Knowles v Health Care Complaints Commission [2025] NSWCATOD 145;

1. The substantive disciplinary proceedings came before the Tribunal on 6, 7 and 8 December 2021. The HCCC brought 17 complaints against Mr Knowles. On the first day of the hearing, the HCCC withdrew two of those complaints (Complaints One and Three) and withdrew a number of particulars to Complaint Eleven. Mr Knowles made admissions in relation to the balance of the complaints. The Tribunal found that all of the remaining complaints were established. The current proceedings are not a review of the disciplinary proceedings or the findings made but rather a review of the order pursuant to s 163B of the National Law. However, the complaints and findings are relevant in the context of our current assessment of Mr Knowles' fitness to practice and it is therefore apt to summarise the complaints and findings made.
2. The complaints related to:

(1) The inappropriate compounding and dispensing of ketamine between 2014 and 2015 on 312 occasions (Complaints Two and Four).

(2) Permitting hormones and peptides to be dispensed to a patient without knowing the patient's medical condition or having a reasonable basis for believing the peptides were prescribed for an appropriate therapeutic purpose (Complaint Five).

(3) Shortly before October 2014, supplying or permitting the supply of melatonin and thymosin beta 4 (which was not an approved drug) to a patient where the patient did not have a prescription for those drugs (Complaint Six).

(4) Between October 2010 and July 2014 permitting 12 prescriptions of the drug HCG to be compounded and dispensed on prescriptions from certain doctors for weight loss in circumstances where, amongst other things, the HCG was not supplied for a recognised therapeutic purpose (Complaint Seven).

(5) Between January and September 2014 permitting peptides to be dispensed on approximately 168 occasions, sometimes in combination with other peptides, without knowing the patients' medical conditions or having a reasonable basis for believing the peptides were prescribed for an appropriate therapeutic purpose (Complaint Eight).

(6) Between June 2014 and May 2016 permitting 7,951 prescriptions for peptides to patients to be compounded and dispensed without knowing the patients' medical conditions or having a reasonable basis for believing the peptides were prescribed for an appropriate therapeutic purpose (Complaint Nine).

(7) Between June and December 2014 permitting different peptides to be dispensed in combinations to four patients in circumstances where the directions on the prescriptions were vague and insufficiently clear and without knowing the patients' medical conditions or having a reasonable basis for believing the peptides were prescribed for an appropriate therapeutic purpose (Complaint Ten).

(8) Between December 2015 and February 2016 permitting phentermine to be compounded and supplied to 184 patients in circumstances where Mr Knowles did not provide appropriate information about the compounded drugs and, amongst other things, without taking reasonable steps to establish that the medication was suitable for the patients supplied (Complaint Eleven).

(9) Between September 2015 and October 2016 permitting testosterone with chrysin to be compounded and dispensed to patients on approximately 418 occasions in circumstances where Mr Knowles had not done any clinical trials to satisfy himself as to the safety and efficacy of the formulation, contrary to Guideline 2 of the Pharmacy Board of Australia (PBA) guidelines on compounding of medicine where there was insufficient information about the topical exposure of chrysin to be satisfied about its safety (Complaint Twelve).

(10) Between September 2015 in October 2016 permitting testosterone and zinc to be compounded and dispensed to patients on approximately 418 occasions in circumstances where there was a commercially available approved product with the Australian Register of Therapeutic Goods (ARTG) and where compounding and dispensing testosterone cream was contrary to Guideline 2 of the PBA guidelines on compounding medicines. (Complaint Thirteen).

(11) Between July 2015 and April 2016 permitting a topical preparation containing testosterone with SARMS 22 (a drug not approved by the ARTG) without a reasonable basis to believe the addition of SARMS 22 had any material effect on the therapeutic purpose of the product (Complaint Fourteen).

(12) Between July 2014 and November 2016 permitting a topical preparation including testosterone and DHEA (a drug which was not approved and had never been registered on the ARTG) to be compounded and dispensed to patients in circumstances where there was a commercially available approved ARTG product, combining and dispensing the topical preparation was contrary Guideline 2 of the PBA guidelines on compounding medicines and where Mr Knowles had no reasonable basis to believe that the addition of DHEA had any material effect on the on the therapeutic purpose of the product (Complaint Fifteen).

(13) Particulars in Complaints Four and Eight to Fifteen were relied on individually to establish professional misconduct (Complaint Sixteen).

(14) From February 2002 to around October 2006 entering into an arrangement to conduct a pharmacy business with a non-pharmacist in contravention of s 25 of the Pharmacy Act 1964 (NSW) (since repealed) by entering into an arrangement with a party in around February 2002 whereby companies controlled by that party referred prescriptions for compounded pharmaceuticals to Mr Knowles and the profits generated from dispensing those prescriptions were paid to the companies controlled by that person until around October 2006 and by dispensing products pursuant to that arrangement for periods for February 2002 and April 2003 to October 2006 (Complaint Seventeen).

1. The Tribunal examined the evidence and, independently of the admissions made by Mr Knowles, was satisfied that each of the Complaints referred to in [9] above was established (at [19]-[57] and [83]).
2. The Tribunal concluded:

(1) The conduct of Mr Knowles which was the subject of Complaints Two to Fifteen was "significantly below the standard reasonably expected" of a practitioner of an equivalent level of training or experience, as defined by s 139B(1)(a) of the National Law: at [70].

(2) Mr Knowles was guilty of "unsatisfactory professional conduct" in respect of the established particulars of Complaints Two and Four to Fifteen, as defined by s 139B(1) of the National Law, and his conduct was unethical: at [74].

(3) In respect of Complaint Sixteen, there were 13 instances of unsatisfactory professional conduct, which, when considered together amounted to conduct of a sufficiently serious nature to justify suspension or cancellation of registration: at [79].

(4) Mr Knowles contravened s 25 of the Pharmacy Act 1964 during a period when to do so was professional misconduct under s 19A of the Pharmacy Act 1964.

(5) If Mr Knowles was still registered as a pharmacist, the Tribunal would have cancelled his registration, and such an order was warranted by the extent, length and nature of the admitted conduct: at [93].

1. The Tribunal ordered, pursuant to s 149C(4)(b) of the National Law, that Mr Knowles be disqualified from being registered in the pharmacy profession for a period of three years from the date of the orders and that the Pharmacy Board of Australia was required to record the fact that the Tribunal would have cancelled Mr Knowles' registration in the National Register kept by the Board. The Tribunal also ordered that Mr Knowles pay the HCCC's costs of the proceedings.

1. Mr Knowles applied for a reinstatement order of his registration by application made to the Tribunal received on 7 May 2025. He stated in the application that he had complied "in full" with the orders made by the Tribunal handed down on 6 April 2022 (a reference to the orders which were the subject of the decision dated 31 March 2022).
2. In support of his application, Mr Knowles relied on an affidavit sworn 16 June 2025 to the following effect:

(1) Throughout his 35 years of practice, he had never received a complaint or report of harm from a patient or treating doctor.

(2) He had consistently dispensed millions of prescriptions without incident and, in agreeing to withdraw the application against his co-accused pharmacist manager, the HCCC acknowledged that there was no evidence of direct patient harm as a result of the conduct and the matter did not raise any novel principles that would justify depriving the Tribunal and the Council of resources to hear other cases.

(3) At the time of the allegations, ACP was the most accredited compounding pharmacy in Australia, being the only pharmacy to receive APB Guideline USP797 and USP795 accreditation from an external auditor (together the "USP standards"). The staff were Good Manufacturing Practice (GMP) trained by TGA (Therapeutic Goods Administration) approved educators, with courses co-written by himself and his co-accused pharmacist manager.

(4) In 2015, after receiving the complaint, Mr Knowles made the decision to elevate his operations by constructing a GMP facility licenced by the TGA for sterile and non-sterile compounding. He achieved this in October 2020 while addressing ongoing inquiries from the HCCC and the Pharmacy Council of Australia.

(5) Upon receiving the TGA licence for ACPharm, he closed the ACP compounding facility in 2020. He also licenced the ACP analytical lab, which had conducted quality control testing for ACP compounding medicines for 10 years. This unique facility was staffed with exceptional pharmacists.

(6) During this period, Mr Knowles experienced one of his greatest achievements, being awarded the title of the Fellow of the Australian College of Pharmacy in April 2019 for his contributions to modern compounding, research and education. He also received a certificate of appreciation from the University of Sydney Pharmacy Department for his contributions to the education and mentorship of numerous pharmacy students in GMP and manufacturing practices at ACP. He also obtained TGA clinical trial approval for his facility to develop an Australian made novel antibiotic combination for head trauma patients in ICU as prevention for pneumonia morbidity. This was a global 14,000 patient HREC Phase 3 trial sponsored by George Global Research Institute which ran from 2015 to 2021 with the goal of helping people in second world countries.

(7) Mr Knowles and his wife relocated to the NSW Central Coast in September 2021, and he continued working in his licenced facility as an unregistered pharmacist and general manager of operations until his retirement in October 2023.

(8) After becoming aware of the critical shortage of pharmacists in his local community on the Central Coast, leading to some local pharmacies temporarily closing due to the lack of registered locums, he decided to return to the pharmacy profession when possible.

(9) He commenced employment at Priceline Kincumber as a shop assistant under the supervision of Trent Playford and Victor Frangos in January 2024. He made significant efforts to become a valued and respected part of the team while complying with all relevant requirements for general registration as a pharmacist. To demonstrate his commitment to his employers and build on the progress made in his first year, Mr Knowles focused on enhancing his knowledge and expertise in community pharmacy arrangements.

