By application for disciplinary findings and orders filed on the 19 September 2019, the applicant seeks the following orders against Dr Bassel Rahman, medical practitioner registration number D0001184435 (the respondent):
1. An order pursuant to s 64 of the Civil & Administrative Tribunal Act 2013 prohibiting the disclosure of the names of Patient A and Z and Person A in the attached Complaint dated 18 September 2019.
In the event the complaints against the Respondent are proved or admitted:
2. Orders pursuant to s 149A (powers to caution, reprimand, impose conditions on registration, etc); s 149B (power to impose a fine) and/or s 149C (powers to suspend or cancel registration, make a prohibition order, etc) of the Health Practitioner Regulation National Law (NSW) ('National Law').
3. Costs
The grounds of the application are stated in the application as follows:
The Director of Proceedings, HCCC, has determined to prosecute a complaint against the Respondent pursuant to s 90B(1) of the Health Care Complaints Act 1993 alleging that he has been guilty of unsatisfactory professional conduct within the meaning of s 139(1)(a)(b) and (l) and/or professional misconduct within the meaning of s 139E of the National Law.
Complaint One
The applicant has particularised complaints against the respondent. Complaint One alleges that the respondent is guilty of unsatisfactory professional conduct under section 139B of the Health Practitioner Regulation National Law (NSW) ("the National Law") in that the practitioner has:
(i) engaged in conduct that demonstrates the judgment possessed, or care exercised, by the practitioner in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience; and/or
(ii) engaged in improper or unethical conduct relating to the practice of medicine.
The particulars to such complaint allege that:
Prescribing Testosterone and Anabolic Steroids
1. In respect of patients who are referred to as patients A,B, E, G, L, M, Q, R, and S, and who are identified in the complaint, on certain dates and in certain quantities, the respondent prescribed Schedule 4D prescribed restricted substances (testosterone and anabolic steroids) namely testosterone undeconate, testosterone enanthate and mesterolone in quantities, or for a purpose, that did not accord with the recognised therapeutic standard of what was appropriate in the circumstances, in breach of clause 34 of the Poisons and Therapeutic Goods Regulation 2008 ("the PTG Regulation").
2. The practitioner failed to undertake or organise sufficient and appropriate investigations including serum testosterone levels collected between 8 and 10 am, physical examination including examination of the testes, and a detailed patient history for Patients A, B, E, G, L, Q, R and S for the purposes of diagnosing testosterone deficiency, or confirmation of the diagnosis by a specialist endocrinologist, prior to prescribing testosterone to those patients.
3. The practitioner failed to recommend or otherwise arrange any sufficient or appropriate follow-up or review of Patients A B, E, G, L, M, Q, R and S including the ordering of blood tests for the purposes of monitoring the patients' response to treatment and identifying any complications arising from the treatment prescribed.
Prescribing Benzodizepines [sic]
4. On the dates and in the quantities shown in Schedules F, G, H, J, N ,O, P, Q, S, T, U, V and W the practitioner prescribed to Patients F, G, H, J, N, O, P, Q, S, T, U, V and W the Schedule 4D special restricted substances (benzodiazepines), namely clonazepam, diazepam, oxazepam and temazepam, in quantities, or for a purpose, that did not accord with the recognised therapeutic standard of what was appropriate in the circumstances in breach of clause 34 of the PTG Regulation.
5. On the dates and in the quantities shown in Schedules F, G, H, J, N, O, P, Q, S, T, U, V and W the practitioner prescribed to Patients F, G, H, J, N, O, P, Q, S, T, U, V and W the Schedule 4D special restricted substances (benzodiazepines), namely clonazepam, diazepam, oxazepam and temazepam:
a. without exercising responsible medical judgment;
b. without performing an appropriate clinical assessment of the patient prior to commencing to prescribe the medications;
c. for excessive periods without a documented management plan or specialist support;
d. in circumstances where he knew or should have known the medications were being abused.
6. On the dates and in the quantities shown in Schedules F, G, H, J, N, O, P, Q, S, T, U, V and W the practitioner prescribed to Patients F, G, H, J, N, O, P, Q, S, T, U, V and W the Schedule 4D special restricted substances (benzodiazepines), namely clonazepam, diazepam, oxazepam and temazepam in combination with Schedule 8 drugs of addiction thereby increasing the risk of significant side effects including excessive sedation, respiratory depression and overdose.
Prescribing Drugs of Addiction
7. On the dates and in the quantities shown in Schedules the practitioner prescribed to Patients C, D, E, F G, I, J, K, N, O, P, S, T, U, V, W and X the Schedule 8 drugs of addiction namely alprazolam, bruprenorphine, fentanyl, oxycodone, methadone, hydromorphone, dexamphetamine, morphine and pethidine in quantities, or for a purpose, that did not accord with the recognised therapeutic standard of what was appropriate in the circumstances in breach of clause 79 of the PTG Regulation.
8. On the dates and in the quantities shown in the prescribing Schedules F, G, H, J, N, O, P, S, T, U, V and W the practitioner prescribed Schedule 8 drugs of addiction to Patients F, G, H, J, N, O, P, S, T, U, V and W:
a. without exercising responsible medical judgment;
b. without performing an appropriate clinical assessment of the patient prior to commencing to prescribe the medication;
c. for excessive periods without a documented management plan or specialist support;
d. in circumstances where he knew or should have known the medications were being abused and where the practitioner had previously been contacted by officers of the Pharmaceutical Services Branch and the NSW Medical Council in connection with his legal and professional responsibilities with respect to prescribing drugs of addiction in 2009 and 2013.
9. On the dates and in the quantities shown in Schedules I, N, O and T the practitioner prescribed the Type B Schedule 8 drugs of addiction morphine and pethidine to Patients I, N, O and T for a period in excess of two months without a authority to prescribe under sections 28A of the of the Poisons & Therapeutic Goods Act 1966 ("the PTG Act").
10. The practitioner prescribed the Schedule 8 drugs of addiction alprazolam, fentanyl, and oxycodone to Patient C on the dates and in the quantities in Schedule C where the practitioner had formed the opinion or ought reasonably to have formed the opinion that Patient D [sic] was a drug dependent person within the meaning of section 27 and without a authority to prescribe under section 28A of the Poisons & Therapeutic Goods Act 1966 ("the PTG Act").
11. The practitioner prescribed the Schedule 8 drugs of addiction, namely alprazolam, buprenorphine, fentanyl, oxycodone, and pethidine to Patient D on the dates and in the quantities in Schedule D where the practitioner had formed the opinion, or ought reasonably to have formed the opinion that Patient D was a drug dependent person within the meaning of section 27 and without an authority to prescribe under section 28A of the PTG Act.
12. The practitioner prescribed the Schedule 8 drug of addiction, namely alprazolam to Patient E on the dates and in the quantities in Schedule E where the practitioner had formed the opinion or ought reasonably to have formed the opinion that Patients E was a drug dependent person within the meaning of section 27 and without a proper authority to prescribe under section 28A of the PTG Act.
13. The practitioner prescribed the drug of addiction, namely alprazolam to Patient F on the dates and in the quantities in Schedule F where the practitioner had formed the opinion or ought reasonably to have formed the opinion that Patient F was a drug dependent person within the meaning of section 27 and without a proper authority to prescribe under sections 28A of the PTG Act.
14. The practitioner prescribed the Schedule 8 drugs of addiction, namely fentanyl, and oxycodone to Patient I on the dates and in the quantities in Schedule I where the practitioner had formed the opinion, or ought reasonably to have formed the opinion that Patient I was a drug dependent person within the meaning of section 27 and without a proper authority to prescribe under sections 28A of the PTG Act.
15. The practitioner prescribed the Schedule 8 drugs of addiction, namely fentanyl and oxycodone to Patient K on the dates and in the quantities in Schedule K where the practitioner had formed the opinion, or ought reasonably to have formed the opinion that Patient K was a drug dependent person within the meaning of section 27 and without a proper authority to prescribe under section 28A of the PTG Act.
16. The practitioner prescribed the Schedule 8 drug of addiction, namely oxycodone to Patient O on the dates and in the quantities in Schedule O where the practitioner had formed the opinion, or ought reasonably to have formed the opinion that Patient O was a drug dependent person within the meaning of section 27 and without a proper authority to prescribe under section 28A of the PTG Act and where the Pharmaceutical Services [sic] and the NSW Medical Council had communicated with the practitioner about his prescribing of drugs of addiction for Patient O in 2010.
