Health Care Complaints Commission v Sallam

Complaint No. 1

1. The first complaint alleges that the respondent is guilty of unsatisfactory professional conduct under s 139B (1) (a) and/or (l) of the National Law, in that the practitioner has engaged in conduct that demonstrates the knowledge, skill or 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 has engaged in improper or unethical conduct relating to the practice of medicine. The complaint alleges that each of the particulars relied upon justifies a finding of unsatisfactory professional conduct or in the alternative if taken together, constitute unsatisfactory professional conduct.
2. The particulars relied upon relate to 19 patients who are identified in the complaint. In respect of each patient, it is alleged that the practitioner, in separate periods has prescribed Schedule 8 drugs to the relevant provisions of the Poisons and Therapeutic Goods Regulation 2008 (the PTG Reg); and contrary to sections of the Poisons and Therapeutic Goods Act 1966 (NSW) (the PTG Act), in circumstances where the practitioner had formed or reasonably had formed the opinion that the relevant patient was a drug dependent person.
3. The particulars in respect of each complaint allege that the practitioner prescribed drugs to 19 patients in circumstances which did not accord with clause 37 of the PTG Regulation in that the practitioner held no authority to prescribe such drugs. It is further alleged with respect to some of the 19 patients that the practitioner prescribed drugs of addiction to a drug dependent person within the meaning of s 27 of the PTG Act.
4. The specific allegations against each patient are described in the Schedule attached to the end of this decision. Since there is some variation between the particulars alleged, it is necessary to repeat the particulars for each of the 19 patients concerned. However, subject to the allegations in respect of particular 7 (b) relating to Patient D (which was not resolved by the evidence) and particular 9 (b) to Patient F (which was not pressed), all other particulars in Complaint 1 are admitted.

Complaint No. 2

1. This complaint alleges that the practitioner is guilty of unsatisfactory professional conduct under s 139B (1) (b) of the National Law arising out of contraventions of the (extant) Health Practitioner Regulation (New South Wales) Regulation 2010 (repealed by the Health Practitioner Regulation (New South Wales) Regulation 2016). The practitioner admits the breaches alleged in the particulars below:

Particulars of Complaint Two

1. The practitioner failed to maintain adequate medical records in accordance with Schedule 2 to the Health Practitioner Regulation (NSW) Regulation 2010 for each of Patients A, B, C, D, E, F, G, I, J, L, O and S in that the practitioner failed to adequately record details including: 1. history; 2. examination findings; 3. opinions; 4. diagnoses; 5. management advice and decisions; 6. medication instructions; 7. treatment goals or plans; 8. drug combinations; 9. patient expectations; 10. sufficient information to allow another doctor to understand the decision making process.

Complaint No. 3

1. Complaint Three alleges that the practitioner is guilty of professional misconduct under s139E of the National Law in that he has engaged in unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of his licence or has engaged in one or more instance of unsatisfactory professional conduct such that when all instances are considered together they amount to sufficiently serious conduct to justify the suspension or cancellation of the practitioner's registration.
2. The particulars relied upon are those set out under the previous two complaints and are repeated and relied upon individually and cumulatively. The respondent admits Complaint Three.

Expert report

1. A report of Dr James Eldridge is relied upon by the HCCC. The report considers in detail the treatment provided to each of the 19 patients referred to in the Schedule. Such report is based upon the clinical notes made by the practitioner in respect of the 19 patients reviewed. The Tribunal has also been provided with such records. The findings conclude that, in almost every case, the practitioner deserves strong criticism of his treatment, his record keeping, and his provision of repeat medication without question. The report finds that the practitioner, in most facets of his practice, falls well below the standard of what would be expected of a medical practitioner.
2. Proceedings were taken against the practitioner under s 150 of the National Law. As a result, a determination was made on 30 June 2015, as a result of which conditions were imposed on the practitioner's prescribing rights.
3. Since the practitioner admits the conduct alleged, subject to the two particulars relating to the issue of whether an appropriate referral for special assistance was provided, it is appropriate that the Tribunal consider the reasons for the practitioner engaging in the conduct, as are set out in the practitioner's reply.

Practitioner's reply

1. The practitioner has provided a statement in which he describes his past history. The practitioner states that he graduated from Cairo University in 1985 with a Bachelor of Science, and in 1989 with a Bachelor of Medicine and Surgery. He was born on [date] 1961 and is now 56 years of age.
2. The practitioner worked as an intern in Cairo University Hospital in 1990 and 1991, and then in a private hospital between 1991 and 1994. Between 1995 and 2001 he worked in a rural area in Egypt as a general practitioner at a clinic for government employees. He migrated to Australia in 2001.
3. The practitioner states: In 2004 I passed the AMC examination and was registered as a medical practitioner in Australia. Between 2004 and April 2008 I worked in hospitals as follows as an intern; RMO and SRMO: a. Aug 2004 - Aug 2005 Prince of Wales Hospital and Lismore Base Hospital - I undertook the following terms: Aged care, Orthopaedics, General Medicine, Emergency; b. Sept 2005 - Aug 2006 Obstetrics & Gynaecology (for 5 months), Emergency, Aged care, Psychiatry, at Sutherland Hospital; c. Sept 2006 - Aug 2007 Paediatrics, Cardiology at St George Hospital; Palliative care at Calvary Hospice, Kogarah; Palliative care at Calvary Hospice, Kogarah; Emergency & Anaesthetics at Albury Hospital; d. Sept 2007 - April 2008 Emergency as SRMO locum mainly at Tamworth Hospital.
4. The practitioner was first registered on the 16 August 2004. Since 1 July 2010 he was registered, until the 13 August 2018, when he was suspended for reasons unknown to this tribunal. He worked in Taree in a practice known as Medisense Health Care from April 2008. He gained his Fellowship of the Royal Australian College of General Practitioners in 2013.
5. The practitioner states that he sees approximately four patients per hour in the bulk billing practice, ranging from the very young to the elderly. ­­­

