Health Care Complaints Commission v Haloob [2025] NSWCATOD 137;

1. Mr Haloob received his Bachelor of Pharmacy in 2003 from the University of Otago, New Zealand. He completed his internship in Australia, working in various pharmacies including at Tamworth and Wyoming, before being registered as a pharmacist in New South Wales in December 2005.
2. Mr Haloob purchased the Liverpool Day & Night Chemist ("the pharmacy") in July 2012. The events set out in the Complaint (see below) occurred during the time he was the proprietor at the pharmacy, working long hours and primarily on his own.
3. On 29 April 2022, Mr Haloob's registration was suspended by the Pharmacy Council of New South Wales ("the Council") acting on a complaint received from the Pharmaceutical Regulatory Unit ("the PRU") on 11 April 2022. An investigation was conducted into the dispensing and supply by Mr Haloob of various drugs including in large quantities and without prescription; and possible fraudulent conduct in obtaining benefits under the Pharmaceutical Benefit Scheme ("PBS") in respect of drugs allegedly not supplied to patients.
4. On 5 October 2022, Mr Haloob made an application under s 150A of the Health Practitioner Regulation National Law ("the National Law") for a review of the Council's decision to suspend his registration. A hearing took place on 31 October 2022, following which the suspension was lifted but strict conditions were imposed on Mr Haloob's registration. These included that Mr Haloob be prohibited from possessing, supplying or dispensing drugs listed in Schedules 4 and 8 of the Poisons and Therapeutic Goods Regulation 2008 (NSW) and practise under Category A supervision of the Pharmacy Council of NSW's Compliance Policy - Supervision ("Council Compliance Policy") and that he meet with an approved supervisor weekly who would provide monthly reports to the Council. The conditions on Mr Haloob's registration effectively rendered him unable to practise as a pharmacist.
5. In January 2024, Mr Haloob made a further application for review under s 150A(4) of the National Law on the basis there had been a change in his circumstances that justified the variation or setting aside of the decision.
6. On 21 February 2024, s 150A proceedings were held resulting in the conditions of Mr Haloob's registration being replaced. New conditions were imposed on his registration including that Mr Haloob not practise as the pharmacist in charge; not possess any access cards, keys or codes to the pharmacy; and to practise under Category C supervision. The Panel who imposed the revised conditions found that Mr Haloob had "made a concerted effort to improve his knowledge of the legislative, ethical and clinical aspects of his practice. He has shown insight into the issues and remorse for his actions and a willingness to undertake any further supervision and training that is required." While these conditions are more relaxed that the previous conditions, he has still been unable to practise as a pharmacist.
7. Mr Haloob ceased working in the pharmacy in April 2022 after his registration was suspended. He sold the pharmacy in September 2024 and is currently engaged to assist in the operations of a warehouse that services major medical devices.

1. Given the nature of the conduct complained of relates to the dispensing of certain drugs in large quantities and the use of prescriptions, it is useful to set out the relevant framework for the regulation of pharmacists.

(1) Clause 4.4(d) of the Guide to the Poisons and Therapeutic Goods Legislation for Pharmacists ("Poisons Guide") relevantly provides that, where a prescription contains no repeat instructions, nor clearly indicates the number of repeats ordered, it may be dispensed once only, then cancelled.

(2) The Poisons and Therapeutic Goods Act 1966 (NSW), s 8 ("the PTGA") proclaims the Poisons List, which contains nine schedules that classify the substances listed. Three categories of substances are relevant to this proceeding: Schedule 4 drugs; Schedule 4D drugs; and Schedule 8 drugs.

(3) Schedule 4 drugs are substances which in the public interest should be supplied only upon a written prescription: see the PTGA, s 8(2). The Poisons and Therapeutic Goods Regulation 2008 (NSW), cl 40(1)(b) ("PTGR") provides that a pharmacist must not supply a restricted substance on prescription if it has already been supplied the maximum number of times indicated by the prescription. The PTGR, cl 54 provides that a pharmacist must not supply any restricted substance in a quantity, or for a purpose, that does not accord with the recognised therapeutic standard of what is appropriate in the circumstances.

(4) Certain Schedule 4 drugs that are prescribed restricted substances are identified in PTGR, Appendix D. Section 16(2) of the PTGA provides that "[a] person shall not forge or fraudulently alter, or utter, knowing it to be forged or fraudulently altered, any prescription of a medical practitioner, nurse practitioner, midwife practitioner, dentist, optometrist, podiatrist or veterinary practitioner including any prescribed restricted substance".

(5) Schedule 8 drugs: Schedule 8, Poisons List, provides a list of "[S]ubstances which are addiction producing or potentially addiction producing".

(6) In relation to the supply of prescribed restricted substances and drugs of addiction, the PTGR relevantly provides:

(a) PTGR, cl 40(1)(g)(ii) a pharmacist must not supply a prescribed restricted substance on prescription more than 6 months before the date on which the supply is requested; and

(b) PTGR, cl 86(1)(e) a pharmacist must not supply a drug of addiction on prescription if the prescription is dated more than 6 months before the date on which the supply is being requested.

1. There is no dispute about the relevant background in the Amended Complaint filed by the Commission on 15 April 2025, which sets out the particulars of the Complaint as it relates to Patients A to F by reference to drugs identified in Annexures A to G to the Complaint which are Schedules 4, 4D and 8 drugs.
2. As noted above the Commission has two grounds of complaint against Mr Haloob. Complaint One seeks findings of unsatisfactory professional conduct under the National Law, s 139B(1)(a) and/or s 139B(1)(l). The Commission relied on each of the particulars 1, 3, 5, 7, 9, 11, 13, 15, 17, 19, 21, 23, 25, 27, 29, 31, 33 and 35 (as set out below) individually as constituting unsatisfactory professional conduct and alternatively the particulars to Complaint One in any combination as constituting unsatisfactory professional conduct.
3. Complaint Two seeks a finding of professional misconduct under the National Law, s 139E on the basis that Mr Haloob has engaged in unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the his registration and/or engaged in more than one instance of unsatisfactory professional conduct which would have the same result. Complaint Two relied on the particulars in Complaint One either individually or cumulatively.
4. The particulars for Complaint One of the Amended Complaint (and as further amended during the hearing) are as follows:

"PARTICULARS OF COMPLAINT ONE

Unauthorised repeat prescriptions

Patient A

1. Between 8 March 2020 and 25 February 2022 on the instances as set out in Annexure A, the practitioner inappropriately issued unauthorised repeat prescriptions to Patient A:

i. ...;

ii. on 20 instances between 22 March 2020 and 25 February 2022, Duloxetine 60mg tablets;

iii. on 12 instances between 22 March 2020 and 6 February 2022, Valproate EC 500mg;

iv. on 64 instances between 13 March 2020 and 25 February 2022, Seretide Accuhaler 500mcg/50mcg;

v. on 20 instances between 11 May 2020 and 22 January 2022, Nurofen Plus (200mg ibuprofen and 12.6mg codeine);

i. on 60 instances between 22 March 2020 and 25 February 2022, Pregabalin 150mg capsules;

ii. on 40 instances between 8 March 2020 and 25 February 2022, Pregabalin 75mg capsules;

iii. on 10 instances between 22 March 2020 and 22 January 2022, Seroquel (quetiapine) 100mg.

