Health Care Complaints Commission v Sharier [2025] NSWCATOD 124;

1. The protection of public safety and health is paramount: s 3A (1) of the National Law.
2. The Commission bears the burden of proof: Lindsay v Health Care Complaints Commission [2005] NSWCA 356.
3. To make any finding we must be "comfortably satisfied" that the matter has been established on the balance of probabilities_: Briginshaw v Briginshaw_ [1938] HCA 34; (1938) 60 CLR 336.
4. The Tribunal is not bound by the rules of evidence: s 38(2) of the Civil and Administrative Tribunal Act 2013 (the "NCAT Act"); cl 2 of Sch 5D of the National Law.
5. The HCCC asserts in its Application that the conduct described in Complaints Two, Three, Four and Five are unsatisfactory professional conduct as defined in s 139B(1) of the National Law. The relevant subsections are the following:

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

(b) A contravention by the practitioner (whether by act or omission) of a provision of this Law, or the regulations under this Law or under the NSW regulations, whether or not the practitioner has been prosecuted for or convicted of an offence in respect of the contravention (Complaints Two and Five).

1. In relation to s 139B(1)(a), determining whether conduct is significantly below a reasonable standard requires the Tribunal to make an objective assessment with reference to the standards of the profession generally: Lucire v Health Care Complaints Commission [2011] NSWCA 99 at [82] per Basten J. Guidance on whether a departure from that standard is significant can be taken from the established principle that the term "may in law be taken to mean not trivial, of importance or substantial": Re A Medical Practitioner and the Medical Practice Act, (NSWMT, 3 September 2007, unrep) at [12]. The Tribunal may apply the specialist expertise of the Panel in making this determination: Health Care Complaints Commission v Bainbridge [2018] NSWCATOD 169 at [16].

1. The father, Ms Shrestha, who is a registered nurse and works at the Revesby Clinic, and Dr Sharier gave evidence and were cross examined.
2. Both the HCCC and Dr Sharier also relied on documentary evidence, including statements from other witnesses who had not been required to attend for cross examination.
3. Section 34A of the Health Care Complaints Act 1993 (NSW) provides that, if the HCCC is investigating a complaint, it can require a person to give evidence. Pursuant to that section, Dr Sharier and Ms Shrestha were interviewed and the transcripts of those interviews are in evidence before us.
4. Dr Young, a general practitioner, was retained by the HCCC and provided an expert report in relation to the conduct of Dr Sharier.
5. Scheduling of medication is a national classification designed to control how medication is made available to the public. Schedule 8 is a list of addictive substances. Oxycodone, an opioid, is in that schedule and OxyNorm is one of the brand names for oxycodone.
6. It is common ground that a potential risk arising from an overdose of oxycodone is death.

1. In Complaint One the HCCC complains that, on 17 August 2023, Dr Sharier was convicted of the following criminal offences:

(1) Supply of a poison, namely oxycodone that was not packaged in accordance with the Poisons Standard contrary to cl 7(1)(a) of the Poisons and Therapeutic Goods Regulation 2008;

(2) Failure to keep a drug register contrary to cl 111(1) of the Poisons and Therapeutic Goods Regulation 2008; and

(3) Failure to store a drug of addiction, namely oxycodone, contrary to cl 73(1) of the Poisons and Therapeutic Goods Regulation 2008.

1. Complaint One is admitted by Dr Sharier.
2. We are satisfied that Dr Sharier was convicted of those three criminal offences.
3. Dr Sharier concedes and we find that it is unsatisfactory professional conduct under the National Law.

1. The effect of s 130(1) of the National Law is that Dr Sharier should have notified the National Board within seven days of being charged with the three offences in Complaint One.
2. Dr Sharier admits he did not do so.
3. Two days after the medication error, investigators from the Pharmaceutical Regulatory Unit went to the Revesby Clinic, spoke to Dr Sharier and inspected his medication handling procedures. Those investigations led to the criminal charges.
4. By way of explanation for not notifying the National Board, Dr Sharier says that, at the time, he understood AHPRA was aware of the incident, and he was not aware that he had a separate obligation to notify AHPRA of the charges.
5. We are satisfied that Dr Sharier should have and did not notify the National Board. Dr Sharier concedes, and we find, that it is unsatisfactory professional conduct under the National Law.

1. The HCCC says Dr Sharier is guilty of unsatisfactory professional conduct because:

(1) He inappropriately provided the father with a plastic syringe containing 0.5ml of oxycodone for administration to Patient A where :

(a) He drew up the syringe from a bottle he believed to contain Panadol Children,

(b) The syringe was unlabelled,

(c) He should have asked the father or the mother to buy Panadol Children instead of providing an unlabelled syringe of medication.

Dr Sharier admits Particular 1 but does not admit it was unsatisfactory professional conduct.

(2) On discovering his mistake and finding out that the oxycodone had been administered to Patient A, Dr Sharier:

(a) Failed to provide clear information to the father as to the name and the dose of medication he had provided, during a telephone conversation at around 1:06pm.

(b) Provided unsafe instructions to the father to observe for symptoms and return to the clinic if necessary during the telephone conversation at around 1:06pm.

(c) Failed to communicate the need for rapid transport to the hospital to the father during the telephone conversation at around 1:06pm.

(d) Failed to explain to the father that emergency opioid antidote could be administered at the hospital during the telephone conversation at around 1:06pm.

(e) Failed to prioritise ongoing communication with Patient A's family throughout the day.

(f) Failed to contact the destination hospital to advise of the approaching emergency.

(g) Failed to provide a referral letter to the destination hospital including relevant clinical details.

1. In the Reply filed by Dr Sharier, Particulars 2 (a), (b), (c) and (d) are not admitted and Particulars 2 (a), (e), (f) and (g) are admitted which Dr Sharier admits amounts to unsatisfactory professional conduct. In counsel for Dr Sharier's written opening, only Particulars 2 (b) and (c) are not admitted.
2. We will consider Complaint Three later in these Reasons.

1. The HCCC says Dr Sharier is guilty of unsatisfactory professional conduct because:

(1) Between early 2022 and around 1 March 2023, he failed to maintain stock levels of the s 8 medicine, oxycodone, at the lowest practical level in patient care areas.

(2) Between around 8 February and 22 March 2023 he inappropriately wrote two prescriptions for the s 8 medication, oxycodone, under the false and fictitious name 'Mr Test Tester' in circumstances where:

(a) he personally presented those prescriptions to a pharmacy and the medication was dispensed to him for use in his practice;

(b) he failed to record handwritten details on the prescriptions including:

(i) the name and strength of the substance;

(ii) the quantity prescribed in both words and numerals;

(iii) adequate directions for use;

(iv) the number of repeats authorised and interval for repeats; and

(v) by his conduct in sub-particulars b)(i) to (iv), he breached cll 80(b)-(f) inclusive of the Poisons and Therapeutic Goods Regulation 2008.

1. Dr Sharier admits Complaint Four Particular 1.
2. In relation to Complaint Four Particular 2, Dr Sharier says that he relied on advice from the pharmacist in relation to how the oxycodone should be dispensed for use in his practice. He concedes that the matters listed in Particular 2(b) should have been included on the prescription to comply with the relevant legislation.
3. Dr Young says, and we agree that:

(1) Stock levels of s 8 medications must be kept to the lowest practical level in patient care areas.

