National Law - Professional misconduct - Steroid prescription - No therapeutic basis - Inadequate records

Dental Act 1939 (WA)

Health Practitioner Regulation National Law (WA) Act 2010, s 3, s 5, s 31, s 193(1)(a)(i), s 196(1)

Medical Practitioners Act 2008 (WA), s 76(1), s 86(1)

Poisons Act 1964 (WA)

Therapeutic Goods Act 1989 (Cth), s 19(5)

Disciplinary matters arise under s 76 of the Medical Practitioners Act 2008 (WA)

This decision relates to three separate applications made by the Medical Board of Australia in relation to the conduct of a medical practitioner, Dr Anish Dwarka Singh. The three applications were consolidated as VR 235 of 2014.

The Medical Board's allegations pertained to Dr Singh's general practice which included failing to keep proper records, prescribing drugs or other treatments when there was no therapeutic basis and prescribing some drugs and treatments which had potential adverse effects. The Medical Board of Australia also made the same allegations in relation to Dr Singh's treatment of two specific patients.

During the course of the hearing, Dr Singh conceded that his medical records were inadequate.

In broad terms, the factual allegation was that Dr Singh was prescribing androgen anabolic steroids and related drugs for physical conditioning and/or body building.

The Tribunal considered all of the evidence before it, including expert evidence from a joint conferral of experts which played a large role in the resolution of the proceedings.

The Tribunal determined that disciplinary matters arise under s 76 of the Medical Practitioners Act 2008 (WA) and that Dr Singh had acted carelessly, incompetently and/or improperly which constituted professional misconduct.

Briginshaw v Briginshaw [1938] HCA 34; (1938) 60 CLR 336

Cranley v Medical Board of Western Australia (unreported, WASC, Library No 8668, 21 December 1990)

Health Care Complaints Commission v Bours (No 1) [2014] NSWCATOD 113

Jemielita v The Medical Board of Western Australia (unreported, WASC Library No 920584, 13 November 1992

Legal Profession Complaints Committee and Wells [2014] WASAT 112

Medical Board of Australia and Bernadt [2012] WASAT 108

Medical Board of Western Australia and Alizadeh [2007] WASAT 52

Medical Board of Western Australia and Bham [2006] WASAT 190

Medical Board of Western Australia and Richards [2010] WASAT 94

Medical Board of Western Australia and Wolman [2011] WASAT 69

Medical Board of Western Australia and Wright [2010] WASAT 48

NOM v Director of Public Prosecutions (2012) 38 VR 618

Ong v The Dental Board of Western Australia (unreported, WASC, Library No 960442, 25 August 1995)

Rejfek v McElroy [1965] HCA 46; (1965) 112 CLR 517

1 The Medical Board of Australia (the Board) is established pursuant to s 31 of the Schedule to the Health Practitioner Regulation National Law (WA) Act 2010 (the National Law) (Board's Further Amended Grounds of Consolidated Application dated 25 August 2016 (Board's CG paragraph 1)).

2 Dr Anish Dwarka Singh was a registered practitioner under the Medical Practitioners Act 2008 (WA) (Medical Practitioners Act), and, subsequently, under the National Law.

3 Dr Singh practised as a specialist physician in West Perth, Western Australia (Board's CG paragraph 4). He has been practising medicine for approximately 25 years (Dr Singh's response statement (SR) paragraph 3).

4 This decision relates to what were three separate applications before the Tribunal: VR 204 of 2012, VR 230 of 2013 and VR 93 of 2014.

5 VR 204 of 2012, filed on 11 December 2012, concerned Dr Singh's conduct in relation to Patient J. This application was brought under s 86(1) of the Medical Practitioners Act. Dr Singh's conduct in relation to this application is to be assessed under the Medical Practitioners Act.

6 VR 230 of 2013, filed on 20 December 2013, concerned Dr Singh's conduct in general practice. This application was brought under s 86(1) of the Medical Practitioners Act. Dr Singh's conduct in relation to this application is to be assessed under the Medical Practitioners Act.

7 VR 93 of 2014 concerned Dr Singh's conduct on relation to Patient B. This application was brought under s 193(1)(a)(i) of the National Law. Dr Singh's conduct in relation to this patient is to be assessed under the National Law.

8 The applications were ordered to be consolidated pursuant to an order of the Tribunal made on 16 December 2014. The consolidated proceedings were consolidated as VR 235 of 2014. In the consolidated proceedings the general practice allegations against Dr Singh were extended to Dr Singh's conduct after 18 October 2010, the date when the National Law commenced in Western Australia. Dr Singh's conduct after 18 October 2010 is to be assessed under the National Law.

9 The Board's case falls into four main parts. Two related to Dr Singh's general practice:

1. prescribing drugs or other treatments when there was no therapeutic basis and, in the case of some drugs and treatments, there were potential adverse effects; and
2. failing to keep proper records.

10 The other two parts make the same allegations in relation to Dr Singh's treatment of two specific patients: Patient J and Patient B.

11 In relation to prescribing drugs or other treatments, Dr Singh contended that there was a therapeutic basis for prescribing the drugs and that there were no adverse effects. In relation to the keeping of records Dr Singh initially denied that his records were inadequate. During the course of the hearing, he conceded that his records were inadequate.

12 In broad terms, the factual allegation is that Dr Singh was prescribing androgen anabolic steroids and related drugs for physical conditioning and/or body building.

