Civil and Administrative Tribunal New South Wales Medium Neutral Citation: Health Care Complaints Commission v Karimi [2018] NSWCATOD 197 Hearing dates: 8, 9, 10 and 11 October 2018 and written submissions 22 October 2018, 5 November 2018 and 19 November 2018. Date of orders: 19 December 2018 Decision date: 19 December 2018 Jurisdiction: Occupational Division Before: Boland ADCJ, Deputy President Dr J Fogarty, Senior Member Dr J Aitken, Senior Member C Gardiner, General Member Decision: (1) Dr Kooshyar Karimi (the practitioner) is reprimanded. (2) The practitioner's registration is suspended for a period of six months from the date of these orders. (3) On the expiration of the practitioner's suspension his registration shall be subject of the conditions set out in the orders at the end of this decision. (4) If the practitioner's principal place of practice is New South Wales the Medical Council of NSW (The Council) is the appropriate review body for the purposes of Part 8, Division 8 of the Health Practitioner Regulation National Law (NSW) (the National Law). (5) If the practitioner's principal place of practice is anywhere in Australia other than New South Wales sections 125 to s127 of the National Law shall apply and a review of the conditions can be conducted by the Medical Board of Australia. (6) The practitioner is to pay the costs of the Health Care Complaints Commission of and incidental to these proceedings as agreed or failing agreement as assessed under the Legal Profession Uniform Law Application Act 2014 (NSW). Catchwords: PROFESSIONS AND TRADES – Registered health practitioner - where practitioner practised while unregistered – falsification of registration certificate and document - where medical practitioner concedes he is guilty of professional misconduct – where practitioner prescribed in names of staff members to obtain stock for medical practice. Legislation Cited: Civil and Administrative Tribunal Act 2013 (NSW) Evidence Act 1995 (NSW) Health Care Complaints Act 1993 (NSW) Health Practitioner Regulation National Law (NSW) Legal Profession Uniform Law Application Act 2014 (NSW). Poisons and Therapeutic Goods Act 1966 (NSW) Poisons and Therapeutic Goods Regulation 2008 (NSW). Cases Cited: Briginshaw v Briginshaw (1938) 60 CLR 336, [1938] HCA 34. Clyne v NSW Bar Association (1960) 104 CLR 186 [1960] HCA 40 Health Care Complaints Commission v Do [2014] NSWCA 307. Health Care Complaints Commission v Philipiah [2013] NSWCA 342. Health Care Complaints Commission v Quan [2018] NSWCATOD 111). Health Care Complaints Commission v Reid [2018] NSWCATOD 162. Karimi v Medical Council of New South Wales [2017] NSWCATOD 180 Texts Cited: Medical Board of Australia, Good Medical Practice – A Code of Conduct for Doctors in Australia (March 2014) Category: Principal judgment Parties: Health Care Complaints Commission (Applicant) Dr Kooshyar Karimi (Respondent) Representation: Counsel: P Aitken (Applicant) Dr Karimi (Self-represented) Solicitors: Health Care Complaints Commission (Applicant) Dr Karimi (Self-represented) File Number(s): 2018/0055151 Publication restriction: The order made on 25 July 2018 under cl 7 of Schedule 5D of the Health Practitioner Regulation National Law, prohibiting publication of the names of the patients set out in the Schedule to the complaint, was varied on 8 October 2018 to include the persons named in the schedule to the complaint and the names of all lay witnesses called by the Heath Care Complaints Commission in the proceedings. REASONS FOR DECISION Introduction 1. These reasons are in respect of the decision made in disciplinary proceedings brought by the Health Care Complaints Commission (the HCCC) against Dr Kooyshar Karimi (the practitioner). 2. The practitioner is a general practitioner. He obtained his medical qualifications in Iran, and after fleeing that country and migrating to Australia as a refugee, he first obtained his registration in Australia in 2003. The practitioner then practised in various locations in New South Wales. His last two places of practice were general practices in a western Sydney suburb and then on the upper north shore of Sydney. The complaints brought against the practitioner by the HCCC all relate to matters occurring in the practitioner's last two places of practice. 3. Following proceedings before the delegates of the Medical Council of NSW (the Council), held on 21 September, 2017, and brought under s 150 of the Health Practitioner Regulation National Law (the National Law), the practitioner was suspended. His appeal against that suspension was unsuccessful (see Karimi v Medical Council of New South Wales [2017] NSWCATOD 180). His registration remained suspended at the date of the hearing. 4. In broad terms, the claims against the practitioner in these proceedings fall into three categories. The first complaint is that the practitioner created or was complicit in creating false documents. The documents were a false registration certificate which the practitioner provided to a pharmaceutical company to obtain Botox for a patient and a letter purporting to have been written on Medicare letterhead. The letter asserted that the practitioner did not have the right to prescribe drugs of addiction (S 4D and S 8 prescribing rights). The second category of complaint relates to the practitioner's prescribing for twelve patients some of who it is asserted were drug dependant or on opioid treatment programs. The prescriptions were all written during a period when the practitioner was not registered. The third category of complaint relates to prescriptions, written by the practitioner in the name of staff members of the western suburbs practice, who were not his patients, to obtain stock for the practice. The practitioner was the medical director of the practice at the relevant time. Certain particulars of these three categories of complaint are relied on individually and cumulatively to ground a finding of professional misconduct. 5. The practitioner appeared on his own behalf in these proceedings without the benefit of legal assistance. In a Reply dated 10 August 2018 the practitioner admitted the vast majority of the particulars of each of the complaints set out in the complaint annexed to the HCCC's application lodged on 19 February 2018. He did not admit some of particulars of the prescribing complaints because he challenged the accuracy of the schedule annexed to the complaint. He denied that he had written prescriptions in the staff members' names without their knowledge or consent. He made further admissions orally at the hearing in respect of an Amended Complaint dated 8 October, 2018. We will refer in detail to those admissions later in these reasons. 6. Following a Case Conference, the parties prepared an Agreed Statement of Facts. A copy of that statement is annexed to these reasons as Appendix A. We have redacted from the statement the names of relevant patients and clinic staff members in conformity with the non-publication order made in these proceedings. 7. We agreed with the parties that these proceedings would not be conducted in two stages and that we would publish our factual findings on the complaints and set out our protective orders in the one decision. However, at the conclusion of the evidence we provided a time-table for the parties to file and serve written submissions addressing the topic of whether or not this Tribunal has power to "back-date" a suspension imposed by the Council. 8. On 22 October 2018, the HCCC provided written submissions limited to the issue of back-dating a suspension imposed by the Council. The practitioner served extensive written submissions on the HCCC on 5 November 2018 and annexed new material, not in evidence before the Tribunal, including expanded explanations relating to particulars of the complaint. No application was made by the practitioner to re-open the hearing and, unsurprisingly, the HCCC in its submissions in reply filed on 19 November 2019 objects to material in the practitioner's submissions which was not in evidence before us. 9. We are conscious that the practitioner has not had the benefit of legal advice or representation. The purpose of the directions made at the conclusion of the hearing for the provision of written submissions was to afford procedural fairness to the practitioner. We envisaged that this process would afford him sufficient time to respond to the detailed oral submissions made by counsel for the HCCC. We have disregarded the new material provided by the practitioner, but we have taken into account those parts of his submissions which relate to his oral or written evidence before the Tribunal or respond to the HCCC's submissions. In making this determination we note that the practitioner filed extensive submissions prior to the hearing as well as correspondence from his two treating psychologists and a number of character references. At the hearing, he was afforded the opportunity to, and did, give oral evidence on his own behalf, and made extensive oral submissions. 10. We also note that, with the exception of two courses completed after the hearing and evidence of attendance on his psychologist also after the hearing, the material which the practitioner raises in his submissions, and in the documents which he annexes, is material that was available at the time of the hearing. 11. During the course of the hearing the practitioner was granted a certificate under s 128 of the Evidence Act 1995 (NSW). 12. Having evaluated all the evidence before us, and taken into account the issues raised in the parties' submissions, we have determined that the practitioner should be reprimanded, and his registration should be suspended for a period of six months from the date of this decision. We have taken into consideration the time that the existing suspension has been in place, but have found that we do not have power to "back date" a suspension imposed by the Council. We have further determined that, on the expiry of his suspension, draft conditions as provided by the HCCC annexed to its submissions (but not proposed by it) should be placed on his registration. We consider it is necessary to impose a health condition on the practitioner's registration, that he attend ongoing psychological consultations with a psychologist of his choice, and that on resuming practice, the number of patients he sees on a daily basis be limited. 13. The HCCC sought that we make an order in its favour for the costs of the proceedings. We have determined that the practitioner is to pay the costs of these proceedings. However, the practitioner's oral evidence before us is that he is bankrupt. In these circumstances, we note that any proceedings for the enforcement of a costs order may, during the period the practitioner's estate is sequestrated, be limited to the HCCC proving in the practitioner's bankruptcy. Our reasons for our decision are as follows. Background 1. The following factual matters are extracted from the Statement of Agreed Facts or are otherwise uncontroversial. Unless noted to be an assertion, the matters are accepted by us as established to the Briginshaw standard (see Briginshaw v Briginshaw (1938) 60 CLR 336, [1938] HCA 34). 2. The practitioner, who was formerly known as Dr Sean Tari, graduated from the Mashad University of Medical Sciences, Iran, in 1994. 3. The practitioner was first registered in Australia on 25 August 2003. 4. In 2013 the practitioner was admitted as a fellow of the Royal Australian College of General Practitioners. 5. From about November 2015 to July 2016, the practitioner practised at a general practice in the western suburbs of Sydney known as Plus Medical Clinic. From about August 2016 to 16 January 2016, the practitioner practised at a general practice known as the Waitara Family Medical Practice (the Waitara practice). 6. In 2016, the practitioner failed to renew his registration by the due date and it lapsed on 30 September 2016. 7. On 14 November 2016, the practitioner lodged a "fast track application" for registration with the Australian Health Practitioner Regulation Agency (AHPRA). 