(10) He assumed additional responsibility as a pharmacist under supervision, which included training junior staff and delivering small lectures on the quality use of medicines to local community groups. He now regularly worked on Thursdays and Fridays at Priceline Kincumber and Wednesdays at Amcal West Gosford. He had completed over 1400 hours under supervision and has received written references from the owners and managers of both stores.

(11) During this period, he rejoined the Pharmaceutical Society of Australia to complete his continuing education and has accrued over 60 continuing professional development points in the current year. He has reviewed the most recent pharmacy practice guidelines and regulatory changes.

1. The HCCC filed a Reply to the application on 7 July 2025, opposing the application, seeking a non-review period of 12 months for any subsequent applications for review under Part 8 of the National Law and an order that Mr Knowles pay the HCCC's costs as agreed or assessed under cl 13 of Schedule 5D of the National Law.
2. Mr Knowles filed a response to the HCCC dated 20 July 2025. He addresses each of the complaints previously made to the Tribunal with the reasons for his "change of mind in the light of the nature of Complaints 2 and 4 to 17 to give comfort to the Tribunal" that he will pose no threat to the public safety or public interest if reregistered. These detailed submissions, which comprise evidence given by Mr Knowles to support his application and on which he was cross examined, are referred to later in these reasons.
3. On 22 July 2025, the HCCC filed material relating to the application for re-instatement, which included material related to the disciplinary proceedings.

Reinstatement - relevant law and legal principles

1. Section 3(1) of the National Law relevantly provides that the object of the National Law is to establish a national registration and accreditation scheme for the regulation of health practitioners. One of the objectives of the National Law is 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": s3(2)(a)
2. The Tribunal is empowered to suspend, for a specified period, or cancel a registered health practitioner's registration if satisfied the practitioner is not competent to practise the practitioner's profession, the practitioner is guilty of professional misconduct, the practitioner has been convicted of or made the subject of a criminal finding for an offence where the circumstances of the offence render the practitioner unfit in the public interest to practise the practitioner's profession or the practitioner is not a suitable person for registration in the practitioner's profession: s 149C(1). If the practitioner is no longer registered, as was the case for Mr Knowles, the Tribunal is empowered under s 149C(4) to make the following orders:

(a) decide that if the person were still registered the Tribunal would have suspended or cancelled the person's registration; and

(b) if the Tribunal would have cancelled the person's registration, decide that the person is disqualified from being registered in the health profession for a specified period or until specified conditions have been complied with; and

(c) require the National Board with which the person was registered to record the fact that the Tribunal would have suspended or cancelled the person's registration in the National Register kept by the Board.

1. Because Mr Knowles was disqualified, he cannot make an application for registration as a pharmacist unless the Tribunal makes a reinstatement order under s 163B of the National Law: s 149E(1)(b) of the National Law.
2. The Tribunal is the "appropriate review body" for the purposes of Part 8, under s 163 of the National Law and exercises jurisdiction under s 163A of the National Law under its general jurisdiction in s 29 of the Civil and Administrative Tribunal Act 2013 (NSW) (NCAT Act).
3. Section 163B provides:

(1) The appropriate review body must conduct an inquiry into an application for review and may then do any of the following--

(a) dismiss the application;

(b) make an order ending or shortening the period of the suspension concerned;

(c) make a reinstatement order;

(d) make an order altering or removing the conditions to which the person's registration is subject, including by imposing new conditions;

(e) make an order--

(i) ending or shortening the period of a prohibition order; or

(ii) altering or removing the conditions to which the person is subject under a prohibition order, including by imposing new conditions.

...

(3) A "reinstatement order" is an order that the person may be registered in accordance with Part 7 if--

(a) the person makes an application for registration to the National Board; and

(b) the relevant National Board decides to register the person.

(3A) Any condition imposed on a person's registration by the National Board under Part 7 applies but only to the extent that it is not inconsistent with conditions imposed or altered by the appropriate review body under subsection (4).

(4) The appropriate review body may also impose conditions on the person's registration or alter the conditions to which the person's registration is to be subject under the reinstatement order.

(5) The order on a review under this section may also provide that the order is not to be reviewed under this Division until after a specified time.

1. Section 163C sets out the purpose, nature and scope of the review as follows:

(1) A review under this Division is a review to determine the appropriateness, at the time of the review, of the order concerned.

(2) The review is not to review the decision to make the order, or any findings made in connection with the making of that decision.

(3) In addition to any other matter the review may take into account, the review must take into account any complaint made or notified to a Council or a National Board, or a former Board under a repealed Act, about the person, whether the complaint was made or notified before or after the making of the order that is the subject of the review and whether or not the complaint was referred under Subdivision 2 of Division 3 or any other action was taken on the complaint.

(4) A Council and the Commission are entitled to appear at any inquiry conducted by the Tribunal under this Division.

1. The legal principles applying to a review under s 163C have been summarised by Brereton JA (Bell p and Emmett AJA agreeing) in Qasim v Medical Council of New South Wales [2021] NSWCA 171 at [16]- [19] as follows:

16. The proceedings below were an application, by way of review under s 163A of the National Law, for reinstatement. Such an application is an inquiry into present fitness, and not a review of the original decision in which the practitioner was deregistered. Although, under earlier legislation, the Medical Tribunal could revisit the earlier decision, the present legislation precludes that course, as s 163C of the National Law provides as follows:

[text of s 163C(1) and (2) omitted]

17. In conformity with s 163C(1), the task of the review Tribunal on a reinstatement application is therefore to determine the appropriateness of an order reinstating the applicant, as at the date of hearing the application. In performing that task, the Tribunal must have regard to the objectives and guiding principles of the National Law, which relevantly include the protection of the public by ensuring that only those practitioners who are suitably trained and qualified to practise in a competent and ethical manner are registered, the paramount consideration being the protection of the health and safety of the public.

18. The position of an applicant for reinstatement is disadvantaged by reason that presumptions of fitness, which might otherwise arise from an absence of contrary suggestion, do not operate for the benefit of an applicant who has been deregistered on the basis of unfitness. An applicant for reinstatement bears the onus of demonstrating that he or she can be trusted to practise in a way that conforms to the professional standards expected of a health practitioner and presents no risk to the safety of the public and their confidence in the profession.

19. Thus the essential task of an applicant for reinstatement is to show that he or she is no longer unfit. In this case, given that the sole basis of the appellant's deregistration was lack of competence by reason of an impairment, what the appellant had to demonstrate was that she was no longer unfit by reason of an impairment of such a nature and degree as impaired her mental capacity to practise. On that issue, she bore the onus of proof.

[citations omitted]

1. As such, the findings and orders made by the Tribunal in the disciplinary proceedings are not the subject of the review, however, they are nonetheless relevant because the decision records findings about Mr Knowles' fitness to practise at the time of the orders based on the evidence before the Tribunal. The findings relate to historical matters but evidence a pattern, over an extended period, of conduct found by the Tribunal to be significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience, unsatisfactory professional conduct and professional misconduct.
2. The task of the Tribunal is to assess at the time of this review whether we are satisfied Mr Knowles should be reinstated to practise. Mr Knowles bears the onus of satisfying us about this and consideration of whether Mr Knowles has insight into his previous conduct and what changes he has made and will make in the future are relevant to the question of whether he is "no longer unfit".
3. As observed by the Court of Appeal in Qasim, the critical issue for the Tribunal is to determine whether, having regard to the material before us, Mr Knowles "can be trusted to practise in a way that conforms to the professional standards expected of a health practitioner and presents no risk to the safety of the public and their confidence in the profession".

1. In additional to his affidavit (Ex A1) and response to the HCCC referred to above (Ex A2), Mr Knowles provided:

(1) His reflections in 2025 on professional practice standards (Ex A3).

(2) Certificate of Fellowship to the Australian College of Pharmacy (awarded 29 January 2020) and Certificate of Appreciation from the University of Sydney School of Pharmacy (22 October 2019) (Ex A4).

(3) Professional reference from Fiona Wolski dated 4 June 2025 (Ex A5).

(4) Professional reference from Trent Playford dated 5 June 2025 (Ex A6).

(5) Document relating to licences and accreditation for Australian Life Science Pharma and Verita Pharma Pty Limited (Ex A7).

(6) Curriculum Vitae for Mr Knowles (Ex A8).

(7) Reference letter from Michael Anderson dated 10 August 2025 (Ex A9).

(8) Response to HCCC written submissions filed 13 August 2025 (Ex A10).

1. The HCCC lodged a tender bundle including copies of the previous decisions of the Tribunal relating to Mr Knowles, transcript of the previous disciplinary proceedings before the Tribunal, selected material from the disciplinary proceedings, including an affidavit of Mr Knowles sworn 1 December 2020, complaints from the Pharmaceutical Regulatory Unit (PRU), expert evidence from the disciplinary proceedings and documents relating to proceedings in 2020 under s 150 of the National Law. The material also included emails between the HCCC and Mr Knowles regarding a request for further information and summons material produced by two of Mr Knowles' referees, Ms Fiona Wolski from the Amcal Pharmacy and Mr Trent Playford from the Priceline Pharmacy (Ex R1).
2. The HCCC provided further summons material from the West Gosford Amcal Pharmacy (Ex R2), an Evidentiary Certificate from AHPRA dated 18 August 2025 with details of Mr Knowles' registration, including registration restrictions, (Ex R3) and reasons for decision in relation to the 2020 proceedings under s 150 of the National Law (Ex R4).
3. Mr Knowles gave oral evidence and his referees, Fiona Wolski and Trent Playford, were cross-examined in relation to their references.

1. In his response to the HCCC's reply and written submissions, Mr Knowles lodged written responses (Exhibits A2 and A10) which comprise written argument about the decision that should be made by the Tribunal, by way of submissions, and assertions about factual matters, by way of evidence. He has also provided his reflections on professional standards (Ex A3).
2. It is convenient to summarise those responses insofar as they contain Mr Knowles' explanation for his previous conduct, what has changed and why Mr Knowles says his registration should be reinstated.

