First, the Alaska Division had proved that the Applicant demonstrated professional incompetence, gross negligence, or repeated negligent conduct, and engaged in unprofessional conduct, by overprescribing high dose opioids (TB 101), including the following breaches:

• voluminous prescribing of controlled substances, and in dangerous combinations (TB 103);
• inadequate patient assessment in a high volume practice (with numerous instances of seeing more than 50 patients a day), and documentation of physical examinations which were inadequate for the purposes of determining a diagnosis (TB 104);
• reliance on high doses which were routinely prescribed to new patients (TB 104-105);
• failing to obtain background information and prior medical records, either initially or on follow up, for patients who were prescribed opioids on the first visit (TB 106-107); and
• insufficient monitoring and following of patients after initiating high dose prescriptions, given the Applicant was only in Alaska a few days each month (TB 108-109).

1. Judge Mandala concluded that, based on the evidence presented, the Alaska Division of Corporations, Business and Professional Licensing had:

...met its burden of proving Dr Ahmad's practices pose a clear and immediate danger to the public health and safety. Summary suspension during the pendency of the disciplinary proceeding on the May 2016 Accusation is therefore justified and should continue in place.

1. Two days later, on 29 June 2016, Ahmad sent a written response to AHPRA's 17 June 2016 notification letter.
2. On 14 July 2016, the Arkansas Board issued an amended emergency order of suspension. The amended order included reference to Judge Mandala's decision to continue the summary suspension in Alaska. The amended order also set the date of hearing to decide whether Ahmad had violated the Arkansas Medical Practices Act for 4 August 2016.
3. On 4 August 2016, the Arkansas Board voted to lift Ahmad's suspension. Ahmad has given evidence that this was because he had surrendered his Drug Enforcement Agency privileges and could no longer prescribe controlled substances.
4. Also on 4 August 2016, the Alaska Board adopted Judge Mandala's decision to uphold the summary suspension.
5. In Australia, that same day, the Board decided to take no further action in relation to the 9 June 2016 notification, as it was satisfied based on the information provided that there were no concerns relating to Ahmad's professional performance or conduct as a registered medical practitioner in Australia. (It did not know of the Alaskan judgment, at that stage.)
6. On 5 August 2016, Ahmad voluntarily surrendered his Alaskan physician licence. The terms were that the surrender concluded the investigation and hearing of the accusation without final action by the Alaska Board, that Ahmad could not and would not practice in Alaska, and that his licence could not be returned.
7. The next day, 6 August 2016, the Alaska Division of Corporations, Business and Professional Licensing notified AHPRA in Australia, of the Alaskan decision upholding the summary suspension of Ahmad's Alaskan licence.
8. On 8 August 2016, AHPRA responded, requesting a notification be completed. AHPRA also wrote to Ahmad, telling him a new notification about his conduct had been received.
9. On 11 August 2016, the Board informed Ahmad via letter that it would not be taking further action in relation to the 9 June 2016 notification.
10. On 22 August 2016, the Immediate Action Committee of the Board wrote to Ahmad informing him of its proposal to take immediate action in relation to his registration. Specifically, the Committee stated that it proposed to suspend Ahmad's registration in Australia. This was as a result of it being notified of the Alaskan judgment and suspension.
11. Ahmad's then attorney, Mr Drake Mann, wrote to the Board on 23 August 2016 in response to the Board's immediate action proposal.
12. On 24 August 2016, the Alaska Board accepted Ahmad's licence surrender, 'in lieu of potential revocation of licensure for professional incompetence, gross negligence, repeated negligent conduct, and unprofessional conduct'.
13. On 25 August 2016, the Board decided to take immediate action to suspend Ahmad's registration in Australia, on the basis that his registration had been suspended in Alaska and on the basis that Ahmad posed a serious risk to persons and it was necessary to take immediate action to protect public health or safety (the immediate action decision).
14. The Board also decided to commence an investigation under the National Law.
15. On 20 September 2016, Ahmad applied to the Tribunal for a merits review of the Board's immediate action decision.
16. On 26 September 2016, the Board informed Ahmad of the issues identified for the purposes of its investigation of him and requested information regarding his practice in Australia. Ahmad provided a response to the Board's investigation on 12 October 2016.
17. On 13 October 2016, the Arkansas Board revoked Ahmad's licence to practice in Arkansas, based on the findings of Judge Mandala in the Alaskan judgment.
18. Nearly two months later, on 3 December 2016, Ahmad's then attorney, Mann, wrote to AHPRA on 3 December 2016 informing it that Ahmad's licence to practice medicine in Arkansas had been revoked on 13 October 2016.
19. The Tribunal heard Ahmad's application to review the Board's immediate action decision in March 2017. On 11 October 2017, it upheld the Board's immediate action decision: see Ahmad (2017).
20. As summarised by the Board in its submissions in this case, the Tribunal in that decision found:
    1. The decision of Judge Mandala in Alaska was relevant not only to the power to take immediate action under s 156(1)(d) (suspension of registration in another jurisdiction), but it also contained a detailed record of evidence presented at the hearing which raised concerns to warrant immediate action under s 156(1)(a) (serious risk to persons) (at [51]-[53]);
    2. The Applicant's registration had been suspended under the law of Alaska for the purposes of s 156(1)(a) of the National Law, notwithstanding that the decision of Judge Mandala was to suspend the Applicant's licence summarily, before a full hearing (at [55], [57]);
    3. The expert evidence of Dr Stacey (relied on in the Alaska proceedings, and who gave evidence to VCAT) was considered and clear, and strongly supported by the patients' records themselves (at [77], [80]). By contrast, the evidence of the Applicant's witness, Dr Huraibi, was of comparatively limited weight. Dr Huraibi was not an independent witness, and his expert report was nearly identical to the Applicant's response (at [81], [83]-[84]);
    4. There was a strong basis in the objective evidence before the Tribunal that the Applicant's performance as a medical practitioner posed a serious risk to persons (at [99]). The material before the Tribunal indicated a lack of sound professional judgment and a reckless practice of medicine (at [100]);
    5. The Tribunal considered that immediate action was necessary to protect public health and safety, within s 156(1)(a). The material before the Tribunal raised serious questions about the Applicant's professional judgment (at [104], [107]). Further, immediate action was warranted under s 156(1)(a), because of the reasons for the suspension in Alaska (at [108]);
    6. The Tribunal decided to suspend the Applicant's registration as an anaesthesiologist, as well as his general registration. Although the practice of anaesthesia involves a different practice environment, it involves pre-operation consultation and assessment, and requires sound professional judgment. Suspending this specialist registration as well was required to manage the risk posed (at [115]-[119]).
21. On 15 July 2018, AHPRA emailed the Arkansas Board requesting information concerning the reasons and circumstances of the revocation of Ahmad's licence. The Arkansas Board supplied the requested information on 18 July 2018.
22. AHPRA notified Ahmad of its proposal to impose a condition not to practice and invited his submission by letter dated 21 August 2018.
23. On 6 September 2018, Ahmad made oral submissions to the Board. The Board varied its decision to take immediate action, by revoking the suspension of Ahmad's registration and imposing a condition not to practice as a medical practitioner, on the basis that it was 'the more appropriate form of immediate action to take'. It informed him by letter dated 11 September 2018.
24. On 13 September 2018, ANZCA emailed Ahmad confirming his membership of that body had been automatically terminated on 16 February 2017. (That was when ANZCA had been notified by AHPRA of the immediate action suspension.)
25. On 26 September 2018, Ahmad applied to renew his general and specialist registration in Australia.
26. A day later, on 27 September 2018, he applied to the Tribunal for a merits review of the Board's decision to impose a condition not to practice.[6]
27. Ahmad's general and specialist registration expired on 30 September 2018.
28. On 20 December 2018, the Board proposed to refuse Ahmad's application to renew his registration. On 17 January 2019 the Board wrote to Ahmad, informing him that it proposed to refuse his application for general and specialist registration renewal and inviting him to make submissions in response.
29. Ahmad provided written submissions and material in support on 18 February 2022 and an addendum on 19 February 2019.
30. On 14 March 2019, the Board made the decision (under review in this case)[7] to refuse Ahmad's application to renew his general and specialist registration on the grounds that he was not a suitable person to hold registration as a medical practitioner. The reasons the Board gave for that decision are summarised in its submissions:
    1. The Board noted that the Applicant had his medical licence in Alaska suspended by the Alaska Board, and that an appeal to the Alaska Office of Administrative Hearings was unsuccessful. The Applicant surrendered his Alaskan medical licence in August 2016, and had his Arkansas medical licence revoked by the Arkansas Board on 13 October 2016. The Board referred to the findings by Judge Mandala that the Alaska Board had met its burden of proof in demonstrating that the Applicant had demonstrated professional incompetence, gross negligence, repeated negligent conduct and unprofessional conduct (TB 646-647 [2]-[3]).
    2. The Board set out the Tribunal's findings in Ahmad (2017) on the concerning aspects of the Applicant's behaviour, and observed that the Tribunal's findings endorsed the earlier report of Dr Stacey in the Alaskan investigation (TB 647 [4]-[5]).
    3. The Board considered that the Applicant's continued submissions that his prescribing and treatment practices were correct demonstrated a serious lack of insight. Accordingly, if the Applicant were permitted to return to practice, he would be unlikely to modify the way he practices medicine. The Board considered that the Applicant had not reflected on his past conduct or learned from it. Although the Applicant submitted that he no longer prescribed pharmaceutical medications, the issue was the Applicant's lack of insight into why his past performance put patients at risk (TB 647-648 [6]-[9]).
    4. Noting the matters set out above, the Board (TB 648 [10]):