2. The practitioner's conduct in issuing unauthorised repeat prescriptions to Patient A on the instances as set out in particular 1 was not appropriate in circumstances where the unauthorised repeat prescriptions had not been authorised on the prescription by the prescriber:

a. having regard to clause 4.4 of the NSW Health 'Guide to the Poisons and Therapeutic Goods Legislation for Pharmacists';

b. for particular 1(b), having regard to section 16(2) of the Poisons and Therapeutic Goods Act 1966 (NSW);

c. in circumstances where the practitioner failed to make appropriate enquiries including with the prescribing practitioner, prior to issuing the repeat prescription;

d. otherwise in the circumstances.

3. Between 8 March 2020 and 25 February 2022 on the instances as set out in Annexure A, the practitioner inappropriately dispensed in PBS quantities unauthorised repeat prescriptions, to Patient A:

i. ..;

ii. on 10 instances between 22 March 2020 and 25 February 2022, Duloxetine 60mg tablets;

iii. on 10 instances between 22 March 2020 and 6 February 2022, Valproate EC 500mg;

iv. on 43 instances between 13 March 2020 and 25 February 2022, Seretide Accuhaler 500mcg/50mcg;

v. on 20 instances between 11 May 2020 and 22 January 2022, Nurofen Plus (200mg ibuprofen and 12.6mg codeine);

i. on 45 instances between 22 March 2020 and 25 February 2022, Pregabalin 150mg capsules;

ii. on 21 instances between 8 March 2020 and 25 February 2022, Pregabalin 75mg capsules;

iii. on 8 instances between 22 March 2020 and 22 January 2022, Seroquel (quetiapine) 100mg.

4. The practitioner's conduct in particular 3 was not appropriate:

a. in that the quantity of the drug dispensed, including the relevant period of time and intervals in which it was dispensed was inappropriate:

i. having regard to the usual dosage, the dosage and quantity prescribed, and/or the maximum recommended dosage for each drug; and/or

ii. having regard to the potential for abuse, misuse or diversion, which the practitioner knew or should have known;

b. for particular 3(a)(v), having regard to the concurrent prescribing and/or dispensing history of Pregabalin, of which the practitioner knew or should have known; having regard to clause 40 of the PTGR;

c. in circumstances where the practitioner failed to make appropriate enquiries, including with the prescribing practitioner, prior to dispensing the drug;

d. otherwise in the circumstances.

Patient B

5. On 13 June 2021, as set out in Annexure B, the practitioner inappropriately issued five unauthorised repeat prescriptions to Patient B for the Schedule 4D drug, Seroquel XR 400mg tablets.

6. The practitioner's conduct in particular 5 was not appropriate in circumstances where the repeat prescriptions had not been authorised on the prescription by the prescriber and:

a. having regard to clause 4.4 of the NSW Health 'Guide to the Poisons and Therapeutic Goods Legislation for Pharmacists';

b. having regard to section 16(2) of the Poisons and Therapeutic Goods Act 1966 (NSW);

c. in circumstances where the practitioner failed to make appropriate enquiries, including with the prescribing practitioner, prior to issuing the repeat prescription;

d. otherwise in the circumstances.

7. Between 10 July 2021 and 23 October 2021 on five instances as set out in Annexure B, the practitioner inappropriately dispensed unauthorised repeat prescriptions, to Patient B for the Schedule 4D drug Seroquel XR 400mg tablets.

8. The practitioner's conduct in particular 7 was not appropriate:

a. the quantity of the drug dispensed, and the relevant period of time and intervals in which it was dispensed was inappropriate:

i. having regard to the usual dosage, the dosage and quantity prescribed, and/or the maximum recommended dosage for each drug; and/or

ii. having regard to the potential for abuse, misuse or diversion, which the practitioner knew or should have known;

b. having regard to clause 40 of the PTGR;

c. in that the practitioner failed to make appropriate enquiries, prior to dispensing the drug;

d. otherwise in the circumstances.

Patient C

9. Between 13 September 2021 and 1 November 2021, as set out in Annexure C, the practitioner inappropriately issued 20 unauthorised repeat prescriptions to Patient C for the Schedule 4D drug, Pregabalin 75mg capsules.

10. The practitioner's conduct in particular 9 was not appropriate in circumstances where the repeat prescriptions had not been authorised on the prescription by the prescriber:

a. having regard to clause 4.4 of the NSW Health 'Guide to the Poisons and Therapeutic Goods Legislation for Pharmacists';

b. having regard to section 16(2) of the Poisons and Therapeutic Goods Act 1966 (NSW);

c. in circumstances where the practitioner failed to make appropriate enquiries, including with the prescribing practitioner, prior to issuing the repeat prescription;

d. otherwise in the circumstances.

11. Between 13 September 2021 and 1 November 2021 on 20 instances as set out in Annexure C, the practitioner inappropriately dispensed unauthorised repeat prescriptions, to Patient C for the Schedule 4D drug, Pregabalin 75mg capsules.

12. The practitioner's conduct in particular 11 was not appropriate:

a. in that the quantity of the drug dispensed, including the relevant period of time and intervals in which it was dispensed was inappropriate:

i. having regard to the usual dosage, the dosage and quantity prescribed, and/or the maximum recommended dosage for each drug; and/or

ii. having regard to the potential for abuse, misuse or diversion, which the practitioner knew or should have known;

b. having regard to clause 40 of the PTGR;

c. in that the practitioner failed to make appropriate enquiries including with the prescribing practitioner, prior to dispensing the drug;

d. otherwise in the circumstances.

Patient D

13. Between 6 July 2021 and 15 November 2021 on the instances set out in Annexure D, the practitioner inappropriately issued unauthorised repeat prescriptions to Patient D for the following Schedule 4D drugs:

a. on 6 July 2021 on five instances, Seroquel (quetiapine) 200mg tablets;

b. on 11 October 2021 on five instances, Pregabalin 300mg tablets;

c. on 15 November 2021 on five instances, Pregabalin 150mg tablets.

14. The practitioner's conduct in particular 13 was not appropriate in circumstances where the repeat prescriptions had not been authorised on the prescription by the prescriber:

a. having regard to clause 4.4 of the NSW Health 'Guide to the Poisons and Therapeutic Goods Legislation for Pharmacists';

b. having regard to section 16(2) of the Poisons and Therapeutic Goods Act 1966 (NSW);

c. in circumstances where the practitioner failed to make appropriate enquiries, prior to issuing the repeat prescription;

d. otherwise in the circumstances.

