Civil and Administrative Tribunal New South Wales Medium Neutral Citation: Health Care Complaints Commission v Ibrahim [2019] NSWCATOD 131 Hearing dates: 11, 12, 13 June 2019 Date of orders: 23 August 2019 Decision date: 23 August 2019 Jurisdiction: Occupational Division Before: Hon Wayne Haylen QC, ADCJ Principal Member Dr J Fogarty, Professional Member Dr K Smartt, Professional Member S Lovrovich, Community Member Decision: (1) The medical registration of the Respondent, Dr George Ibrahim, is suspended for a period of 6 months commencing on the date of publication of this decision. (2) Upon re-registration as a medical practitioner, the Respondent, Dr George Ibrahim, shall be subject to the conditions specified in Annexure A to this decision. (3) Dr Ibrahim is to pay the costs of the Applicant in these proceedings, as agreed or as assessed. Catchwords: Medical practitioner – performance of cosmetic procedure – patient develops hypotension and not able to be aroused – ambulance called and patient hospitalised – serious lack of competence, judgment and maintenance of standards demanded of a general practitioner - findings of unsatisfactory professional conduct and professional misconduct – practitioner suspended from practice for a period of six months – extensive conditions imposed on return to practice Legislation Cited: Poisons and Therapeutic Goods Regulation 2008, reg 73 Health Practitioners Regulation (NSW), Regulation 2010 (repealed) Cases Cited: Chen v HCCC [2017] NSWCA186 Category: Principal judgment Parties: Health Care Complaints Commission (Applicant) Dr George Ibrahim (Respondent) Representation: Counsel: I Latham (Applicant) P Aitken (Respondent) Solicitors: Health Care Complaints Commission (Applicant) HWL Ebsworth Lawyers (Respondent) File Number(s): 2019/00010980 Publication restriction: Prohibition on publication of the name of Patient "A" as referred to in the Application and in this decision REASONS FOR DECISION 1. The Respondent to these proceedings, Dr George Ibrahim, has been a General Practitioner since 1991. In that year he commenced practice at Hassall Grove, a suburb of Sydney approximately 46km from the CBD and located in the Local Government area of the City of Blacktown. He was the principal and owner of the practice until it was sold in mid 2017. 2. The Hassall Grove Practice consisted of three consulting rooms and a treatment room. In 2016 there were two other doctors working at the practice; one doctor was full-time, and the other worked part time. At this time Dr Ibrahim was working about 50 hours per week over five days and was seeing about 40 patients per day. The practice did not open on week-ends. The practice was not accredited. 3. In June 2009 Dr Ibrahim received training in Bangkok through the American Academy of Aesthetic Medicine in the procedure entitled "Minimally Invasive Lipolysis Course". Lipolysis is a cosmetic procedure involving the removal of body fat by hydrolysis. He attended further courses in Australia and Kuala Lumpur between 2010 and 2013. From around 2013 Dr Ibrahim began performing lipolysis in his Hassall Grove rooms. From about 2010 he undertook training and performed some injectable fillers and botox in his rooms. He regarded cosmetic work as forming a very small component of his practice but between 2013 and 2016 he had performed between 50 and 60 lipolysis procedures in his rooms. Most of these procedures involved the stomach and hips but infrequently involved a patient's upper arms. 4. In late April 2016 a female patient attended the Hassall Grove practice and requested Dr Ibrahim to perform abdominal lipolysis. He took a history and conducted a clinical examination of the patient, including taking blood pressure, heart rate and listening to her chest. He did not observe the patient to have an irregular heart beat and she denied any history of cardiac conditions. He explained to the patient the nature of the lipolysis procedure and alternatives, potential risks and likely results. The patient was given a detailed consent form to take home and complete. He also took blood for pathology testing and gave her a script for prophylactic antibiotics. 5. In late May 2016 the female patient returned to the practice to undergo the abdominal lipolysis previously discussed. The detail of what occurred during the procedure will be considered later in this decision but for present purposes it is sufficient to state that Dr Ibrahim encountered a number of difficulties that led to the procedure being stopped because the patient had fallen into a deep sleep from which she could not be roused. Dr Ibrahim usually would administer pethidine and valium prior to the procedure but pethidine was not available on the day. He instead used morphine as a substitute although he had never used morphine before and was not sure of the appropriate dosage. During the procedure he noticed that the patient was snoring and that she appeared cyanosed with her lips appearing blueish in colour. He concluded that she had a reaction to the morphine and so administered Naloxone. When he concluded that more Naloxone was required he found that none was available. Dr Ibrahim continued to observe the patient but after a significant period noticed that the patient's blood pressure had dropped and that her heart beat was irregular. He then arranged for an ambulance to attend the practice and on arrival the patient was unresponsive and her lips were blue. The patient was subsequently hospitalised in the Emergency Department of the Mt Druitt Hospital for a number of days and was treated for inappropriate opioid and benzodiazepine administration and rapid atrial fibrillation. 