Civil and Administrative Tribunal New South Wales Medium Neutral Citation: Health Care Complaints Commission v Buys [2020] NSWCATOD 44 Hearing dates: 9, 10, 11 and 12 December 2019, 31 January and 20 April 2020 (submissions) Date of orders: 30 April 2020 Decision date: 30 April 2020 Jurisdiction: Occupational Division Before: The Hon F Marks, Principal Member Dr T Boland, Senior Member Dr A Lang, Senior Member S Lovrovich, General Member Decision: Consequent upon the finding of professional misconduct which we have made we make the following orders: (1) the applicant is to inform the respondent within 7 days what protective orders and other orders that it then currently seeks to be made against the respondent (2) the respondent is to file and serve within 1 month of receipt of the information in (1) above the evidence and submissions upon which he seeks to rely for the purpose of the stage 2 hearing (3) the applicant is to file and serve within 21 days of receipt of the material in (2) above any evidence and submissions upon which it seeks to rely (4) the parties will be informed by the Tribunal upon receipt of the above of the date of any stage 2 hearing and the means by which it will be conducted. Catchwords: TRADES AND PROFESSIONS – dental practitioner – inappropriate prescription of drugs of addiction and other restricted drugs – failure to secure drugs in premises – failure to maintain drug register – failure to record issue of prescriptions in clinical notes – issuing prescriptions in name of practitioner or dental practice – held constituted professional misconduct – proceedings stood over for stage 2 hearing Legislation Cited: Health Practitioner Regulation National Law (NSW) Poisons and Therapeutic Goods Regulation 2008 (NSW) Cases Cited: Health Care Complaints Commission v Do [2014] NSWCA 307 Spicer v NSW Medical Board & Ors (Court of Appeal (NSW), 19 February 1981, unrep) Category: Principal judgment Parties: Health Care Complaints Commission (Applicant) Dr Peter Joseph Brian Buys (Respondent) Representation: Counsel: S Maybury (Applicant) Solicitors: Health Care Complaints Commission (Applicant) Respondent (Self Represented) File Number(s): 2018/00373160 Publication restriction: Publication of the name of any patient of the respondent or any material which might tend to identify any such person is prohibited REASONS FOR DECISION Introduction 1. These proceedings are constituted by a Further Amended Application. The applicant, the Health Care Complaints Commission alleges by way of Complaints that the respondent Dr Peter Joseph Brian Buys is guilty of unsatisfactory professional conduct and of professional misconduct in his practice as a dental practitioner as those terms are defined in the Health Practitioner Regulation National Law (NSW) ("the National Law"). The respondent did not file any Reply document to the various iterations of the Application but did indicate his response to each of the Complaints and particulars during the course of the hearing before us. The respondent's response was amended during the course of the hearing, in reaction to evidence which had been adduced by the applicant and during the respondent's evidence given in the hearing. The applicant sought that the initial hearing of these proceedings be confined to a consideration of whether or not the respondent is guilty of unsatisfactory professional conduct or professional misconduct, and that any determination of any resultant protective orders be deferred until we had made findings about these matters, to be dealt with in the course of a stage 2 hearing. We proceed accordingly, and these reasons for decision are so confined. 2. We set out hereunder the Application in its final amended form. Parts of this document have been anonymized consistent with the protocols adopted by this Tribunal. The Health Care Complaints Commission of Level 13, 323 Castlereagh Street, Sydney NSW, having consulted with the Dental Council of New South Wales in accordance with sections 39(2) and 90B(3) of the Health Care Complaints Act 1993 and section 145A of the Health Practitioner Regulation National Law (NSW) ("the National Law") HEREBY COMPLAINS THAT Dr Peter Buys ("the practitioner") of (address omitted) NSW being a dentist registered under the National Law, COMPLAINT ONE is guilty of unsatisfactory professional conduct under section 139B of the National Law in that the practitioner has: i. engaged in conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of dentistry is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience; and/or ii. engaged in improper or unethical conduct relating to the practice or purported practice of dentistry. BACKGROUND TO COMPLAINT ONE The practitioner was first registered as a Dental Practitioner on 1 December 2004. The practitioner owns and operates two dental practices, 'Lisarow Dental' and 'Wyong Dental', located in Lisarow and Wyong New South Wales. At all relevant times the practitioner worked at these practices. PARTICULARS OF COMPLAINT ONE 1. Between around February 2007 and September 2016, the practitioner failed to keep drugs of addiction in a separate room, safe, cupboard or other receptacle securely attached to a part of the premises in that he kept drugs of addiction in a locked desk drawer at his dental practice or dental practices, in circumstances where staff members knew the location of the key to the drawer, in contravention of regulation 73 of the Poisons and Therapeutic Goods Regulation 2008 ("PTG Regulation.') 2. Between around February 2007 and September 2016, the practitioner failed to keep, maintain and / or make entries in a drug register in accordance with regulations 111 and 112 of the PTG Regulation in that he did not make entries into a drug register when he had possession of Schedule 8 drugs. 3. The practitioner failed to demonstrate appropriate judgement when he collected medications within the meaning of schedule 8 of the Poisons List of the Poisons and Therapeutic Goods Regulation 2008 ("Schedule 8 drugs") from a pharmacy on behalf of his patients on two or more occasions: a. Without recording the patient's express authority and subsequent collection of the medication in their dental records. 4. The practitioner failed to demonstrate appropriate knowledge, skill or judgement before writing prescriptions for Schedule 8 drugs for patients A - G and I respectively on the dates and in the manner detailed in the Schedule to this complaint in that: a. On a number of the occasions set out in the schedules there was no record of the patient having attended either practice; and on a number of occasions there was no indication in the patient's dental records on the dates that a prescription was provided. 5. Between 17 May 2013 and 6 June 2016, the practitioner failed to demonstrate appropriate knowledge or judgement in that he prescribed approximately 844 tablets of Ondansetron in his own name or the practice's name for general practice use in circumstances where the use of Ondansetron in a dental setting is exceedingly rare. 6. Between 17 May 2013 and 6 June 2016, the practitioner failed to demonstrate appropriate knowledge or judgement when he provided Ondansetron to members of his family on two or more than two occasions for nausea not related to dental work. 7. The practitioner failed to exercise appropriate judgement in that he prescribed and obtained the following medications in the approximate amounts listed below within the meaning of schedule 4 and 4D of the Poisons List of the Poisons and Therapeutic Goods Regulation 2008 ("Schedule 4 and Schedule 4D drugs") and Schedule 8 drugs in the name of his dental practices in circumstances where the prescribing and obtaining of this quantum of medication for practice use was outside the acceptable standards for use in a dental setting: a. 80 tablets of Oxycodone during the period 22 July 2013 — 09 July 2014; b. 694 tablets of Ondansetron during the period 17 May 2013 — 3 June 2016; c. 250 tablets of Alprazolam during the period 17 May 2013 — 3 January 2014; d. 200 tablets of Lorazepam during the period 26 July 2014 — 16 July 2015; e. 5 tablets of Naloxone on 15 June 2015. 8. The practitioner failed to exercise appropriate judgement in that he prescribed and obtained the Schedule 4 and Schedule 4D drugs and Schedule 8 drugs in the approximate amounts listed below in his own name in circumstances where the prescribing and obtaining of this quantum of medication for practice use was outside the acceptable standards for use in a dental setting: - a. 150 tablets of Ondansetron during the period 9 November 2015 — 6 June 2016; b. 50 tablets of Alprazolam on 14 March 2013; c. 30 tablets of Bromazepam on 5 January 2015; d. 300 tablets of Diazepam during the period 20 June 2014 — 26 November 2015; e. 100 tablets of Lorazepam during the period 1 December 2014 — 21 May 2015. 9. The practitioner failed to demonstrate appropriate knowledge, or exercise appropriate care or judgement before he prescribed a Schedule 8 drug namely Oxycodone to Patients A — K respectively on the dates and in the manner detailed in Schedules to this Complaint: a. In excessive quantities and / or dosage b. For an excessive period; c. Without appropriate monitoring, review or documented management plan; d. When there was not sufficient clinical indication for the prescription for patients A, B, C, D, E, F, G, I, J and K; e. For Patients B and D, in circumstances where: i. The prescribing was not indicated for women of child-bearing age, ii. The practitioner did not ask the patients whether they were pregnant or planning to become pregnant before prescribing Oxycodone. 10. The practitioner failed to maintain adequate clinical records for Patients A — K respectively on the dates and in the manner detailed in Schedules to this Complaint in that he: a. Failed to make a written record of the supply of Oxycodone to Patients A, B, C, D, E, F, G, H, I, J and K; b. Failed to record appropriate assessments of Patients A, B, C, D, E, F, G, H, I, J and K on the dates he prescribed Oxycodone. 11. The practitioner failed to exercise appropriate care and demonstrate skill and judgement in that he diagnosed Patients C, D and E as "opioid tolerant" and / or "opiate tolerant" when he did not have the requisite specialised training to make such a diagnosis on the following occasions: a. Patient C on 6 June 2016; b. Patient D on 1 August 2013, 10 June 2014 and 7 September 2015; c. Patient Eon 3 August 2013 and 10 June 2014. PATIENT A 12. The practitioner failed to demonstrate appropriate knowledge or judgement in that he prescribed Oxycodone to Patient A on the dates and in the manner detailed in Schedule A to this Complaint in circumstances where: a. Prescribing of a Schedule 8 medication was not clinically indicated and another treatment, namely a localised dressing of the socket with an increased dose of nonsteroidal anti-inflammatory drugs (NSAIDs) was the appropriate treatment. b. The practitioner failed to refer Patient A to a medical practitioner, an oral and maxillofacial surgeon or an Oral Medicine specialist for management of Patient A's bone sequestration and issues with healing post tooth extraction. PATIENT B 13. The practitioner prescribed Oxycodone to Patient B on the dates and in the manner detailed in Schedule B to this Complaint in circumstances where the prescribing of a Schedule 8 medication was not clinically indicated and another treatment, namely the use of NSAIDs and paracetamol with or without codeine was the appropriate and accepted standard of treatment. PATIENT C 14. The practitioner failed to demonstrate appropriate knowledge or judgement and exercise appropriate care in that he prescribed Oxycodone to Patient C on the dates and in the manner detailed in Schedule C to this Complaint without having sufficient contact with the patient's treating clinicians in circumstances where the patient suffered from anxiety and trigeminal neuralgia and managing those conditions was beyond the scope of the practitioner's practice. PATIENT E 15. The practitioner failed to demonstrate appropriate knowledge or judgement and exercise appropriate care in that he prescribed Oxycodone to Patient E on the dates and in the manner detailed in Schedule E to this Complaint, without sufficiently consulting with the patient's general practitioner or a specialist in pain management to assist the practitioner in handling the patient's complex medical and pain related issues. 