Practitioner's explanation

1. The practitioner states that he takes full responsibility for his inappropriate prescribing, and offers the following explanation: "During the time I practised in Egypt in general practice I did not prescribe the drugs listed in Schedule 8 or Schedule 4. They were not prescribed in general practice in Egypt. Paracetamol; ibuprofen or aspirin can be obtained over the counter at pharmacies. A GP cannot prescribe any stronger analgesics as they are not available in Egypt. During the time I spent in the Australian hospital system - August 2004 to April 2008, I did not receive any training or education about the regulatory system concerning the prescribing of Schedule 8 drugs. Nor did I encounter the issue during my studies for College Fellowship. Consequently I had little experience or knowledge of Schedule 8 and Schedule 4 medications when I commenced practising in Taree. I have never really received any specific education in relation to schedule 8 medications. I only needed 1 year of supervised general practice experience in Australia to be eligible to sit the Fellowship exams. As an IMG, I was subject to the 10 year moratorium in respect of my provider number from Medicare which meant I needed to work in an area of need supervised position in a rural area. Dr Nguyen was my supervisor and mentor. He has been before a Tribunal for inappropriate prescribing of Schedule 8 medications and is subject to a decision dated 30 May 2018. Whilst this is not an excuse for my conduct, it is the context in which it occurred. I first became aware of the need to apply for authorities when I was interviewed in February 2015 by Mr Batty and Mr Smith from the Pharmaceutical Services Unit. I stopped prescribing Schedule 8 drugs on 10 April 2015. When I appeared before the s 150 delegates on 10 April 2015, I instructed my counsel to inform the delegates that I was willing to surrender my rights to do so. The delegates made an order in those terms and I surrendered my prescribing rights to the PSU later that day. My approach to Schedule 8 drugs was that if a patient was being prescribed drugs by another general practitioner or specialist I would continue to do so. I naïvely believed that the treating medical practitioners work together as a team and that I could rely on what previous treating practitioners had done."

Observations

1. Since the practitioner admits all of the relevant particulars alleged in the complaints, it is not necessary for the Tribunal to set them out in detail. Nevertheless, for completeness, the particulars relied upon by the applicant in respect of each patient are set out hereunder, followed by a summary of those findings of Dr Eldridge with which the Tribunal concurs.

PATIENT A 1. Between 7 October 2012 and 30 August 2013, the practitioner prescribed the schedule 8 drug Fentanyl to Patient A in the quantities set out in the schedule attached and marked A: (a) without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; (b) in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the Poisons and Therapeutic Goods Regulation 2008 (the PTG Reg); (c) without an authority to prescribe drugs of addiction to a drug dependant [sic] person (within the meaning of section 27 of the Poisons and Therapeutic Goods Act 1966 ("the PTG Act") from the NSW Ministry of Health, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient A was a drug dependant [sic] person; (d) without recognising and responding appropriately to Patient A's drug- seeking behaviour.

1. Patient A: Expert Opinion: inadequate notes; no mention of patient assessment; referral to surgeon is not explained; very limited patient history; no outline of any current or intended management plan; no referral to a drug and alcohol specialist although in the note to another doctor in the same practice there was a reference to such need; fentanyl prescribed for an excessive period, namely one year for chronic pain whereas four weeks of opiates can lead to development of tolerance; no suspicion of misuse of opiates being prescribed; quantity of fentanyl provided was inappropriate; patient exhibited drug seeking behaviours including lost scripts and frequent early presentations for more medication.

PATIENT B 2. Between 6 February 2014 and 16 October 2014, the practitioner prescribed the schedule 8 drug Alprazolam to Patient B in the quantities set out in the schedule attached and marked B: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. without appropriate referrals for specialist assistance in relation to Patient B's long-term benzodiazepine use; c. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in thecircumstances, contrary to clause 79 of the PTG Reg; d. without an authority to prescribe a type B drug of addiction incircumstances where the period of prescribing exceeded two months,contrary to section 28(2) of the PTG Act; e. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient B was a drug dependant [sic] person; and f. without recognising and responding appropriately to Patient B's drug- seeking behaviour. 3. Between 11 July 2012 and 16 October 2014, the practitioner prescribed the schedule 4D drugs Temazepam and Diazepam to Patient B in the quantities set out in the schedule attached and marked B: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. without appropriate referral for specialist assistance in relation to Patient B's long-term benzodiazepine use; c. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in thecircumstances, contrary to clause 34 of the PTG Reg; d. without recognising and responding appropriately to Patient B's drug-seeking behaviour; and e. in an inappropriate combination with Alprazolam, a schedule 8 drug of addiction, as set out in the schedule attached and marked B .

