(3) Complaint 3 - the practitioner is guilty of professional misconduct under s 139E of the National Law, because the practitioner has engaged in more than one instance of unsatisfactory professional conduct that, when the instances are considered together, amount to a conduct of a sufficient serious nature to justify the suspension or cancellation of the practitioner's registration.

Health Care Complaints Commission v Matthew Youssef [2025] NSWCATOD 159 | Case summary | Zoe

NSWNSWCATOD

Health Care Complaints Commission v Matthew Youssef [2025] NSWCATOD 159;

[2025] NSWCATOD 159

NCAT Occupational|2025-12-05|Before: Member Decision

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NCAT Occupational

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2025-12-05

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Judgment (105 paragraphs)

[1]

This matter concerns an inquiry about a Pharmacist (the practitioner). The applicant is the Health Care Complaints Commission (the Commission).
On 24 March 2025, the Commission submitted an application for disciplinary findings and orders.
The inquiry is in response to a complaint made by the Commission, as amended on 14 August 2025, pursuant to Section 145D of the Health Practitioner Regulation National Law (NSW) (the National Law). There are three complaints. The first two are complaints of unsatisfactory professional misconduct, each complaint for a different reason, and the third is a complaint of unprofessional conduct.
More specifically, the complaints are:

[2]

(1) Complaint 1 - the practitioner is guilty of unsatisfactory professional conduct pursuant to s 139B(1)(a) or (l) of the National Law, because the practitioner has engaged in conduct which demonstrates that his knowledge, judgment, and care exercised in the practise of pharmacy is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience; or that the practitioner has engaged in improper conduct relating to the practise of pharmacy.

(2) Complaint 2 - the practitioner is guilty of unsatisfactory professional conduct under s 139(B)(1)(a) or (l) of the National Law, because the practitioner has engaged in conduct that demonstrates that the practitioner's knowledge, judgment, and care exercised in the practise of pharmacy is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience; or that the practitioner has engaged in improper or unethical conduct relating to the practise of pharmacy;

[26]

Mr Dalzell was retained by the Commission to review the material and prepare a report responding to a series of questions put to him in a letter dated 28 May 2024, which attached an 18-page outline of assumed facts (Exhibit A1 p557). His report sets out his qualifications to provide an opinion based on specialist knowledge(Exhibit A1 p576). It was not contested that he received his Bachelor of Pharmacy from Otago University in 1994 and was first registered as a pharmacist in NSW in 2002. He has worked in various roles, including pharmacy management, in pharmacies that participated in Opioid Replacement Therapy, in various iterations. He was responsible for implementing the OTP in his current placement, in 2019. As such, he claims to have the requisite specialist knowledge and experience to express an expert opinion about the required standards of a pharmacist managing the OTP.
In Paric v John Holland (Constructions) Pty Ltd [1984] 2 NSWLR 505, the High Court of Australia held that for expert medical opinion to be of any value, the facts upon which it is based must be proved by admissible evidence. The majority wrote: "It is a question of fact whether the case supposed is sufficiently like the one under consideration to render the opinion of the expert of any value".
In Lang v The Queen [2023] HCA 29, the High Court held that expert opinions must be more than authoritative assertions and must be grounded in specialist knowledge and clearly reasoned from identifiable facts.
The weight that we should give to Mr Dalzell's opinions will depend on the extent to which we find that his assumptions are sufficiently like the evidence that is proven and the reasons for the opinions expressed are transparent. This requires us to consider whether Mr Dalzell's assumptions diverge substantially from the facts of this case when the requisite standard of proof is applied. Mr Dalzell was cross-examined about his expertise. He gave evidence that, in preparing his report, the concept of "standard of care" was not based on objective criteria but on his 30 years' experience as a pharmacist, during which he had mentored colleagues who were experiencing challenges. He said that he considered the minimum requirements 'to remain legal and safe' and then assessed whether the facts established fell below, equated to, or exceeded those minimum requirements.
He said he took into account whether the practitioner's breaches may be explained by reasonable human error. However, in this case, he formed the view that the practitioner's breaches fell below or significantly below that standard.
He conceded that he had never owned a pharmacy. Instead, he has gained his experience as a manager of a friendly society pharmacist. He said he is regarded as the proprietor for the purpose of the regulator and compliance. This, he said, means he has the appropriate specialist knowledge to express an opinion on what the appropriate standard for a proprietor of a pharmacy would be. He said that as a proprietor there is an obligation to be "more fully aware of the rules and regulations" than a pharmacist in charge. He expressed his opinion that a breach by a pharmacy proprietor is greater than that of a pharmacist in charge for that reason.
Mr Dalzell gave evidence that he tried to adopt a balanced approach and consider whether there were mitigating circumstances for what he considered to be the practitioner's "dangerous practises".
The rules and regulations that the pharmacist was obliged to comply with are objective standards. Mr Dalzell made it clear that he had recourse to those objective standards in addition to what he described as the subjective standards of his own experience. He gave his evidence in a forthright manner. We do not consider that the cross-examination made any inroads into his credibility or experience.
His assumptions were based on the facts set out in the investigation report of Mr Ludington and Ms Dolan (Exhibit A1 p 16), which, with minor exception, were not contested. There was no evidence to suggest that Mr Dalzell lacks appropriate specialist knowledge to assess the conduct of the practitioner and determine whether it fell below appropriate standards. We accept his uncontested evidence that he has provided mentoring to colleagues over 30 years and that he is considered, for regulatory practices, to be a pharmacist in charge. The factual assumptions upon which he relied were those set out in the report of Mr Ludington and Ms Dolan which are also uncontested. The process by which he arrived at his conclusions was also clear from his report and oral testimony.
There is no proper basis to find that Mr Dalzell's expertise and experience is impugned. There is no contrary expert evidence. Furthermore, the practitioner has agreed with his opinions for the most part. He only took issue with the calculations, in relation to how much Methadone had been dispensed. This is a matter for our consideration and is dealt with later in these Reasons for Decision. There is nothing else in the written statements that refutes Mr Dalzell's opinion.
We are satisfied that his evidence should be accepted.

[38]