16. The practitioner failed to demonstrate appropriate knowledge or judgement and exercise appropriate care in that he prescribed a Schedule 4D drug namely Diazepam to Patient E two or more than two occasions including on 2 December 2013 and 5 June 2014, without consulting with the patient's multi-disciplinary team. PATIENT G 17. On 13 May 2014, the practitioner failed to demonstrate appropriate knowledge or judgement and exercise appropriate care in that he prescribed antibiotics and Oxycodone to Patient G after a telephone conversation with the patient and based on the patient's own pain assessment, without a proximate clinical examination and subsequent monitoring. 18. On 13 May 2014, the practitioner failed to demonstrate appropriate judgement in that he arranged for the Oxycodone to be dispensed and posted to the patient, or in the alternative posted a script for Oxycodone to the patient. PATIENT H 19. On 7 June 2016, the practitioner failed to demonstrate appropriate knowledge or judgement in that he paid for and collected Patient H's Oxycodone from the Optimal Pharmacy in Wyong, New South Wales, in circumstances where: a. The practitioner failed to record an entry into Patient H's records noting her consent to collection of her medication by the practitioner; b. The practitioner failed to record an entry into Patient H's records noting that the medication was given to Patient H with appropriate instructions; c. The practitioner was aware that Patient H had been in the pharmacy at the same time or earlier the same day. 20. On 7 June 2016, the practitioner failed to demonstrate appropriate judgement and exercise appropriate care in that he: a. Failed to give Patient H the Oxycodone that he had collected from the pharmacy on her behalf when he saw her walk back into the pharmacy; b. Provided the Oxycodone to Patient H in a bag with a bottle of wine, in circumstances where Oxycodone can be fatal if combined with alcohol in large quantities. 21. The practitioner failed to make and maintain adequate clinical records on various occasions between 7 February 2007 and 7 June 2016 when he treated Patient H at Lisarow Dental and / or Wyong Dental. PATIENT I 22. The practitioner failed to demonstrate appropriate knowledge or judgement in that he prescribed a Schedule 8 drug namely Oxycodone to Patient I on the dates and in the manner detailed in Schedule I to this Complaint in circumstances where the prescriptions were not clinically indicated as the patient received straightforward implant treatment. COMPLAINT TWO 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 TWO The background to Complaint One is repeated. PARTICULARS OF COMPLAINT TWO 1. The Particulars identified in Complaint One are repeated and relied upon individually. 2. The Particulars identified in Complaint One are repeated and relied upon cumulatively. The evidentiary background 1. A large amount of documentary evidence was tendered by both parties. The applicant tendered four volumes of material including documents created during the course of an investigation into complaints initiated by a pharmacist, patient records of those patients whose circumstances are the subject of these proceedings, transcript of proceedings before the Dental Council of NSW conducted under section 150 of the National Law in which the respondent participated, the report of an expert retained by the respondent, Dr Gautum Sridhar, and Medicare and other prescribing information concerning each of the patients. The respondent also tendered into evidence a bundle of documents. Oral evidence was given by Dr Sridhar, a pharmacist, Mr Louis Tran and the respondent. The narration which follows is based upon this evidentiary material and we shall refer to those portions of it which are relevant to our consideration of the Complaints and Particulars. 2. Before embarking upon our consideration of the factual material we observe that in making any findings which are relevant to our consideration of these proceedings we proceed on the basis that we must be "comfortably satisfied" on the balance of probabilities that such findings may properly be made. 3. A perusal of the Complaints and Particulars set out above will readily demonstrate that they arise out of the inappropriate use and prescription of regulated drugs of addiction and other controlled drugs by the respondent in the course of conducting his dental practice. A convenient starting point in describing the factual background to these proceedings is a document entitled "Prescribing Policy for Pain Relief" issued by the respondent with respect to dental practices being conducted by him at Lisarow and Wyong, NSW, which he said represented the approach which he and other dental practitioners performing work in those practices should adopt. In that document the respondent made the following points: 1. the best form of pain relief is to treat the underlying cause 2. all patients should be given appropriate pain relief rather than endure unnecessary pain which normally involves Ibuprofen or Paracetamol 3. if this first line pain relief does not work, then Panadeine Forte either alone or in combination with Ibuprofen is appropriate. 4. More severe pain should be treated by opiates. In this regard "low-dose Oxycodone is not dangerous" within recommended dose levels. 1. These proceedings have their genesis in a complaint made by Mr Louis Tran, pharmacist, to the Pharmaceutical Regulatory Unit of NSW Health by telephone on 8 June 2016. Mr Tran complained that a patient, known as Patient H in these proceedings, had presented to the pharmacy earlier that day with a script for antibiotics written by the respondent. She had left the script at the pharmacy and was to return later to pick up the medication. Later, the respondent came to the pharmacy and presented a prescription for oxycodone 10 mg for that patient, waited for the script to be filled, and then collected and paid for it. Whilst the respondent was still in the pharmacy the patient returned to pick up the antibiotic medication. Mr Tran asked her whether she required pain relief and she said that she did not. Mr Tran observed the respondent then speaking to the patient. Later that day Mr Tran spoke to the patient who denied having been given the oxycodone medication by the respondent. Mr Tran spoke to another pharmacist in the area who also noted concerns about the number of prescriptions written by the respondent in which he had prescribed oxycodone or similar medication for patients. Mr Tran was concerned about the number of prescriptions which he had filled for this medication and later forwarded details of them to the Unit. In the meantime, the patient telephoned Mr Tran and said that some days later she had been given a box of oxycodone by the respondent together with a bottle of wine as a birthday present. Mr Tran explain to her that it was dangerous to take oxycodone and alcohol. He repeated this advice when the respondent subsequently telephoned him about his conversation with the patient. 2. Mr Tran provided a detailed statement concerning these matters on 14 November 2016 which became evidence in the proceedings and he also gave oral evidence. It was the evidence of Mr Tran that on most occasions when the respondent prescribed oxycodone or similar medication he personally attended the pharmacy and presented the scripts himself, picked up the medication himself and either paid for it personally or charged it back to his practice account. On some occasions the respondent's receptionist would present the script and pick up the pain medication. Mr Tran thought that it was unusual for a dentist to write so many scripts for oxycodone, and to personally attend the pharmacy to have the scripts filled. 3. Included in the evidentiary material is a statement of Mr Kurt Smith, pharmacist who worked in a pharmacy conducted in Wyong dated 20 November 2016. He had known the respondent since 2013, and had dispensed scripts issued by the respondent from his practice at Wyong. Mr Smith said he became concerned about the level of scripts issued by the respondent for drugs of addiction, many of which were issued as private scripts and not as PBS scripts. He was also concerned that the respondent would either personally attend the pharmacy to pick up the scripts when filled or have his dental assistant do so. In addition, some of the medication was said to be for "office use." Sometime in 2014 Mr Smith informed the respondent that it was inappropriate for him to personally pick up medication for patients, and the respondent ceased doing so. 4. The respondent participated in proceedings conducted by delegates of the Dental Council of NSW under section 150 of the National Law at a hearing on 10 August 2016 in which he was given the opportunity of providing detailed information concerning a number of complaints made against him. We shall refer to information provided by the respondent on that occasion where necessary. At the conclusion of that hearing the delegates determined to suspend the respondent's registration. 5. On 22 January 2018 the respondent made detailed submissions to the Dental Council of NSW seeking the lifting of the suspension of his registration. He spoke of the severe financial pressure that had been placed upon him as a result of the suspension of his right to practice, and the reputational damage which he had suffered. He asked that he be permitted to continue to practice with conditions imposed. The respondent rejected assertions that he had himself personally picked up a large quantity of the regulated medication which he had prescribed, stated that all of the patients for whom it had been prescribed had been given the medication and said that although many of his clinical records were below standard, he would change his practice to ensure compliance. On 27 April, 2018 delegates of the Dental Council of NSW set-aside the suspension of the respondent's registration and imposed practice conditions essentially prohibiting the prescription of drugs of addiction and the prescription of medication for family members or friends, together with an audit requirement and a direction to undertake certain medical treatment. 6. On 10 April 2019 the respondent's registration was changed to that of non-practising. Prescribing drugs of addiction and other regulated drugs – the statutory matrix 1. A perusal of the Particulars of Complaint One reveals that these proceedings are fundamentally concerned with the alleged inappropriate use by the respondent of regulated drugs, many of them being drugs of addiction, in the treatment which he afforded to his patients. The Poisons and Therapeutic Goods Regulation 2008 (NSW) ("PTG Regulation") regulates the circumstances in which these restricted regulated drugs may be prescribed by health practitioners, including, for current purposes, dental practitioners. 2. Of the drugs referred to in the Particulars of Complaint One, Oxycodone is classified as a drug of addiction under Schedule 8 of the PTG Regulation. Oxycodone hydrochloride is part of a group of drugs known as opioids and is most commonly prescribed to relieve moderate to severe pain. By Regulations 73, 111 and 112 the respondent was required to comply with mandatory storage provisions, to keep a drug register and to ensure that certain entries were made in that register. These provisions are set out below: 73 Storage generally (1) A person who is in possession of any drug of addiction must keep the drug— (a) in his or her possession stored apart from all other goods (other than cash or documents) in a separate room, safe, cupboard or other receptacle securely attached to a part of the premises and kept securely locked when not in immediate use, or (b) stored in any other manner approved by the Director-General for the particular person or class of persons to which the person belongs. (2) A person who is an authorised practitioner or a person referred to in clause 101(1)(g) is taken to comply with subclause (1)(a) if he or she keeps any drug of addiction (for use in an emergency only) in a bag that is in a room, or in a vehicle, kept locked when not occupied by the person. Maximum penalty—20 penalty units. 