17. The practitioner prescribed the Type A Schedule 8 drug of addiction, dexamphetamine sulphate to Patient P on the dates and in the quantities shown in Schedule P without the appropriate authority under section 29 of the PTG Act.
18. The practitioner prescribed the Schedule 8 drugs of addiction, namely oxycodone and methadone to Patient P on the dates and in the quantities shown in Schedule P where the practitioner had formed the opinion or ought reasonably to have formed the opinion that Patient P was a drug dependent person within the meaning of section 27 and without a proper authority to prescribe under section 28A the PTG Act.
19. The practitioner prescribed the Schedule 8 drugs of addiction, namely oxycodone and fentanyl to Patient S on the dates and in the quantities shown in Schedule S where the practitioner had formed the opinion, or ought reasonably to have formed the opinion that Patient S was a drug dependent person within the meaning of section 27 and without a proper authority to prescribe under section 28A of the PTG Act.
20. The practitioner prescribed the Schedule 8 drugs of addiction namely, pethidine, morphine and fentanyl to Patient T on the dates and in the quantities shown in the Schedule T where the practitioner had formed the opinion or ought reasonably to have formed the opinion that Patient T was a drug dependent person within the meaning of section 27 and without a proper authority to prescribe under section 28A of the PTG Act.
21. The practitioner prescribed the drug of addiction, namely alprazolam to Patient U on the dates and in the quantities in Schedule U where the practitioner had formed the opinion or ought reasonably to have formed the opinion that Patient U was a drug dependent person within the meaning of section 27 and without a proper authority to prescribe under section 28A of the PTG Act.
22. The practitioner prescribed the drugs of addiction, namely alprazolam and oxycodone to Patient V on the dates and in the quantities in Schedule V where the practitioner had formed the opinion or ought reasonably to have formed the opinion that Patient V was a drug dependent person within the meaning of section 27 and without a proper authority to prescribe under section 28A of the PTG Act.
23. The practitioner prescribed the drugs of addiction, namely alprazolam and oxycodone to Patient W on the dates and in the quantities in Schedule W where the practitioner had formed the opinion or ought reasonably to have formed the opinion that Patient W was a drug dependent person within the meaning of section 27 and without a proper authority to prescribe under sections 28A of the PTG Act.
24. The practitioner prescribed the Schedule 8 drugs of addiction, namely alprazolam, oxycodone and hydromorphone to Patient X on the dates and in the quantities in Schedule X where the practitioner had formed the opinion or ought reasonably to have formed the opinion that Patient X was a drug dependent person within the meaning of section 27 and without a proper authority to prescribe under section 28A of the PTG Act.
Other Schedule 4 Drugs
25. The practitioner prescribed Patient E a Schedule 4 restricted substance Tamoxifen on the dates and in the quantities in Schedule E in a quantity, or for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances contrary to clause 34 of the PTG Regulation.
26. The practitioner prescribed Patient Q the Schedule 4 restricted substance Zolpidem on the dates and in the quantities shown in Schedule Q:
a. in a quantity or for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances contrary to clause 34 of the PTG Regulation;
b. without exercising responsible medical judgment;
c. for an excessive period;
d. in circumstances where he knew or should have known the medication were [sic] being abused.
27. The practitioner prescribed Patient W the Schedule 4 restricted substances zolpidem and anastrazole [sic] on the dates and in the quantities shown in Schedule W:
a. in a quantity or for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances contrary to clause 33 of the PTG Regulation;
b. without performing an appropriate clinical assessment of the patient prior to commencing to prescribe the medications;
c. without a documented management plan.
28. The practitioner prescribed Patient L the Schedule 4 restricted substances Human Chorionic Gonadotrophin (hCG) and Somatropin on the dates and in the quantities shown in Schedule L in quantities, or for a purpose, that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances contrary to clause 33 of the PTG Regulation.
29. The practitioner failed to undertake and/or organise and/or record sufficient and appropriate investigations, including a physical examination, of Patient L prior to prescribing hCG and Somatropin.
30. The practitioner prescribed Patient R the Schedule 4 restricted substances Human Chorionic gonadotrophin (hCG) and Somatropin on the dates and in the quantities shown in Schedule R in quantities, or for a purpose, that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances contrary to clause 33 of the PTG Regulation.
31. The practitioner failed to undertake and/or organise and/or record sufficient and appropriate investigations, including a physical examination, of Patient R prior to prescribing hCG and Somatropin.
Prescribing for Relatives and Self-prescribing
32. The practitioner inappropriately prescribed Schedule 4 restricted substances and Schedule 8 drugs of addiction to close family members Patients Y and Z on the dates and in the quantities shown in Schedules Y and Z contrary the NSW Medical Board Policy 'Medical Practitioners Treating Relatives and Self'.
33. The practitioner inappropriately self prescribed Schedule 4 and 4D restricted substances on the dates and in the quantities shown in Schedule AA contrary to clause 58 of the Poisons and Therapeutic Goods Regulation 2008 and/or the NSW Medical Board Policy 'Medical Practitioners Treating Relatives and Self'.
34. The practitioner inappropriately self prescribed Schedule 8 drugs of addiction on the dates and in the quantities shown in Schedule AA, contrary to the NSW Medical Board Policy 'Medical Practitioners Treating Relatives and Self'.
Other
35. The practitioner ordered quantities of the Schedule 4D medication Somatropin for direct supply to patients at the Medical Centre. The practitioner failed to promptly report the theft of 45 vials of Somatropin from his car on 22 September 2015 to the NSW Ministry of Health.
Respondent's Reply to Complaint One
The respondent admits the particulars in Complaint One, subject to Particular 35. As to Particular 35, the respondent says that the theft was reported to the police and to his lawyer. The respondent states that he was not aware of the necessity to report the theft to the Ministry of Health and was not advised to do so.
Complaint Two
The complaint alleges that the respondent is guilty of unsatisfactory professional conduct under section 139B(1)(b) of the National Law in that the practitioner has:
(i) contravened the Health Practitioner Regulation (New South Wales) Regulation 2010 (repealed) (the 2010 regulation).
Background
As for Complaint One.
PARTICULARS OF COMPLAINT TWO
1. The practitioner failed to make and keep adequate clinical records for Patients A to Z regarding his:
a. assessment,
b. examination,
c. diagnoses,
d. clinical opinion,
e. advice,
f. planning, and
g. reasoning.
Respondent's Reply to Complaint Two
The respondent admits Complaint Two.
Complaint Three
The complaint alleges that the respondent is guilty of professional misconduct under section 139E of the National Law in that the practitioner has:
(i) engaged in unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration, or
(ii) engaged in more than one instance of unsatisfactory professional conduct that, when the instances are considered together, amount to conduct of a sufficiently serious nature to justify the suspension or cancellation of the practitioner's registration
PARTICULARS OF COMPLAINT THREE
Complaints 1 and 2 and the particulars thereof are repeated and relied upon both individually and cumulatively.
Respondent's Reply to Complaint Three
The respondent admits Complaint Three.
Investigative report
An investigative report was compiled following an investigation. The report establishes that the respondent first came to the notice of the Pharmaceutical Services Branch, now the Pharmaceutical Regulatory Unit ("the PRU"), following a complaint lodged with the applicant on 6 November 2008. The respondent was referred to the NSW Medical Board, now the Medical Council of New South Wales ("the Council") for a performance interview. A performance interview was scheduled for 20 May 2009.
On 23 June 2009 the Council's Performance Committee noted the performance interview report and decided to take no further action. In consequence, the PRU informed the applicant on 17 December 2009 of the results of the investigation. The applicant advised the PRU that the matter would be referred to the Council. A further complaint was received on 17 December 2009 concerning the respondent's prescribing. Ultimately, on 23 February 2011 it was recommended by the Performance Committee that the respondent be counselled in relation to improved record keeping and computerisation. A further complaint was received on 6 October 2015 which resulted in the matter being referred under section 150 of the National Law.
Proceedings took place on 28th October 2015 and 2 November 2015. As a result, numerous conditions were imposed upon the practice of the respondent. The Council's decision is contained in written reasons published on 19 November 2015.
Expert report
Dr Steven Howle, medical practitioner ("the expert"), has provided two reports concerning the professional conduct of the respondent. The expert has provided a detailed analysis, as summarised hereunder, concerning the respondent's treatment of patients who are known as Patient A to Patient X inclusive. The expert's findings are stated below, followed by the Tribunal's findings in relation to such patients.
