Health Care Complaints Commission v Echano

Material before Tribunal

1. Applicant: Six volume bundle containing Application for Disciplinary Findings and Orders including Complaint; Pharmaceutical Services Unit (PSU) Investigation report; Expert Report (Dr Graeme Thomson, MBBS Hons (UNSW), Dip (Obs) RACOG, FRACGP); Respondent's replies to Applicant's investigation; Clinical Records Patients A to L; Various Guidelines and Policies including publications relevant to Poisons and Therapeutic Goods prescribing and Responsible Opioid Prescribing; NSW Health guidelines for recognising and handling drug dependent persons, notes for medical practitioner; NSW Health guidelines for recognising and handling patients liable to abuse benzodiazepines; various relevant RACGP guidelines; Prescribing Authority Requirements; MIMS full prescribing information on drugs under notice in this case; and 36 scholarly publications relating to proper practice in the matters under notice in this case.
2. Respondent: Reply to Application for Disciplinary Findings and Orders; Statement by Dr Echano dated 3 November 2017; Assessment of Dr Echano by Dr M-A Friend MBBS (Hons), FRANZCP, Consultant Psychiatrist (10pp), dated 17 May 2017; testimonials from Ms T Richardson, Practice Manager, 9 August 2017; Dr B Patel, Manning Valley Medical Practice, Taree, 8 August 2017; List of articles read, and courses completed, or to be completed by Dr Echano, including various certificates of successful completion, as at 31 January 2018.

Treatment of the 12 Patients

1. In brief, the 12 patients to whom Complaints 1 and 2 refer, all had a history of drug dependence or drug abuse. In the period 2011-2014 Dr Echano gave them prescriptions for the following drugs: Fentanyl, Alprazolam and Diazepam (Patient A, 17 events); Alprazolam and Clonazepam (Patient B, 20 events); Fentanyl, Diazepam (Patient C, 10 events); Fentanyl (Patient D, 6 events); Fentanyl (Patient E, 8 events); Fentanyl (Patient F, 2 events) Fentanyl (Patient G, 4 events); Oxycodone (Patient H, 3 events); Oxycodone (Patient I, 10 events); Oxycodone (Patient J, 18 events); Oxycodone, Phetermine (Patient K, 15 events); Morphine (Patient L, 3 events). In several cases it was alleged that he had failed to exercise care in dealing with patients who had engaged in drug seeking behaviour.
2. The Poisons List prescribed under the Poisons and Therapeutic Goods Act 1966 is divided into nine schedules. Schedule 8 itemises substances which are 'addiction producing or potentially addiction producing'. Schedule 4 itemises substances 'which in the public interest should be supplied only upon the written prescription' of various categories of human and animal health practitioner.
3. Fentanyl, Alprazolam, Oxycodone and Morphine are S8 drugs. Alprazolam, Diazepam, Clonazepam, and Phetermine are S4D drugs (i.e. prescribed restricted substances). We note that Fentanyl is usually administered in the form of patches. It is a potent opioid that is easily diverted and injected with high risk of harm, including overdose and death.
4. The charges against Dr Echano derive from an investigation undertaken by the Pharmaceutical Services Unit in 2015. The PSU stated in its report that was concern over the extent of distribution of Fentanyl patches in the Taree area. The PSU had received anecdotal reports of abuse, trafficking and deaths attributable to the injection of Fentanyl derived from Fentanyl patches.
5. The PSU reported the outcome of its investigation to the Medical Council. The Council empanelled a s 150 inquiry. It did not proceed as Dr Echano agreed to consent orders placing conditions on his registration preventing him from prescribing drugs of addiction and restricted substances (date 15 June 2015). He continued in active practice until August 2017.
6. The HCCC filed its disciplinary application on 11 May 2017. The hearing took place on 8 and 9 February 2018. At this point, Dr Echano had not been in practice for approximately six months, because of an inability (explained later) to obtain a Medicare provider number.
7. It is plain from this brief account that this is a case of great seriousness. In its cross examination of Dr Echano, the HCCC focussed on the scale and degree of Dr Echano's prescription of the scheduled drugs to 12 drug dependent persons, his failure to have any methods or strategies to detect and deal with drug seeking behaviour, and the sheer inadequacy of his medical records which failed to include any basic information that might explain the prescriptions, their number and their frequency. (Patients A, B, C, D and E were on the OTP at the time and Patients F, G, H, I, J, K and L were exhibiting strong drug seeking behaviours.)
8. The HCCC seeks the cancellation of the Dr Echano's registration, with any review not earlier than 12 months.
9. Dr Echano's position is that he has recognised the wrongs he committed, wrongs that he says were founded in ignorance, on his part, of the standards that he should apply to dealing with drug dependent patients and his newness to private practice. He is deeply sorry for what he did, and in the period since June 2015 he has thoroughly familiarised himself with the laws and standards of practice that apply to the prescription of S8 and S4D drugs. He has done likewise in relation to dealing with drug dependent persons and drug seeking behaviours. He also points to the fact that he has not been the subject of any complaints from patients in the period since June 2015. He asks that he be permitted to retain his registration, and, if necessary, subject to the conditions that have applied since 2014.