15. Between 2 August 2021 and 2 January 2022, the practitioner inappropriately dispensed unauthorised repeat prescriptions to Patient D for the following Schedule 4D drugs:

a. between 2 August 2021 and 29 November 2021 on five instances, Quetiapine 200mg tablets;

b. between 15 November 2021 and 2 January 2022 on two instances, Pregabalin 300mg tablets;

c. on 2 January 2022, Pregabalin 150mg tablets.

16. The practitioner's conduct in particular 15 was not appropriate:

a. in that the quantity of the drug dispensed, including the relevant period of time and intervals in which it was dispensed was inappropriate:

i. having regard to the usual dosage, the dosage and quantity prescribed, and/or the maximum recommended dosage for each drug; and/or

ii. having regard to the potential for abuse, misuse or diversion, which the practitioner knew or should have known;

b. having regard to clause 40 of the PTGR;

c. in that the practitioner failed to make appropriate enquiries including with the prescribing practitioner, prior to dispensing the drug;

d. otherwise in the circumstances.

Patient E

17. Between [19 January 2021 and 20 August 2021] ... on 10 instances as set out in Annexure E, the practitioner inappropriately issued unauthorised repeat prescriptions to Patient E for the Schedule 4D drug, Pregabalin 25mg capsules.

18. The practitioner's conduct in particular 17 was not appropriate in circumstances where the repeat prescriptions had not been authorized on the prescription by the prescriber:

a. having regard to clause 4.4 of the NSW Health 'Guide to the Poisons and Therapeutic Goods Legislation for Pharmacists';

b. having regard to section 16(2) of the Poisons and Therapeutic Goods Act 1966 (NSW);

c. in circumstances where the practitioner failed to make appropriate enquiries, prior to issuing the repeat prescription;

d. otherwise in the circumstances.

19. Between 12 February 2021 and 4 December 2021, the practitioner inappropriately dispensed 9 unauthorised repeat prescriptions to Patient E for the Schedule 40 drug, Pregabalin 25mg capsules.

20. The practitioner's conduct in particular 19 was not appropriate:

a. in that the quantity of the drug dispensed, including the relevant period of time and intervals in which it was dispensed was inappropriate:

i. having regard to the usual dosage, the dosage and quantity prescribed, and/or the maximum recommended dosage for each drug; and/or

ii. having regard to the potential for abuse, misuse or diversion, which the practitioner knew or should have known;

b. having regard to clause 40 of the PTGR;

c. in that the practitioner failed to make appropriate enquiries, prior to dispensing the drug;

d. otherwise in the circumstances.

Patient F

21. On 29 April 2021, on five instances as set out in Annexure F, the practitioner inappropriately issued unauthorised repeat prescriptions to Patient F for the Schedule 4D drug, Pregabalin 75mg capsules.

22. The practitioner's conduct in particular 21 was not appropriate in circumstances where the repeat prescriptions had not been authorized on the prescription by the prescriber:

a. having regard to clause 4.4 of the NSW Health 'Guide to the Poisons and Therapeutic Goods Legislation for Pharmacists';

b. having regard to section 16(2) of the Poisons and Therapeutic Goods Act 1966 (NSW);

c. in circumstances where the practitioner failed to make appropriate enquiries, prior to issuing the repeat prescription;

d. otherwise in the circumstances.

23. On each of 25 October 2021 and 14 December 2021 as set out in Annexure F, the practitioner inappropriately dispensed unauthorised repeat prescriptions to Patient F for the Schedule 4D drug, Pregabalin 75mg capsules.

24. The practitioner's conduct in particular 23 was not appropriate:

a. in that the quantity of the drug dispensed, including the relevant period of time and intervals in which it was dispensed was inappropriate:

i. having regard to the usual dosage, the dosage and quantity prescribed, and/or the maximum recommended dosage for each drug; and/or

ii. having regard to the potential for abuse, misuse or diversion, which the practitioner knew or should have known;

b. having regard to clause 40 of the PTGR;

c. in that the practitioner failed to make appropriate enquiries, prior to dispensing the drug;

d. otherwise in the circumstances.

Quantity of drugs dispensed

Patient A

25. During the period between 8 March 2020 and 25 February 2022 in the quantities and on the occasions as set out in Annexure A, the practitioner dispensed to Patient A:

i. Pregabalin 150mg capsules;

ii. Pregabalin 75mg capsules;

iii. Seroquel (Quetiapine) 100mg tablets;

i. Salbutamol 100mcg/dose inhaler;

ii. Duloxetine 60mg tablets;

iii. Venlafaxine 150mg capsules;

iv. Valproate EC 500mg tablets;

i. Seretide Accuhaler 500mcg/50mcg.

26. The practitioner's conduct in particular 25 was not appropriate:

a. in that the quantity of the drugs dispensed, including the relevant period of time and intervals in which it was dispensed was inappropriate:

i. having regard to the usual dosage, the dosage and quantity prescribed, and/or the maximum recommended dosage for each drug;

ii. for particular 25(a), having regard to the potential for abuse, misuse or diversion, which the practitioner knew or should have known;

iii. for particular 25(b)(ii), having regard to the concurrent prescribing and/or dispensing history of Venlafaxine, of which the practitioner knew or should have known;

iv. for particular 25(b)(iii), having regard to the concurrent prescribing and/or dispensing history of Duloxetine, of which the practitioner knew or should have known;

v. in that the practitioner failed to make appropriate enquiries, including to the prescribing practitioner, prior to dispensing the drug;

vi. otherwise in the circumstances.

Patient B

27. During the period between 2 April 2019 and 23 October 2021 in the quantities and on the occasions as set out in Annexure B, the practitioner dispensed to Patient B:

a. the Schedule 4D drug, Seroquel (Quetiapine) 400mg tablets;

b. the Schedule 4 drug:

i. Lipitor (Atorvastatin) 20mg tablets;

ii. Lipitor (Atorvastatin) 40mg tablets;

iii. Lipitor (Atorvastatin) 80mg tablets.

28. The practitioner's conduct in particular 27 was not appropriate:

a. in that the quantity of the drugs dispensed, including the relevant period of time and intervals in which it was dispensed was inappropriate:

i. having regard to the usual dosage, the dosage and quantity prescribed, and/or the maximum recommended dosage for each drug;

ii. for particular 27(a), having regard to the potential for abuse, misuse or diversion, which the practitioner knew or should have known;

iii. in that the practitioner failed to make appropriate enquiries, including to the prescribing practitioner, prior to dispensing the drug;

iv. otherwise in the circumstances.

Patient C

29. During the period between 2 April 2019 and 23 October 2021 in the quantities and on the occasions as set out in Annexure C, the practitioner dispensed to Patient C:

a. the Schedule 4D drug, Pregabalin 75mg tablets;

b. the Schedule 4 drug, Symbicort Rapihaler 120 doses.