(2) Dr Sharier's storage, handling, and adjustment of systems and behaviour in relation to s 8 drugs fell significantly below the standard expected of a practitioner of an equivalent level of training or experience; and

(3) Dr Sharier's lack of basic knowledge about prescribing together with his failure to check the numerous resources available easily through the internet, such as the RACGP's "Medication management and supply: A guide for general practice" meant that his systems and behaviour in relation to s 8 drugs were not adequate or appropriate so that his conduct fell significantly below the standard expected of a practitioner of an equivalent level of training or experience.

1. We accordingly find Dr Sharier guilty of unsatisfactory professional conduct in respect of Complaint Four.

1. The HCCC says Dr Sharier is guilty of unsatisfactory professional conduct because:

(1) On or about 1 March 2023, he failed to maintain adequate records in relation to Patient A in that he:

(a) failed to record an adequate history, including;

(i) an accurate birth history.

(ii) current weight.

(iii) vital signs.

(b) failed to record the fact that oxycodone had been mistakenly provided to Patient A.

(c) failed to record any details of his conversations with the father and the mother including learning that the oxycodone had been administered to Patient A and any advice he provided.

(d) by his conduct in sub-particulars (a) to (c) above, Dr Sharier contravened clause 8 and clause 1 of Schedule 4 of the 2016 Regulations.

1. Dr Sharier admits Complaint Five.
2. Dr Sharier says he had assumed he would receive a discharge letter from the hospital, after which he intended to update Patient A's records. However after the investigators from the Pharmaceutical Regulatory Unit attended, he was concerned that retrospectively making a record would be seen as self-serving or attempting to retrospectively change the records. He decided to preserve the state of the notes as they were.
3. Dr Young noted that Dr Sharier's documentation of his treatment of Patient A consisted of only a completed parent proforma, a signed consent by the mother, and an operation history that was clearly an autofill which had not been edited and personalised. One entry which related to the method of his birth was wrong. A brief birth history was not entered, nor a current weight nor were any vital signs recorded.
4. In addition, Dr Sharier had not recorded the medication error, nor the phone calls with the family, which, Dr Young said, should be part of everyday medical record entry.
5. Dr Young noted that Dr Sharier's documentation of his treatment of Patient A did not comply with the Health Practitioner Regulation (NSW) Regulation 2016 which provides that a record must be made contemporaneously with the provision of the medical treatment or other medical service or as soon as practicable afterwards.
6. Dr Young concluded, and we agree and find, that Dr Sharier's documentation of his treatment of Patient A was not adequate or appropriate and his conduct fell significantly below the standard expected of a practitioner of an equivalent level of training or experience.
7. We accordingly find Dr Sharier guilty of unsatisfactory professional conduct in respect of Complaint Five.

1. The Health Care Complaints Commission says Dr Sharier's unsatisfactory professional conduct amounts to professional misconduct.
2. Complaint 6 is not admitted.
3. We will consider Complaint Six later in these Reasons.

1. Much of what occurred on 1 March 2023 is not in dispute.
2. There is no complaint made about the circumcision procedure itself.
3. However there is a significant dispute about what Dr Sharier told the father when Dr Sharier called him at 1.06 pm to disclose the medication error. The discrepancies in the evidence relate to the words which Dr Sharier used to describe the medication, the word or words he used to describe the symptoms that Patient A may develop, whether he informed the father clearly of the gravity of the situation and whether he told the father to take Patient A immediately to the hospital.
4. The HCCC says that, in that first conversation, Dr Sharier did not tell the father to take Patient A to hospital, he told the father to monitor Patient A for drowsiness and to call him or bring him to the Revesby Clinic if he had any concerns. Despite giving that instruction Dr Sharier did not monitor his phone nor instruct anyone else to monitor his phone while he attended to the next patient, and when the family couldn't get through to Dr Sharier they called Ms Hogan, a midwife at Westmead hospital who told them to immediately take Patient A to the nearest hospital.

1. Dr Sharier attended a hearing convened pursuant to s150 of the National Law on 28 March 2023, a hearing convened pursuant to s34A of the National Law on 5 September 2023 and made a number of statements before giving evidence during the hearing before us.
2. At the s 150 hearing on 28 March 2023, Dr Sharier said:

For the next procedure, when I went to the same room, I noticed that the Panadol and oxycodone was there on the same table. Instantly I got terrified to see that these two is there. And I instantly recognised that I made a mistake.

So I was nervous; I rushed to the reception, got on the phone and I rang [the father]. "Did you give the medication? At the syringe I gave?" He said that oh, just five minutes ago he was crying, I just gave. It was, like, a - this one, to me, a thunderbolt on the back of my body that it's been given. And, I instantly told him, "I'm really - really - sorry that I made a bad mistake. I gave you adult strong pain medication instead of infant Panadol. This medication can cause drowsiness, respiratory depression and cardiovascular effect." I didn't use any layman language. I don't know why; I just told them, "It can cause drowsiness, respiratory depression and cardiovascular effect. It needs to be observed in the hospital, to check whether that medication adversely affect the newborn." And he said, "What do you do?" I - "What you did?" I said that, "You have option for antidote, if they want to give. But you need to be go -" "Where are you now?" He said, "I'm in Liverpool." I said, "You need to go to the hospital." He said, "Okay, I will."

And I told him specifically, "Please get in touch with me all the time. If you need anything, you have got my mobile number. And on the way to the hospital, you always get in touch with me." So it's a part of my duty of care, making sure that on the way, if anything happens, I can be help in during the time - if anything happens. Then I gave the injection for my second patient. I went to the procedure room; I finished that procedure. After - by the time I come back, I found the missed call. And then they rang me again. Then I was talking with them, he said, "Oh, my baby's getting drowsy. We spoke with the community nurse and we are on the way to the hospital." I said, "You are doing the right thing." ... the consequence of the events could have been catastrophic.

1. In his statement dated 19 April 2023, Dr Sharier said that after he realised he had given the father a syringe containing OxyNorm, he called the father and told him that he had given him the wrong medication in the syringe by mistake. The father told him that he had just given the medication to Patient A.
2. Dr Sharier said he explained to the father that he had given him a very strong adult medication which could cause Patient A to suffer respiratory depression, drowsiness, and cardiovascular problems. He advised the father to observe Patient A for signs of respiratory depression, drowsiness, and cardiovascular problems. He told the father to take Patient A to the emergency department at the local hospital immediately so that they could administer an antidote, if necessary. He said the father replied, "Ok, we will do it" Dr Sharier said he told the father to keep in touch and to observe Patient A on the way to the hospital.
3. In his statement dated 25 June 2025 Dr Sharier said that, after he informed the father that he had provided the wrong medication in error, he told the father to take Patient A to the emergency department at the local hospital immediately so that they could administer an antidote, if necessary. He told the father that he had given an adult strong medication, which could cause drowsiness, respiratory depression and cardiovascular effect, and that he needed to be observed in the hospital because they had the option of an antidote. He said the father replied "Ok, we will do it". Dr Sharier said he told the father to keep in touch with him and observe Patient A on the way to the hospital.
4. Dr Sharier said he had not used the words OxyNorm or oxycodone, because they were chemical names and he was concerned that the father would not understand them. He used lay terms to alert him to the seriousness of the error to make them go to the hospital immediately. He said that when he told the father that he was available by telephone and could ring any time, he intended to advise the hospital doctor verbally of the name and dose of the medication. He formed the impression that the father understood that the wrong medicine had been given to Patient A, he needed to go to the hospital immediately, and that they would contact him when they arrived at the hospital.
5. Dr Sharier told the s 34A hearing on 5 September 2023 that when he called the father at 1.06 pm, he told the father that he had dispensed very strong adult pain medication. The father said they had given it to Patient A. Dr Sharier said he was terrified that he had given the wrong medication. The transcript records the following:

DR SHARIER: I looked at the bench and I found the two bottles together. And I didn't recall the opening of the paper box of the Panadol, so I instantly realised I have made mistake. I spoke with - I told my nurse that I give the wrong medication, immediately, and please get his number and ring him. And I immediately ring him, and he picked up the phone and said, "Look, I have dispensed the - with a very strong adult pain medication, which can ... did you give the medication?" He said, "Oh, we just gave it now." And I was terrified that I have given wrong medication, and they have just given the medication.