Dr Echano's Background

1. Dr Echano was born in the Philippines in 1953 and grew up there. He is now 64 years old. He has practised in Australia for the last 9 years. He obtained his Australian registration as a doctor in 2008 at the age of 55, after passing the Australian Medical Council examinations. As a young man, he had qualified in Medicine in the Philippines (1978, D Med S, U of Philippines), and practised there for five years in various hospitals. For the next 25 years, according to his evidence, 'he underwent employment in a range of research and allied health roles in the United States and Australia'. He re-entered the environment of medical practice in 2007. He worked at Nepean Hospital as a medical intern and RMO in the period January 2007 to April 2008. He has not completed his internship and is registered as a Non-Vocational General Practitioner.
2. After obtaining his Australian registration, he commenced work in 2008 as a GP at Medisense Health Centre, Taree. The practice had just been started by an owner/doctor and he was the next doctor employed. The practice slowly built up to a busy one over the next three years. As we understood his evidence, by 2011 the practice had become a busy one, it had moved for example from a walk-in practice to an appointment-only practice. He said that at one point it had 8 GPs. He attributed in part his laxness in dealing with the patient cases under notice to the demands of the practice, and the need to get patients in and out quickly. We note in that regard that his evidence at hearing was that he was not contracted to see a certain number of patients. Though it is not to be seen as a necessarily acceptable explanation, he was not encumbered in that way against choosing how many patients he saw in a clinical session. He also said that apart from the owner, who was Australian trained, all the other doctors were overseas trained, and they were employed under 'area of need' allowances.
3. His employment at Taree ended in August 2017. Accreditation by the Royal Australasian College of General Practitioners (RACGP) is normally required for the issuance of a Medicare provider number to Vocational General Practitioners. During the years 2008-2017 he had been able to have a provider number without vocational accreditation, on the basis of an 'area of need' recommendation from the Rural Doctors Network, and his agreement to a mentoring arrangement with a Vocational General Practitioner who is in practice with no conditions on his registration. The RDN had declined to renew its annual recommendation (we understand because of the 10 year rule that applies to non-accredited doctors). He explained at hearing that the practice had no choice in those circumstances but to end his employment. He remained in an amicable relationship to the practice, and goes to practice mentors and has regular contact with his mentor, Dr Kang. He became eligible to sit the RACGP examinations in 2013, after meeting the requirement of four years of local experience. He said that he had passed the written exams for the accreditation in 2016, but had recently failed to pass the oral examination (17 December 2017).
4. The result is that he can now only practise medicine in an environment where there is no need for the doctor to interact with the Medicare payments system. Practice positions of that kind exist in government, corporate and industrial settings. So far he has not been able to find a position of that kind, pending the outcome of these proceedings.