1. Patient B: Expert Opinion: no record of assessment; had a history of schizoaffective disorder but no letter of referral from practitioner to a psychiatrist requesting opinion about appropriate management; incorrect prescribing in respect of appropriate therapeutic purpose; large quantity of medication provided over a long period of time and potentially inconsistent medication which could result in increased sedation and overdose; failure to understand drug dependence including legal issues and convictions notes do not refer to any consideration of interaction between alprazolam and temazepam, nor between these benzodiazepines with other medications particularly method and that the patient was receiving through an opiates treatment program; no documentation of a satisfactory history or physical examination; referral to psychiatrist who found no psychiatric issues; temazepam and alprazolam were prescribed regularly in the period from 16 October 2012 to 16 October 2014 and diazepam intermittently;

PATIENT C 4. Between 14 August 2014 and 20 February 2015, the practitioner prescribed the schedule 8 drugs Buprenorphine, Fentanyl, to Patient C in the quantities set out in the schedule attached and marked C: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; g. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; b. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed theopinion that Patient C was a drug dependant [sic] person; and c. without recognising and responding appropriately to Patient C's drug-seeking behaviour. 5. Between 1 December 2014 and 20 February 2015, the practitioner prescribed the schedule 8 drugs Codeine Phosphate, Codeine Phosphate Linctus and Oxycodone to Patient C in the quantities set out in the schedule attached and marked C: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; c. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient C was a drug dependant [sic] person; and d. without recognising and responding appropriately to Patient C's drug- seeking behaviour. 6. Between 29 August 2014 and 11 February 2015, the practitioner prescribed the schedule 4D drugs Temazepam and Diazepam to Patient C in the quantities set out in the schedule attached and marked C: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. without appropriate follow up after specialist referral; c. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in thecircumstances, contrary to clause 34 of the PTG Reg; d. without recognising and responding appropriately to Patient C's drug-seeking behaviour; and e. in an inappropriate combination with schedule 8 drugs of addiction, as set out in the schedule attached and marked C.

1. Patient C: Expert Opinion: no documentation of assessment to justify continued medications; complex medical issues but little detail in notes concerning assessment of each drug prescribed and whether it met the therapeutic purpose; scripts provided too frequently and dosage was excessive.

PATIENT D 7. Between 2 January 2014 and 29 September 2014, the practitioner prescribed the schedule 8 drug Fentanyl to Patient D in the quantities set out in the schedule attached and marked D: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. without appropriate referrals for specialist assistance; c. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; d. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient D was a drug dependant [sic] person; and e. without recognising and responding appropriately to Patient D's drug- seeking behaviour.

1. Patient D: Expert Opinion: no record of appropriate assessment; inadequate assessment for prescribing of fentanyl; referral to pain specialist but no follow-up to determine whether patient attended; fentanyl prescribed without authority; no questioning of early replacement of scripts when requested following an alleged theft of prescription; medical records inadequate.

PATIENT E 8. Between 17 December 2013 and 31 January 2015, the practitioner prescribed the schedule 8 drugs Morphine Sulfate and Oxycodone to Patient E in the quantities set out in the schedule attached and marked E: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; and c. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient E was a drug dependant [sic] person.

1. Patient E: Expert Opinion: no detailed examination; no apparent determination of whether drugs being provided were for an appropriate therapeutic purpose; narcotics prescribed in excessive quantities and without authority; inadequate notes.

PATIENT F 9. Between 27 December 2009 and 20 February 2015, the practitioner prescribed the schedule 8 drugs Oxycodone, Fentanyl, Hydromorphone, Morphine Sulfate and Pethidine Hydrochloride to Patient F in the quantities set out in the schedule attached and marked F: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. without appropriate referrals for specialist assistance to determine appropriate prescribing; c. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; d. without an authority to prescribe a type B drug of addiction in circumstances where the period of prescribing exceeded two months contrary to section 28(2) of the PTG Act; e. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient F was a drug dependant [sic] person; and f. without recognising and responding appropriately to Patient F's drug-seeking behaviour.

1. Patient F: Expert Opinion: no record of assessment; repeat scripts provided for morphine; referral to a specialist did not question specifically what levels of prescribing were appropriate; prescriptions in excess quantities; failure to appreciate drug seeking habits.

PATIENT G 10. Between 3 September 2014 and 16 October 2014, the practitioner prescribed the schedule 8 drug Fentanyl to Patient G in the quantities set out in the schedule attached and marked G: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; c. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient G was a drug dependant [sic] person; and d. without recognising and responding appropriately to Patient G's drug-seeking behaviour.

1. Patient G: Expert Opinion: no proper records; prescription of excessive doses of fentanyl patches; no authority for such prescription.

PATIENT H 11. Between 21 June 2013 and 12 February 2015, the practitioner prescribed the schedule 8 drugs Buprenorphine, Fentanyl and Oxycodone to Patient H in the quantities set out in the schedule attached and marked H: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; c. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient H was a drug dependant [sic] person; and d. without recognising and responding appropriately to Patient H's drug-seeking behaviour.

1. Patient H: Expert Opinion: history of suicide; notes do not record appropriate assessment prior to prescribing buprenorphine, fentanyl and oxycodone; no record of monitoring; referral to psychiatrist who recommended strong analgesia; practitioner prescribing opiates from 21 June 2013 to February 2015; prescribed; no apparent reason why opiates were considered the appropriate treatment; no plan documented for lowering dosage; patient presented every 14 days for fentanyl on one occasion only five days after the previous prescription; no explanation recorded; no suspicion of abuse.

PATIENT I 12. Between 7 February 2012 and 3 February 2014, the practitioner prescribed the schedule 8 drugs Fentanyl, Morphine Sulfate and Oxycodone to Patient I in the quantities set out in the schedule attached and marked I: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; c. without an authority to prescribe a type B drug of addiction in circumstances where the period of prescribing exceeded two months, contrary to section 28(2) of the PTG Act; d. without an authority to prescribe drugs of addiction to a drug dependent person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient I was a drug dependent person; and e. without recognising and responding appropriately to Patient I's drug-seeking behaviour.