30. The practitioner's conduct in particular 29 was not appropriate:

a. in that the quantity of the drugs dispensed, including the relevant period of time and intervals in which it was dispensed was inappropriate:

i. having regard to the usual dosage, the dosage and quantity prescribed, and/or the maximum recommended dosage for each drug;

ii. for particular 29(a), having regard to the potential for abuse, misuse or diversion, which the practitioner knew or should have known;

iii. in that the practitioner failed to make appropriate enquiries, including to the prescribing practitioner, prior to dispensing the drug;

iv. otherwise in the circumstances.

31. On or around 1 November 2021, in the quantities and on the occasions as set out in Annexure C, the practitioner dispensed and supplied to Patient C:

a. 5 dispensings of Bion Tears Eye-Drop 3 units;

b. 24 dispensings of Systane Eye-Drops 15ml;

c. 6 dispensings of Celecoxib 100mg tablets 60;

d. 12 dispensings of Diaformin 500mg tablets 100;

e. 5 dispensings of Duodart (dutasteride 500mcg and tamsulosin 400mg) 30 and Flomaxtra (tamsulosin 400mg);

f. 5 dispensings of Exforge-HCT (amlodipine 10mg, valsartan 320mg and hydrochlorothiazide 25mg) tablets 28 and 17 dispensings of perindopril 10mg tablets 30;

g. 6 dispensings of Ezetimibe 10mg + simvastatin 80mg tablets 30;

h. 6 dispensings of paracetamol 665mg tablets 192;

i. 8 dispensings of aspirin 100mg tablets 112;

j. 31 dispensings of Symbicort Rapihaler 200mcg + 8mg 120 doses;

k. Schedule 4D drug Pregabalin 75mg capsules.

32. The practitioner's conduct in particular 31 was not appropriate:

a. in that the quantity of the drugs dispensed, including the relevant period of time and intervals in which it was dispensed was inappropriate:

i. having regard to the usual dosage, the dosage and quantity prescribed, and/or the maximum recommended dosage for each drug;

ii. for particular 31(c), having regard to drug interaction with the drug Exforge HCT, which the practitioner knew or should have known;

iii. for particular 31(f), having regard to drug interaction with the drug Celecoxib, which the practitioner knew or should have known;

iv. having regard to the potential for abuse, misuse or diversion, which the practitioner knew or should have known;

v. having regard to the potential for Pharmaceutical Benefits Scheme ('PBS') fraud in that PBS subsidised drugs could be diverted to individuals other than the patient;

vi. in that the practitioner failed to make appropriate enquiries, including to the prescribing practitioner, prior to dispensing the drug;

vii. otherwise in the circumstances.

33. On or around 24 January 2022, in the quantities and on the occasions as set out in Annexure C, the practitioner dispensed and supplied to Patient C:

i. Celecoxib 100mg (60 tablets);

ii. Flomaxtra (tamsulosin hydrochloride) 400mcg (30 tablets);

iii. Metformin AN 500mg (100 tablets);

iv. Prexum (perindopril) 10mg (30 tablets);

v. Symbicort Rapihaler 200+6mcg;

b. the Schedule 4D drug, Pregabalin 75mg (56 capsules).

34. The practitioner's conduct in particular 33 was not appropriate:

a. in that the quantity of the drugs dispensed, including the relevant period of time and intervals in which it was dispensed was inappropriate:

i. having regard the quantities of the drug previously supplied in or around November 2021;

ii. for particulars 33(a)(iv) and (v), having regard to section 16(2) of the Poisons and Therapeutic Goods Act 1966 (NSW);

iii. having regard to the usual dosage, the dosage and quantity prescribed, and/or the maximum recommended dosage for each drug;

iv. in that the practitioner failed to make appropriate enquiries, prior to supplying the drug;

v. otherwise in the circumstances.

Dispensing expired prescriptions

35. Between approximately 20 August 2021 and 17 February 2022, in the quantities and on the occasions as set out in Annexure G, the practitioner inappropriately dispensed to various patients, the following drugs:

a. the Schedule 8 drug, Endone (oxycodone hydrochloride);

b. the Schedule 4D drugs:

i. Diazepam;

ii. Lorazepam;

iii. Oxazepam;

iv. Pregabalin;

v. Quetiapine;

vi. Temazepam;

vii. Tramadol hydrochloride,

in circumstances where the drugs were dispensed on prescriptions that had passed their 6-month expiry date."

1. In his amended reply to the application for disciplinary findings, Mr Haloob admits the facts set out above, save that he clarified that he would typically work five days per week (Monday, Tuesday, Friday, Saturday, Sunday), not every day. Mr Haloob also admits that his conduct constituted unsatisfactory professional conduct and professional misconduct.
2. Mr Haloob did not admit to issuing and dispensing unauthorised repeat prescriptions for drugs of addiction within the meaning of the PTGA, being drugs contained within Schedule 8 of the Poisons List proclaimed under the PTGA, s 8 (see particular 35 above of the amended complaint). This was a result of the way the issue was pleaded. During the course of the hearing this issue was resolved and the allegation made by the Commission in respect of the Schedule 8 drug Endone, was limited to one occasion "dispensing drugs on expired prescriptions" which Mr Haloob admitted.

1. The Commission filed a two volume bundle of documents including: pharmacy dispensing records for each of the patients; dispensing records for expired prescriptions; a report by the PRU dated 7 April 2022; correspondence between the Commissioner and Mr Haloob, a transcript of interview conducted under s 150; reasons for decision by the Council; the monthly reports of Mr Cross and reflections of Mr Haloob from the date the conditions were first imposed; and an expert report from a senior lecturer in pharmacy practice, Dr Helen Benson from the University of Technology, Sydney. A supplementary bundle of material was filed which included evidentiary certificates, as well as an Amended Complaint. Opening and closing written submissions were also provided.
2. Mr Haloob filed some documents including a statement by him, his reply and opening and closing written submissions.
3. Mr Haloob was the only witness cross-examined at the hearing.

1. The principles relevant to disciplinary proceedings under the National Law are uncontroversial, with the overarching principles found in s 3 and s 3A. Section 3A mandates that in determining proceedings the Tribunal has as its paramount consideration, the protection of the health and safety of the public.
2. The Tribunal may exercise the disciplinary powers conferred by Subdiv 6 of Div 3 of Pt 8 of the National Law if

(1) it finds the subject matter of the complaint to have been proven; or

(2) the practitioner admits to it in writing to the Tribunal: National Law, s 149.

1. The Tribunal is not bound by the rules of evidence in these proceedings (National Law, cl 2 of Sch 5D) and the Commission bears the onus of proving the complaints against Mr Haloob on the balance of probabilities.