So I told him that this is a very strong pain medication. It can adversely affect babies with respiratory depression, drowsiness and cardiovascular problem. And he needs to be observed in the hospital. So Liverpool Hospital is the closest hospital. He is taking baby to Liverpool Hospital so that he can be observed. And if it requires, they can use the antidote for the medication. It's a doctor who will do it. And then I started my second procedure...

At - back in the first phone call I always told them, "You need to observe and you can ring me any time while you are on the way to the hospital if anything happens to him...."

And that's how I actually stress them out as well, that is a really strong adult medication. I didn't use the word "oxycodone" because it's a common practice for a general doctor, not - we more use layman term rather than generic name or the chemical name. And that's how I rephrased the information on that particular point of time. I was definitely really terrified. If I knew that it was my son, what would I do...

And I - and that's how I convey information to the parents (indistinct) that they need to be in the hospital for observation. If the sign of toxicity of the medication observed, then they do have option for antidote ... they will have option for antidote. I ... knew that giving the narcotics (indistinct) the liver, put the child at risk of having the drowsiness, respiratory depression, and a very easy option is to give antidote, and it is very safe to, you know, get them back on track. So I knew that the drug can affect adversely, and they do have very easy option at the hospital to manage it properly....

.3 to 35 milligram is the limit of the oxycodone normal dose. So .5 milligram - so I was hoping that, you know, when you draw a 5.5 ml syringe, there is always a bubble at that time - the bit, and you cannot push everything inside, because the keep - they do have some gap as well. So even if you push everything, you cannot pull the rest of that in. So with all those mind, I was thinking that it could possibly - though, obviously, it could possibly do the respiratory repression; worst case scenario, they need to be observed in the hospital...

So I took it from the beginning that this is the worst case scenario, he gave overdose of medication and that needs to be observed in the hospital. But I was hoping, I was praying that it is not the case...

Q: Did you consider texting him the name of the medication, being oxycodone, after the first phone call? And if not, what was going through your mind, I suppose?

DR SHARIER: I didn't think to texting him the - I was thinking to when they were in the hospital, I don't - I told them that they get in touch with me so that I can talk with the doctor and let them know what I gave...

Q: Okay. When you say that you - on the first phone call with (the father], at approximately 1 pm, that you had advised him to immediately take [Patient A] to the hospital: ... What did he say, exactly? Or just to the best to your memory.

A: "Yeah. Okay, we'll do it."

Q: When you spoke to [the father] at 1 pm, did you - in advising him to take [Patient A] to the hospital, did you qualify that advice or those instructions with anything in terms of, you know, you were quite insistent that there was no - you were quite insistent that he go directly to the hospital; your instructions weren't, "Monitor his symptoms. See how he goes. See how he progresses, then decide -" or to ring you back to make a decision about going to the hospital? You were quite clear on that very first phone call, "Go directly to the hospital," and he acknowledged that; is that correct?

Q: Correct. I specifically told him that that medication can cause respiratory depression, drowsiness, and cardiovascular - normally, when you - I mean, when you speak with patient, you try to avoid medical jargon. But this is exactly the phrase that I told him, because I was so terrified, I was so afraid that things can go wrong. So to keep the importance of going to the hospital, I told him that monitor the symptom, you can ring me any time, even if you are in the hospital, or not hospital. So I was hoping that he will make to the hospital before the symptom starts; it takes at least half an hour to kick in, and by the time he is in the hospital (indistinct) ...

1. We were not assisted with any detailed review of the inconsistencies in the evidence. It seems however that this was the first occasion on which Dr Sharier said, in that first conversation, he expressly told the father to get in touch with him from the hospital so he could talk with the doctor and tell the doctor what medication Patient A had been given.

1. Ms Shrestha works as a registered nurse for Dr Sharier. She overheard Dr Sharier speak to the father at 1.06 pm.
2. In her statement dated 22 August 2023, Ms Shrestha said she had heard Dr Sharier say:

(1) He had accidentally given the father oxycodone instead of paracetamol;

(2) Patient A's condition should be monitored by looking out for increased drowsiness and respiratory distress. If any of those symptoms were present or they had any concerns, they should go to the nearest hospital emergency department.

1. At Ms Shrestha's s 34A interview on 19 October 2023 she said she had heard Dr Sharier say:

(1) He had mistakenly given them Endone instead of Panadol;

(2) Just monitor for any signs of respiratory distress or any conscious levels and then "if it's concerning you need to go to hospital straight away". He did not mention any other symptoms.

(3) She did not remember Dr Sharier saying "strong adult medication".

(4) She did not remember Dr Sharier directing the father to take Patient A immediately to the hospital.

(5) She did not remember Dr Sharier saying that the father could call him if anything came up or that he could reach out to him at any time, he would be available.

1. However in cross examination before us Ms Shrestha said:

(1) Dr Sharier had said to the father that they potentially needed to go to the hospital to monitor Patient A's symptoms. She later added that Dr Sharier had told them to monitor for respiratory distress and go to the hospital. Finally she said that when Dr Sharier said to go to the hospital he meant immediately and that he expressed urgency.

(2) Dr Sharier's demeanour during the conversation was worried, but he made sure what he said was clear. As far as she remembered he mentioned the hospital and did not say Patient A should be brought to the Clinic.

(3) She did not hear Dr Sharier say that the hospital would monitor for symptoms nor that the hospital could give Patient A the antidote.

1. The father said that, after they arrived home at around 1:00pm_,_ he saw the mother administer the medication into Patient A's mouth.
2. The father then received a call from Dr Sharier at 1.06 pm. In his statement dated 18 July 2023 he recounts the following conversation:

Dr Sharier: "Have you given him the medicine?"

CFMB: "Yes you told me to give it to him straight away".

Dr Sharier "I have a few doubts that I may have given bigger kids panadol. Watch for symptoms. If he feels drowsy. If he does, come back to my clinic or call me.

1. The father said the conversation took about two minutes and Dr Sharier's demeanour was quite calm.
2. The father then told the mother about the call and they both noticed that Patient A was quite drowsy. The father called Dr Sharier's mobile number at 1:32pm but there was no answer. He called again at 1:45pm to the same number with no answer. At around this time the mother contacted a midwife at Westmead Hospital who advised them to take Patient A to the Emergency Department of the nearest hospital.
3. The father unsuccessfully tried to call Dr Sharier again from the car at 1:48pm and 2.04pm. At 2:05pm they called the Revesby Clinic telephone number, the mother spoke to Dr Sharier after which the doctor texted them the medication details.
4. On cross examination before us, the father said that Dr Sharier had not told them to take Patient A to hospital.