1. Mr Knowles states that this response is an addendum to his affidavit and at the outset observed that the complaint brought by the HCCC was pursuant to s 149C of National Law which did not apply to pharmacists such as himself because he was unregistered at the time of the Tribunal hearing. Mr Knowles appears to have overlooked or may not have been aware of the provisions of s 149C(4), which empowered the Tribunal to make this order.
2. The balance of the response document sets out Mr Knowles' written evidence in support of his case. In summary, Mr Knowles states:

(1) He understood and accepted the Tribunal's decision; he fully acknowledged the seriousness of his professional misconduct and the potential implications for patient safety and public trust in the pharmacy profession at the time and deeply regretted any actions that may have contributed to patient risk or diminish these standards of the pharmacy profession.

(2) Mr Knowles now realises fully the deficiency in his decision-making and training that led to these outcomes. To this end, he has over the past 10 years, since receiving the initial complaint, been committed to addressing the issues with "humility, accountability and resolve to uphold the highest standards of practise moving forward".

(3) Mr Knowles was an officer of an TGA registered facility and is now fully aware of his obligations under the Poisons and Therapeutic Goods Act 1966 and the regulations. While he made genuine efforts to comply with the relevant regulations and legislation, there were instances where he misinterpreted and, on reflection, ignored or flouted certain requirements. He now recognises that this led to actions that were not aligned with ethical or professional standards.

(4) Since this time, Mr Knowles has taken steps to educate himself more thoroughly and he has developed a clearer understanding of his legal and ethical obligations. He is committed to approaching all future decisions with greater diligence and integrity, ensuring that he will seek clarification if he needs it and he will act in accordance with both the letter and spirit of the law.

(5) In relation to the complaints about understanding safety requirements of off-label dispensing and essential risk assessment required before dispensing (Complaints 4, 7, 8, 10 and 12 to 15), he has undertaken training in risk management and clinical trial medication supply. The experience of a five year project with the TGA registered facility of Australian Life Sciences Pharma has given him new insights into the inadequate precautions and risk management that he conducted at ACP. For instance, he would have not proceeded with dispensing the off-label medications and acknowledges that some of his past decisions, while not intentionally harmful, were made based on a flawed understanding of his ethical and legal obligations.

(6) In relation to the complaints about a pharmacist's responsibilities to understand the intended purpose, patient needs and appropriate quantities of medication regardless of having a legal prescription (Complaints 2, 5, 6 and 9 to 11), he now understands the intended meaning of quantity and purpose and understands that the phrase "recognised therapeutic standard" underscores the expectation that pharmacists will exercise professional judgement to ensure that any supply aligns with evidence based therapeutic standards. He admits that his judgement in the circumstances outlined in the complaint was below the standard expected of a pharmacist of his training and experience.

(7) Mr Knowles accepts that compounded medicines, including peptides, are subject to additional scrutiny. He also accepts that his decision to compound various peptides and creams did not include sufficient evidence for their safe compounding. Mr Knowles states that he has changed his risk assessment process and would not compound these medicines given his learned insight. He further states that he now understands that his supply of compounded peptides, even on legal prescriptions, may not have met the recognised therapeutic standard required under the law, for which he now takes full responsibility.

(8) In relation to Complaint 17, Mr Knowles states that he successfully defended this complaint about pecuniary interest in the Supreme Court but now understands that he must consider further the implications to the profession as well as the pure legality of the situation. He states that if he was presented with this "opportunity" again, he would make a totally different decision.

(9) Mr Knowles deeply regrets any potential risk that his actions may have posed to patients and that, by compounding peptides, he inadvertently contributed to a practice that could undermine public confidence in the safety of compounded medicines. He states that pharmacist must act as gatekeepers, critically evaluating prescriptions to prevent inappropriate supply and that his failure to adequately scrutinise the therapeutic appropriateness of the peptides he supplied was a deviation from his professional duty. He acknowledged the supply of injectable ketamine for an off-label indication of treatment resistant depression may not satisfy the rigorous guidelines surrounding clinical trials. He further acknowledges that he did not have specific robust evidence to support the addition of certain medications.

(10) The complaints have prompted him to undertake a significant reflection on his practise and decision making process and he acknowledges that he should have been more vigilant in ensuring compliance with the relevant legislation and guidelines. To address these shortcomings, he has taken proactive steps by enrolling in the Pharmaceutical Society of Australia's Pharmacy Practice Guidelines in December 2024 and the TGA's 2020 public discussion for development of sterile compounding guidance. He has initiated a comprehensive audit of his dispensing practices from the time of receiving the complaints until he closed his compounding pharmacy in June 2020. He has also sought guidance and supervision from senior colleagues over the past 18 months and has implemented a more rigorous documentation process to record his rationale for supplying compounded medicines. He built and licenced a TGA sterile compounding facility and digital GMP documentation system between 2015 and 2020 which vastly increased his knowledge of compounded medicine.

(11) Mr Knowles has not practised for over four years and at the age of 67 years old, he has no intention of practising as a proprietor of a compounding or non-compounding pharmacy. He wants to be reregistered to respond to the critical shortage of a registered pharmacist in the Central Coast region.

(12) He is prepared to give further undertakings that he will not participate in modern or complex compounding other than that contained in the Australian Pharmaceutical Formulary (APF). He also undertakes to only work as an employed pharmacist and not to take any proprietor or ownership role in a pharmacy business.

Mr Knowles' reflections on continuing professional development

1. Mr Knowles states as he is not practised as a community pharmacist for four years reflecting on implementation of the newly released professional practise standards in pharmacy practise is important for his future practise. He states that he has completed 17 continuing professional development (CPD) modules and has gained greater understanding of such concepts of patient-centred care, interprofessional collaboration and ethical practice. Attached to this submission are details of the CPDs that Mr Knowles has completed. His implementation plan which sets out his CPD activities, includes the professional practice standards implementation program, the NSW opioid treatment program, diabetic eye disease, 1st and 2nd generation antihistamines, Blepharitis causes and management, age-related macular degeneration, conjunctivitis, atopic dermatitis, on managing uncomplicated cystitis, prostate cancer and the Priceline Pharmacist master class. According to the record produced by Mr Knowles, these courses were undertaken between October 2024 and February 2025 and the combined total of CPD points are over 40. He also states he had accumulated over 60 CPD points up to the time of the hearing.
2. Mr Knowles provides further reflections on the learnings from attending each of these courses. We have no doubt Mr Knowles has completed these courses.

Mr Knowles' response to the HCCC's written submissions

1. This document contains both submissions and statements made by Mr Knowles asserting certain facts or opinions. It is therefore apposite to summarise the effect of those assertions and opinions in the outline of the evidence.
2. In summary, Mr Knowles:

(1) Disagrees with the HCCC's "sparse description" of his grounds for reinstatement and further states that he has a long term commitment to remediation, he has gained new insight into his previously inadequate appreciation of the potential risks associated with extended medical supplies to patients, he let his passion for pharmacy and emotional desire to be perceived as helpful cloud his decision making, and he has undertaken a 10 year process of learning and contributing back to the industry as evidenced by the "humbling recognition" by two groups of his peers about his contributions to the profession.

(2) By way of expanding upon his long term commitment to remediation, Mr Knowles states that he has over the nearly 10 years since the original complaint in 2015 reflected upon his decision making and conduct leading to the 2015 complaint and has, over the past 10 years, taken steps to gain the necessary insight. He notes that the complaint of December 2019 was a second amendment of the original complaint and so he believes his insights and knowledge gained should be evaluated since 2015. Mr Knowles points to the fact that his practice was independently audited and accredited to USP standards and that he was the only pharmacist in Australia to achieve this.

(3) He notes that in his affidavit of 1 December 2020 in the disciplinary proceedings (referred to the HCCC submissions), he stated that he was not registered and that he undertook never to apply to be registered as a pharmacist in any jurisdiction. However, he gave this undertaking in the context of the HCCC agreeing to the complaint against his "co-accused" pharmacy manager being withdrawn. Mr Knowles also applied for the Tribunal not to make an inquiry into the complaint, and he attempted to negotiate the same arrangement. When this was not agreed to, he decided to rescind his offer at that time. The representation that he made in 2020 that he did not wish to reapply for registration was based on his circumstances at the time but since that time he has missed being a pharmacist serving in his local community. This should not be held against him.

(4) Mr Knowles also notes that the HCCC raises concerns about his employment in the past three years and about whether he was acting as an unregistered pharmacist. Mr Knowles states that the reference in his affidavit to working as an unregistered pharmacist was to indicate that he did not hold himself out to be a registered pharmacist. His role did not require him to make clinical decisions or deal with customers or patients. When he commenced working, his employers had full knowledge of his unregistered status and employed him as a pharmacy assistant grade 4 He has not worked in a role as a pharmacist and recognises that there is a distinction between a pharmacy assistant and an unregistered pharmacist.

(5) In his view, an unregistered pharmacist is someone who has completed pharmacy education but is not registered with AHPRA. They may work under the supervision of a registered pharmacist, but the scope of practice is limited to that of pharmacy assistant. A pharmacy assistant can work under the supervision of a registered pharmacist, but the assistant is limited to non-clinical tasks such as managing inventory, assisting customers and performing basic sales functions. His role has been focusing on supporting the registered pharmacist and store managers and to ensure compliance with pharmacy laws and regulations. If a patient has questions about their medication, they have health concerns or complex queries or there is need to discuss medication management, he refers those questions to the pharmacist.