6. In November 2016, the Medical Council dealt with a complaint from the Head of the Emergency Department at Mt Druitt hospital concerning Dr Ibrahim's treatment of his female patient as described above. Acting under the provisions of s150 of the Health Practitioner Regulation National Law (NSW), the Medical Council found numerous shortcomings in Dr Ibrahim's treatment of his female patient, commenting that he was practising in this area without adequate knowledge. The Council was also concerned that is was not clear whether Dr Ibrahim had necessarily identified and understood his deficiencies in this area. 7. The Medical Council made a number of recommendations as to how he might improve the standard of his general practice, including action regarding the adequacy of his medical records, the storage of opioids, the lack of preparedness for emergencies and the need for continuing professional development. Conditions were placed on his registration prohibiting Dr Ibrahim from performing any cosmetic procedures and a direction not to perform any surgical procedures other than non-cosmetic minor procedures in his consultation rooms which required nothing more than local anaesthetic infiltration. An audit of his medical practice was also ordered. The Medical Council subsequently referred the matter to the Health Care Complaints Commission (the HCCC) for further investigation as a complaint. 8. In 2019 the HCCC filed a complaint in this Tribunal alleging that Dr Ibrahim was guilty of two counts of unsatisfactory professional conduct and thirdly alleging that he was guilty of professional misconduct. In early June, after considering matters raised by Dr Ibrahim, the HCCC filed an amended complaint that slightly reduced the scope of the allegations. 9. At the commencement of the proceedings in the Tribunal the HCCC tendered a further amended complaint that further reduced the scope of the allegations. In summary the complaints were as follows: 1. alleged unsatisfactory professional conduct between 21 April and 27 May 2016 due to: the failure of the Respondent to keep drugs of addiction secured but kept in an unlocked drawer in the Medical Practice, contrary to Reg 73 of the Poisons and Therapeutic Goods Regulation 2008; on 27 May the practitioner administering a higher dose of Morphine than recommended in therapeutic guidelines for an opiate naïve patient of his patient's weight; on the same date he administered Valium 20mg to his patient where the dosage was higher than recommended in therapeutic guidelines for an opiate naïve patient of his patients weight; the practitioner relied only on observations to monitor his patient's vital signs during the procedure, where he administered Lignocaine being an agent he should reasonably have known causes cardiac arrhythmias, administered opiates he should have reasonably known can cause respiratory depression, he did not have a defibrillator on the premises to use if the procedure caused arrhythmia, and had access to a pulse oximeter and failed to use it to identify his patient's decreasing oxygen saturation; at approximately 1430 hours he failed to immediately call an ambulance when his patient went into a deep sleep and became cyanosed in circumstances where, he did not have access to oxygen, airway equipment or a defibrillator, had access but did not use the pulse oximeter, he did not have access to an adequate supply of Naloxone, he did not have an ECG to confirm the cause of his patient's cyanosis, he should have been aware that his patient was at risk of developing a hypoxic brain injury, and should have been aware that delay in calling for an ambulance could have resulted in his patient dying from respiratory arrest; he administered lignocaine in circumstances where he had no knowledge of what constituted a toxic Lignocaine dosage and had no knowledge of the signs associated with Lignocaine toxicity; he carried out the laser lipolysis procedure without access to resuscitation equipment, without monitoring his patient's blood pressure or pulse throughout the procedure and without appropriate safety equipment or safety protocols for such a procedure; and, he carried out the procedure when he had only one dose of Naloxone 400mcg available, he should have known that the half-life of Naloxone is less than Morphine and therefore more than one dose of Naloxone may have been required to be administered to the patient, and should have reasonably anticipated that one dose of Naloxone may not have been sufficient to revive the patient if required. 2. alleged unsatisfactory professional conduct in that he contravened the Health Practitioner Regulation (New South Wales) Regulation 2010 (repealed) in that: on 21 April 2016 he contravened the Regulation in failing to document in the patient's clinical record, any pre-treatment baseline blood pressure, heart rate or assessment of respiratory and cardiovascular system. On 27 May 2016 he contravened the regulation in failing to document the following in the patient's clinical record, namely : any pre-treatment baseline blood pressure, heart rate, or assessment of the procedure; the dosage of Lignocaine infused prior to commencing the procedure; the patient's deterioration around 1630 hours; the fact that an ambulance was called; the fact that the patient was transferred to hospital by ambulance; and the failure to record the patient's blood pressure and pulse readings during the procedure. 3. alleged that the respondent was guilty of professional misconduct, relying on the particulars set out in complaints one and two both individually and cumulatively. 