111 Drug registers to be kept (1) A person who has possession of drugs of addiction at any place must keep a separate register (a drug register) at that place. (2) A drug register is to be in the form of a book— (a) that contains consecutively numbered pages, and (b) that is so bound that the pages cannot be removed or replaced without trace, and (c) that contains provision on each page for the inclusion of the particulars required to be entered in the book. (3) Separate pages of the register must be used for each drug of addiction, and for each form and strength of the drug. (4) The Director-General may from time to time approve the keeping of a drug register in any other form. Maximum penalty—20 penalty units. 112 Entries in drug registers (1) On the day on which a person manufactures, receives, supplies, administers or uses a drug of addiction at any place, the person must enter in the drug register for that place such of the following details as are relevant to the transaction— (a) the quantity of the drug manufactured, received, supplied, administered or used, (b) the name and address of the person to, from, or by, whom the drug was manufactured, received, supplied, administered or used, (c) in the case of a drug that has been administered to an animal or supplied for the treatment of an animal, the species of animal and the name and address of the animal's owner, (d) in the case of a drug that is supplied or administered on prescription— (i) the prescription reference number, and (ii) the name of the authorised practitioner by whom the prescription was issued, (e) in the case of a drug that has been administered to a patient, the name of the authorised practitioner (other than a veterinary practitioner) by whom, or under whose direct personal supervision, the drug was administered, (f) in the case of a drug that has been administered to an animal, the name of the veterinary practitioner by whom, or under whose direct personal supervision, the drug was administered, (g) in the case of a drug that has been administered by a person authorised to do so by an authority under Part 8, details of the circumstances requiring administration of the drug, (h) in the case of a drug that has been used by a person who is in charge of a laboratory, or is an analyst, the purpose for which the drug was used, (i) the quantity of drugs of addiction of that kind held at that place after the transaction takes place, (j) any other details approved by the Director-General. (2) Each entry in a drug register must be dated and signed by the person by whom it is made. (3) The Director-General may, by order in writing, exempt any person or drug of addiction, or any class of persons or drugs of addiction, from any or all of the requirements of this clause. (4) Such an exemption may be given unconditionally or subject to conditions. Maximum penalty—20 penalty units or imprisonment for 6 months, or both. 1. The remaining drugs listed in the Particulars of Complaint One are required to be made available by prescription only because they fall within Schedule 4 or Schedule 4D of the Regulation. Accordingly, they may only be prescribed for an appropriate and proper therapeutic purpose, and in the case of a dental practitioner only for the purpose of providing dental treatment. The expert report of Dr Gautam Sridhar 1. The applicant retained Dr Gautam Sridhar, an experienced dental practitioner to furnish an expert opinion concerning complaints made against the respondent. Dr Sridhar completed a MSc in the Faculty of Medicine, University of Sydney in December 2019 with a major in pain management. He provided an expert report dated 30 March 2018 and a subsequent report following the provision of additional information dated 27 May, 2018. Dr Sridhar had been furnished with extensive documentation by the applicant including the transcript of the section 150 proceedings, witness statements, prescribing schedules and Medicare records, and patient clinical notes. 2. In summary, Dr Sridhar furnished an expert opinion on the following matters of a general nature: 1. the respondent had informed the Dental Council that it was his practice on some occasions to prescribed regulated painkiller medication in advance for implant treatment or for treatment that he anticipated would result in pain. In the opinion of Dr Sridhar this was inappropriate without having been given an appropriate history and having assessed the patient's pain. This practice was said to be significantly below the standard expected of a dental practitioner with an equivalent level of training and experience of that of the respondent ("the relevant standard"). 2. the respondent had conceded to the Dental Council that he was aware of the requirements to keep a register for Schedule 8 drugs but was unaware this requirement applied to drugs which were being temporarily stored. Dr Sridhar rejected this explanation as justifying the failure of the respondent to keep and maintain such a register. He concluded that this was significantly below the relevant standard 3. the respondent had conceded to the Dental Council that Schedule 8 medication had been kept in the desk drawer of his office manager, who was a family member. He further conceded that the whereabouts of the key to that draw was well known to practice staff. Furthermore, there was no system of accountability for the storage of that medication. Dr Sridhar concluded that this was significantly below the relevant standard. 4. Having regard to the Medicare and pharmacy dispensing records made available to him, Dr Sridhar concluded that the prescription pattern of the respondent of opioids was outside the clinical indications for such prescription and was outside the accepted therapeutic standards regarding dosage, frequency and duration for the prescribing of that medication within the scope of dentistry. He thought that "the use of stronger opioids such as oxycodone or tramadol requires adequate research and training on the part of the dental practitioner", the initial dosage if justified should be at a lower level and reviewed after a 48 hour period and if the pain was worse and intractable the patient should have been referred to a tertiary institution or specialist practitioner. Furthermore, there were risks and contraindication of prescribing oxycodone generally, of prescribing oxycodone to patients with a history of drug dependence or abuse or who exhibited drug seeking behaviours and for chronic/long-term pain management of patients. This all indicated that the conduct of the respondent was significantly below the relevant standard. 5. The respondent had informed the Dental Council that he had issued private scripts for oxycodone where he was unsure whether the medication was covered by the PBS. Dr Sridhar said that this practice demonstrated a lack of awareness and reasonable understanding of the operation of the PBS system, and that it was inappropriate to issue private scripts for this medication when available under the PBS, as the respondent had done. He said that this was significantly below the relevant standard. 6. The respondent's prescription records indicated that he had prescribed oxycodone or similar medication to 11 patients in varying quantities or strengths ranging from 5 mg, 10 mg and/or 20 mg in 20, 30 and/or 40 tablet form. Dr Sridhar said that these prescribing patterns exceeded best practice for patients in moderate or severe pain and was significantly below the relevant standard. 7. The respondent had admitted to the Dental Council that he had prescribed quantities of Ondansetron for general patient use and had stored it at his practices. He had said that he had handed this medication out quite readily to any patient who was having nitrous oxide. He had also given this medication to family members who were suffering from nausea and was aware that staff may have taken this medication from the stored supply. Dr Sridhar said that none of this conduct was within normal dental practice and was significantly below the relevant standard. 8. In oral evidence Dr Sridhar said that it would be exceedingly rare for Ondansetron to be prescribed in a dental setting. If a patient became nauseous whilst being given nitrous oxide, the quantity could be reduced. He said this drug can affect the liver and kidneys and should be used with caution. 9. When appearing before the Dental Council, the respondent had said that Schedule 8 medication prescriptions were always written for a patient, and not in the name of the practice. However, prescribing records provided by pharmacies and Medicare indicated that the respondent had prescribed a number of Schedule 4 and 4D drugs and Schedule 8 drugs in the name of the dental practice with indicia such as "for surgery use", "for doctor's use", and "use as directed by your doctor" amongst others. Dr Sridhar summarised the nature and extent of these prescriptions as follows; 1. temazepam = 25 tablets on 10 July 2014 2. paracetamol and codeine = 340 tablets over the period 13 October 2014 to 13 March 2015 3. oxycodone = 80 tablets over the period 22 July 2013 to 9 July 2014 4. Ondansetron = 694 tablets over the period 17 May 2013 to 30 June 2016 5. alprazolam = 250 tablets over the period 17 May 2013 to 3 January 2014 6. Lorazepam = 200 tablets over the period 26 July 2014 to 16 July 2015 7. naxolone = 5 tablets on 15 June 2015 Dr Sridhar said the "sheer quantum of the scheduled medications prescribed over this three-year period is almost not comprehensible for use in a dental setting. 25 tablets of temazepam and 340 tablets of paracetamol and codeine are the only ones……that would be considered reasonable… Naloxone is a drug that is primarily used to block the effect of opioids and has little to no place in a Dental Surgery without appropriate medical supervision." Dr Sridhar described this conduct as "completely reprehensible" other than the prescription of temazepam and paracetamol + codeine and was significantly below the relevant standard. 1. Records made available to Dr Sridhar indicated that the respondent had prescribed a large quantity of temazepam, paracetamol and codeine, Ondasetron, alprazolam, bromazepam, diazepam and Lorazepam during the period 14 March 2013 to 6 June 2016 in his own name. Dr Sridhar said that it was not uncommon to prescribe schedule drugs "under one's own name and/or for surgery use" but the quantities of these drugs were extremely unusual, and more so when considered in conjunction with the drugs described in (9) above. His criticism would have been exacerbated if there was evidence that some of the drugs had been prescribed for the respondent's own use or had been prescribed other than in conjunction with his practice of dentistry. He said that this conduct was significantly below the relevant standard. 1. Dr Sridhar then dealt with the circumstances pertaining to each of the patients who are the subject of these proceedings, which we summarise as follows: Patient A 1. Dr Sridhar noted that this patient had consulted the respondent on 19 out of 20 occasions in which he received treatment at the practices and had issued prescriptions for 410 tablets of varying strength of oxycodone in the name of the patient on 20 occasions. However, the patient records document the prescribing of oxycodone on only 7 occasions. 2. Furthermore, in reviewing the patient records and the treatment afforded to this patient Dr Sridhar thought that there was "an extremely strong case" this patient did not need to be prescribed oxycodone at all, let alone on 20 occasions. Based upon the clinical treatment notes, this patient's problem could have been treated by applying a localised dressing to a painful socket with an increased dose of Ibuprofen, or alternatively by reference to an oral and maxillofacial surgeon or other specialist. 3. Dr Sridhar said that the respondent had failed to carry out a proper assessment of the patient's condition before prescribing oxycodone, had failed to apply an appropriate treatment regime, and the high level of oxycodone of 10 mg and more was inappropriate in any event. In all the circumstances the treatment afforded to this patient was said to be significantly below the relevant standard. 