Findings
37We find all of the particulars of Complaints 1 and 2 proven, and rely in that regard on the analysis contained in Dr Stevenson's report.
38We draw attention to the following findings in Dr Stevenson's report. Dr Stevenson reviewed the documentation provided to her in relation to the 30 patients whose treatment is the subject of Complaints 1 and 2, treatment belonging to the period March 2010 to August 2011. She was asked to provide her opinion as to whether the standard of conduct fell below the standard to be expected of a practitioner of an equivalent level of experience, and if it did, the significance of the departure. In particular she was asked to provide her opinion in relation to the adequacy of his prescribing practices in relation to each patient, and the clinical appropriateness of his prescribing practices for patients diagnosed with post-traumatic stress disorder (PTSD) or diagnosed with attention deficit hyperactivity disorder (ADHD). She was asked to provide her opinion in relation to the clinical appropriateness of prescribing dexamphetamine to patients for self administration, and the clinical management of patients referred to him. She was asked to provide her opinion in relation to the adequacy of Dr Street's medical records practices; and his conduct in self-prescribing and using prescriptions ostensibly written for patients as a means of obtaining drugs for his own consumption.
39In all of the 30 patient cases Dr Stevenson reviewed, she made negative comments in relation to most or all of the matters to which she was asked to give attention. Those matters were: the purpose of the prescription; its quantity; its duration; its frequency; contraindications; risk of dependence/abuse; failure to apply for NSW Ministry of Health authority (MHA) with specific reference to s 28 of the Poisons and Therapeutic Goods Act 1996; and failure to maintain a drug register.
40She referred in a number of instances to the prescription of drugs that are not recommended for treatment of the presenting conditions (for example, dexamphetamine for a PTSD presentation, several instances; and the same for an ADHD presentation, again several instances). She referred to numerous instances of over-prescribing. She referred to failures to evaluate the effect of a prescription. She referred to numerous failures to take a proper patient history, and in particular instances where the patient history itself suggested care needed to be exercised in prescribing particular medications. She referred to numerous failures to maintain a drug register. She referred to instances where the patient manifested side effects, and no corrective action or change in the prescription regime was made.
41In relation to the adequacy of Dr Street's record-keeping, Dr Stevenson reported under three headings in relation to each patient: the quality of the records regarding prescribing; the quality of consultation records; the accuracy of records. Again her report was overwhelmingly negative. In each instance there were negative comments in relation to the first two matters (prescribing, consultation), and often she could not offer an opinion on accuracy due to the prior inadequacies of the records.
42In relation to Dr Street's conduct in self-prescribing, Dr Stevenson described his conduct in writing prescriptions in the name of his patients, having them filled and then using him for his own purposes, as 'fraud'. Even in those cases where the medication obtained was passed on to the patient she noted that this was not good clinical practice, as it broke the important nexus between the pharmacist and the patient in this area. She referred to the specific guidelines that govern self-prescribing by medical practitioners; endorsing prescriptions with invalid MHA numbers; and the supply of drugs of addiction to patients.
43At hearing, Dr Street was taken in cross-examination to a representative cross-section of opinions expressed by Dr Stevenson. He did not dispute any of her conclusions. For example in the instance of the matter addressed in Schedule C of Complaint 1, Patient H, he acknowledged that he had obtained the medication prescribed for his own use, and had fraudulently used the name of the patient. He said that 'my level of functioning at that time was appalling', and that he doubted that any of his clinical decisions 'were remotely well reasoned'. This answer was typical of his replies to many of the questions put to him about specific instances of misconduct.
44He was cross-examined on his reasons for making contra-indicated drug prescriptions for PTSD and ADHD patients. He said that his prescription of dexamphetamines to PTSD patients was influenced by studies with which he had been aware in his days at the Northside Clinic in the War Related Trauma Centre that suggested psycho stimulants produced a marked improvement in patients with PTSD. He acknowledged that he had never taken these studies to peer review. He acknowledged that at the time of the actions under notice in the complaint he lack knowledge of current clinical understanding of this issue. He also referred to research that he had tracked down on the internet in 2006 that he had saw as giving him a justification for his practices, but he now accepted that his lucidity at the time was affected, and that in retrospect it was bizarre treatment. He would 'absolutely not' consider using these treatments for PTSD and ADHD patients in future.
45He gave answers along similar lines in relation to his behaviour in fabricating prescriptions, misleading pharmacists, and self-prescribing.
46Complaints 1, 2 and 3: In our view the only sensible conclusion is that the conduct proven constitutes professional misconduct. It is conduct of the gravest kind, involving a dereliction of duty towards the patients nominated in the ways specified in the complaints. It involves a sustained pattern of fabrication and deceptive conduct. Not only did Dr Street engage in self-abusive behaviour that affected his competence to practise, he also implicated unknowingly his patients in his pattern of deception by issuing prescriptions in their names that were not meant for them.
47In a number of instances, Dr Street failed to obtain any useful history that would have alerted him to underlying conditions such as schizophrenia where amphetamines were absolutely contraindicated or in patients with cardiovascular disease including hypertension and the like. We do not accept that he was at all times so impaired that he did not appreciate that what he was doing was wrong and dangerous for his patients.
48Accordingly we find the particulars set out in Complaints 1 and 2 proven, and uphold Complaint 3. We find Dr Street guilty of professional misconduct.
49Complaint 4: As to Complaint 4, Dr Street formally admitted that he was suffering from an impairment.
50In his report of 10 December 2012, Dr Pethebridge said (at p 8):
Dr Street has clearly been impaired during two periods in his career. The first was when he was using omnopon in Darwin which he was aware was creating problems for him and was able to cease using with the help of a friend and career break. The second point was over recent years when he started to self-prescribe dexamphetamine at increasing doses. He was clearly affected by this medication when he was in his clinic. The reasons for commencing this drug were not clearly related to a known indication for this stimulant.