1. The HCCC supported the complaints as originally filed in the Tribual with an expert's report from Dr Adam Rish. Dr Rish held the position of Vice-President and Fellow of the Cosmetic Physicians College of Australia and had been involved in laser and cosmetic medicinesince 1985. He was a speaker and publisher internationally on cosmetic and laser medicine and had delivered over 40 papers at conferences in Australia and overseas in the past 12 years. 2. Dr Rish's report examined nearly 30 issues arising from Dr Ibrahim's care of his patient, including some issues that were finally not pressed in the Tribunal. In the great majority of issues considered, Dr Rish found the Respondent's conduct significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience and as inviting his strong criticism. He found the administration of Valium 20mg to be excessively high. He was strongly critical of the circumstances in which Morphine was substituted for Pethidine , noting that the last minute visit to the Pharmacy next door betrayed a lack of planning in the practitioners clinical practice. There was no excuse for administering a drug without being certain of the dose. This action deserved strong criticism. The dosage of Lignocaine was not able to be established from clinical notes and Dr Ibrahim had betrayed ignorance of the AAAM training manual dealing with appropriate doses. There was no excuse for not recording the Lignocaine dosage and this aspect invited strong criticism. Dr Rish observed that for anyone to carry out Liposuction without a very exact knowledge of the main drug they were using for the procedure was significantly below the standard reasonably expected of a practitioner of Dr Ibrahin's training or experience and invited strong criticism. 1. Although Dr Ibrahim had attended training courses regarding this procedure Dr Rish was of the opinion that he was definitely deficient in his set up, safety equipment and safety protocols. If he was to continue in this area of practice he needed further training and mentoring to guarantee patient safety. Dr Ibrahim had clearly underestimated the risks associated with this type of cosmetic practice and it was fortunate that his patients had not suffered more serious outcomes. 2. There was also criticism of Dr Ibrahim's failure to record any pre-treatment baseline blood pressure or heart rate or assessment of the respiratory and cardiovascular system. If undertaken, his patient's no doubt (or probable) pre-existing atrial fibrillation would have been picked up andthen she could have had an ECG allowing the procedure to be delayed and an assessment to be conducted by a cardiologist. Dr Rish regarded it to be unforgiveable to rely on observation only to monitor a patient's vital signs during a long procedure such as liposuction using Lignocaine, an agent known to cause cardiac arrhythmias and opiates known to cause respiratory depression. It was "bizarre" that Dr Ibrahim had a pulse oximeter yet did not use it. 3. Dr Rish was also highly critical of the lack of oxygen, airway equipment, and a defibrillator at the practice. Without this equipment the ambulance should have been called when the patient appeared cyanosed. He strongly criticized the two hour period before this action was taken by Dr. Ibrahim. Strong criticism was also directed at the failure to take clinical notes during the procedure and the fact that his clinical notes generally were regarded as "grossly inadequate". 4. 15. Dr Rish was not required for cross-examination and his report was accepted by Dr Ibrahim, with some minor explanations. The Tribunal raised numerous issues with Dr Ibrahim while giving evidence and in particular examined his knowledge of drugs used in his practice and the methods by which he kept his medical knowledge up to date. Dr Ibrahim conceded that he was not well versed in using computer technology to keep up to date with medical issues but since 2016 had tried to improve this area of research. He had made little progress, however, and accepted that there was a great deal more for him to learn. He now asked fellow practitioners about issues where he was unsure or otherwise needed assistance. 5. Although not part of his statement of evidence filed in the Tribunal, Dr Ibrahim in oral evidence gave some detail about personal issues that had troubled him at around the time of the procedure in question in these proceedings and for some time after. He had made investments that had severe consequences for his financial position and those matters were worrying for him at the time and clouded his thinking and responses. As a result of treatment for depression he now regarded himself as being back to normal. 6. It is appropriate to note, at this stage, that Dr Ibrahim ceased to perfom the laser lipolysis procedure immediately after the events of 27 May 2016 and had informed the Medical Council that he did not intend to practice in this field again. That position was confirmed in the s150 proceedings in November 2016 where the Medical Council made it a condition of his registration that he not perform cosmetic surgery. In the proceedings before this Tribunal Dr Ibrahim stated that he would not perform laser lipolysis procedures in the future and had no objection to such a condition being attached to his registration for the future. 7. On behalf of Dr Ibrahim the allegations of unsatisfactory professional conduct were accepted. It was the suggestion of both parties that the Tribunal firstly deal with the question of whether or not the allegation of professional misconduct had been established. That question, once determined, left the parties able to address the question of appropriate final orders in the time allocated to the case. In the circumstances of this case, as it developed, the Tribunal concluded that the proposed course was appropriate. 