8. On 13 January 2017, the HCCC received a complaint from Allergan Australia Pty Ltd (Allergan) about possible falsification of a certificate of registration provided to it by the practitioner. The certificate was provided by the practitioner to Allergan accompanied by an account application form. 9. The Pharmaceutical Regulatory Unit (PRU) of the NSW Health Department was notified of the Allergan complaint. On 16 January 2017, Ms K Dolan (Ms Dolan) of the PRU interviewed the practitioner about the complaint and some prescribing issues. 10. During his interview with Ms Dolan, the practitioner produced a letter on letterhead purporting to be from Medicare. The letter stated the practitioner was no longer permitted to prescribe S 4 or S 8 or other controlled drugs. 11. The practitioner did not dispute (until these proceedings) that the letter produced to Ms Dolan was on Medicare letterhead (the statement of agreed facts notes that Medicare letterhead is not visible on the copy produced). 12. Between November 2016 and up until 16 January 2017, the practitioner continued to practise at the Waitara practice. The practitioner asserts that he requested nursing staff members to contact AHPRA about his registration status. He asserts that the practice manager told him advice from AHPRA was that he could continue to practise pending the renewal of his registration. 13. During the period the practitioner was unregistered he prescribed Durogesic for Patients A, C, D, E, F, G, H, I, J, K, and L. He also prescribed Durogesic, Oxycontin and Endone for Patient B whilst unregistered. 14. On 27 February 2017 AHPRA refused the practitioner's application for registration. 15. On 28 February 2017 the HCCC wrote to the practitioner notifying him of an investigation into the Allergan complaint. 16. On 17 May 2017 the practitioner wrote to the HCCC and explained that a female patient had asked the practitioner to perform a Botox procedure for her prior to her daughter's wedding. Because no Botox was available at the clinic the practitioner applied to Allergan for an account. The practitioner asserts he had formerly held an account with the pharmaceutical company for many years in his former name, but Allergan required him to open a new account in the name of Karimi. In the same letter. the practitioner explained that: …to assist with my issue of not always being able to refuse patients that are seeking drugs of addiction, I have started to see an experienced psychologist, Mr Justin Cogley, and he is assisting me to work through these issues. 1. On 20 June 2017, the practitioner's application for registration was approved, subject to conditions, including a condition that he not prescribe S8 drugs. The PRU notified the practitioner of the withdrawal of his prescribing rights by letter dated 8 August 2017. 2. Following proceedings conducted by the delegates of the Council on 21 September 2018 under s 150 of the National Law the practitioner's registration was suspended. As noted above, the practitioner's appeal against his suspension was unsuccessful and he remained suspended at the date of the hearing. Matters in issue 1. We have identified the following issues as requiring determination in these proceedings: 1. Did the practitioner ask the receptionist at the Waitara practice to create a letter purporting to be from Medicare to show patients who sought S 4 and S 8 drugs? 2. Although the practitioner has made full admissions in relation to the prescribing complaints for the Patients A to L named in the schedule to the complaint, does he have the insight, and ability to refuse inappropriate requests from patients in the future? This issue requires consideration of: 1. the practitioner's experience and personality; 2. the practitioner's level of insight into his conduct; 3. the remorse, if any, displayed by the practitioner for the effect of his conduct on these patients and others; and 4. any remedial steps taken by the practitioner to address his compliance with patients' requests. 1. Did the practitioner write a prescription in the name of Person C without her permission or consent in order to obtain stock for other patients of the Plus Medical Clinic? 2. Does the practitioner's admission of professional misconduct, and our evaluation of that conduct, lead to a conclusion that the practitioner's registration should be cancelled, and a substantial period of time imposed before he can seek a re-instatement order? 3. Is the more appropriate protective order a reprimand, a period of suspension and the imposition of conditions on the expiration of the period of suspension? If suspension is appropriate, what period of suspension should be imposed? 4. Should a costs order be made in favour of the HCCC? Relevant law 1. These proceedings are brought under s 139B (1) (a) and (l) and s 139E of the National Law. 2. Section 139B (1) (a) and (l) provide as follows: 139B Meaning of "unsatisfactory professional conduct" of registered health practitioner generally [NSW] (1) Unsatisfactory professional conduct of a registered health practitioner includes each of the following— (a) Conduct significantly below reasonable standard Conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of the practitioner's profession is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience. … (l) Other improper or unethical conduct Any other improper or unethical conduct relating to the practice or purported practice of the practitioner's profession 1. Section 139E defines professional misconduct. It provides as follows: 139E Meaning of "professional misconduct" [NSW] For the purposes of this Law, professional misconduct of a registered health practitioner means— (a) unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration; or (b) more than one instance of unsatisfactory professional conduct that, when the instances are considered together, amount to conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration. 1. Disciplinary proceedings conducted in the Tribunal are guided and informed by the objects and principles of the National Law. In this case the relevant provisions are parts of s 3 and s 3A. It is relevant that we set out those provisions: 3 Objectives and guiding principles (1) The object of this Law is to establish a national registration and accreditation scheme for— (a) the regulation of health practitioners; and …. (2) The objectives of the national registration and accreditation scheme are— (a) to provide for the protection of the public by ensuring that only health practitioners who are suitably trained and qualified to practise in a competent and ethical manner are registered; and … 3A Objective and guiding principle [NSW] In the exercise of functions under a NSW provision, the protection of the health and safety of the public must be the paramount consideration. Note. This section is an additional New South Wales provision. 1. The HCCC bears the onus of proof of the complaint. Because of the nature of these proceedings and the serious consequences of disciplinary proceedings for the practitioner the standard of proof is one of reasonable satisfaction in accordance with the statements of the High Court in Briginshaw. 2. It is well established that the purpose of protective orders made at the conclusion of proceedings is to protect the public, not to punish the practitioner (see Clyne v NSW Bar Association (1960) 104 CLR 186; [1960] HCA 40. The conceded particulars of the complaints 1. It is useful we commence our discussion of the admitted complaints by reference to s 139B (1) (l). Other Improper or unethical conduct 1. It will be remembered that the HCCC relies on s 139B (1) (l) of the National Law as the basis for all the complaints in this matter except Complaint Fourteen and Complaint Sixteen (the professional misconduct complaint). Complaint Fourteen is stated to be under s 139B and recites the wording of s 139B (1) (a) and part the wording of s 139B (1) (l) omitting, however, the word "other", which precedes the words "improper and unethical" in the provision. That is, the text of the statute makes it plain that the conduct asserted under s 139B (1) (l) must be conduct that is different to the type of conduct set out in s 139B (1) (a) to (k). 2. We have earlier in these reasons set out s 139(1) (l). The meaning of the words "improper" and "unethical", having regard to their text, context and the purpose of the National Law is discussed in a number of decisions of this Tribunal including recently in Heath Care Complaints Commission v Reid [2018] NSWCATOD 162 at [523]-[525]. We adopt the reasoning in those paragraphs which are as follows: The words "improper" and "unethical" are not defined in the National Law. The words have been considered in a number of cases in the Tribunal (see HCCC v Little [2016] NSWCATOD 146; HCCC v Liu [2016] NSWCATOD 133; HCCC v Perera [2018] NSWCATOD 112.) Reliance has been placed on the dictionary definition of "improper". That is, not in accordance with propriety of behaviour, manners etc or abnormal or irregular behaviour." Unethical is discussed in Perera by reference to the dictionary definition as follows: "Unethical" is defined in the Macquarie Dictionary as follows: contrary to moral precept; immoral. in contravention of some code of professional conduct. 1. The drafting of Complaint Fourteen asserts reliance firstly on s 139B(1) (a) and/or s 139B (1) (l). We accept, therefore, that reliance may be properly based first on conduct of the practitioner that demonstrates that: 1. the practitioner's knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of medicine was below the standard reasonably expected of a practitioner of an equivalent level of training or experience, and/or 2. the practitioner engaged in other improper or unethical conduct relating to or purporting to relate to the practice of medicine. 1. The admitted particulars of Complaint One are, first, that between October 2016 and January 2017 the practitioner continued to practice in circumstances where he was not registered. Secondly, the practitioner admits that he altered an older certificate of registration, which then purported to show that he was registered until October 2017. Thirdly, the practitioner admits that around 4 January 2017 he provided a copy of the altered certificate to a pharmaceutical company in support of an application for an account with that company in order to obtain the wholesale supply of Schedule 2, 3 4 and 4D drugs. 2. While conceding these particulars in both his Reply, and his submissions, both oral and in writing, the practitioner explained that he was in financial difficulties at the time of his registration renewal and did not have the funds to pay for his registration. He explained that, after he submitted a fast track re-registration application, he asked a staff member to contact the AHPRA, to check if he could practise pending receipt of his registration. He asserts that the practice manager told him he could practise. He says he also took into account that Medicare continued to process payments for his consultations and that pharmacists filled prescriptions he wrote. 3. The practitioner now concedes that it was his responsibility to have contacted AHPRA and he should not have delegated this task to a staff member. Complaint One, particulars 1, 2 and 3– discussion and conclusions 1. The practitioner concedes that he practised while unregistered between 1 October 2016 and 16 January 2017. We accept that this concession is properly made. 2. We also accept that the practitioner's acknowledgement that it was his responsibility to check his registration status is appropriate. 