Clause 6 of the NSW Opioid Treatment Community Pharmacy Dose Protocol states that hard copy drug registers and subsidiary drug registers must be kept, recording the receipt and supply of Methadone and Buprenorphine. The drug register must be in a form of a bound book with pages that are consecutively numbered. Entries into the drug register must be made daily, on the day the Methadone or Buprenorphine is received or supplied. They must be kept at the pharmacy. The protocol provides that entries for a drug register must include the:
date of entry (the day of transaction)
quantity of Methadone liquid (mL) or Buprenorphine tablets/films or depot Buprenorphine received or supplied,
name and address of the supplier of Methadone or Buprenorphine received,
name and address of the person to whom the Methadone or Buprenorphine was supplied by the pharmacy,
original prescription reference number,
name of prescriber,
balance of Methadone or Buprenorphine in stock after each transaction,
signature of the pharmacist making the entry.
It also provides that different strengths and formulations of Buprenorphine, Subutex, Suboxone and other drugs must be individually entered on separate pages of the drug register. Similarly, two different brands of Methadone formulations must each have their own page in the drug register.
Clause 6.4 provides for the use of a 'subsidiary drug register'.
The standard method of recording each dose is one patient per line. However, in a situation where a pharmacy may be dosing a number of Methadone or Buprenorphine patients, it is acceptable to maintain a daily dosing subsidiary register. The subsidiary drug register must be used for Aspen Methadone, Biodone Forte, Subutex, and Suboxone:
the books must be in bound form with pages numbered consecutively. A spreadsheet does not meet the requirements and must not be used,
the cover of the book must describe its contents and indicates the period covered,
each page must have a clear heading and be ruled up in a consistent fashion with a heading for each column/line as applicable,
entries must be made in the book daily, summarised in a clear and unambiguous way and the daily total quantities of Methadone or Buprenorphine dispensed transferred to the drug register daily;
the subsidiary drug register book must include the patient's name, prescription number, the actual quantity dispensed to each patient on that particular day (including takeaways), the date each dose is supplied, the dispensing pharmacist's signature, the name of the prescriber, provision for a daily total quantity of drug supplied, and an indication of the days for which the takeaway doses has been supplied,
together, the subsidiary register and main drug register must provide a clear history of Methadone usage (by patient and quantity) and must reflect the actual balance of Methadone or Buprenorphine held,
a system should be put in place to identify the pharmacist responsible for dispensing each dose, given many pharmacies have more than one pharmacist working on any day.
Clause 6.4 also provides that the entry of the daily totals in the subsidiary drug register must be entered into the main drug register at the end of each day.
We have assumed that particular 1 relates to the failure to maintain the subsidiary drug register and drug registers for methadone and buprenorphine.
The Commission's complaint is underpinned by the findings of the Inspector , Mr Ludington and Ms Dolan. He found that the practitioner failed to always keep a record of the supply of Methadone and Buprenorphine. He found that the last complete record for Methadone in the subsidiary drug register was made on 24 April 2021, and the last time the information was transferred from the subsidiary drug register to the drug register was on 31 March 2021. In the case of Buprenorphine, the last time a record was made in the subsidiary drug register was 13 April 2021 and the last time information was transferred to the drug register was 3 April 2021. The inspection occurred on 23 March 2022.
We reviewed copies of the subsidiary drug register for Methadone (Exhibit A 1 pp 161-182). These confirmed that the practitioner last made a complete record on 24 April 2021. He made his last entry in the drug register on 17 February 2022, only one month prior to the inspection. To that extent, we do not agree with Mr Ludington and Ms Dolan's findings.
The Buprenorphine records corroborated Mr Ludington and Ms Dolan's findings.
In his reply, filed on 18 June 2025, the practitioner denied the allegation that he failed to make a record of the supply of the drugs outlined in particular 1 in a subsidiary drug register. He maintained that he made a record of the supply, which he is now unable to produce.
The practitioner wrote (Exhibit R 1 p 8 para 7.4), that he is aware that subsidiary registers and Schedule 8 drug registers must be held within a pharmacy and remain accessible for at least two years. He said it was not his general practice to discard or dismiss such registers and that he deeply regrets he is unable to determine the whereabouts of what he describes as the missing records.
The practitioner accepts that he failed to maintain appropriate records, because the subsidiary drug registers are missing. He offered several hypotheses to explain this. On one hand, he offered what he described as the "only feasible explanation" for the fact that his records were missing. He said he recalled that the PSU inspection took place on what he described as "rubbish collection day". He stated that he was completing routine shredding the night before, to maximise space in the rubbish bin for collection the following morning. He reiterated his assertion that the records existed but said he could not be certain whether they had been mistakenly shredded or were simply misplaced.
Nevertheless, he accepted responsibility, as proprietor of the pharmacy, of the fact that these records cannot be produced and admitted that he engaged in unsatisfactory professional conduct, and that his conduct demonstrated that his knowledge, judgment, and care exercised in the practise of pharmacy was significantly below the standard reasonably expected of a practitioner of an equivalent level of training or expertise and that he engaged in improper conduct relating to the practise of pharmacy.
It is the practitioner's obligation to account for how the drugs have been dispensed. Having reviewed the subsidiary drug registers and drug registers we are satisfied that there was ample space after the last entry made in each register for additional entries to be made.
The subsidiary drug registers for Methadone were partially filled on for several dates after the last complete entry. This does not support the practitioner's assertion that he did complete further records, which he is now unable to produce. We do not accept his evidence about this issue.
There is no dispute, and we find that the practitioner cannot produce the subsidiary drug registers and drug registers for the supply of Methadone and Buprenorphine for the specified periods. We find this element of the complaint proven.

[47]

The practitioner denies that he failed to make daily entries in the drug register. However, he says that he is now unable to produce those records.
Mr Ludington and Ms Dolan inspected the records and found that the drug registers for the drugs named in the complaint were defective. We also reviewed the photocopies of the drug registers, that were admitted as part of Exhibit A1:
The drug registers for Biodone Forte appear to have been abandoned on 5 November 2021 (Exhibit A1 p 84).
The last entry in the drug register for Subutex 0.4mg is on 29 September 2021 (Exhibit A1 p 107).
The last entry in the drug register for Subutex 2mg was made on 29 September 2021 (Exhibit A1 p111).
The last entry in the drug register for Subutex 8mg is on 29 September 2021 (Exhibit A1 p 117).
For Suboxone 2mg film, the practitioner last made an entry in the drug register on 29 September 2021 (Exhibit A1 p 119).
For Suboxone 8mg film, the practitioner last made an entry in the drug register on 29 September 2021 (Exhibit A1, at page 123).The last record for Biodone Forte was made on 5 November 2021.
The drug registers are also deficient in that they do not record any information about how the relevant drugs have been dispensed. They only record the receipt of the drugs of addiction.
The practitioner said that he did complete the drug registers in accordance with his obligation, but is now unable to produce them. In his statement (Exhibit R1), he said he acknowledged concern that he may have left the registers in his car or at home (paragraph3.4(b)).
The practitioner said he first became aware that the drug registers were missing during the PSU inspection on 23 March 2022. He said he did not inform the PSU independently that they were missing, as he is obliged to do, because he understood that, as a result of their inspection, the PSU was aware that the registers were missing.
He said he followed the PSU's officer's instructions to start an S8 register "anew" and that they had advised him that he did not need to do so retrospectively. The practitioner said that he has now introduced the STRONG ROOM program, which makes it easier to maintain accurate records, with the benefit of a time stamp.
He said that he cannot explain why he cannot find the drug registers in question. He accepted that the "loss of these records is my fault as the proprietor of the pharmacy. I failed to uphold what I know is a minimum requirement of any good pharmacy practice and in doing so I let down the public and the profession."
He conceded that the fact that he could not produce them is sufficient to justify a finding that he is guilty of unsatisfactory professional conduct.
None of the final entries in the drug registers appear at the bottom of the page. There is ample space, in each case, for further entries to have been made. This does not support the suggestion that the records that are allegedly missing existed. There is no suggestion that the practitioner may have commenced making entries on the top of a subsequent page in a new book, in relation to each drug, which he can now not locate. Nor do we consider that any such suggestion plausible.
Therefore, we cannot be reasonably satisfied that the practitioner complied with his obligation to make entries into the subsidiary drug register, as required by the PTGR and OTP Protocol. On balance, we find that he did not. We, therefore, find this allegation proven.