4. In addition to the above matters Dr Sridhar described the standard of overall recordkeeping for this patient as being poor, rendering it "close to impossible for a practitioner to keep on top of complex clinical situations which span over a significant period of time." He said that this would have rendered it essentially impossible for either the respondent or another health practitioner to identify the quantum of drugs used by the patient in the event of a complication/overdose. These matters also indicated conduct significantly below the relevant standard. Patient B 1. The respondent was this patient's primary dental practitioner for the period 24 April 2008 to 14 July 2016. During this period, she was described as attending for general cleaning, periodic check-ups and the management of an ongoing temporomandibular joint dysfunction. The pharmacy dispensing and Medicare records show that during the period 27 June 2015 to 17 May 2016 the respondent prescribed 200 oxycodone 10 mg tablets to this patient. However the respondent's patient records and appointment book showed that this patient consulted the respondent on only 2 of the 11 occasions when he prescribed oxycodone and the records do not document the prescribing or provision of oxycodone to this patient on any of the 11 occasions that he prescribed medication in her name. 2. In Dr Sridhar's opinion the respondent should not have prescribed oxycodone for acute exacerbation of a temporomandibular disorder, and he said that the prescription of this drug to a woman whom he had been treating from the age of 17 to 20 was "disgraceful" because it was a TGA pregnancy category C drug, with no record of having checked on its status even once. Such a check would have revealed that it is known to have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. 3. Furthermore, there was no record of the respondent having conducted any appropriate assessment of this patient prior to prescribing oxycodone on each occasion. It was possible that if she was suffering pain this may have been caused by a treatable condition such as an infection. In any event analgesia should have commenced with Ibuprofen and paracetamol with or without codeine. The respondent had failed to maintain contemporaneous appropriate patient records relating to all medications prescribed. His overall recordkeeping was poor and it would have been "close to impossible for a practitioner to keep on top of complex clinical situations span over a significant period of time….. It would have been essentially impossible for him or an alternative health practitioner to identify the quantum of drugs used by a given patient in the event of a complication/overdose." 4. Dr Sridhar said that the overall planning and execution of treatment for this patient had been substandard at best and significantly below the relevant standard. Patient C 1. The respondent was this patient's primary dental practitioner between 11 April 2007 and 13 September 2016. His clinical records noted that he suffered from anxiety and trigeminal neuralgia, for which he had been taking Effexor 275 mg and oxycodone 60 mg. During the period of treatment, the patient had undergone a range of dental treatment including extractions and ongoing restoration work. Pharmacy dispensing and Medicare records indicated that the respondent prescribed 840 oxycodone tablets of varying doses on 40 occasions between the period 15 March 2013 and 8 August 2016. 2. The respondent's patient records and appointment book indicated that the patient consulted him on only 8 of the 40 occasions on which he prescribed oxycodone in the name of the patient and of those 8 occasions, the respondent documented that he had prescribed oxycodone for this patient on 5 occasions only. The patient records do not document prescribing oxycodone to this patient on 35 of the 40 occasions that he issued scripts in the patient's name. 3. In his report Dr Sridhar noted that this patient was under the care of multiple health practitioners for his health conditions, all of whom would have been more qualified than the respondent to prescribe oxycodone and manage his treatment. The nature and extent of the prescription of oxycodone for this patient in circumstances where the respondent was not the primary health practitioner in managing the patient's pain related issues indicated that the respondent had failed to recognise the part that he played in the patient's care. Dr Sridhar said that he was "horrified" at the inappropriate and reprehensible conduct of the respondent. Although there was evidence that the respondent had attempted to contact the patient's treating health practitioners, he had nevertheless proceeded to prescribe oxycodone without having made contact with them. 4. On 6 June 2016 the respondent prescribed oxycodone for this patient and noted in the script that he was opioid tolerant and on a pain management plan. Dr Sridhar was critical of the respondent's conduct in determining that the respondent was opioid tolerant in circumstances where he was not trained or qualified to make such a diagnosis. 5. Dr Sridhar assessed the respondent's overall recordkeeping for this patient as being poor. He said that "without good records it would be close to impossible for a practitioner to keep on top of complex clinical situations which span over a significant period of time …It would have been essentially impossible for him or an alternative health practitioner to identify the quantum of drugs used by a given patient in the event of a complication/overdose" 6. Dr Sridhar assessed the prescribing pattern for this patient and the state of the clinical records as both being significantly below the relevant standard. Patient D 1. The respondent was the primary dental practitioner for this 38-year-old patient for the periods 19 July 2009 to 4 August 2016. During this period, she received a range of dental treatment including extractions, root canal therapy and fillings, and had an underlying health history including rheumatoid arthritis, fibromyalgia, anxiety and a stomach ulcer. She was noted to be on pain medication consisting of OxyContin 30 mg and Panadol osteo to manage her medical conditions. 2. Pharmacy dispensing and Medicare records indicated that the respondent prescribed 140 tablets of oxycodone 10 mg to this patient during the period 30 July 2013 to 14 April 2016. However, although the patient consulted the respondent on 7 occasions when he prescribed oxycodone, there is no record of oxycodone having been prescribed on 2 of these occasions. 3. Dr Sridhar said that there was no clinical dental indication for the prescription of oxycodone to this patient. Furthermore, she was of childbearing age at the time and the respondent should not have repeatedly prescribed a TGA pregnancy category C drug to her without recording whether he checked on this status. Oxycodone is in a category of drugs recognised by the TGA as having caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. 4. In all the circumstances it was the opinion of Dr Sridhar that the respondent had failed to conduct an appropriate assessment of this patient prior to prescribing oxycodone. His conduct in all the circumstances was significantly below the relevant standard. This was exacerbated by notations made by the respondent on 2 occasions to the effect that this patient was opioid tolerant. It was said that the respondent had little or no training or qualifications to make such a determination, particularly when this patient was under the care of medical specialists. 5. Dr Sridhar was also critical of the standard of the respondent's clinical notes with respect to this patient. 6. Overall, Dr Sridhar assessed the respondent's conduct as being significantly below the relevant standard. Patient E 1. The respondent was the primary dental practitioner for this patient for the periods April 2007 to February 2015. During the period 26 July 2012 to 18 February 2016 pharmacy dispensing and Medicare records indicated that the respondent prescribed 180 oxycodone tablets of either 10 mg or 20 mg strength. 2. However, the patient records and appointment book indicate that this patient consulted with the respondent on only 1 of the 8 occasions that he prescribed oxycodone in her name. Accordingly, there is no notation in the records that the respondent prescribed oxycodone on 7 occasions. 3. Dr Sridhar referred to the clinical notes concerning this patient and noted that on occasions she was suffering from complex medical conditions and was under the care of a number of medical practitioners. Taking into account the nature and extent of the dental treatment provided by the respondent for this patient, Dr Sridhar said that there was no clinical dental indication for the prescription of oxycodone for her. There was no notation of the respondent having discussed the patient's pain management and his prescription of medication with her treating medical practitioners or having considered referral to a specialist in pain management. Furthermore, there was no indication that the respondent had conducted an appropriate assessment of the patient prior to prescribing oxycodone. 4. Dr Sridhar was critical of the respondent in having made a notation in the clinical records that the patient was "opioid tolerant" and/or "opiate tolerant". He thought that the respondent was not qualified to make such a diagnosis, and he should have consulted with her treating medical practitioners for this purpose. 5. Overall Dr Sridhar said that the respondent's clinical notes were poor, particularly in failing to notate the reason for the prescription of oxycodone on each occasion. 6. Dr Sridhar noted that on 5 June, 2014 the respondent had recorded that the patient was able to make informed choices on the taking of Schedule 4D and Schedule 8 drugs and that the patient had "a better medical knowledge than most doctors." The respondent further recorded in his notes that the patient was not a drug seeker. Dr Sridhar thought that all of these matters were indicative of inappropriate conduct by the respondent. 7. Dr Sridhar assessed the respondent's conduct as being, in respect of each of the matters detailed above, significantly below the relevant standard. Patient F 1. This patient came under the primary dental care of the respondent during the period 12 August 2010 to 30 July 2015. Pharmacy dispensing and Medicare records show that he prescribed a total of 280 oxycodone tablets of varying strengths in this patient's name during the period 7 March 2013 to 21 July 2016 on 14 occasions. However, the patient records and appointment book show that this patient attended on the respondent on 5 only of those 14 occasions. Therefore, the patient records do not document any consultation or the prescribing of oxycodone on 9 of the 14 occasions when oxycodone was said to have been prescribed for this patient. 2. After taking into account the patient records Dr Sridhar said that there was no clinical dental indication for the prescription of oxycodone for this patient, and there was no evidence that the respondent had conducted an appropriate assessment of the patient prior to prescribing oxycodone on each occasion. Furthermore, the respondent's overall recordkeeping was assessed as being poor because of the failure to make any notation of all of the occasions on which the respondent had prescribed oxycodone for this patient. 3. Dr Sridhar assessed the respondent's conduct as being, in respect of each of the matters detailed above, significantly below the relevant standard. Patient G 1. The respondent was the primary dental carer for this patient during the period 5 July 2013 to 20 July 2016 and received a range of dental treatment including implant treatment. Pharmacy dispensing and Medicare records indicate that during the period 27 July 2013 to 13 September 2014 the respondent prescribed 160 oxycodone 10 mg tablets for this patient on 6 occasions. However, the patient records show that he prescribed oxycodone on one occasion only. 2. Having regard to the patient's notes, Dr Sridhar could find no clinical dental indication for the prescription of oxycodone for this patient. Those notes contained no indication that the respondent conducted a basic assessment of the patient's needs prior to prescribing oxycodone. 