13 The names of patients have not been used in these reasons. The patients have been identified by a number or a letter. The patient's name and the corresponding number are found in Exhibit A Volume 5.

14 The Board's closing submissions were extremely thorough. The Tribunal has largely adopted those submissions, particularly in relation to the identification of extracts from the evidence.

15 The Board bears the onus of proof. In Legal Profession Complaints Committee and Wells [2014] WASAT 112 at [8], the Tribunal stated:

The Committee bears the onus of proof. It is to the civil, not criminal standard but the principles of Briginshaw v Briginshaw [1938] HCA 34; (1938) 60 CLR 336 (Briginshaw) apply. That is, while needing to be proved only on the balance of probabilities, the nature and seriousness of the allegations are relevant to the question whether the issues are proved to the reasonable satisfaction of the Tribunal and the process by which reasonable satisfaction is attained.

16 By reason of the nature of the allegations, the Tribunal must feel an actual persuasion of the occurrence or existence of the relevant facts in determining whether or not the case against the practitioner is made out: Medical Board of Western Australia and Wright [2010] WASAT 48 at [31]; and see Medical Board of Western Australia and Bham [2006] WASAT 190 at [144], Rejfek v McElroy [1965] HCA 46; (1965) 112 CLR 517 (Rejfek).

17 In Briginshaw v Briginshaw [1938] HCA 34; (1938) 60 CLR 336 (Bringinshaw) at 362, Dixon J, as he then was, observed '[i]n such matters ''reasonable satisfaction'' should not be produced by inexact proofs, indefinite testimony or indirect inferences'.

18 The standard of proof required in a civil case where serious allegations are made was stated in Rejfek, where Barwick CJ, Kitto, Taylor, Menzies and Windyer JJ observed at 521 that:

... The 'clarity' of the proof required, where so serious a matter as fraud is to be found, is an acknowledgment that the degree of satisfaction for which the civil standard of proof calls may vary according to the gravity of the fact to be proved ...

But the standard of proof to be applied in a case and the relationship between the degree of persuasion of the mind according to the balance of probabilities and the gravity or otherwise of the fact of whose existence the mind is to be persuaded are not to be confused[.]

19 In NOM v Director of Public Prosecutions (2012) 38 VR 618 at [124], the Victorian Court of Appeal stated:

... Mere mechanical comparison and probabilities independent of a reasonable satisfaction will not justify a finding of fact. The fact finder must feel an actual persuasion of the occurrence or existence of the fact in issue before it can be found. Where, as in the present case, the standard of proof is to be applied to circumstantial evidence, satisfaction as to a reasonable and definite inference is required.

The Medical Practitioners Act

20 Section 76(1) of the Medical Practitioners Act provides that a 'disciplinary matter' arises when a respondent acts carelessly, incompetently or improperly for the purposes of the Medical Practitioners Act.

21 In Medical Board of Western Australia and Richards [2010] WASAT 94 at [26], the Tribunal considered the meaning of the expression 'acting carelessly' for the purposes of the Medical Practitioners Act:

In our view, acting carelessly for the purposes of the MP Act still requires that the carelessness requires that the conduct complained of assumes a scale of gravity which is sufficiently serious to warrant, in the eyes of professional colleagues of good repute and competence, punishment and disciplinary action for the protection of the public. That is because s 76 is concerned with professional disciplinary proceedings. The objects identified in s 3 of the MP Act are designed 'for the purpose of protecting consumers of medical services'. ... Acting carelessly involves, for the purposes of the MP Act, not giving sufficient attention or thought to avoiding harm or mistakes or showing no care or interest or effort in the treatment of a patient, but does not include trivial error not warranting disciplinary action.

22 In Jemielita v The Medical Board of Western Australia (unreported, WASC Library No 920584, 13 November 1992 (Jemielita), Owen J considered the meaning of incompetency in the context of the expression 'gross carelessness or incompetency' as used in the now repealed Medical Act 1984 (WA). Owen J held that the concept of incompetency involves an unfitness to practise in a particular field of medicine or an inability to perform the techniques or judgments needed for the proper practice of medicine in that field, and that incompetency is usually suggestive of a generalised deficiency in the way in which a respondent handles his or her affairs rather than individual or sporadic shortcomings.

23 In Ong v The Dental Board of Western Australia (unreported, WASC, Library No 960442, 25 August 1995) (Ong), Murray J considered the meaning of the expression 'incompetence' in the context of the Dental Act 1939 (WA). His Honour referred to Jemielita, and continued:

A case such as this will always involve a judgment about the standard of care and skill which, in the view of the Board, ought to have been brought to bear upon the treatment of the particular patient, in the particular field of professional discipline which was involved. Carelessness in that regard rather implies the falling short of appropriate standards of care and skill on the particular occasion in question. Incompetence in my opinion involves the view that such falling short of the proper standards of care and skill thought to be required on the occasion in question reveals a lack of knowledge or skill justifying an adverse judgment about the respondent's professional capacity or fitness to practice in the particular field of expertise involved.

24 In Medical Board of Australia and Bernadt [2012] WASAT 108, the Tribunal considered whether the expression 'incompetency' could relate to a single act. The Tribunal referred to Ong, and continued:

Murray J's comments suggest that incompetency may be found in relation to a single act. That approach is consistent with the ordinary and natural meaning of the words of s 76(1)(b)(ii) which identifies a disciplinary matter where 'a person in the course of his or her practice as a medical respondent ... acted incompetently'. A person may act incompetently on a particular occasion, notwithstanding that they may not be found to be generally incompetent to practice medicine, either generally or in a particular field.