[51]

Clause 112 of the PTGR requires a pharmacist to record, on the day it was received, the wholesale receipt of drugs of addiction. The practitioner conceded that he failed to record the receipt of wholesale drugs in accordance with this obligation. The records were examined by Mr Ludington and Ms Dolan, during his inspection of the practice and he set out his findings in his report. We have also examined them.
The Methadone registers, between 6 February 2020 and 17 February 2022, suggest that the practitioner did record daily receipt of Methadone until one month prior to inspection. Mr Ludington and Ms Dolan found that the practitioner may have missed a few entries, and the practitioner admitted this. We can, therefore, be reasonably be satisfied that the records in relation to Methadone are incomplete.
Mr Ludington and Ms Dolan also found that wholesaler records from Symbion showed that 608 litres of Methadone were supplied to the pharmacy between 1 March 2020 and 23 March 2022. There were five supplies that do not appear in the drug registers seized during the inspection. These pertain to supplies on 6 May 2021, 3 June 2021, 25 February 2022, 4 March 2022, and 17 March 2022 (Exhibit A1, at page 25).
Furthermore, Mr Ludington and Ms Dolan found that a significant number of entries in the drug register were not in chronological order. This revealed that the entries were not made on the day of the transaction, contrary to clause 112 of the PTGR.
Mr Ludington and Ms Dolan also made findings that there were deficiencies in relation to the receipt of wholesale receipt of other drugs. We have considered that evidence and because this allegation is uncontested, we do not find it necessary to set out each example here. We are satisfied that the deficiencies found by Mr Ludington and Ms Dolan are established.
Because there is no dispute about this issue, and because it is corroborated by the records available to us, we are persuaded that the practitioner failed to record, on a day on which it was received, the wholesale receipt of drugs of addiction and that this constituted a breach of clause 112 of the PTGR.

[55]

The practitioner admitted this. He submitted that although he cannot produce records accounting for the above medications, the patients received their medication in accordance with their correct dosage during the relevant period.
A definition of the term "failed to account for" was not offered by either party, for the purpose of this hearing. We have adopted the commonly understood usage of that phrase, as a failure to provide and explanation, record or reason.
At page 92 of Exhibit 1, there is an entry in the drug register, dated 17 February 2022, which records of balance of 266,710.26ml of Methadone in stock. The practitioner agreed that that is an accurate record.
Mr Ludington and Ms Dolan annexed the drug registers for Methadone between 6 February 2020 and 17 February 2022 to his report. These recorded the receipt of Methadone by the pharmacy and the balance in stock but did not record the amounts dispensed for the entire period. The last entry on the Methadone drug register was 17 February 2022, approximately one month prior to Mr Ludington and Ms Dolan's inspection.
When Mr Ludington and Ms Dolan conducted his inspection on 23 March 2022, the pharmacist had 6,718ml in stock (Exhibit A1 p 92). This means that there is no account for approximately 259,000ml of Methadone. Therefore, we find that this fact is established.
In Exhibit A1, at page 103, it is evident that the last entry for Biodone Forte was made on 5 November 2021. As at that time, the pharmacist had 23,475ml in stock. Approximately six months later, at the time of Mr Ludington and Ms Dolan's inspection, the pharmacist had 2,098ml of Biodone Forte in stock. We find that approximately 21,377ml is unaccounted for.
On 23 December 2021 (Exhibit A1, at page 107), the last entry with respect to Subutex 0.4mg was made on 23 December 2021. Three months later, on the date of the inspection, Mr Ludington and Ms Dolan found one tablet in stock. The allegation that 1,057.5mg are unaccounted for is, therefore, correct.
On 29 September 2021, the practitioner made the last entry in the drug register for Subutex 2mg tablets (Exhibit A1, at page 111). At that date, the pharmacy had 313 tablets in stock. At the date of the inspection, there were only three tablets in stock. Therefore, the assertion that 310 tablets are unaccounted for is correct.
Also on 29 September 2021, the last entry was made in the drug register about Subutex 8mg (Exhibit A1, at page 117). On the date of the inspection, Mr Ludington and Ms Dolan found 61 tablets in stock. We find that 2,658 tablets are unaccounted for.
On 29 September 2021, the practitioner made the last entry prior to the inspection with respect to Suboxone 2mg films. At that time, he entered that there were 1,724 films in stock (Exhibit A1, at page 119). Mr Ludington and Ms Dolan found 215 films in stock (Exhibit A1, at page 30). The allegation that 1,509 films of Suboxone 2mg are unaccounted for is, therefore, correct.
On 29 September 2021, the practitioner made the last entry in the drug register for Suboxone 8mg films (Exhibit A1, at page 123). He recorded stock in hand of 3,915 films. Mr Ludington and Ms Dolan found 114 films in stock on the day of inspection (Exhibit A1, at page 31). Therefore, 3,771 films are unaccounted for.
On the basis of the evidence set out above, we are satisfied that particular five is proven.

[57]

The Commission complains that, between March 2020 and March 2022, the practitioner failed to perform mandatory six-monthly stock checks of S8 drugs, contrary to clause 118 of the PTGR.
The Commission submits that the practitioner's conduct invited strong criticism from Mr Dazell. Mr Dazell opined that the practitioner's failing led to his inability to account for the range of addictive drugs outlined in the complaint and that the practitioner's conduct was significantly below the standard expected of a proprietor Pharmacist with 14 years professional experience (Exhibit A1 starting at 575).
The records seized by Mr Ludington and Ms Dolan contained the only stock checks he was able to discover during his inspection. Mr Dalzell gave evidence that it is the proprietor's responsibility to ensure that stock takes are done in accordance with the regulations and that, therefore, the proprietor ought to have appropriate systems in place.
Mr Ludington and Ms Dolan found that the only stock check recorded in the Biodone drug register for the period 25 February 2020 and 23 March 2022 was conducted on 31 March 2021. This means that during that period, three mandatory stock checks were not recorded in the drug register, in breach of clause 118 of the PTGR.
Furthermore, he found that it was unlikely that the stock check that was performed was correct (Exhibit A1, at page 24). Photographs of the drug register (Exhibit A1, at pages 93-103) confirm a valid stock check entry on 31 March 2021. However, they also confirm that, apart from that single stock check on 31 March 2021, there are no other entries for a stock check between 25 February 2020 and 23 March 2023.
Mr Ludington and Ms Dolan found that there were also no mandatory stock checks recorded in the drug register for Aspen Methadone between February 2022 and 23 March 2022. The drug registers contained in the report confirm this finding.
Mr Ludington and Ms Dolan also found that the mandatory stock checks for Subutex 0.4mg tablets between March 2021 and September 2021 were not recorded in the drug register. This is corroborated by the photographs of the drug register (Exhibit A1, at pages 106-107). According to Mr Ludington and Ms Dolan, the mandatory stock checks for the Subutex 2mg tablets were also not recorded between March 2021 and September 2021. Again, this is corroborated by the photographs of the drug register (Exhibit A1, at pages 108-111).
Mr Ludington and Ms Dolan also found that the stock checks for the Subutex 8mg tablets were not performed (Exhibit A1, at pages 112-117).
The records pertaining to Suboxone 2mg films are found at Exhibit A1, at pages 118-119. They reveal that a valid check entry was made on 30 September 2022, however, there are no further entries between then and 29 September 2021 which is the date of the last entry. Mr Ludington and Ms Dolan found that there were no mandatory stock checks between March 2021 and September 2021.
The same applies to the mandatory stock checks for the Suboxone 8mg films (Exhibit A1, at pages 120-123).
With respect to the Vyvanse 50mg tablets, the photographs of the drug register in Mr Ludington and Ms Dolan's report (Exhibit A1, at pages 340-344) show that a valid stock check entry was made on 30 September 2020 and 31 March 2021. However, there are no further entries for a stock check between 30 September 2021 and 20 November 2021, which is the date of the last entry.
We find, on that basis, that Mr Ludington and Ms Dolan erred when he said there was no stock check registered between March 2020 and September 2021. Nevertheless, we are satisfied that the stock checks were not conducted with the regularity required by clause 118 of the PTGR.
Exhibit A1, at page 46, is where Mr Ludington and Ms Dolan have set out their finding that there was no stock check recorded in the drug register in March 2020, March 2021, or September 2021 for Ritalin 10mg tablets. The last recorded stock check was on 30 September 2020. This is borne out by the photographs in the drug register (Exhibit A1, at pages 348-352).
Mr Ludington and Ms Dolan also found that there was no stock check recorded in the drug register in March 2020 or September 2021 in relation to Endone 5mg tablets. However, the photographs of the drug register in the report (Exhibit A1, at pages 357-373) show that there was a valid stock check entry on both 30 September 2020 and 31 March 2021. These are, however, the only entries for a stock check within the relevant period.
The photographs of the drug register pertaining to Physeptone 10mg tablets (Exhibit A1, at pages 391-393) show that a valid stock entry was made on 30 September 2022. However, there are no further entries for stock check between 30 September 2020 and 25 October 2021, which is the date of the last entry.
With respect to the drug Kalma 2mg (Exhibit A1, at pages 397-406) confirm that valid stock check entries were made on 30 September 2020 and 31 March 2021. However, there are no further entries for a stock check between 30 September 2020 and 25 October 2021, which was the date of the last entry.
The practitioner admitted this breach. The practitioner wrote (para 7.7 Exhibit R1 p 8) that he is aware of the requirement of stock checks to be completed in March and September every year. He said he has now come to realise that such stock checks should be completed more regularly in order to avoid and remedy error at the earliest possible time.
He said that consequently he has adopted the practice of ensuring that pharmacy stock checks are performed on a fortnightly basis. The results are recorded electronically, signed and time stamped by the Pharmacist in charge. He acknowledged that the mandatory stock check had not been completed in September 2021 and that this falls below the standard expected of his as a Pharmacist.
Having analysed the available records, summarised above, and because the practitioner has admitted that he failed to record requisite stock takes, we find this element of the complaint is established.
On the basis of the material set out above, we are satisfied that the practitioner is guilty of unsatisfactory professional conduct pursuant to s 139B(1)(a) or (l) of the National Law, because he has engaged in conduct which demonstrates that his knowledge, judgment, and care exercised in the practise of pharmacy is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience.