3. The patient's notes show that the patient had a telephone consultation with the respondent on 13 May 2014. Based on the patient's complaints of pain and request for pain medication, the respondent prescribed antibiotics and Oxynorm medication, and said that he would arrange for the medication to be dispensed and posted to the patient. Dr Sridhar said that it was inappropriate to have arranged for the dispensation and posting of a Schedule 8 drug. 4. Dr Sridhar assessed the respondent's conduct as being, in respect of each of the matters detailed above, significantly below the relevant standard. Patient H 1. This patient was a former employee of the respondent. Her patient notes indicate that she attended the practice on 3 occasions during the period 7 February 2007 to 7 June 2016. On 7 June 2016 the patient records show that the patient attended concerning her wisdom teeth and complaints of gum pain. The respondent "advised antibiotics" and he took 3D dental scans. Pharmacy dispensing and Medicare records show that on that date the respondent prescribed 20 oxycodone 10 mg tablets in the patient's name. 2. In answer to questions raised by delegates of the Dental Council during the course of the section 150 hearing on 10 August 2016 the respondent said that the patient had attended suffering from pericoronitis which he said he had previously treated her for. However, he had not detailed her treatment including the prescription of antibiotics and oxycodone in her patient records because the patient "was a staff member I would have often treated her for nothing and not recorded it." 3. Dr Sridhar said that pericoronitis was often painful but in the absence of any notation in the patient records, there was no clinical indication that required the prescription of oxycodone as the drug of choice. Nor was there any indication that the respondent had carried out an appropriate assessment before prescribing this drug and in determining that alternative pain medication might have been more appropriate. 4. Other factual circumstances concerning this patient are set out in [6] above. Dr Sridhar was critical of the respondent in having attended on the pharmacist to pick up the medication for this patient, and in having provided it to the patient together with a bottle of wine. Furthermore, the fact that she was a former employee did not justify a failure to keep proper clinical notes concerning his treatment of her. 5. Dr Sridhar assessed the respondent's conduct as being, in respect of each of the matters detailed above, significantly below the relevant standard. Patient I 1. The respondent was the primary dental carer for this patient during the period 3 April to 28 August 2015 during which she was provided with implant treatment. On 12 May 2015 the respondent prescribed 20 oxycodone 5 mg tablets. The clinical records indicate that this patient underwent a straightforward implant placement which Dr Sridhar said "should be an essentially painless procedure with excellent prospects for recovery with minimal post-operative pain." The notes indicate that the respondent thought that the patient would be in severe pain and he prescribed oxycodone accordingly. Dr Sridhar said "There is no scientific or clinical background for the use of opiates in this manner." 2. The clinical notes did not disclose any appropriate assessment having been made by the respondent concerning this patient's circumstances and whether alternative pain medication would have been more appropriate. 3. Dr Sridhar assessed the respondent's conduct as being, in respect of each of the matters detailed above, significantly below the relevant standard. Patient J 1. This patient is the sister of the respondent. Clinical records indicate that she attended the respondent's Lisarow practice between 26 August 2007 and 12 December 2012. During this period, she received a range of dental treatment including crown and restoration work. There are records indicating that she attended the Wyong practice during the period 31 March 2011 to 1 June 2014. 2. Pharmacy dispensing and Medicare records show that the respondent prescribed 160 oxycodone tablets of varying strengths on 7 occasions between 14 May 2013 and 19 May 2015. Patient records and the appointment book for this period indicate that the respondent prescribed oxycodone on only one occasion, namely 1 June 2014. Accordingly, there is no documentation showing that he prescribed this medication in her name during this period except on this one occasion. 3. In oral evidence given by the respondent to delegates of the Dental Council on 10 August 2016 the respondent said that he had prescribed oxycodone on 1 and 8 June 2014 because the patient had reported extreme pain between the completion of crown preparation and cementing. He referred to "severe food impaction." The respondent then referred to the patient suffering from irreversible pulpitis which necessitated root canal therapy. The respondent explained to the delegates that he would not prescribe oxycodone for food impaction, but he was concerned that the patient was suffering from repeated pain, he acknowledged that the amount prescribed was excessive but she was not living nearby and he wanted her to have further supplies. 4. Dr Sridhar said there was no justification for prescribing oxycodone, and the respondent should have instituted a treatment regime to remove the main infective cause. 5. Dr Sridhar assessed the respondent's conduct as being, in respect of each of the matters detailed above, significantly below the relevant standard. Patient K 1. This patient was a former employee of the respondent. He attended on the respondent and other dental practitioners in the same practice between 12 August 2013 and 2 October 2014. He received a range of dental treatment including the management of pericoronitis, involving the removal of a wisdom tooth following infection. 2. Pharmacy dispensing and Medicare records show that the respondent prescribed 420 oxycodone tablets of varying strengths for this patient between 9 August 2013 and 5 January 2015. However the patient records and appointment book show that this patient consulted with the respondent on 4 only of the 21 occasions on which he had prescribed oxycodone in the name of the patient, and had only issued a prescription for oxycodone on 3 of those occasions. 3. Dr Sridhar noted that pericoronitis can be significantly painful. However, there was nothing in the respondent's records to indicate that he had "followed basic scientific and diagnostic protocols to ensure that the appropriate drugs were being prescribed at the appropriate time." In the circumstances there was no justification contained in the notes for the prescription of oxycodone rather than some alternative form of pain relief. 4. Dr Sridhar expressed concern that if this patient had consumed 420 tablets of oxycodone "there would be a real risk of a fatality." 5. Dr Sridhar assessed the respondent's conduct as being, in respect of each of the matters detailed above, significantly below the relevant standard. 6. In a supplementary report dated 27 May 2018 Dr Sridhar responded to assertions made by the respondent questioning the scientific basis upon which he had said that it was inappropriate to prescribe opiates as first-line pain relief. He noted that in correspondence with the Dental Council the respondent continued to assert that there was a scientific basis for the prescription of opiates. In response Dr Sridhar quoted the following extract from an article in the Journal of the American Dental Association of April 2018 entitled "Benefits and harms associated with analgesic medications used in the management of acute dental pain." Opioid medication and medication combinations are not among the most effective or long lasting of the options available for relief of acute dental pain. In addition, opioid medication and medication combinations are associated with higher rates of acute adverse events. From the perspective of risk-benefit analysis, justifying general use of opioid medications as first-line therapy for management of acute pain remains unclear. The large set of published research reports summarized here suggests that relief of post-operative pain in dental practice with the use of nonsteroidal anti-inflammatory drugs, with or without acetaminophen, is equal or superior to that provided by opioid -containing medications. The respondent's evidence 1. The respondent prepared a detailed statement dated 2 December 2019 and annexures in which he addressed a number of general matters, and then dealt specifically with the circumstances of each of the patients whose treatment is the subject of these proceedings. In addition, the respondent gave oral evidence including cross examination. 2. The respondent provided detailed written submissions dated 20 April 2020. In those submissions the respondent introduced new material which had not been considered during the course of the hearing. We acknowledge that the respondent was at all times self represented. In normal circumstances we would not have considered this additional material without having given the applicant an opportunity of dealing with it. We are, however, prepared to make an exception because we are able to consider this additional material in circumstances which do not prejudice the applicant. Furthermore, there has already been an inappropriate delay in delivering these reasons for decision, because the respondent did not file his final submissions until 20 April 2020. 3. The additional material consists of excerpts from the 2019 version of a publication entitled "Therapeutic Guidelines, Oral and Dental." The respondent asked that we consider this material on the basis that it represents current best practice. The extract provided is restricted to 2 pages dealing with analgesic regimens for both mild to moderate and for severe acute dental pain in adults. The extract does not set out those factors that are said to affect the choice of analgesic regimen. For adjunctive analgesia required for mild to moderate acute nociceptive dental pain it is recommended that ibuprofen 400 mg in combination with paracetamol 1000 mg be used, in dosages set out in the document. There is also a reference to the use of a NSAID if required. 4. For severe such pain, a 3 drug regimen is recommended the basis of which are the 2 drugs recommended for mild to moderate pain together with oxycodone immediate release 5 mg every 4 to 6 hours "for the shortest duration possible and no more than 3 days." Dentists are urged to prescribe "the lowest effective dose and advise patients to take a dose only when necessary. Ensure the patient understands the intended duration of opioid use and when to stop taking the opioid or return for review (e.g. if pain persists for longer than expected). This is of particular importance because long-term opioid use often starts with the use of opioids to treat acute pain. As the tissue heals and the patient requires less analgesia, use a stepwise approach to tapering and stopping analgesics. First, stop oxycodone, then stop ibuprofen or celecoxib, and lastly, stop paracetamol." 1. We have set out above details of the prescribing pattern of the respondent for a number of patients, when summarising the report of Dr Sridhar. In many cases there are no clinical notes for these patients describing their condition at the time that they were prescribed oxycodone, there is no notation of any advice given to the patients about the need to minimise exposure to oxycodone, there are no notations requiring review within a 3 day period, and the quantities prescribed far exceed the recommendations contained in the excerpt to which we were referred by the respondent in this submission. We do not apprehend that this excerpt in any way supports the respondent's contention that his prescription of oxycodone for these patients accords with general standards of dentistry, and on the contrary we regard this excerpt as supporting the applicant's case against the respondent. 2. In his written statement the respondent said that he had commenced his career as a dental surgeon in 2004. He opened his practice in Lisarow in 2007 and in Wyong in 2011. Prior to commencing his own practice, the respondent said that he had worked as a locum in rural NSW towns, including towns which did not have a public dentist on staff at the regional hospital. He said that he had undertaken "a lot of very difficult dentistry including working on patients under general anaesthetic and general oral surgery." He developed a personal interest in implant dentistry, medically compromised patients, oral surgery and functional crown and bridge work. 3. The respondent denied that he had been guilty of any "deliberate wrongdoing" but said that his practice was not adequate in relation to storage of drugs and recordkeeping. He also denied that he had written scripts in the circumstances of those patients where no patient records were made. He said he could not "record something that did not happen." 