Consideration

1. The misconduct admitted by Dr Echano is of great seriousness. Modern Australia has a significant problem with pharmaceutical drug misuse, diversion, and high risk prescribing leading to increased risk of harm including poisoning, overdose and death.
2. While many people who use drugs are dependent on or misuse illicit substances, there is also a big population of users who use restricted substances for non-medical reasons. Doctors and pharmacists are the conduit to the community for those substances. It is critical to the protection of the health and safety of the public that doctors exercise sound professional judgment and adhere to applicable laws in prescribing opioids and other restricted substances.
3. Dr Echano did not challenge in any respect the expert report provided by Dr Thomson (tab 6, supplementary report tab 8, in the HCCC's bundle). Dr Thomson had regard to evidence given by Dr Echano to the HCCC in the course of its investigation on 10 August 2015, in which he sought to explain his reasons for issuing prescriptions in each of the 12 cases.
4. In his report Dr Thomson commenced by outlining, in relation to each of the drugs under notice, the clinical indications, accepted therapeutic standards (both dosages and duration), risks connected with the drugs (divided into general and those applicable to persons with a history of drug dependence or abuse), risks in combination with other drugs, the steps that should be taken in ascertaining history of drug dependence or misuse, and the appropriate response if a doctor is concerned that drugs are being requested for non-therapeutic purposes. He dealt with a number of more specific issues. In the case of each of the S8 drugs under notice he referred, for example, to their role in opioid maintenance therapy for opiate dependence, and limits on dosages. He noted that doctors could access information in relation to approved indications, contraindications, dosages, warnings, side effects and interactions by consulting MIMS online.
5. In his executive summary, he noted that he had expressed opinions to the HCCC in response to 90 questions regarding matters of concern raised by the HCCC. In 76 instances he considered that Dr Echano's conduct was considered to fall significantly below the standard reasonably to be expected for a medical practitioner of his training and experience. In all those instances the degree of departure from the expected standard was sufficient to invite strong criticism.
6. As our account of his personal background indicates, Dr Echano was a new and inexperienced doctor in the Australian practice environment and the time of the events under notice. He had only obtained his Australian registration in 2008, and was in his third year of practice when the conduct under notice began to occur. It is the case that he had been a doctor in hospitals in the Philippines for about five years, but that was almost thirty years earlier.
7. In his evidence at hearing, Dr Echano painted a picture of himself as an inexperienced doctor confronted for the first time with the environment of private practice. In the Philippines and in his internship year at Nepean he had worked in hospital settings. On his account, he was also working in a start-up practice in a region of the State with high levels of disadvantage. We accept that prior to going to Taree he had had no involvement with private practice and its exigencies.
8. He depicted a work life in the Taree practice that became increasingly busy as the practice built up. In relation to issues such as the prescribing of drugs of addiction, he said the practice had no policies in place. He said that when he joined the Taree practice he had no appreciation of the existence of 'doctor shoppers', their behaviours and how to manage them. He had no appreciation of the strategies that patients would employ to get prescriptions for non-medical reasons. In his oral evidence, he said that he only became aware of the doctor shopper hotline in 2013.
9. He said that in the period 2011-2014 he was seeing about 45 patients a day on the days he worked 8am-5pm and more on days that he worked 8am-8pm. He acknowledged that his average time with a patient was about 10 minutes, with some above or below that average. He stated in his oral evidence that he could have chosen to see less patients per hour, and so spend more time with complex cases. But there was no evidence to suggest that he ever made any adjustments of that kind.
10. He acknowledged that he had failed to spend enough time with the patients under notice, especially in a first consultation. He said that he realised now the inadequacy of the records he had kept in relation to the patients under notice. He acknowledged in cross examination that he was aware of the value of keeping good medical records from when he was working in the Philippines and working as an RMO in Nepean Hospital.