The first report is dated 17th of April 2018 and considers several aspects of the conduct of the respondent, as follows:
Self-prescribing
The expert was asked for his opinion concerning the respondent's self-prescribing of diazepam, oxycodone and phentermine over the period 19 November 2013 to 9 July 2015.
The expert stated:
[I]t is generally recommended (see Document 1: Code of Conduct) that medical practitioners avoid self prescribing and if medication is needed that they address such a need with their usual GP (having your own GP is also recommended). This self prescribing is especially frowned upon with respect to S 4 and S 8 drugs (i.e., in this case: Diazepam, Oxycodone, and Phentermine). The risk of prolonged prescribing and subsequent drug dependency is quite high.
This is significantly below the standard expected and so invites strong criticism.
The expert noted that the respondent commenced self-prescribing on 3 January 2015 but there is nothing in the medical records to substantiate his alleged "periodic fever", nor is there a list of symptoms or signs, or any blood tests or letters to or from specialists confirming the diagnosis. The notes gave no indication why such strong pain tablets would be required, especially when self-prescribing. Such conduct was significantly below the expected standard and invited strong criticism
A further record was commenced on 19 November 2013 for self-prescribing Valium 2 mg. There was no medical history recorded.
Further entries existed throughout 2014 and 2015 for the self-prescribing of Endone, Valium and Stilnox. The only notes indicating a reason for the scripts are very brief and indicate "sciatica", "ongoing pain" and "muscle pains" from "periodic fever". There is no detailed history or examination following a consultation by a "doctor ARG" on 4 August 2014. There are no details of investigations or results of seeing a "Dr Mcechnie". Such conduct was significantly below the standard expected and invited strong criticism.
[1]
Prescribing Schedule 8 drugs to patients with a history of drug dependence
With respect to 5 patients, namely Patients J, K, P, V and X, the respondent prescribed Schedule 8 drugs to patients who had a history of drug dependence or abuse.
[2]
Prescribing benzodiazepines to patients with a history of drug dependence
The respondent provided benzodiazepines to Patients F, J, K, P, V and X. Such patients had a history of drug dependence. The expert stated that in such patients, the risk of restarting or exacerbating the dependency is quite high. He also stated that they were all capable of causing dependence on their own, or tolerance. Withdrawal commonly involves insomnia, anxiety, panic attacks, palpitations, vertigo, depression or delusional thoughts.
The expert stated that it was necessary to assess the patient to ascertain risk factors such as age, frailty and other medications and comorbidities and to explain the potential side-effects of continuing the drugs. One needed to check as to the safety of the patient with respect to the combination of drugs, for example, whether they were to drive a car or operate machinery, whether they have support at home and whether they needed to be hospitalised for initial observation.
Opioids are known to have an increased risk of toxicity when used in conjunction with benzodiazepines. The combination has been associated with fatalities and there is a risk of increasing side-effects.
[3]
Prescribing Schedule 8 drugs in combination with benzodiazepines
The respondent prescribed Schedule 8 drugs in combination with benzodiazepines to Patients E, J, K, P, V, X, D, O and T. The expert considered that the same risks applied as set out for prescribing benzodiazepines to patients with a history of drug dependence.
[4]
Prescribing gonadal hormones
The respondent provided gonadal hormones to Patients A, B, E, G, M, Q, and S.
The expert stated that such drugs are usually only prescribed by specialists working in the field of infertility, or in males with specific conditions such as hypogonadism, delayed puberty, or cryptorchidism not due to obstruction. It is also used in certain cases of sterility due to deficient spermatogenesis.
The expert referred to the risks associated with such drugs and stated:
[A] GP should consider with each of the above that the drug is to be prescribed for the appropriate therapeutic purpose for which it is intended…
He/she should consider the associated pathology, possible imaging… and letters from other involved doctors before commencing the medication.
[5]
Prescribing human growth hormones
The respondent prescribed somatropin to Patients L, R and Y.
The expert described somatropin as a synthetic human growth hormone, used specifically for the condition where the body's natural growth hormone is absent, reduced or inadequate. Such drugs are usually only prescribed by specialists such as paediatricians, endocrinologists and general physicians. However general practitioners may be involved in monitoring these conditions with the specialist. The drug is prescribed following careful assessment and investigation by specialists.
There are risks of interactions with diabetes, hypothyroidism and pituitary disorders, as well as brain injury or cancer. Acute overdose can involve tremor, fast heart rate, headaches, drowsiness, weakness, hunger and nausea.
[6]
Withdrawal scheme
The respondent documented in his clinical notes that he was withdrawing some patients from drugs of addiction and/or benzodiazepines by reducing a dosage over time.
The expert stated that there was a procedure to be followed in such a way that the patient was willing and able to comply with the reduction dosage. He stated that one would normally discuss and commonly notate a fixed reduction regime. The dangers are several. The reduction, if based on one source of supply, may be supplemented by an increase in use of illicit sources for the medication and potential overdose as well as a risk of "doctor shopping".
Summary of patients' treatment
The expert considered the standard of treatment provided to the patients referred to in the schedule to the report. The tribunal will provide its findings in respect of each of the patients at the conclusion of the summarised findings of the expert set out hereunder:
Patient A
The prescribing of testosterone and the absence of record keeping was significantly below the standard reasonably expected of a practitioner and invited strong criticism. There was no documentation of an appropriate examination or the results of appropriate tests. The low testosterone level referred to was incorrectly collected at the wrong time of day. The patient should have been referred to an endocrinologist prior to prescribing any testosterone treatment. The drug was not prescribed for an appropriate therapeutic purpose and it was not prescribed in an appropriate quantity. The patient presented more frequently than would be usual for normal testosterone replacement scripts and this was suggestive of drug seeking, but the respondent did not address this possibility. The records are deficient.
Patient B
The prescribing of testosterone was significantly below the standard reasonably expected and the conduct in so prescribing invites strong criticism. There was no documentation of an appropriate examination or the results of appropriate tests. The low testosterone level referred to was collected at the wrong time of day. It was not prescribed for an appropriate therapeutic purpose and the quantity of the drug prescribed was twice the recommended therapeutic dose. Because of the excess quantity of prescribing, this was suggestive of drug seeking behaviour by the patient and the clinical records were inadequate.
Patient C
The respondent prescribed alprazolam, diazepam, clonazepam, fentanyl and oxycodone to this patient from 31 December 2013 to 24 August 2015.
This patient first saw Dr Rahman on 31 December 2013 and had not visited the clinic since 11 March 2013. A prior doctor's consultation notes, made on 2 December 2012, recorded a detailed history of a probable "addiction" and set out a plan to "slowly wean off". On 1 February 2013, a note recorded "not on Xanax now".
A comprehensive psychological assessment was required and the respondent should have contacted the patient's previous prescribing practitioners and allied health providers to obtain information on current management and plans.
With respect to opioids (fentanyl and oxycodone) Dr Rahman's notes record a prescription for Endone on 17 April 2014 and 4 June 2014. However at neither consultation is there any detailed description of symptoms or signs related to the need for strong pain relief. On 17 June 2014 a prescription was written for high dose fentanyl (50mcg/hr) without any clinical record or reasoning. Such conduct is below the standard reasonably expected and invites strong criticism.
Further, the patient exhibited drug seeking behaviour and ongoing psychological problems. A psychologist and psychiatrist should have been engaged. There is no evidence of any such referral. There had been no diagnosis since 2008 and the prescription of drugs was well in excess of the normal quantities used and inappropriate. The respondent should have checked before adding opioids (Schedule 8 drugs). Since there is no diagnosis to explain the use of either drug, it was impossible to support an appropriate use and the combination of opioids and benzodiazepines can be dangerous, with a higher incidence of accidental and fatal overdose and increased dependency on both. There was no plan for weaning the patient off the drugs even though the respondent claimed that he counselled the patient. The records are below the standard reasonably expected.