3. In his submissions and Reply the practitioner refers to "external stressors" being responsible for his failure to renew his registration. Before us, the practitioner explained: Q. So you disagree with Ms XXX's evidence where she said this morning that you said to her words to the effect, "I forgot to pay"? A. No, I have always said this, and it's the truth, and the first trial that I had, they went through my bank statements and they realised I didn't have money. If I may explain, I was involved in the last four years in the renewable energy project, and I've got electronic backgrounds from Iran, and in renewable energy project, I met Mr Honourable Victor Dominello, the Minister of Science and Innovation, in regard to very serious project, it consumed my life, obsessively I was in this, and working day and night, and actually affected my judgment and my practice heavily, at last 12 months of my practice, and I spent every money in that, so I've got a pile of my dockets and invoices and everything, and I was contracted with a big company called Kennards, you've probably heard of them, it's a large corporate that invested on it, and when I got suspended, it's been just hanging there, waiting for me to, when I feel emotionally stable, I continue. I simply spent every money in that project, and I didn't have money in my credit card. Q. Do you accept that you said to Ms XXX words to the effect, "I forgot to pay for my registration"? A. No-- Q. "I forgot to lodge my registration, I forgot to pay". A. No, I didn't have money. It was not that I forgot. And then I, yeah, I received a reminder email from AHPRA. By the time I had money, it had lapsed. Q. So, my question is, do you remember saying something to Ms XXX about the need to put the registration documents in, and saying to her something along the lines of, you'd forgotten to pay for it? A. No, I never said I forgot to pay for it. Three years ago, what I exactly said, I might have felt embarrassed to say in front of my staff that I didn't have money to renew, and have said something else, but the truth is that I really simply didn't have money enough to do it. When you do registration, it takes ten minutes on line to do it. The only reason was, I managed my funds very poorly, that was my fault really. 1. We note, however, that the differently constituted tribunal hearing the practitioner's appeal recorded at [222]-[224] In Dr Karimi's solicitors' letter of 21 August 2017 to the HCCC, the solicitors wrote (at par 1): "Renewal of Dr Karimi's registration with AHPRA was required by 30 September 2016. He did not renew his application by this date due to financial difficulties. On realising that in early November 2016, Dr Karimi urgently made a fast track application to AHPRA. A staff member at the medical practice he was employed at rang AHPRA to confirm receipt of his urgent application and to confirm that he could continue to practise while his registration was being processed with AHPRA. The staff member advised that this was the case." On the material before the Tribunal, this solicitors' letter was the first occasion it was suggested that Dr Karimi's failure to renew was the result of financial difficulties. On a review of Dr Karimi's banking records which were before the Tribunal, it is far from obvious that he could not afford the $638 renewal fee in the period July to October 2016, when he was in receipt of significant income from his practice and his registration could have been renewed without any late fee or requirement to lodge a fresh application for registration. In his first affidavit of 6 November 2017, Dr Karimi did not refer specifically to "financial difficulties" but rather "turmoil in [his] life" at the time when he failed to renew. He continued (at par 15): "I reiterate that fact that a staff member had already called up and spoken with AHPRA on my behalf with regard to my fast tract application. My staff member then advised me that AHPRA confirmed to them that I was able to practice while my registration was pending. …" 1. Unlike at the appeal hearing, we did not have the benefit of the practitioner's bank statements or other financial evidence before us. The apparent discrepancies in the practitioner's evidence cause us some concern about the veracity of his explanation about the lapse in his registration. We discuss this further when considering the professional misconduct complaint and appropriate protective orders. 2. The practitioner also conceded that he fraudulently altered his registration certificate during the period he was not registered. The practitioner says that he did this in order to obtain Botox for a patient to be administered prior to the patient's daughter's wedding. The practitioner's evidence about the request for Botox is corroborated by a statement from the patient. 3. At the hearing, the practitioner also acknowledged that his earlier written explanation to AHPRA that the patient requiring Botox had been "pushy", was false. 4. We note however, that the concession by the practitioner about his falsification of the registration certificate, and correction of his assertions about the patient seeking Botox injections, were only made at the hearing. 5. Again, we were troubled by the practitioner's change of position from what was asserted at the s 150 hearing, at the appeal and in his submissions. Before the delegates the practitioner asserted that the Administrative Manager had "changed the date on it [the registration certificate] and sent it back [to Allergan]". [transcript 21.9.2017 p 26 – Exhibit "A" tab 39 p 42]. The practitioner maintained his position in his evidence at the appeal against the delegates' decision confirming that staff at the Waitara practice had falsified documents on two occasions [transcript 20.11.2017 p 82 Supplementary Bundle Tab 1]. 6. We accept the practitioner's evidence that he had maintained an account with Allergan under his former name for many years. However, that fact does not explain or exonerate the practitioner's conduct in providing a false certificate to the company in support of an account application. It was a deliberately deceitful action. Even more troubling was the practitioner's position, maintained essentially up to this hearing, of seeking to attribute blame to the receptionist and the relevant patient. We are independently satisfied the practitioner's conduct in this respect was improper and unethical. Did the practitioner ask the receptionist at the western suburbs practice to create a letter purporting to be from Medicare to show patients who sought S 4 and S 8 drugs? 1. At the hearing there was a factual dispute about the circumstances relating to the creation of the purported Medicare letter. 2. In his Reply, the practitioner states: In regard to the Medicare letter, while I did not create the letter, or I did not ask for it to be created and I never used it, I should have reprimanded the employee responsible, educated that employee on why this was unacceptable and destroyed the document. [practitioner's original emphasis] 1. In his submissions dated 26 June 2018, the practitioner said about the Medicare letter "this letter was neither prepared or ordered by me". 2. The former Administrative Manager/Receptionist (receptionist) of the Waitara practice gave evidence before us. She had previously provided a statement dated 21 August 2018 to the HCCC. At [16] of her statement she says: I recall in around June or July 2017, Dr Karimi said to me words to the effect of, "I have real difficulty saying no to people who have issues with addiction. They cry and throw themselves on the floor, and just refuse to leave, it's horrible. I wish only specialists could prescribe this medication. Could you write a letter from Medicare saying that I cannot prescribe Schedule 8 drugs. I have had this letter in the past at a previous surgery, and it really helped. If I have the letter, I can show it to patients when they ask to get them to go away". This happened at the front desk in front of the Practice Manager and Practice Nurse. 1. Before us, the receptionist frankly acknowledged that she had created the relevant letter and given it to the practitioner. At [19] of her statement the receptionist said: Now I realise that I probably should not have created that letter. I felt innocent at the time as it was never going to be used in an official capacity. It was very difficult to say no as there was also a lot of pressure from Dr Karimi and other staff members for me to help him at the time. The ladies working in the practice with me had told me on several occasions that they were really scared of these people coming in, and Dr Karimi seemed genuine in his desperation not to prescribe. He had assured me this would help as it had worked in the past. 1. In answering a question posed by the practitioner the receptionist denied that the letter had been created as a result of a suggestion made by her. 2. In answers given in cross-examination the practitioner appeared, to concede, for the first time, that there had been a conversation, the day prior to the creation of the letter, something along the lines reported by the receptionist who had then typed the letter. He referred to saying he "wished" he had a letter saying he could not prescribe drugs of addiction. However, he later said he was "100 per cent sure" he had never asked the receptionist to create the letter. 3. We accept and prefer the evidence of the receptionist to that of the practitioner on this topic. The receptionist took full responsibility for the content of the letter, which she created unaided by the practitioner. She explained that she used "Google" to source relevant information to include in the letter. She also explained that she accepted that the practitioner was genuinely distressed by the cohort of patients who sought drugs of addiction from him and wished to discourage these patients. 4. We accept that the practitioner voluntarily produced the false letter to Ms Dolan, and that he also had signs placed in the waiting area advising that the practice did not prescribe drugs of addiction. We are satisfied that the receptionist interpreted the practitioner's conversation with her to be a request to produce a letter to be shown to patients and that the letter would not otherwise have been created. We are satisfied that particular 4 of Complaint One is established. Complaints Two, Three, Four, Five, Six, Seven, Eight, Nine, Ten, Eleven, Twelve, Thirteen and Fourteen. 1. Each of the above complaints relates to the practitioner's prescribing for patients identified in the schedule as Patients A to L. The first particular in support of these complaints is one that the practitioner prescribed for the relevant patient whilst unregistered. Other particulars relate to particular patients being either on NSW Opioid Treatment Programs or patients the practitioner should have identified as drug seeking. As we have already noted the practitioner concedes the majority particulars of each of these complaints. He disputed the accuracy of entries in the schedule that disclosed the issue of two prescriptions on the same day on the basis this was a software error. 2. The practitioner's evidence is that a number of the patients were from Iran, and they sought out the practitioner who speaks four languages including Farsi. He explained at least one patient had become addicted to Opium as a young person in Iran. He also explained that some of the patients did not understand that, by using a Fentanyl patch, rather than taking a drug orally, they were using a drug of addiction. 3. The practitioner explained that he did not have a problem with drug-seeking patients whilst he engaged in practice at Tea Gardens but that he encountered the drug-seeking patients when he commenced practice at Plus Medical Clinic. Some of those patients sought him out at the Waitara practice. 4. In his Reply, the practitioner concedes that he prescribed for the patients whilst unregistered, but says he relied on the practice manager's advice that he could continue to work. We pause to note that the receptionist's evidence corroborates, in part, the practitioner's evidence on this point. She explained that she was aware that a nurse at the Waitara practice had spoken to AHPRA about the practitioner's registration. That nurse told her that the advice received was that the practitioner could continue to practise, notwithstanding that his name did not appear on the AHPRA register [transcript 9 October 2018 p 11]. We refer to and repeat our earlier findings that it was the practitioner's responsibility to ensure that he did not practise whilst unregistered. 