1. Section 139B of the National Law provides a detailed list of behaviours that are covered by the term "unsatisfactory professional conduct" in relation to registered health practitioners in NSW.
2. Sections 139B(1)(a) and/or s 139B(1)(l); are the relevant paragraphs regarding the complaint against Mr Haloob, which provide as follows:

139B Meaning of "unsatisfactory professional conduct" of registered health practitioner generally [NSW]

(1) Unsatisfactory professional conduct of a registered health practitioner includes each of the following -

(a) Conduct significantly below reasonable standard

Conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of the practitioner's profession is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience.

...

(l) Other improper or unethical conduct

Any other improper or unethical conduct relating to the practice or purported practice of the practitioner's profession.

1. A determination of whether conduct was significantly below the reasonable standard under s 139B(1)(a) requires an evaluative process, and was discussed by the Tribunal in Health Care Complaints Commission v Amalakumar [2019] NSWCATOD 173 at [25] as follows:

"Determining whether the 'knowledge, skill or judgment' possessed by a practitioner, or the 'care exercised' by a practitioner is significantly below the standard reasonably expected, in order for the elements of s 139B(1)(a) to be established, requires the undertaking of an evaluative process. A benchmark standard which is expected of practitioners in the relevant field must be ascertained, and then the conduct which has been proven against the practitioner the subject of the disciplinary action, must be assessed against that standard. If the conduct is considered to be below the standard arrived at, then a further evaluation must be made as to whether the conduct is significantly below that standard. If that conduct is assessed to be significantly below the standard reasonably expected, then there is no discretion as to whether that conduct is characterised as unsatisfactory professional conduct. The section designates it as such."

1. In the context of s 139B(1)(l) the Tribunal considered the meaning of improper and unethical in Health Care Complaints Commission v Bolton [2021] NSWCATOD 160, with which we agree and adopt here. The Tribunal stated:

"[86] The words 'unethical or 'improper' are not defined in the National Law. The Macquarie Dictionary defines 'improper' relevantly as 'not in accordance with propriety of behaviour, manners etc' or 'abnormal or irregular' and 'unethical' as 1. 'contrary to moral precept; immoral' and 2. 'in contravention of some code of professional conduct.'

[87] Assistance in determining what is meant by 'improper' can also be gained from what the High Court of Australia said of the word 'impropriety' in R v Byrnes & Hopwood [1995] HCA 1. If conduct is not in conformity with standards of professional conduct and practice it can be seen as improper."

[88] In Health Care Complaints Commission v Nguyen [2018] NSWCATOD 168 the Tribunal considered the scope of 'improper conduct' in s 139B(1)(l) stating at [47]-[49]:

'The High Court has noted that "improper" is not a term of art: The Queen v Byrnes [1995] HCA 1; (1995) 183 CLR 501 at 514, citing Grove v Flavel (1986) 43 SASR 410 at 420. In Byrnes at 514-5, Brennan, Deane, Toohey and Gaudron JJ explained the concept of impropriety as follows:

"Impropriety does not depend on the alleged offender's consciousness of impropriety. Impropriety consists in a breach of the standards of conduct that would be expected of a person in the position of the alleged offender by reasonable persons with knowledge of the duties, powers and authority of the position and the circumstances of the case."

This approach to determining whether conduct is 'improper' has been adopted in a disciplinary context in numerous cases, including Health Care Complaints Commission v Liu [2016] NSWCATOD 133 at [54] and [55] and the cases there cited.'"

1. Professional misconduct is defined in s 139E of the National Law as follows:

139E Meaning of "professional misconduct" [NSW]

For the purposes of this Law, professional misconduct of a registered health practitioner means -

(a) unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration; or

(b) more than one instance of unsatisfactory professional conduct that, when the instances are considered together, amount to conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration.

1. The term "professional misconduct" for the purposes of the National Law, is thus a category of "unsatisfactory professional conduct" which is sufficiently serious to justify suspension or cancellation: Chen v Health Care Complaints Commission (2017) 95 NSWLR 334; [2017] NSWCA 186 at [19] (Basten JA) ("Chen"). The exercise involves an evaluative judgment to be made by the Tribunal as to the nature and seriousness of the conduct: Chen at [20].
2. In Health Care Complaints Commission v Robinson [2022] NSWCA 164 the Court noted at [35] that the "seriousness of the conduct" concerns not only acts or omissions, but also the circumstances of their occurring.

1. As Mr Haloob has admitted Complaint One in writing, pursuant to s 149 of the National Law, we find that he is guilty of unsatisfactory professional conduct under ss 139B(1)(a) and 139B(1)(l) of the National Law. We would have made the same findings on the evidence before us, in any event, for the reasons that follow.
2. Mr Haloob gave evidence in a written statement and in cross-examination about the circumstances surrounding the issue of unauthorised repeat prescriptions and dispensing drugs to patients as set out below.

1. Patient A was a repeat customer at the pharmacy and a person of limited mobility. Despite the ordinary practice of receiving prescriptions with repeats already on them, when Patient A presented with prescriptions without repeats, Mr Haloob believed Patient A's assertion (on numerous occasions) that the treating doctor must have forgotten to include the repeat. Mr Haloob said he felt sympathy for Patient A including because Patient A had difficulties physically attending the pharmacy and the doctor. Mr Haloob said that he believed Patient A was a "genuine patient in genuine clinical need".
2. Consequently, Mr Haloob generated repeat prescriptions for Patient A and dispensed a significant quantity of drugs (often on the same date). He did not make any enquiries with Patient A's general practitioner. The quantity of drugs dispensed to Patient A is unusually excessive.
3. Mr Haloob also said that in respect of the issue of dispensing Schedule 4 and Schedule 4D drugs in significant quantities, Patient A told Mr Haloob in 2020 that he was going to Lebanon for several months to visit family and that he would not have access to medication but also, given the COVID-19 Pandemic, he was concerned about being stuck there without medication. Mr Haloob said that it was on this basis that he dispensed the significant quantity of Schedule 4D and Schedule 4 drugs. However, this is inexplicable on the evidence for this reason. Having been told on one occasion that Patient A was going to Lebanon for six months, Patient A continued to visit the pharmacy on repeated occasions directly afterwards. The inference from the records is that Patient A did not go to Lebanon for several months as he was continuously attending the pharmacy and having the drugs dispensed. Even if Mr Haloob thought, on the first occasion when Patient A requested the drugs to be dispensed in bulk, that this was because of pending travel, there is no explanation for why that pattern continued over the next two years.
4. In cross-examination Mr Haloob could not remember why he did not contact Patient A's treating doctor about the prescriptions. He also said that at that time he did not understand that it was the doctor's sole responsibility to work out how much medication a patient required and then prescribe that medication. He said that at that time he should have been, but was not, privy to all of the rules and regulations governing repeat prescriptions or that dispensing of drugs in large quantities was abusable.