(a) decided that the Applicant was not a suitable person to hold general registration on the basis of the cancelled registration previously held in another jurisdiction, under s 55(1)(e) of the National Law (and was therefore unsuitable to hold specialist registration under s 60); > > (b) was not a fit or proper person to hold registration under s 55(1)(h)(i) of the National Law, and therefore was not a suitable person to hold registration; > > (c) was unable to practise the profession competently and safely under s 55(1)(h)(ii) of the National Law, and therefore was not a suitable person to hold registration.

31. On 18 March 2019, Ahmad was notified of the Board's refusal to renew his general and specialist registration.
32. On 9 April 2019, Ahmad lodged the application for review of the Board's decision.
33. Twenty months later, in December 2020, Ahmad made inquiries to the Alaska Board about reinstating his licence in Alaska.
34. Between 1 April 2021 to 11 June 2021, Ahmad made inquiries with the Saskatchewan Health Authority and College of Physicians and Surgeons of Saskatchewan regarding licensure in Saskatchewan.
35. On 8 June 2021, Ahmad wrote to the American Board of Anaesthesiology seeking reinstatement to that organisation, in order to fulfil the College of Physicians and Surgeons of Saskatchewan's requirements for licensure.
36. On 9 October 2021, Ahmad commenced working with MSC Cruises as a cruise ship doctor. He indicated at the hearing that he really enjoyed this work and intended to continue practice as a maritime doctor. He filed letters from satisfied patients and others, indicating that he is well regarded in that role.
37. On 21 October 2021, Ahmad applied to the Alaska Board for reinstatement of his Alaska medical licence.
38. On 12 January 2022, Ahmad made inquiries about reinstating his Arkansas medical licence, and sent a further letter to the Alaska Board seeking a return to practice there.
39. On 7 April 2022, the Arkansas Board decided to permit Ahmad to re-apply for an Arkansas medical licence in that State. In cross-examination at the hearing in this case, Ahmad said he had not yet lodged an application but intended to do so shortly.
40. The Tribunal has review jurisdiction in relation to decisions made by the Board in relation to renewal of registration, under s 199(1)(c) of the National Law. In exercising that jurisdiction, the Tribunal stands in the shoes of the Board. It is required to make the correct or preferable decision having regard to the material before the Board, and to new material that comes to light after the decision under review. It assesses the requirements for renewal of registration as at the time of its decision (not when the Board's decision was made). It is required to consider if Ahmad 'is' not a fit and proper person, or 'is' unable to practice the profession competently and safely (s 55(1)(h)).[8]
    1. In determining this matter, the Tribunal gives proper weight and respect to the opinions of the Board, as it is the regulatory body with specialist expertise.[9] However, it notes that it considers the evidence as a whole strongly supports the decision the Board made, and which the Tribunal confirms, in any event.