5. The practitioner further acknowledges in his Reply that he did not make enquiries to establish if Patients B, F, H, I, J and L were on the NSW Opioid Dependence Treatment Program and he prescribed without the relevant authority. He acknowledges that he should not have prescribed for Patient C, a drug dependent patient. He makes similar admissions about Patient D, E, F, G, H, I, J, K, and Patient L. The practitioner acknowledges that his actions in prescribing were wrong. He refers to courses he has attended and steps he has taken to deal with drug-seeking patients. 6. Before us, the practitioner made it clear that he did not seek to have his S 8 or S 4D prescribing rights re-instated when (and if) his suspension is lifted. 7. In his oral evidence in answers to questions posed to him in cross- examination, the practitioner gave some background to the circumstances which led to his prescribing and the particular patients' conditions. 8. It is important, in the light of the practitioner's concessions, that we do not "gloss over" or ignore the practitioner's prescribing for the patients the subjects of the complaints. Between 1 October 2016 and 13 January 2017 the practitioner provided 41 prescriptions for Patient B including Oxycodone, Paracetamol/Codeine, Endone, Fentanyl, and Temazepam. Twenty-seven of the scripts were written as private prescriptions. Patient C received 6 scripts for Fentanyl between 1 October 2016 and 5 January 2016. All were private prescriptions. Patient D was prescribed Fentanyl on 12 occasions between 8 October 2016 and 13 January 2017. All were private prescriptions. Patient E was prescribed Fentanyl on 8 occasions between 8 October 2016 and 16 January 2017. All were private prescriptions. 9. We found it difficult to accept the practitioner's statement that he was comfortable writing private prescriptions for patients because there was no impost on the Australian taxpayer. The practitioner did, however, in his oral evidence acknowledge that he knew in 2017 patients sought such prescriptions in their belief that this would avoid detection of their drug addiction. It is evident that the practitioner wrote private and Pharmaceutical Benefits Scheme (PBS) prescriptions for Patient B, a seriously addicted patient on the same day. The practitioner, in his oral evidence, said that he had not written prescriptions for 40 and 60 Endone tablets on the same day, but rather after printing a prescription, he had reconsidered and written a prescription for the smaller number of tablets. 10. We commence our discussion of the issues relevant to the practitioner's prescribing, which we identified earlier in these reasons, by noting the following. First, the HCCC did not adduce any expert evidence to support the claim that, in each instance, Complaints Two to Thirteen inclusive were improper and/or unethical. No reliance was placed on s 139B (1) (a) that the prescribing was conduct which demonstrated that the practitioner's knowledge, skill or judgment exercised by the practitioner in the practice of medicine was significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience. We discern that the latter provision was not relied on because the prescriptions were written while the practitioner was unregistered. Thus, this was not conduct by a practitioner in the practice of medicine. We also take into account, when considering the accumulation of established particulars in respect of our conclusions on professional misconduct, that no expert evidence was adduced to support the particular that the practitioner knew or ought to have known the patients were drug dependent. 11. We are satisfied that it was clearly improper for the practitioner to see these patients, and to write prescriptions for them, when he was not legally entitled to do so. In this regard we adopt as cogent the questions put to the practitioner by Dr Alison Reid at the s 150 hearing about the potential adverse consequences for patients of a doctor purporting to practice while unregistered, including voiding of professional indemnity insurance cover (see transcript 21 September 2017 p 24 Ex "A" p 40). 12. We note that if the practitioner had been registered, which was not the case, his prescribing would have demonstrated a serious lack of clinical judgment. As an unregistered practitioner, he was not bound by the Good medical practice: a code of conduct for doctors in Australia. That Code explicitly states in its opening paragraph that the Code "describes what is expected of all doctors registered to practice medicine in Australia". Accordingly, while we are satisfied that the practitioner's conduct was improper, we are not satisfied that the HCCC has established to the Briginshaw standard that the practitioner's prescribing conduct was unethical. Although the practitioner has made full admissions in relation to the prescribing complaints for the Patients A to L named in the schedule to the complaint, does he have the insight, and ability to refuse inappropriate requests from patients in the future? This issue requires consideration of: (a) the practitioner's experience and personality; and (b) the practitioner's level of insight into his conduct; 1. The practitioner explained that he had difficulty in refusing patient requests. His difficulty was not limited to drug-seeking patients, but included his patient who wanted Botox injections prior to her daughter's wedding, and his inability to control the number of patients he saw daily at Tea Gardens. The latter trait led to him incurring a $60,000 debit to Medicare. 2. During the course of the HCCC's investigation, the practitioner referred himself to Mr J Cogley, a psychologist practising in the same premises as the Waitara practice, to address this issue. He later consulted Mr Seyed Hosseinipour, a registered psychologist. Mr Cogley and Mr Hosseinipour both gave evidence by telephone and were cross-examined by counsel for the HCCC. 3. The practitioner relied on a report of Mr Cogley dated 20 September 2017. Mr Cogley explains in his report that he commenced seeing the practitioner in March 2017. In his oral evidence Mr Cogley reported that the practitioner had seen him on four occasions in 2017, the last being a consultation on 20 September 2017. Mr Cogley noted that the practitioner had consulted him for assistance in relation to refusing patient requests, including requests for drugs of addiction. Mr Cogley reported that the practitioner had gained "significant insight and understanding regarding the origins of this difficulty in a short period of treatment" and went on to note that the practitioner had reported "great change in his professional and personal life". 4. In his oral evidence, Mr Cogley confirmed that he had not treated the practitioner in recent times. Although the practitioner sought to place considerable weight on Mr Cogley's report we found it of limited use. The report is some fourteen months' old and the practitioner's consultations with Mr Cogley were limited. We do accept that the practitioner sought professional assistance in dealing with demanding patients and his action in so doing shows a level of insight into his short-comings. 5. Mr Hosseinipour was an impressive witness. In his oral evidence he explained that he had worked with the Department of Corrective Services for 22 years, holding the position of regional senior psychologist. He provided a report, dated 6 July 2018, and gave oral evidence by telephone. Mr Hosseinipour set out a brief history of the practitioner's employment in Australia, and summarised the practitioner's present dire financial circumstances which preclude the practitioner from travelling to Tasmania to see his infant children and difficulties in obtaining any form of employment, except as a labourer. Mr Hosseinipour readily conceded that he had not conducted any psychometric testing of the practitioner, rather he had used a semi structured assessment interview approach in his consultations. 6. Mr Hosseinipour opined that the practitioner does not have a cognitive impairment, but said that the practitioner had a long-standing untreated post-traumatic stress disorder (PTSD) from his experiences in Iran. He opined that the practitioner had no intention to cause harm to his patients, but that in prescribing for drug dependent patients, there was no doubt what the practitioner did was not correct. However, he explained, taking the practitioner's situation into account it seemed that he was affected by the crisis in his marriage and that the practitioner misjudged the situation. 7. Mr Hosseinipour opined that the practitioner definitely needed to undergo courses about professional ethics, and spend at least one year undergoing intensive cognitive behavioural therapy to address his PTSD. 8. Mr Hosseinipour explained that, like the practitioner, he also spoke Farsi and had a number of Farsi speaking patients who had been treated by the practitioner. He said these patients described the practitioner as a very caring, very good and very kind doctor in the community. Mr Hosseinipour opined that the practitioner's reputation was that he was regarded in the Iranian community as one of the good Iranian doctors practising in that community. 9. In response to a question posed by Dr Aitken, Mr Hosseinipour explained that the consequences suffered by the practitioner as a result of his wrong doing were a big indicator that he would not likely repeat similar conduct. It is useful that we set out the questions posed by Dr Aitken and Mr Hosseinipour's response. Q. My next question was about his acceptance about his wrongdoing. You stated that he had indicated to you that there was no harm to patients through his actions and also it has over the last year or two been apparent that he has tried to shift the blame to other people as well. Do you consider this, what do you think of that in terms of the level of insight into the effects that his behaviour has had? A. In this case Dr Aitken, when I interviewed Dr Karimi he never, he never blamed any other person, I mean just I have no experience, I don't recall that he is saying to me, of course when we constantly blame the others for our wrong things, and the risk of reoffending would be higher and the likelihood of rehabilitation would be long but that was not the case unless you know, suggest in my experience in during the interviews with Dr Karimi, he never did it. Q. And also you referenced in your report that he had demonstrated genuine remorse and was deeply regretful of what had happened. Do you believe this is no actual, his reflection on his behaviour or do you think it is more based on the actual consequences of being caught and being punished as a result of it? A. Of course both of them, of course. I mean we really can't dismiss and not looking into the consequence of his problems and we have to take this into the account as well of course and I suggest that there, the consequences of our wrongdoings I suggest is always a big indicator of not repeating them. That's why you know so the whole judgment system (not transcribable) people and stopped them from wrongdoing. No I really can't dismiss that, that part of the matter but the other part that he is genuinely remorse and truly don't even think to repeat all his wrongdoings, that's another part that I have no doubt that he is absolutely genuine. 1. We note that the practitioner is an experienced, vocationally trained practitioner. At Tea Gardens he was responsible for the training of other doctors. In these circumstances his ignorance of prescribing requirements for opioid dependent patients appears to us inexcusable. This is particularly so having regard to concessions he made before the delegates at the s 150 proceeding and recorded in the reasons of the delegates. The practitioner there conceded as follows: he knew he was prescribing in some instances in excess of the therapeutic guidelines; that some of his patients were "diverting drugs onto the streets", but said he had stopped prescribing when he became aware of this conduct; and had acceded to requests to write private scripts (see Ex A Tab 39 p 7; transcript 21 September 2017 p 45 Ex A Tab 39C p 45). 