8. Counsel for Dr Ibrahim conceded that the allegations of unsatisfactory professional conduct had been made out. In the Reply filed by the Respondent, the issue of professional misconduct had been "left to the Tribunal". The Tribunal adjourned to determine the first stage issues. 9. Both counsel addressed the legislative scheme and the operation of s 139 of the National Law defining the meaning of "misconduct". There was no dispute between the parties as to the legal principles applicable and both referred to the relevance of the decision of the Court of Appeal in Chen v HCCC [2017] NSWCA 186. 10. In announcing its determination of the first stage issues the Tribunal stated that although the complaints of unsatisfactory professional conduct had been conceded by the respondent, that concession did not absolve the Tribunal from the task of satisfying itself that those allegations were made out. Having regard to Dr Ibrahim's evidence and the expert report of Dr Rish, the Tribunal is in no doubt that the allegations of unsatisfactory professional conduct have been made out. 11. In this case the issues that have led to findings of unsatisfactory professional conduct, in combination, are sufficiently serious to justify suspension or cancellation of registration. The Tribunal agrees with the submission of counsel for the HCCC that the evidence paints a picture of inadequate care or carelessness that strongly suggest incompetence in performing the procedure of laser Lipolysis. The Respondent showed himself to be inadequately trained in the procedure and of having a disastrously low level of understanding of the drugs he routinely used and those he chose to use in this particular case. Here there was a potential for serious harm to the patient and it appears to be more a case of sheer luck than professional competence that saved Dr Ibrahim's patient from a much more serious outcome. Having regard to the totality of the evidence the Tribunal concludes that Dr Ibrahim's conduct as particularised constitutes professional misconduct. 12. The Tribunal cannot accept the submission for Dr Ibrahim, that the procedure should be considered as a whole and treated as one bad incident in a long career spanning 26 years at the Hassall Grove practice. The Tribunal concludes that Dr Ibrahim's conduct in relation to this patient demonstrated significant failings across a wide domain where clinical competence should be expected. Further, it appears, as found by the Medical Council, that it is not clearly established that Dr Ibrahim has fully identified and understood his deficiencies in this area of practice. Since the 2016 procedure he has done little to address his lack of knowledge of computer technology in order to quickly and efficiently keep his medical knowledge up to date. There is little, if any, evidence of him taking steps to improve his knowledge and understanding of drugs and their interaction. 13. In further submissions on the second stage of proceedings it was argued that Dr Ibrahim had acknowledged his numerous shortcomings and had demonstrated insight as to their causes and the means by which they could be addressed. He had undertaken some online courses, but quite recently, and was now seeking assistance from his son regarding the use of computers to keep up to date. He had accepted that his actions warranted findings of unsatisfactory professional conduct and had admitted using more valium than had been particularised by the HCCC. Further, he had immediately stopped performing Lipolysis and did so prior to the Medical Council prohibiting that practice. He now proposed to practice more cautiously and to seek advice from fellow practitioners. 14. Dr Ibrahim was less certain about other matters. He initially stated that he would never again perform this aspect of cosmetic surgery but late in the hearing said that with time it could be possible with considerable training. He had said that he would completely retire from practice in June 2019 but during the hearing said he wanted to undertake charity work in Egypt with medical registration. It was also possible for him to return to practice part time but he would not perform more complicated procedures. He accepted that a return to practice would be likely to involved a number of conditions being placed on his registration. 15. Significantly, late in the proceedings, Counsel for Dr Ibrahim announced that his client would accept a suspension of 6 months duration together with such conditions as the Tribunal thought appropriate. However, in terms, the concepts of contrition and remorse were not directly addressed although some general submissions could be considered to more broadly address those matters. 16. Having regard to all the evidence and submissions, the Tribunal concludes that Dr Ibrahim should be suspended for a period of six months commencing from the date of this decision. Upon return to practice he shall be required to abide by the comprehensive list of conditions set out in the formal orders appearing at the conclusion of this decision. ORDERS 1. The medical registration of the Respondent, Dr George Ibrahim, is suspended for a period of 6 months commencing on the date of publication of this decision. 2. Upon re-registration as a medical practitioner, the Respondent, Dr George Ibrahim, shall be subject to the conditions specified in Annexure A to this decision. 