1. Patient I: Expert Opinion: no appropriate assessment before prescribing drugs which had already been prescribed by other doctors in the same medical practice; no assessment of risks and benefits for continuation of medication; referral to pain specialist but large quantities of opiates continued to be prescribed; therapeutic benefit not described in notes; prescriptions of quantities far in excess of what would be considered appropriate; no suspicion of drug seeking behaviour obviously displayed; failure to notice that another practitioner had applied for authority to prescribe opiates for this patient and that such application had been refused.

PATIENT J 13. Between 1 May 2013 and 6 August 2013, the practitioner prescribed the schedule 8 drug Fentanyl to Patient J in the quantities set out in the schedule attached and marked J: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; c. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient J was a drug dependant [sic] person.

1. Patient J: Expert Opinion: inadequate notes concerning assessment; fentanyl apparently prescribed for chronic pain; notes failing to record that fentanyl patches were required for management of chronic severe disabling pain; practitioner following earlier prescriptions by other practitioners; length of time that fentanyl prescribed appears excessive; prescription without authority.

PATIENT K 14. Between 2 July 2014 and 11 March 2015, the practitioner prescribed the schedule 8 drugs Buprenorphine, Codeine Phosphate Linctus, Fentanyl and Oxycodone to Patient K in the quantities set out in the schedule attached and marked K: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; c. without an authority to prescribe drugs of addiction to a drug depenant person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient K was a drug dependant [sic] person; and d. without recognising and responding appropriately to Patient K's drug- seeking behaviour. 15. Between 16 July 2014 and 10 June 2015, the practitioner prescribed the schedule 4D drug Diazepam to Patient K in the quantities set out in the schedule attached and marked K: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. in an inappropriate quantity and 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 Reg; c. without recognising and responding appropriately to Patient K's drug- seeking behaviour; and d. in an inappropriate combination with schedule 8 drugs of addiction as set out in the schedule attached and marked K.

1. Patient K: Expert Opinion: no evidence of proper assessment; referral to pain specialist; practitioner continued to prescribe high doses of fentanyl, diazepam and Panadeine Forte apparently regardless of any treatment by specialists; drugs prescribed in quantities far in excess of that considered appropriate for chronic pain; no authority to prescribe such drugs.

PATIENT L 16. Between 3 September 2011 and 11 January 2015, the practitioner prescribed the schedule 8 drug Buprenorphine to Patient L in the quantities set out in the schedule attached and marked L: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. without appropriate referrals to a pain management specialist and drug and alcohol services; c. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; d. without an authority to prescribe drugs of addiction to a drug depenant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient L was a drug dependant [sic] person; and e. without recognising and responding appropriately to Patient L's drug-seeking behaviour.

1. Patient L: Expert Opinion: patient's long history (in excess of two years) of opiate dependence and chronic pain; not referred to his pain specialist; buprenorphine prescribed frequently such that it would have little analgesia benefit after a few months' use; notes inadequate; no authority to prescribe.

PATIENT M 17. Between 10 September 2014 and 27 January 2015, the practitioner prescribed the schedule 8 drug Fentanyl to Patient M in the quantities set out in the schedule attached and marked M: a. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the [sic] practitioner had formed, or ought reasonably to have formed the opinion that Patient M was a drug dependant [sic] person.

1. Patient M: Expert Opinion: no detailed history and physical assessment to determine patient's level of function and abilities to daily conduct activities; fentanyl prescribed by previous medical practitioners and continued; attempt to reduce fentanyl dose; potential drug seeking habit was not recognised by practitioner.

PATIENT N 18. Between 16 October 2014 and 5 December 2014, the practitioner prescribed the schedule 8 drugs Fentanyl and Oxycodone to Patient N in the quantities set out in the schedule attached and marked N: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; c. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient N was a drug dependant [sic] person; and d. without recognising and responding appropriately to Patient N's drug-seeking behaviour.

1. Patient N: Expert Opinion: limited notes about patient's history: fentanyl and oxycodone prescribed following diagnosis of fracture of the greater tuberosity; alternatives to strong opiates should have been considered; initiation of fentanyl slow-release patch should only have occurred after detailed consideration; no explanation for such high doses of fentanyl prescribed without adequate documented assessment; fentanyl slow-release patch not a suitable medication for acute pain.

PATIENT O 19. Between 23 December 2013 and 27 February 2014, the practitioner prescribed the schedule 8 drug Fentanyl to Patient O in the quantities set out in the schedule attached and marked O: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; c. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient O was a drug dependant [sic] person; and d. without recognising and responding appropriately to Patient O's drug-seeking behaviour.

1. Patient O: Expert Opinion: record that the patient was visiting from Victoria with history of back pain; high dose of fentanyl prescribed; inadequate check; patient recorded on the "Dr shopper" list of Medicare; medication was only appropriate following sufficient assessment; no proper assessment; patch strength of 75 mcg was excessive; no authority to prescribe.

PATIENT P 20. Between 12 July 2013 and 31 July 2013, the practitioner prescribed the schedule 8 drug Fentanyl to Patient P in the quantities set out in the schedule attached and marked P: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. without appropriate and timely referral to drug and alcohol services; c. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; d. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient P was a drug dependant [sic] person; and e. without recognising and responding appropriately to Patient P's drug-seeking behaviour.