2. We are satisfied that the practitioner now has a level of insight into his conduct, and this has been a continuing process since the commencement of these proceedings. Although he expresses full responsibility for his actions, he maintains elements of self-justification for his prescribing and other actions. We find that the completion of the Public Health ethics course being undertaken by the practitioner at the University of Sydney at the time of the hearing is likely to consolidate and enhance his developing insight. (c) the remorse, if any, displayed by the practitioner for the effect of his conduct on these patients; 1. The practitioner, in both his documents and orally, explained that his actions were inappropriate. He has demonstrated some insight in that he acknowledges that he should have insisted that his drug seeking patients were referred to appropriate drug and alcohol services. We acknowledge that although referrals may be made to such services, waiting times and acceptance of patients into relevant services, are problematic. He also explained that he was remiss in not knowing the appropriate regulations for prescribing for patients on the NSW Opioid Treatment Program or checking the Doctor Shopper Hotline. 2. The practitioner explained that, at least in one instance, where two prescriptions for a patient appear in the Schedule, particularly prescriptions for antibiotics, this was not because he gave the patient two prescriptions at the same consultation, but rather that a printing error occurred with the Medical Director software and of the one prescriptions was destroyed by him. The provenance of the entries set out in the Schedules to the complaints is unknown. It appears that the Schedule to the complaint may have been compiled by the HCCC using the patient's medical records, rather than Medicare or other like records, as the majority of items do not have dispensing dates, and many are private scripts. This is not a criticism of the HCCC, but explains why we give some weight to the practitioner's explanation, at least in respect of Patient F, that Medical Director records, where there are two identical prescriptions shown in the schedule on the one day, may not accurately reflect the prescriptions the patient received. But these instances form an exception to the norm for the prescriptions recorded in the schedules. 3. As we address later, the practitioner relied on a number of character referees some of whom were required for cross-examination. His medical colleague referees opined that, whist practising at Tea Gardens, the practitioner was a well-regarded general practitioner. However, in expressing remorse before us in his oral evidence, the practitioner focussed almost exclusively on the consequences, both emotional and financial to him, of his wrongful actions. Although he ultimately acknowledged a number of his wrongful actions, he did not focus on remorse for his challenge to the truthfulness of the receptionist at the Waitara practice, his attack on the character of the patient who wanted Botox treatment, or any harm caused to his drug seeking patients. 4. We find that the practitioner's suspension, which has now endured for more than a year, has wrought devastating emotional and financial hardship on him. We accept that the practitioner's marriage broke down and that his second wife and their young children now reside in Tasmania making regular physical contact impossible in circumstances where the practitioner has no or little income. We also accept that the practitioner has struggled to find any employment, and that his family home, which was substantially encumbered, has been sold, as has his car. The practitioner is, or has had to, make arrangements to surrender his independent control of a renewable energy project and to enter into an arrangement with the University of Wollongong to continue development of this technology which he formerly passionately pursued to the detriment of his private and professional life. 5. In these circumstances, we are not as critical as we might otherwise be the case of the practitioner's lack of expressed remorse for all his conduct. His evidence before us demonstrated that he has been so weighed down by the effect of his suspension, including the consequent loss of his family, home and status that these matters have overshadowed or diverted his ability to reflect and appreciate true remorse for his actions on his patients, the professional staff at Plus One Clinic and the Waitara practice. 6. We accept and rely on Mr Hosseinipour's opinion about the practitioner's remorse and his view that it is unlikely that the practitioner would engage in wrong doing in the future. (d) remedial steps taken by the practitioner to address his compliance with patients' requests. 1. As we have earlier noted, it is the practitioner's position that, at the conclusion of these proceedings, we should make an order continuing the suspension his registration period of two years but backdated to September 2017, and on expiration of that period, conditions including the surrender of his S 8 and S 4D prescribing rights, should be imposed on his registration. 2. We accept that the imposition of such a condition will, if made, have the practical effect, while in operation, of precluding the practitioner from prescribing drugs of addiction. However, we are more concerned with the practitioner's underlying behavioural traits. 3. We accept that the practitioner has recently undertaken a number of courses including "Think GP 'New Treatment Pathways for Prescription Opioid Dependence", a one hour online course on 21 June 2018, RACGP Alcohol and drug issues in the LGBT community completed on 3 July 2018, "Think GP 'Codeine rescheduling and chronic pain management'" a one hour on line course completed on 21 July 2018, and "Think GP 'Helping our patients get health'" a one hour on line course completed on 26 June 2018. Although there was no corroborating evidence before us, the practitioner explained that he was enrolled in the Public Health Ethics Course at the University of Sydney costing $1,100 and that the course fees had been paid on his behalf by a friend. The practitioner states he has passed the first two exams in this course which is due to complete in November 2018. 4. We were somewhat at a loss at the practitioner's apparent reluctance to accept Mr Hosseinipour's diagnosis of significantly untreated PTSD and the impact of that diagnosis on his acquiescence to patient requests. We are conscious that AHPRA recorded, in its letter to the practitioner dated 4 January 2017, as follows: In considering your application, the Board noted your criminal history, including charges of assault and two charges of driving with low range PCA, and your further advice regarding the circumstances surrounding these issues. It is also noted your previous history with the NSW Medical Board and your advice regarding previous health issues, including PTSD and depression. 1. Mr Cogley also alluded to underlying issues from the practitioner's upbringing and experiences in Iran causing him to be susceptible to patients' requests. The practitioner submitted that a correct diagnosis is one of reactive depression to his present circumstances. We accept that the practitioner does not suffer a cognitive impairment that would, of itself, render him unfit to practice. 2. We further note the practitioner's evidence, before the differently constituted Tribunal on the appeal against his suspension, that he explained whilst practising at Tea Gardens, notwithstanding that he asked staff not to double book him, at times he saw in excess of 50 patients a day and up to 80 patients on 22 days. This resulted in him having to repay Medicare approximately $60,000 [transcript 20.11.2017 p 79 Supplementary bundle Tab 1 p 79]. Again, this indicates to us that, at least at that time, the practitioner, who was the Medical Director of the practice, did not take a firm stand with the practice staff and ensure that he was not grossly overbooked. 3. We were left with some residual concerns about the practitioner's ability to exercise independent judgment and to refuse inappropriate patient or other practice requests. Consequently, as we later discuss, we are satisfied that the practitioner requires ongoing psychological assistance from either Mr Hosseinipour, or another appropriately qualified clinical psychologist or a psychiatrist, to continue to address his inability to refuse inappropriate requests. If and when he is permitted to engage in practice, we are satisfied that strict conditions governing his practice of medicine are necessary. Complaint Fourteen 1. As we earlier noted, this complaint, which is centred on the practitioner's practice of writing prescriptions in the name of staff members to obtain stock for the emergency room at Plus Medical Clinic, and subsequently used for other patients, was denied by the practitioner 2. It is the practitioner's evidence that whilst he practised at Tea Gardens, if stock was required for the practice, he wrote an order which was filled by the local pharmacy. 3. The practitioner asserts that, on commencing practice at the Plus Medical Clinic as medical director, there were no systems and little stock in place. The practitioner says that the initial practice manager, an inexperienced employee who had formerly managed a dental practice, told him that the pharmacy with which the practice maintained an account required a prescription in a patient's name to provide stock. The practitioner says he acted on this advice, and that staff knew and acquiesced in the practice. It is not disputed that all relevant prescriptions had endorsed on them by the practitioner the words "for Plus Medical Clinic [or Clinique]". 4. It is the practitioner's evidence that he personally paid for stock and medications obtained, or some of them, were given to impecunious migrant patients who did not have access to Medicare benefits. This evidence is corroborated in part by Clinic Staff Member A. 5. A registered nurse, who was a staff member of the clinic, provided a statement. Unlike other staff, her name is not included in the schedule to the complaint. However, in conformity with our order prohibiting publication of the other staff members' names, we will refer to this staff member as Person E. Person E's statement was dated 9 June 2016. She explained at [13] of her statement: Whilst I was very concerned about prescriptions being in the employees' names, I assumed because the prescriptions had written on them; "for Plus Medical Clinic" and this had been the accepted and authorised way to obtain medication for the treatment room in the past that it was ok to proceed. I initially showed these to [first name], the Practice Manager as I was concerned about this prescribing practice. [First name] would always authorise the order. [First name] said words to the effect; "You are the clinical nurse and you should know. [First name] also said words to the effect; "Dr Karimi printed the script, so he would be aware of it, and be liable for his actions, he's a Doctor, he should know". 1. Person E explained how this practice of obtaining stock did not continue when a new practice manager, who was responsible for seeking accreditation for the practice, commenced employment at the clinic 2. The second practice manager, to whom we will refer as Person F, provided a statement and gave oral evidence before us. He described practices at other medical practices at which he had been employed and related how doctor's bag prescriptions were filled at those practices. 3. Person F gave evidence that after he had seen prescriptions written in staff members' names, he had accessed those staff members' records with their consent and discovered that the prescriptions were in the specific prescription tab of the Medical Director software, but that "there were no notes generated by the doctor to indicate that [sic] why these had been generated" [transcript 8 October 2018 p 23]. 