25 'Improper' can be regarded as denoting conduct of the same kind as was contemplated by the term 'improper conduct in a professional respect' that appeared in the Medical Act 1894 (WA): Medical Board of Western Australia and Wolman [2011] WASAT 69.

26 In Cranley v Medical Board of Western Australia (unreported, WASC, Library No 8668, 21 December 1990) (Cranley) the term 'improper' was held to embrace conduct which would reasonably have been regarded as improper by professional colleagues of good repute and competence.

27 In Jemielita a distinction was articulated between carelessness and impropriety, in that the concept of 'gross carelessness' was found to involve 'unacceptable conduct without any intentional wrong doing on the part of the respondent'. This distinction was approved in Medical Board of Western Australia and Alizadeh [2007] WASAT 52.

28 Under s 196(1) of the National Law, the Tribunal may decide:

1. Dr Singh has no case to answer and no further action is to be taken in relation to the matter; or
2. relevantly, any one or more of the following ­
   1. Dr Singh has behaved in a way that constitutes unsatisfactory professional performance;
   2. Dr Singh has behaved in a way that constitutes unprofessional conduct;
   3. Dr Singh has behaved in a way that constitutes professional misconduct.

29 The term 'professional misconduct' is defined in s 5 of the National Law as conduct which includes:

1. unprofessional conduct by the practitioner that amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and
2. more than one instance of unprofessional conduct that, when considered together, amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and

1. conduct of the practitioner, whether occurring in connection with the practice of the health practitioner's profession or not, that is inconsistent with the practitioner being a fit and proper person to hold registration in the profession[.]

30 The first and second limbs of the definition of 'professional misconduct' incorporate the term 'unprofessional conduct' which is in turn defined in s 3 of the National Law as:

[P]rofessional conduct that is of a lesser standard than that which might reasonably be expected of the health practitioner by the public or the practitioner's professional peers[.]

31 The relevant authorities are set out in the reasons for decision of Health Care Complaints Commission v Bours (No 1) [2014] NSWCATOD 113 at [524]­[527]:

Interpretation of the legislation is assisted by the body of common law in the area of professional disciplinary matters. The classic common law definition of professional misconduct derives from Allinson v General Counsel of Medical Education and Registration (1894) 1 QB 755, namely:

[Conduct] which could be reasonably regarded as disgraceful or dishonourable by his professional brethren of good repute and competency.

The essence of this definition was restated by Priestley JA in Qidwai v Brown (1984) 1 NSWLR 100 at 105:

... whether the practitioner was in such breach of the written or unwritten rules of the profession as would reasonably incur the strong reprobation of professional brethren of good repute and competence[.]

...

Contemporary cases involving unsatisfactory professional conduct and professional misconduct primarily consider the wording of the relevant statute rather than the considerations of moral condemnation found in earlier decisions, expressing their views 'in terms of strong criticism'. (Lucire v Health Care Complaints Commission [2011] NSWSC 99; Donnelly v Health Care Complaints Commission (NSW) [2011] NSWSC 70).

32 Section 3 of the National Law provides that unprofessional conduct of a registered health practitioner means professional conduct that is of a lesser standard than that which might reasonably be expected of the health practitioner by the public or the practitioner's professional peers.

33 The term 'unsatisfactory professional performance' is defined in s 5 of the National Law as meaning:

[T]he knowledge, skill or judgment possessed, or care exercised by, the practitioner in the practice of the health profession in which the practitioner is registered is below the standard reasonably expected of a health practitioner of an equivalent level of training or experience[.]

34 These allegations are to a large degree founded on documents obtained by the Board during the course of its investigations in response to various notices to produce issued to various parties, including Dr Singh. These documents included:

• the Morris Pharmacy dispensing history for Dr Singh (Exhibit A Volume 5);
• Mckenzies Compounding Chemist dispensing history for Dr Singh (Exhibit A Volume 5);
• clinical patient notes provided to the Board by Dr Singh on 30 April 2014 in response to a notice to produce, being 68,848 pages of notes, test results and correspondence contained on a USB drive; and
• the evidence of Dr Singh.

35 It emerged during Dr Singh's evidence that Dr Singh was also referring patients to at least three other pharmacies, being Oxford Compounding Chemist, Friendlies Chemist in Leederville and a 777 Pharmacy in Applecross. Dr Singh said that in the last few years Oxford Compounding Chemist has replaced Mr Balestra from the Morris Pharmacy as his primary referrer (T:59­61; 22.08.16). The Tribunal's findings are based upon only a sample of Dr Singh's overall practice. However, the sample provides a sufficient basis for the Tribunal's findings.

36 Expert evidence played a large role in the resolution of these proceedings. The Board filed expert evidence from Professor Gary Wittert and Professor David Anthony Joyce. Dr Singh filed expert evidence from Professor Sean Hood, Professor David Nutt and Professor Alistair Vickery. Each of these professors also gave oral expert evidence. A large part, though not all, of the evidence was given concurrently.

37 Professor Wittert was a highly qualified expert. His curriculum vitae appears in Exhibit E, at page 539, and Exhibit A Volume 1, at pages 1-33. Professor Wittert is a specialist physician with registration in General Medicine and Endocrinology. He obtained his MBBch at the University of Witwatersrand, Johannesburg, in 1983. He became a fellow of the Royal Australasian College of Physicians in 1992 and a fellow of the Royal College of Physicians, United Kingdom, in 2009. He has an MD from the University of Otago awarded in 1994.