[60]

There are several sub-particulars specified in relation to Patient A. We set them out, in turn, in this section of the Reasons for Decision.
The Commission complains that the practitioner inappropriately dispensed Schedule 4D drugs, namely Zolpidem and Diazepam, to patient A, between 4 January 2021 and 17 March 2022, in breach of clause 54 of the PTGR.
The Commission alleges that the practitioner dispensed 2,898 10mg tablets zolpidem, which is an average of 6.6 tablets per day during the relevant period. The practitioner has admitted this.
The Commission also complains that the practitioner regular dispensed multiple repeats of medications to patient A on the same day. This is also admitted.
The Commission complains that, between 27 September 2021 and 25 October 2021, the practitioner dispensed both Zolpidem 10mg and Zolpidem 12.5 mg controlled release, and that, between 9 March 2021 and 22 March 2022, the practitioner dispensed Zolpidem 10mg and Diazepam concurrently.
The practitioner has admitted both of these factual assertions.
The Commission further alleges that the practitioner continued to dispense medications to patient A, after one of her prescribers had advised the practitioner that patient A was "a doctor shopper".
The practitioner denies this element of the complaint. He responded, on 18 June 2025, that a "Dr T" informed him that he had been notified by Medicare that patient A was a "doctor shopper". The practitioner added that when patient A subsequently presented to the pharmacy, with prescriptions from other practitioners, the practitioner refused to dispense the drugs and contacted "Dr T" to inform him that this had occurred.
Despite this, the practitioner admits that he has breached clause 54 of the PTGR. He conceded that he should not have dispensed medication to patient A, in the amount and with the regularity that he did. He acknowledged that he should have refused to dispense these prescriptions, and he now understands that she was "doctor shopping". He said once he became aware of this, having been notified by patient A's prescriber, he refused supply.
He conceded that this does not excuse the fact that he did not make further enquiries, as was required of him. He explained that patient A's conduct was threatening, and submitted that, due to his previous experience of having been assaulted, his mental health and judgment were clouded and he did not wish to be harmed.
He said that he has had the opportunity to reflect on his conduct and acknowledges that this fell below the standards expected of him.
The evidence the practitioner gave in evidence differs from that which he gave at his section 150C proceedings in relation to this issue. This is evident from the transcript (Exhibit A 1 p 835) and Mr Dalzell's report (Exhibit A1 p 968).
During his Section 150C proceedings, on 15 August 2022, the practitioner gave evidence that he had contacted three of Patient A's doctors. He conceded, during that hearing, that Patient A had 9 prescribers in total. During those proceedings, he admitted that he continued to dispense medication to Patient A after Dr T advised him that Patient A was a doctor shopper.
The practitioner also gave evidence, at those proceedings, that Dr T had told the practitioner that Patient A was "better off instead of going to multiple chemists and avoiding that [they] would monitor her. Otherwise, he wouldn't prescribe the prescriptions". The practitioner admitted that he had not considered that he was placing Patient A at risk.
The Section 150C transcript does not support the fact that the practitioner ceased dispensing Diazepam and Zolpidem to Patient A, having become aware she was a doctor shopper. This fact, and because he has admitted the remainder of the factual allegations pertaining to Patient A, we are reasonably satisfied that the conduct described by the Commission is proven.

[61]

The Commission alleges that between 27 April 2020 and 17 March 2023, the practitioner inappropriately dispensed Testosterone, which is a Schedule 4B drug, and Metformin and Tadalafil, both S4 drugs, to patient B in circumstances where he knew the drugs were being prescribed "off label" for body building and had the potential to be misused, and that this constituted a breach of clause 54 of the PTGR.
The Commission submitted that the practitioner ought to have been aware of the potential for abuse and "curated the supply quantities more rigorously".
The practitioner admitted that he prescribed the drugs to Patient B. In his statement (paragraph 9.6, p 10, Exhibit R 1), the practitioner wrote that he now acknowledges that Patient B was abusing Sustanon/Testosterone. He also acknowledged that Patient B then required Tadalafil for sexual functioning, and Metformin to prevent his glucose levels being too high, in order to overcome the side effects of Sustanon.
The practitioner conceded that he should not have provided these medications to Patient B. However, he said that he recalls communicating with Patient B's prescribing doctor, who maintained the request that the prescriptions be issued and dispensed. He stated that the prescribing doctor told him that Patient B was competing to be a professional athlete. The practitioner asserts that the prescribing doctor told him that he would monitor Patient B. He said that he relied on the prescribing doctor's advice rather than exercising his own professional judgment.
In his Section 150C proceedings, he said (Exhibit A1, at page 837): "I was happy to dispense it once the doctor said to me that he was going to monitor it and he was the one that prescribed it". He said he also checked with Patient B's other prescribing doctor. Despite this, he conceded that it was not the right thing to do.
Mr Dazell provided his expert opinion that the prescriptions dispensed to Patient B were dispensed for other than a recognised therapeutic purpose. The practitioner did not contest this opinion.
He acknowledges that he should have decided not to dispense this medication. He admitted that his conduct constituted a breach of clause 54 of the PTGR.
We accept Mr Dalzell's evidence that this conduct fell below the standard reasonably expected of a pharmacist, for reasons already provided. On that basis, and because the practitioner has admitted the allegation, we find this aspect of the complaint proven.