(6) Mr Knowles states that he has acted in good faith and he has not represented himself to the general public as a qualified pharmacist or a pharmacist under supervision.

(7) Mr Knowles acknowledges the importance of adhering to legal requirements and states he has taken steps to comply with the National Law. He admits that the conduct warranting the disqualification was serious and occurred over a significant period of time. He further states that one of the reasons for the significant period for the conduct was that he had on several occasions visits from the professional standards unit (PSU) of the NSW Health Department during 2010 and 2015 but at no time did officers tell him he was contravening the legislation until nearly five years later. He states that if he had been told this in 2010, he would have immediately stopped his practice.

(8) Mr Knowles attributes much of his failure to uphold the requisite standards to a misinterpretation or a lack of understanding of the expectations of the governing standards that the period of conduct to the lack of immediate enforcement by PSU before December 2015. He further states that the fact that he had undergone extensive risk assessment and pharmacy practice guidance training confirms his ethical and risk management commitment as a pharmacy professional.

(9) Mr Knowles states that he takes full responsibility for his actions and now has a full understanding and insight of the risks he posed to the safety of his patients. His focus on the fact that there was no complaint from a customer or treating doctor relates to one of the reasons reportedly given by the HCCC in relation to his "co-accused', Mr Plummer. He submits that these statements do not demonstrate his failure to take account of risks associated with his conduct. He has undertaken many professional development courses both before and after the disciplinary proceedings and the HCCC "cherry picks" the fact that only two of the courses directly addressed the conduct which led to the original disciplinary proceeding. The HCCC has also excluded significant courses that he undertook prior to his 2025 CPD year, his 10 year process to change his practice regarding risk assessment and ethical decision making and his voluntary community service at local care homes, Central Coast Catholic health services and as a life force coach for the prostate Cancer Foundation of Australia. He has already achieved 61 CPD points in this year alone.

(10) Mr Knowles states that he has completely admitted the conduct of the complaint and it is "mischievous" of the HCCC to describe his evidence as merely "considerable progress". The HCCC has neglected to acknowledge the total revamp of his compounding practice between 2015 and 2020.

(11) Mr Knowles states that the restrictions he has proposed, which limit compounding to that contained in the APF, are reasonable and demonstrate his respect for regulatory standards.

1. Mr Michael Anderson, consultant pharmacist and reportedly past Pharmacy Council Member, provided a written referenced for Mr Knowles dated 10 August 2025. The reference states that Mr Anderson had the privilege of knowing Mr Knowles for his entire professional career as a pharmacist for a period spanning more than 45 years. He was aware that Mr Knowles was deregistered following some poor decisions made during his time as a pharmacy proprietor. Mr Anderson states that he believes Mr Knowles has used his period away from practice for deep reflection and personal growth. He further states that Mr Knowles is committed to making amends and if permitted is eager to dedicate the remaining years of his working life to serving the community once again. Mr. Anderson strongly supports any decision that enables Mr Knowles to return to his profession. Mr. Anderson did not give evidence at the hearing to expand upon this reference.
2. Mr Trent Playford, the joint owner of the Priceline Pharmacy at Kincumber and the Amcal Pharmacy at West Gosford, provided a written reference dated 5 June 2025. He also gave evidence at the hearing. The reference was also signed by Mr Victor Frangos, a friend of Mr Knowles and one of the other proprietors of the pharmacies. Mr Frangos did not give evidence at the hearing.
3. Mr Playford and Mr Frangos state Mr Knowles has worked under their supervision for the past 18 months. They have observed firsthand Mr Knowles' strong clinical knowledge, professionalism and his commitment to patient care. According to the reference, Mr Knowles has shown a comprehensive understanding of the ethical and professional standards required in pharmacy practice and his conduct under their supervision has reflected the level of accountability and care expected of a pharmacist seeking to return to the profession. They support Mr Knowles' application to re-register as a pharmacist and believe he would be a valuable and trusted member of the profession.
4. In his oral evidence, Mr Playford said that he was one of the proprietors of three pharmacies. They also operated a store at Newcastle. Mr Playford said that his business partner, Mr Frangos, approached him about Mr Knowles working at the pharmacy as a pharmacy assistant. Mr Playford was asked whether he knew about Mr Knowles' registration status at the time he employed him as a pharmacy assistant. He said that he knew that Mr Knowles was not registered but he did not know that he had been disqualified until the pharmacy was summoned by the HCCC. At the time Mr Knowles was employed he understood Mr Knowles did not want to become registered. When he provided the reference for Mr Knowles, Mr Knowles told it him that it was for his re-registration, but he did not know it would be used in proceedings before the Tribunal. The reference was prepared by Mr Knowles, which he read and agreed with and then signed. Mr Playford agreed that Mr Knowles had not been open about his registration status.
5. Mr Playford was questioned about Mr Knowles' role at the pharmacy. He said a pharmacy assistant can dispense but can only do so after this had been checked by the pharmacist. Mr Knowles had been dispensing medication but had been using the dispensing system under direct supervision. Mr Playford was asked why the dispensing records had not been produced and why, in response to a request for dispensing records, Mr Playford responded that there were no records. Mr Playford clarified this and said that he had understood this to mean dispensing records by Mr Knowles as a pharmacist and not as a pharmacist assistant.
6. Mr Playford was asked whether he had a conversation with Mr Knowles about his registration status after he became aware of his disqualification. Mr Playford said that he had not really had any conversation although he had read the decision of the disciplinary proceedings and he was now aware of the complaints made. He said the reference was provided before he was aware of this information. Mr Playford was asked whether this knowledge impacted his reference, and he said that it did not. He would still support Mr Knowles' re-registration. When pressed about this Mr Playford was asked whether he would support Mr Knowles but with "some reservations" now that he had more information. Mr Playford responded "perhaps" but also said that in the time that Mr Knowles had worked with him, he would not question Mr Knowles judgement. He agreed Mr Knowles had not been open with him and this was an issue, but he could understand why he did not disclose these matters at the time. While Mr Playford agreed while the recent information that had come to light may change his interacts with Mr Knowles, he had no concerns with his honesty and the work that he had undertaken for him as pharmacy assistant.
7. Mr Playford was asked if the Tribunal decided to reinstate Mr Knowles' registration, what supervision would he consider to be appropriate? Mr Playford said that there are strict controls on what goes on anyway so he did not believe there would need to be further restrictions. He also said that Mr Knowles had shown that he was open to learning new things and that he understands what is required and what needs to be referred to a pharmacist. The scope of practice for pharmacies had broadened over the years and it had been important for the pharmacy assistant to know when they need to refer matters to the pharmacist. He had no concerns about this with Mr Knowles.
8. Mr Playford said that Mr Knowles had undertaken the training provided by Priceline Pharmacy extracted in the tender bundle (Ex R1). One of the training courses Mr Knowles had attended was a My Health Records course. This assisted decision making for pharmacists in relation to products, but pharmacy assistants did not have access. Mr Knowles did not have access.
9. Ms Fiona Wolski, pharmacist manager and trainer at Amcal, West Gosford, provided a written reference dated 4 June 2025. The first part of the reference was almost in identical terms to the written reference provided by Mr Playford. Ms Wolski further stated that Mr Knowles had contributed meaningfully to the training and mentoring of junior staff, he had shown genuine dedication to remaining current with pharmacy practise developments and he currently already completed over 60 CPD points in that year. She stated that given the current pharmacist shortage in the Central Coast community and Mr Knowles commitment to re-engaging in the profession, she believed he had much to offer and that he had conducted himself with professionalism and integrity throughout her time working with him.
10. Ms Wolski gave evidence at the hearing. She said she was Mr Knowles' supervising pharmacist at Amcal. She first met Mr Knowles in July 2024. At the time he commenced working in July 2024 she was not aware that he had been disqualified and only became aware of this at the time of receiving the summons. Ms Wolski said that she was asked to complete a reference for Mr Knowles. She completed the first draft and Mr Knowles then assisted with final draft. At the time she prepared the reference she knew that Mr Knowles had worked as a pharmacist in compounding and understood he had retired and now wanted to come back to work. She said she had not read the decision disqualifying Mr Knowles, although she had an article about his case which Mr Playford had sent to her. Ms Wolski was asked whether the fact that Mr Knowles did not tell her about the disqualification and she was not aware of this at the time she prepared her reference changed her views. She said this did not change her views because the disqualification was about Mr Knowles' role as a compounding pharmacist and he would be working as a community pharmacist, which was different. She also said that she did not question Mr Knowles about the disqualification when she found out because she considered that there was no need to do so.
11. Ms Wolski said that all pharmacy assistants had a supervising pharmacist and if a pharmacy assistant dispensed medication this would be checked by the pharmacist. A pharmacy assistant cannot sell pharmacy medication without the supervision of a pharmacist. She also said, like Mr Playford, that when the pharmacy was requested to produce records relating to dispensing, this was taken to mean dispensing by Mr Knowles as a pharmacist. As such no records were produced. She said that a pharmacy assistant can give the medication to a customer, but it depends on whether there is a need for instruction. If instruction was required, this would be done by a pharmacist. In short, Ms Wolski said that Mister Knowles was working as a pharmacy assistant not a pharmacist. She also said that, from her observation, he did not hold himself out to be a pharmacist when he was working with the public.
12. She did not know the history of Mr Knowles' case but said she had never seen him do anything unsafe as a pharmacy assistant. She was also asked whether Mr Knowles had ever been allowed to answer questions about medications given that he had knowledge over and above that of a pharmacy assistant. She said that Mr Knowles would only ever do this if he checked with her first.

