The practitioner was first registered as a dentist in 1997. These proceedings arise from a series of incidents flowing from Dr Meredith's self-prescription of Sch 8 and Sch 4D drugs.
These proceedings comprise six complaints, being: 1. the practitioner is impaired (by reason of both a poly-substance use disorder and lumbar scoliosis); 2. is not competent to practice; 3. has been convicted on an offence; 4. is guilty of improper or unethical conduct in attempting to fill prescriptions written by him in the name of others on multiple occasions while under conditions and suspended, and in making a false declaration to the Council on 16 August 2016 that he had complied with his suspension; 5. is guilty of unsatisfactory professional conduct in failing to comply with conditions; and 6. is guilty of professional misconduct by reason of the above.
The practitioner was diagnosed with severe lumbar scoliosis in November 2012. It is undisputed that this is a very painful condition, and Dr Meredith has since that time undergone three surgical procedures in an attempt to remediate the symptoms.
As early as 2011 Dr Meredith was taking prescription painkillers that were prescribed to his wife. In 2014 he developed a tolerance to Codeine and started using benzodiazepine. Sometime in 2014 Dr Meredith began using other forms of opioids. In September 2014 the practitioner was admitted to hospital suffering cellulitis in his leg caused by self-injecting pethidine. By late 2014 and early 2015 the practitioner was taking very significant quantities of opioids in various forms.
In February 2015 the Pharmaceuticals Services Unit raised a complaint concerning Dr Meredith's prescribing practices and withdrew his Sch 8 prescribing authority. The Dental Council held s 150 proceedings. In those proceedings Dr Meredith admitted using drugs which he was prescribing in the name of his wife, and conditions requiring thrice weekly urine drug testing were imposed.
In March 2015 the practitioner was assessed by Dr Giuffrida as part of the impaired registrants program. Dr Giuffrida accepted the practitioner's account that his use of opioids was only over a few months in response to acute pain and therefore found that he did not suffer from a substance use disorder.
In May 2015 the Council considered whether to convene s 150C proceedings because the practitioner had failed to attend for drug testing on multiple occasions and some of the tests had returned positive results indicating drug use. A further health assessment was conducted by Dr Fisher in May 2015. Dr Fisher found that, by reason of his tolerance to opioids and persistence in seeking them out including through illegal means, Dr Meredith did have a substance addiction. He further concluded that the reported levels of pain and restriction of movement from Dr Meredith's spinal condition constituted an impairment.
We pause to note that it appears that Dr Meredith understated both the quantity of medication he was taking and the duration of time he had been taking it in his self-reports to Dr Giuffrida and Dr Fisher. For example in his first report Dr Fisher notes the practitioner's statement that he began self injecting pethidine in February 2015, yet he had sought medical assistance for the physical effects of pethidine self-injection in September of the previous year.
The Council held s 150C proceedings in June 2015 because of the practitioner's repeated non-compliance with conditions, and further conditions were imposed. However, it appears that it was not until September 2015 that Dr Meredith voluntarily entered into a condition as part of an impaired registrant's panel inquiry not to prescribe Sch 8, 4 and 4D medications (except local anaesthetics and antibiotics for dental treatment) and to advise the Council if another practitioner prescribed him such medications. Other health conditions were also added at this time, including that he attend upon a pain specialist for treatment and a clinical psychologist for the treatment of addiction.
From October 2015 to January 2016 there were literally dozens of breaches of these conditions by Dr Meredith, in particular failures to attend drug testing, attend for medical treatment, disclose the prescription of drugs to him by other practitioners, and to attend health assessments directed by the Council.
In January 2016, the Council initiated further s 150 proceedings in response to this pervasive history of non-compliance. The proceedings were postponed three times in response to medical advice, and were not held until April 2016, at which time Dr Meredith's registration was suspended. In the intervening period, Dr Meredith breached the conditions on many more occasions, including by prescribing and obtaining medication in the names of other people. He also overdosed and was hospitalised on two occasions in February due to the use of fentanyl prescribed by other practitioners. Dr Meredith undertook spinal fusion surgery in March.
In August 2016 the practitioner signed a statutory declaration that he had complied with the suspension of his registration for the period April-August 2016.
Dr Meredith was directed to attend a further health assessment with Dr Fisher but did not do so. In December 2016 Dr Fisher conducted another health assessment on the documents and concluded that the practitioner was still impaired. In that report he expressed concern about the pattern of non-compliance with conditions.
Following suspension, Dr Meredith continued to prescribe Sch 4D medications in the names of other people for his own use. A number of mandatory notifications were made by pharmacists in January and May 2017 as a result of the practitioner attempting to fill those scripts. Dr Meredith was convicted in March 2018 of three criminal offences of obtaining a restricted substance by false representation in relation to these events.
In all, the practitioner issued scripts in the names of four different people for his own use, but primarily did so using the unmarried name of his wife.
In March 2017 Dr Meredith underwent further spinal fusion surgery.
