In Health Care Complaints Commission v Buys [2020] NSWCATOD 44 ("the stage 1 decision") we found the respondent to these proceedings, Dr Peter Joseph Brian Buys guilty of professional misconduct in his practice as a dental practitioner as that term is defined in section 139E of the Health Practitioner Regulation National Law (NSW) ("the National Law"). The misconduct of the respondent is fully described in the stage 1 decision, and reference should be made to that decision as forming the basis of these reasons for decision which are concerned with what protective orders should appropriately be made consequent upon the finding of professional misconduct.
Dr A Lang, Senior Member had participated in the stage I proceedings. However, she was unable to participate in the stage 2 hearing. Pursuant to section 165C of the National Law we proceeded in her absence, she having vacated her office.
The proceedings concern the respondent's treatment of 10 patients for whom he prescribed a Schedule 8 drug, Oxycodone, in excessive quantities and dosage for an excessive period, without appropriate monitoring, review or a documented management plan when there was not sufficient clinical indication for the prescription of these drugs to these patients. In addition the respondent failed to maintain adequate clinical records for these patients in that he failed to make a written record of the supply of Oxycodone and failed to record an appropriate assessment of them on the dates that he prescribed this drug. Furthermore, with respect to some of these patients the respondent had failed to consult with medical practitioners who were concurrently treating his patients for other conditions, and with respect to one patient he prescribed antibiotics and Oxycodone after a telephone conversation and based on the patient's own pain assessment without conducting a clinical examination and subsequent monitoring. With respect to a patient referred to as Patient A, the respondent prescribed 350 Oxycodone tablets of varying strengths between 5 December 2014 and 21 July 2016. With respect to Patient B the respondent prescribed 220 20 mg Oxycodone tablets between 27 June 2015 and 17 May 2016. There are similar prescribing patterns for other patients.
In addition, the respondent obtained a number of Schedule 4 and 4D drugs under prescriptions issued by him either in the name of his dental practices or in his own name in circumstances where the quantum of this medication for practice use was outside acceptable standards for use in a dental setting. The approximate amounts were
1. 230 tablets of Oxycodone during the period 22 July 13 - 6 June 2016
2. 744 tablets of Ondansetron during the period 14 March 2013 to 6 June 2016
3. 300 tablets of Alprazolam during the period 17 May 2013 to 3 January 2014
4. 300 tablets of Lorazepam during the period 26 July 2014 to 16 July 2015
5. 5 tablets of Naloxone on 15 June 2015.
6. 30 tablets of Bromazepam on 5 January 2015
7. 300 tablets of Diazepam during the period 20 June 2014 to 26 November 2015.
In the stage 1 decision we summarised the respondent's conduct in the following terms
136 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.
137 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]
The finding of professional misconduct
In determining whether the respondent was guilty of professional misconduct under section 139E of the National Law it was necessary for us to consider whether his conduct was such that it would justify cancellation or suspension of his registration as a dental practitioner. For the purpose of considering this matter it was necessary for us to have regard to the protective jurisdiction with which we are dealing in these proceedings. In the stage 1 decision we said
131 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."
132 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.
133 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
134 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.
135 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]
The applicant's submissions
In written submissions the applicant said that consistent with established principles concerning the determination of appropriate protective orders the nature and extent of the misconduct which we have found to have been committed by the respondent justified the cancellation of his registration and the fixing of a period of one year before which the respondent might reapply for registration. The applicant submitted, and we agree, that the evaluation of the appropriate protective orders that should be made should be undertaken as at the date of our consideration of the respondent's circumstances.
The applicant emphasised that although the respondent accepted that his prescribing practices were inappropriate there were matters which he was not prepared to concede until confronted with them in the course of cross examination during the hearing. These included his inadequate record-keeping and his improper prescribing practices. The applicant also emphasised the serious nature of the respondent's misconduct which we have summarised in [6] above. All of these matters had a profound propensity to create risk for the safety and welfare of patients. The inability of the respondent to engage in meaningful retraining and further education regarding the deficiencies in his practice to which we shall shortly refer compounds the risks to the safety of the public which are at the heart of these proceedings, and against which protective orders must be made.
[4]
The respondent's evidence and submissions.
The respondent was first registered as a dental practitioner on 1 December 2004. His registration was suspended on 10 August 2016 until 24 April 2018 when the suspension was lifted and he continued to practice until 10 April, 2019. On that date the respondent sought non-practising registration status as a result of certain injuries which he had sustained, and this status continues based on an undertaking given by the respondent to the Tribunal that he would not seek to change it prior to the determination of these proceedings.
In the course of his submissions for the stage I hearing the respondent expressed regret for the amount of Oxycodone he had prescribed to his patients who are the subject of these proceedings and for his lack of insight "into the potential devastating effects of overprescribing oxycodone." He said that his prescribing pattern constituted misguided attempts to relieve pain with inappropriate dosages of Oxycodone. He also agreed that his recordkeeping was poor on some occasions.
The respondent submitted that he has not practised as a dental practitioner for a considerable period which has precluded him from earning an income to support his family over a period of 36 months. He said that if his registration was cancelled for a further period of 12 months, this would inflict a punitive financial regime on him. Furthermore, he said that he has had ample opportunity to "reflect upon my actions" and that he was remorseful for his misconduct.