4. However in cross examination the respondent conceded that his records for many of the patients were "woefully inadequate", there was an absence of notation of clinical indicia, there were generally no notations of any clinical assessment, and the issue of some scripts had not been recorded. 5. We comment that the respondent devoted some time in his statement to allegations about his ability to prescribe various levels of opioids, and his misunderstanding about what those levels were. It is not necessary that we deal with these matters, because as will be plain from our narration of the substance of the expert's report, his main concern as reflected in the Complaints before us is that the respondent tended to prescribe opioids as a first line method of providing pain relief to his patients, rather than assessing and evaluating the removal of the cause of the pain, and providing more orthodox pain relief. 6. We note that in general terms the respondent conceded in cross examination that he had prescribed large amounts of oxycodone to patients over inappropriate periods of time, that his prescribing pattern was not appropriate for the pain relief which should have been afforded to the patients and "in retrospect it was the wrong thing to do." 7. The respondent also denied in a general sense that he had picked up a substantial portion of the oxycodone scripts which he had provided for patients. He said that he or his staff had picked up "only a very small portion of scripts". He did agree that he and his staff often dropped off prescriptions at the pharmacy "which were later delivered by pharmacy staff to our reception area and given to patients on arrival. I also agree that on a few occasions, I picked up Schedule 8 medication in behalf of my patients. I did so in circumstances where I anticipated a procedure would end, or its effects become most prevalent after the pharmacy had closed, and the patient would therefore be left without pain relief until it opened again." The respondent conceded that he "sometimes wrote the script and had the medication dispensed in advance of the procedure, and although it was based on an assumption strong pain relief would be required, I still ensured I always conducted an assessment of the patient prior to providing the Schedule 8 medication to ensure it remained appropriate. My motivation was naive but simple…" The respondent went on to say that he now appreciated that his conduct was inappropriate "particularly given the Schedule 8 medications were not properly recorded or stored once in my possession." He said that he would not continue that practice in the future. 1. In his statement the respondent rejected the comments of Dr Sridhar about his use of oxycodone. He said that his treatment related to "repeated episodes of acute pain management" which was not the same as treating chronic pain. He questioned Dr Sridhar's opinion, and said that he relied on the expertise of a Ms Geraldine Moses in corroborating his approach to pain relief for his patients. We note that the respondent has not provided to us any material attributed to Ms Moses, and in particular any material which would indicate that she was of the view that oxycodone and similar medication could generally be given as first-line pain relief. 2. The respondent also pointed out that he always prescribed oxycodone before 2016 in conjunction with Ibuprofen, which reduced any inflammation. 3. The respondent denied that he prescribed Ondansetron to family members, other than his sister. 4. Finally, the respondent vehemently denied that he had prescribed medication in his own name and in the name of the dental practice. However, in cross examination the respondent was taken to the clinical records relating to Patient C. In an entry dated 10 February, 2011 the respondent had recorded; "again issued Augmentin duo forte from surgery supply and OxyContin 20 mg from surgery supply – strong painkillers given as patient admits use of codeine on regular basis and says not relieving pain present – cautioned in use of opiates and not to use codeine while using oxycodone." There then follows a reference to advice given to the patient that no more painkillers would be supplied unless he completed the course of treatment and a strong suggestion that he visit his general practitioner regarding general use of painkillers. The respondent conceded that he did in fact have a surgery stock of opioids but said that he should have written oxycodone instead of OxyContin. We note also that there is ample evidence that the respondent wrote many scripts for oxycodone which were said to be prescribed for surgery use, as outlined above when discussing the expert report of Dr Sridhar. These matters in the aggregate refute the respondent's denial. 1. In cross examination the respondent conceded that in 2013 he had received advice from the Health Care Complaints Commission concerning his failure to comply with Guidelines in Dental Records issued by the Dental Board of Australia with respect to the adequacy of his clinical records. 2. In cross examination the respondent was taken to the circumstances of a number of the patients, and we summarise his evidence with respect to them as follows: Patient A 1. The clinical notes reveal that this patient consulted the respondent on 14 May 2016 when a tooth had broken off. The patient asked for antibiotics and pain relief. He sought Oxynorm "due to panadeine forte ineffective." The patient had not consulted the respondent, according to the clinical notes, since 14 May 2015. However, the respondent's prescribing records show that he prescribed 20 oxycodone 10 mg for this patient on 12 May 2015, two days before the visit on 14 May. On each of 14 and 16 May 2015 the respondent prescribed 20 oxycodone 10 mg for this patient. When asked why he had prescribed 60 tablets of oxycodone 10 mg over 4 days the respondent said that he then currently had no recollection why this had happened and could only speculate that the patient may have been in a lot of pain. He said that with hindsight he did not think that it was an appropriate level of prescribing, that he now had different beliefs about appropriate pain relief and that he had always felt that pain relief was under-prescribed in dentistry. 2. However, in conceding that this particular prescribing pattern for this patient was inappropriate he said that he still believed that not all of his prescribing was inappropriate. 3. The respondent conceded that there was no clinical note in his records for the issue of a script on 14 May 2015, nor were there any clinical records relating to the patient's attendance that day. Nevertheless, there was a notation in the "appointment history" that the patient attended on the respondent at 10.45 that day and was 5 minutes late. 4. Some of the scripts for oxycodone for this patient were written on the PBS and some were written as private scripts. The respondent explained this by saying that he had been told to write private scripts if they were for medication outside PBS criteria, which provided that the patient had to be in moderate to severe pain. He said he prescribed private scripts because he wanted on some occasions to go straight to oxycodone. He disagreed that this was contrary to good dental practice. 5. The respondent issued scripts for oxycodone for this patient on 23, 25 and 30 May 2016, but there were no clinical notes associated with their issue save for 30 May. The respondent was unable to provide any explanation, reason or excuse why he would have issued these scripts in 2016. He said that he knew in 2016 that prescribing oxycodone to patients created a risk to their health, that they were in danger of becoming addicted and taking this medication could prove fatal. Patient B 1. In cross examination the respondent conceded that he was not the primary treating practitioner for this patient's temporomandibular joint condition and he was only treating her pain. He conceded that he had issued a number of scripts for oxycodone for her without making any clinical notes and agreed that this was "grossly inappropriate." Nevertheless, he maintained that it was appropriate to continue to prescribe oxycodone for her because she was in tears and in acute pain, although there was no clinical note that she presented in this way. He said he now knows that this patient was also being prescribed oxycodone by her general practitioner. He accepted that it was inappropriate for him to have continued to prescribe oxycodone over a long period of time. Patient C 1. The respondent agreed in cross examination that notwithstanding that this patient was under the care of a number of health practitioners, including a pain management specialist, he prescribed oxycodone to him on 30 occasions between 15 March 2013 and 6 June 2016. He conceded that he had concluded that this patient was drug dependent but was unable to say when he had formed this opinion. The respondent agreed that it was dangerous for a patient to obtain opioid medication from multiple sources and that he should have enquired of the other treating practitioners whether they were also prescribing this medication for this patient. Patient E 1. In cross examination the respondent acknowledged that this patient had complex medical conditions including chronic pain and chronic respiratory problems. He acknowledged that diazepam and oxycodone which he had prescribed for her could depress the patient's respiratory system. Although the respondent had spoken to her treating medical practitioners "once or more" he had not asked them about the medication which he was prescribing but he had only enquired about her then current medication from each of them. The respondent conceded that his prescribing pattern should have been monitored by the patient's general practitioner or specialist practitioner rather than him. However, he said that she was "very aware of her own condition. She knew it was okay because she had not had scripts from her doctors for some time." The respondent said he was relying on the patient's self-report and acknowledged that this was inappropriate. 2. In general terms the respondent acknowledged that his clinical notes concerning this patient were inadequate. There was nothing contained in his notes concerning any diagnosis that the patient was opioid tolerant. There was no record of him having spoken to the patient's general practitioner on each occasion that he said that he had done so, or clinical note entries on each occasion he had prescribed for her. 3. The respondent had issued a script for 50 diazepam 5 mg on 2 December 2013 and for 20 diazepam 5 mg on 5 June 2014. He said the first script was issued for her to take before coming to him for further treatment. He agreed that a quantity of 50 was inappropriate and that he should have prescribed a quantity of 10. He said he did not realise that the patient may have been taking Valium for other purposes, and he only found out later she had also been receiving this medication from her general practitioner. With respect to the second script, the respondent agreed that he should not have prescribed Valium on this occasion because the prescription was not related to any particular dental condition for which he was treating her and was related more to her underlying general medical condition. Patient F 1. In cross examination the respondent agreed that he was treating this patient's pain as a symptom and was not treating the underlying cause. He said he should have sent the patient to an oral surgeon but the patient could not afford this and he continued to be in pain. The respondent said that throughout the period 2013 to 2016 he had "a real problem in saying no" to patients who were complaining of pain and asking for pain relief. He said that he agreed that his role should have required him to stand firm and resist their requests. 