1. Patient P: Expert Opinion: little detail in notes concerning assessment before prescription of fentanyl; high dosage prescribed; dosage renewed after new scripts every few days; necessity to refer such patient to drug and alcohol services; no details of alleged surgery nor mention when such surgery occurred or how long patient had been treated; failure of practitioner to appreciate effects of long-term prescription of such drug in such dosage; failure to recognise drug seeking behaviour.

PATIENT Q 21. On 3 November 2014 the practitioner prescribed the schedule 8 drug Alprazolam to Patient Q in the quantities set out in the schedule attached and marked Q: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; c. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient Q was a drug dependant [sic] person; and d. without recognising and responding appropriately to Patient Q's drug- seeking behaviour.

1. Patient Q: Expert Opinion: patient visiting practice on two occasions, the latter with the practitioner; patient seeking alprazolam alleging that prescriptions had been stolen; one prescription issued without question; inadequate history: patient also on methadone: practitioner should have enquired; quantity of 50 tablets of appraisal was excessive; no authority to prescribe.

PATIENT R 22. Between 26 May 2010 and 23 February 2015, the practitioner prescribed the schedule 8 drug Pethidine Hydrochloride to Patient R in the quantities set out in the schedule attached and marked R: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. without appropriate referrals to a neurologist drug and alcohol services; c. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; d. without an authority to prescribe a type B drug of addiction in circumstances where the period of prescribing exceeded two months, contrary to section 28(2) of the PTG Act; e. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient R was a drug dependant [sic] person; and f. without recognising and responding appropriately to Patient R's drug-seeking behaviour. 23. Between 26 May 2010 and 23 April 2014, the practitioner prescribed the schedule 4D drug Diazepam to Patient R in the quantities set out in the schedule attached and marked R: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. without appropriate referrals for specialist assistance; c. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; d. without recognising and responding appropriately to Patient R's drug- seeking behaviour; and e. in an inappropriate combination with schedule 8 drugs of addiction, set out in the schedule attached and marked R .

1. Patient R: Expert Opinion: practitioner prescribing Pethidine Hydrochloride and diazepam from May 2010 to February 2015; record of long history of migraines only responsive to Pethidine and Valium IM; no detail of any assessment in subsequent notes but rather regularly recorded "repeat scripts filled"; no apparent consideration to the fact that the patient was already on opiates and benzodiazepines; referral to neurophysiologist to assess management of migraines but nothing directly addresses the prescribing of pethidine or diazepam; dosage excessive; no authority for S8 medication prescriptions; notes inadequate containing few details of history, examination findings, opinions, diagnoses, management advice, medication instructions, treatment goals or plans.

PATIENT S 24. Between 4 November 2012 and 25 March 2014, the practitioner prescribed the schedule 8 drugs Fentanyl and Oxycodone to Patient S in the quantities set out in the schedule attached and marked S: a. in an inappropriate quantity that did not accord with the recognized therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; b. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient S was a drug dependant [sic] person; and c. without recognising and responding appropriately to Patient S's drug- seeking behaviour. 25. Between 21 January 2013 and 31 October 2014, the practitioner prescribed the schedule 4B and 4D drugs Testosterone and Mesterolone and the schedule 4 drugs Tamoxifen and Human Chorionic Gonadotrophin to Patient S in the quantities set out in the schedule attached and marked S: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; and c. without recognising and responding appropriately to Patient S's drug-seeking behaviour.

1. Patient S: Expert Opinion: from January 2013 to 31 October 2014 the practitioner prescribed anabolic steroids and restricted substance to patient on 38 occasions; history of patient taking anabolic steroids for bodybuilding purposes; following motor vehicle accident on 30 July 2013, practitioner commenced to regularly prescribe oxycodone and on one occasion, fentanyl; length of time for such prescriptions fell below appropriate standards; dosage of oxycodone was high and continued longer than recommended; no authority; notes brief containing few details of history, examination findings, opinions, diagnoses, management advice, medication instructions, treatment goals or plans especially relating to the monitoring of the effects of anabolic steroids. The practitioner ceased the oxycodone medication in March 2014 but continued to prescribe steroids until October 2014.
2. The practitioner was subjected to extensive cross examination over two days. As a result of that cross examination, and of the material provided to the Tribunal, the Tribunal concurs with the opinion of Dr Eldridge that in virtually every instance, the conduct of the practitioner fell significantly below the standards of acceptable practice for a medical practitioner.