The National Law and registration of medical practitioners

1. The National Law covers the registration of medical practitioners. As the Board outlines in its submissions:
   1. The registration of medical practitioners is governed by Pt 7 of the National Law.
   2. Objects and purposes (ss 3-4): By s 4, an entity with functions under the National Law is to exercise those functions having regard to the objectives and guiding principles of the scheme, and the paramount guiding principle.

(a) The object of the National Law is to establish a national registration and accreditation scheme for the regulation of health practitioners (s 3(1)). The objectives of that scheme include: to provide for the protection of the public by ensuring that only health practitioners who are suitably trained and qualified to practice in a competent and ethical manner are registered (s 3(2)(a)); and to facilitate the provision of high-quality education and training of health practitioners (s 3(2)(c)). > > (b) The guiding principles of the scheme include: the scheme is to operate in a transparent, accountable, efficient, effective and fair way (s 3(3)(a)); and restrictions on the practice of a health profession are to be imposed only if it is necessary to ensure health services are provided safely and are of an appropriate quality (s 3(3)(c)).

3. The fundamental objective of the National Law is to maintain public safety and public confidence in the health profession and the standards of conduct of health practitioners. That fundamental objective is reinforced by a policy direction dated 3 January 2020 made by the Ministerial Council under s 11(2) of the National Law, which states: 1. The Council supports that regulatory decision making by Ahpra and National Boards within the National Registration and Accreditation Scheme must act in the interests of public protection, patient safety and support the safety and quality of health services.

2. In applying the guiding principle contained in section 3(3)(c) of the National Law, when determining whether it is necessary for regulatory action to be taken, National Boards and Ahpra must

1. take into account the potential impact of the practitioner's conduct on the public, including vulnerable people within the community such as children, the aged, those living with disability and people who are the potential targets of family and domestic violence; and
2. consider the extent to which deterring other practitioners from participating in similar conduct would support the protection of the public and engender confidence in the regulated profession.

1. Suitability for general and specialist registration (Divs 1 and 2): The eligibility requirements for general registration are contained in s 52 of the National Law, and include that "the individual is a suitable person to hold general registration in the health profession" (s 52(1)(c)).
2. By s 55(1), a National Board may decide that an individual is not a suitable person to hold general registration in a health profession if (relevantly):

(e) the individual's registration (however described) in the health profession in a jurisdiction that is not a participating jurisdiction, whether in Australia or elsewhere, is currently suspended or cancelled on a ground for which an adjudication body could suspend or cancel a health practitioner's registration in Australia;

(h) in the Board's opinion, the individual is for any other reason -

(i) not a fit and proper person for general registration in the profession; or

(ii) unable to practise the profession competently and safely.

1. The eligibility requirements for specialist registration are contained in s 57, and include that "the individual is a suitable person to hold registration in the health profession" (s 57(1)(c)). By s 60, s 55 applies to a decision by a National Board that an individual is not a suitable person to hold specialist registration in a recognised speciality.
2. In each case, the period of registration is not more than 12 months (s 56; s 61).
3. Registration (Div 6): Part 7, Div 6 deals with applications for registration.
4. A National Board may refuse to grant an applicant registration in the health profession on the grounds in s 82(1)(c). Those grounds include that "the Applicant is ineligible for registration in the profession under a relevant section because the Applicant ... is not a suitable person to hold registration" (s 82(1)(c)(i)(C)). "Relevant section" includes both s 52 and s 57 (s 82(2)).
5. A National Board may impose any condition on registration that the Board "considers necessary or desirable in the circumstances" (s 83(1)).
6. Renewal of registration (Div 9): Part 7, Div 9 deals with renewals of registration.
7. A National Board may refuse to renew an Applicant's registration on the grounds in s 112(2). Those grounds include "any ground on which the Board could refuse to grant the registration or endorsement under section 82 ... if the application were for a grant of registration ..." (s 112(2)(a)).

