a rehabilitation medicine consultant from premises in Taree. The practitioner was born on 4 September 1956. He received his degrees of Bachelor of Medicine and Bachelor of Surgery from the University of Madras, India in 1989. He underwent postgraduate training in rehabilitation medicine in the United Kingdom and had a one-year placement at the Southport Spinal Injury Centre, Merseyside, UK. From 1990 to approximately 1995 he undertook a Fellowship in rehabilitation medicine in Paris, completing three different subspecialties in urodynamics, ortho-prosthetics and advanced level technologies applied to rehabilitation. During such work, he was exposed to the biggest spinal unit in Europe, the Centre Propara in Montpelier. During such work he was exposed to all types of rehabilitation from new role-Orthopaedic to paediatric, geriatric and burns. He was exposed to the prescription of high doses of equivalence of OxyContin, Norspan, fentanyl, oxycodone in view of the severe pain syndromes experienced in such patients. 2. The practitioner moved to India in January 1999 to set up a charitable hospital, Amrita Institute of Medical Sciences in Cochin. He then returned to France in December 2000 and became medical director of a 100-bed rehabilitation unit at Centre Le Bonnais at Bourbon Lancey where he was appointed to administrative and clinical work. 3. In June 2005, the practitioner moved to Taree. The practitioner was first granted conditional registration as a medical practitioner in New South Wales on 20 June 2005, to work in an area of need position under s 7(1) of the Medical Practice Act 1992 (NSW). The practitioner remained registered until 14 January 2007. 4. On 15 January 2007, the practitioner was granted conditional registration in NSW under s 7(1)E of the Medical Practice Act 1992 following recognition of his specialist qualifications and experience. As a conditional specialist, the practitioner's registration was subject to the following conditions: 1. To work as a Specialist in Rehabilitation Medicine; and 2. May not undertake any medical work outside the field of specialty. The practitioner remained so registered until 30 June 2010, when the National Law became operative. 1. The practitioner, before coming to Australia, had been working in post-surgical rehabilitation (spinal and orthopaedics and rehabilitation after acute injury). 2. Upon arriving in Australia the practitioner was supervised for one year at the Mayo Private Hospital at Taree. At the end of that year (2006) he achieved Fellowship of the Australasian Faculty of Rehabilitation Medicine of the Royal Australasian College of Physicians. Thereafter he has completed WorkCover NSW training in the Evaluation of Permanent Impairment (2005). In August 2007 the practitioner completed the Motor Accidents Authority Training in the Evaluation of Permanent Impairment and also completed (in 2011) the WorkCover WA Guides For the Evaluation of Permanent Impairment. 3. The practitioner was initially employed in Taree at the Mayo Private Hospital then became a Visiting Medical Officer and continued his work in rehabilitation medicine at the Mayo Private Hospital, Forster Private Hospital, and Port Macquarie Private Hospital. 4. The practitioner's practice in Taree became focused on pain management especially acute and chronic back pain. 5. References have been provided to the Tribunal by Dr Therese M Dawson, consultant rheumatologist dated 5 March 2018; Associate Professor Nimeshan Geevasinga, consultant neurologist and neurophysiologist and senior clinical lecturer, University of Sydney (dated 13 March 2018) and by Dr Peter D Braude, consultant physician, dated 13 March 2018. Each reference speaks highly of the capabilities and practices of the practitioner. Evidence of Practitioner Concerning Patients 1. The practitioner readily acknowledges the risk of addiction by patients who are provided with opioid analgesic drugs, and provides the following details concerning each patient. 2. Patient A: the practitioner accepts that this patient would have benefited from more comprehensive management. The practitioner states that he was unsuccessfully endeavouring to reduce the amount of pain medication that the patient was taking following surgery. In view of the time it was taking, the practitioner acknowledges that more assistance should have been sought. He accepts that the patient's wearing of two fentanyl patches on 29 May 2014 was indicative of drug dependence and drug-seeking behaviour. His response was to attempt to reduce the dose of fentanyl. The practitioner acknowledged that at this stage it would have been preferable to refer the patient back to his referring doctor (Dr Russo) or to an addiction medicine specialist. 