1. In Mr Haloob's written statement he said he could not recall any circumstances or information provided by Patient B which caused him to issue unauthorised repeat prescriptions of Seroquel XR 400mg on 13 June 2021 and dispensing them between 10 July 2020 and 23 October 2023.
2. He explained it as follows:

"When a medicine to be dispensed was selected in the Pharmacy's dispensing software, 'Aquarius' by 'Simple Retail, the field for the prescription's number of repeats was automatically filled as '5'. If a prescription was issued with less than 5 repeats, the software required the pharmacist to manually change this automatically filled field. If this field is not manually changed, the prescription was recorded and/or dispensed with 5 repeats.

I believe that, on 13 June 2021, I may have failed to manually change this field, thereby creating 5 additional repeats, which were then dispensed. This error was then compounded in dispensing the medication each time after that. I recognise that this was inappropriate, both in the issuing of the repeat and the dispensing of the medication on those unauthorized repeats. I was also unaware at the time that Seroquel was a schedule 4D drug."

1. In respect of the issue of significant quantities of drugs to Patient B, Mr Haloob recalled that in relation to the drug Lipitor, Patient B had different general practitioners; was taking different dosages of Lipitor; was suffering some side effects from Lipitor 80 but that Lipitor 20 was not enough to reduce cholesterol so was alternating between dosages.
2. In cross-examination Mr Haloob was initially equivocal about whether he knew the procedure around the process issuing repeat scripts.

1. In respect of Patient C, again Mr Haloob could not remember specific details about how he dispensed unauthorised repeats of 20 prescriptions on two occasions: 13 September 2021 and 1 November 2021. However, he did recall that Patient C was travelling to Iraq and might not have been returning to Australia which is why early dispensing of medicine was required. The quantity dispensed to Patient C on these two occasions was significant. On 1 November 2020 for example, 153 medications were issued to Patient C. Mr Haloob said he provided larger quantities because Patient C needed them overseas. He said he did not know that Pregabalin was a Schedule 4D drug; did not know the effect stockpiling medication might have on the PBS; and did not question the amounts of drugs being requested - he just dispensed them on the basis Patient C did not know when he might return to Australia.

1. Mr Haloob did not recall the specific circumstances of issuing unauthorised repeat prescriptions on four occasions to Patient D nor dispensing unauthorised repeats between 22 August 2021 and 2 January 2022. He thought he might have inadvertently dispensed inaccurately or failed to manually change the field in the software.
2. Mr Haloob did recall however that he felt threatened and intimidated by Patient D who behaved in a verbally loud and physically aggressive manner. Patient D would push ahead of others in line, accuse pharmacy staff of losing repeats and in those circumstances Mr Haloob would dispense half a packet or a few tables as an "owing script" and ask the doctor to issue a script. Mr Haloob could not recall if this was what caused the issue of the unauthorised repeats or whether it was unrelated to the dates the subject of the Complaint.

1. While Mr Haloob could not recall the specific circumstances that led to him issuing unauthorised prescriptions to Patient E or the inappropriate dispensing of those repeats, he recounted that Patient E was a person who presented in a very rushed manner often talking over Mr Haloob and not listening to him. Patient E would frequently come in during "rush hour" and would be quite pushy wanting to get out as quickly as possible. He felt this was a contributing factor to him making mistakes.
2. In his written statement, Mr Haloob surmised that he might have failed to manually change the field in the dispensing software for Patient E. However, in cross-examination he could not recall exactly.

1. Again, Mr Haloob had no recollection of the circumstances in which he issued unauthorised repeats and dispensed drugs to Patient F. He said he did little thinking when he was dispensing and so was unaware.
2. In respect of the issue of dispensing medications on expired prescriptions, Mr Haloob acknowledged that most of the drugs were Pregabalin or Seroquel which he said he was unaware had become Schedule 4D drugs and so did not realise they only had a six month expiry on them. He otherwise stated he did not recall how he came to dispense the other Schedule 4D drugs (such as the benzodiazepines) other than to say "it was an unacceptable mistake". Similarly with the dispensing of Endone on 19 September 2021 on a prescription which had expired by seven days, he could not recall how that happened but said it must have been an error or a computer error.

1. When pressed further in cross-examination and in particular in answering questions by the Tribunal about the method of generating unauthorised prescriptions from escripts, Mr Haloob admitted that his signature was on the unauthorised scripts and ultimately accepted that the system does not change the prescription date itself for escripts but that this has to be manually overridden and then the script signed - in other words they are not the result of a computer error.
2. A number of these signed scripts were put before him and he was asked a number of questions about how the scripts came to be falsified. Mr Haloob objected to answering some questions on the basis it might incriminate him and he was ultimately given a certificate under s 128 of the Evidence Act 1995 (NSW) in relation to evidence given by him about the falsification and dispensing of repeat prescriptions.
3. Mr Haloob then accepted the scripts had been manipulated and manually changed but said either his employee had prepared them and put them in front of him to sign or the employee had forged his signature. He could not explain it.

1. During cross-examination, Mr Haloob was repeatedly questioned about his inability to remember the circumstances surrounding his conduct. His answers on every occasion were denials of knowledge or awareness about why he engaged in this conduct or how it happened except to say that he was very remorseful and ashamed; that he was reckless, dangerous and stupid; that he was burnt out at work getting little sleep or food; that the disciplinary action had caused him significant emotional pain; that he feels he has let himself and his family down; he has learned that he is not the person he thought he was; that he would never put himself in that situation again; and that prior to his suspension, he had a significant lack of competence, knowledge, understanding, including of the legislation, but that he has now become knowledgeable through all the hours spent in professional development courses and time being supervised. In other words, on most occasions when asked to explain events and pharmaceutical practices engaged in at the relevant time, Mr Haloob's default position was to express deep regret, indicate he was being as honest as he could but not directly answer the question. On more than one occasion we had to ask him to answer the question he was asked rather than explain what he now knows and what he would now do in the same situation.
2. In circumstances where Mr Haloob has been a practitioner for over 18 years and the PTGA and Poisons Guide have been in effect since at least 1996, we find Mr Haloob's explanations lacked credibility. We do not accept that he had no idea or did not appreciate the regulations or rules at that time. We perceived his evidence as being self-serving.
3. We also consider, from the evidence Mr Haloob gave, that he was withholding information relevant to the disposition of this matter. That may have been as a result of the fact that there are still ongoing investigations into his conduct by the Australian Government Solicitor (into issues around the PBS). It might also have been, as Mr Haloob contended, because he lacked attention, education and awareness at the time of his conduct. We find that Mr Haloob being unable to remember such significant shortfalls in pharmaceutical practice is implausible and we do not accept his evidence on this. Equally we do not accept his excuse that he had no knowledge of his professional obligations, or the regulations, and was just not paying attention.
4. The Commission submits that the issuing of unauthorised repeat prescriptions was conduct which fell significantly below the expected standard. This was supported by the findings of Dr Benson that the conduct was significantly below the expected standard of a dispensing pharmacist and also that of a pharmacist proprietor of an equivalent level of training and experience. Dr Benson's report noted that the issuing of unauthorised repeats "puts the pharmacist in the role of prescriber" which the PRGR legislation does not allow; and that Mr Haloob failed to make sufficient inquiries of the patients before he issued Schedule 4 drugs in large quantities. In addition, Dr Benson's evidence was to the effect that repeated instances of dispensing drugs on expired prescriptions over a period of six months was outside the scope of the regulatory framework and was conduct significantly below the expected standard. We note Mr Haloob also agreed his conduct was "well well below the standard" expected of someone in his position.
5. In our view, Mr Haloob's conduct was improper, not inadvertent, showed reckless disregard of his obligations and was significantly below the standards expected of pharmacists. We find that Mr Haloob engaged in unsatisfactory professional conduct under the National Law, s 139B(1)(a) and (l).