During 2017 Dr Meredith spiralled further; there were two more hospital admissions as a result of drug overdoses and Dr Meredith was scheduled as an involuntary patient due to his poor state of mental health. The practitioner spent 6 weeks receiving in-patient treatment.
In July and August 2017 the practitioner was approached by police as a result of his behaviour in public places. He was convicted in January 2018 of one count of possession of prohibited drugs and in March 2018 of three counts of possession of prohibited drugs.
Since January 2018 the practitioner has been prescribed methadone as part of a treatment process.
In January 2018 the practitioner commenced outpatient treatment at Cumberland Hospital for substance dependence and mental health issues. He has seen a treating psychiatrist or psychologist every 4 to 5 weeks as part of that treatment.
Dr Meredith was hospitalised in May 2018 following a diazepam overdose.
The most recent health assessment was undertaken by Dr Fisher in May 2018. Dr Fisher expressed the opinion that the practitioner continued to be impaired by reason of a drug use disorder. He also expressed concern that the multiple overdoses the practitioner had experienced, involving lengthy periods of unconsciousness, and intensive care including intubation and cardiorespiratory support, could have led to brain damage. At that time Dr Fisher was of the view that the practitioner displayed 'a trend towards more extreme deterioration in global functioning.'
Medical records indicate that the practitioner reported fentanyl usage in October 2018.
Extracts of medical records indicate that Dr Meredith was hospitalised in April 2019 following a self-harm episode.
It is undisputed that on three occasions in May, July and August 2019 the practitioner tested positive for drug use within his treatment program, for benzodiazepines and fentanyl.
[2]
The Hearing
Although Dr Meredith did not file any material and indicated to the HCCC in late October 2019 that he conceded all the complaints and did not intend to participate in proceedings, he did in fact attend the hearing by telephone. The HCCC tendered on Dr Meredith's behalf his correspondence with them from October 2019 and also some documents associated with the practitioner's worker's compensation claim, which he had sent to the HCCC in August 2018.
In September 2019 the practitioner attempted to relinquish his registration. On 14 November 2019 the Dental Council took the unusual step of lifting the suspension in order to allow Dr Meredith to surrender his registration, and he did so.
It was Dr Meredith's position that the proceedings should be terminated on the basis that he had surrendered his registration and had no intention to practise dentistry in the future. He also suggested that dentistry would be difficult, if not impossible, for him to undertake given his on-going physical disability.
The HCCC opposed terminating the inquiry on the basis that the public interest required an inquiry into Dr Meredith's current circumstances, a determination of the complaint, and a recording of the outcome on the public register.
We appreciate that Dr Meredith, and indeed many other health practitioners in similar circumstances, cannot understand the necessity of disciplinary proceedings at a point in their lives when the conduct complained of is some years in the past and they have left their profession with no intention to return. In such circumstances, especially when struggling with a serious impairment and acting unrepresented, a practitioner may understandably feel that a public legal inquiry such as this one is unnecessary and punitive, even cruel. We have considerable sympathy with the stress, and distress, that follow from the often-lengthy delays that occur as part of such proceedings.
However, the practical difference between the practitioner surrendering his registration and the orders sought by the HCCC is considerable. If no inquiry were held and no decision rendered, there would be no record on the public register concerning the practitioner's registration, and he would effectively be free to reapply at any time in the future to be returned to the register. The HCCC sought an order that the register record that the practitioner's registration would have been cancelled had it still been in effect and an order that he not be permitted to apply for review of such order for at least 5 years.
While there are decisions of this Tribunal to terminate proceedings in situations of fulsome admissions, surrender of registration and voluntary undertakings not to reapply, these determinations have largely occurred in the context of practitioners significantly older than the current practitioner who were, effectively, retiring from practice: see discussion in Health Care Complaints Commission v Duggan [2015] NSWCATOD 142, [41]-[51].
Given that Dr Meredith has potentially 20 or more years of working life ahead of him we would need to be very confident that there is no risk to the public through the possibility of his renewed practice in the future before taking a decision to terminate the proceedings. The paramount consideration in the exercise of our functions is the health and safety of the public: National Law s 3A. A decision to terminate an inquiry concerning a practitioner who has ceased to be registered requires that the Tribunal be satisfied that it is not in the public interest to continue: National Law Sch 5D, cl 12(1)(b).
We find that we cannot be satisfied that the course proposed by Dr Meredith would adequately protect the public for the following reasons. First, we have no objective evidence of the practitioner's current state of physical impairment by reason of his spinal condition; second, we have no firm basis upon which to rely on the practitioner's present undertaking given his extensive and prolonged history of breached undertakings and conditions; third, he is still in treatment and not fully recovered from his substance disorder such that his current view of his circumstances and future prospects may be coloured and liable to change.
Further, the matter involves fraudulent and repeated criminal conduct over a prolonged period. It is in the public interest that patients should be able to know of such conduct should they choose to be treated by the practitioner in the future.
For these reasons, the Tribunal denied the practitioner's application and proceeded to undertake a limited inquiry, comprising a one day hearing involving brief oral evidence from the practitioner, oral submissions from both parties and written submissions from the applicant.