[62]

Particular 3 concerns seven related allegations relating to the inappropriate dispensing of Schedule 4 and 4D drugs, Codeine and Diazepam, to Patient C, between the period of 30 March 2020 and 21 March 2022, in breach of clause 54 of the PTGR.
The first allegation the Commission raises is that all of the prescriptions for Diazepam and Codeine were forged.
The practitioner admits that he dispensed the medication but asserts that he was unaware the prescriptions were forgeries. He said that he has previously received valid prescriptions from this provider and that the prescriptions in response to which he dispensed the medication were from the same provider.
Secondly, the Commissioner complains that 33 out of 38 prescriptions for Codeine were forged. The practitioner responded that he was unaware that the prescriptions were forgeries.
The third allegation is admitted. The practitioner conceded that he "failed to recognise red flags" including the fact that the prescriptions were handwritten and contained repeats and were private prescriptions.
In his more detailed statement, the practitioner acknowledged that the supply of Codeine and Diazepam for Patient C was inappropriate. He stated that he did not know that the prescriptions were forged by Patient C until after the PSU had contacted the prescriber who subsequently advised the pharmacy of this. Having been so advised, the practitioner cancelled Patient C's prescriptions immediately. He conceded that he should have been more diligent in terms of checking prescriptions and exercising his own professional judgment.
The practitioner gave evidence that, during the period of Covid-19 and some period thereafter, the government permitted Pharmacists to dispense prescriptions from faxes and emails. He had not been fully aware of the functions of the pharmacy's Fred Dispense Software, which meant that he dispensed medications as "owing scripts". He has subsequently come to understand, from Fred Dispense technicians, that this was incorrect practice.
In cross examination, the practitioner was asked about a "screenshot" of Patient C's notes, which contained the entry "possibly patient is presenting with fraudulent prescriptions" (Exhibit A 2 p 907A). He said that he had made the entry because he was advised to do so by Mr Ludington and Ms Dolan when he raised the concern about possible forgeries with him.
In relation to the fourth point, the practitioner admitted that he failed to contact the prescribing doctor to discuss the prescription plan for Patient C, and to ascertain whether the prescriptions were authentic, prior to dispensing the medication.
He said that the pharmacy's procedure now necessitates checking "SafeScript" NSW to ascertain which medication Patient C is prescribed, and the identity of the prescriber. The pharmacy has taken steps to minimise such risk in future by instituting regular checks of the NSW Health website which lists lost and stolen prescriptions.
There was no evidence adduced to suggest that the forged prescriptions were so obviously dissimilar to an authentic prescription that the practitioner ought reasonably to have noticed. We cannot be satisfied that he knew or ought to have known that they were forgeries. However, for the following reasons, we find that this element of the complaint is nevertheless proven.
The practitioner admitted the fifth point, namely that he regularly dispensed Diazepam at short intervals.
The Commission raised, as its sixth point, the fact that Patient C had been enrolled in the OTP since 1997 and had been dosed at the pharmacy since 2013.
The practitioner admitted that Patient C had been dosed at the pharmacy since 2013 but said he was unaware of the date when Patient C was first enrolled in the OTP. However, he conceded the seventh point, which was that the prescription of Diazepam and Codeine are contraindicated for concomitant use of opioids.
The eighth point raised by the Commission is that the practitioner knew or ought to have known that Patient C was "a doctor shopper". The practitioner denied this. He asserted that Patient C had never presented to the pharmacy with a prescription of this type from anyone other than the usual prescriber.
However, in his response to the Commission in 2023 (Exhibit A1 p 902), the practitioner said that he was concerned that Patient C was a doctor shopper and that this caused him to contact her methadone prescriber and psychiatrist. In cross examination, he conceded that his earlier response indicated that he was, in fact, aware that Patient C might be doctor shopping.
In response to the ninth and final point pertaining to Patient C, the practitioner agreed that he had breached clause 54 of the PTGR by his conduct in relation to particular 3 of the complaint. Clause 54 of the PTGR prohibits a pharmacist from supplying 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.
Although we cannot be satisfied that the practitioner knew or ought to have known that the prescriptions were forged, we are satisfied that had he most probably knew that she was doctor shopping. More rigorous enquiry would likely have alerted the practitioner to the fact that the prescriptions were forgeries.
We also accept Mr Dalzell's opinion that the supply of Codeine and Diazepam, in the quantities supplied, was contrary to Clause 54 of the PTGR, for the reasons explained in a different section of the Reasons for Decision.
For this reason, and because of the concessions made by the practitioner, we are satisfied that this element of the complaint is proven.

[68]

The practitioner responded, to sub-particular (a), that he did not know when Patient E was first enrolled in the OTP. He conceded that Patient E had been dosed at the pharmacy since 2017.
The practitioner admitted sub-particulars (b) and (d). He said that Diazepam had been prescribed by two General Practitioners, including Patient E's Methadone prescriber and his General Practitioner. Because he regularly consulted both doctors, he believed that each doctor knew the other doctor was also prescribing this medication.
Mr Dalzell expressed his opinion about the practitioner's conduct in relation to dispensing this medication to Patient E (Exhibit A1 p 598). He opined that the dose from the Methadone prescriber may have been appropriate as part of a complex treatment plan, but the additional dose prescribed by the General Practitioner "took dose levels to above the treatment plan", which could increase dependence and potential for significant harm to Patient E.
The practitioner gave evidence that Patient E is still a patient of the pharmacy and registered on the OTP. He understands that Patient E still receives Diazepam from his OTP prescriber, but this is provided as a staged supply.
The practitioner denied sub-particular (c). He did not admit the allegation that he dispensed 50 tablets at a time to Patient E. He said that Patient E was on "a staged supply", which meant that the medication was kept in the pharmacy. He said that each week, Patient E was supplied 14 tablets taken from a box of 50.
Mr Dalzell conceded that this was a possibility but said that the practitioner should have been able to produce records to confirm that.
It was not contested that the correct dose of Diazepam for Patient E is two tablets a day. This equates to 14 tablets each week. We accept the practitioner's evidence that there are 50 tablets in a box of diazepam. Mr Dalzell corroborated that.
Even though the dispensing schedule (Amended annexure C p 47), recorded that there were occasionally intervals of fewer than 25 days between the dates on which the dispensation of Diazepam was recorded, we cannot be reasonably satisfied that the dispensing slip reflects that 50 tablets were handed to Patient E on each occasion.
We reviewed the material annexed to the amended complaint (amended annexure C). This showed that, between 23/9/21 and 2/3/22 ( a period of 181 days) Patient E received 450 tablets. This equates to the supply of 2.43 tablets per day. This is not such a significant departure from the prescribed two tablets a day to suggest that Patient E was receiving more than the prescribed dose of Diazepam.
For this reason, we are not satisfied that this element of the complaint is proven. On that basis, we find that the conduct in sub-particulars (a),(b),(d) is proven, but not that set out in sub-particular (c).