3. Patient B: this patient had a history of significant pain associated with widespread osteoarthritis especially in the right knee, right hip replacement and failed knee replacement. The practitioner liaised with the rheumatologist and orthopaedic surgeon in relation to the patient's management and he referred her to a further orthopaedic surgeon for a second opinion. The practitioner rejects the criticism of the HCCC reviewer that the practitioner did not form an appropriate assessment of her before prescribing medication. He does not consider that he did not perform an appropriate assessment of the patient but acknowledges that he was unsuccessful in his attempts at reducing her pain. 4. Patient C: this patient consulted the practitioner on two occasions on 4 and 18 October 2013. The patient was referred on 4 October 2013 by his general practitioner who noted a history of chronic middle/low back pain and current medication as Panadeine Forte. The patient informed the practitioner that he had been taking fentanyl 75mcg per hour given to him by a friend. The practitioner states that he prescribed fentanyl 50 mcg in an effort to reduce the dosage the patient had been taking. 5. The patient returned on 18 October 2013 with a CT scan which revealed no abnormality or pathology. The practitioner therefore advised the patient that he did not need to continue with fentanyl. To wean him off the medication, the practitioner prescribed fentanyl 25mcg per hour and fentanyl 12mcg per hour. 6. Patient D: the criticism of the practitioner arises in respect of one consultation on 16 July 2013 when the practitioner prescribed fentanyl and MS Contin. 7. The practitioner states that the patient had a long history of continuing pain from neurovascular and orthopaedic injuries resulting from motor vehicle accident. The patient had consulted the practitioner in 2009 and was again referred in May 2013 for opinion and review of his chronic opioid use. 8. The practitioner recommended physiotherapy and use of a sling to decrease his pain and he charted out a plan to reduce pain medication. The practitioner states that he was then concerned that the patient was becoming dependent on morphine and referred to that fact in his letter to the referring general practitioner. 9. On 16 July 2013 the patient reported he was taking increased doses of his medications including fentanyl 100mcg per hour which had little impact on pain reduction. The practitioner was concerned about such usage and referred the patient to the Hunter Integrated Pain Service for review. 10. The practitioner accepts that in the circumstances he should not have provided the patient with scripts for fentanyl 100mcg per hour and MS Contin but should have trialled a reduction in his medication. 11. Patient E: the criticism of the practitioner relates to the maintenance of the prescription of fentanyl without proper assessment and asserts that the practitioner did not respond to drug seeking behaviour in the period 10 April 2014 to 19 January 2015. 12. The practitioner saw the patient on four occasions in this period on referral. The patient had suffered injuries in a motor vehicle accident. On his first consultation with the practitioner, the practitioner stated he was concerned about the high dosage of fentanyl (100mcg per hour) that he was taking. At the time the practitioner noted that the patient was drowsy and had slurred speech. The practitioner explained that the dosage would need to be reduced. The practitioner provided prescriptions for fentanyl 75mcg per hour on two single scripts with no repeats to ensure that the patient was closely monitored. The practitioner notified the patient's general practitioner of the change and advised that no other scripts were to be issued. To compensate for the reduction, the practitioner prescribed Lyrica, one tablet daily at night and Celebrex 200 mg in the morning. 13. The practitioner saw the patient on two further occasions. On 8 May 2014 in the presence of the patient, the practitioner dictated a letter to the general practitioner advising of a further reduction to fentanyl 62mcg per hour and requested that the practitioner repeat the same scripts in two weeks' time, and thereafter fentanyl 25 mcg per hour should be prescribed. The patient did not return until 19 January 2015. The patient provided a letter from Dr David Keogh of the Justice Health and Forensic Mental Health Network advising that the patient had been released from custody in December 2014 and was suffering from chronic pain disorder. 14. The practitioner was informed that the patient had been prescribed fentanyl 100 mcg per hour and Rivotril. The practitioner did not consider such dosage was necessary. Accordingly the practitioner issued a prescription for fentanyl 12mcg per hour to be reviewed in 14 days. Later, the local pharmacist informed the practitioner that the prescription had been altered to a dosage of 100 mcg per hour. The prescription was cancelled and the patient did not return. 15. Patient F: The criticism of the practitioner relates to the assessment and prescription by the practitioner of medications to the patient on 25 July 2014 and 11 August 2014. 