1. The mother also made a statement dated 18 July 2023. In that statement she said that when Patient A arrived home he was crying a lot and she thought she would give him the medication and then feed him. After she dropped the medicine into his mouth he almost immediately stopped crying.
2. Normally, when it was time for his feed, Patient A was very alert. However, he appeared asleep and she thought that perhaps he was just tired from the procedure so she put him down for a nap.
3. Shortly after, the father received a phone call from Dr Sharier. She did not overhear the conversation. After he finished the call, the father asked her whether Patient A was drowsy. She started moving Patient A lightly and tickling his toes but he would not wake up. The father then said that Dr Sharier had advised that Patient A had been given "big kids Panadol" and had asked them to keep an eye on Patient A to see if he was drowsy or tired.
4. The mother saw that Patient A was very drowsy and started panicking. The father remained calm and said they had no reason to be alarmed or seriously concerned.
5. The mother called the midwife service at Westmead Hospital and, at around 1:35pm spoke to Ms Hogan. Ms Hogan asked the mother to do some tests on Patient A and then very calmly said "okay you need to go to the nearest children's hospital straight away". She also asked the mother to get the name of the medicine from the doctor because it was not specific enough to refer to it as "big kids Panadol".
6. The mother said that the reason they took Patient A to the hospital was because of the very clear and direct advice given by the midwife urging them to go to the nearest emergency department.
7. On the way they tried to call Dr Sharier several times on his mobile but no one picked up the phone. They then called Revesby Clinic and spoke to Dr Sharier. He told them Patient A had been given oxycodone and the mother asked him to text the name to her. He did so.

1. Ms Hogan made a statement on 7 June 2023 which was based on the contemporaneous file notes she made on 1 March 2023.
2. Ms Hogan is a registered midwife and on 1 March 2023 was working at the Midwifery in the Home service based in Westmead Hospital. She received a call from the mother. They had never met and did not know each other. Ms Hogan described the mother as quite panicked, frantic and speaking quite quickly.
3. The mother told Ms Hogan that Patient A had undergone a circumcision earlier that day. They had administered the medication provided by the doctor. Shortly after, they had received a phone call from the receptionist informing them that they had mistakenly been provided with the wrong dose of medication. The mother said the receptionist had been quite vague about the issue and had basically instructed that she monitor Patient A's symptoms. Ms Hogan did not recall being told by the mother that the receptionist or the doctor had advised her to take Patient A to the hospital.
4. The mother described Patient A as having become increasingly drowsy and non-reactive.
5. After asking the mother a number of questions, including whether Patient A was responsive and breathing normally, and to lift his arms up to check the tone, Ms Hogan strongly repeated her initial advice that the mother take Patient A to the emergency department and find out from the doctor precisely what kind of medication had been given and what the dosage was.

1. Dr Carman was working in Liverpool Hospital as a neonatal intensive care consultant on the day that Patient A was admitted. She first met the family on the following day, 2 March 2023. She made a statement dated 7 July 2023 based on the file note she had made on 2 March 2023.
2. In her statement dated 7 July 2023 Dr Carman said:

15. Shortly after the parents had returned home with [Patient A] they administered the medication because he had started crying. Not long after, [the father] received a phone call from the clinic and was advised that the syringe had actually contained paracetamol intended for older children but that it was still okay to have administered it to him.

16. [The mother] continued to try and feed [Patient A] but he became increasingly drowsy and would not finish his feed. [The mother] tried to call the circumcision clinic multiple times but she could not reach the doctor. As a result, she called her midwife who advised her to attend the nearest emergency department. The midwife had also instructed her to call the clinic and have them provide the exact name and dosage of the medication given to Patient A.

17. Whilst [the father] was driving to the emergency department, [the mother] continued to try to call the clinic and after several attempts was able to get through to the doctor who advised her by text message that the medication provided to [Patient A] had been oxycodone.

...

22. I note that no one from the circumcision clinic called Liverpool Hospital to follow up or see how [Patient A] had progressed and, as far as I was aware, they did not get in contact with either of the parents whilst he was still admitted in hospital on 2 March 2023.

1. Ms Dolan, an investigator with the Pharmaceutical Regulatory Unit made a statement dated 17 March 2023.
2. On 3 March 2023, Ms Dolan conducted an interview with Dr Sharier at the Revesby Clinic. Before that interview, she called the father and asked him to explain what had occurred. Her contemporaneous file note of the conversation says:

Left office, arrived home, gave contents to baby. Dr called and said he had made an error and gave children's panadol not infant strength by error. Keep an eye on symptoms and call him before bringing anywhere.

Baby became drowsy and not feeding well, [the mother] became concerned and called midwife who advised to take to hospital asap. On way to Liverpool Hospital baby having difficulty breathing, [the mother] called and demanded to speak with doctor ASAP and asked what was actually given, Dr Sharier admitted it was oxycodone liquid 1mg/ml given by mistake.

1. Dr Sharier's evidence as to telling the father to take Patient A immediately to hospital in that first telephone call is only supported by the evidence of Ms Shrestha in cross examination. It is not supported by her two earlier statements, nor the evidence of any other witness. The evidence of three of those witnesses is based on a contemporaneous note.
2. We accept that the evidence of those other witnesses is based on what they were told by the father. However, given the fraught circumstances of that day, we cannot see any reason why the father would not have taken Patient A to hospital immediately if that was what Dr Sharier had said.
3. In addition, the surrounding circumstances do not support Dr Sharier being overly concerned about the medication error he had made. He says he told the father to contact him if he became concerned, but he admits he did not monitor his mobile (which we will refer to as his personal mobile). In his affidavit dated 20 June 2025 Dr Sharier said:

I understand that [the father] tried to contact my personal mobile number ... following our telephone conversation at 1:06pm without success on two occasions, prior to contacting the practice mobile number at approximately 2:00pm. As I had been corresponding with [the father] utilising my personal practice number ..., I did not consider [he] would seek to contact me on my personal mobile number, particularly as I would not have provided [him] with this number during our dealings at the Practice. This was not a number that I actively monitored during the working day. It is possible [the father] had stored this number on his phone based on our dealings at the Sefton Clinic. In any event, I acknowledge that following the initial contact at 1:06pm, I ought to have ensured that I was readily contactable and I should not have waited for [them] to contact me. Rather, I ought to have prioritised a scheduled call to [him] by no later than 30 minutes of our initial phone call to confirm if they had attended hospital and to obtain any status update.

1. However Dr Sharier did not make this excuse about not expecting the call on his personal mobile at the s 150 hearing:

Q: And I - you've already said this, but just to be clear, and you provided him with - do you recall which number you provided him with? Which phone number?

A: Yeah. That - the mobile number I - and they do have my - in my - in the booklet, they do have my personal number as well....

Q: But then you - so you're saying you don't recall where your mobile phone was, and you didn't bring it in with you to the treatment room during that next procedure? ...

Q: Yep. So during the clinic time, I only accept the clinic mobile or the landline, but in addition, actually, I gave him personal mobile number, in case the clinic - he can ring everywhere to figure out where am I.

A: Okay. But then you didn't - but you didn't have your phone with you, so he wasn't able to reach you, is what you're saying?

Q: Yeah. He does have the more - he rang - I can see he definitely rang my personal mobile number, which was not with me during the procedure. And I picked up his phone on my clinic mobile number. (emphasis added)

1. In fact the father tried two mobile numbers before the mother rang the Revesby Clinic number. The father says he made an unanswered call at 1.48 pm to the mobile number described by Dr Sharier as the clinic mobile's number.
2. We also take into account that Dr Sharier did not take any proactive steps to facilitate a hospital admission, such as contacting the hospital to ensure that they were aware of the urgency of the situation and the precise details of the medication administered, but rather continued working.
3. Nor did Dr Sharier make any note of the conversation in the patient's file.
4. There are other inconsistencies in the evidence of the various witnesses, for example the language used by Dr Sharier to describe the medication which he had provided and the possible symptoms which Patient A might develop. We do not consider any significant issue arises from these inconsistencies.
5. We find that we prefer the evidence of the father to Dr Sharier where they conflict.