1. Mr Knowles was questioned by counsel for the HCCC about four key areas.
2. The first was about his failure to tell Mr Frangos, Mr Playford and Ms Wolski about the circumstances leading to his current registration status. The second related to representations made in the previous proceedings about whether he would apply for re-registration.
3. Mr Knowles said that he had known Mr Frangos since university days. He and his wife had decided to move to Avoca in 2022 to retire but when he went to the pharmacy where Mr Frangos was working, Mr Frangos came out to see him and suggested that he may want to work in the pharmacy as a pharmacy assistant. Mr Frangos knew that Mr Knowles was not registered but Mr Knowles did not discuss his disqualification with him. Mr Knowles was asked why he did not raise this with Mr Frangos or the other pharmacists, and he said that he was not proud of it. He was also asked whether this would have been a relevant matter to discuss, and Mr Knowles said it was not relevant to his role as a pharmacy assistant. However, he agreed that it did not give the other pharmacist the full history.
4. Mr Knowles said that he decided to re-register about nine months after working with customers in the pharmacy. He acknowledged that he had previously signed a statutory declaration to the effect that he would not seek to be re-registered and that this was for the purposes of his application to have the proceedings discontinued (referred to in paragraph 21 of the disciplinary proceedings decision). However, he said that he made this representation in the context of the decision made by the HCCC to withdraw the complaint against Alan Plummer, noting that one of the grounds for the withdrawal was that Mr Plummer would not seek to re-register as a pharmacist.
5. As set out in his written statement, Mr Knowles stated that he changed his mind when the HCCC did not withdraw the complaint against him. He said that this undertaking was conditional as far as he was concerned and he would only give the undertaking if the complaints were withdrawn. Mr Knowles said that he considered that there was inequity in the approach taken as between he and Mr Plumber, although it was pointed out to him that a key difference was that he was the proprietor of ACP and Mr Plumber was the pharmacy manager.
6. Mr Knowles was asked about whether he had taken full accountability for the complaints given he had failed to discuss those matters with Mr Frangos and the other supervising pharmacists, Mr Playford and Ms Wolski. Mr Knowles said that he was embarrassed and in retrospect he should have been honest about the disqualification and told the pharmacists the full story. He was then asked whether he had sought references under "false pretences". Mr Knowles had not told each of the referees that the references would be used in proceedings before the Tribunal. Mr Knowles said that he asked for those references before he realised that he needed to make an application to the Tribunal under s 163B of the National Law. However, counsel for the HCCC pressed Mr Knowles on this issue, noting that he must have known this at the time he asked for and obtained the references because his application for reinstatement was dated 2 May 2025 and was filed on 7 May 2025. He had participated in a directions hearing on 4 June 2025 where orders were made about the evidence to be filed.
7. Mr Knowles was also questioned about whether he really had changed his mind and whether his evidence could be relied on more generally given that the only explanation that he gave for not being truthful with his referees was that he was not aware that there would be proceedings. For the reasons outlined above, the HCCC contended that this could not be correct. Later in the hearing, after having been presented with this inconsistency, Mr Knowles said that he did not see this as a material matter to discuss with these referees at the time and he apologised to the Tribunal for his lack of understanding about the system. However, there is an inconsistency between this evidence and the earlier evidence, which was a matter raised directly with Mr Knowles by the Tribunal. Mr Knowles did not explain the apparent inconsistency. Overall, Mr Knowles' explanation for the failure to disclose these matters to the referees was unconvincing.
8. Mr Knowles was also asked about who wrote the references because they were similar. He said that he and Mr Playford discussed the contents, but Mr Knowles prepared the draft, and Mr Playford signed it. However, Mr Knowles was of the view that the information contained in the reference was Mr Playford's belief. Ms Wolski prepared much of her draft. Ultimately, little turned on this.
9. The third aspect that Mr Knowles was questioned about were the apparent inconsistencies between assertions made by him in the disciplinary proceedings and the current assertions made in his affidavit and submissions dated 20 July 2025 to the effect that he had acknowledged his previous deficiencies and had changed.
10. One example was the challenge made by Mr Knowles to the disciplinary proceedings where he requested that the Tribunal exercise its discretion not to make an inquiry into the complaint by the HCCC. Mr Knowles was asked about paragraph 18 of the 2021 decision, which recorded Mr Knowles' contention that the complaint was "vexatious" and that the Pharmacy Council of NSW had subjected him to a "targeted vendetta" in circumstances where "his only crime was to be the first and largest compounder of modern complex compounded medicines in Australia". It is also recorded in the decision that Mr Knowles contended that as part of this vendetta the Council and the HCCC subjected former ACP staff to "uncalled for treatment, public humiliation bullying and career-destroying actions".
11. Mr Knowles was asked to reflect on this submission and whether he still has those views about the complaints made by the HCCC given he now says he accepts the findings made by the Tribunal, based on those complaints. Mr Knowles said he has reflected on this but still believed that the staff at ACP lost their jobs because the Pharmacy Council of NSW closed down ACP with "little or no reason". When it was pointed out to Mr Knowles by counsel for the HCCC that the reason why ACP had closed was because of the complaints made against him and the subsequent investigations and the suspension of his licence, Mr Knowles did not accept that this was the case. In response to this evidence, the HCCC tendered the written reasons of the Pharmacy Council of NSW in respect of three proceedings under s 150 of the National Law in 2020 (Ex R4).
12. Section 150(1) of the National Law provides that a Council must, if anytime it is satisfied it is appropriate to do so for the protection of the health or safety of any personal or persons or if satisfied the action is otherwise in the public interest, suspend a registered health practitioner's registration or impose any conditions relating to their practice that the Council considers appropriate. Before taking such action come up the Council must give written notice before taking such action and give reasons for the action.
13. In this case, the Pharmacy Council of NSW gave notice to Mr Knowles about concerns it had, based on complaints received. The Pharmacy Council imposed conditions on Mr Knowles' registration following a hearing on 23 April 2020, with reasons dated 11 May 2020, varied the decision following a hearing on 19 May 2020, with written reasons dated 16 June 2020, and suspended Mr Knowles' registration, following a hearing on 6 July 2020 with written reasons dated 3 August 2020 (Ex R4).
14. After being taken through the various hearings culminating in Mr Knowles' registration being suspended, Mr Knowles was asked whether he now accepted that it was not the "fault" of the Pharmacy Council or the PRU that 26 ACP staff lost their jobs but rather this was a consequence of Mr Knowles' registration being suspended. This suspension was based on complaints made about Mr Knowles' practice following hearings by the Pharmacy Council and the reasons recorded in Ex R4. Mr Knowles conceded that this was the case but said that he had changed and the Tribunal should take into account the work he had done between 2015 and 2020 to improve standards. He also submitted that the last complaint was 2016 but, in any event, (as submitted in his affidavit of 16 June 2025 at para 2), he had "never received a complaint or report of harm from a patient or treating doctor" throughout his 35 years of pharmacy practice.
15. Mr Knowles was then taken to the decision of the Pharmacy Council dated 11 May 2020 (Ex R4) which related to a complaint initiated by the Pharmacy Council on 1 April 2020 for compounding at ACP in contravention of the Therapeutics Goods Regulation 2008 and the PBA guidelines on Compounding Medicines. The decision records at [2] the allegation ACP was compounding certain products for dental practitioners in circumstances where the products were compounded in batches or manufactured without a TGA manufacturing licence, were not compounded in receipt of a prescription, were not compounded for an individual patient and were will not labelled for an individual patient and were being used for off-label use where appropriate risk assessments were not conducted. The decision recorded, amongst other things, that that there was no evidence risk assessments were conducted for individual patients and that the expiry date for most of his products was three months yet the USP only an allowed an expiry date of 24 hours without extensive tense testing. Mr Knowles accepted that the complaint that was the subject of the decision made by the Pharmacy Council dated 11 May 2020 was evidence of a more recent complaint. He also said that he now understood the fact that there was "no evidence" of reported harm does not mean that there was in fact no harm or, at least, the potential for risk and harm.
16. Mr Knowles was also referred to the finding made by the Pharmacy Council in its decision dated 3 August 2020 at paragraph 70 where it was noted that Mr Knowles had presented to the council an "independent" audit report from Verify Compounding as evidence to demonstrate ACP's compliance with the Council's premises and equipment guidance for non-sterile complex compounding. The author of the report was Brianna Porter who was also known as Brianna Knowles, Mr Knowles' daughter. The decision notes that while Mr Knowles did not deny this during the s 150 proceeding once it was raised, he did not disclose this when he provided the report to the Council "in an attempt to portray it as an independent report in support of his requests for a review an alteration of conditions". It was put to Mr Knowles that his conduct with his current employers in failing to disclose important relevant information was similar to the conduct in 2020 where he had not been fully frank. Mr Knowles asked if this was an example aware he was not being open and honest. Mr Knowles said that he was telling the truth today and he now realises his mistakes. At that time of the s 150 proceedings, he was trying to save his business, and he realises that he made some very poor decisions.
17. The fourth area that Mr Knowles was questioned about was the assertion made in his submissions filed with the Tribunal on 13 August 2025 to the effect that it was the delay of the PRU in taking action that caused problems for him and if this had been brought to his attention earlier, he would have stopped his conduct. Counsel for the HCCC raised that this appeared to be inconsistent with paragraph 4.3 of his 20 July 2025 submission to the effect that he had ignored or flouted certain requirements. Mr Knowles said that he did not do this intentionally.
18. After giving his evidence and being cross examined by the HCCC, Mr Knowles was questioned by the Tribunal.
19. Given that one of the findings made by the Tribunal in its disciplinary proceedings was that his conduct was unethical, Mr Knowles was asked about what changes he had made and what had he learned in relation to this issue. Mr Knowles said he learned that even though something was legal, he had still made some poor ethical decisions. He accepted that even though he was the proprietor of ACP, he bent the rules based on client's desires and not based on their best outcomes.
20. Mr Knowles was asked whether providing references to the Tribunal where he had not disclosed either to the referees or the Tribunal all circumstances was consistent with ethical practice. Mr Knowles said this was an oversight and he apologised to the Tribunal for this. He was also questioned about the explanation for his previous contraventions contained in his affidavit and submissions to the effect that he had wanted to please customers, even where to do so could be detrimental to providing the optimal and clinical solution and could amount to a breach of professional boundary standards in the Code of Conduct. Mr Knowles was asked about how he would be able to resist this, even while working in a community pharmacy. Mr Knowles said he now understood that his legal obligations would override what a customer or treating practitioner wanted. He also said there was the added precaution that he would be watched by the other pharmacists. Mr Knowles was asked whether he had identified this issue with the other pharmacists and had discussed it with them. He said that he had not discussed it with the other pharmacists, but he had discussed it with another very experienced pharmacist, David Preswick. He said that he had discussed these issues with David Preswick in recent years on an informal and ad hoc basis. Mr Knowles was asked why Mr Preswick did not provide a written reference and he said that there had not been enough time left for him to obtain a reference.
21. Mr Knowles was asked whether he had received any professional health counselling or mentoring over the years to gain further insight into and learn strategies to deal with the risks of crossing professional boundaries. He said that he had not. Mr Knowles was also asked whether he had considered attending any additional ethics courses such as through the St James Ethics Centre. He said he had not done so but would consider this.