FINDINGS

1. The practitioner failed to demonstrate and apply appropriate clinical acumen in respect of the patients who are the subject of this enquiry. This is evident, for example, from the fact that the practitioner took guidance from a patient, who was relaying advice from the patient's personal trainer. The practitioner accepted the direction of the patient and on this basis, the practitioner provided prescriptions for anabolic steroids, hormonal and other treatments for non-therapeutic purposes. On some occasions, such drugs were administered to the patient. On other occasions, the practitioner permitted the patient to administer the substances themselves.
2. On many occasions, the practitioner was prepared to prescribe medication solely on the basis that a previous practitioner had provided such treatment. The practitioner did not appear to bring any independent decision-making as to the appropriateness of the treatment.
3. The practitioner demonstrated that he frequently accepted, without question, complaints of pain or discomfort from patients and was willing to prescribe painkilling medication, oftentimes in high doses and quantities.
4. The records maintained by the practitioner do not disclose that he carried out comprehensive and appropriate clinical assessments of his patients.
5. The practitioner's naïveté in the role of prescription medication in substance use disorders was evident in the majority of the patients who were the subject of these proceedings and were under his care. The practitioner was unable to discern drug seeking behaviour in circumstances which should have triggered a high degree of suspicion. The practitioner was unaware that the drugs he prescribed could have been diverted into the illicit drug market. The practitioner displayed a poor knowledge of the opiate treatment program, believing it to be a self-referral system only, and that the program did not apply to prescription medication abuse.
6. Whilst the practitioner appears to now have an improved knowledge of opiate pharmacology, it remains imperfect. For example, he displayed an inadequate understanding of opiate cross-tolerance. Further, the practitioner prescribed pethidine when such medication was already considered an inappropriate practice. Several patients were also permitted to take away from the practice large quantities of opiates for injection by themselves or by their partner.
7. The practitioner displayed an ignorance in the prescription of more common medications, in their indication, dosage and monitoring. For example he prescribed Lasix for side effects related to the administration of anabolic steroids, without consideration of that drug's potential for adverse effects, and at a dosage higher than would have been appropriate.
8. The practitioner's medical records of his patients were inadequate, in that they failed to provide a comprehensive history of the patient and of the patient's medical condition, and did not disclose any management plan. Often the patient records provided no indication that the practitioner had provided an appropriate physical examination.
9. The practitioner failed, when referring patients to a specialist, to provide the necessary detail in the referral sufficient to describe the patient's background, condition and especially medication history. Failure to provide a comprehensive background potentially exposed other medical practitioners to the risk of harm. For example, the failure to disclose that a patient had a history of drug abuse and was therefore at risk of hepatitis C and HIV might have exposed health workers to risk.
10. Whilst demonstrating a capacity to recognise suicide risk, in some cases, the practitioner displayed an unsound and potentially dangerous prescribing habit; specifically in patient H, who had a number of risk factors for completed suicide. The practitioner provided a prescription of a potentially lethal quantity of oxycodone (OxyContin).
11. The practitioner demonstrated that he possessed a wholly inadequate knowledge of the regulatory requirements for the prescription of Schedule 8 drugs and of Schedule 4 medications.
12. In relation to the practitioner's clinical notes pertaining to Patient B, there was discussion regarding the practitioner's prescription of alprazolam for panic. The practitioner indicated that pharmacotherapy was the mainstay of his treatment for panic which the Tribunal considered inadequate and failed to meet appropriate standards.

MITIGATING FACTORS

1. The Tribunal was mindful of certain factors which have contributed to the practitioner falling below the acceptable standards. In particular, the Tribunal considers that the practitioner was placed at a distinct disadvantage from his entry into private practice in Australia because of sub-optimal practices demonstrated by his colleagues in general practice as well as some of the specialist practitioners from whom he sought guidance.
2. Some of those practitioners have come to notice and have already been dealt with by the Tribunal. For the first year of his practice in Taree, it was a requirement that the practitioner be supervised. The evidence before the Tribunal suggests that the supervision was poor. The evidence also suggests that ongoing education and mentorship was not an integral element of the practice.
3. The practitioner stated that in his training in Egypt, there was no education in respect of prescription of opiates and no restriction upon prescribing such drugs.