1. Dr Sharier admits and we find that Dr Sharier inappropriately provided the father with a plastic syringe containing 0.5ml of oxycodone for home administration to Patient A believing the bottle contained Panadol Children, the syringe was unlabelled and he should have asked the father to buy Panadol Children instead of providing an unlabelled syringe of medication.
2. Dr Sharier does not admit that this was unsatisfactory professional conduct.
3. Dr Young has advised, and we accept, that most general practitioners would have Infant's and Children's paracetamol syrups in the practice medication cupboard for pain or fever, most often when the patient is unwell and has not received a dose at home, but also proactively when pain is expected, such as after a vaccination. It would be also reasonable, with the parent(s) consent, to administer a dose in the practice after a procedure when ongoing pain was expected, such as after a circumcision.
4. However, giving a patient a drawn up, unlabelled syringeful of Panadol to take home for use in the event of pain is not usual practice. In the circumstances of this case, it would be more usual to ask an adult to purchase Panadol Children if they did not have any at home because it empowers the parents to manage their child's discomfort/pain, it allows education of its use by instructions on the container, supplemented by the doctor explaining dose by weight and safety of use under one month, the medication is supplied with a more appropriate measured syringe and squirter than an intravenous syringe, it allows further dosing if needed, rather than a single dose and an intravenous syringe of Panadol could easily accidentally be emptied, even if stoppered.
5. Dr Young concluded that it was not appropriate for Dr Sharier to provide a plastic syringe containing 0.5ml of (what he incorrectly believed to be) Panadol Children, and in doing so his conduct fell below the standard expected of a practitioner of an equivalent level of training or experience.
6. We agree with this opinion.
7. The definition of unsatisfactory professional conduct does not include conduct falling below the standard expected of a practitioner of an equivalent level of training or experience. Unsatisfactory professional conduct is defined as conduct which falls significantly below that standard.
8. Complaint Three Particular 1 must fail.

1. Next, the HCCC says that, on discovering his mistake and finding out that the oxycodone had been administered to Patient A, Dr Sharier failed to provide clear information as to the name and the dose of medication he had provided, provided unsafe instructions to observe for symptoms and return to the clinic if necessary, failed to communicate the need for rapid transport to the hospital, failed to explain that emergency opioid antidote could be administered at the hospital, failed to prioritise ongoing communication with the parents throughout the day, failed to contact the hospital to advise of the approaching emergency and failed to provide a referral letter to the hospital including relevant clinical details.
2. As set out earlier in these Reasons, Dr Sharier admits some of this conduct and admits it is unsatisfactory professional conduct.
3. We are satisfied that the HCCC has established all of the particulars as they are consistent with the evidence of the father.
4. Dr Young has said the conduct falls significantly below the standard expected of a practitioner of an equivalent level of training or experience.
5. We agree and find that the HCCC has established Complaint Three Particular 2.

1. Complaint Three asserts that Dr Sharier is guilty of professional misconduct under s 139E of the National Law. This defines professional misconduct as unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner's registration. If there is more than one instance of unsatisfactory professional conduct, they can be considered together.
2. In Chen v Health Care Complaints Commission [2017] NSWCA186 at [20], Basten JA explained:

There is no category of unsatisfactory professional conduct which is not capable, depending on the circumstances, of giving rise to professional misconduct and hence engaging the power of either suspension or cancellation of registration. The only requirement is that it be "sufficiently serious" to justify such an order, a characterisation which must depend upon an evaluative judgment made by the Tribunal. Some, perhaps all, categories include conduct which may reveal a defect of character as to which the Tribunal may conclude that the person should not be allowed to practise his or her profession unless at some future date the practitioner is able to satisfy the Tribunal that the defect has been overcome. Incompetence or inadequate care may in some circumstances be remediable by specific steps; in other circumstances the Tribunal may be concerned that the carelessness, for example, is such as to cast doubt on the suitability of the person to practise medicine. Each of the criteria for cancellation or suspension may be analysed in this way. Each case will depend upon an evaluative judgment to be made by the Tribunal as to the nature and seriousness of the conduct.

1. In assessing the seriousness of Dr Sharier's conduct we have taken the following matters into account.

1. The fact that Patient A has apparently made a full recovery is not due to any intervention by Dr Sharier.
2. We have already found that Patient A was taken to hospital because the mother sought advice from Ms Hogan.
3. In addition, when the family arrived at Liverpool Hospital Emergency Department, they were instructed to sit in the waiting room. The mother tried several times to explain to the receptionist what had happened, but she was told repeatedly that they had to wait their turn. After about 15 minutes, and because Patient A was still not waking up, the mother called Ms Hogan again at approximately 2:39pm. She told Ms Hogan that Patient A had been given oxycodone and Ms Hogan said "you need to be seen quickly" and "even if you are told to wait tell them you need to be seen quickly". The mother went back to the receptionist, said my midwife wants to talk to you and handed the phone to the receptionist. The receptionist spoke to Ms Hogan and Patient A was seen four or five minutes later.
4. Ms Hogan said that the mother had called her from the hospital and told her that she had been waiting in the Emergency Department for approximately twenty minutes without having been attended to. This confused Ms Hogan because the baby was clearly a priority. She asked the mother to let her speak to the nearest hospital staff member. Ms Hogan immediately asked them why someone with a newborn baby suffering from a suspected drug overdose was still sitting and waiting in the emergency room. There was a very quick exchange and perhaps 10 to 30 seconds later she heard shuffling background noise and the mother said "they are taking me in now''.
5. In relation to the conduct underlying Complaint Three Particular 2 we agree with the following observations made by Dr Young:

44. An insightful, safe, humble GP upon realising (s)he had committed a serious error would be able to assess the clinical situation - that a newborn had been erroneously overdosed on an opioid medication and needed emergency hospital treatment with naloxone 7, an opioid blocker/antidote, as well as possibly ICU management.

45. Such a GP's initial response would be to put everything else on hold until (s)he had communicated this to the parents in a clear and apologetic manner, emphasising the need for rapid transport to hospital by family vehicle or ambulance, even if the baby's clinical state was stable. A caring GP would also give instructions to the parents to contact her/him once they had been admitted to A+E to ensure care had been aptly handed over.

46. Such a GP would have also rung the destination hospital to ensure they were aware of the approaching emergency and fill them in with the relevant clinical details, possibly also texting the parents the overdose details.

47. A thorough GP would ask the best fax number or email for the destination hospital and then send through a referral letter with details as outlined in the Preamble section on referral letters, especially so that the hospital had the GP's contact details for any follow up.

48. In contrast, ... while he did ring [the father] to inform them of that a mistaken 'very strong adult' medication had been dispensed and correctly related possible sequelae and the need to proceed immediately to hospital, he failed to: -

• Detail the medication and dose given to the parents or to the hospital.

• Explain an emergency opioid antidote could be given at the hospital.

• Offer ambulance transport.

• Communicate respectfully with his colleagues in handover of care, thus jeopardizing prompt optimal care ...

49. An indictment of Dr Sharier's poor management in this regard was that [Patient A] ended up in the A+E waiting room. It took the Community Nurse's intervention to make sure the staff was aware a medical emergency was present.

50. As well, although he offered his continued mobile phone contact, he did not ensure this was possible; in fact, Dr Sharier proceeded to attend to his next patients and did not keep his personal mobile phone with him, leading to at least three missed calls from [the father]. Caring, safe GPs would have handed the mobile to the practice nurse, outlining the evolving emergency situation and the need to stay in touch until the patient was in the safe care of the A+E team.