Patient D
The respondent prescribed temazepam, diazepam, alprazolam, oxazepam, buprenorphine (patch), pethidine hydrochloride (injection), fentanyl and oxycodone to this patient over the period of 14 March 2011 to 17 August 2015. The first recorded consultation with the respondent was on 13 November 2012 and the patient had not attended the practice in the previous 11 months. The only clinical record on that date in respect of the patient's pain was "analgesia". Endone and Tramal were prescribed and there is no record of any consultation for a further nine months. The clinical notes then record "recent cspine surgery on multiple meds". Tramal and Endep were prescribed. One week later a Norspan patch (buprenorphine) was prescribed. Benzodiazepines were first prescribed on 24 September 2019 for "r groin strain unable to sleep last night? Muscle strain". Valium was prescribed, followed 7 days later by Xanax. There were numerous times when more than one benzodiazepine was prescribed simultaneously. The clinical notes are inadequate and there is no documented reason or evidence to establish that they were prescribed for an appropriate therapeutic purpose. The conduct of the respondent was significantly below the standard and invited strong criticism. With regard to benzodiazepines prescribed from late 2013, the dose written does not correspond to the prescribing table and the frequency of prescribing is excessive.
The alprazolam was prescribed whilst the patient was taking other benzodiazepines. The mixture was not appropriate. Whilst the respondent claimed he tried to wean the patient off, no documented management plan supports such an assertion. The notes are inadequate and are significantly below the expected standard and invite strong criticism.
Patient E
The respondent prescribed testosterone enanthate, mesterolone, diazepam, alprazolam, zolpidem, oxycodone, methylphenidate, tamoxifen, anastrozole and human chorionic gonadotrophin (hCG).
The expert was unable to find documentation of an adequate history of examination and diagnosis or a management plan with respect to such prescribing of hormonal medications. There is a reference to low sperm count but a comprehensive history and examination was required. The low testosterone level referred to was collected at the wrong time of day and further testing at the correct time of day was required, followed, if truly low, by tests to determine the cause before treatment with testosterone. Similarly there are inadequate clinical notes with regard to the prescribing of benzodiazepines and opioids. Referral to an endocrinologist would have been appropriate. The patient had been referred to a psychiatrist from time to time by the respondent, but the brief referral letters do not mention that the respondent was prescribing a number of medications which may have been of great importance to any psychiatrist trying to assist both the patient and the respondent.
There was no recorded diagnosis or evidence in the clinical notes to support the appropriateness of high doses of testosterone and later, anti-oestrogen medication, nor the use of high doses of long-term benzodiazepines and concurrently of opioids. Further, it was not appropriate to prescribe Ritalin. Such prescription is restricted to specialists only and GPs are not usually permitted to prescribe such a drug, even with an authority. The patient's frequency of attendance to get further scripts at intervals closer than needed should have been a warning that the patient was a drug seeker but there is no notation in the clinical notes to suggest the respondent considered this a possibility.
The conduct is significantly below the standard expected and the conduct, especially in respect of prescribing, invites strong criticism.
Patient F
The patient was prescribed diazepam, alprazolam, temazepam and clonazepam in the period 5 December 2013 to 9 August 2015. The respondent prescribed benzodiazepines to the patient who was drug dependent whilst he was on an opioid treatment program (OTP) with another prescriber. The respondent's notes record the need to "ween [sic] off" medications and prescribe "one-off" medications and "reduce" the dose. However, the respondent continued to issue prescriptions. On occasions it was stated that the prescriptions were reportedly stolen. The respondent prescribed alprazolam without an authority under section 28A of the Poisons and Therapeutic Goods Act 1966 (NSW) (the PTG Act).
The expert states that the respondent did not conduct an appropriate assessment of the patient before prescribing the drugs; there is no diagnosis; no history of medication doses or interventions tried; no history of psychological or psychiatric interventions; no background history of other illnesses, work history or social history; and no documentation that he was aware of any previous or current OTP. Such conduct is significantly below the standard reasonably expected of a practitioner and invites strong criticism.
A brief referral was made to a psychiatrist, Dr Saker, in three letters dated 13 March 2014, 7 May 2014 and 27 June 2014. The letters are incomplete. It is not clear whether the psychiatrist's letter was supportive of the respondent's drug regime.
All the drugs prescribed are benzodiazepines and are usually not prescribed concurrently. The doses were excessive and the prescribing was significantly below the standard reasonably expected of a practitioner and the conduct invites strong criticism.
The respondent admitted that the patient did exhibit drug seeking behaviour and that he did try to counsel the patient. However the clinical records are well below the standard expected with little notation as to the reasons for medication change or dosage change, or symptoms of the patient's illness, and there is no record in the summary page of the patient's diagnoses. There is only one reply from one specialist. There is no record of any telephone calls. This is significantly below the expected standard and invites strong criticism.
Patient G
The respondent prescribed testosterone enanthate, mesterolone, alprazolam, diazepam, oxycodone and naloxone in the period 14 November 2013 to 1 June 2015.
The expert states that the clinical record is inadequate in that there is no record to indicate why the patient had been receiving Primoteston previously. The initial consultation records "hypertension, high cholesterol and NIDDM", conditions that may be affected by testosterone therapy, but there is no recorded plan for surveillance of complications of testosterone therapy. The benzodiazepines were used mainly between 22 January 2015 and 14 April 2015. The first notation on 22 January 2015 records "has prn Karma for anxiety". There is no history as to why such treatment was required. The clinical record is significantly below the standard expected and the conduct invites strong criticism.
Further, there were no clinical notes available for either the patient's apparent hormonal problem or his anxiety, which is below the expected standard. There is no evidence in the notes of testosterone deficiency in the medical record and accordingly it is impossible to determine an appropriate therapeutic purpose for the prescription. The quantity of drugs prescribed, namely Primoteston and Sustanon, was excessive and as the instruction for benzodiazepines was "as required" it was not possible to know how much the doctor expected the patient to require each day. The seven scripts of 50 tablets (350 tablets in total) were prescribed in less than 90 days, suggesting four tablets a day, which is excessive. The conduct is below the expected standard and invites strong criticism.
The expert states that the respondent should have been aware of drug seeking behaviour in view of his frequent attendances and the need for large doses of benzodiazepines. The clinical record is inadequate and below the expected standard and invites strong criticism.
The prescribing of large quantities of benzodiazepines for three months, and then none at all would create concern about the patient's drug use. This is below the standard expected of an experienced general practitioner
Patient H
Between 26 April 2013 and 29 July 2015, the respondent prescribed benzodiazepines in excessive quantities. The patient was taken over from another doctor whose notes described possible addiction and a withdrawal programme. Within four days, the patient presented a second time for a new prescription of Xanax. The respondent wrote "loss [sic: lost] script". The patient appeared to have been using such drug for many years for "panic attacks". The clinical record does not record the nature of the attacks, symptoms or causes. The expert states that the notes are below the expected standard and invite strong criticism.
The expert notes that the clinical record refers, in July 2015, to a referral to a "psych": however there is no referral letter in the clinical record. An entry made on 22 April 2013, prior to Dr Rahman's care, records "suffers from panic disorder and anxiety". Whilst Xanax is useful for such a condition, the respondent did not explain in his notes why he changed the patient from Xanax to a different benzodiazepine. The quantities prescribed, issuing 50 or 100 tablets a time, was excessive and was significantly below the expected standard and the conduct invites strong criticism. Further, the frequent consultations requesting more medication at intervals shorter than expected, the "lost" scripts and the "going overseas" reasons for more medication suggest drug seeking behaviour. The respondent continued to supply the excessive amounts despite these warning signs: such conduct is significantly below the expected standard and invites strong criticism. The notes are significantly below the expected standard and also invite strong criticism.
Professional Member comment: extreme caution should be exercised in relation to prescribing Xanax without specialist review, in light of its high association with dependence. Alternate approaches to management of anxiety are considered more appropriate.
Patient I
Over the period from 9 February 2014 to 23 August 2015 the respondent prescribed pethidine hydrochloride (injection), morphine sulphate (injection), oxycodone hydrochloride and fentanyl. However it is not until late 2015 that the patient's clinical record records evidence of a complicated regime of medications for various conditions including diabetes and hypertension.
The prescription of pethidine injections, then morphine injections, without any adequate documentation of the need for or the use of injectables is significantly below the expected standard and invites strong criticism.
The expert states that the prescription of Schedule 8 drugs without an authority under section 28A of the PTG Act falls significantly below the standard expected.
The Tribunal notes that pethidine has not been covered by the Pharmaceutical Benefits Scheme since 2007,and has not been included in Prescriber Bag supplies since 2006. It is an entirely inappropriate therapeutic approach for management of recurrent pain.
Patient J
The respondent prescribed diazepam, oxycodone, alprazolam, clonazepam, flunitrazepam and morphine sulphate to the patient in the period 19 July 2011 to 20 August 2015.