4. Clinic Staff Member A also provided a statement, dated 13 May 2016. Clinic Staff Member A was an inexperienced registered nurse, who commenced employment in the practice when she was first registered in January 2015. She relates that a large number of the practitioner's patients spoke no or limited English and communicated with the practitioner in Farsi. She says in her statement, in about April 2015, that she discovered that the practitioner was writing prescriptions in her name and the names of other clinic staff members without their knowledge or consent. She says that when the medications were received at the clinic they were placed in the treatment room. At [9] she records: The medication was used regularly by Dr Kamiri and free of charge when he was treating some patients 1. Clinic Staff Member A records at [10]-[11] of her statement: I was very concerned about my name (and the other staff members names) being used on prescriptions by Dr Karimi in this manner as I knew this was inappropriate and illegal. I queried it with Dr Karimi and he said words to the following effect: 'it's ok [the first practice manager] is aware of this and he said it is not a problem; he has authorised this practice of obtaining medication in this manner. I ensure I have this medication for my patients who are in severe or chronic pain and do not have the money to buy their own medication. A lot of these patients are refugees who have limited financial means". I also queried Dr Karimi's conduct of prescribing in this manner with [the first practice manager] at the time. From my conversation with [the first practice manager] I understood that he was not concerned with Dr Karimi's conduct. He also said words to the following effect: "it's fine I know about this prescribing by Dr Karimi, I have authorised it". Following this conversation I felt that I did not have the support of [the first practice manager] despite my serious concerns. I also felt that I had to continue to do as directed by Dr Karimi as he made me feel intimidated". 1. In her oral evidence Clinic Staff Member A made it clear that she did not have actual knowledge that other staff members knew the practitioner was prescribing using those staff members' names and had not consented to that practice. 2. In answer to questions posed to her by the practitioner, Clinic Staff Member A explained that she thought the practitioner was a good doctor, but the practice he adopted was wrong and she felt intimidated. She said that other staff members whose names were used may not have known that the practitioner had written prescriptions in their names. She also explained that the other doctors at the practice wrote PBS prescriptions. 3. Also in evidence before us were notices under s 34A of the Health Care Complaints Act 1993 (NSW) directed to the first practice manager and the pharmacist who filled prescriptions from the Plus Medical Clinic. The first practice manager denied that he had authorised the practitioner to issue prescriptions in employees' names. The pharmacist responded to a request to provide an explanation as to why medications had been dispensed "in the knowledge that the medication was not for the person whose name appeared on the prescription". Notwithstanding the leading form of the question posed, which assumes the pharmacist knew the person on the prescription was not to receive the medication, the pharmacist said: In my experience, doctors often prescribe and carry medication for use in their surgery. However, a prescription cannot be dispensed if there are no patient details recorded and the prescription is just in the name of the medical centre/surgery. 1. Having noted that she became aware "later on" that the prescriptions were written in the names of Plus Medical Clinic employees, she said "In effect, the prescriptions were treated as 'Doctor's Bag' prescriptions" 2. In response to the question "What was your knowledge and understanding of the reason for this type of prescribing by Dr Karimi?" she responded: From a clinical perspective, the medications prescribed were not typically drugs commonly abused. Also, there were various types of medications prescribed rather than one specific type. I do not know the reason for the type of prescribing by Dr Karimi. I would have refused to dispense a prescription if it had been presented to us written "for surgery use" without any patient details as I am aware that is not sufficient. In hindsight, I should have made further inquiries into the nature of the prescribing, in particular by contacting him to confirm he medications were for the Doctor's Bag or something similar, and if so another more appropriate way to write the prescriptions. 1. The pharmacist responded to a question about any conversations with the first practice manager "about the type of prescribing", denying such a conversation. The pharmacist did not provide a statement and did not give evidence before us. 2. We accept and prefer the evidence of Clinic Staff Member A, to that of the first practice manager. We also find that the pharmacist was at least confused, or ignorant about requirements for stock for emergency use. Her answers to the HCCC support, at least in part, the procedure the practitioner adopted to obtain stock. 3. We had the benefit of expert evidence from Dr Stephen Howle on this complaint. Dr Howle was retained by the HCCC and provided a report dated 21 September 2016. Dr Howle opined that the practitioner's practice of accessing the clinic staff records to write prescriptions was unusual, unethical and significantly below the standard of a medical practitioner of similar training and experience as the practitioner. 4. Dr Howle explained that the practitioner's humanitarian motive may have been true, and that he had been misled by the first practice manager, but that did not excuse the conduct. He noted, very fairly, in mitigation of the practitioner's conduct, the fact that the practitioner made no attempt to hide that the medications were for use in the practice, not for his personal use, and he appeared to receive no personal reward. We agree with these observations by Dr Howle. 5. In his oral evidence Dr Howle explained that, because there was no record in the Clinic Staff Members' patient notes, another doctor accessing the notes (we interpolate the prescription tab) could interrogate the patient as to why they had been given a particular prescription for an unknown reason and "with nothing in the notes to say why, then in practical terms, the patient shouldn't be damaged in any way by it" (transcript 8 October 2018 p 49). We accept Dr Howle's opinion on this point. 6. Dr Howle drew attention to the fact that it was the inappropriate accessing of the Clinic Staff's records that lay at the heart of this complaint. We accept his opinion of the inappropriate practice adopted by the practitioner. First, he did not consider the power imbalance between himself and a very inexperienced nurse when she sought to challenge his practice. We accept that Clinic Staff Member A was intimidated by the practitioner. Secondly, the practitioner's actions resulted in the staff whose records were utilised, including Clinic Staff Member A, having false and inaccurate medical records, albeit limited to the prescription tab of the practice software. The prescription was written without a clinical consultation with the patient. Thirdly, the practitioner had, for a number of years while practising at Tea Gardens, obtained supplies using an order for emergency supplies in reliance on Regulation 46 of the Poisons and Therapeutic Goods Regulation 2008 (NSW). He well knew this procedure, but did not take the time or trouble to challenge the first practice manager's inaccurate advice, or to speak to the pharmacist and institute the correct procedure for obtaining emergency supplies. 7. Dr Howle sought to clarify with the PRU the legalities and practice of obtaining supplies for stock in a practice, in addition to those drugs available to a medical practitioner for a "doctor's bag". The resulting information supplied to him was not definitive, and he frankly admitted in his oral evidence that he remained confused. Dr Howle was asked by Dr Aitken about each of the drugs prescribed by the practitioner using staff members' names and then kept in the treatment room. He explained that the vast majority of the antibiotics were ones which would not normally be kept for emergencies, although one or two were (Amoxyl, Augmentin and Keflex), as well as Prednisolone. Dr Howle opined that the drugs, including antibiotics, were ones that it would be reasonable to keep for emergency use. He also explained that Tramadol is kept by a lot of practices as an emergency pain killer. 8. In answer to a question posed to him by the practitioner, Dr Howle agreed that it was not unreasonable for the majority of the medications the practitioner had prescribed to be kept for emergency use. We note that, in response to questions posed to him by the HCCC, the practitioner explained that the only unaccounted medication (morphine sulphate) had been left in the safe when he ceased practising. That evidence accords with that of Clinic Staff Member A who referred to accompanying the second practice manager to destroy and dispose of drugs in the treatment room when the practitioner left the practice. 9. The relevant regulation is Regulation 46. It is in the following terms: 46 Supply by pharmacists to health practitioners for emergency use A pharmacist may supply an authorised practitioner with a restricted substance (including a prescribed restricted substance) for emergency use, but only on a written order signed and dated by the authorised practitioner. 1. There appears to be a dispute on the interpretation of this regulation by the authorities responsible for the administration of the Poisons and Therapeutic Goods Act 1966 (NSW) and the Regulations made under that Act. It appeared from the pharmacist's answers to the HCCC that she was unaware of reg 46. Pursuant to reg 46 it is strongly arguable, given the text of the regulation, that a doctor may properly order certain quantities of drugs as stock to be retained in a practice for use in the anticipated event an emergency may occur (ie "for emergency use"). However, it appears to be suggested by the PRU that, if the drugs are not ordered for a specific identified emergency, a pharmacist may not fulfil the order unless the relevant practitioner is authorised by the regulations to be supplied with wholesale quantities of the substance or a prescription is written in the name of the patient who suffers the emergency. This requirement is said to arise because of the definition of "wholesale supply" in the Poisons and Therapeutic Goods Act 1966 (NSW). 2. While not directly relevant to the issues we have to determine in this matter we note that the issue of prescribing for the purpose of having stock, albeit not in case of an anticipated emergency, has been raised recently in the Tribunal (see Health Care Complaints Commission v Quan [2018] NSWCATOD 111). 3. We consider the issue of stock for emergency use to be a serious and relevant one for all general practitioners and pharmacists and we take this opportunity to draw the matter to the attention of the Council and the Pharmacy Council who may consider it prudent to provide advice to registered medical practitioners and pharmacists on this topic. 4. Before leaving the topic of Complaint Fourteen, we note the practitioner conceded particular 6 relating to the storage of S 8 medications in that he agreed that the safe, which he arranged to be installed in the Plus Medical Centre when he commenced practising at that clinic, was not affixed to the wall. We accept the practitioner's evidence that the practice was a relatively new practice, and that he took steps to set up the emergency room, institute the keeping of drug registers and to acquire a safe. These were all responsible and appropriate actions. Professional misconduct 1. The practitioner has admitted that his conduct constitutes professional misconduct. The particulars of Complaint Sixteen, as set out in the amended Complaint, are as follows: COMPLAINT SIXTEEN is guilty of professional misconduct under section 139E of the National Law in that the practitioner has: i. engaged in unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration, or ii. 