1. Complaint Two is that Mr Haloob engaged in professional misconduct under the National Law, s 139E and relies on the particulars to Complaint One.
2. Again, while Mr Haloob has admitted Complaint Two, we find the particularised conduct is established by the evidence.
3. We find that Mr Haloob's conduct involved unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of his registration as:

(1) The conduct occurred over a number of years;

(2) It involved repeated breaches and multiple patients;

(3) The quantity of restricted substances which were dispensed by Mr Haloob to various patients was significant: often multiple packs of the same substances were dispensed on the same day; multiple instances of the same substances were dispensed in the same month; and dispensing of substances within short intervals of each other. In particular, Mr Haloob dispensed to Patient A:

(a) 1,064 capsules of duloxetine 60mg 38 units of 28 capsules over a 705 day period;

(b) 784 capsules of venlafaxine 150mg (28 units of 28 capsules) and 3,024 capsules of venlafaxine 75mg (108 units of 28 capsules) over a 719 day period;

(c) 7,800 tablets of valproate 500mcg EC (78 units of 100 tablets) over a 687 day period;

(d) 86 units of Seretide 500mcg/50mcg Accuhaler over a 714 day period;

(e) 4,984 capsules of pregabalin 150 mg (89 units of 56 capsules) over a 705 day period;

(f) 2,968 capsules of pregabalin 75mg (53 units of 56 capsules) ovr a 719 day period;

(g) 2,070 tablets of quetiapine 100mg (23 boxes of 90 tablets) over a 671 day period.

1. It is a core responsibility of a pharmacist to ensure that drugs (particularly drugs on the Poisons List), are dispensed appropriately. Mr Haloob did not so do. Rather, he dispensed drugs on unauthorised prescriptions including in circumstances where no contact was made to the prescriber who issued the prescriptions. Further, as submitted by the Commission, Mr Haloob's purported ignorance of pregabalin and quetiapine being included in Schedule 4D drugs, and his dispensing of these substances in excessive quantities to various patients, demonstrated a serious lack of knowledge and care for substances that are liable to be misused, abused and trafficked with a disregard of the risk of potential accidental overdose and misadventure.
2. As noted above, in cross-examination, Mr Haloob was unable to adequately explain why he engaged in the conduct. He gave various excuses including a lack of attention to what he was doing; unawareness of his responsibilities and obligations under the various pharmaceutical guidelines due to his inability to keep up with continuing professional development; distraction in the form of his phone and internet; being overworked and overwhelmed as the only practitioner on duty; and feeling sorry for patients who would otherwise have to go back to the doctor to have repeats issued and/or patients who were travelling overseas and needed medication because of the extended period of travel.
3. We had difficulty accepting his evidence in this regard. He presented as a witness who did not want to admit that he had any knowledge of what he was doing. Further, some of his excuses lack cogency. For example, Mr Haloob is an experienced pharmacist of over 18 years. Lack of knowledge of process and procedure in conformity with pharmaceutical guidelines might be more readily accepted in someone with little experience but that was not the case here. Further, his excuse that he dispensed large quantities to Patient A in circumstances where Patient A was leaving for overseas with an indefinite return date was inexplicable given Mr Haloob continued to dispense large quantities to Patient A over the balance of the period.
4. In our view, Mr Haloob showed a reckless disregard and gross dereliction of his obligations.
5. We find that Mr Haloob's conduct, either considered individually or considered cumulatively, constitutes professional misconduct. Complaint Two is established on the evidence.

What if any disciplinary orders should be made?

1. Having established each of Complaints, the parties have requested the Tribunal to determine what protective orders should be made.
2. The disciplinary powers available to the Tribunal where a complaint is found proven are contained in Part 8, Div 3, Subdiv 6 of the National Law. They include the power to caution, reprimand and counsel a practitioner and impose conditions on the practitioner's registration. Where, as in this case, the Tribunal is satisfied the practitioner is guilty of professional misconduct, the Tribunal may suspend the practitioner's registration for a specified period or cancel their registration: s 149C(1) of the National Law.
3. The principles underlying the purpose of protective orders was summarised by President Wright J in Health Care Complaints Commission v Dr Della Bruna [2014] NSWCATOD 31 at [88] as follows:

"[88] In determining the appropriate protective orders that it should make in this matter, the Tribunal is guided by the following considerations:

(1) In the exercise of its functions under Subdivision 6 of Division 3 of Part 8 of the National Law, the protection of the health and safety of the public must be the Tribunal's paramount consideration - s 3A of the National Law.

(2) Disciplinary proceedings against members of a profession are intended to maintain proper ethical and professional standards, primarily for the protection of the public but also for the protection of the profession - Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630 at 637,

(3) The public interests served by protective orders include, indirectly, the standing of the medical profession and the maintenance of public confidence in the high standards of medical practitioners - Prakash v Health Care Complaints Commission [2006] NSWCA 153 at [91].

(4) Protective orders also involve an element of deterrence or, to put it more positively, encouragement to other practitioners to recognise the importance of complying with professional standards and the risks of failing to do so - Prakash v Health Care Complaints Commission [2006] NSWCA 153 at [91].

(5) Although the specific purpose for which the Tribunal makes orders is protective of the public interest and not punitive with respect to the practitioner, that is not to deny that such orders may be punitive in effect and that punitive effect may be relevant in formulating a protective order - Lee v Health Care Complaints Commission [2012] NSWCA 80 at [20] citing Director General, Department of Ageing, Disability and Home Care v Lambert [2009] NSWCA 102; (2009) 74 NSWLR 523 at [83]."