38 Professor Wittert is currently a Professor of Medicine (personal chair) at the University of Adelaide and head of the Discipline of Medicine at that University. He is also head of the Freemason's Foundation Centre for Men's Health. He practises as a Senior Consultant Endocrinologist at the Royal Adelaide Hospital and is the coordinator of the Endocrine Test Unit and the Obesity Clinic at that Hospital. He has worked at both institutions continuously since 1994.

39 Professor Wittert spends half a day a week in private practice. He has particular expertise in the physiology and pathophysiology of stress, pathophysiology and management of obesity, physiology and use of androgens, disorders of sleep and their relationship to chronic disease. He has published over 280 peer­reviewed publications, book chapters and expert reports. In particular, he has published, or co-published, the following articles:

1. Haren MT, Morley J, Chapman I, O'Loughlin P, Wittert G. 'Defining 'relative' androgen deficiency in aging men: How should testosterone be measured and what are the relationships between androgen levels and physical, sexual and emotional health?' Climacteric, (2002) 5(1):15-25
2. Barton, C, March S, Wittert GA. 'The Low Dose Dexamethasone Suppression Test: Effect of Time of Administration and Dose.' J Endocrinol Inves, (2002) 25(4):RC10-2

1. Wittert G, Chapman I, Haren M, Mackintosh S, Coates P, Morley. 'Low dose oral testosterone supplementation increases muscle mass and decreases fat mass in healthy elderly males with low-normal gonadal status.' J Gerontol, (2003) 58:618-25

1. Haren MT, Wittert GA, Chapman IM, Coates P, Morley JE. 'The effect of 12­months of oral testosterone supplementation on the cognitive function, mood and quality of life of healthy elderly males with low-normal gonadal status: A randomised controlled trial.' Maturitas, (Feb 2005) 50(2):124-133

1. Haren MT, Wittert GA, Chapman IM, Coates P, Morley. 'Effect of 12-month oral testosterone on testosterone deficiency symptoms in symptomatic elderly males with low-normal gonadal status.' Age Ageing, (Mar 2005) 34(2):125-30

1. Martin DM, Wittert G, Burns NR. 'Gonadal steroids and visuo­spatial abilities in adult males implications for generalized age-related cognitive decline.' Aging Male, (Mar 2007) 10(1):17­29,

1. Martin DM, Wittert G, Burns NR, Haren T. 'Testosterone and cognitive function in Ageing Men: Data from the Florey Adelaide Male Ageing Study (FAMAS).' Maturitas, (Jun 2007) 57(2):182­94

1. Martin DM, Burns NR, Wittert G. 'Free Testosterone Levels, attentional control, and processing speed performance in aging men.' Neuropsychology, (Mar 2009) 23(2):158-67

1. Atlantis E, Martin SA, Haren MT, O'Loughlin PD, Taylor AW, Anand-Ivell R, Ivell R, Wittert GA and Members of the Florey Adelaide Male Aging Study. 'Demographic, physical and lifestyle factors associated with androgen status: the Florey Adelaide Male Aging Study (FAMAS).' Clinical Endocrinol (Oxf), (Aug 2009) 71(2):261-272,

1. Atlantis E, Lange K, Martin S, Haren MT, Taylor A, O'Loughlin PD, Marshall V, Wittert GA. 'Testosterone and modifiable risk factors associated with diabetes in men.' Maturitas, (Mar 2011) 68(3):279-85,

1. Radathy A and Wittert G. 'Hypogonadism in man: How to evaluate and when to treat.' Modern Medicine, (Jan 2012) 13(1):47-49

1. Grossmann M and Wittert GA. 'Androgens, Diabetes and Prostate Cancer.' Endocrine-Related Cancer. 2012 Sep 5;19(5):F47-62. Oct 2012

1. Gates M, Mekary R, Chiu G, Ding E, Wittert G, Araujo A. 'Sex steroid hormone levels and body composition in men.' J Clinic Endocrinol Metab. (Jun 2013) 98(6):2442-50, PMID: 23626004

1. Atlantis E, Fahey P. Cochrane B, Wittert G, Smith S. 'Endogenous testosterone levels and testosterone supplementation therapy in chronic obstructive pulmonary disease (COPD): a systematic review and meta-analysis'. BMJ Open. (Nov 2013) 3(8):e003127, PMID: 23943774

1. Sato K, Samocha-Bonet D, Handelsman D, Fujita S, Wittert GA, Heilbronn LK. 'Serum sex steroids and steroidogenesis-related enzymes in skeletal muscle during experimental weight gain in men Diabetes & Metabolism' (Accepted March 2014)

1. Wittert GA. 'Sibutramine and Rimonabant: Gone, but is their passing instructive?' Controversies in Obesity, edited by Drs David Haslam, Arya Sharma and Carel le Roux
2. Wittert GA. 'A Practical Approach to Obesity Management.' Roche Press. (2004)

40 Professor Wittert conducted a detailed review of about 240 of the 740 patient 'records' (see below).

41 Professor Wittert was the Board's principal expert witness. He gave his evidence in a very clear and competent manner. He demonstrated great command of the facts of this case and the relevant medical science.