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 SIXTEEN As for Complaint One and Complaint Fourteen fifteen. PARTICULARS OF COMPLAINT SIXTEEN 1. The following particulars are relied upon individually: (a) Complaint 1 particulars 1, 2, 3 and 4; (b) Complaint 2 particular 1(a) and (b); (c) Complaint 3 particular 1(a) and (b); (d) Complaint 4 particular 1(a); (e) Complaint 5 particular 1; (f) Complaint 6 particular 1(a) and (b); (g) Complaint 7 particular 1(a) and (b); (h) Complaint 8 particular 1(a); (i) Complaint 9 particular 1 (a) and (b); (j) Complaint 10 particular 1(a) and (b); (k) Complaint 11 particular 1(a) and (b); (I) Complaint 12 particular 1(a); (m) Complaint 13 particular 1(a) and (b); (n) Complaint 14 particular 1, 2, 3, 4, 5, 6(a) and 6(b)j (o) Complaint 15 particular 1, 2, 3, A, 5 and 6. 2. Complaints 1 to 14S and the particulars thereof are relied cumulatively or in any combination. 1. We are satisfied that the practitioner's admission of professional misconduct is properly made. We find that his falsification of his registration certificate, his request to the receptionist to provide a letter to be shown to patients, his prescribing whilst unregistered, and inappropriate and unauthorised prescribing in staff members' names without such members' informed consent, cumulatively amounts to conduct of such a serious nature as to justify the suspension or cancellation of the practitioner's registration. In reaching this finding, we rely on and repeat our detailed findings in respect of the particulars of the complaint set out above. 2. Mr Aitken submitted to us that this panel, in reliance on its own expert knowledge and without the benefit of any evidence adduced by the HCCC on the topic, could find that the particular pleaded in respect of the practitioner being aware that the patients were drug-seeking patients was established. He submitted that we could then take that particular into account in reaching a finding of professional misconduct. 3. We do not propose to take that course in circumstances where it was open to the HCCC to adduce such expert evidence, but more particularly because the practitioner is self-represented. We note that the Amended Complaint setting out the particulars relied on to establish professional misconduct was produced on the first day of the hearing, and the practitioner conceded he was guilty of professional misconduct relying on the matters set out in the original complaint. We think it would be procedurally unfair to the practitioner to accumulate this particular with other particulars in the circumstances we have outlined in reaching our finding of professional misconduct. Appropriate protective orders 1. As noted at the commencement of our reasons, the HCCC urged that we make orders cancelling the practitioner's registration and that he be precluded from applying for a re-instatement order for a period of not less than two years. Mr Aitken submitted that, if we determine a suspension is the outcome, it would not be an appropriate protective order unless the suspension was for not more than six months. We accept that a longer period would not be appropriate having regard to the time the practitioner would have been out of practice and our ability to craft conditions that would be relevant, say, twelve or eighteen months hence. If we determined that if an extended period of suspension was required, then cancellation would be the more appropriate order as it would require a re-instatement application by the practitioner when his position could be independently re-assessed by a differently constituted tribunal. 2. The practitioner's position is that we should "back date" the suspension imposed by the Council in September 2017. 3. In his helpful submissions on this topic, Mr Aitken points out that an order made under s 150 "only has effect until either the complaint about the practitioner is disposed of or the suspension is ended by the Council" (see s 150 (2) of the National Law). At para 4 Mr Aitken notes that disposal of the complaint will occur on the publication of our decision. He submits, and we concur, that: There is no facility provided in s 150 to "pick up" and continue an existing suspension; in fact it explicitly provides to the contrary by specifying that the suspension no longer has effect once the complaint is 'disposed of" 1. The submissions go on to canvass the situation where proceedings are conducted in two stages, and findings made and published after Stage One. Given the manner in which these proceedings are being conducted it is unnecessary we make a finding on whether a complaint is then "disposed of". 2. We consider that Mr Aitken's thoughtful analysis of the purpose of a suspension imposed by a Council, and the different purpose of a suspension imposed by a Tribunal under s 149C is relevant to this matter. A suspension under s 150 is imposed, often on an urgent basis, to protect the health and safety of the public. A suspension imposed under s 149C, a protective order, serves a number of purposes. Such an order is made to protect the public, to uphold the standards of the profession and to act as a deterrent to similar conduct (see Health Care Complaints Commission v Do [2014] NSWCA 307). 3. Mr Aitken notes at para 9 of his submissions: 9. The fact that the practitioner had already been subject to a period of suspension may potentially be a relevant consideration when considering protective orders, but it does not entitle the Tribunal to engage in any form of actual backdating, in the applicant's respectful submission, nor does it oblige or require the Tribunal to forgo the imposition of a further period of suspension if that is what the misconduct establishes is required, having regard to all the relevant principles underpinning the making of protective orders. 1. We agree with that submission. We do however take into account, as a matter of fact, that the practitioner has been suspended from practice since September 2017 and further that he only practised for a very limited period from when the Medical Board imposed conditions on his registration until his suspension by the delegates of the Council. 2. The practitioner relies, in addition to the evidence of Mr Hosseinipour and Mr Cogley, and on a number of character referees. Dr Sokiah Krishnan provided an email headed "to whom it may concern", dated 14 May 2017. Dr Krishnan explained that he had known the practitioner for five years when he worked with the practitioner at Tea Gardens. He stated that the practitioner "was a great doctor and the community of Tea Gardens respected and adored him". Dr Krishnan gave evidence by telephone and was cross-examined. Dr Krishnan did not know details of the complaints against the practitioner, but had given his reference on the basis that it was relevant to an over servicing complaint by Medicare. It was clear to us that he had no real appreciation of the complaints against the practitioner. We were able to afford little or no weight to his testimonial in these circumstances. 3. The practitioner also supplied two character references from Rabbi Levi Wolff dated 29 June 2018 and Rabbi Mendel Kastel dated 25 June 2018. Neither Rabbi was required for cross-examination. Rabbi Kastel referred to the charges against the practitioner. He recorded that "He [the practitioner] understands that he has done wrong and assures me he would not repeat his actions now he understands the severity of them". 4. The practice manager of the Waitara practice, Dr Chand Raja, a medical scientist, also provided a testimonial dated 3 August 2017. Dr Raja was not available for cross-examination and we indicated to the practitioner we could give no weight to her testimonial in those circumstances. We did admit into evidence a reference from Dr Hamish Meldrum. His reference emphasised the practitioner's financial contributions to the Tea Gardens practice. The attributes of financial viability of the practice emphasised to us the pressures to which the practitioner had been exposed to see many patients and his difficulties to control this aspect of his practice. We were unable to give any significant weight to this reference. 5. Two patients, being the patient who sought Botox treatment and her husband, provided testimonials for the practitioner. They were not cross-examined. We gave some weight to their testimonials. Each reported receiving excellent care from the practitioner. 6. Ms Kelly Ashton, the second in charge manager of the practice at Tea Gardens also provided a reference for the practitioner and gave oral evidence before us. Ms Ashton said: I have found Dr Karimi to be a thorough, compassionate, detail-oriented GP. He is highly regarded by staff, patients and the community. I have witnessed Dr Karimi go above and beyond to provide the best outcomes for his patients, often providing after hours care and home visits to do so. During four years of work at Tea Garden Medical Centre, Dr Karimi was highly regarded by everyone as a very knowledgeable clinician and a wonderful, kind hearted practitioner who helped everyone. Dr Karimi has displayed professionalism and initiative whilst dealing with every patient's medical needs. He has shown excellent communication skills whilst coordinating a multidisciplinary approach to patient care, displaying a friendly and very caring attitude, even when he is under time pressures. I am sure that he is a dedicated and highly experienced asset to the medical profession. 1. We accept Ms Ashton is a witness of truth. We find she had first-hand knowledge of the practitioner's practice over an extended period of time at Tea Gardens. We accept her evidence in its entirety. 2. The practitioner also relied on a testimonial, dated 7 October 2018, from Dr Benjamin Bahmani, a chemist with a Ph.D, a long-time friend and sometime patient of the practitioner. He reported attending the Plus Medical Clinic in early 2015 and observing three police officers trying to remove a man from the waiting room. He explained that, when he asked the practitioner about the incident, the practitioner had explained his distress about patients who had approached him demanding or begging for addictive medications, and that he had called the police to remove such a patient from his practice. He further reported the practitioner said that "he was not staying at that particular centre, mainly due to the large number of these troubling patients". 3. We find Dr Bahmani's evidence corroborates the practitioner's evidence about his distress at the cohort of drug-seeking patients he encountered at the Plus Medical Clinic and his reason for leaving that practice. We also accept his evidence about the practitioner's treatment of him and his satisfaction with the practitioner's care of him. 4. The weighing of the differing protective orders that may be made in this case is a finely balanced one. We accept that the practitioner has now made appropriate concessions about his wrongful conduct. On the one hand, we have concerns about the practitioner's conduct, up to the date of the hearing seeking to implicate staff at the Waitara practice in the fraudulent production of the registration certificate and instructions, or at a minimum, a direct or implied request, to create the Medicare letter. We also found apparent discrepancies in the practitioner's evidence about his ability to pay for his registration as and when it fell due. The practitioner clearly prioritised his own financial imperatives, including his renewable energy project and his older daughter's allowance, in lieu of responsibly ensuring he had sufficient funds to pay his registration. He inappropriately delegated enquiries about his registration status to staff. 5. Of significant concern to us was the practitioner's apparent lack of remorse for his actions in seeking to incriminate his staff for his actions, any real remorse for accessing clinic staff medical records to prescribe, notwithstanding his motive to obtain emergency stock for the practice, coupled with our concern about his present ability to refuse inappropriate requests from patients. Further, we were significantly concerned that the practitioner was untruthful in his evidence before the delegates at the s 150 hearing. His explanation is that he feared he would be suspended. 