2. The respondent conceded that his clinical notes were inadequate as alleged. Patient G 1. In cross examination the respondent conceded that his prescribing pattern was inappropriate. He said that the patient lived in Macksville and travelled 5 hours to see him for multiple implants. He conceded that he should have told the patient to see his general practitioner for pain relief. However, he knew that some medical practitioners would not write Schedule 8 drugs for oral pain and accordingly he forwarded a script to him by mail. The respondent conceded that he could have called the patient's general practitioner himself and discuss the matter with him. He also conceded that it was inappropriate to have written a script for oxycodone without examining the patient. Nevertheless, he said that he thought the patient's complaints were consistent with the effects of the treatment and he was prescribing for the future in the event that the patient's pain worsened. Patient H 1. The respondent conceded in cross examination that it was inappropriate for him to have given the medication to her together with a bottle of wine. Nevertheless, she was a registered nurse and he thought that she would know of the dangers of consuming alcohol with oxycodone. 2. The respondent also conceded that in a letter forwarded by his solicitors on 10 August 2016 that he had previously denied that he had given this patient the oxycodone with a bottle of wine. Patient I 1. In cross examination the respondent said that he had prescribed oxycodone because there had been a complication with the placement of the implants. However, he conceded that there was no record in the clinical notes of this having occurred. He also conceded that he had been too quick to prescribe oxycodone and should have waited to see how the patient's condition progressed. He said that he was anticipating that the patient might suffer pain. Patient J 1. In cross examination the respondent conceded that he had prescribed oxycodone partly only for his dental treatment but also with respect to the patient's overall general medical condition, and that this was inappropriate. He also conceded that his clinical notes were inadequate in this regard. Patient K 1. In cross examination the respondent conceded that it was inappropriate to prescribe oxycodone to this patient. He conceded that he had written all of the scripts referred to in the Particulars of the Complaint other than temazepam on 13 April 2014, because his son had been born that day and he was not present at the practice. Concessions made by the respondent 1. During the course of the hearing the respondent made a number of concessions concerning Complaint One and Particulars and denied others. Subsequently, the applicant amended the Complaints, and the respondent made concessions following those amendments. 2. In summary, during the course of the hearing the respondent conceded the following Particulars of Complaint One, namely 1, 2, 3, 4, 5, 6, 7 and 8. Findings on Particulars of Complaint One Particular 1 1. The evidentiary material demonstrates that oxycodone was kept either in a desk drawer or a cabinet, both of which had locks. However the respondent's mother who was not a dental or other health practitioner had access to a key, and other staff also knew the location of the key. The respondent said that he was unaware of the nature and extent of this requirement and properly conceded that he had failed to comply with the provisions of Regulation 73. We find this Particular proven. Particular 2 1. The respondent conceded in evidence that he had failed to maintain and make entries in a drug register as required by Regulations 111 and 112. These breaches occurred over a period exceeding 9 years. We find this Particular proven. Particular 3 1. Although the respondent initially sought to resist this Particular, he was ultimately forced to concede that it was proven, by reference to the clear documentation which demonstrated that he was guilty of this conduct. We find this Particular proven. Particular 4 1. The respondent conceded that he was guilty of this Particular, his guilt having clearly been demonstrated by the evidence to which we have earlier referred, in considering the observations of Dr Sridhar. This is misconduct of a most serious kind given the prescribing patterns of the respondent, and the obvious dangers associated with the inappropriate prescription of drugs of addiction. We find this Particular proven. Particulars 5 and 6 1. At first, the respondent declined to accept that he had issued the quantity of drugs alleged in Particular 5. However, when confronted with the underlying documentation he conceded that the allegation had been made out. The prescription of this drug was severely criticised by Dr Sridhar, and it demonstrates that the respondent was acting either out of abject ignorance or gross carelessness in prescribing it to patients who were having nitrous oxide, and, as conceded by him, making it available to family members. We find these Particulars proven. Particulars 7 and 8 1. These particulars are interrelated. The evidence consists of the copies of the scripts issued by the respondent. Certainly, in the case of the scripts for oxycodone, the respondent was required by the Regulations to issue scripts in the names of the individual patients. Arguably, the same approach should be adopted with respect to scripts for drugs regulated by Schedules 4 and 4D. Whilst, on the evidence of Dr Sridhar, there may be circumstances where a dental practice may wish to keep a small amount of medication available for patients in need, the nature and extent of the drugs which are the subject of these Particulars falls far beyond acceptable quantities. Furthermore, on the evidence, the quantities of these drugs and some of the drugs themselves were beyond what could properly have been prescribed by the respondent as a dental practitioner, assuming they were intended for particular patients. These circumstances are exacerbated by the concession by the respondent that he sometimes anticipated that his patients might suffer pain, and he prescribed oxycodone on this basis. Such conduct incurred the strong criticism of Dr Sridhar because the respondent had failed to make a proper assessment of the patient's condition before prescribing oxycodone, and without first providing alternative and more appropriate pain relief. 2. We find these Particulars proven. Particular 9 1. We have previously described the circumstances pertaining to these patients when considering the expert opinion of Dr Sridhar. There is no information before us which would tend to discredit the underlying factual assumptions upon which Dr Sridhar's opinion is based, and we are comfortably satisfied that those factual assumptions have been proven. The comments made by Dr Sridhar with respect to each of these patients which we have summarised above are sufficient to enable us to find that each of the matters contained within this Particular is proven. Particular 10 1. The state of the respondent's clinical records is the subject of comment by Dr Sridhar, which we have earlier summarised Particular 11. The respondent conceded many of the matters referred to in subparagraph a, and all of the matters in subparagraph b. Having regard to the examination of the clinical records of the respondent undertaken by Dr Sridhar, we are comfortably satisfied that all of the matters referred to in this Particular have been proven, and we so find. Particular 11 1. We have earlier noted that Dr Sridhar expressed reservations about the descriptions "opioid tolerant" and "opiate tolerant" used by the respondent in his clinical notes. In his opinion such a diagnosis could only be made by a health practitioner with specialist training or specialised experience. In his evidence the respondent relied upon what he had learned when undertaking a Bachelor of Dentistry degree but was unable to point to any specific subject which would have indicated that he was qualified to make these diagnoses. Furthermore, there is no evidence that the respondent possessed any specialised experience in working in the area of drug dependency. We find this Particular proven. Particulars 12 and 13 1. Based on the expert opinion of Dr Sridhar and the concessions made by the respondent in the course of cross examination concerning the circumstances of Patients A and B, we accept the criticism levelled by Dr Sridhar concerning the treatment of these patients by the respondent, which we have summarised above. We have also summarised the concessions made by the respondent concerning these patients. 2. It is clear that the respondent prescribed an extraordinarily large volume of oxycodone for these patients, he did not first attempt the use of alternative and preferable pain relief and, in the case of Patient A the application of a localised dressing of the socket. Nor, in the case of Patient A, did the respondent refer the patient for specialist treatment. These are substantial examples of a lack of appropriate knowledge and judgement on the part of the respondent. We find these Particulars proven. Particular 14 1. The respondent conceded in cross examination that this Particular had been established. Having regard to this evidence of the respondent concerning Patient C, and the expert opinion of Dr Sridhar we find this Particular proven. Particulars 15 and 16 1. The respondent conceded that these Particulars had been proven in the course of cross examination concerning the circumstances of Patient E. It is clear from his evidence and from the evidence of Dr Sridhar that the respondent's prescription of both oxycodone and diazepam was in all the circumstances inappropriate for this patient. Furthermore, as the respondent conceded, he had prescribed diazepam in circumstances unrelated to his dental treatment. We find these particulars proven. Particulars 17 and 18 1. These particulars concern the circumstances of Patient G. The respondent conceded in the course of cross examination that these Particulars had been proven. He endeavoured to justify the prescription of oxycodone on the basis that the patient might encounter pain in the future. Such justification has been firmly rebutted by Dr Sridhar, whose opinion we accept. On the basis of that opinion there can be no justification for prescribing drugs of addiction in case a patient might suffer pain in the future. Overall, having regard to the evidence of the respondent and the expert opinion of Dr Sridhar concerning the circumstances of this patient we find that these Particulars have been proven. Particulars 19, 20 and 21 1. These Particulars concern Patient H. In the course of cross examination the respondent conceded that each of these particulars had been proven. Based on this evidence, and on the evidence of Mr Tran and Dr Sridhar we find that these Particulars have been proven. We agree with the applicant that failing to make clinical notes for a patient because she was an employee is "totally unsatisfactory." Particular 22 1. This Particular concerns Patient I. In the course of cross examination the respondent conceded that this particular had been proven. Based on this evidence and on the evidence of Dr Sridhar we find that this Particular has been proven. Does the respondent's conduct constitute professional misconduct as alleged in Complaint Two? 1. The applicant alleges that by reason of Complaint One the respondent should be found guilty of unsatisfactory professional conduct and by reason of Complaint Two, the more serious form of misconduct, professional misconduct. We have determined to find that the respondent is guilty of professional misconduct, and we now set out our reasons for so finding. 2. Professional misconduct is defined in the National Law 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. This definition in turn refers to the definition of unsatisfactory professional conduct which is found in section 139B of the National Law. We reproduce hereunder that part of that definition which is relevant to our consideration of these proceedings: 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. (b) Contravention of this Law or regulations A contravention by the practitioner (whether by act or omission) of a provision of this Law, or the regulations under this Law or under the NSW regulations, whether or not the practitioner has been prosecuted for or convicted of an offence in respect of the contravention. 