16. The practitioner states that the patient had presented with a history of chronic lower back pain which had been increasing. He had tenderness on palpation of the facet joints at L5 – S1 and to a lesser extent at L4 – 5. The practitioner prescribed Celebrex 200 mg and Panadol Osteo 665mg. 17. The next consultation was on 25 July 2014. As a result of the patient reporting that the Celebrex was not providing pain relief the practitioner decided to trial the patient with tramadol 100 mg slow-release. The practitioner provided also one script of fentanyl 12 mg per hour. Such prescription was based upon the belief that the patient had significant pain levels. 18. The practitioner accepted that the patient's reference to having previously been prescribed fentanyl was potential drug-seeking behaviour and should have alerted him to drug dependency. 19. The patient returned on 11 August 2014 reporting he is no longer taking tramadol and this drug was ceased. However fentanyl continued. 20. The patient returned on 20 September 2014 requesting fentanyl increase from 12mcg per hour to 50mcg per hour. The practitioner did not agree and reported this to the patient's referring doctor. The practitioner acknowledges that he should have been alert to the patient's real motive. 21. Patient G: It is alleged by the HCCC expert that the practitioner did not conduct appropriate assessments for prescribing medication. 22. The initial consultation took place in April 2013 when the patient presented with a history of chronic back pain for a number of years. Recent imaging demonstrated degenerative changes and possible discitis. The patient was on a high dose of fentanyl (100 mcg per hour). The practitioner reduced such dosage to 75mcg per hour and issued a single prescription. 23. The practitioner states that the patient returned in November 2013 with further decreased fentanyl dosage to 50mcg per hour. The practitioner continued dosage at fentanyl 50mcg per hour. 24. The patient was reviewed on 22 November 2013 and pain had reduced but the practitioner maintained the prescription at 50mcg per hour. 25. In June 2014 the patient returned with pain in the mid lumbar spine with paraesthesia and muscle spasms. The patient was then taking fentanyl 75mcg per hour. The practitioner explained that such dose was equivalent to 230 – 240mg of morphine per day and informed the patient that the fentanyl was to be reduced to 25mcg per hour. The practitioner realises that he should have been more alert to the patient's possible drug dependency. 26. Patient H: the complaint relates to the lack of proper assessments of this patient from May 2013 to January 2014. 27. The practitioner states that the patient had a complex history of chronic pelvic pain and severe endometriosis with poor control of pain. She was taking OxyContin, Endone and Targin upon referral. The practitioner consulted with two gynaecologists who were managing her. The practitioner considered that no morphine would be needed once the gynaecological procedures were completed and that an appropriate level of opioid analgesic should be provided in the interim. The practitioner declined, when asked, to provide further scripts for her opioids and also for Panadeine Forte. 28. In June 2013 the patient reported increasing her dose of Targin. She had arrangements to be reviewed by her gynaecologist. The practitioner was concerned at her possibly developing a drug dependence on morphine explained that she needed to be weaned off that once gynaecological treatment was complete. 29. On 4 September 2013 she returned to report that she had undergone a procedure but the current dose of Targin was not providing pain relief. Accordingly the practitioner provided a prescription for Norspan 10mcg per hour; Targin 200mg per day; Endone 5mg and Panadol and ibuprofen. The practitioner states that the patient presented a complex challenge and that he was unaware that she had developed an opioid dependency. 30. Patient I: this patient was referred in February 2014 with pain arising from disc protrusions with nerve root impingement. He was awaiting review by a neurosurgeon and then surgery. The practitioner tried pain medication regimes and spinal injections to control pain. Only single prescriptions of Sch 8 medications were provided to this patient requiring him to return regularly for assessment. 31. The HCCC expert criticised the practitioner regarding the practitioner's assessments. The practitioner states that he undertook constant review of the patient's medication as he awaited surgical review. 32. In November 2014 the practitioner was alerted to the patient having acquired prescriptions from both himself and from his general practitioner. As a result the practitioner contacted the general practitioner and it was agreed that only one practitioner would prescribe morphine to the patient. By January 2016 the patient was undertaking Panadol Osteo and has made a successful recovery. 