42 Professor Joyce was a highly qualified expert. His curriculum vitae appears in Exhibit E, at pages 621­623.

43 Professor Joyce holds the following qualifications:

• Bachelor of Medicine, Bachelor of Surgery (MB BS) from the University of Western Australia 1976;
• Fellow, Royal Australasian College of Physicians (FRACP) 1983; and
• Doctor of Medicine (MD) from the University of New South Wales 1988.

44 Professor Joyce holds the following current appointments:

• Professor of Medicine & Pharmacology at the University of Western Australia since 2010. (He was a Senior Lecturer from 1987­1997 and an Associate Professor from 1997­2010);
• Head, Department of Clinical Pharmacology & Toxicology and Consultant Physician at the Department of General Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia since 1987; and
• Head, Clinical Pharmacology and Toxicology at Pathwest Laboratory Medicine, Nedlands, Western Australia since 2005.

45 Professor Joyce chairs the Clinical Drug Trials Committee of the Sir Charles Gairdner Hospital, which has the responsibility to assess whether there is sufficient evidence of benefit and risk to allow the use of novel drugs in experimental situations. Under his chairmanship, the Committee makes risk­benefit assessments on an average of three to four new drug trial applications each month. Professor Joyce personally makes a risk­benefit assessment for every one of these applications.

46 From 1989 until 2012, the Committee had responsibility for assessing applications made by medical practitioners for recognition as authorised prescribers for unregistered drugs, under s 19(5) of the Therapeutic Goods Act 1989 (Cth). The resulting recommendation was a basis for Therapeutic Goods Authority granting or withholding authorised prescriber standing.

47 Professor Joyce served, from time to time, on the Drug and Therapeutics Committee for Sir Charles Gairdner Hospital, providing advice on risk­benefit assessment for drugs that have been proposed for inclusion among the hospital's prescribable drugs.

48 Professor Joyce gave his evidence in a very clear manner.

49 Professor Hood is a highly qualified expert. His curriculum vitae appears in Exhibit O, at pages 319-339.

50 Professor Hood is a Medical Specialist (Consultant Psychiatrist) registered with the Medical Board of Australia. He has practised as a medical practitioner since 1994; his medical degree was conferred by the University of Western Australia.

51 Professor Hood is a Fellow of the Royal Australian and New Zealand College of Psychiatrists (2004) and has unconditional registration and practice rights as a Psychiatrist in Western Australia and England. He is a Professor in Psychiatry at the University of Western Australia. Professor Hood is also an immediate past Chair of the Western Australian Psychotropic Drug Committee and Executive Member of the Western Australian Therapeutics Advisory Group. He was a member of the North Metropolitan Human Research Ethics Committee in 2006.

52 Professor Hood provided one expert report, dated 21 June 2013 (Exhibit O Volume 2 Witness Statements, at pages 295-339), and took part in both of the joint expert conferrals referred to below.

53 Although Professor Hood is a highly qualified expert in psychiatry, his expertise for the purposes of these proceedings was essentially limited to two drugs, fluoxetine and sibutramine. In his expert report at page 298, Dr Hood stated that Dr Singh's treatment for Patient J was appropriate. In the course of his examination he made it clear that he was referring to Dr Singh's use of fluoxetine and sibutramine. At the conclusion of the evidence, the allegations against Dr Singh in relation to fluoxetine and sibutramine were not pursued.

54 Dr Singh gave evidence that Patient J suffered from body dysmorphia syndrome with binge eating disorder.

55 Professor Hood's report considered the appropriateness of referring Patient J to a psychiatrist for treatment of the diagnosis of body dysmorphic syndrome with binge eating disorder (paragraph 3.5 at page 302).

56 The Tribunal notes that it did not accept Dr Singh's diagnosis for Patient J. Accordingly, Professor Hood's evidence was largely irrelevant.

57 Professor Hood was also a professional colleague of Dr Singh and worked at Dr Singh's clinic, the Empire Clinic, during some of the relevant period the subject of the allegations. Professor Hood referred patients to Dr Singh and Dr Singh referred patients to him. Despite Professor Hood's professional relationship with Dr Singh the Tribunal found him to be a credible expert witness.

58 Professor Nutt was a highly qualified expert. His curriculum vitae appears in Exhibit R, at pages 363-377.

59 Professor Nutt is a Professor of Neuropsychopharmacology at Imperial College, London and an honorary Consultant Psychiatrist in the Central and Northwest London Mental Health Trust. He has had a lifelong interest in the actions of drugs in the brain and has considerable preclinical and clinical research experience in the field.

60 Professor Nutt's clinical practice and research is in psychopharmacology. For the past 25 years he has run a large teaching clinic in psychopharmacology treatment issues, especially for patients with depressive and anxiety disorders, addiction and sleep problems. He has researched these illnesses and their drug treatments extensively and has published over 500 research papers as well as several hundred specialist reviews and 28 books in this field.

61 Between 1988 and 1992, Professor Nutt worked in the pharmaceutical industry and both before and since then, has conducted a great many volunteer studies of psychotropic drugs (mostly antidepressants and anxiolytics/hypnotics). In addition, he has acted as consultant to many pharmaceutical companies with respect to experimental agents undergoing testing in phases 1, 2 and 3. His group has been a clinical research centre in a number of trials of selective serotonin reuptake inhibitors and other new antidepressants in a depression and anxiety disorders and of new hypnotic agents and he has acted as principal investigator for some of these.

62 Professor Nutt provided one expert report, dated 15 May 2014 (Exhibit R Volume 2 Witness Statements, at pages 358-377), and took part in the joint conferral of November 2015.