The respondent said that whilst practising recently he had implemented new policies and procedures in both of his dental practices which covered inter-alia pain management and script writing. He had also attended a course in Perth on 25 November 2016 concerning safe prescription and drug use in dental practice for which he was awarded 6 CPD hours. The respondent listed a number of courses which he said he was prepared to undertake. However, he said that lack of funds precluded him from paying the costs to attend those courses.
The respondent sought orders that he be permitted to return to practice with conditions for a 12 months' duration precluding any authority to prescribe drugs of addiction, precluding the storage of drugs on surgery premises, providing evidence that his dental surgeries were fully accredited, evidence of implementation of policies and procedures relating to the use and management of medication within a dental practice and evidence of completed courses for his continued professional development.
The respondent also produced a number of character references. Some of these were from dental practitioners to whom the respondent had referred patients and others were from patients. These references spoke of his dental work in positive terms, but none of them addressed the serious issues of misconduct which we have found to have been committed by the respondent. We do not find them helpful in determining what is an appropriate protective order in the circumstances of these proceedings.
The respondent stressed that during the period that he was practising whilst his suspension had been lifted he was subject to conditions which included the inability to possess, supply administer or prescribe Schedule 8 and Schedule 4D drugs, prohibition of prescription for family members or friends and issuing private prescriptions. He was also required to submit to an audit, to attend treatment by a general practitioner, to attend for counselling by a psychologist and counselling and treatment by a psychiatrist. The respondent said that he had complied with all of these conditions, and the applicant did not suggest otherwise. The respondent said that there were no complaints about his treatment during this period and this was indicative of his ability to practice safely.
In oral submissions the respondent said that he now had an ability to interact differently with people and that this made him "a better practitioner."
The respondent also emphasised that he had been punished by the publicity which had surrounded the finding of professional misconduct which had been made against him, the impact that this had had on his family and his practice, and the damage sustained to his reputation in the local area where he had been practising. Whilst these are unfortunate consequences for the respondent and his family, it must be emphasised that his circumstances are caused solely by the fact that he engaged in a course of misconduct of a serious kind, justifying a finding that it constituted professional misconduct. To this extent his authorship of his own misfortune is irrelevant in determining what protective orders should be made.
[5]
Protective orders
We now consider what protective orders should be made consequent upon the findings which we have made. The available protective orders are set out in section 149C of the National Law the relevant parts of which are
149C Tribunal may suspend or cancel registration in certain cases [NSW]
(1) The Tribunal may suspend a registered health practitioner's registration for a specified period or cancel the registered health practitioner's registration if the Tribunal is satisfied -
(a) the practitioner is not competent to practise the practitioner's profession; or
(b) the practitioner is guilty of professional misconduct; or
(c) the practitioner has been convicted of or made the subject of a criminal finding for an offence, either in or outside this jurisdiction, and the circumstances of the offence render the practitioner unfit in the public interest to practise the practitioner's profession; or
(d) the practitioner is not a suitable person for registration in the practitioner's profession.
…
(7) An order may also provide that an application for review of the order under Division 8 may not be made until after a specified time.
The determination of what protective orders should appropriately be made involves a consideration of the factors identified in [132] in the stage 1 decision set out at [6] above which are in turn based on the decision in Do, an extract from which has also been set out. Those factors must be considered in the context of the nature and extent of the respondent's misconduct which we have previously summarised and which is referred to more fully in the stage I decision.
In determining what are appropriate protective orders we take into account also the matters referred to in [5] above. We also take into account that there is no evidence before us that whatever caused the respondent to engage in the extensive and pervasive conduct which is the subject of these proceedings has now been eradicated such that we can have confidence that he will not repeat it.
Having regard to all of these matters we conclude that an appropriate protective order is one that involves the cancellation of the respondent's registration. Such an order will not only perform its protective function but also serve as a deterrent to the respondent and to other dental practitioners in the event that they might be tempted to engage in a practice marked by the inappropriate prescription of drugs of addiction, combined with the other shortcomings in the respondent's practice which we have identified. Such an order will also assist in upholding the integrity of the profession in the eyes of the public.
We agree with the applicant's submission that an appropriate period of one year should be fixed before the respondent is entitled to seek a review of this order under Division 8 of Part 8 of the National Law. This will give the respondent an opportunity to undertake courses and other action designed to assist in his return to safe practice as a dental practitioner.
[6]
Costs
This is a costs jurisdiction. The applicant sought an order for costs. The respondent resisted such an order on the basis firstly of his impecuniosity and secondly because he had been sufficiently punished by his inability to practice.
It is well accepted that impecuniosity is not an appropriate reason for refusing to make a costs order, nor are costs orders made to punish an unsuccessful party. In circumstances where there are no other matters which would preclude such an order being made, we propose to make a costs order.
[7]
Orders
We make the following orders
1. Pursuant to s 149C(1)(b) the registration of the practitioner as a dental practitioner is cancelled
2. Pursuant to s149C(7) the respondent may not apply for review of Order 1 for a period of one year
3. The respondent is to pay the costs of the applicant in an amount assessed in default of agreement
[8]
I hereby certify that this is a true and accurate record of the reasons for decision of the Civil and Administrative Tribunal of New South Wales.
Registrar
DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment or decision. The onus remains on any person using material in the judgment or decision to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court or Tribunal in which it was generated.
Decision last updated: 10 September 2020