33. Patient J: this patient had a history of chronic cervical pain syndrome, generalised arthritis and a referral to the Hunter pain service some years previously. The medication regimen provided by the practitioner was directed to reducing the amount of pain medication. The practitioner stated his objective was to move away from prescription of fast acting hydromorphone to slower acting oxycodone plus naloxone. The practitioner stated he was successful in wearing the patient off fentanyl. 34. The practitioner states that the patient was a difficult patient and sometimes exhibited drug-seeking behaviour. He accepts the criticism that he should have been more alert and referred the patient for counselling. Generally 1. The practitioner states that he has reflected significantly upon his practice management of patients. He has ceased to prescribe Sch 8 drugs. The practitioner states that he prides himself upon being up-to-date with treatment regimens including pain medications. Observations 1. The Tribunal is mindful that the practitioner does not claim to be a pain specialist, and expressly disavowed such specialty. His specialty is in rehabilitation medicine. Because of his expertise in rehabilitation medicine, it is apparent that the practitioner has been relied upon for referral by general practitioners who have difficult patient cases in pain management. In the area of the Manning River where the practitioner conducts his practice, the availability of a pain management specialist is limited. 2. The Tribunal is also aware of the practitioner's long experience in rehabilitation medicine and of the fact that he provides services to 3 private hospitals in the vicinity of his consulting rooms. At those hospitals he treats inpatients as well as outpatients. 3. There is no evidence before the Tribunal that any patient has actually suffered harm by reason of the practices adopted by the practitioner which have brought him to the attention of the HCCC. That is not to say however that if the shortcomings, referred to below, had not existed, treatment of a different and probably of a more beneficial kind could have been provided to patients. 4. The Tribunal considers that the most significant failing of the practitioner lies in his lack of insight for the need to consider and to treat each patient in a holistic manner. Because the practitioner has adopted, as part of his everyday practice, a narrow focus on the complaint of a patient, there is no overall consideration of other matters which may directly impact upon a patient's need for medical treatment. This approach has resulted in the practitioner relying upon what has been told him by patient as a basis for diagnosis and treatment. It does not appear that the practitioner has, in the majority of cases, made more extensive enquiries into the background of the patient, existing medications and why they were prescribed, psychosocial issues, work practices and living conditions of the patient. Whilst the practitioner considers that such matters are outside the scope of his enquiry, it demonstrates a significant shortcoming in his assessment, diagnosis and treatment of patients. 5. As a result of such approach, it follows that the medical records of the practitioner have been deficient because they do not contain a detailed and comprehensive history or details of the kind of matters referred to above. 6. Even after the events giving rise to the Complaints came to the attention of the practitioner, he has not satisfactorily appreciated the need to change. The practitioner has provided samples of letters which he has written to general practitioners which, he informed the Tribunal, take into consideration the shortcomings in his approach to his patients which he acknowledged. The revised form of letters still fail to recognise the reasons underlying the need for alterations to his practices. That is, although he has adopted a formulaic approach now to topics which he should address, there seems to be no recognition or appreciation by the practitioner of the need for fundamental change: that is, there is a lack of insight by the practitioner into the importance and relevance of a patient's whole medical and social history. The practitioner does not understand why a holistic approach is necessary. 7. Detailed hereunder are the specific matters which the Tribunal finds constitutes the practitioner's shortcomings. CONCLUSIONS REGARDING THE PRACTITIONER The practitioner operates in a very narrow biomedical paradigm 1. The practitioner's approach to his patients was more biomechanical rather than biomedical. He demonstrated a very outcome-focussed/result-orientated approach, saying words such as: "foremost criterion is pain relief"; "if that purpose had not been reached, nothing else would be relevant"; "what matters is how you get the patient out of his pain". His focus was entirely on the pain management; whilst such aim is laudable, it is but part of a wider spectrum. His highly focused approach or outcome depends on "finding source of pain". He stated for example that "blood tests are more important than examination". 