63 Professor Nutt practises in the United Kingdom. To the extent that he gave evidence of practice in Australia, he lacked experience in that practice.

64 Although Professor Nutt is a highly qualified expert in psychiatry, his expertise for the purposes of these proceedings was essentially limited to three drugs: fluoxetine, sibutramine and diethylpropion. In his expert report at page 360, Professor Nutt stated that Dr Singh's use of these drugs for the treatment for Patient J was appropriate. At the conclusion of the evidence these allegations were not pursued.

65 Dr Singh gave evidence that Patient J suffered from body dysmorphia syndrome with binge eating disorder.

66 Professor Nutt's report considered the appropriateness of referring Patient J to a psychiatrist for treatment of the diagnosis of body dysmorphic syndrome with binge eating disorder (paragraph 3 at pages 360-361).

67 The Tribunal notes that it did not accept Dr Singh's diagnosis for Patient J. Accordingly, Professor Nutt's evidence was largely irrelevant.

68 Professor Vickery is a general practitioner. His curriculum vitae appears in Exhibit P at page 509 and pages 524­529.

69 Professor Vickery is a registered medical practitioner in Western Australia who is well qualified in general practice. He has had a particular clinical interest in the management of obesity and has worked in the medical assessment and ongoing management and care of the co­morbidities of obesity in general practice, specialist practice and as a bariatric assessor for patients before and after bariatric surgery. He graduated from the University of Western Australia with a Bachelor of Medicine and Surgery in 1985 and attained his Fellowship to the Royal Australian College of General Practitioners in 1996. Professor Vickery has been working in general practice since 1988. He is currently Professor of Primary Health Care at the University of Western Australia. He continues to practice part­time as a general practitioner at the Gwelup Medical Practice and as an obesity assessor at the Mercy Bariatric Centre. Professor Vickery is Chair of the first primary health care organisation in Western Australia, Panorama Health Network and Deputy Chair of the Postgraduate Medical Council of Western Australia and Chair of the Education Committee.

70 Professor Vickery's evidence was of very limited value. He is a general practitioner and his Chair is in general practice. He is neither qualified in internal medicine nor psychiatry, and although he has a part­time practice in obesity, his research and the majority of his practice is in primary health care and the delivery of health services to the community. The expertise of the other experts far outweighs the expertise of Professor Vickery (T:175­176; 18.08.16).

71 Professor Vickery stated that he has known Dr Singh personally and professionally for the last 15 years. He has been a patient of Dr Singh since 2002 and he worked alongside Dr Singh between 2004 and 2006 in the Metabolic Medicine Clinic in West Perth which was operated by Dr Singh.

72 Professor Vickery stated that he held Dr Singh in high regard as he had saved his life on two occasions and that he 'has a particular fondness for him' (T:176­177; 18.08.16).

73 Professor Vickery did not review the 740 patient records that were provided to him by Dr Singh's solicitors. He described himself as obtaining a general gist of the structure of the notes and the sort of treatments that Dr Singh was prescribing. His comments in relation to Dr Singh were based on his personal knowledge of and belief in him and his experience in working alongside Dr Singh rather than detailed analysis of the patient records (T:180; 193­194, 197 and 240; 18.08.16). Professor Vickery conceded that his 'independence was compromised in terms of Dr Singh' (T:179; 18.08.16). Professor Vickery stated that he 'would have difficulty second-guessing [Dr Singh's] judgment' (T:241; 18.08.16).

74 Professor Vickery's expertise reflected the opinions and beliefs of Dr Singh rather than the opinions that he held independently. When being cross-examined about human growth hormone, at a point where Dr Singh retracted his previous position that human growth hormone promoted lean muscle mass, Professor Vickery said that he too would change his view about human growth hormone based solely upon Dr Singh having changed his mind (T:250; 18.08.16).

75 The Tribunal is not satisfied that Professor Vickery has the requisite level of independence from Dr Singh to give expert evidence.

76 The Tribunal does not find that Professor Vickery's evidence was deliberately misleading. He was simply too personally close to Dr Singh to give objective evidence.

77 The Tribunal has afforded Professor Vickery's expert evidence little or no weight. The Tribunal has not addressed every point on which Professor Vickery has disagreed with Professor Wittert and Professor Joyce because it finds that Professor Vickery lacks the necessary expertise and independence to give expert evidence.

78 In reaching its conclusion, the Tribunal prefers the evidence of Professor Joyce and Professor Wittert over Professor Vickery.

79 Professors Wittert and Hood participated in a joint conferral of experts in November 2013. The results of that conferral appear in Exhibit Q at pages 340­353. Professor Yovich also participated in that conference but he was not called to give evidence and his contributions have not been relied on.

80 Professors Wittert, Joyce, Hood, Nutt and Vickery participated in a joint conferral of experts in November 2015. The results of that conferral appear in Exhibit Q Volume 3, at pages 631-692.

81 The results of joint conferral were tabulated by reference to a series of questions and each of the expert's response, if any.

82 The joint conferrals considerably narrowed the areas of difference between the experts. The Tribunal is very grateful to each of the experts for the obvious time and effort they put into the joint conferrals, particularly Professor Wittert.

83 Dr Singh was unrepresented at the hearing. However, Clayton Utz acted for him until 5 July 2016. His response to the grounds set out in the applications, his witness statement and the witness statements filed on his behalf, were all prepared during the time that Clayton Utz were acting for him. Dr Singh cannot claim that he was not properly advised in the preparation of those documents as he had very capable and experienced legal representatives.