1. The question for the Tribunal is whether, having regard to the evidence before the Tribunal about Mr Knowles current circumstances, his registration should be reinstated.

1. Prior to the hearing, the HCCC submitted that the Tribunal should not order reinstatement and should further order a non-review period of 12 months for subsequent applications. The HCCC further submitted that Mr Knowles' conduct warranting the disqualification was serious and occurred over a significant period. In his written submissions, Mr Knowles attributes much of his failures to uphold the requisite standards on misinterpretation or a lack of understanding of the governing standards and requirements. His evidence does not adequately address how he will ensure such misinterpretations do not occur in the future and how such lapses in judgement should not occur.
2. Mr Knowles' submission during the course of the disciplinary proceedings and in support of this application was to the effect that there was "no evidence" of any actual or probable theoretical harm to a patient and this demonstrates a failure by Mr Knowles to take accountability for the risk associated with his conduct. While Mr Knowles has recently demonstrated some acknowledgement of key ethical failings, there is limited evidence to demonstrate that he understands his ethical obligations or that he has undertaken to develop this. The evidence of the numerous professional development courses he has undertaken do not demonstrate his commitment to ethics and there are only two program that he has undertaken that would address the conduct which was the subject of the proceedings.
3. The HCCC expressed concern about Mr Knowles' written evidence that he was working as a "pharmacist under supervision", which suggests that he may have been practising while unregistered. This evidence needed to be tested but if there was evidence that Mr Knowles has been practising as a pharmacist under supervision while disqualified, this would weigh heavily against reinstatement of his registration. The HCCC submits that there is a lack of information concerning Mr Knowles work at his TGA licenced facility following the disciplinary proceedings.
4. While the HCCC accepts there is evidence to indicate Mr Knowles is remorseful for his actions, there is little evidence that he has insight into the seriousness of the conduct or that there are processes in place to ensure such failings do not occur in the future. Notably, Mr Knowles has only completed limited courses related to ethics.
5. Mr Knowles submits he is willing to accept restrictions on practise that he will not participate in modern or complex compounding other than what is contained in the APF and that he will only work as an employed pharmacist and will not take any proprietorship or ownership role in a pharmacy business. However, the HCCC submits that this is not adequate. If Mr Knowles wants to resume compounding, the proposed restrictions only confine the medicines that can be compounded yet the severity of the complaints which were the subject of the disciplinary proceedings goes beyond this.
6. In closing oral submissions at the end of the hearing, the HCCC maintained its position and further contended that, while Mr Knowles' compounding practice and his proprietorship was the subject of a number of serious complaints, the inappropriate dispensing of medications had also a significant problem. It was not clear that the restrictions proposed by Mr Knowles would resolve these issues.
7. The HCCC accepted that Mr Knowles had acknowledged a number of important issues relating to his previous conduct but submitted that the Tribunal should not be satisfied that Mr Knowles has sufficient insight into those issues. This was demonstrated by the fact that he was not frank, open and honest about the nature of the references that were provided to the Tribunal or in his disclosures to the referees. There was also relevant that Mr Knowles sought to minimise in his evidence the seriousness of the concerns raised in relation to the references and in relation to the seriousness of some of the previous conduct. The HCCC also noted that Mr Playford supported Mr Knowles but with some reservation. Mr Knowles has come a long way, but the HCCC submitted more work is required, which is why the HCCC submitted that the Tribunal order a non-review period of a further 12 months.
8. The HCCC submitted that if the Tribunal was minded to order reinstatement, it should do so subject to eight conditions including: a prohibition on Mr Knowles having a financial interest in a pharmacy business and from practising as the sole proprietor or as pharmacists in charge, registration to practise under Category B supervision in accordance with the Pharmacy Council compliance policy with a supervisor approved by the Pharmacy Council, providing reports to the Council at two monthly intervals or as specified by the Council, notifying any pharmacist in charge of his conditions on registration before commencing to practise, a prohibition in undertaking the compounding of medicines for human or veterinary use, providing a CPD plan for 2025/26 and completing within 12 months a course in Ethics and Dispensing in the Pharmacy Practice course organised by the Pharmaceutical Society of Australia.
9. The reference in the proposed conditions to Category B supervision relates to one of the categories of supervision set out in the policy and guidelines published by Pharmacy Council (Pharmacy Council of NSW website). There are three categories of supervision: Category A, which provides for direct supervision at all times with the supervisor practising at the same location as the pharmacist and undertaking weekly review meetings and reports to the Council once a month, Category B supervision where the supervisor is to monitor and provide indirect supervision and be readily available to provide assistance or direct supervision as required, with the supervisor to practise at the same location as the pharmacist but may, in exceptional circumstances be off site with fortnightly review meetings and reports to the council every three months, and Category C supervision, which is indirect supervision (not at the same location) with the supervisor being able to be contacted by telephone with monthly review meetings and reports to the Council every six months.

1. In support of his application and in response to the submissions of the HCCC, Mr Knowles contends that he is not only remorseful, but he has changed and has insight in relation to the conduct which was the subject of the disciplinary proceedings. He has abided by the Tribunal orders and has not worked as a pharmacist in his own right or under supervision. The reference to working as an unregistered pharmacist under supervision was not intended to convey that he was working as a pharmacist but merely an acknowledgement that he was unregistered.
2. Mr Knowles submits that he changed his mind about seeking reinstatement because he wants to contribute to the profession and the community. He wants to continue to learn and has undertaken significant professional development over the last 10 years. His referees have given evidence they would still offer him a position, even knowing about his deregistration. He would like to help his colleagues and the community. He has learned that actions may be legal but not ethical and that risk assessment goes "hand in hand" with ethical considerations. He concedes he was out of his depth in his compounding practice, and he now understands that there is a need to practise safely and that the absence of actual harm is not enough.
3. Mr Knowles submits that the Tribunal should not look at the position as it was 10 years ago but now. The Tribunal should not focus on the past and the disciplinary proceedings. He is a changed man, he is "more humble".
4. Mr Knowles further submits that he is prepared to offer an undertaking that he would refrain from engaging in compounding in breach of the APF guidelines, he would not take an ownership role in a pharmacy, and he would be prepared to complete 400 hours of supervision by a pharmacist in charge. He did not want to submit to Category B supervision but would agree to Category C supervision. He agrees not to engage in compounding in breach of the APF guidelines and otherwise would agree to the additional conditions proposed by the HCCC.

1. The conduct that was the subject of the 2021 proceedings was serious and covered an extensive period, although we accept that the most recent conduct which was the subject of the findings was November 2016. We also accept that these matters were considered by the Tribunal at that time and that Mr Knowles was disqualified for three years based on the available evidence. These proceedings are not a review of that decision, and the purpose of the jurisdiction is to protect the public, not for punishment of the former practitioner. As observed by the Court of Appeal in Qasim at [16], an application for reinstatement requires that the Tribunal make an inquiry into present fitness. An applicant for reinstatement bears the onus of demonstrating that he or she is no longer unfit because they "do not have presumptions of fitness, which might otherwise arise from an absence of contrary suggestion": at [18]-[19].
2. In a case such as this, an applicant must satisfy the Tribunal that the conduct which was the subject of the previous disciplinary proceedings will not happen in the future if the applicant is reinstated to practise. Mr Knowles contends that this is the case, and the Tribunal should be satisfied that he is now fit to practise.
3. As observed by the Tribunal in Shah v Health Care Complaints Commission [2014] NSWCATOD 94 in summarising the relevant considerations in reinstatement cases at [34] as follows:

• the applicant bears the onus of proving that he is a fit and proper person to be engaged in the profession of nursing as an endorsed enrolled nurse (see [41] and the authorities there referred to);

• the standard of proof to be applied by the Tribunal is the civil standard of proof, the balance of probabilities, tempered by the requirements of Briginshaw v Briginshaw [1938] HCA 34; (1938) 60 CLR 336); (see [41] and the authorities there referred to; see too In Re Jason Martin [2010] NSWMT 13 at [41]);

• the purpose of the jurisdiction is "not punishment or further punishment" of the former practitioner, rather the jurisdiction is exercised is for the protection of the public (see [47] and the authority there referred to);

• the power to reinstate should "be exercised with great caution and only upon solid and substantial grounds" (see [48] and the authority there referred to);

• there is no public interest in denying forever the chance of redemption and rehabilitation to former practitioners. The public is better served if, in appropriate cases, those who have offended, once they have affirmatively proved reform, are afforded a second chance (see [49] and the authority there referred to);

• in making an assessment of the applicant's worthiness and reliability for the future the Tribunal may draw inferences from what has happened in the past and, in particular, what led to their being removed from the Register. At [50] the Tribunal referred to In Re Jason Martin [2010] NSWMT 13 where the Medical Tribunal pointed out it is not "a question of what an applicant has suffered in the past. It is a question of his [her] worthiness and his [her] reliability for the future". That Tribunal noted the difficulty associated with predicting how a practitioner would behave in the future and remarked that "the decision in the particular case is to a greater or lesser extent dependent upon the Tribunal's assessment of the applicant".