1. We consider the conduct of Dr Sharier from 1.06 pm on 1 March 2023 a very significant and serious departure from an acceptable response to the crisis which he had created.

1. Another serious issue is Dr Sharier's conduct in relation to the safe keeping of s 8 medication and failing to maintain a drug register.
2. Dr Sharier said that, while working at the Sefton Clinic, he infrequently administered liquid OxyNorm to some adolescent and adult male patients to attempt to improve post procedure pain and kept a drug register
3. Dr Sharier said that, until the investigators from the Pharmaceutical Regulatory Unit arrived on 3 March 2023, he did not know that he had lost his drug register. He was required to keep a drug register for s 8 medications and pleaded guilty to contravening s111(1) of the Poisons and Therapeutic Goods Regulation 2008 (Complaint One).
4. Section 112 of the Poisons and Therapeutic Goods Regulation 2008 provides Dr Sharier should have made a corresponding entry into the drug register whenever he used oxycodone.
5. Dr Sharier says he probably lost the drug register in the move from Sefton to Revesby.
6. We note that the evidence is that:

(1) Dr Sharier used liquid OxyNorm at the Sefton Clinic;

(2) Dr Sharier moved from the Sefton Clinic to the Revesby Clinic in February/March 2022.

(3) Dr Sharier says that in March 2022, when he had started the process of moving to the Revesby Clinic, he decided to stock up medication for use at the Revesby Clinic. He already had two bottles of OxyNorm, but only one had been opened. At the time, he was still unsure about whether he was planning to continue the use of OxyNorm at the Revesby Clinic.

(4) The four bottles of OxyNorm were dispensed on separate occasions - 8 February 2022 (two bottles), 25 March 2022 (one bottle) and 25 March 2022 (1 bottle).

(5) Dr Sharier said he utilised post-operative OxyNorm for approximately one year. He then says in his affidavit dated 25 June 2025:

I ultimately ceased using OxyNorm as a form of pain relief shortly after moving to the (Revesby Clinic), noting there was a lot of paperwork involved with administering OxyNorm, such as having the nurse and myself co-sign on the administration of the medication and to monitor the patient's vitals and record it. It was therefore more convenient not to administer OxyNorm, particularly where patients were not reporting any real benefits. At the time I ceased using OxyNorm, three of the four bottles remained intact and unopened. (emphasis added)

1. In other places in his evidence Dr Sharier says he did not recommence the use of OxyNorm at the Revesby Clinic.
2. There is also uncertainty as to the circumstances in which the opened bottle of OxyNorm came to be on the bench next to the Panadol Children. Dr Sharier says that, on the day before the medication error, he had conducted an audit of the medication and equipment at the Revesby Clinic to identify and dispose of any expired medication and equipment. He took out the open bottle of OxyNorm from the locked medication cupboard. As he had not used OxyNorm for some time, he decided to dispose of the bottle and placed it on the bench in the storage room ready for disposal at a pharmacy on his way home. However he did not take the bottle when he left that day. He says he does not know how this occurred but believes he became preoccupied with his patients that day and simply forgot to take it.
3. Dr Sharier did not mention this explanation to the investigators from the Pharmaceutical Regulatory Unit. They recorded that they saw a bench in the treatment room and took a photograph of the two bottles next to each other on the bench:

Ms Dolan questioned if Oxynorm® bottle has always been on the bench, to which Dr Sharier concurred. Dr Sharier does not appear to be aware of the requirement for the proper storage of a Schedule 8 drug when it is not in immediate use.

1. The next issue is the explanation given by Dr Sharier for the OxyNorm being on the bench next the Panadol Children when the investigators arrived. Dr Sharier said that when the team arrived, he told them to wait, and he went into his consultation room and removed the bottle of OxyNorm from the cupboard and placed it on the bench next to the bottle of Panadol, so the two bottles appeared as they had on 1 March 2023.
2. It seems he did not mention this to the investigators from the Pharmaceutical Regulatory Unit. They said they asked Dr Sharier why, if a mistake had been made, the OxyNorm liquid was still sitting on a shelf next to the Panadol and not in the drug safe as this was an accident waiting to happen. Dr Sharier replied that it was hardly used and then only for adult and older children's circumcision procedures.
3. Next, Dr Sharier did not disclose the existence of the three unopened bottles of OxyNorm to the investigators. He has said he kept them in his own room in a locked cupboard secured against the wall and he had totally forgotten that he had them in his possession. On 30 March 2023, after receiving the brief of evidence in relation to the criminal charges which included the prescriptions, he remembered that he had them and took them to the local pharmacy for disposal. There is a receipt from that pharmacy in evidence.
4. Lastly the investigators from the Pharmaceutical Regulatory Unit were shown the drug cabinet where Dr Sharier said he stored his s 8 drugs. It was not securely attached to the premises as required by the Regulations and was full of old cardboard boxes. This was the subject of one of the offences referred to in Complaint One.
5. Not all of this conduct is the subject of a complaint and we do not make any findings in respect of those matters where there is conflicting evidence. However we consider that the totality of this evidence shows that Dr Sharier had a very casual attitude to complying with the legal requirements relating to s 8 medications. An example of the consequences which can flow from this attitude is the medication error which occurred and which could have had grave consequences.

1. We do not agree with counsel for Dr Sharier's submission that this was only a single serious event of the administration of a powerful opioid to a newborn baby.
2. We accept this part of a submission made by counsel for the HCCC - that on the day Dr Sharier made the medication error, he did not recall he had three other bottles of oxycodone on the premises, he did not have a drug register, the drugs were not properly stored, and the opened bottle was next to Panadol Children in his treatment room. In that context, the medication error, while it may have been the result of momentary inattention on an unusually stressful day, it was a foreseeable consequence of a cluster of failures in relation to drug safety that continued unchecked until the risk the regulations were designed to avoid materialised. He then failed to take any reasonable steps to address the potentially grave consequences which could have flowed from the medication error, by proactively intervening to ensure that Patient A received appropriate and timely treatment.
3. We are satisfied that the conduct is of a sufficiently serious nature to justify suspension or cancellation of Dr Sharier's registration, within the meaning of s 139E(b) of the National Law.

(1) Cancellation of Dr Sharier's registration with a non-review period of one year.

(2) Dr Sharier pay the HCCC's costs, as agreed or assessed.

1. Dr Sharier says that suspension or cancellation of his registration is not required and submits that the appropriate orders would be that of a reprimand, fine, caution and/or the placing of conditions on his registration.

1. We have found Dr Sharier guilty of professional misconduct and therefore the range of protective orders which can be made includes suspension or cancellation of his registration: s 149C(1)(b) of the National Law.
2. However the fact that we have found that Dr Sharier's conduct was of a sufficiently serious nature to justify suspension or cancellation of his registration does not mean it must be suspended or cancelled.
3. The main guiding principle of the national registration and accreditation scheme is that the protection of the health and safety of the public must be the paramount consideration: s 3A (1) of the National Law and, in making our decision, the protection of the health and safety of the public must be the paramount consideration: ss 3B and 4 of the National Law.
4. The objectives of the national registration and accreditation scheme are to provide for the protection of the public by ensuring that only health practitioners who are suitably trained and qualified to practise in a competent and ethical manner are registered: s 3(2)(a) of the National Law.
5. The purpose of disciplinary orders is protective rather than punitive: Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630 at 637.
6. In Health Care Complaints Commission v Do [2014] NSWCA 307 at [35] the Court held:

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.