2. With respect to psychosocial aspects, the practitioner did not consider it useful, stating that he could not see the purpose of it and that there was no need to ask about such matters. When referring to letters sent by a general practitioner, he said: "I know more about a patient than what is in these letters". The practitioner's confidence is misplaced. 3. It was clear that other elements would not have mattered. He repeatedly said that such matters would not have influenced him and "would not have affected at all the technicality of the pharmacological management". He claimed that the "outcome of asking is zero on one side"; that he obtained "more than enough to come to the right diagnosis"; that enquiries were "not done because it is not important". He felt he was able to review a case without the patient's detailed medical and sociological details. The practitioner's knowledge and skills require upgrading 1. The practitioner is focused on a narrow conceptual framework. His approach is very biomechanical. Accordingly he does not consider matters outside of the condition he perceives. Such approach constitutes an outdated "triage". For example, the practitioner referred to the following: that there should be "no treatment because of CT scan findings"; that he had to have matching symptoms, signs, investigations (before he could treat). The Tribunal considers that this probably reveals that the practitioner has very limited examination skills. 2. The practitioner has not adequately elicited a comprehensive medical history; has not performed a comprehensive physical examination; has failed to formulate a diagnosis; and has accordingly prepared a fragmented plan of management. As a result of these failures, the practitioner's medical records are very much below the standard of consulting practice. They do not comply with the requirements of para 1( 2 ) of Sch 2 of the National Law in that in most cases, an inadequate history is recorded. But more importantly, a proper history was never obtained. In consequence, the records fail to comply with Para 2 of the Schedule, which requires that an appropriate level of detail be recorded containing sufficient information to permit another practitioner to continue to manage that patient. 3. The principal means of treatment used by the practitioner is by injections and drugs, and occasionally physiotherapy. 4. The Tribunal is concerned about the practitioner's lack of knowledge about opioid pharmacology, about recognition of drug dependence, and about prescribing limitations, especially in respect of opioids. 5. The Tribunal considered that the practitioner demonstrated a lack of insight into: 1. His own behaviour, including lack of skills. 2. His failure to incorporate contemporary knowledge and practice. 3. His own naivete, in readily accepting the statements of patients. 4. His own limitations and lack of awareness that there might have been alternative medical issues, social issues and psychological issues, and methods of treatment. This evidence showed that the practitioner clearly out of his depth in respect of pain management. For example, he stated: "In my practice, I did not feel I needed an overall picture for pain management". 5. The practitioner did not consider a complete history of each patient was required before any diagnosis could be made, saying: "I haven't done it because I didn't think it important at that time". Yet the practitioner acknowledged that not taking the full history of a patient, he could not have made a full assessment. 1. The Tribunal finds that the practitioner was protocol-driven. Following commencement of proceedings, rather than adapting protocol to patients, the practitioner chose to treat patients who "fitted my approach". This method demonstrated a poor capacity for reflection, and undue rigidity. The practitioner is not acting as a consultant 1. The practitioner has displayed no recognition of responsibility to "value-add" to referrers; to optimise patient function; to give advice to patients. The practitioner was "blaming" referrers for lack of detail. 2. The practitioner was very judgemental of patients, making statements such as: 1. "99% of patients will tell you that their pain began in childhood"; 2. "patients can mimic anything"; 3. "no genuine problem"/"no basis for pain"; and 4. "I take it as it is". 1. The practitioner applied different approaches to inpatients / outpatients / Workcover patients, when such an approach is contrary to good practice. 