3. Dr Ibrahim is to pay the costs of the Applicant in these proceedings, as agreed or as assessed. ********** CONDITIONS At the conclusion of the period of suspension imposed by the Tribunal, the practitioner's registration shall be subject to the following practice conditions: 1(a). In accordance with the Medical Council of NSW (the Medical Council) Compliance Policy-Supervision, as varied from time to time, the practitioner is to practise medicine under Level B supervision; 1(b). Prior to the practitioner commencing employment he is to nominate a supervisor to monitor and review his clinical practice and compliance with the practice conditions applicable under Level B supervision. He is not to practise until a supervisor has been approved by the Medical Council; 1(c). The nominated supervisor is to be provided with a copy of all conditions of registration and the decision of the Tribunal in this matter; 1(d). The practitioner is to bear all costs associated with the supervision arrangements; 1(e). The practitioner and the nominated supervisor are to meet on a fortnightly basis for at least one hour, with the first meeting to take place within 14 days of the practitioner returning to employment. The supervisor is to observe the practitioner conduct 2 patient consultations at the place of the practitioner's practice and the practitioner is to observe the supervisors consultations not less than two monthly; 1(f). At each meeting the practitioner and the supervisor are to review the practitioner's work progress and address any relevant work related or professional matters, including but not limited to, the practitioner's work load, record keeping, the safe administration of medication to patients, his learning needs, his clinical decision making and his use of clinical resources; 1(g). At each such meeting the supervisor is to complete a record of matters discussed at the meeting; 1(h). The supervisor is to forward to the Medical Council, initially on a twice monthly basis, a Supervision Report; 1(i). The supervisor is authorised to inform the Medical Council immediately if there are any concerns relating to the practitioner's compliance with the supervision requirements, clinical performance, health or if the supervisor relationship ceases. The practitioner authorises the supervisor to provide such information to the Medical Council; 1(j). In the event that the approved supervisor is no longer willing or able to provide the supervision required, details of a replacement supervisor are to be forwarded to the Medical Council within 21 days of the cessation of the supervisory relationship. This provision shall apply to any further change of supervisor. 2. The practitioner is to submit to a Performance Assessment of his medical practice by a person or persons nominated by the Medical Council. The Performance Assessment is to be held within three months from the date of resuming practice. The practitioner is to meet all costs associated with the Performance Assessment and any subsequent reports. 3. The practitioner is to nominate an experienced medical practitioner outside of his place of employment, to act as his professional mentor. The nominated mentor is to be approved in accordance with the Medical Council's Compliance Policy-Mentoring, as varied from time to time and as subsequently determined by the appropriate review body. The mentor is authorised to report, in an appropriate format, to the Medical Council every three months about the fact of contact and to inform the Medical Council if there is any concern about his professional conduct, health or personal wellbeing. 4. The practitioner is prohibited from performing any cosmetic procedures as defined by the Medical Board of Australia's Guidelines for registered medical practitioners who perform cosmetic and surgical procedures. 5. The practitioner is prohibited from performing any surgical procedures other than non-cosmetic minor procedures in his consultation rooms that require nothing more than local anaesthetic infiltration. 6. The practitioner is to practice only in a group practice approved by the Medical Council. For the purposes of these conditions a group practice is defined as being comprised of at least three general practitioners. Prior to taking up such an engagement the practitioner is to provide the Medical Council with full details of the proposed group practice. If the practitioner seeks to change the group practice with which he proposes to be engaged, he must provide full details of that practice to the Medical Council 7. In relation to engagement in a group practice, the practitioner is: (a) at all times to practice medicine where there are at least two other practitioners present on site; and, (b) restricted to seeing a maximum of thirty patients per day with a total of no more than one hundred and twenty five patients to be seen in a week. 8. In the period of three months prior to, or within three months following the expiration of, the suspension period the practitioner shall undertake and complete educational training dealing with: electronic record keeping; medication safety training; and, basic and advanced life support. Within twenty eight days of completion of each of these training courses the practitioner is to provide evidence of that fact to his supervisor and to the Medical Council. 9. The practitioner is to provide the Medical Council annually with evidence of his compliance with the Medical Board of Australia's Continuing Professional Development Registration Standard. 10. The practitioner shall authorise and consent to any exchange of information between the Medical Council and Medicare Australia, for the purpose of monitoring compliance with these conditions. 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 19 September 2019 - Paragraph 9(a) - typographical error corrected. "400mg" corrected to "400mcg". 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: 19 September 2019