11. He was asked a number of questions relating to the importance of keeping good medical records. As was true of answers he gave on other topics, the formal content of his answer was often quite comprehensive, and generally accurate as to the nature of a practitioner's obligations to keep appropriate records, and ones that would be usable by others who might become involved in the patient's care. We have no doubt that he understands now, in a way that he did not then, the relevant standards.
12. But we were left with the impression that his answers on the subject of record keeping standards, and other issues (such as behaviours for dealing with apparent or known doctor shoppers) were the product of a kind of rote learning of material he has now read. We were left unconvinced as to whether he would show better judgment in future in implementing and applying those standards in a practice setting.
13. He referred at a number of times in his evidence to what he saw as his personal cultural background that drove him not to stand in the path of patients in being provided with what they wanted, and to have them leave his consulting room happy. In that way, he sought to explain, at least in part, the abject failures identified by Dr Thomson in the cases under notice. He said that he would be more assertive with patients in future who pressed him for drugs in circumstances where prescription was not clinically indicated.
14. In our view, personal cultural explanations of this kind should have no place in the practice of medicine. It is plain that a doctor must adhere to community standards, themselves designed to maintain the protection of the safety and health of the public, in his or her dealings with individual patients. Their perception of their needs and wants can never be the determinative consideration. A detached, informed professional judgment must always be brought to the decision to treat and the decision to prescribe.
15. In our view, his early training in the Philippines should have exposed him to the hard choices that a doctor must often make in his or her approach to the treatment of patients.
16. He conceded, under cross examination, that in his 16 months at Nepean in 2007-2008, he had in fact been exposed to drug-seeking and drug dependent patients, had written prescriptions, and had kept medical records conscious of their importance for other doctors and health staff who might need to consult and use them. He acknowledged that if he formed the view that opioids needed to be prescribed he did that with the approval of his supervisor. The approval extended to the issue of potential side effects and long term problems with the use of opioids. In his period as an RMO at Nepean (spent mainly in emergency paediatrics) the system required him to obtain approvals from the specialist.
17. He acknowledged that he had had occasions at Nepean to prescribe (subject to approval) S8 or S4D drugs, and that he was aware of the possibility of side effects especially if they were mixed with other medications the patient might be using.
18. He sought to explain his lack of adequate recordkeeping on the time constraints that bore on him. He was always keen to wrap up the consultation as quickly as possible especially when the waiting room was crowded.
19. He said that when a drug dependent patient came in to the consultation room, he felt pressured, because of their aggression. He was inclined to lose his composure and he just wanted to wrap it up. He said that he now realised he should have written something afterwards about the situation and put it on the computer. He realised now that he should have been more assertive. He felt that his personality was one that sought to avoid conflict and involved a misplaced desire to help others. He referred to the behaviours he had encountered, and his account not managed well. He said that he would now send difficult drug dependent patients to a specialist who would be in a better position to help, or to a psychiatrist or psychologist.
20. He said that by early 2015 he had become more familiar with the 'trickeries' that doctor shoppers used to get prescriptions. He had become aware of the phenomenon of doctor shoppers by that time, and had read relevant articles. He said he should have been in touch with the PSU or the RACGP about how to deal with them.
21. He was taken in cross-examination to egregious instances of overprescribing. For example, in the case of Patient I he had prescribed the S8 drug oxycontin (generic name oxycodone) four times in eight days as follows: 80mg (14/1/2014); 40 mg (14/1/04); 80 mg (22/1/2014; 40 mg (22/1/2014). He explained why he had repeatedly prescribed these drugs without observing the usual 14 day period between prescriptions. He answered that he didn't know what he had in mind.