84 The ultimate findings of this Tribunal reflect a tragic fall from grace of a very well educated and experienced physician.

85 Dr Singh is plainly a highly qualified physician. He obtained science degrees before commencing medicine. He has two doctorates. He was a Fellow of the Royal Australasian College of Physicians. It was obvious from his evidence that he is highly intelligent.

86 It is appropriate at this point to deal in general terms with one of the principal allegations against Dr Singh, namely, that he was, in effect, prescribing drugs for physical conditioning and/or body building for non­therapeutic purposes (Board's CG paragraph 50). Dr Singh denied that he prescribed drugs for non­therapeutic purposes, for example, in a letter Dr Singh wrote to the Board on 26 October 2009 (Exhibit A, at page 686) he stated 'I do not prescribe to body builders'.

87 In Dr Singh's written statements (Exhibit S Volume 1 Witness Statements, at pages 1­51 and 165-279), he nowhere concedes that he had prescribed drugs for body building purposes. For example, he described his prescription of Methandrostenolone as being prescribed for its anabolic effects, particularly treatment of anaemia, osteoporosis, tissue breakdown and poor healing (Exhibit T Volume 1, at page 176, paragraph 46).

88 There is barely a hint in any of Dr Singh's witness statements that he was prescribing these drugs for physical conditioning and/or body building purposes.

89 Dr Singh's explanations as to why he prescribed those drugs to various patients are explained in his evidence in medical terms and with medical justifications. However, the objective evidence does not support Dr Singh's explanations and paints a very different picture.

90 The clearest example of a patient who was prescribed drugs for body building purposes by Dr Singh was Patient 71. In his letter to the Australian Health Practitioner Regulation Agency (AHPRA) dated 20 July 2012 (Exhibit A, ABD Volume 3, at page 719), Dr Singh stated that (71) consulted him for obesity. Photos of Patient 71 appear in Exhibit A Volume 3, at pages 588-611. The photographs show a man who is a body builder and who is certainly not obese. Dr Singh treated Patient 71 over a number of years. His prescription history is in Exhibit A Volume 5, at pages 1188­1195. The prescriptions date from 15 January 2008 to 26 April 2013. The photographs of Patient 71, particularly at page 588, from November 2007, and page 589, from Christmas 2007, that is, immediately prior to the commencement of the prescriptions in January 2008, show a man who is already a very developed body builder. (71) was prescribed Stanozolol, Methandrostenolone, Primoteston, Sustanon, Deca­Durabolin, Oxandrolone, as well as the complementary body building drugs Clenbuterol and Clomid, in large quantities throughout 2008 to June 2013.

91 It is rarely that a witness cracks in the witness box and concedes the other party's case. But crack, Dr Singh did. The extent to which Dr Singh cracked is best set out in Dr Singh's own words:

SINGH, DR: I was at the time, technically [Patient 71's steroid supplier], yes, prior to that he was getting it on the street ...

(T:96; 22.08.16)

QUAIL, MR: And if we turn over the page, you continued to be his steroid supplier. Page 591, this is how he looks in July of 2011. 592 is how he looks, same date, July 2011.

SINGH, DR: Yes.

QUAIL, MR: Still suffering from sarcopenic obesity, is he?

SINGH, DR: No, not then, he's a nut bag, I told you.

QUAIL, MR: But you still kept supplying this nut bag with steroids -

SINGH, DR: Yes, I did.

(T:96; 22.08.16)

SINGH, DR: So - I mean, I've seen those pictures. What's your point? Is he not allowed to receive - is there a law which says he cannot receive prescriptions from a doctor in anabolics? Who is to make the decision this is naughty or bad or illegal? It's right - within his rights?

QUAIL, MR: What therapeutic purpose were you supplying him with steroids for, Dr Singh?

SINGH, DR: Therapeutic purpose, no conventional therapy. Is there a law which says it's not allowed for that, it's not restricted, is it?

HIS HONOUR: That wasn't the question.

SINGH, DR: Therapeutic? Therapeutic?

HIS HONOUR: What was the therapeutic purpose?

SINGH, DR: No conventional therapeutic treatment.

QUAIL MR: Which unconventional therapeutic treatment was it?

SINGH, DR: Keeping him off the streets and using illicit drugs.

QUAIL, MR: Nothing more than that?

SINGH, DR: No. And to monitor - at least - okay. To try and restrict his use, at least. He - - -

(T:97; 22.08.16)

QUAIL, MR: In October of 2013 why were you still supplying this man with steroids?

SINGH, DR: He was asking for a prescription, and knowing that he had used illicitly before I didn't - I think a doctor should, at least, take control and that way we don't, as it were - it's not prohibition that we are living with here, so there is no ­ ­ ­

QUAIL, MR: Okay. So to keep him - -

SINGH, DR: Yes.

QUAIL, MR: To keep him off the streets and getting the drug illegally. ­ - -

SINGH, DR: Well - - -

QUAIL, MR: - - - you were happy to continue supplying him with it?

SINGH, DR: I just did supply it, yes. Whilst - it's not an S8, it's not a restricted agent.

(T:98; 22.08.16)

SINGH, DR: It's within his rights to ask for it and he, by doing it openly, he's - I'm not, you know, selling them. And if he wants to take them that is his business, isn't it?

QUAIL, MR: And that was the basis upon which you approached the prescription of steroids generally.