[71]

Clause 109 of the PTGR prohibits a pharmacist from supplying any drug of addiction in a quantity, or for a purpose, that does not accord with the recognised therapeutic standard of what is appropriate in the circumstances.
The practitioner admitted that Patient F had been dosed at the pharmacy since 2013 but denied that he did not discuss the Benzodiazepine prescribed with Patient F's OTP prescriber (Dr B). He said that he notified Dr B, who advised him that she had spoken to the practitioner who prescribed the Alprazolam directly (Dr Y) and that Dr B did not direct him not to supply the medication.
Mr Dalzell found that Patient F had two prescribers for Alprazolam and Temazepam, and three for Diazepam. He also found that none of the prescriptions were written by Dr B. He observed that patient F had been supplied with all three benzodiazepines on the same day on at least one occasion. Mr Dalzell opined that the practitioner had failed to exercise his professional judgement in dispensing three benzodiazepines concurrently to the patient in contravention of clauses 54 and 109 of the PTGR.
Whilst the practitioner admitted that he is aware that Benzodiazepine is contraindicated for patients with concomitant opioid use, he said he believes that Patient F is still prescribed Benzodiazepine and Methadone, with the Benzodiazepine being prescribed as a staged supply with her daily Methadone use.
The practitioner also admitted that he has dispensed Alprazolam concurrently with another Benzodiazepine but said that this was because Dr Y and Dr B both indicated that Patient F's symptoms are stable on the current treatment regime and that it is beneficial for her.
The practitioner gave evidence (paragraph 9.21 p 11 Exhibit R1) that he did liaise with all of Patient F's treating doctors and advised them of each other's prescriptions. He said that, as a result of these conversations, he asserted his professional judgment and was satisfied that the complex treatment was appropriate. He maintained that Patient F is still on the OTP and is being prescribed Benzodiazepine as a staged supply.
The documentary evidence (Exhibit A3 p 907C) is a file note that records that the practitioner spoke only to Dr Y (the general practitioner) only. He did not produce any record of having spoken to Dr B ( the methadone prescriber). We cannot find evidence to support his claim that he spoke to all of the doctors involved.
In any event, the practitioner admitted that he has breached clause 109 of the PTGR. We are satisfied that the evidence, including Mr Dalzell's expert opinion, justifies a finding that his conduct fell below the standard expected of him. We find this element of the complaint proven.

[77]

The practitioner admitted that he purchased the quantities of Rikodeine alleged and that this constituted more than that purchased by any other pharmacy in New South Wales. He also admitted that he knew or ought to have known, with the benefit of hindsight, that Rikodeine was prone to abuse. He said he should have been aware of its popularity in the pharmacy, particularly with a specific patient demographic.
The practitioner gave evidence (paragraph 11.1, p 12 Exhibit R 1) that once he became aware of the potential for abuse of Rikodeine, he removed it from the shelves of the pharmacy's S3 section. It is no longer kept in clear view of patients. He said Rikodeine is no longer a medication regularly stocked at the pharmacy and is now only supplied on prescription.
Furthermore, since the PSU inspection, Rikodeine has gradually been removed entirely from the pharmacy. He said the staff have been trained to provide patients with alternative pharmacies nearby so they can obtain Rikodeine if doctors have recommended it.
This issue was not addressed in detail at the hearing, and we rely on the evidence tendered. We observe that it was concern about the supply of Rikodeine to the pharmacy that triggered the PSU investigation in the first place.
Mr Dazell (Exhibit A1 p 601) wrote that: "The lack of a mandated recording system has made the control of Rikodeine sales more difficulty, but the volume sold at (the) pharmacy, the lack of any recording method, and demographics of the patients suggested that the pharmacy had become a target for Rikodeine shoppers".
He opined that volume of Rikodeine sold at the pharmacy was "so far in excess of what I would expect" that he suspected it was being sold inappropriately. He said that pharmacies "significantly busier" than the practitioner's would generally receive 3-4 genuine requests for Rikodeine in the winter months and less in the warmer months.
The records confirm and the practitioner admits the facts alleged in this particular of the complaint. We find the allegation that the practitioner sold the quantities of Rikodeine asserted by the Commission proven. For reasons set out above, we accept Mr Dalzell's opinion that this constituted conduct that fell well below the standard expected of the practitioner.
The practitioner agreed with Mr Dazell's opinion about the general standards expected of a Pharmacist. He agreed that he did not have sufficient knowledge at the relevant time or adequately apply the knowledge he did possess. Consequently, he acknowledges that he failed to meet the standards expected of him. The practitioner maintains that he has reflected upon that criticism and has taken steps to improve his health and well-being as well as his professional standards.
On the basis of the material set out above, we are satisfied that the practitioner is guilty of unsatisfactory professional conduct pursuant to s 139B(1)(a) or (l) of the National Law, because he has engaged in conduct which demonstrates that his knowledge, judgment, and care exercised in the practise of pharmacy is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience.

[85]