22. He had seen Patient H, a 37 year old man, three times for chronic lower back pain. He had prescribed as follows: 2/5/13, oxycodone HCL, 80mg; 13/5/13, oxycodone HCL, 80mg; 30/5/13, oxycodone HCL, 80mg. In his written statement to the HCCC during its investigation, he had said that he had prescribed oxycodone twice a day based on a health summary from a health clinic located in another town. He said in evidence that he should not have acted as he did, and said that after the third occasion he had told the patient he could no longer help him. He acknowledged now that he had been dealing with a doctor shopper. He said that he had been aware by this time, May 2013, of the Doctor Shopping Information Service and should have contacted it. He acknowledged that he should have taken that approach universally to problematic patients.
23. Dr Echano had 17 prescription interactions of concern with Patient A in the period 14/11/11 to 31/1/14. He acknowledged in evidence that Patient A had, when he first saw him, been recently released from gaol. He accepted now that he had, in seeing him, been engaged in drug seeking behaviour.
24. In the case of Patient B, he acknowledged that his clinical records included a note from another source suggesting that he was involved in selling drugs, but that he failed to check into that, and continued to prescribe significant quantities of Alprazolam (variously described in the PSU schedule as either a S4D or S8 drug). Across 20 interactions in the period 23/5/13 to 13/10/14, the total of the quantities prescribed is 1500 tablets i.e. an average of 3 a day, well in excess of normal prescribing.
25. He had commenced seeing Patient C on or about 20/9/13, and saw him 10 times between that date and 14/1/14. He acknowledged that on 9/10/13 (after the second time he saw the patient) he had received a letter from the patient's pain specialist in which he had been told of the inappropriate use of Fentanyl by the patient. He said in evidence that at that time he was starting to get worried. He could give no explanation as to why he had not followed up the specialist's letter. He later received another letter from the pain specialist (early in November) in which he stated that there was no ground to give the patient Fentanyl. He acknowledged that notwithstanding that communication he had prescribed him Fentanyl on 4 further occasions (which we understand from the material to be those listed in the PSU schedule dated 27/11/13, items 6 and 7, and 13/12/13, item 8, and 31/12/13, item 9. He had no explanation for this conduct, and simply said at hearing that he did not remember why he did it.
26. In the case of Patient E he prescribed Fentanyl on 8 occasions between 5/4/13 and 24/7/13. The dose prescribed was to be taken once every three days.
27. He agreed that the original dose prescribed was 100mcg/hr, and that was 4 times the recommended dose. He said in explanation that he had followed what someone else was prescribing already. He said he would not normally have started with a big dose. He could not explain why he had started with such a big dose. He acknowledged that starting a patient on such a big dose could be fatal.
28. He had two prescription interactions of concern with Patient F, on 23/3/14 and 29/3/14. Again he prescribed Fentanyl on each occasion in the dosage 100mcg/hr (the same as the original dose in the Patient E case). He acknowledged that Patient F's records disclosed that he had been the subject of two refusals to prescribe by other doctors in the practice. He could give no reason as to why he acted as he did in those circumstances, and why the dosage level, again, was so high.
29. Patient G is another patient to whom he prescribed Fentanyl (four interactions of concern). In one instance the practice's records showed that the patient had been at the practice 2 hours earlier, and recorded him as a known doctor shopper. He said in evidence that he had not read the notes.
30. In the case of Patient I (2/1/14-27/2/14) he acknowledged that the local chemist had rang him after he had first prescribed Oxycodone telling him that the patient had a history of doctor shopping. He had no explanation as to why he kept on prescribing. He saw this as another mistake.
31. In the case of Patient J (12/4/13-13/5/14, 18 prescriptions of Oxycodone) he acknowledged that the clinical notes showed that other doctors had refused to prescribe to him. He said that it had crossed his mind to refuse him prescriptions, but that he had exercised poor judgement. He now recognises that his prescription levels were too high, and said that he did not have a proper understanding at that time of maximum doses.
32. He agreed that he should have known optimum dose levels, and appropriate therapeutic levels. He could not explain why he had not sought to familiarise himself with maximum doses. Agreed that prescribing above the maximum dosage levels was risky behaviour with possibly fatal consequences.
33. In the case of Patient L (3 prescriptions of Morphine, dispensed 22/10/13, 24/10/13, 26/10/13) he acknowledged that Morphine was not a recommended medication for constipation. Dr Thomson in his report stated a prescription of Morphine was totally inappropriate for constipation. We note further that constipation is a common side effect of Morphine. Dr Echano also agreed that the dosages prescribed were 3 times greater than previous doses that patient had been prescribed. He could not explain that.