CONSIDERATION

1. The jurisdiction exercised by the Tribunal is protective. Section 3A of the National Law requires that the "protection of the health and safety of the public must be the paramount consideration" when considering an application to practise medicine. Inherent in such a requirement is that the applicant must be considered to be a "fit and proper person" to practise. In Australian Broadcasting Tribunal v Bond (1990) 94 ALR 11 at [56] (Toohey and Gaudron JJ), when speaking of the risk of a possible recurrence of a failure to observe the standards, said: "The question may be whether it can be assumed that it will not occur, or whether the general community will have confidence that it will not occur. The decision stated that there may be sufficient ground to make a finding that a person 'is not fit and proper to undertake the activities in question'."
2. For other examples, confirming the protective nature of the jurisdiction, see for example Health Care Complaints Commission v Do [2014] NSWCA 307 at [35] where Meagher JA said: "The objective of protecting the health and safety of the public is not confined to protecting the patients or potential patients of a particular practitioner from the continuing risk of his or her malpractice or incompetence. It includes protecting the public from the similar misconduct or incompetence of other practitioners and upholding public confidence in the standards of the profession. That objective is achieved by setting and maintaining those standards and, where appropriate, by cancelling the registration of practitioners who are not competent or otherwise not fit to practise, including those who have been guilty of serious misconduct. Denouncing such misconduct operates both as a deterrent to the individual concerned, as well as to the general body of practitioners. It also maintains public confidence by signalling that those whose conduct does not meet the required standards will not be permitted to practise."
3. The Tribunal considers that in this instance the repeated prescription of drugs of addiction, especially without authority, is serious, constituting not only unsatisfactory professional conduct but also professional misconduct. The observations of the Tribunal in Health Care Complaints Commission v Chen [2016] NSWCATOD 144, at [137], are pertinent, when the Tribunal said (inter alia): "Medical practitioners are in a unique position in enabling members of the public to have access to drugs of addiction and the community is entitled to rely on the integrity and professional expertise of medical practitioners to avoid creating drug addicts and to avoid feeding the habits of drug addicts. This is not necessarily an easy task, but there are well-recognised protocols for the administration of drugs of addiction and well-recognised resources to assist medical practitioners in treating their patients. The respondent clearly failed in all of these areas and did not display any initiative or insight in meeting the challenge which she says she perceived she had when dealing with this cohort of patients. This is a most serious matter and calls into question the ability of the respondent generally to practice [sic] medicine safely."
4. Unsatisfactory professional conduct of a practitioner can extend to professional misconduct, as such term was considered by the NSW Court of Appeal in Chen v Health Care Complaints Commission [2017] NSWCA 186, especially at [19]-[20], [23], and [75]. See also Health Care Complaints Commission v Karalasingham [2007] NSWCA 267; Sabag v Health Care Complaints Commission [2001] NSWCA 411 at [42].
5. For other instances of conditions concerning the need to protect the public: see Health Care Complaints Commission v Litchfield (1997) 41 NSWLR-630 and for the maintenance of standards: see Gayed v Walton [1997] NSWSC 297; Prakash v Health Care Complaints Commission [2006] NSWCA 153 at [91]; Health Care Complaints Commission v Howe [2010] NSWMT 12 at [113]; Health Care Complaints Commission v Iskander [2015] NSWCATOD 30.
6. In instances of improper prescription of drugs, the following discussion in Spicer v NSW Medical Council (unreported, NSWCA, 19 February 1981) is relevant: "In my opinion, it is clear beyond argument that the proper handling and prescribing of drugs by medical practitioners are of the greatest importance to the community. If a medical practitioner handles or carries out that very great responsibility in a way that is reckless and which shows a disregard for the law, it cannot be said that he is fitted at such a time to be a medical practitioner. In my opinion, the view expressed by the Tribunal has implicit in it that not merely was he presently unfitted to treat those addicted or habituated to drugs but that unfitness in itself demonstrated his present unfitness to be a medical practitioner."
7. Taking these considerations into account, the Tribunal must determine what measures must be taken to protect potential patients should it determine that, contrary to the submissions made by the applicant; the practitioner is permitted to practise under conditions.
8. The practitioner has urged the Tribunal to reinstate his right to practise subject to conditions similar to those imposed by the Medical Council, which effectively restricted his prescribing of opiates.
9. The practitioner states that whilst he was in the Australian hospital system from August 2004 to April 2006 he received no training or education concerning the prescribing of Schedule 8 drugs and that he had little experience or knowledge of Schedule 8 and of Schedule 4 medications when he commenced practising in Taree. The practitioner obtained his Fellowship through the Practice Pathway program and did not have the benefit of the training provided through the GP registrar training program. His statement continues: "I have never really received any specific education in relation to schedule 8 medications. I only needed 1 year of supervised general practice experience in Australia to be eligible to sit the Fellowship exams. As an IMG, I was subject to the 10 year moratorium in respect of my provider number from Medicare which meant I needed to work in an area of need supervised position in a rural area. Dr Nguyen was my supervisor and mentor. He has been before a Tribunal for inappropriate prescribing of schedule 8 medications and is subject to a decision dated 30 May 2018. Whilst this is not an excuse for my conduct, it is the context in which it occurred. I first became aware of the need to apply for authorities when I was interviewed in February 2015 by Mr Batty [sic] Battye and Mr Smith from the Pharmaceutical Services Unit. I stopped prescribing Schedule 8 drugs on 10 April 2015. When I appeared before the s150 delegates on 10 April 2015, I instructed my counsel to inform the delegates that I was willing to surrender my rights to do so. The delegates made an order in those terms and I surrendered my prescribing rights to the PSU later that day."

CONCLUSION

1. The Tribunal is satisfied that the conduct of the practitioner, referred to in Complaint One and Complaint Two constitutes professional misconduct as alleged in Complaint Three. The Tribunal finds the explanation of the practitioner that he was unaware of the need to have authorisation to prescribe Schedule 8 drugs to be credible, despite his considerable experience in Australia. Irrespective of such finding the circumstances demonstrate a gross failure on the part of the practitioner to inform himself of the requirements for prescribing Schedule 8 drugs and Schedule 4 medications.
2. As a consequence, there has been a flagrant breach of the National Law. The Tribunal acknowledges that such conduct was not performed with illegal intent: the practitioner was simply oblivious to the statutory requirements. But the practitioner should have known them, and the ignorance of the practitioner reflects very adversely upon his competence to practise medicine.
3. Further, the Tribunal is satisfied that the practitioner's approach to his patients was deficient, in that no comprehensive clinical assessments appear to have been made prior to prescribing medication and repeats the findings already made concerning the inadequacy of his approach to treatment of patients, especially those with drug seeking habits. These matters in themselves constitute unsatisfactory professional conduct.
4. In Pillai v Messiter (No.2) (1989) 16 NSWLR 197, Kirby P at 200 said: "Departures from elementary and generally accepted standards, of which a medical practitioner could scarcely be heard to say that he or she was ignorant could amount to such professional misconduct. But the statutory test is not met by mere professional incompetence or by deficiencies in the practice of the profession. Something more is required. It includes a deliberate departure from accepted standards or such serious negligence as, although not deliberate, to portray indifference and an abuse of privileges which accompany registration as a medical practitioner."
5. At 201 Kirby P said: "The public needs to be protected from delinquents and wrong-doers within professions. It also needs to be protected from seriously incompetent professional people were ignorant of basic rules or indifferent as to rudimentary professional requirements. Such people should be removed from the register or from the relevant roller practitioners, at least until they can demonstrate that their disqualifying imperfections have been removed."
6. The Tribunal considers that the observations of Kirby P are entirely appropriate and applicable in the complaints now before it.