The expert notes that the clinical records do not make note of any diagnosis or symptoms suggesting the need for benzodiazepines or opioids. The respondent had access to existing medical records which indicated the patient was on the Prescription Shopping Information Service and already had another regular medical practitioner. The respondent should have checked with the regular GP and the failure to do so is below the expected standard and invites strong criticism. The respondent did attempt to slowly reduce the dose of OxyContin but there is no actual diagnosis listed to know the drugs were supplied for an appropriate purpose. The conduct is below the expected standard and invites strong criticism. Further, the quantities were excessive. The respondent would have known that the patient was a "Doctor Shopper" and was possibly receiving opioids from other sources. The combination of the two drugs (benzodiazepines and opioids) can be dangerous, with a higher incidence of accidental overdose and increased dependency on both.
The Tribunal notes that such a combination can result in fatalities.
It was not appropriate for the respondent to prescribe Schedule 8 drugs without an authority under section 28A of the PTG Act: the conduct was below the expected standard and invites strong criticism.
The respondent should have responded in a way that avoids being caught up in the drug seeking behaviour of the patient. The notes are very brief and do not document how Dr Rahman planned to address this behaviour and are significantly below the expected standard.
Patient K
The patient was prescribed diazepam, oxycodone, Oxazepam, Paracetamol/Codeine, fentanyl and naloxone in the period 1 June 2014 to 30 August 2015.
The expert notes that Dr Rahman's first entry in the clinical record on 1 June 2014 was "50 Valium 5 mg". There is nothing else written on that date. In the last prior entry on 21 January 2014, another doctor declined to prescribe benzodiazepines. There is no history of the patient's current illnesses and nothing to indicate a diagnosis requiring Valium. There is a record that the patient had been on methadone. There is no mention of the respondent contacting any medical practitioner who may have been treating the patient previously, or concerning the current prescribed or illicit drugs. The conduct is below the expected standard and invites strong criticism.
On 2 December 2014 there is a record of a referral letter to Dr Saker, Psychiatrist. The referral letter mentions diagnoses but no allergies, no current medications, no past history, no smoking, no alcohol history, nothing about methadone and nothing about large doses of OxyContin or the current use of Valium. There is a reply from Dr Saker, who started the patient on an anti-depressant and referred him to a Drug and Alcohol Clinic, but there is no reference to this new medication in the clinical record.
There is no diagnosis to support the prescribing of benzodiazepines or opioids and it is not possible from the clinical notes to say whether the treatment was appropriate therapeutic practice.
The clinical record is inadequate: it is below the expected standard and invites strong criticism.
The respondent did not prescribe medications in appropriate quantities. The frequency of scripts is consistent with both benzodiazepines and opioids being consumed at a higher rate than prescribed: this conduct (frequency of scripts) is significantly below the expected standard and invites strong criticism.
The expert states that it was not appropriate for the respondent to have prescribed Schedule 8 drugs without an authority under section 28A of the PTG Act as the patient was or had been on an OTP and was known to be addicted to opioids. The frequent attendance at the clinic for medications and the fact that the patient was or had been on the OTP list are suggestive of drug seeking behaviour. The conduct of the respondent in providing drugs was inappropriate and invites strong criticism.
Patient L
The respondent prescribed testosterone Enanthate, testosterone undecanoate, somatropin, hCG and oxycodone hydrochloride between 19 March 2013 and 19 August 2015.
Dr Rahman recorded in the clinical notes "on testosterone for deficiency", "difficulty erection" and ordered blood tests (which showed normal testosterone and growth hormone levels). He did not mention any other symptoms related to possible testosterone deficiency, nor write to an Endocrinologist, Professor Terry Diamond, who had seen the patient previously, or any previous treating doctor, to obtain information to make an informed diagnosis. He commenced Sustanon and somatropin. It is normal and expected practice to obtain a comprehensive history and examination and refer to an Endocrinologist before prescribing hormones, such as growth hormone (somatropin). Such conduct is below the expected standard and invites strong criticism.
The expert does not consider that the prescribed drugs were appropriate. Dr Rahman did later refer the patient to Dr Aziz, an Endocrinologist, whose reports do not support the use of the prescribed drugs, particularly somatropin. No explanation is contained in the clinical notes for a change to different testosterone preparations. The prescribing of somatropin is mainly documented in a handwritten ledger rather than in the Medical Centre records. This ledger was not available to other practitioners at the medical centre, and so significantly impaired their capacity to provide appropriate shared care for this patient. This is below the expected standard and invites strong criticism. The short intervals between testosterone prescriptions suggest excessive doses, especially as there is no documented and accepted therapeutic reason. It constitutes conduct below the expected standard and invites strong criticism. The patient presented frequently for more scripts and there is no record that the respondent did anything to discourage this behaviour. The clinical notes are uniformly of poor quality with little information to assist in knowing the symptoms and whether any benefit was occurring. These matters are below the expected standard and invite strong criticism.
Patient M
Between 11 September 2013 and 27 August 2015, the respondent prescribed mesterolone and testosterone enanthate. At the first consultation on 11 September 2013 he prescribed Proviron (mesterolone). Such an androgenic hormone is used for the treatment of hypogonadism. A full assessment, investigations and diagnosis is required and the notes do not support a diagnosis of hypogonadism. This is below the expected standard and invites strong criticism.
The expert notes that there was no referral or evidence that Dr Rahman tried to get information about previous investigations. This is below the expected standard and invites strong criticism. There is no evidence that the drugs prescribed were for a therapeutic purpose and the quantities were excessive. Both matters show conduct below the expected standard and invite strong criticism. The respondent should have been aware that the conduct of the patient, namely seeking frequent appointments for medications in excess of therapeutic need, was drug seeking behaviour. The clinical records are below the expected standard and invite strong criticism.
Patient N
The patient was prescribed pethidine hydrochloride (injection), morphine sulphate (injection), diazepam, alprazolam, nitrazepam in the period 29 May 2013 to 25 August 2015. The patient had previously been treated with pethidine injections for headaches and abdominal or loin pain but several doctors, according to the medical record, had refused to give him pethidine in the past. Dr Rahman's claim that Dr Ghouganian, a Neurologist who saw the patient in 2007, had supported the use of pethidine for his headaches, is not supported by the available clinical records.
The respondent's clinical notes do not record questioning about the patient's "severe migraines", nor whether there was an authority in place for the use of pethidine injections. There was no follow-up with any specialist. The intermittent short acting opioids for treatment of migraines is inappropriate and it is below the expected standard and invites strong criticism. Further, the respondent did not have the authority to prescribe Schedule 8 drugs and doing so is below the expected standard and invites strong criticism. It was not appropriate to prescribe benzodiazepines as well as opioids as the combination can be dangerous with a higher incidence of accidental overdose and increased dependency on both and this is below the expected standard and invites strong criticism.
The clinical notes record that the patient frequently requested pethidine and gave multiple excuses as to why these medications were needed urgently: this should have caused the respondent to be cautious, especially when he notes "one off", or "last script". This is below the expected standard. The notes are of poor quality, are below the expected standard and invite strong criticism. The expert states that he would be concerned if a full dose of injections were given at the same time as taking benzodiazepines in combination with Schedule 8 drugs and considered this to be below the standard. The constant request for urgent pethidine relief and the continued writing of scripts is conduct significantly below the standard.
Patient O
The respondent prescribed morphine sulphate, oxycodone, diazepam, alprazolam and temazepam in the period 8 March 2011 to 31 August 2015.
The expert was unable to find any reference to facial pain when the respondent was first consulted by the patient on 26 November 2012. The patient had apparently received morphine injections and MS Contin in 2005 following an operation in 1996 and had been treated elsewhere from 2007 until late 2012. The notes record nothing about the cause of the pain or any complications from neurosurgery in 1996. There is nothing in the clinical notes to suggest contact with previous GPs or specialists. The clinical record is below the expected standard and invites strong criticism.
The notes record a referral by the respondent to a surgeon for symptomatic gallstones and an incomplete referral to a pain specialist. There is no reply on the record and the respondent should have recorded the result of the referrals. Such conduct is below the expected standard and invites strong criticism.
The expert was unable to determine whether the prescription of the above drugs was for an appropriate therapeutic purpose, but as the nature of the pain is unclear he could not answer such a question and considered the absence of records to be below the expected standard.
The practitioner did not have authority to prescribe morphine, contrary to section 28 of the PTG Act. Such conduct is below the expected standard and invites strong criticism.