Disciplinary Order

1. The purpose of disciplinary orders is protective: see generally, Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630, 637. Orders operate as an indication to the profession generally of the sanctions that will be visited on professional misconduct of the kind identified in a particular case. They play a role in educating doctors and the public generally as to the minimum, expected standards of practice. They serve to protect the public in removing from the profession doctors whose conduct has been dangerous, and placed at risk the safety and welfare of patients. The protection of the health and safety of the public is a paramount consideration: s 3A, National Law. Appropriate disciplinary orders remind other members of the profession of the public interest in the maintenance of high professional standards, emphasise the unacceptability of the particular conduct and serve to maintain confidence in the high standards of the relevant profession: NSW Bar Association v Meakes [2006] NSWCA 340 at [114] per Basten JA. See also Health Care Complaints Commission v Do [2014] NSWCA 307 at [35] per Meagher JA (with whom Basten and Emmett JJA agreed).
2. We have highlighted in the above resume of the hearing, the answers given by Dr Echano in relation to his management of the various aspects of the prescriptions issued to the 12 patients.
3. They demonstrate, in our view, a complete failure to observe professional standards. He responded mechanically to the wishes of the patients. He took no care in relation to appropriate dosage levels, and frequency. He acknowledged that in some cases the dosages prescribed risked fatal consequences. He ignored external warnings from a pain specialist and a neurologist, from a local chemist and from within his practice. It is not clear whether he had regard at any point to practice clinical records that raised doubts about patients.
4. In our view, this is conduct that warrants the severest denunciation, and an order for cancellation would have followed, we think without doubt, had these offences been before a disciplinary tribunal soon after they occurred. As Hope JA (Reynolds and Hutley JJA agreeing) stated in Spicer v NSW Medical Council (unreported, NSWCA, 19 February 1981): 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 for 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 unfitness in itself demonstrated his present unfitness to be a medical practitioner.
5. See also Health Care Complaints Commission v Lo [2016] NSWCATOD 119 at [154]; and Health Care Complaints Commission v Suri [2016] NSWCATOD 54 at [88]-[89].
6. But our task is to determine whether at the time of hearing an order for cancellation is appropriate.
7. As is often seen in medical disciplinary cases, a long period has now passed between the immediate action taken by the Medical Council using its s 150 powers and the disciplinary hearing.
8. As a result of the consent orders made at the time of the s 150 proceedings, Dr Echano has now practised for a further two years - under restrictions (no authority to issue S4D and S8 prescriptions). There have been no complaints against him over that time. As we understand his entire history since 2008, at no time has he attracted a patient complaint. The present complaints emerged from PSU investigations.
9. The concern at the heart of these proceedings is that in treating patients he seeks to subscribe to their wishes and does not bring an independent professional judgement to bear. He was so indifferent to his responsibility to exercise independent professional judgment that he chose to deal with patients he should not have treated, and then gave prescriptions in dosages that placed at risk the life of some of them.
10. He made a case at hearing that he had taken a number of rehabilitative steps.
11. He spoke of the efforts he had made to inform himself of the literature surrounding doctor shopping, treatment of addictive and addicted patients, and of the medical databases in relation to proper dosage levels and the like. He also referred to his attendance at CPD events and the like over his years in practice. We note that all the courses that he has undertaken appear to be didactic and not face to face, involving interaction with specialists such as addiction specialists.
12. It is apparent that the Taree practice had a poor internal culture when it came to such matters as practice meetings and CPD. He referred to the drop off in clinical meetings that had occurred in the practice as it moved from its build-up period (2008-11) to the busy period (2011-2015). He also referred to mentoring processes into which he had entered involving other doctors in the practice. Two of the doctors had ceased to be mentors because of prescribing investigation in one case, and recordkeeping problems in the other case.
13. As we have already noted, in explanation of his conduct, he frequently referred to, what he saw as, his personality weaknesses, ones derived from his cultural background. On its face, this is a self-serving explanation, designed to minimise the culpability of his conduct.
14. Dr Friend's assessment was a thorough and helpful one. Dr Friend's description corresponded with his presentation at hearing, i.e. 'a preference to avoid conflict and a tendency to be unassertive'. Dr Friend's report did show some progress on Dr Echano's part in developing insight into his behaviour. But equally he continued to have difficulty with the challenge of making appropriate adjustments to minimise the risks under notice in this case. She said at p9 of her report: Dr Echano attributed some of his acquiescence to patient demands for S4D and S8 drugs to factors including the time limitations and burdens inherent in a busy general practice and time constraints associated with understanding his statutory requirements. Despite this Dr Echano did not take steps to modify his practice to address these difficulties and barriers to the management of complex patients, and continues to practise in the same manner, notably seeing four patients per hour, five or six days a week. In my opinion, this demonstrates an ongoing lack of insight into his personal and professional limitations and the difficulties inherent in practising in this manner.
15. Frequently at hearing, he gave long answers to questions to do with such matters as the principles that underlie the need for good record keeping practice, the matters that should be routinely covered in clinical notes, the special importance of a first consultation, the amount of time that should be spent with patients and the sources to which one should go to obtain detailed information in relation to the poisons list and appropriate dosages. We were left with the impression that he had a good ability to absorb and repeat detail of this kind, and to do so accurately. But we were left unconvinced that he had improved in his insight into dealing with patients with difficult behaviours.
16. We were given no independent evidence of practical steps he had taken to improve, for example, recordkeeping. We were not given any independent evidence of practices and systems now adopted in his practice in relation to doctor shopper problems despite him saying that he had been advised by his medical indemnity insurer to look at clinical policy within the practice, and to keep better medical records. He produced no evidence of taking that advice in the subsequent time in practice at Taree.
17. But we did not have any practice-based evidence that might have assisted us in forming a view as to his present ability to cope with the daily pressures of a busy practice; and with difficult presentations where a doctor may be required to respond negatively to a demand.
18. Dr Thomson's assessment of his practice in relation to the cases under notice is strongly critical of his medical reasoning and medical practice. Without evidence of a substantial turn around in his competency, we can only assume that his level of competency remains poor.
19. Dr Echano may also have benefited from a practice assessment. However, no practice assessment was provided. In our view, the onus was on Dr Echano to demonstrate to us how his practice has improved or evolved.
20. While we accept that he has demonstrated contrition and remorse for the wrongs he did, we are not satisfied that he no longer presents a risk of offending again in the ways identified in this case. In our view, he remains unfit to practise.
21. In our view the unfitness to be registered that he displayed in his conduct in the period 2011-2014 has not been assuaged by the passage of time.
22. The applicant applied for order requiring the respondent to pay its costs, under Sch 5D, cl 13 of the National Law. The respondent did not contest the application. The applicant has succeeded in its application. The application was conducted in an orderly and expeditious way. The usual order will be made.

Order 1. That the respondent's registration be cancelled as from the date of publication of this decision and that he not be permitted to apply for review for one year from the date. 2. That the respondent pay the applicant's costs of the proceedings.

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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: 05 March 2018