Ahmad is not a suitable person to hold general registration

1. The Tribunal finds that Ahmad is not a suitable person to hold general registration under the National Law because the Tribunal considers that he is not a fit and proper person for general registration in the profession: s 55(1)(h)(i).
   1. There only needs to be one reason for the Tribunal to find Ahmad not a suitable person to hold registration, in order for it to affirm the Board's decision not to renew Ahmad's licence. However, the Tribunal also finds that Ahmad is not a suitable person to hold general registration under the National Law because the Tribunal is of the opinion that he is unable to practise the profession competently and safely: s 55(1)(h)(ii).[10]
   2. The reasons the Tribunal considers that Ahmad is not a fit and proper person for general registration are, in short, the serious deficiencies in his Alaskan practice between August 2015 and May 2016 (after issues having already occurred in 2012), some of his conduct since, and, significantly, his ongoing lack of insight into his responsibility for those deficiencies.
   3. The meaning of 'fit and proper' depends on context, but it includes whether the person has the necessary honesty, knowledge and ability, and sufficient moral integrity and rectitude of character to be entrusted with registration.[11]
2. The Tribunal is not satisfied that the protection of the public and maintenance of professional standards could be met, if Ahmad were allowed to resume practice as a medical practitioner.[12]
3. The reasons the Tribunal considers that Ahmad is unable to practice the profession competently and safely, under s 55(1)(h)(ii) of the National Law, are much the same as the reasons it considers that he is not a fit and proper person for general registration.
4. 'Competence' in the context of National Law refers to the capacity of the practitioner to exercise the requisite skill or judgment for the particular profession. The standard of skill and judgment by which a practitioner should be measured is the standard reasonably expected of a practitioner of equivalent seniority and experience by fellow practitioners and members of the public.
5. The Tribunal is satisfied that Ahmad's practice of medicine in Alaska in 2015-2016 was contrary to Australian standards of competency and fitness for the practice of pain management. These deficiencies in his Alaskan practice are relevant to the present consideration of his competency and fitness to hold general registration, and/or practice as an anaesthetist, in Australia.
6. As indicated above, the Tribunal accepts the evidence of Cohen, an Australian expert in pain management, and prefers his evidence to Ahmad's expert witnesses.
7. Cohen carefully considered records provided from Ahmad's Alaskan practice, providing detailed conclusions in his reports.[13] He refers to three main themes which permeated Ahmad's then practice.
8. First, Ahmad had an inadequate knowledge base, including as to the clinical pharmacology of opioids (and other drugs), opioid tolerance, and equianalgesic doses of opioids.
9. Secondly, Ahmad demonstrated poor clinical method, at the assessment level (with a 'one size fits all' method of assessment, illustrated by his high reliance on a written questionnaire to tell him what was going on with patients), the diagnostic level (with generic diagnoses, with terms varying over time), and the therapeutic level (with gross over-prescription of opioids, and routine co-prescription of the benzodiazepine diazepam in high doses). This raised major pharmacotherapeutic questions.
10. Thirdly, Ahmad demonstrated poor clinical judgment, with a failure to modify his opinions or therapeutic plans based on subsequent presentations of particular patients. He demonstrated naivete (as he concedes). This presented as a failure to recognise blatant aberrant opioid-related behaviour, and in uncritical reliance on the information (or lack of it) provided by patients - without obtaining earlier medical records - and on patients' compliance with the instructions he provided about dosages to be taken.
11. Cohen was of the view that Ahmad's assessment of individual patients 'are egregiously inadequate, to the extent of perpetuating harm'. He said that Ahmad's assessments were characterised by the formulaic, questionnaire-driven approach, and the physical examination component is 'grossly inadequate'.
12. Some of these difficulties no doubt arose from the way Ahmad practiced in Alaska at that time, flying in and out and seeing patients over one three day weekend each month. (He gave evidence that in 2016 he was practicing in each of Australia, Arkansas and Alaska, spending about a week a month in Alaska and in Australia, and two weeks a month in Arkansas). In Alaska, he saw 179 patients over one three day weekend in December 2015. On a busy day in November 2015, he saw 54 patients, with appointments every 15 minutes. He considered five minutes sufficient to talk to patients before making prescriptions - together with reviewing a written questionnaire. His prescription practices so concerned pharmacists filling them that ultimately 10 of them wrote to report similar concerns about the levels of opioids being prescribed: see Alaskan judgment p 5.
13. Cohen did not see one example, in the 38 cases he reviewed, of appropriate prescription of any medication. He stated that the doses and combinations of medications used 'are likely only to have adversely affected the patients' cognitive function and overall quality of life'. Cohen was of the view that not one of the therapeutic interventions of Ahmad that he reviewed was safe. He was also critical of Ahmad's level of follow-up and monitoring of patients after prescribing opioids, and his record keeping practices.
14. Cohen's views are much the same as Judge Mandala's findings in the Alaskan case, and this Tribunal's decision in 2017. As the Board submits about the 2017 Tribunal decision:

... the Tribunal found that there was a strong basis in the objective evidence for a reasonable belief that the Applicant's performance as a medical practitioner posed a serious risk to persons: Ahmad (2017) [98]. The Tribunal summarised the matters which supported that view as follows in [99]:

• The prescription of controlled substances at the first appointment, for all patients in the records reviewed for this proceeding and in the Alaskan proceeding
• at uniformly high and dangerous starting doses
• often in dangerous combination with other controlled substances
• in circumstances where Dr Ahmad did not seek or insist on receiving patient records and images or otherwise verifying patients' self-reported history in respect of controlled or illicit substances and he did not access the PDMP database
• in circumstances where the patient records strongly suggest inadequate assessment and unsupported diagnoses and
• the nature of his practice in Alaska meant that he did not return for a follow-up appointment for a month.

1. The Tribunal in 2017 was considering a different statutory question (that is, did Ahmad pose a serious risk to persons within s 156(a) of the National Law). Judge Mandala was also considering a different question, and did so the context of a summary suspension of Ahmad's licence being sought. However, the factual findings were similar, as were the concerns about Ahmad's prescribing practices. Judge Mandala found Ahmad's conduct constituted a danger to public health and safety. The Tribunal found that the material before it indicated a lack of sound professional judgment and a reckless practice of medicine: see Ahmad (2017) at [100].
2. Notably, too, Huraibi, who was called for Ahmad, gave some evidence which highlighted the difficulties with Ahmad's practice in 2015/2016. Whilst Ahmad did not then get patients' medical records before prescribing medication, Huraibi said that he would make every attempt to obtain patient medical records before prescribing medications, and if that were not practicable, would prescribe and schedule a follow up appointment in 1-2 weeks when records arrived. He also made clear that - unlike the situation where Ahmad often did not record relevant points in medical notes - Huraibi would record relevant matters in medical notes (for example, if he had a conversation with a patient about why a urine test was inconsistent, he would record that answer in his notes). He also said that he would not include reference to a service he had not in fact performed for a patient - whereas Ahmad's records did include this on occasion.
3. Ahmad had various explanations for these issues, including needing to use particular types of computerised notes for insurance purposes, the exigencies of time and only having three days to see a lot of patients before he flew out of Alaska for another month, the different 'landscape' regarding pain relief in America in that period. However, none of them overcome the weight of the expert evidence, which the Tribunal accepts, as to the inadequacies in his practice. (And, perhaps to state the obvious, Ahmad was not being forced to see so many patients or to prescribe the drugs he prescribed in those dosages, on the basis of such short consultations.)
4. Ahmad did not produce much evidence of his ability as a general practitioner. The expert reports he relied on were directed more towards the difference between practice of pain management and anaesthesia, with a view to showing that the fact that he had deficiencies in pain management practice in the past should not stop him being entitled to practice as an anaesthetist. However, his practice in pain management is relevant to both general registration, and to being entitled to practice as a general practitioner and as an anaesthetist. That is why in the 2017 decision, the Tribunal decided to suspend the Applicant's registration as an anaesthetist, as well as his general registration: see Ahmad (2017) at [114]-[119]. Although the practice of anaesthesia involves a different practice environment, it involves pre-operation consultation and assessment, and requires sound professional judgment. Suspending this specialist registration as well was required to manage the risk posed. This Tribunal agrees with the previous Tribunal's comments about that.
5. The Tribunal accepts the evidence of Rosewarne that it is not possible to separate pain management skills from anaesthesia skills in Australian anaesthetic practice. The Tribunal notes too that Goucke - who was called for Ahmad - agreed that deficiencies in the practice of pain management, which raised concerns about a practitioner's pharmacology of opioid medication and exercise of independent medical judgment, would raise concerns about the ability of that practitioner to practice anaesthesia safely and competently. Those are substantially the same as Rosewarne's views.
6. Ahmad's medical practice since October 2016 has apparently consisted of intermittent medical practice in Pakistan - where he did not have access to opioids - and his practice as a cruise ship doctor. None of this practice since 2016 satisfies the Tribunal that something has changed such that he is currently able to practice competently and safely, or that he is fit to hold registration as a general or specialist practitioner, in the light of the problems that previously arose in Alaska.
7. Ahmad continues to show a concerning lack of insight into his responsibility for the deficiencies that occurred in Alaska in 2015 and 2016 in the conduct of his medical practice there.
8. At the time of the Board's decision, he had not demonstrated any real insight.
9. Later, he demonstrated a little. The letter he sent to the Board on 25 February 2021 states that he has now reflected further on matters and considers that his first responses to regulatory authorities were 'legalistic--denying fault, blaming others and avoiding reflection.' He says that with some distance from those events, he has considered his own conduct more critically.
10. However, Ahmad still has not squarely confronted the serious deficiencies in his earlier practice, nor has he accepted that what he did put some of his patients at serious risk of harm.
11. Many of the same responses he had made earlier (before Judge Mandala or the Tribunal in 2017) continued before this Tribunal.
12. He referred to the prescribing practices of some other doctors, who he said had even worse prescribing practices than him, and made it clear he thought it was unfair that he was being pursued. He repeated at the Tribunal hearing that his research had indicated there were 808 deaths from prescribing opioids in Alaska since his suspension in May 2016, with no other doctors being prosecuted, when he had no deaths or overdose from his practice. The fact that, fortunately, his practices did not lead to any deaths or overdoses does not somehow make that level of over prescribing safe, and it points to the possibility that some drugs were being diverted into the community: see Judge Mandala's comments about this (Alaskan judgment, pages 34-35) and the Tribunal's comments in Ahmad (2017) at [88].
13. Ahmad blamed the computerised forms he needed to fill in for insurance, and the way they were set out, and effectively says that it would not have been cost effective to have given his patients sufficient time. He was clearly driven by maximising the return on payments from medical insurers in the way he filled in the computerised forms, including claiming to have done some procedures he had not.
14. Ahmad has also displayed a lack of candour. In his application for a role working with MSC Cruises, on 9 November 2020, he did not mention being the subject of any disciplinary hearings in any jurisdiction. Asked about this in cross-examination, he said that the fact his registration is not current in particular places was shown on his CV. The CV did not show that the licences had been surrendered or revoked. Later he claimed in evidence to have disclosed this in an interview. This was inconsistent with his earlier evidence about it being shown in the CV. And Ruth McCabe, who interviewed him twice, does not recall any adverse details about his pain management practices, the voluntary surrender of his licence in Alaska or the state of his registration in Australia being discussed. The Tribunal does not accept Ahmad's evidence that it was discussed.
15. Section 112(2) of the National Law is discretionary in that it provides that the Tribunal 'may' refuse to renew registration. However, it operates by reference to s 82, under which the tribunal must refuse registration if it determines the person is not suitable to hold registration: Orchard v Medical Board of Australia [2013] VCAT 1729 at [20].
16. As the Tribunal has decided Ahmad is not suitable to hold registration, it upholds the Board's decision to refuse to allow his application to renew his registration.[1]