51We note that the evidence before us is that Dr Street's dexamphetamine consumption began as a result of a prescription given by a treating doctor based on a legitimate therapeutic indication. Later he began to self-prescribe. We would qualify Dr Pethebridge's statement to that extent.
52Despite Dr Street's formal admission of Complaint 4, there was, in our minds, some uncertainty as to whether that was, strictly interpreted, the position that he was putting at hearing. In his evidence at hearing he tended to put the view while once impaired he was no longer impaired, or at the least he was not impaired to an extent that might bear on his fitness to recommence practice.
53He appeared at times to be drawing a line between a past condition, which he acknowledged unreservedly was one of addiction (for the periods set out in the particulars to complaint 4) and what he saw as his present situation - no involvement with drugs for the last two years, a sound general state of health, and good mental functioning. In that regard he referred to the reports from doctors Brash and Lack, in particular.
54Dr Street has a history of addiction wider than is suggested by the particulars. It extends at least to a third type, alcohol addiction. Dr Street referred in his evidence to a pattern of heavy drinking when he was a medical student between 1972 and 1977, and further heavy drinking when he worked in Darwin between 1979 and 1981, and his entry into alcohol addiction recovery programs to address that issue.
55He also stated, and we accept, that there were long periods when he was successful in overcoming the various addictions. He referred to his active participation in support groups to assist him in that process (he mentioned in evidence Doctors in Recovery and Alcoholics Anonymous, and referred often to its Twelve Steps recovery program).
56Our conclusion is that Dr Street has struggled with drug and alcohol addiction throughout his career. While there are long periods when he has managed to avoid addictive behaviour they have recurred at intervals that suggest an underlying vulnerability that persists. We acknowledge that his present treatment regime and personal regime is working well, and the evidence is that he has no present aberrant behaviour.
57In his affidavit, Dr Street stated that he abstained from all drugs in the period 1982 to 2002, and this was not challenged. In that period he held appointments at the Mona Vale Hospital (in Accident and Emergency), 1982-1986 and in 1986 commenced psychiatric training at Royal North Shore Hospital under Dr Jurd. From 1993 on, he stated that he worked as a private psychiatrist at St Leonards, and ran several in patient clinics at Northside clinic. He was also appointed a VMO at Ryde and Hornsby Hospitals. During this period he was involved in Doctors in Recovery and in giving assistance to impaired doctors with addictions, such as alcohol and gambling. He said that around 1996 he was diagnosed with adult ADHD.
58He admitted that he was affected by addiction for the whole period 2002-2012. By the year 2000 he had moved to Swansea and taken up private practice. His evidence was that he retained a connection to Hornsby Hospital and that continued into the first part of the period after 2002. But for most of the period between 2002 and 2012, he practised in isolation as a sole practitioner. Dr Street acknowledged that in the 2004-2006 period he was deeply affected by addiction to amphetamines. He referred to the impact of divorce on his mental health. He was non-specific as to extent and duration of his misuse of amphetamines, but referred in his affidavit to reaching a point where he was regularly taking 75 tablets a day of dexamphetamine, in three divided doses. He referred in florid terms in his oral evidence at hearing to the depth of his situation in that period. He referred to the chaos of his family life, his failures in personal relationships and his inability to manage basic matters, such as household finances and paying bills, and the like, in circumstances, he said, where he had the means to pay.
59We are not satisfied that Dr Street does not continue to be affected by impairment. In these regards we note the following statements in Dr Brash's first report, each of which was the subject of cross-examination:
My own assessment of him tended to agree that he probably did have Attention Deficit Disorder with symptoms present from childhood that were presenting in adulthood with impulsivity, disorganisation and memory problems. ...
After several visits, Dr Street gave me further information about his misuse of dexamphetamine that had gone largely undetected for about 10 years and involved using eight different pharmacies.
My diagnosis is that he does have Attention Deficit Hyperactivity Disorder that it has probably been present all his life and has caused problems with disorganisation and impulse control. Unfortunately, this has also led to self-prescribing excessive amounts of amphetamine.
60Dr Brash stated in his second report in reply from a question from Dr Street's solicitors as to whether Dr Street's behaviour was a result of his addictions to amphetamines:
This is very clearly the case in my opinion. He was taking extremely large amounts on a daily basis and would have been behaving in an erratic way. At that time I had been told by some of his patients who I had seen for second opinions that Dr Street had painted his room completely black, had grown a long beard and looked unkempt, was commonly late for appointments and at times seemed to be somewhat distracted and confused. These behaviours are certainly consistence [sic] with someone taking very large amounts of psycho-stimulants.
61In answer to the next question, as to whether ongoing successful psychiatric treatment might be expected to address these behaviours, he said:
With abstinence and proper controlled prescribing of psycho-stimulants in normal therapeutic doses, these behaviours would be expected to change quite rapidly. In fact, this was very the case by the time he came to see me for treatment have was no longer abusing dexamphetamine he was behaving quite normally again.
62It is necessary to identify a present impairment to find the complaint proven (see Tung v Health Care Complaints Commission [2011] NSWCA 219 at [58], [60]). It is not necessary to define the condition suffered with a high level of precision, or in terms of narrow diagnostic labels (Grant v Health Care Complaints Commission [2003] NSWCA 73 at [11]).
63We find Complaint 4 proven, though we would describe the present impairment not in the way suggested by the particulars, but as a significant vulnerability to drug and alcohol abuse originating in a continuing ADHD condition.