We must consider the nature of the wrongdoing reflected in the complaints established. For that purpose, we will have regard to:
the gravity of the misconduct;
how long the misconduct occurred;
what has occurred in relation to the practitioner since the misconduct occurred;
the practitioner's level of remorse and degree of insight, if any, into his misconduct;
what, if any steps, have been taken by the practitioner by way of rehabilitation to address the misconduct proven.
We have found that the practitioner is guilty of unsatisfactory professional conduct in relation to complaints 1 and 2, because he has engaged in conduct which demonstrates that his knowledge, judgment, and care exercised in the practice of pharmacy is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or expertise. We have not found that he engaged in improper or unethical conduct relating to the practice of pharmacy.
Nevertheless, the fact that the practitioner failed to exercise appropriate diligence in maintaining the subsidiary drug register and drug register and because he did not conduct stock checks is objectively very serious and a breach of his professional obligations.
The practitioner has accepted that his conduct in relation to complaint 2 in relation to the dispensing of medication to several individual patients was also unsatisfactory. It is uncontested that this conduct has the potential to cause serious harm to those patients. We accept the Commission's submission that this suggests a lack of appropriate caution and non-compliance with the provisions of the PTGR. It placed the health of those specific patients at risk.
Mr Ludington and Ms Dolan's investigation revealed that the failure to account for Methadone and Buprenorphine commenced in approximately March 2021, until the date of investigation which was 23 March 2022. The deficiencies in the record keeping for other Schedule 8 drugs commenced on 30 December 2020.
The exceptions to this are the failure to account for Subutex 2mg and the fact that the drug registers for Methadone were made until 17 February 2022, albeit incompletely.
The practitioner had been the owner and the practitioner in charge of the pharmacy since 2013. There is no evidence to support the suggestion that the practitioner's unsatisfactory professional misconduct existed prior to that time.
We considered whether there was evidence to suggest that the practitioner had been involved in unethical conduct, such as selling drugs without prescription for commercial gain, or abusing the drugs himself. We found nothing to suggest that this is the case and it was not submitted by the Commission that we should have any such concern.
The practitioner took issue with the figures and quantities estimated by Mr Dazell. He stated that, on occasion, the pharmacy would dispense more than 2,321 ml of Methadone per day, especially on a weekend of public holiday but that at other times the quantities would be significantly less. He gave evidence that the pharmacy had a list of patients on the OTP, the doses they were given at the pharmacy, and an older subsidiary drug register. He maintained that these documents were taken by the PSU officers during the course of their inspection.
The practitioner gave evidence that, despite the lack of record keeping, in the context of the quantities unaccounted for, as compared to the prescribed dose for each patient, he attempted his own reconciliation of the S8 medications against the records of his usual customers. He submitted, based on those calculations, that the missing medication accounts reconcile, and that the medication is missing "in records only", demonstrating that the medication was supplied to his patients and not misused. There was no evidence to contradict that.
The practitioner stated that he also gave evidence, at the s 150 hearing on 8 April 2022, that prior to becoming the proprietor of the pharmacy, he was involved in two hold ups at another pharmacy in Newtown. This included one incident when a customer held a blood-filled syringe to his neck. The incident had a profound impact on him, and he was subsequently diagnosed with PTSD by Dr Robert Fischer, Psychiatrist, to whom the practitioner was referred by the Council. Dr Fischer said he considered that the condition did not impair his ability to fulfil role as a Pharmacist, noting the conditions that were in place at the time on the practitioner's registration.
In his statement, dated 22 July 2025, which is uncontested, the practitioner wrote that at the time of the PSU inspection, in March 2022, he did not employ any other Pharmacists to assist him in the pharmacy. Although he had employed a long-term pharmacy assistant previously, she resigned as a result of abuse from frustrated customers who could not purchase rapid antigen tests during the Covid-19 pandemic. He said he had difficulty finding a suitable employee.
The practitioner stated that, prior to the PSU inspection, he was present, on site at the pharmacy during opening hours, as the Pharmacist in charge. Since becoming the proprietor of the pharmacy in September 2013, he said he had not taken a sick day or holiday. During the Covid-19 pandemic, his working hours increased. He maintained that he routinely worked from 7:00 am until 10:30 pm without a break.
We accept that the practitioner experienced the challenges he described. Whilst that does not diminish the seriousness of the practitioner's unsatisfactory professional conduct, it provides a context for the apparent deterioration of the practitioner's professional standards. The practitioner admitted that he was not coping. His conduct presented a risk to the community. His failure to keep records is in breach of the standards, as is his failure to use appropriate diligence whilst dispensing drugs of addiction and restricted substances. Furthermore, the quantities and intervals at which these medications were dispensed are also highly problematic.
We are satisfied, however, that the practitioner has displayed considerable insight into and remorse about his failures. He did not seek to challenge the findings of Mr Ludington and Ms Dolan nor the opinions of Mr Dalzell. He gave evidence that he has taken measures to rehabilitate himself.
The practitioner stated that he has taken considerable efforts to improve his mental health and adjust his personal and professional life. In relation to his mental health, the practitioner stated that he has attended 8 sessions with a Psychologist, Alvin Lo, which he found beneficial. This ceased approximately 12 months ago when Mr Lo advised the practitioner that he did not perceive the need for the practitioner to return to him.
The practitioner gave evidence that he has commenced sessions with Dr Gordon Hyde, Psychiatrist. The practitioner tendered Dr Hyde's report, dated 10 June 2025 (Exhibit R 1 p 23 of 38). Dr Hyde assessed the practitioner on the date of the report and found that there was no suggestion that he was suffering from PTSD, although he acknowledged a history of PTSD symptoms in the past, which appear to have largely resolved over time. He considered that the practitioner continues to experience mild anxiety, as a result of the traumatic experiences of having been held up, compounded by cultural and personal beliefs about masculinity and stress, preventing the practitioner from seeking help or discussing his experiences with family or professionals.
Dr Hyde has diagnosed the practitioner with adjustment disorder with mild anxiety features.
The practitioner stated that he also seeks assistance from a nutritionist, personal coach, and that he finds exercise beneficial. He also cited the beneficial effects of the close relationship he has with his family, which consists of his parents, older brother, and younger sister. The practitioner's brother is a Cardiac Paediatrician. The practitioner's sister is a Solicitor. He also finds his involvement with his Coptic Orthodox Church community beneficial. He has been in a relationship with a woman he met through the Church for many months. He states that this is a stabilising factor.
The practitioner also stated that he has engaged frequently in personal professional development. He maintains that he completes compulsory development courses on a weekly basis and attended to annual conferences as well as attending additional workshops. The practitioner provided to the Tribunal examples from his CTP reflection journal and certificates to confirm his attendance at a PSA Ethics and Dispensing Practise Course and a PSA Legislative and Pharmacy Practise Course and a Fundamentals Training in Opioid Treatment Course, amongst other regular programs.
The practitioner also gave evidence that he has made considerable changes to the way in which the pharmacy operates. He noted that he had been the proprietor of the pharmacy for 9 years, prior to his suspension. He has only attended the pharmacy on one occasion since his registration was suspended, namely 15 December 2023, with the express approval of the Council, in order to obtain records to satisfy a Notice to Produce issued by the Commission.
The practitioner now has a Pharmacist in charge, who works six days a week and has been employed for over 12 months. The pharmacy is open six days per week. In addition to the Pharmacist in charge, the practitioner has employed two pharmacy assistants, who are both dispensing technicians and front of house staff. The practitioner stated that he remains involved, to the extent possible, to ensure that the pharmacy's processes and procedures are improved and compliant. He highlighted a number of improvements made in the pharmacy. These include:
a transferring from a paper base system for the OTP subsidiary drug registers to an electronic system ("STRONG ROOM");
off-site storage for backups of the pharmacy's store operations, including dispensing, OTP, and point of sales;
installation of CCTV cameras to capture footage instore, particularly at the dispensary, where OTP patients are dosed, adoption of the Pharmacy Guild Self Audit Tool, completed for a random selection of five patients per month;
purchase of new Methadone pumps in 2023 to ensure reliable calibrated equipment is used for the OTP;
adoption of NSW Health "Best Practices Indicator" for the appropriate administration and delivery of Methadone to patients in the pharmacy;
regular use of "SafeScript" to monitor whether patients are presenting to multiple doctors and to access patients' records when they have been flagged on the electronic dispense system as being potentially problematic;
daily calls to the Pharmacist in charge to receive updates on the running of the pharmacy;
completion of stock check of Schedule 8 medications every two weeks. These records are kept on STRONG ROOM;
working towards QCPP accreditation for the pharmacy. This has required the pharmacy to test the fridges and dispensary processes and to ensure current expertise of the pharmacy staff.
None of this evidence was contested by the Commission.
In his supplementary statement, dated 5 September 2025, the practitioner wrote that he has sold his pharmacy. The contract of sale was exchanged on the day his statement was attested. He understands that settlement will take place before the end of 2025. He provided a copy of the contract of sale which corroborated his evidence to this effect.
He gave evidence that for the past 18 months that he has worked as support worker for an online platform assisting people to provide and receive disability and aged care support. He is a casual employee working with aged care clients approximately 40 hours each week This requires him to drive older people to medical appointments and assist them with their shopping and gardening. He said he finds the work very rewarding.
Despite this, if he is permitted to, he would like to return to pharmacy.
The Commission submitted that we could not be satisfied that the practitioner has displayed true insight into the seriousness of his unsatisfactory professional conduct. The Commissioner also submitted that the Tribunal should find that the practitioner has reconstrued certain events during his evidence, particularly in relation to the whereabouts of the subsidiary drug registers, which would call the practitioner's credit and fitness to practice into question.
We agree that there are many inconsistencies in the practitioner's evidence. However, we do not find that this impugns his credit overall. The evidence of Dr Fischer and Dr Hyde demonstrates that he was suffering from PTSD and burnout at the time of and following the events leading to the investigation. There was no evidence of moral turpitude, although his practices were gravely deficient. He has, at the hearing, displayed appropriate remorse and insight into the seriousness of his conduct overall.
Mr Ludington and Ms Dolan's investigation report is thorough and reveals many instances of unsatisfactory professional conduct that, when considered together, amount to conduct of a sufficiently serious nature to justify the suspension or cancellation of the practitioner's registration. The practitioner accepts Mr Ludington and Ms Dolan's findings are factually correct.
We are satisfied that the practitioner's unsatisfactory professional conduct was such that it could place his patients and the community at risk, based on Mr Dalzell's opinion and the practitioner's concessions.
We are, therefore, satisfied that the cumulative effect of his unsatisfactory professional conduct supports a finding that he is guilty of professional misconduct.