2. The practitioner had a very narrow concept of his role, as evidenced by his response to the general practitioner's requests: "that's all I was asked for". He appeared to reach conclusions quickly, on the limited information provided to him, without enquiring of the patient about other biopsychosocial issues which could have had an important bearing upon the appropriate treatment. For example, he did not enquire about a patient's prior drug use or history. FINDING 1. The Tribunal considers that the practitioner is guilty of unsatisfactory professional conduct in respect of each complaint, by reason of the shortcomings referred to above. DISCIPLINARY ACTION 1. The paramount consideration is the protection of the public as required by s 3A of the National Law. In this instance, the practitioner has admitted unsatisfactory professional conduct but disputes the claim that he is guilty of professional misconduct. The Tribunal is not satisfied that cumulatively, the conduct of the practitioner constitutes professional misconduct. However each individual complaint, having been established, warrants disciplinary action. 2. The HCCC has indicated that a suspension would serve to remind other practitioners that the conduct of the practitioner is unacceptable practice. The Tribunal does not consider that the particular circumstances which have caused the practitioner to come to notice warrant suspension. The shortcomings identified during the hearing are confined solely to the methods and practices adopted by the practitioner. It is unlikely that similar shortcomings are widespread amongst other practitioners. 3. Nevertheless, it is clear that disciplinary sanctions are required. The Tribunal is of the opinion that the practitioner must be reprimanded in view of the shortcomings and failures identified during the evidence. Further conditions must be imposed on the registration of the practitioner. The parties have suggested competing versions of the appropriate conditions. In the circumstances the Tribunal considers that generally the conditions suggested by the HCCC should be adopted and the Tribunal will order compliance with such conditions. ORDERS 1. The Tribunal orders that the practitioner be reprimanded pursuant to s 149A(1)(a) of the National Law. 2. The Tribunal orders that conditions be imposed upon the registration of the practitioner as follows. 1. Education 1. The practitioner shall within 12 months: 1. Undertake a course held by the University of Sydney headed "Opioid Treatment Accreditation Course" and provide evidence in writing to the Council of his successful completion of the course. 2. Complete the E-Learning module E-Learning: E&5558 AVANT WEBINAR: Proscribing Perils – Opioids, polypharmacy and Medication Errors. 3. Complete a course offered by the Chapter of Addiction Medicine (RACP) through the elearningracp.edu.au website entitled "Opioid Risk Management in Chronic Pain" comprising of two modules, namely: 1. Minimising Risk when Prescribing Opioids; and 2. Structuring Opioid Therapy. 1. Complete the E-learning modules 1-12: Better Pain Management Complete Program offered by the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists. 2. Complete a course in the keeping of medical records. 1. If any course specified in this condition is unavailable, then the practitioner is to complete an equivalent course as approved by the Medical Council of NSW ("the Council"). 1. Prescribing restriction 1. The practitioner shall not possess, supply, administer or prescribe any "drug of addition" (Sch 8 drug) as defined by the PATG Act. 2. The practitioner shall provide written evidence to the Council that he has attended the offices of the Pharmaceutical Services Branch 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 Sch 8 drug within 14 days of these orders. 3. The practitioner shall not reapply to the Pharmaceutical Services Branch for a new authority to possess, supply, administer or prescribe any "drug of addition" (Sch 8 drug) as defined by the PATG Act ("a new authority") at least until he has successfully completed the education courses required by condition ­­­(1). 1. Audits 1. To submit to an audit of his medical practice by a random selection of his medical records by a person or persons nominated by the Council to be held during the 12-month period from the date of these orders or as required thereafter by the Council. The auditor is to assess his compliance with good medical record keeping standards and legislative requirements. 2. To submit to an audit of his medical practice by a random selection of his medical records by a person or persons nominated by the Council to be held within 6 months from the grant of a new authority and subsequently as required by the Council. The auditor is to assess his compliance with appropriate prescribing of Sch 8 drugs and legislative requirements. 3. To authorise the auditor to provide the Council with a report on his/her findings. 1. Review 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. 1. Expenses 1. The practitioner is responsible for any costs arising out of compliance with these conditions. 1. The Tribunal orders that the costs of the HCCC of these proceedings be paid by the practitioner as agreed. ********** 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 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: 10 May 2018