1. This decision involved two proceedings, heard together. The principal issue in this case was in proceeding Z285/2019 - the review of the Board's decision to refuse to renew Ahmad's registration in 2018. As discussed above, the Tribunal has affirmed the Board's decision.
2. A further issue before the Tribunal is whether or not it should dismiss proceeding Z889/2018. In that proceeding (issued before Z285/2019) Ahmad sought review of a Board decision, made 6 September 2018, which had, relevantly, imposed a condition on his registration: a requirement that he not practice.[14] Ahmad had wanted that condition removed.
3. That proceeding was stayed by the Tribunal on 9 April 2019, because Ahmad intended to apply to the Tribunal to review the Board's later refusal to renew decision. (That of course is what he did in proceeding Z285/2019, the main subject of this judgment.)
4. The Board applied to strike out proceeding Z889/2019 pursuant to s 75 of Victorian Civil and Administrative Tribunal Act 1998 (Vic), on the basis that the application in that proceeding is lacking in substance and/or misconceived because Ahmad's registration as a practitioner had subsequently expired.
5. The Tribunal will strike proceeding Z889/2018 out under s 75. The condition that Ahmad not practice only had effect until the time that the registration then on foot expired (on 30 September 2018). Reviewing that decision is misconceived in circumstances where there is nothing to be gained by considering that issue now. That decision (and application) has been overtaken by the application to review the Board's decision on 14 March 2019 to refuse to renew Ahmad's registration.
6. Had the Tribunal needed to decide the issue in proceeding Z889/2018, it would have affirmed the Board's decision imposing a condition not to practice. The reasons why it would have done so are clear from the analysis above.