1. The Commission seeks orders from the Tribunal under the National Law, s 149C(1)(b) for the cancellation of Mr Haloob's registration, with a non-review period of 12 months. Mr Haloob submitted that a combination of reprimands and conditions would be appropriate protective orders; or at the higher end, a suspension.
2. Mr Haloob submits that his diligence and level of knowledge, though clearly below standard and not to be excused, was "not informed by any moral turpitude". He asked that the Tribunal be cautious in the imposition of protective orders, and to undertake a consideration of the severity of the conduct, but also "what informed or caused it and the capacity for that to be remedied".
3. Mr Haloob asserts that his evidence demonstrates that he is aware of the seriousness of his conduct and he does not attempt to evade responsibility for it. He submits that in addition to his written statement and oral evidence, his accounts of his conduct and his attitudes towards it were clear and remorseful from the beginning of the investigation including on:

(1) 31 March 2022 at the interview with the PRU;

(2) 28 April 2022 at the s 150 hearing;

(3) 31 October 2022 at the s 150A hearing;

(4) 23 March 2023 at the s 34A interview with the Commission;

(5) 21 February 2024 at the second s 150A hearing;

(6) 25 April 2024 in Mr Haloob's s 40 submissions to the Commission.

1. Mr Haloob submits that his misconduct was caused by an "unfortunate mix of a lack of professional development and professional isolation"; and that he did not fully understand the extent of his wrongdoing, nor the possible consequences of it.
2. Further, despite the Commission's submissions to the contrary, Mr Haloob asserts that he has provided an adequate explanation for his conduct - it is consistent with what he recalls and he has not attempted to make up a story to help his case. It is also consistent with his responses in the hearings listed above.
3. Mr Haloob submits that his conduct since first being suspended in April 2022 also speaks to his remorse for his misconduct. After six months' suspension, Mr Haloob was allowed to practise with conditions. Those conditions were eased and replaced at a further s 150 hearing on 21 February 2024.
4. Mr Michael Cross, the approved supervisor for Mr Haloob, has written 20 supervision reports since his appointment on 16 November 2022. Those reports show that Mr Haloob has made a significant effort to learn from his mistakes and "reposition himself as a reliable, educated and ethical health practitioner". Mr Haloob relies on the following comment from Mr Cross (emphasis indicated by underlining), dated 4 November 2024:

"[Mr Haloob] had done an amazing amount of work to prove to the HCCC that he has total insight into what he did wrong and has taken steps to ensure that it cannot happen again.

Nevertheless, he will do everything he can to assure the NCAT panel that he is not a danger to the public. Evidence of this is the amount of CPD he has already done this year."

1. Mr Haloob submits that Mr Cross's comment above is supported by the evidence before the Tribunal, including his completion of 964 units of continuing professional development programs since 2022, and in his self-reflections, evidenced by documents submitted to the various hearings, the s 40 submission and in Mr Haloob's statement.
2. Mr Haloob understands that the Tribunal must make orders to adequately reflect the seriousness of his conduct, but submits that the Tribunal does not need to be concerned that there is any risk to the public in allowing him to practise in the future.
3. The Commission contended that Mr Haloob offered inadequate explanations in the witness box for his conduct. While he has expressed contrition, Mr Haloob's reflection and development do not address the concerns raised by the deeper gaps in his skillset and attitude demonstrated by the seriousness of the conduct which occurred. The Commissioner submitted that the facts support a cancellation order and given the seriousness of the conduct it also attracts considerations of general deterrence noting that pharmacists "have a significant gatekeeping function for the proper dispensation of drugs including for the safety of patients to regulate the efficient supply of drugs and to maintain the integrity of the PBS which is publicly funded." It was also submitted by the Commission that a 12 month non-review period is necessary for the protection of the public and would send a clear message to the public, the profession and Mr Haloob about the professional standards which are to be maintained.
4. We have weighed up the evidence and the submissions made.
5. In our view Mr Haloob's conduct was of a serious nature. It involved undermining a system which safeguards patients and relies on the integrity and professionalism of pharmacists. Mr Haloob failed in this regard.
6. We also consider that Mr Haloob has taken full responsibility for his conduct, is remorseful and has shown a degree of insight into his wrongdoing. The nature and extent of the education and upskilling Mr Haloob has undertaken over the past three years since suspension is significant and shows that he has developed mechanisms to deal both ethically or procedurally with difficult patients and situations. Mr Haloob has addressed his lack of education and awareness and his reflections following continuing professional development sessions demonstrate knowledge gained and skills to be implemented. The ongoing supervision and guidance that Mr Haloob has received from Mr Cross, over an extensive period of time, has been invaluable. Mr Haloob has demonstrated a level of insight and development (as Mr Cross has recorded) that gives us confidence that this conduct will not be repeated.
7. We have weighed these considerations against the seriousness of the conduct of Mr Haloob and his inability to give answers, which, as noted above, we considered were guarded and self-serving. We also acknowledge and consider that any protective orders need to take into account both general and specific deterrence. It is important that Mr Haloob's conduct be denounced which will occur both through publication of these reasons and the imposition of the orders and conditions we make.
8. We have decided that the protective function is best served by ordering that Mr Haloob be suspended for six months from the date of this decision following which several conditions will be imposed on Mr Haloob's registration including a period of Category B supervision and additional review by the Council.
9. In reaching this decision we are influenced by the significant CPDs undertaken by Mr Haloob and supervision by Mr Cross over a period of three years. Mr Haloob's registration has been suspended for a considerable period already and during that period he has taken steps to reform himself and his approach to practice. This process has opened his eyes as to the seriousness of his conduct and produced a level of insight that did not previously exist: Qasim v Health Care Complaints Commission [2015] NSWCA 282 at [74] per Meagher JA (McColl JA at [1] and Ward JA at [91] agreeing. General deterrence however calls for a clear message to the profession and the public that this kind of behaviour is unacceptable and is likely to have an adverse impact on registration. Further, and noting our impression of Mr Haloob in cross-examination, the conditions on his registration after the period of suspension are to further protect the public from any remaining risk, even if minimal, from the conduct being repeated.

1. The Commission seeks its costs as assessed or agreed. In exercising the power to award costs conferred by cl 13, Sch 5D of the National Law, the general rule is that costs follow the event unless there has been some disentitling conduct by the successful party.
2. We have not identified any disentitling conduct of the Commission (nor has any been contended). Costs should be awarded in the Commission's favour.

(1) Under s 149(C)(1) of the Health Practitioner Regulation National Law, the Respondent's registration is suspended for a period of six months from the date of this decision.

(2) Under s 149A(1)(b) of the Health Practitioner Regulation National Law the following conditions are imposed on the Respondent's registration at the expiry of the period of suspension in order (1) above:

(a) Not to practise as pharmacist in charge.

(b) To practise under Category B supervision in accordance with the Pharmacy Council of NSW's Compliance Policy - Supervision (as varied from time to time) and as subsequently determined by the appropriate review body.

(c) Pharmacy Council of New South Wales is the appropriate review body.

(d) After a period of six months of supervised practice, the Respondent is to undergo a performance review conducted by a suitable pharmacist appointed by the Pharmacy Council after which the condition of Category B supervised practice is to be reviewed by the Pharmacy Council of NSW.

(3) The Respondent is to pay the costs of the Commission as agreed or assessed.

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.

02 October 2025 - Coversheet: "(e)" amended to (3).