The expert considered that the prescription of benzodiazepines in combination with opioids was inappropriate as the combination can be dangerous for reasons previously stated and this was below the expected standard. Further, the frequent attendance for Valium could be suggestive of drug seeking. The clinical record does not confirm Dr Rahman's statement that he counselled the patient and made appropriate referrals and in this respect his conduct was below the expected standard and invites strong criticism.
Patient P
The respondent prescribed oxycodone, diazepam, dexamphetamine sulphate, methadone, phentermine in the period 24 January 2012 to 22 July 2015. The respondent first saw the patient on 7 December 2012, noting "Mediterranean fever panic attacks" and "prn endone".
The notes of Dr Rahman do not record the symptoms or signs or if the patient actually had any pain. The patient had been receiving frequent prescriptions for Endone for the previous six months from another doctor for alleged knee pain and back pain. There is no comprehensive history of any illness by Dr Rahman from which the patient was suffering before continuing Endone.
Diazepam was first prescribed by Dr Rahman on 10 January 2013 but no explanation was given for the use of a benzodiazepine which is normally used for short-term treatment of anxiety. This conduct is below the expected standard and invites strong criticism.
The notes record that on 24 May 2014 the patient was having trouble concentrating and previously had ADHD: there are no other symptoms listed or an apparent attempt to obtain details of this diagnosis or its prior treatment and the prescription of dexamphetamine can only be provided by a psychiatrist or paediatrician or by a GP with a covering letter from either one of those. There is nothing to support such use. This conduct is below the expected standard and invites strong criticism. The same observation, that there is nothing to support its use, is made of the prescription for Duromine (phentermine) on 15 December 2015. This is below the expected standard and invites strong criticism.
The diagnosis of Mediterranean fever is uncommon in this country and a specialist opinion should have been sought: there is no evidence of a referral to a physiotherapist or specialist with respect to the patient's back pain. This omission constitutes conduct below the expected standard and invites strong criticism.
It is not possible to say that the drugs were prescribed appropriately or that the quantity was appropriate. Medications were prescribed without the appropriate authority. Benzodiazepines were prescribed in combination with opioids which can be dangerous. Generally the conduct falls below the expected standard and invites strong criticism. The respondent was aware that the patient was drug seeking and stated he tried to reduce or control the dosage: this is difficult to confirm. This conduct falls below the expected standard and invites strong criticism.
The notes rarely give any clinical details of symptoms or signs of the patient's apparent illness and do not provide any advice back from the specialists nor refer to plans for weaning the patient from medications. The conduct is below the expected standard and invites strong criticism
The Tribunal notes that Dr Rahman was not authorised to prescribe methadone, nor did he have any specific training in the use of this medication. His prescription of methadone invites strong criticism.
Patient Q
The patient was prescribed testosterone, testosterone enanthate, testosterone undecanoate (capsule), testosterone undecanoate (injection), zolpidem, temazepam, diazepam, fentanyl and oxycodone in the period 3 April 2011 to 30 August 2015.
The respondent's notes of the interview on 29 November 2012 records "previously on Sustanon". There are no other clinical notes, blood tests or letters of previous treating specialists, or evidence of any phone contact with previous doctors, to indicate why the patient was receiving medication. A preliminary examination would be appropriate. This failure is below the expected standard and invites strong criticism.
With respect to the other drugs, such as Stilnox, temazepam and diazepam, there are no clinical notes to indicate the need for such drugs. Oxycodone was prescribed on 13 November 2013 for migraines and back pain but there is no other history. This is significantly below the expected standard and invites strong criticism.
The drugs of recurring use, zolpidem and the testosterone products, were recurrently prescribed without any referrals to appropriate specialists and this constitutes conduct below the requisite standard and invites strong criticism. There is no appropriate therapeutic purpose for such drugs recorded in the clinical notes and if they were prescribed for accepted therapeutic reasons the prescribing was excessive. Both constitute conduct below the expected standard and invite strong criticism.
The use of benzodiazepines was intermittent and unlikely of clinical importance except that the patient would need to be counselled concerning side effects with other routine medications (Epilim, Avanza and thioridazine), such as increased sedation, and cautioned regarding driving but there is no written evidence to confirm that this was done.
The patient attended asking for scripts for Stilnox and for testosterone in amounts that were excessive given how long the quantity should have lasted for. There is no documented response to this behaviour and this conduct is below the expected standard. The medical records are inadequate and below the expected standard and the conduct invites strong criticism.
Patient R
The respondent prescribed hCG, testosterone enanthate and somatropin in the period 13 February 2013 to 25 March 2015.
There was no appropriate assessment made of the patient recorded in the clinical notes. Such is below the expected standard and invites strong criticism.
The respondent wrote referrals to fertility specialists in 2013. There is no record of any responses. Further, there was no record of any appropriate purpose for these drugs nor the quantity prescribed: these matters are below the standard expected and invite strong criticism.
Further, with respect to the medical records, the referral letters are very brief and give little information to the specialists; there is no indication of the patient's previous medical history, operations, medications, pathology tests and apparent obesity. The loose-leaf handwritten notes suggest that the respondent kept a second medical record for some patients. Such conduct is below the expected standard and invites strong criticism.
Patient S
The respondent prescribed oxycodone, hydromorphone, alprazolam, temazepam, diazepam, fentanyl, oxazepam and testosterone enanthate in the period 14 June 2011 to 30 August 2015.
The respondent recorded on 14 June 2011 that the patient "had a long history of back pain, previous back surgery, on Lyrica and Endone… Continue meds, will need to transfer his file".
Prior to prescribing Endone and Lyrica, no examination of the patient is recorded; no history of the nature of the cause of the pain; and no record of the daily quantities of each drug being used. Further, other drugs were prescribed, namely Jurnista, alprazolam and temazepam. In the clinical notes it appears that the prescription of temazepam was excessive. It was first prescribed in April 2012 but not recorded in the clinical notes and then prescribed in excess on three occasions in 2013. On 20 May 2013 Primoteston was prescribed, but again there are no notes to justify the use and excess quantities were prescribed. These matters of prescribing are below the expected standard and invite strong criticism.
There is no evidence that the respondent made appropriate referrals to experts apart from a pain specialist, Dr Lam, who indicated that he was going to cease Endone and use Physeptone on 6 February 2013. The absence of evidence of appropriate referral is significantly below the expected standard and invites strong criticism.
There is no justification in the clinical record to continue prescribing any of the benzodiazepines to the patient: this conduct is below the expected standard and invites strong criticism.
Further, the quantities of Endone appear excessive. By way of example, between January 2013 and October 2013 (304 days) the listed dose was twice daily and the patient received 20×50 tablets (2000 in total) which would be at least three times the prescribed dose. This conduct is significantly below the standard expected and invites strong criticism.
The combination of benzodiazepines and opioids is hazardous and is below the expected standard. The excessive amounts should have alerted the respondent to the fact that the patient was drug seeking. The clinical notes do not give a clear picture of what is being treated or why such medications were used and the referrals are very incomplete and would be of little assistance to any specialist seeing the patient. They are not adequate. Such conduct is significantly below the expected standard and the conduct invites strong criticism.
Patient T
The respondent prescribed pethidine (injection), morphine sulphate (injection and tablets), oxycodone, fentanyl, diazepam, temazepam and alprazolam in the period 17 July 2013 to 11 August 2015.
The notes record that the first consultation that the respondent had with the patient was on 17 July 2013, when a prescription for pethidine was given to the patient. In fact, the clinical records of the practice record that the patient had been given scripts for such drug as far back as 2006 and again in 2009 and the notes describe the patient as a "doctor shopper". Further, the notes record a call from the health department stating that the patient was a "Pethidine addict going to seven to eight different doctors".
Had the respondent read the previous clinical record and taken a history he should have been aware that he was prescribing to an addict and he should have checked to determine if he was the only person so prescribing. Such conduct is below the expected standard and invites strong criticism.
The respondent did refer the patient to various pain management specialists but there is little information with respect to ongoing management. However a report in the record from Dr Ditton, a pain specialist, does discourage the use of pethidine. It is possible that the drugs were not used for an appropriate therapeutic purpose, which is below the expected standard and the quantities suggest very frequent use.
It was not appropriate for the respondent to continue to prescribe injections for several years without an authority, especially in light of the history in the clinical record: such conduct is below the expected standard and invites strong criticism.