1. Matters that may be relevant to the question of whether Mr Knowles is fit to practise include Mr Knowles' insight into the previous established misconduct, evidence of any change in attitude, whether he has demonstrated genuine and sincere remorse for his previous conduct, evidence of further training, education and professional development directed to the issues which were the subject of the disciplinary proceedings and evidence of any suitable conditions or supervision and mentoring, if necessary, to provide guidance and checks and balances in the initial stages of reinstatement to practise.
2. Mr Knowles provided detailed written statements and submissions directed to these matters. He also provided details of the professional development undertaken by him over the past few years, evidence of certificates of recognition or appreciation in 2019 and 2020, evidence about Mr Knowles operation of TGA licenced facilities and professional references. Mr Knowles gave oral evidence in support of his application and put forward two referees who also gave oral evidence.
3. Despite Mr Knowles' detailed written submissions and oral evidence, we are not satisfied that his registration should be reinstated at this time, with or without conditions. We further order, consistent with the HCCC's contention, that Mr Knowles is not entitled to seek a review for 12 months from the date of this order under s 163B(5) of the National Law.

Why have we decided to refuse Mr Knowles' application and to make a non-reviewable order?

1. In summary, we agree with the HCCC that Mr Knowles has come a long way since March 2022, but we are not satisfied his registration should be reinstated at this stage. We also find that a further period of reflection before he can make another application would give Mr Knowles the opportunity to undertake mentoring or counselling to address the current concerns identified.
2. Mr Knowles has the onus to establish that he is now fit to practise. The findings made by the Tribunal in the disciplinary proceedings were serious and remain relevant to our consideration. While Mr Knowles has addressed some aspects, especially in his written material, we are concerned about whether Mr Knowles has sufficient insight into his conduct such that we could be confident of real change.
3. In considering the exercise of this discretion under s 163C(1)(c) we must have regard to ss 3A and 3B of the National Law which state:

3A 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.

3b In the exercise of functions under a NSW provision, the protection of the health and safety of the public must be the paramount consideration.

1. There is material before us in Mr Knowles' favour but, on balance, we are not satisfied that he understands the importance of ethical practise, accepts the seriousness of the potential for harm caused by his unsatisfactory professional conduct and professional misconduct or that he has yet taken all necessary steps to educate himself about these matters. For instance, if Mr Knowles were to engage in compounding and dispensing to please customers or treating doctors without knowing the patient's medical condition or having a reasonable basis for believing the medication prescribed was for an appropriate therapeutic purpose, there would be a risk to public health and safety. This is contrary to the objective under the National Law that the protection of the health and safety of the public must be paramount consideration.
2. Mr Knowles has worked as a pharmacy assistant for the past 18 months. The HCCC raised concerns about whether he has been actually undertaking functions of an unregistered pharmacist. The HCCC relies on the wording in Mr Knowles' affidavit, which referred to him working as a "pharmacist under supervision". Mr Knowles criticises the HCCC for raising this issue without proof.
3. If Mr Knowles had been undertaking pharmacist duties, this would be a breach of the orders and would be in contravention of the National Law. This would be a serious matter that would weigh heavily against his reinstatement and may have been, without a cogent and persuasive explanation for the breach, a decisive factor against Mr Knowles. The HCCC was correct to raise this and to test the evidence.
4. Mr Knowles explanation, together with the evidence of Mr Playford and Ms Wolski is persuasive. The wording used by Mr Knowles in his affidavit is somewhat loose and on face value conveys the meaning that Mr Knowles is performing an unauthorised role. However, both Mr Playford and Ms Wolski, who were extensively questioned about this issue, supported Mr Knowles' evidence that he had a limited role. We accept their evidence.
5. Mr Knowles referred to himself in his written material and in his oral evidence as a pharmacist who was unregistered. He still sees himself as a pharmacist after many years of practise and his evidence demonstrates his pride in his profession and in his previous achievements. There would have been a strong temptation for Mr Knowles to go beyond his more limited role while working in the pharmacies. However, there is no evidence that Mr Knowles has done so and this counts in his favour.
6. We also accept Mr Knowles' evidence that when he initially commenced working at the Amcal and Priceline Pharmacies on the Central Coast, he did not have an intention to return to practise. In the absence of evidence to the contrary, we accept that his decision to apply for re-registration was made more recently, probably at the time when he was coming up to the expiry of his disqualification. The fact that Mr Knowles gave an undertaking in the context of the 2021 application does not compel a conclusion or even lead to an inference that he gave the original undertaking without having an honest belief that he would comply with such an undertaking in the future. We accept Mr Knowles' evidence that this was an undertaking proffered in the context of the 2021 application for dismissal. Because the proceedings were not dismissed and resulted in the findings made by the Tribunal in the disciplinary proceedings, there was no obligation for him to comply with such an undertaking. Relevantly, this was not an undertaking that was referred to or factored into the Tribunal's consideration of the matter in the disciplinary proceedings. As such, we accept that Mr Knowles simply changed his mind about seeking re-registration.
7. In his first affidavit in support of his application, Mr Knowles focused on his achievements, the fact that he had 35 years of practice and that he had consistently dispensed millions of prescriptions without incident and without evidence of harm. He did not refer to the disciplinary proceedings or the complaints which were the subject of those proceedings and did not express any contrition or remorse for his previous conduct. It was not until these issues were raised by the HCCC that Mr Knowles acknowledged certain failings in his detailed written response dated 20 July 2025.
8. Even though Mr Knowles acknowledged the complaints and failings in his second written response, the force of this response is diminished by inconsistency with some of his submissions in the 2021 interlocutory application for dismissal and in his oral evidence before this Tribunal. For instance, Mr Knowles gave evidence in these proceedings justifying his submission in the 2021 application that the action by the Pharmacy Council complaint was vexatious and unnecessarily caused ACP to close down and the loss of jobs. As outlined above, Mr Knowles adhered to his evidence during his cross examination and it was not until he was taken to the detail of the s 150 proceedings, that he eventually resiled from this position. This demonstrates that Mr Knowles not only rejected the legitimacy of the Pharmacy Council complaints in 2021 but maintained this position in these proceedings. This belies his statement that he now fully acknowledges the seriousness of his professional misconduct and the potential implications for patient safety in public trust.
9. Despite his written acknowledgement of the seriousness of his previous conduct which was the subject of the disciplinary proceedings, Mr Knowles had a tendency to minimise this by characterising his misconduct narrowly as "only" relating to his compounding practice and his role as a proprietor. He overlooked that many of the complaints also related to inappropriate dispensing and concerns about patient care and blamed the PRU for failing to take action sooner.
10. Mr Knowles further submitted that the conduct in question was ten years old and that the HCCC had not taken into account his ten years of improvements and achievements or his recent CPD and the work he had undertaken as part of licencing a TGA approved facility. However, this assertion did not acknowledge the complaints made in 2020 that were the subject of the s 150 proceedings, which he later conceded after he was taken to the relevant material. Nor did his evidence about the TGA licenced facility explain or support his contention that the licencing process had improved or would improve his practise and insight about patient care.
11. At the core of a number of the complaints was Mr Knowles' failure to recognise the ethical considerations in providing unproven and untested compounded prescriptions to patients. Mr Knowles described this practise as being driven by his desire to please patients. While this may be so - still raising a serious concern - such a description fails to recognise that some of the complaints related to, and were possibly driven by, the profitable volume compounding and dispensing model operated through ACP. Mr Knowles does not expressly acknowledge or identify the potential for financial conflicts as an ethical consideration in his evidence to the Tribunal.
12. This demonstrates a lack of insight into an issue of critical importance for practitioners. We agree with the HCCC submission that Mr Knowles' CPD which we accept is extensive, is deficient in this regard. Mr Knowles did not identify the need for counselling and mentoring focusing on ethical concerns. While he said he would consider this further, this was only when it was brought to his attention by the HCCC and the Tribunal.
13. One of the most concerning matters is Mr Knowles' failure to advise his referees, first, about his disqualification and, secondly, about the purpose of their reference for use in these proceedings. We accept that Mr Knowles was ashamed about his disqualification, but he was working as a pharmacy assistant in a pharmacy practice, and, in our view, this is a matter that was relevant to the discharge of his role. It would have been important for Mr Knowles' employers to understand the circumstances leading to his being unregistered to give them the option of whether they wished to employee him or whether they decided to put additional measures in place during the period of his disqualification. Employing a pharmacist who is unregistered because they are retired is very different from making a decision to employ an unregistered pharmacist with full knowledge that he was disqualified.
14. In this regard, we accept the failure to give full and frank disclosure to his employers demonstrates an ethical flaw in Mr Knowles' character. We agree that this conduct is similar to the conduct relating to the representations made by him to the Pharmacy Council about the independent auditing of his practice. A representation that Mr Knowles had retired without also explaining the circumstances leading to his retirement is misrepresentation by omission. Notably, this is recent conduct, not conduct which is over five years old.
15. This conduct was exacerbated by the fact that Mr Knowles asked the pharmacists to provide references which he knew or ought to have known would be provided to the Tribunal in these proceedings. He did not disclose the purpose of the references, that the references would be given to the Tribunal or that the referees may potentially be required to give evidence to the Tribunal. Mr Playford said that he was surprised when the pharmacy practice was summoned. Mr Knowles attempted to justify the failure to disclose this information to the pharmacists by saying that he did not understand how the references were to be used. He also said he did not understand that the application for reinstatement required an application to this Tribunal. This evidence is not credible because Mr Knowles application was filed in May 2025, well before the references were drafted and finalised.
16. The references of Mr Frangos, Mr Playford and Ms Wolski are favourable. The oral evidence of Mr Playford was also supportive, although he said his support was "reserved" given the failure of Mr Knowles to disclose the disqualification to him in the context of the reference and the Tribunal proceedings. Mr Playford was a credible and measured witness. We accept his evidence that he has observed Mr Knowles over the past 18 months and formed a favourable impression of his conduct and professionalism. This evidence is, however, limited by the limited role Mr Knowles was undertaking and the fact that Mr Playford was unaware of Mr Knowles' history during the period of his supervision and was therefore less likely to be scrutinising his conduct closely.
17. Ms Wolski was also very supportive of Mr Knowles, but we give her evidence less weight to the extent that she, somewhat surprisingly, did not appear to be concerned Mr Knowles had failed to disclose important information to her. Overall, we had the impression that Ms Wolski was genuine but nonetheless a strong advocate for Mr Knowles rather than an objective independent witness.
18. The HCCC proposed potential conditions requiring a high level of supervision if Mr Knowles' registration were to be reinstated. Mr Knowles does not accept that this supervision is required but states, if conditions were to be imposed, that he would be prepared to accept the less intensive Category C supervision. Mr Knowles' acceptance of a supervision condition is not determinative of whether such a condition would be imposed but his attitude to such a condition is relevant. First, it demonstrates a lack of insight by Mr Knowles about the need for a period of intense supervision before he can return to full practise, particularly having regard to the seriousness of the previous breaches. Secondly, it is possible that the effectiveness of supervision is at risk where the practitioner being supervised does not fully recognise or embrace the need for close supervision and where it is imposed.
19. Despite this, we are not satisfied that such a condition would be sufficient in any event. This is because we are not satisfied that Mr Knowles yet has sufficient insight into the shortcomings that led to his disqualification.
20. We accept that there is no public interest in "denying forever" the chance of redemption and rehabilitation to former practitioners. Against this, the practitioner must affirmatively prove reform and that the power to reinstate should be exercised with "great caution and only on solid and substantial grounds".
21. In this case, we are not so satisfied. This is because, in exercising our functions under the National Law, the protection of the health and safety of the public must be the paramount consideration.
22. We also agree with the HCCC's submission that we should make an order under s 163B(5) that the order not be reviewed for 12 months because we are not satisfied that Mr Knowles is yet fit to be re-registered. Making another application without first undertaking further education on ethics and formal or informal mentoring would be counterproductive.