DISCIPLINARY SANCTIONS

1. The Tribunal has received the practitioner's evidence concerning attempts that he has made to inform himself, and repeats the relevant portion of the practitioner's statement to the Tribunal as follows: In June 2017 my legal representatives forwarded my S40 response to the HCCC. On page 2 of that letter they listed a number of courses I had completed which had been offered by my insurer. They also listed some publications I had read which I found particularly helpful. As noted, I have completed: a) Avant's risk IQ course 'Doctor Shoppers, the law and addiction; prescribing drugs of dependence'; b) Avant's risk IQ course 'Gathering Diagnostic Information'; c) Avant's risk IQ course 'Prescribing perils: opioids, polypharmacy and medication errors'; d) Avant's risk IQ course 'Prescribing: principles and practices'; e) Avant's risk IQ course 'Consent: the key issues'; f) Avant's risk IQ course 'Common Medico-Legal Issues for General Practitioners'; g) Avant's risk IQ course 'On the record: medical records and documentation'; and h) Avant's risk IQ course 'Chaperones: intimate examinations and cultural sensitivities' and read: i) Prescribing Drugs of Dependence in General Practice, Part A and Part B, published by RACGP, Melbourne and edited by Dr Evan Ackermann (Chair, RACGP National Standing Committee for Quality Care; University Medical Centre, Southern Cross University, Queensland) published on the Royal Australian College of General Practitioners' website; and j) Opioid use in chronic non-cancer pain written by Dr Simon Holliday (GP in Taree and staff specialist Drug and Alcohol Clinical Services), Dr Chris Hayes (Director of Hunter Integrated Pain Service) and Dr Adrian Dunlop (Area Director and staff specialist Drug and Alcohol Clinical Services) Since that time I have undertaken the following educational activities: k) 'Over-The-Counter Codeine Use' through the Australian Doctor Education on 10 April 2018; l) 'Managing Knee Osteoarthritis - A Review Of Non-Surgical Options', mdBriefcase on 2 April 2018; m) 'The GP's Role In Maximising Quality Of Life For Patients With Chronic Non-Cancer Pain', mdBriefcase dated 2 April 2018; n) 'Optimising The Function Of Older Patients With Chronic Non-Cancer Pain: The Importance Of A Tailored Approach To Assessment And Treatment', mdBriefcase on 2 April 2018; o) 'Effective Management Of Low Back Pain With A Neuropathic Component', mdBriefcase on 31 March 2018; p) 'Codeine Rescheduling And Chronic Pain Management' by ThinkGP on 2 April 2018; q) 'Management Of Chronic Non-Cancer Pain In Older Patients' by ThinkGP on 31 March 2018; r) 'SPOT Clinical Audit: Safety Prescribing Opioid Treatment' by ThinkGP on 2 April 2018; and s) 'Wholistic Management of Chronic Non-Cancer Pain', General Practice Conference by GPCA on 19 and 20 May 2018."
2. The practitioner also states that he has undertaken online courses through Avant's Risk Advisory Service, namely: 'Doctor shoppers'; The Law and Addiction; Prescribing Drugs of Dependence; Prescribing Perils: Opioids, Polypharmacy and Medication Errors; Prescribing Perils Part 2: Drugs of Dependence; Prescribing: Principles and Practices. He has also completed the course entitled Gathering Diagnostic Information. All these courses were undertaken in October 2015.
3. Despite the courses undertaken, the Tribunal does not consider that they will provide the necessary educational standard required for the practitioner. The Tribunal notes that most of the courses recently undertaken by the practitioner were completed online. Whilst the practitioner professed to have an improved knowledge from the courses he has undertaken, the Tribunal was concerned that adequate learning was not reflected in his responses.. Rote learning and formulaic reponses which were displayed by the practitioner but there was no evidence to show that the practitioner was able to use the theoretical knowledge in his clinical practice.
4. A course which should be undertaken by the practitioner is the Vocational Training Program conducted by the Royal Australian College of General Practitioners or a similar course.
5. Furthermore the practitioner is in need of an experienced mentor to monitor and assist the practitioner in his daily practice. Such mentor should not be involved in the Medisense practice.
6. The practitioner should undertake intensive courses directed to mental health, addiction medicine, and pain management to improve his knowledge and practical skills at a higher level, and preferably where lectures and presentations are provided, and learning formally assessed. He may also benefit from the involvement of a psychologist (or other like professional) with the aim of improving his capacity to resist patients' inappropriate demands whilst maintaining an emphatic balance of clinically indicated assistance.
7. The issues raised in the above three paragraphs will be of critical importance in any future application by the practitioner for re-registration. He will need to be able to demonstrate that he has taken effective measures to overcome the deficiencies referred to in this decision. The proposals suggested by the Tribunal in the paragraphs above will be relevant to any future application.
8. The Tribunal considers that, whilst the practitioner sought a reprimand and that conditions be imposed on his right to practise, such sanctions would be inadequate for the protection of the public. The Tribunal is satisfied that nothing short of cancellation of the practitioner's registration is required.
9. These proceedings were clearly necessary, as is admitted by the practitioner. In these circumstances, the practitioner should be ordered to pay the applicant's costs of the proceedings: see Health Care Complaints Commission v Philipiah [2013] NSWCA 342 at [42].

ORDERS

1. The Tribunal orders: 1. That the registration of Dr Atef El-Sayed Mahmoud Sallam as a medical practitioner (Registration Number MED0001195401) be cancelled pursuant to s 149C(1)(b) of the National Law. 2. The respondent may not apply for a review of the cancellation order for a period of 12 months from the date of these orders pursuant to s149C(7). 3. The respondent is to pay the costs of the applicant.

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: 26 September 2018