[99]

In Health Care Complaints Commission v Chau [2015] NSWCATOD 25 (at [132]) and Health Care Complaints Commission v Ahmad [2015] NSWCATOD 103 (at [309]-[311]) it has been held that the most relevant issue for the Tribunal is to consider the extent to which the practitioner poses a risk to the public.
The Commission submitted that it is appropriate to cancel the practitioner's registration for a period, because his professional misconduct occurred over several months or years and only ceased because it was detected. The Commission argued that, had the concerns not been raised, the risk to the community would have continued and that the Tribunal should be satisfied that, when looked at cumulatively, the conduct was sufficiently severe to satisfy the
Counsel for the Commission asked the Tribunal to find that the practitioner's answers to the Tribunal were reconstructed, particularly in relation to the whereabouts of the subsidiary drug registers and the drug registers, and the evidence he gave in relation to the staged supply of medication to patient C. He submitted that this raises concerns about the practitioner's credit, and the risk he poses to the public.
Counsel for the practitioner conceded that if we were to find that the practitioner was dishonest, we may feel comfortable cancelling his registration. However, Mr Flaherty submitted that the practitioner has been candid and forthright in his evidence and has made appropriate concessions.
Counsel for the Commission said there were inconsistencies between the practitioner's accounts during the s 150 and s 150C hearings and his statement three years later. However, Counsel for the practitioner asked us to accept that these inconsistencies do not undermine his credit as a whole. He said at the time of the s 150 and s 150C hearings, the practitioner's "life was upside down" and he was impaired. This, he submits, is no longer the case.
With the exception of the evidence about the existence of the subsidiary drug registers and drug registers, we agree that the practitioner has been generally candid and made appropriate concessions.
In relation to the staged supply of medication to patient C, Mr Flaherty asked us to accept the practitioner's evidence on re-examination that, whilst the prescription provided for the supply of 50 tablets, the practitioner only dispensed 14 at a time. There is nothing to contradict that and we accept the practitioner's evidence for that reason.
He also asked us to consider the fact that the professional misconduct occurred against a background of the practitioner working for 13 years without holidays, minimal assistance, six days a week, and with the added challenges imposed by the government's response to Covid-19. He also submitted that the practitioner's post-traumatic stress disorder is a factor which we should take into consideration.
He conceded that the practitioner's record keeping, during the relevant period, was "atrocious" but noted that this was an isolated period against a history of the practitioner providing exceptional service to the local community for 12 years prior to that. He said apart from the practitioner's failures during the relevant period, there has not been any other blemish on his record.
The practitioner submitted that he has already been suspended for three years. As a result of this, he has been forced to sell his home and practice. During this period, he has suffered a loss of earnings and has sought treatment, guidance and therapy from health care professionals. The records confirm that he has engaged in over 400 hours of professional development in one year. This has not been challenged by the Commission.
Counsel for the practitioner conceded that the practitioner most likely posed a risk to the community between 2020 and 2022. However, he asked the Tribunal to find that, because of the measures taken by the practitioner, in conjunction with the insight, remorse and judgment that he now displays, the Tribunal could not be satisfied that he poses a risk to the public at the time of the hearing. Furthermore, he noted that the practitioner has sold the pharmacy.
He submitted that it would not be in the public interest to cancel the practitioner's registration after he has worked so hard to rehabilitate himself. He submitted that the evidence does not support a suggestion that the practitioner was profiteering or was guilty of moral turpitude. He said that the evidence instead suggests that the practitioner was doing the best he could but "dropped the ball" which resulted in shambolic record keeping.
This is a protective not a punitive jurisdiction. Counsel for the practitioner asked us to accept that if the practitioner's registration were cancelled, a process for reinstatement may take several years which would result in the practitioner losing his recency status.
He asked the Tribunal to find that the practitioner does not pose any current risk to the public and that alternative orders are available to ameliorate any concern that he may do so. These include the practitioner working under supervision with a mentor. He asked the Tribunal to find that the practitioner has demonstrated his determination to rehabilitate and that his failures were due to a mental illness which has now been found to have resolved.
Counsel for the practitioner asked us to accept that nothing was put to the practitioner to suggest that his clinical knowledge is deficient or that he still poses a risk to the community. That is the case.
He asked us to reprimand the practitioner, and to imposed conditions which would enable the practitioner to obtain employment under category B supervision for a period of time. In the alternative, he submitted that an appropriate order would be a small period of suspension.
We have found that the practitioner is guilty of professional misconduct. This occurred between 2020 and 2022. The relevant time for assessing the competence of a practitioner to practise and any risk to the public is at the time of the hearing.
We note that there is no evidence to suggest that any of the prescribing doctors or patients expressed concern about not receiving their correct medication, as might be expected if the practitioner had been using the medication, for which he is unable to account, for illegal or unethical purposes. This does not diminish the seriousness of his deficiencies, but it negates potential concerns about moral turpitude or on the part of the practitioner.
The practitioner consulted Dr Fischer on 28 May 2025 for the purpose of obtaining a current assessment of his mental health. Dr Fischer's report, dated 13 June 2025, was tendered by the practitioner (Exhibit R1 p 28). In summary, Dr Fischer reported that the practitioner is fit to return to practise, from a psychological perspective.
At page 8 of his report (Exhibit R1 p 35), Dr Fischer wrote that, whilst the practitioner had developed severe symptoms of PTSD, this has been effectively treated with EMDR, and supportive psychotherapy. He also noted that the PTSD was accompanied by "burn-out". He wrote that, in the context of these two conditions, the practitioner undoubtedly practised well below the standard expected of any Pharmacist, let alone one with 12 years professional experience.
He added that if the practitioner were to be re-registered, he should not have his own pharmacy but work as an employed Pharmacist. Nor should he work alone. Dr Fischer felt that the practitioner would benefit from having an independent supervisor and that this should be reviewed after a period of six months. He also felt that the practitioner had a clear insight into the dangers of being too focused on his work.
We are satisfied that the evidence demonstrates the practitioner has used the time, during which he has been suspended, for productive rehabilitation, counselling and training. We are satisfied that he has appropriately reflected on his shortcomings and the reasons why they occurred. These included his PTSD, his timidity and concepts of masculinity which he has now addressed with appropriate therapy. We accept Dr Fischer's evidence that the practitioner's PTSD is in remission, there is no suggestion that he lacks the clinical competence or knowledge to practice safely in his profession as a pharmacist.
It is generally in the public interest that a suitably qualified pharmacist is able to practice their profession and provide service to the community.
We find that the practitioner undoubtedly posed a risk to the public, at the time of Mr Ludington and Ms Dolan's investigation. However, there is no evidence to contradict Dr Fischer's report and professional opinion, that this is a thing of the past. Any residual concern about whether the practitioner still poses a risk to the public could be addressed by the imposition of condition on the practitioner's registration.
In this instance, we find, on balance of probabilities, that the practitioner no longer poses a risk to the public. Therefore, decided to reprimand the practitioner for his unsatisfactory professional conduct and professional misconduct and to impose conditions for a period of six months.
Those conditions are that the practitioner may not be the proprietor of a pharmacy and may only practise pharmacy under category B supervision. Furthermore, a performance assessment must be conducted after six months to assess whether he is fit to resume unsupervised practice. This is consistent with the recommendation of Dr Fischer.
Having made that decision, it is unnecessary to consider whether a non-review period or prohibition order should be made. Neither was pressed by the Commission during the hearing.