Leave was granted to the practitioner to file written submissions on costs subsequent to the hearing, but he did not do so.
[3]
Findings
The Tribunal is independently satisfied that all of the complaints are proved to the required standard.
The practitioner suffers an impairment within the meaning of the National Law by virtue of his longstanding and not fully resolved poly-substance use disorder. He has taken considerable steps towards recovery through participation for the better part of the past two years in a drug treatment program but remains reliant on prescribed methadone. He has had recent relapses into use of opioids and benzodiazepines.
We find that the impairment by reason of substance dependence is very likely to detrimentally affect the practitioner's capacity to practise the profession of dentistry and that, relatedly, he is not currently competent by reason of lack of physical and mental capacity to practise as a dentist.
Further, it is unknown what level of pain or physical impairment would resurface when the practitioner's methadone use ceases, or how that pain would be medically managed.
We find that the repeated breaches of conditions and of professional standards, false declaration to his professional Council, and the criminal convictions that arise from the practitioner's fraudulent prescription of medications, occurring over a period of years, are of grave severity.
Many particulars involve improper and unethical conduct. Taken together the proved conduct is of such repetition and such severity that there is no question that the threshold of professional misconduct is met. This is so even though the conduct flowed from the impairment in the sense that the conduct all occurred in the service of a substance dependence. The practitioner was provided with a great deal of supportive assistance through the impaired registrants' scheme over a long period, and in that process abused the trust of his professional body and profession.
Furthermore the circumstances of the criminal offences render the practitioner unfit in the public interest to practise as a dentist. They involved dishonesty and also the possession of illicit drugs. We note that the practitioner's engagement with a treatment program occurred following these convictions, and we sincerely hope that this marks a turning point for him.
We find that the public interest requires that the public register record that Dr Meredith's registration would have been cancelled had it still been current.
The HCCC sought an order that a non review period of 5 years be imposed such that Dr Meredith could not reapply to the Tribunal to seek reinstatement to the register until after that time. The HCCC submitted that this was consistent with the Court of Appeal jurisprudence in Chen v Health Care Complaints Commission [2017] NSWCA 186, in that it signalled the seriousness of the conduct to the profession and public and also allowed an appropriate time for the practitioner to demonstrate remediation with the prospect of a return to practice after that time.
While there is a certain artificiality in the setting of non-review periods in instances in which the primary or foundational issue is that of impairment, the practitioner did not oppose such an order. We find that it is appropriate in this matter to make such an order primarily to set a framework around remediation should the practitioner wish to return to practice in the future. The conduct occurred over at least three years, and even in the past two years the practitioner has not managed to completely overcome his substance dependence, with a number of relapses evident as well as ongoing medically managed use of methadone. In these circumstances, it is reasonable to consider that a settled period of recovery and stability over a period of five years would be required to demonstrate fitness to practise.
At present the practitioner has no intention to return to dentistry. Should he wish to do so in the future we suggest that he would need to take active and sustained steps in the coming years to demonstrate that he has tackled his psychological issues, including substance dependence, with the assistance of professional intervention and supervision.
A lengthy period of evidenced abstinence from substance use would necessarily be part of such process, but we stress that, given the current Tribunal findings, abstinence from drug use would likely be seen by any future Tribunal as a necessary but not sufficient step towards a demonstration of rehabilitation and remediation. A sustained period of abstinence accompanied by treatment, insight, renewed commitment to ethical and professional standards, and professional and personal stability would likely be required to demonstrate fitness to practise in the future.
[4]
Costs
The HCCC sought its costs on the basis that it had been successful in its case. The respondent was provided an opportunity to make later written submissions on costs but did not do so.
The awarding of costs is discretionary but that discretion must be exercised judicially and by reference to relevant considerations, among which the impecuniosity of a party is not counted: Northern Territory v Sangare [2019] HCA 25. In general, in disciplinary proceedings, costs will follow the event in order to compensate the successful party, unless there is reason to depart from that approach: Health Care Complaints Commission v Philipiah [2013] NSWCA 342.
It is appropriate that the HCCC be awarded their costs as they have been successful in the entirety of their case and conducted the proceedings with efficiency.
[5]
Orders
1. Pursuant to findings of misconduct, impairment and lack of capacity to practise, AHPRA is required per s 149C(4)(c) to record on the national register that the tribunal would have cancelled the registration of the practitioner as a dentist had he still been registered.
2. A non-review period of 5 years from the date of these orders pursuant to s 149C(7).
3. The respondent to pay the applicant's costs of these proceedings as agreed or as assessed under the Legal Profession Uniform Law Application Act 2014 (NSW).
4. Pursuant to s 64 of the Civil and Administrative Tribunal Act 2013 (NSW) prohibition of disclosure or publication of the names of the patients listed in the schedule to the complaint.
[6]
I hereby certify that this is a true and accurate record of the reasons for decision of the Civil and Administrative Tribunal of New South Wales.
Registrar
DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment or decision. The onus remains on any person using material in the judgment or decision to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court or Tribunal in which it was generated.
Decision last updated: 14 January 2020