1. The Tribunal has affirmed the Board's decision refusing Ahmad's application on 1 October 2018 to have his registration renewed. It has done so on the basis that it is not satisfied that Ahmad is a suitable person to hold general registration and specialist registration as a medical practitioner.

[1] Throughout this judgment Dr Ahmad and others are referred to by their surname, after first referring to them by their title (such as Dr).

[2] Two review proceedings issued by Ahmad were heard together. The refusal to renew decision review is sought in proceeding Z285/2019. This judgment also deals later with proceeding Z889/2019, in which Ahmad sought review of an earlier Board decision.

[3] This was long after the decisions under review. Ideally, the Tribunal should review decisions of this nature as close to the time they are made as possible. Extensive delays in getting this matter to trial after the applications for review were filed (the latest in April 2019), occurred partly due to the pandemic, partly to the parties' state of preparation given the number of documents and experts involved, partly to finding hearing dates when all concerned could be present, and partly due to two adjournments of the hearing date due to Ahmad's unavailability. Following the final documents in the matter being submitted on 30 September 2022, the pressure of other matters and Panel availability unfortunately delayed the completion of the judgment.

[4] The Tribunal panel there was constituted by Members Wentworth, Reddy and Molloy.

[5] In the Matter of Mahmood Ahmad [OAH No. 16-0514-MED Agency No. 2015-002049 (the Alaskan judgment).

[8] Although Tribunal asses the criteria for renewal at the time of the Tribunal's decision, it is only able to consider whether that renewal should have been made on 1 October 2018 (the date Ahmad's previous registration would have ended). Even if the renewal was allowed, the period of renewal would have expired 12 months later (ie 1 October 2019): see ss 56, 61, 107, 108, 112(6) of the National Law. The situation would be different if Ahmad had applied for registration under s 77 (as opposed to renewal).

1. [9] See eg Morris v Medical Board of Australia [2021] VCAT 548 at [176]- [180], discussing Macedon Ranges Shire Council v Romsey Hotel Pty Ltd [2008] VSCA 45; (2008) 19 VR 422 at [51] and [53] (the Court); Shvetsova v Medical Board of Australia [2018] VCAT 867 at [33]; and Chow v Medical Board of Australia [2017] VCAT 1972 at [41]. It appears that the Applicant seeks to make something of the qualifications of the Board members: see point 3 in his email dated 11 June 2021 (TB 941); Transcript Day 1 (examination in chief) (T 20 (25-39)). The point in Morris concerns the place of the Medical Boards in the scheme of the National Law, rather than a case-by-case assessment of individual Board members' expertise. In any event, the decision-maker in this proceeding is the Tribunal.
2. [10] The third ground the Board relied on for refusing the renewal of Ahmad's registration is under s 55(1)(e) of the National Law - the fact that his registration in Arkansas is currently cancelled on a ground for which his registration could be cancelled in Australia. There is no need to consider this ground of refusal, given that the Tribunal affirms the decision under s 55(1)(h).

[11] Orchard v Medical Board of Australia [2013] VCAT 1729 at [80]; Drury v Medical Board of Australia [2011] VCAT 858 at [20]- [21], quoting Wilks v Medical Board (SA) [2010] SASC 287 at [30]- [31] (Gray J).

[12] Sherman v Medical Board of Australia [2012] VCAT 47 at [22].

1. [13] Ahmad provided the medical records of 38 patients to the Alaskan medical authorities under subpoena. These records were then examined by Stacey in his report and by Judge Mandala in her decision. The Tribunal considered a sub-set of those records in Ahmad (2017). Ahmad provided fresh copies of these records for the purpose of this proceeding. Cohen examined those records as the basis of his report, together with the Applicant's evidence at the Tribunal hearing in 2017. Huraibi examined the same records for his 2020 report.

[14] It has also lifted the earlier suspension of his registration.