1. Mr Knowles submits that the Tribunal should make an order that each party pay their own costs, consistent with usual costs order that applies to Tribunal proceedings under s 60(1) of the NCAT Act. Section 60(2) provides that the Tribunal may award costs but only if it is satisfied there are "special circumstances" warranting an award of costs. Those special circumstances are set out in s 60(3) of the NCAT Act and include matters relating to the conduct of the proceedings by the parties, the relative strengths of the claims made by the parties, the nature and complexity of the proceedings and whether the proceedings were frivolous, vexatious or otherwise misconceived or lacking in substance.
2. Mr Knowles acknowledges that different rules apply to proceedings in the Occupational Division but contends that the Tribunal should be guided by the provisions of s 60 in this case and should order costs if there are special circumstances.
3. Mr Knowles accepts that the HCCC, acting in the role of contradictor in his application for reinstatement, is a necessary party to assist the Tribunal. However, Mr Knowles contends that the Tribunal should take into account that the costs incurred by the HCCC in engaging senior counsel was unnecessary and disproportionate in the circumstances, particularly given Mr Knowles was unrepresented, and the role of contradictor could have been adequately discharged by presenting the relevant material and undertaking a review his material without the need to engage counsel.
4. The HCCC submits that Tribunal's power to order costs is conferred by cl 13, Sch 5D to the National Law. Cl 13(1) provides that the Tribunal may order the complainant (if any), the registered health practitioner or student concerned, or any other person entitled to appear to pay costs to another person as decided by the Tribunal. Cl 13(4) states that cl 13 applies instead of s 60 of the NCAT Act.
5. The HCCC submits the general rule is that costs follow the event: Health Care Complaints Commission v Philipiah [2013] NSWCA 342 at [42]; Qasim v Health Care Complaints Commission [2015] NSWCA 282 at [85] and Health Care Complaints Commission v Do [2014] NSWCA 307 at [51]
6. The HCCC also relies on Ake v Health Care Complaints Commission [2019] NSWCATOD 165. In Ake, citing Ristevski v Medical Council of NSW [2026] NSWCATOD 18 with approval, the Tribunal found:

51 We agree with the view expressed by the Tribunal in Ristevski at [70]-[71] that in conducting a review of a relevant order under s 163B of the National Law, there is a public interest in the Tribunal being assisted by the relevant practitioner Council or the Commission. Without a respondent in this class of matters, there is a risk that the Tribunal might only have available the self-serving evidence adduced by the applicant practitioner. The involvement of, to use the term coined in Ristevski, a "public interest respondent" in review proceedings, assists the Tribunal in discharging its obligation to ensure that all relevant material is disclosed so as to enable it to determine all relevant facts in issue: s 38(6)(a) of the Civil and Administrative Tribunal Act 2013 (NSW).

52 While we have considerable sympathy for Ms Ake**'**s position and the inevitable financial burden imposed by a costs order, the authorities have consistently stated that mere impecuniosity of the losing party is not a justifiable reason to departing from the usual rules in respect of costs: Health Care Complaints Commission v Philipiah at [42].

1. Relevantly, the Tribunal found in Ristevski at [87]:

Provided the respondent conducts its case appropriately, it should be compensated regardless of whether the order is granted or refused.

1. As such, the HCCC submits that regardless of the outcome, it should be awarded costs.

1. The Tribunal has published the Occupational Division Guideline, Costs (August 2017). Clause 14 provides:

The Tribunal may make a costs order in disciplinary proceedings or an appeal brought under the Health Practitioner Regulation National Law. Costs are generally awarded to the successful party unless there are disqualifying circumstances.

1. The general principles in relation to costs in matters under the National Law have been summarised in the decision of Deputy President, Seiden SC, DCJ, in Puri v Medical Council of New South Wales (No 2) [2024 NSWCATOD 122.
2. As observed by Deputy President Seiden at [13] and [14], principles relevant to the general rule are that costs generally follow the event, although this is not an absolute rule. Costs compensate the winning party and are not a form of punishment, but this rule may be displaced if the winning party engages in conduct that disentitles them to costs. The onus is on the losing party to establish a basis for any departure from the usual rule: Health Care Complaints Commission v Balafas (No 2) [2021] NSWCATOD 175. Costs may be apportioned or reduced, or various orders may be made that reflect the circumstances and are consistent with the underlying decision. Costs are in the Tribunal's discretion which should be exercised judicially: Cole DCJ in Health Care Complaints Commission v Wilcox (No 2) [2020] NSWCATOD 51 at [11]
3. However, these are reinstatement proceedings and the question of whether the "compensatory principle" applied is such proceedings was discussed by the Tribunal in Ameisen v Medical Council of NSW [2015] NSWCATOD 49. The Tribunal observed at [90] that the reinstatement proceedings arise because of the prior misconduct of an applicant. The proceedings can be seen as ancillary. Characterising an applicant as successful where the applicant's registration is reinstated "misunderstands the nature of the respondent's involvement at the inquiry". In that case, the Tribunal made an order for costs in favour of the Medical Council, even though it made a reinstatement order but excluded costs thrown away because of an adjournment. Ameisen was cited with approval in Ake at [48], where the Tribunal also ordered costs despite ordering that the practitioner's registration be reinstated.
4. In the present case, the HCCC sought an order for costs of the review.
5. We have accepted many of the HCCC's contentions and declined to reinstate Mr Knowles' registration, consistent with the submissions made by the HCCC soon after the commencement of the proceedings. The HCCC maintained this submission at the end of the hearing, but it is possible the HCCC could have changed its view if the evidence had been more favourable to Mr Knowles. However, for the reasons outlined above, this is not the critical factor on costs. A relevant consideration is whether the HCCC conducted its case appropriately or whether there was "disentitling" conduct by the HCCC in opposing the reinstatement. This does not involve consideration of whether there are "special circumstances" because s 60 has been expressly ousted from application.
6. In our view, the HCCC is entitled to its costs on an ordinary basis. The HCCC did not delay or prolong the proceedings and took issue, appropriately in our view, with certain evidence and propositions put forward by Mr Knowles. It was important that the evidence be tested, and this provided considerable assistance to the Tribunal in the course of its inquiry. We did not accept some of the submissions raised but the thorough exploration of certain contentious issues at the hearing satisfied us about those matters.
7. We order that Mr Knowles pay the costs of the proceedings.

(1) Mr Knowles' application for reinstatement is dismissed.

(2) Mr Knowles is not entitled to seek a review for 12 months from the date of this order

(3) Mr Knowles is to pay the costs of the HCCC on an ordinary basis as agreed or assessed.

I hereby certify that this is a true and accurate record of the reasons for decision of the New South Wales Civil and Administrative Tribunal.

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.