1. In Director-General, Department of Ageing, Disability and Home Care v Lambert [2009] NSWCA 102 at [83] the Court held:

As is well-established in the disciplinary jurisdiction generally, including with respect to legal and medical practitioners, the specific purpose for which orders are made is protective in the public interest and is not punitive with respect to the individual ... That is not to deny that such orders may be punitive in effect...Nor does it necessarily follow that punitive effects may not be relevant in formulating a protective order. ... Further, the punitive effects may be directly relevant to the need for protection. Thus, in a particular case, there may be a factual finding that the harrowing experience of disciplinary proceedings, together with the real threat of loss of a livelihood may have opened the eyes of the individual concerned to the seriousness of his or her conduct, so as to diminish significantly the likelihood of its repetition. Often such a finding will be accompanied by a finding that the person concerned has achieved a level of insight into his or her own character or misconduct, which did not previously exist.

1. However, any protective orders made by the Tribunal should not result in "more serious consequences for the practitioner than is reasonably necessary in execution of the protective purpose of the legislation": NSW Bar Association v Meakes [2006] NSWCA 340 at [114].

1. In determining the appropriate protective Orders we have taken the following matters into account:

1. Our findings as to the seriousness of Dr Sharier's conduct when we determined Complaint 6.

1. We are also concerned about the explanation Dr Sharier has given for the medication error in para 46 of his affidavit dated 20 June 2025:

I recall that day as being very unusual and stressful for me due to a number of factors:

(a) My wife was sick at home with the flu;

(b) I was down a staff member as my wife was not present working at the clinic that day due to being sick; and

(c) Prior to (Patient A's) presentation, I had received a phone call from my wife, informing me that the bathroom shower upstairs at our home was leaking and the first floor of our home was flooded with water. She asked me to find somebody to fix it immediately as the new carpet was being damaged from the leak. This house was a new build, it was therefore frustrating that we were having leakage issues. I was stressed trying to organise for a plumber and builder to attend the property urgently to resolve the leak in between seeing patients.

1. At around 2.40 pm the father received a text message from Dr Sharier's mobile saying "I have got a plumber onsite to look into the leaking ...". The father ignored it as he was busy. Shortly afterwards the father received another text message from the same number "Sorry wrong number It was supposed to send it to plumber." The father also ignored this text. We note that these messages were sent by Dr Sharier at around the time Ms Hogan was speaking to the staff at the Emergency Department to make clear the seriousness of Patient A's condition as we have discussed earlier in these Reasons.
2. We consider that any orders that we make should assist Dr Sharier to gain further insight into how, on 1 March 2023, his decision making became significantly impaired by what we consider to be the type of stressors which everyone experiences from time to time, so that it does not occur again.

1. Counsel for Dr Sharier submitted that Dr Sharier occupies a unique position in the community, possessing a special skill and offering a unique area of medical practice to the public. This should be a consideration when determining the appropriate protective orders.
2. We accept that in some cases the desirability of making available to the public any special skills possessed by the practitioner will be relevant. While Dr Sharier does specialise in circumcisions which is an important clinical role in his community, there is no evidence before us that the procedure could not be done by other medical practitioners, including urologists.

1. Dr Islam is a Specialist General Practitioner with 16 years of experience. He met Dr Sharier in 2011 when they worked as registrars in the rural vocational training scheme and have stayed in contact on a professional basis. They often discuss complex clinical cases, share insights on best practice guidelines and support each other. They co-founded the Australia Bangladesh Health Forum which socially and professionally connects Bangladesh practitioners and allied health professionals. He is aware that Dr Sharier is held in high regard, particularly by those colleagues who have worked closely with him. He has witnessed Dr Sharier's capacity to show great empathy towards those from diverse backgrounds and challenging life circumstances.
2. Dr Islam refers patients requiring a circumcision to Dr Sharier and has never received any complaints. He took his own son to Dr Sharier for a circumcision procedure and was pleased with the care received.
3. In Dr Islam's opinion, Dr Sharier has always demonstrated a clear understanding of the significant responsibilities associated with Schedule 8 medications.
4. Dr Sharier has expressed to Dr Islam a sincere desire to learn from the complaint, regardless of the outcome of the proceedings. On several occasions, he has mentioned specific steps he has taken to review his practice protocols, particularly concerning the areas that had been highlighted in the complaint. He is reflective and understands his ongoing need for self-assessment and robust practice systems to support safe and effective patient care. Dr Sharier understands that good intentions alone are not always sufficient and that diligent adherence to professional guidelines is paramount.
5. Dr Islam considers that these proceedings have clearly had a profound impact on Dr Sharier who has been and is committed to making any necessary changes to ensure his practice meets the highest possible standards moving forward.
6. Dr Neil Pollock is a Clinical Instructor at the University of British Columbia's Faculty of Medicine and the founder and lead physician of Pollock Clinics. He developed the "Pollock Technique" for minimally invasive circumcisions which he continues to teach internationally.
7. Dr Pollock met Dr Sharier in 2014 when Dr Sharier completed advanced clinical training in the Pollock Technique under Dr Pollock's direct supervision. He has advised that during the intensive two weeks program, Dr Sharier demonstrated an exceptional combination of technical competence, ethical clarity, and patient-centred care. He repeatedly proved himself to be reliable, respectful, and methodical. He approached every case with a deep sense of responsibility and humility, eagerness to learn and willingness to improve every single day. Dr Sharier regularly engaged in thoughtful discussions about medical ethics, patient autonomy, pain control, informed consent and the cultural aspects of care. Dr Pollack said it became apparent that Dr Sharier was not only a gifted clinician, but a reflective practitioner who cared deeply about doing the right thing.
8. Dr Pollock has remained in close contact with Dr Sharier. They discuss the technical aspects of performing circumcisions including pain management strategies for infants. He felt Dr Sharier had a good understanding of the heightened responsibility of practitioners in prescribing and dispensing high risk medications.
9. Dr Pollock believes Dr Sharier has acknowledged the seriousness of the complaint and demonstrated a genuine commitment to change. The complaint has had a significant impact on Dr Sharier who has taken deeply considered steps to grow and improve his practice. Suspending or cancelling his license would, in his considered opinion, be a loss not only to him but to the medical community and patients who continue to benefit from his care and the unique services he offers.
10. Dr Datta has practiced as a general practitioner in Sydney since 2017. He met Dr Sharier in 2018. He has referred at least seven or eight patients to Dr Sharier, none of them had had any complications and they all spoken highly of his care. He also contacts Dr Sharier approximately every six months for clinical advice related to follow-up care. He has been struck by Dr Sharier's calm, respectful demeanour and thoughtful approach.
11. Within the medical community, Dr Datta understands that Dr Sharier is held in high regard. He knows many general practitioners who refer patients to Dr Sharier regularly and received positive feedback.
12. Based on their discussions Dr Datta is confident that Dr Sharier has appropriately reflected on and learnt from the complaint.

1. Dr Sharier has undertaken the following education, directed at issues raised in the Complaint:

(1) Reviewed the Medical Board of Australia, 'Good Medical Practice: a code of conduct for doctors in Australia', March 2023 and the RACS, 'Code of Conduct', to re-educate himself on the professional standards and responsibilities expected of health professionals.

(2) Completed the NPS MedicineWise course titled "Medication Safety (version 3) 2023' which consisted of seven online modules and two case studies on preventing medication errors and ensuring safe prescribing.

(3) Completed a course on "High Risk Medications- Part 1 on safe storage of high risk medication".