1. It is clear from the expert opinion of Dr Sridhar, which we accept, that the conduct of the respondent constitutes unsatisfactory professional conduct. All of the conduct of the respondent which is the subject of each of the Particulars of Complaint One has been assessed by Dr Sridhar as being significantly below the standard reasonably expected of a dentist of an equivalent level of training and experience of that of the respondent for the reasons which he has given. Each of these matters reflects upon the knowledge, skill and judgement of the respondent in his practice of dentistry. We are comfortably satisfied that in the aggregate all of these matters constitute unsatisfactory professional conduct and we so find. 2. It is now necessary to determine whether the respondent is guilty of professional misconduct as asserted by the applicant. By reason of the definition contained in section 139E which we have set out above, it is necessary to determine whether the unsatisfactory professional conduct is of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration or there is "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." 3. This directs attention to a consideration of those circumstances which would justify suspension or cancellation of registration. Whilst this involves the exercise of a value judgement having regard to all of the relevant factual circumstances, it must be undertaken in the context of the statutory regime which applies to these proceedings. 4. It is well-established that the jurisdiction of this Tribunal is primarily protective in nature. In exercising this jurisdiction there are a number of matters to which we must have regard. They have been succinctly referred to in the judgement of Meagher JA in the New South Wales Court of Appeal in Health Care Complaints Commission v Do [2014] NSWCA 307 (Basten and Emmett JJA agreeing). At [35] and following his Honour said; 35. The objective of protecting the health and safety of the public is not confined to protecting the patients or potential patients of a particular practitioner from the continuing risk of his or her malpractice or incompetence. It includes protecting the public from the similar misconduct or incompetence of other practitioners and upholding public confidence in the standards of the profession. That objective is achieved by setting and maintaining those standards and, where appropriate, by cancelling the registration of practitioners who are not competent or otherwise not fit to practise, including those who have been guilty of serious misconduct. Denouncing such misconduct operates both as a deterrent to the individual concerned, as well as to the general body of practitioners. It also maintains public confidence by signalling that those whose conduct does not meet the required standards will not be permitted to practise. 36. In Law Society of New South Wales v Foreman (1994) 34 NSWLR 408 Mahoney JA described (at 441) the scope of the objective of protecting the public interest in the context of disciplinary proceedings against a solicitor as follows: "The protection of the public has been described as, for example, the primary purpose or primary object of such proceedings: ... In the relevant sense, the protection of the public is in my opinion not confined to the protection of the public against further default by the solicitor in question. It extends also to the protection of the public against similar defaults by other solicitors and has, in this sense, the purpose of publicly marking the seriousness of what the instant solicitor has done. But, in my opinion, it would be wrong to confine the objects of disciplinary proceedings and the purposes to be achieved by the orders made in them strictly to matters of this kind. Those purposes and objectives have traditionally been seen as having a wider operation. In the end, the question to be determined is whether the solicitor is a fit and proper person to be a solicitor of the Court and the orders to be made are to be directed to ensuring that, to the extent she is not, her practice is restricted." 37. In Herron v McGregor (1986) 6 NSWLR 246 McHugh JA referred more briefly to the same consideration (at 258): "It is, of course, of fundamental importance to bear in mind the public interest in disciplining doctors who are guilty of professional misconduct. In many cases the protection of the public and the maintenance of professional standards requires that the names of doctors be removed from the register. However, it is present fitness to practise which is the principal and ultimate issue of public interest." 1. We should make it clear that in determining whether the conduct of the respondent may be characterised as professional misconduct justifying cancellation or suspension of registration, such a characterisation is not necessarily determinative of any consequential appropriate protective orders. Our concern for present purposes is to determine whether or not the conduct is such that cancellation or suspension is warranted. In determining this matter we have regard to the protection of the public, the maintenance of public confidence in the integrity of the profession, and the deterrent effect both on the respondent and on other members of the dental profession. 2. As has been endorsed often by this Tribunal, a medical practitioner who prescribes and handles drugs of addiction recklessly and contrary to the law engages in conduct which constitutes professional misconduct. In Spicer v NSW Medical Board & Ors (Court of Appeal (NSW), 19 February 1981, unrep), Hope JA (Reynolds and Hutley JJA agreeing) said: In my opinion it is clear beyond argument that the proper handling and prescribing of drugs by medical practitioners are of the greatest importance to the community. If a medical practitioner handles or carries out that very great responsibility in a way that is reckless and which shows a disregard to the law it cannot be said that he is fitted at such a time to be a medical practitioner. In my opinion the view expressed by the Tribunal has implicit in it that not merely was he presently unfitted to treat those addicted or habituated to drugs but that that unfitness in itself demonstrated his present unfitness to be a medical practitioner 1. There is no reason why these comments made in Spicer should not apply equally in the case of a dentist who is also given the privilege of prescribing to the public restricted drugs, including drugs of addiction. 2. The pervasive and substantial failure of the respondent to make a record of the issue of prescriptions for drugs of addiction for each of the patients as detailed in the Particulars of the Complaints is a serious matter. The observations of Dr Sridhar concerning the necessity of ensuring that records of these matters are kept scrupulously are reinforced by the provisions of the Code of Conduct issued by the Dental Board of Australia. The version issued in March 2014 notes that it is essential that dental practitioners maintain clear and accurate health records "for the continuing good care of patients or clients." Those records should be kept in such a form that they can be understood by other health practitioners. As Dr Sridhar observed, the necessity of accurate records is enhanced when dealing with drugs of addiction, especially in circumstances where patients were being treated by other health practitioners and, in some cases, also being prescribed drugs of addiction. 3. We summarise the conduct of the respondent which we have earlier described as including: 1. a failure to carry out a proper assessment of the patients' conditions 2. a failure to make timely and appropriate specialist referral 3. the prescription of drugs of addiction for an improper purpose and in inappropriate quantities 4. the failure to make appropriate and proper clinical notes 5. the failure to store drugs of addiction appropriately in accordance with legislative requirements 6. the failure to maintain a drug register as required by law. 1. Assuming that it was the intention of the respondent to competently practise safe dentistry, he was clearly out of his depth in prescribing drugs of addiction. He has demonstrated an inadequate knowledge of the circumstances in which drugs of addiction should be prescribed and all of the cautionary measures which should attend their prescription. There is occasional reference in his notes to the addictive nature of the drugs being prescribed by him and the precautions which he said he gave to the patients, but such information was rarely shared with the bulk of his patients, at least as recorded in his clinical notes. This demonstrates that he had at least some inkling that he had a responsibility in this area, and yet he failed to fulfil that responsibility in most cases. Furthermore, the respondent failed in some cases to adequately and appropriately monitor the progress or otherwise of the patients, offer alternative medication or treatment and insist on the patients complying with requests for referral to specialists or allied health practitioners. And of course, the failure of the respondent to conduct, in some cases any, and, in most other cases some appropriate examination of the patients and to take an appropriately detailed history is also indicative of incompetence as a dental practitioner. This failure is compounded by the failure to make and maintain appropriate clinical notes as required by the legislation. 2. We commenced our consideration of the factual background to these proceedings in [5] by referring to the respondent's own Prescribing Policy for Pain Relief. It is a tragedy that if the respondent had followed his own policies, he would not have embarked upon a course of treatment that resulted in him being found guilty of professional misconduct. 3. In all the circumstances we find that the conduct of the respondent which we have found that he engaged in is so serious that in the aggregate it justifies a finding that he is guilty of professional misconduct. That is, the conduct is so serious that it would justify cancellation or suspension of the respondent's registration as a dental practitioner on the basis that he is not a fit and proper person to practice as such. The further course of the proceedings 1. Consequent upon the finding of professional misconduct which we have made, it then becomes necessary to determine by means of a stage 2 hearing whether any and what protective orders should be made. 2. The applicant should initially indicate to the respondent what protective orders it intends seeking based on our findings and our reasons therefor. 3. We stand the proceedings over to enable the respondent to file such evidence upon which he seeks to rely and any submissions he wishes to make concerning the making of any protective orders. The applicant should then be permitted to file any evidence and submissions in reply. On receipt of this material we shall advise the parties concerning a hearing date for the stage 2 hearing, and the means by which any hearing will be conducted. Orders 1. Consequent upon the finding of professional misconduct which we have made we make the following orders: 1. the applicant is to inform the respondent within 7 days what protective orders and other orders that it then currently seeks to be made against the respondent 2. the respondent is to file and serve within one month of receipt of the information in (1) above the evidence and submissions upon which he seeks to rely for the purpose of the stage 2 hearing 3. the applicant is to file and serve within 21 days of receipt of the material in (2) above any evidence and submissions upon which it seeks to rely 4. the parties will be informed by the Tribunal upon receipt of the above of the date of any stage 2 hearing and the means by which it will be conducted. ********** I hereby certify that this is a true and accurate record of the reasons for decision of the Civil and Administrative Tribunal of New South Wales. Registrar DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment or decision. The onus remains on any person using material in the judgment or decision to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court or Tribunal in which it was generated. Decision last updated: 30 April 2020