It is potentially hazardous to combine drugs and the frequent attendances are suggestive of drug seeking behaviour. These matters are below the standard of conduct required. The clinical records are inadequate and below the expect standard and invite strong criticism.
Patient U
The respondent prescribed alprazolam and diazepam in the period 20 February 2013 to 27 August 2015. The respondent was first consulted on 20 February 2013 and recorded a brief history. Dr Rahman should have been aware that the patient was dependent on alprazolam and had been for many years. In this context the Tribunal notes that where the respondent consulted with a patient he knew, or should reasonably have suspected, was drug dependent, he would require state authority to prescribe alprazolam. His failure to obtain such authority invites strong criticism. The patient stated that she was to see a psychiatrist in four weeks' time. The patient was not seen by the respondent again until March 2014. It appears that a psychiatrist, Dr Saker, had stated that the patient was taking Xanax 1mg (alprazolam) three times per day.
The respondent gave prescriptions which were excessive and such conduct was below the expected standard and invites strong criticism. Further, from early 2014 an authority under section 28A of the PTG Act was required to prescribe Schedule 8 drugs.
Patient V
The respondent prescribed oxazepam, alprazolam, diazepam, Paracetamol/Codeine and oxycodone between 31 January 2013 and 20 October 2015.
The respondent first saw the patient on 31 January 2013 and noted "lumbar disc prolapse and sciatica as per recent CT scan". The notes also state "takes PRN OxyContin lasts him 2-3months". There is no history recorded of the pain, the radiation to one or other leg, what may have caused the prolapsed disc or who first prescribed the OxyContin, or any examination findings.
The patient returned consecutively 17 days, 14 days and seven days later for 28 tablets each time. There is no record of how long the patient had been on the OxyContin or if he was or had been on an OTP.
Benzodiazepines were first prescribed on 2 October 2013, but there is no mention of any appropriate history or diagnosis: only that the patient was apparently "coming off OxyContin".
All of the above is significantly below the expected standard and the conduct invites strong criticism.
There are no referrals to psychologists or psychiatrists with respect to anxiety or depression despite the patient being on a constant dose of alprazolam for a long period. There is mention of waiting to be admitted to a drug and alcohol centre at Fairfield Hospital but there is nothing to indicate who referred the patient. The notes are significantly below the expected standard.
The expert considered that the use of opioids for chronic back pain may have been appropriate. The Tribunal is of the view that this use is no longer appropriate. The benzodiazepines were commenced for undisclosed reasons. The frequency of the prescriptions is below the expected standard. Further, the practitioner should have obtained authority for the prescription of the Schedule 8 drug in early 2014 and the failure to do so is below the expected standard and invites strong criticism.
The combination of drugs is potentially dangerous and the prescription shopping program letter in the records is strong evidence of drug seeking behaviour, yet the respondent, several times, refers to "last prescription" or similar in the patient records, when the patient was not weaned off the opioids until 25 May 2014.
The records do not give information as to the symptoms or signs of disease, nor any formulated plan of withdrawal, which is significantly below the expected standard.
Patient W
The respondent prescribed diazepam, alprazolam, temazepam, anastrozole and oxycodone to the patient between 22 September 2013 and 8 June 2015.
The respondent prescribed temazepam on 22 September 2013 for "has history of insomnia". There is no explanation for the possible cause, how much sleep the patient was having, or the nature of the sleep pattern, nor any other measures that might have been taken.
Diazepam was prescribed on 11 May 2014 along with anastrozole (a breast cancer drug). There is no explanation for the prescription of either medication and no mention of breast cancer.
Alprazolam and was first prescribed on 25 September 2014. The notes record "ongoing analgesia I am going overseas". No reason for the prescription is given.
Oxycodone was prescribed on 22 December 2013 for "ongoing chronic pain secondary to widespread OA and prn Endone". There are no clinical notes as to how such diagnosis was made, what choices were involved, the extent of the disability and other treatments and who first prescribed the Endone. There are no letters to previously prescribing doctors to find out the reason for the prescription of Endone.
In the circumstances the prescription of drugs was significantly below the standard reasonably expected and invites strong criticism.
There is a reference to a chiropractor on 26 October 2014. There is no referral to a psychologist concerning the patient's insomnia and no referrals for x-rays with respect to her "OA". Such conduct is below the expected standard. Since there are no records to substantiate the use of anastrozole, no record of back pain, and no record concerning anxiety and major depression, the prescription of drugs was not appropriate and is significantly below the expected standard and invites strong criticism.
The oxycodone was stopped after a relatively short period of regular use. Schedule 8 drugs require the prescriber to hold an authority. Such conduct in the prescribing of these drugs is significantly below the expected standard. The combination of drugs is below the expected standard. The medical records are inadequate and fall significantly below the expected standard and invite strong criticism.
Patient X
The patient was prescribed diazepam, alprazolam, clonazepam, oxycodone and hydromorphone in the period 25 January 2011 to 27 July 2015.
The respondent first records a consultation with the patient on 26 February 2013, in which the respondent recorded a request by the patient for a prescription for OxyContin: "for brain injury: "refused". There is no other entry with respect to brain injury. The prescribing table shows that Dr Rahman prescribed OxyContin on over forty occasions for the patient between 2011 and 2012, but a record of such prescriptions is not contained in the clinical notes.
On 6 March 2013, during another consultation, the respondent recorded: "requires PRN Xanax for insomnia", "one off given".
Alprazolam was prescribed until May 2014. On 26 May 2014 the patient was prescribed Rivotril (clonazepam). Such drug is normally used for epilepsy but there is no record of epilepsy. This is conduct below the expected standard and invites strong criticism.
Opioids were prescribed until September 2014, but again there is no assessment of the patient or diagnosis prior to its introduction on 10 June 2014. From September 2014, OxyContin is again introduced but there are no reasons advanced.
The lack of documentation is significantly below the standard expected and invites strong criticism. There is no referral letters to any pain specialists or a psychologist or psychiatrist. The conduct is below the standard expected and invites strong criticism.
It appears that some prescriptions were excessive in their quantities: Xanax - 350 tablets in 121 days; OxyContin - 252 tablets in 96 days. This is below the standard reasonably expected of a practitioner.
The prescription of Schedule 8 drugs required the proper authority under section 28A of the PTG Act and the failure to have that is below the expected standard and invites strong criticism.
The combination of opioids and benzodiazepines is to be avoided and not recommended for long term treatment of anxiety, depression and insomnia.
The letter from the prescription shopping program suggests that the patient was drug seeking: yet the respondent did not record any response to such behaviour. This conduct is below the expected standard and invites strong criticism. The clinical notes are deficient and also below the expected standard and invite strong criticism.
Patient Y
The patient was prescribed somatropin in the period from 14 January 2015 to 10 June 2015. This drug is a biosynthetic human growth hormone indicated in children over the age of three with growth hormone disturbance from a variety of causes. The Tribunal observes that it is approved as a prescription drug to treat children's growth disorders and adult growth hormone deficiency. The patient was a close relative of the respondent. There is no indication in the brief clinical notes of any reason for prescribing the drug. A loose-leaf sheet states the reason was "Bilateral menisci tear knees" and "R Shoulder Repair". Neither of these conditions are Monthly Index of Medical Specialities approved indications for prescribing the drug. Such conduct is below the expected standard and invites strong criticism.
The respondent should have referred the patient to an expert: his failure to do so is below the expected standard and invites strong criticism. The reasons advanced, namely that the respondent "discussed use of Somatropin re general wellbeing and (?) post op recovery" are not recognised therapeutic purposes. The prescription of these drugs is significantly below the expected standard and invites strong criticism.
The medical record does not detail any accepted diagnosis with respect to the possible use of this drug in an adult; nor is there any record of physical examination except for blood pressure. None of the reports in the various specialist letters mention a need for this drug; nor is the drug mentioned in the respondent's referrals to specialists in 2015. Such conduct is below the standard and invites strong criticism.
The Tribunal observes that the conduct is further compromised because the patient is a close relative. The respondent should not treat a family member. The on-selling of growth hormone purchased directly from a drug company or supplier is not the conduct expected of a GP and invites strong criticism.
Supplementary report
On 24 January 2019 the expert provided a supplementary report. Such report relates to the treatment provided by the respondent to two close relatives. The expert comments on whether the treatment accorded with the Medical Board of Australia's Good Medical Practice: A Code of Conduct for Doctors in Australia (Medical Board of Australia, July 2010) ("the Code").