(4) Read various educational papers and articles on safe prescribing and medication storage.

(5) Thoroughly reviewed various Australian infant pain management guidelines, including those developed by various hospitals. He says these guidelines now inform his clinical practice and understanding of best practices in procedural and post-operative pain relief in infants.

(6) Consistently achieved more than the required 130 Continuing Professional Development ('CPD') points bi-annually.

(7) Reviewed various resources regarding Open Disclosure.

1. Dr Sharier has also made the following changes to his practice:

(1) On 30 March 2023, he disposed of all remaining s 8 medications at the Revesby Clinic by surrendering the unopened bottles of OxyNorm.

(2) On 4 April 2023, he surrendered his s 8 prescribing authority.

(3) By not having any s 8 drugs at the Clinic, he says a similar medication error will not happen again in the future. He has also decided not to dispense any medication to patients at the Revesby Clinic and prescribes pain medication as required with clear instructions provided regarding dosage and when to take the medication

(4) He has undertaken a review of his medication administration processes.

(5) Based on the training and education he has undergone, he says he has developed a greater appreciation of the risks associated with dispensing and storing medications and the increased vigilance they require, particularly where they are stored, prescribed or dispensed. Even if his s 8 authority was reinstated, he does do not intend to store or dispense such high-risk medications in the future.

(6) He understands the importance of maintaining contemporaneous and up-to-date records which must be sufficiently comprehensive and document all clinical incidents, regardless of their severity.

(7) He has re-familiarised himself with his statutory obligations and now understands he must notify AHPRA of any relevant event within seven days and will ensure he complies with the reporting obligations in the future.

1. Dr Sharier says that he recognises that the information provided to the father in the first telephone call and his overall management of the medication error did not meet the required standard. He lacked a structured open disclosure process. That is now in place.
2. Dr Sharier accepts that:

(1) The error occurred because he did not store the Oxynorm bottle safely.

(2) It was inappropriate to leave the Oxynorm bottle on the bench. It should have been in a secured locked cupboard or safely disposed of.

(3) He should have checked the label on the bottle when dispensing the medication to the father. In any event, he should not have provided the father a dose in a syringe.

(4) He failed to keep a drug register of all s 8 medications.

1. Dr Sharier says he now understands he should have:

(1) Provided the name and dose of the medication orally and in writing in the initial contact with the father.

(2) Contacted the hospital to alert them to Patient A's arrival, faxed or emailed a written referral to the hospital and followed up with a call to the hospital to ensure receipt.

(3) Ensured that after 1:06pm, he was readily contactable and prioritised a scheduled call to the father no later than 30 minutes later to confirm that they had attended hospital and to obtain a status update.

(4) Stopped work for the day to prioritise follow-up and make notes.

1. Dr Sharier admits he made a significant medication error and says he accepts he is responsible for what happened. He has apologised to the family. He also apologises to the community.
2. Dr Sharier says the complaint has affected him deeply and he has learnt a big lesson that he carries at every consultation. He now works even harder to earn the trust of his patients and to be the careful, honest, and safe doctor that they deserve.

1. Taking into account the need for the protection of the health and safety of the public, the seriousness of the conduct, the need for general deterrence and the maintenance of confidence in the medical profession we do not consider that cancellation of Dr Sharier's registration is appropriate or necessary.
2. We have decided to suspend Dr Sharier's registration for six months.
3. We have also decided to place conditions on Dr Sharier's registration to take effect when the six month suspension period has ended. The purposes of these conditions are the following:

(a) To improve Dr Sharier's pre-operative assessment of small children for circumcision to the standard expected of a surgeon assessing for such procedures.

(b) To ensure that Dr Sharier's clinical decision making is appropriate with respect to which patients should have procedures and when the procedure should be done.

(c) To ensure that Dr Sharier understands and implements clear safety netting processes after procedures. These would include the formulation of a clear plan in respective of each proposed procedure. That plan would be explained to patients and/or carers and documented in Dr Sharier's medical records. The plan would include a description of possible negative outcomes from the proposed procedure and the course to be followed if such an outcome was to occur.

(d) To improve Dr Sharier's approach to open disclosure and appropriate communication when dealing with clinical errors / adverse events including notification of his Medical Indemnity insurer and/ or Medical Regulators as required.

(e) To ensure that Dr Sharier is aware of the requirements to appropriately store pharmaceuticals and other dangerous chemicals.

(f) To ensure that Dr Sharier is aware of and complies with the legislation around medical record keeping.

1. The HCCC seeks a costs order. The Tribunal has power to order costs pursuant to cl 13 of Sch 5D of the National Law.
2. The application is not opposed by Dr Sharier.
3. The "usual rule" of costs following the event applies to this jurisdiction: Health Care Complaints Commission v Philipiah [2013] NSWCA 342.
4. Dr Sharier is to pay the costs of the HCCC.

(1) Dr Sharier's registration is suspended for a period of six months.

(2) When the period of suspension has expired, Dr Sharier's registration is subject to the following conditions:

(a) In relation to Education, Dr Sharier is to:

(i) Complete within six months a tailored education course organised by Morrison Consulting, or such other education provider as approved by the Medical Council of NSW. This education should focus on:

1. Pre-operative assessment of small children
2. Clinical decision making
3. Safety netting after procedures
4. Open disclosure and appropriate communication and when dealing with clinical errors / adverse events
5. The legislation around prescribing and storing pharmaceuticals and in particular S8 medications

(ii) Provide to the Medical Council of NSW evidence of his enrolment in the abovementioned course.

(iii) Provide to the Medical Council of NSW evidence from the education provider that he has satisfactorily completed the course.

(iv) Bear the cost incurred in meeting this condition.

(b) In relation to Audit and Inspection, Dr Sharier is to:

(i) Submit to a practice and medical record audit, of the Gentle Procedures Practice conducted by the Medical Council of NSW.

(ii) The audit is to be held within 6 months from the date on which the suspension of his registration expires and subsequently as required by the Council.

(iii) The audit should focus on:

1. Compliance with the legislation with respect to medical record keeping
2. Pre-operative assessment of small children
3. Clinical decision making
4. Safety netting after procedures
5. Open disclosure and appropriate communication when dealing with clinical errors / adverse events
6. Appropriate storage of pharmaceuticals and other dangerous chemicals.

(c) In relation to Medication, Dr Sharier is NOT to possess, supply, manufacture or dispense any substance listed in Schedule 4D or Schedule 8 of the Poisons and Therapeutic Goods Regulation 2008 (NSW) or any substance in an equivalent list in any other Australian State or Territory.

(d) In relation to Supervision, Dr Sharier is to:

(i) Practise under Category C supervision in accordance with the Medical Council of NSW's Compliance Policy - Supervision (as varied from time to time) and as subsequently determined by the appropriate review body.

(ii) Meet with an approved supervisor for a minimum of one hour on a weekly basis.

(iii) Authorise the supervisor to provide a report to the Council on a monthly basis.

(iv) At each meeting, review and discuss his practice with his approved supervisor with a focus on

1. Pre-operative assessment of small children
2. Clinical decision making
3. Safety netting after procedures
4. Open disclosure and appropriate communication when dealing with clinical errors / adverse events
5. Appropriate prescribing of S8 medications
6. Appropriate medical record keeping

(e) The Medical Council of NSW is the appropriate review body for the purposes of Division 8, Part 8 of the Health Practitioner Regulation National Law (NSW).

(3) Dr Sharier to pay the costs of the Health Care Complaints Commission.

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.

26 September 2025 - Coversheet & Paragraph 184 - Order 2(e) added