6. Truthfulness and candour are fundamental character traits and qualities to be expected of members of the medical and legal professions in the practice of their profession. Display of those traits and qualities is particularly important when a practitioner is dealing with the professions' respective councils. The role of the delegates of councils, both medical and legal, is to ensure the safety of the public and the integrity of the profession. That role can be properly carried out when persons, the subject of investigation, are, subject to the protections afforded by law, honest and candid in the statements they make to their relevant council. 7. On the other hand, we accept that the practitioner, a highly intelligent man, is well regarded by those who have worked with him or shared patients with him including Ms Ashton and Mr Hosseinipour. He is also well regarded in the community as evidenced by his Rabbis' testimonials and Dr Bahmani's evidence. He practised in regional NSW for an extensive period without complaint in respect of his clinical skills. He has many talents to offer patients, particularly those with limited or no English, who can communicate with him in Farsi or the other languages in which he is fluent. He acknowledges that, given the seriousness of his conduct, any order we make must have an element of deterrence to other practitioners, uphold the standard of the profession and protect the public. He accepts that a period of suspension is warranted, albeit he asks that his existing suspension be taken into account. The practitioner's stance on the orders he seeks we make demonstrates considerable insight into the nature and purpose of protective orders and is to his credit. 8. We also take into account that, when practising while unregistered, the practitioner did rely on the advice of the nurse who contacted AHPRA, that in writing prescriptions in staff names, on all occasions he wrote on the prescriptions that they were for the clinic, and the drugs obtained were ones essentially suitable to be held by the practice for an emergency. We also accept that he was genuinely distressed by the cohort of drug-seeking patients who sought him out at Plus Medical Clinic and some of whom followed him to the Waitara practice. 9. As earlier noted, we accept Mr Hosseinipour's opinion that the practitioner is unlikely to engage in future wrong-doing. 10. Evaluating and weighing all the evidence, we conclude that the essential elements of a protective order will be satisfied if the practitioner is reprimanded, suspended for a period of six months, and if the conditions attached to the HCCC's submission in reply, including the critical compliance conditions, are made. We note that the proposed condition that the practitioner should surrender his prescribing rights in respect of S 8 drugs may be redundant given the PRU notification to the practitioner dated 4 August 2017 (Ex A Tab 39) that those rights have been removed. 11. We also conclude that the practitioner should continue to receive psychological support for at least a year to address his reactive depression and/or PTSD, and that when he resumes practice he should be limited to seeing no more than 40 patients per day. This latter provision will alleviate any concern that he may become overworked, as he was in the past. Costs 1. Costs may be awarded in proceedings under the National Law (see cl 13 of Schedule 5D). The principles relevant to the award of costs are discussed in a number of decisions including Health Care Complaints Commission v Do and Health Care Complaints Commission v Philipiah [2013] NSWCA 342. 2. In Health Care Complaints Commission v Do Meagher JA explained: In Health Care Complaints Commission v Philipiah [2013] NSWCA 342 the Court accepted that "[a]s a general rule, costs of proceedings before the Tribunal should follow the event": at [42]. Noting that the mere impecuniosity of the losing party was not a justifiable reason for departing from that "rule", the Court also accepted "that there are factors that might militate against the recovery by the Commission of all of its costs in particular proceedings" including the possibility that the Commission was only partly successful, referring to Lucire v Health Care Complaints Commission (No 2) [2011] NSWCA 182 at [48]- [52]. 1. Although the practitioner conceded the majority of the complaints asserted against him, the proceedings had at their core the practitioner's conduct. We find no matters that would cause departure from the usual "rule" in this instance. We are satisfied that it is appropriate to make the costs order sought by the HCCC. ORDERS 1. Dr Kooshyar Karimi (the practitioner) is reprimanded. 2. The practitioner's registration is suspended for a period of six months from the date of these orders. 3. On the expiration of the practitioner's suspension his registration shall be subject of the following conditions: 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 to palliative care patients under the management of a palliative care specialist. 2. To provide written evidence to the Council that he has attended the offices of the Pharmaceutical Regulatory Unit and consented to an Order being made under the Poisons and Therapeutic Goods Regulation 2008 (NSW) to prohibit him from possessing, supplying, administering or prescribing any Schedule 8 drug within 14 days of the expiry of his suspension]. 3. Not to possess, supply, administer or prescribe any substance listed in Schedule 4 Appendix D of the Poisons and Therapeutic Goods Regulation 2008 (NSW), 4. To provide written evidence to the Council that he has attended the offices of the Pharmaceutical Regulatory Unit and consented to an Order being made under the Poisons and Therapeutic Goods Act 1966 to prohibit him from possessing, supplying, administering or prescribing any Schedule 4 Appendix D drug within 14 days of the date of expiry of his suspension. 5. Conditions 3 (a), and (c) are each critical compliance conditions within the meaning of s l49A(4) and (5) of the National Law, such that a contravention of either of these conditions will result in the practitioner's registration being cancelled. 6. To obtain Council approval prior to changing the nature or place of his practice. 7. To practice only in a group practice approved by the Council where there are at least 2 registered medical practitioners (excluding the subject practitioner): 1. Where the patients and patient records are shared between medical practitioners. 2. Where there is always one other registered medical practitioner on site. 3. Which is an accredited practice. 4. Not to see more than 40 patients on any day. 1. Not to undertake a locum position of less than 4 weeks. 2. To authorise and consent to any exchange of information between the Council and Medicare Australia for the purpose of monitoring compliance with these conditions. 3. To provide the Council within 14 days of obtaining employment, 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 3. any other senior officer at any other place of his employment. 1. In the event that the practitioner changes his place of practice, he is to provide the Council within 14 days of such change of employment, evidence that a copy of the conditions and the decision which imposed this condition 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 3. any other senior officer at any other place of employment. 1. To complete within 12 months of the expiry of his suspension the Mastering Difficult Interactions with Patients course organised by The Cognitive Institute, the Prescription Drug Misuse Module organised by the Royal Australasian College of Physicians (RACP) Australasian Chapter of Addiction Medicine or equivalent courses approved by the Medical Council of NSW and a medical ethics course approved by the Medical Council of NSW. 1. Within 3 months of the expiration of his suspension he must provide evidence to the Council of his enrolment in the abovementioned courses. 2. Within 1 month of completing each of the abovementioned courses, he is to provide documentary evidence to the Council that he has satisfactorily completed the courses. 3. To bear the responsibility for any costs incurred in meeting this condition. 4. In the event that any of the abovementioned courses are unavailable, he must propose to the Council for approval similar course(s) to be undertaken in accordance with the requirements of this condition. 1. To provide the Council within 3 months of the expiration of his suspension with the following: 1. A summary prepared by him of the relevant legislation and guidelines on the keeping of good medical records. This summary must describe the information to be included in a patient record. 2. An overview of the steps he has taken to ensure that he is creating and keeping good medical records. 3. A copy of the records of 3 patients who have attended for consultation with him since 19 December 2018. 4. Any audit of his medical records subsequently conducted in accordance with any condition of his registration will include a review of those medical records to determine if they accord with the standard required. 1. To submit to an audit of his medical practice, by a person or persons nominated by the Council and: 1. The audit is to be held within 6 months of the practitioner gaining employment and subsequently as required by the Council. 2. The auditor(s) is to examine and assess the following aspects of his practice including: treatment planning, medical history, assessment, prescribing in relation to quantity of medication prescribed and appropriateness, administering and recording of drugs of addiction and drugs of dependence. 3. To authorise the auditor(s) to provide the Council with a report on their findings. 4. To meet all costs associated with the audit(s) and any subsequent reports. 1. To practice under Category C 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. The terms of the Council's Compliance Policy -Supervision are varied as follows: 1. Within 14 days of the expiry of his suspension the practitioner is to nominate a proposed supervisor for approval by the Council. 2. The practitioner is to meet with the approved supervisor each fortnight for the first three months and thereafter on a monthly basis for at least two hours. At each supervision meeting the practitioner is to review and discuss his practice with a particular focus on: case studies, patient history taking, difficult patients, treatment plans, clinical decision making, clinical diagnosis, record-keeping, patient/doctor communication and prescribing. 3. The supervisor is to forward a report to the Council every three months. The report is to address whether the practitioner's records comply with good medical record keeping standards, legislative requirements and compliance with conditions. 4. To be responsible for any costs associated with the supervision process. 5. To authorise the Council to provide proposed and approved supervisors with a copy of the decision which imposed this condition 1. To attend for at least 12 months after the expiration of the suspension on a duly qualified psychologist or psychiatrist approved by the Council at a frequency determined by the psychologist or psychiatrist. 1. If the practitioner's principal place of practice is New South Wales the Medical Council of NSW (The Council) is the appropriate review body for the purposes of Part 8, Division 8 of the Health Practitioner Regulation National Law (NSW) (the National Law). 2. If the practitioner's principal place of practice is anywhere in Australia other than New South Wales sections 125 to s127 of the National Law shall apply and a review of the conditions can be conducted by the Medical Board of Australia. 3. The practitioner is to pay the costs of the Health Care Complaints Commission of and incidental to these proceedings as agreed or failing agreement as assessed under the Legal Profession Uniform Law Application Act 2014 (NSW). Appendix A (1.16 MB, pdf) ********** 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 20 December 2018 - Par 48 - name redacted 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: 20 December 2018