The expert considers that the treatment provided to the two close relatives fell below the standard reasonably expected of a practitioner. Further, in relation to Patient Y, the prescription of drugs was inappropriate and below the requisite standard.
The expert provided a third report relating to certain particulars which were not admitted by the respondent. As a result, the respondent admitted all particulars.
Tribunal findings
The Tribunal agrees with the findings of the expert and the opinions expressed by them in relation to each of the Patients A to Y inclusive. The Tribunal makes the further observations hereunder concerning the respondent's practices.
Record keeping
With respect to each of the patients referred to by the expert, the clinical notes recorded by the respondent were found to be below the standard reasonably expected. The notes were universally of a clinically poor standard. Such notes failed to meet the criteria set out in the Health Practitioner Regulation (New South Wales) Regulation 2010 (NSW) (since repealed, now the Health Practitioner Regulation (New South Wales) Regulation 2016 (NSW)). Part 4 (now Part 3) requires a medical practitioner to, in accordance with the Part and Schedule 2, make and keep a record, or ensure a record is made and kept, for each patient of the medical practitioner: see clause 7 (now clause 6). Schedule 2 (now Schedule 4) sets out the information that must be kept by medical practitioners and medical corporations in relation to patients. It includes information that is relevant to the patient's diagnosis or treatment, such as the patient's medical history, the results of any physical examination of the patient and information concerning the patient's mental state; particulars of any clinical opinion reached by the medical practitioner; any plan of treatment for the patient; particulars of any medication prescribed for the patient; and the date of any medical treatment given or performed by the medical practitioner. The notes kept by the respondent did not satisfy the requirements of Schedule 2.
The notes were inadequate to enable another medical practitioner to continue the patient's medical care. The notes were further compromised by the use of a separate handwritten record for selected patients. Such notes were not accessible to other practitioners at the practice nor to specialists. This had the potential to significantly impair the provision of appropriate clinical care for patients.
The standard of referral letters was universally very poor. They failed to provide a specialist with an adequate clinical background for the patient. On many occasions the prescribing details were not maintained in the progress notes. There was a universal paucity of clinical notes referring to the general medical care of Patients A to X. The notes failed to show appropriate history taking, examination, clinical plans or appropriate investigations for the assessment of such patients, particularly prior to commencing medications for such patients.
Prescribing
The reviewed notes reveal extensive prescribing of benzodiazepines, narcotics, hCG, testosterone and other androgens and growth hormones. The clinical decision-making prior to the prescription of these medications was universally inadequate in respect of Patients A to X.
The medications were prescribed in quantities far in excess of appropriate clinical practice. The frequent combination of opioid medication and potent benzodiazepines, particularly alprazolam, poses a potentially significant risk of overdose to patients. The volume of prescriptions and their frequency raise serious concerns that these medications had the possibility of being diverted into the community. The respondent repeatedly denied this possibility. The prescription of testosterone, growth hormones and hCG was made without adequate clinical assessment, investigation, specialist review or informed consent from the patient. The Tribunal is concerned that such prolonged prescribing exposes the community to risks associated with aberrant prescribing. This aberrant prescribing persisted despite recurrent interventions by the Council, who provided repeated advice from 2008-2009 to the respondent regarding his inappropriate prescribing. The respondent also received prescribing advice from the PRU in 2013 concerning his aberrant prescribing.
Further, the Tribunal is highly critical of the respondent's continued prescribing of medications which require proper authority under the PTG Act. This included the prescribing of methadone and alprazolam and long-term prescriptions of injectable pethidine and morphine. This prescribing was to patients who the respondent knew, or should reasonably have suspected, were drug dependent. Further, the prescribing persisted even though the respondent admitted that he was aware that after 2014 he would need to obtain appropriate authority to prescribe such drugs
Self-prescribing and prescribing for family members
The respondent's prescribing for family members was entirely inappropriate. The respondent was in a position to easily refer family members to another practitioner. The respondent prescribed medications that were "off-label" to a close relative. As with all the prescribing of this medication, that prescribing was done without appropriate clinical assessment, specialist review or with the provision of appropriate informed consent. Prescribing for family members is specifically discouraged in the Code.
Gross overprescribing
Examples were provided to the Tribunal of prescribing in volumes which could have had no therapeutic reason. For example, between 2 June 2013 and 16 June 2013 four prescriptions for alprazolam were issued by the respondent to Patient E, for a total of 200 tablets. In respect of Patient F, between 15 January 2014 and 3 February 2014 three prescriptions were written for a total of 150 diazepam tablets. In respect of Patient C, between 26 June 2014 and 8 July 2014 five prescriptions were issued to the patient for a total of 250 tablets.
In other instances, the prescribing of drugs was carried out on a scale which the Tribunal finds was entirely inappropriate. For example, the respondent had written prescriptions for Patient S between the 16 February 2015 and 7 April 2015 for a total of 540 Endone tablets. In the period April 2012 to June 2015 the patient was prescribed more than 6,000 Endone tablets. There is no possible clinical or therapeutic reason for such an extraordinary quantity to be issued to the patient in the above period. The patient consulted the respondent on 16 occasions and, in addition to Endone, was issued prescriptions for Lyrica, Tramal, Primoteston, Nexium and Avanza. Overprescribing is also apparent in relation to other patients who have been referred to by the expert.
Unexplained excess drugs
During the course of the respondent's evidence, he stated that, when prescribing pethidine or morphine, he would issue a prescription to the patient who would have the prescription dispensed at a pharmacy. The patient would then return to the clinic to have the injection administered either by the respondent or by the practice nurse. The residual ampoules for either drug would be stored in a secure manner at the medical practice. However, on reviewing the schedule for Patient T, it is noted that prescriptions for both morphine ampoules (five) and pethidine ampoules (five) were issued in close proximity, often within three or four days of each other. This does not explain the narrative that the residual ampoules were retained at the medical practice. The Tribunal is concerned that the residual ampoules then became available for diversion.
Source of drug supply
The respondent stated that he purchased somatropin from a pharmaceutical supplier. The respondent stated he did so in order to provide the medication to his patients at a cheaper rate than if they had otherwise purchased the drugs from a pharmacy. The respondent sold the medication directly to the patient and stated that he made a small profit by doing so. The receipt book recording such sales has been destroyed by his accountant. One patient expended approximately $49,000 to purchase 32 vials of synthetic human growth hormone with the object of reducing his weight.
Particular 35
The respondent disputes one particular in Complaint One, namely Particular 35. The applicant claims that the respondent failed to immediately notify the Ministry of Health of the theft of vials of drugs from his motor vehicle on 21 October 2015. The respondent states that he notified his lawyer and the police on the same day as the theft but did not realise that he was required to notify the Ministry of Health forthwith. Notification was provided within four weeks of the loss.
Clause 67 of the Poisons and Therapeutic Goods Regulation 2008 (NSW) provides:
67 Loss or theft of prescribed restricted substances
(1) A person must immediately notify the Director-General if the person loses a prescribed restricted substance or if a prescribed restricted substance is stolen from the person.
(2) This clause does not apply to the loss of any substance by, or the theft of any substance from, a person who has been supplied with the substance by, or on the prescription of, an authorised medical practitioner.
Maximum penalty - 20 penalty units.
The Tribunal considers Particular 35 to have been established.
Complaint One
The Tribunal finds, with regard to each particular alleged in Complaint One, that the conduct referred to is established. The Tribunal finds that the conduct of the respondent, as particularised in Complaint One, together constitutes unsatisfactory professional conduct under section 139B(1)(a) and (l) of the National Law, as alleged in the Complaint.
Complaint Two
The Tribunal finds that the conduct of the respondent, as particularised in Complaint Two, together constitutes unsatisfactory professional conduct under section 139B(1)(b) of the National Law.
Complaint Three
The Tribunal finds that the conduct of the respondent, as particularised in Complaints One and Two, constitutes professional misconduct under section 139E of the National Law, as alleged in Complaint Three.
The Tribunal makes the following directions:
1. The proceedings be referred to the callover list for the allocation of dates for the continued hearing of these proceedings to determine any disciplinary sanctions arising from the above findings.
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: 11 March 2021
Parties
Applicant/Plaintiff:
Health Care Complaints Commission
Respondent/Defendant:
Rahman
Legislation Cited (5)
Health Practitioner Regulation (New South Wales) Regulation 2010(NSW)
Health Practitioner Regulation (New South Wales) Regulation 2016(NSW)