SINGH, DR: No, just with him, but that's the point, it's not illegal. I'm not doing anything that is. - - - forbidden.

QUAIL, MR If that is your philosophy to us, generally, and it must be your belief more generally than [Patient 71]. Your philosophy generally is it's better for you to supply the steroids - - -

SINGH, DR: Yes.

QUAIL, MR: - - - than for them to go out on the street and get them; yes?

SINGH, DR: Yes.

(T:99; 22.08.16)

QUAIL, MR: All right. How many were there like [Patient 71]?

SINGH, DR: I don't think too many.

QUAIL, MR: For those reasons in relation to body building?

SINGH, DR: I can't put a number to it.

QUAIL, MR: More than 20?

SINGH, DR: Probably.

(T:100; 22.08.16)

92 Dr Singh then conceded that he was supplying steroids for body building for a large number of patients (T:101; 22.08.16)

93 Up until that point, all of his statements and all of his evidence had been directed to a therapeutic explanation for his prescription of those drugs.

94 The Board made the following submissions as to Dr Singh's credit generally, in addition to the purpose for which he prescribed drugs:

(a) Dr Singh's witness statement in relation to his qualifications is not accurate. Dr Singh accepted that his claim to have Masters of Science 'with first class honours' was not true as his academic record indicates his Masters degree resulted in him achieving a 'D Pass'. In correspondence to solicitor Mr Massey in relation to [one of his Dr Singh's patients], Dr Singh erroneously asserted that he had a Bachelor of Science in Radioisotope Chemistry when he had a Diploma in Radioisotope Chemistry (Exhibit A page 726).

(b) Dr Singh's approach to his qualifications and his recitation of them in his witness statement reflects his approach to practice generally, his note taking and his approach to these proceedings and the preparation of his witness statements.

(c) In his evidence generally Dr Singh lacked recall on specific matters which only served to highlight the inadequacy of his note taking and unprofessional approach to practice generally.

(d) In relation to his witness statements Dr Singh said on a number of occasions that they were not his words and sought to blame his solicitors while still agreeing that he had signed the statements as true. He essentially indicated that he had not read them closely nor paid attention to the detail, which is again reflective of his approach to his practice of medicine and record keeping generally.

95 The Tribunal accepts the Board's submissions as stated above.

96 In the light of Dr Singh's concession, and the other evidence, it became apparent that much of Dr Singh's evidence was deliberately untrue. Normally, the Tribunal would consider the evidence Dr Singh gave as a medical practitioner and a physician and take it into account, in answer to the expert evidence of Professor Wittert and Professor Joyce. However, this Tribunal has been unable to place any reliance on Dr Singh's evidence. No scientific rationale advanced by Dr Singh can be safely relied upon by this Tribunal, given that he has persisted in untruths as to the basis for his prescribing.

97 Dr Singh sought to adopt various scientific studies when it suited him but rejected those that did not. The following exchange in evidence is illustration of this:

...

SINGH**,** MR**:** A judgment, clinical judgment and experience are superior to the pseudoscience we present as pharmacology now. And - - -

LESLIE, MS: Can you say that again.

SINGH, MR: Clinical - - -

LESLIE, MS: Give me that one again.

SINGH, MR: Clinical judgment and experience in my ­ have more value in determining drug outcome than a published paper and I will give you one good example. All psychiatric drugs generally - - -

LESLIE, MS: I think you used an expression like the pseudoscience that is pharmacology - - -

QUAIL, MR: The pseudoscience of pharmacology.

SINGH, MR: Yes. It is. It absolutely is pseudoscience.

QUAIL, MR: s it a pseudoscience?

WITNESS, JOYCE: I fear for medicine in the hands of a practitioner who pays no respect to its history and its science. If I understand it correctly, what I'm hearing is that nothing that has ever been researched, scrutinised, proven, rescrutinised and, found to still stand, has to be disregarded in favour of some pre­hippocratic shamanistic practice.

(T:245­246; 18.08.16)

98 It is convenient to consider the allegations in relation to Dr Singh's general practice first as the matters raised in relation to Dr Singh's general practice are also relevant to his specific conduct in relation to each of Patient J and Patient B.

The use of a combination of anabolic androgen steroids and other drugs in body builders

99 In order to put the evidence that follows in context, it is useful to explain the reason for the use by body builders of a combination of drugs in association with androgen anabolic steroids. Professor Wittert's evidence was:

The prescription of concurrent and/or sequential use of various anabolic androgenic steroids as appears to be the case in the clinical notes for the patients listed above is typical of the pattern of use of these drugs by body builders. That often occurs with the concurrent or subsequent administration of drugs that block the production or action of oestrogen (Tamoxifen, anastazole and clomiphene [Clomid]) and others such as HCG [Human Chorionic Gonadotropin] that stimulate the production of testosterone more directly in order to overcome the effects of the large doses of anabolic androgenic steroids to suppress the normal production of testosterone by the body.

(Exhibit D Volume 2, at page 382)

100 Professor Wittert's explanation is consistent with Dr Singh's explanation of the basis of his prescribing practice for anabolic androgen steroids and associated drugs made after his concession that he was prescribing for body building purposes.

QUAIL, MR: Why body builders would be using multiple steroids in the combinations that they do, and in the combination you prescribe them? What's the hypothesis behind that?

SINGH, DR: Because excess - well, androgens can convert to oestradiols, you have to (indistinct) with that. They can also shut down endogenous production so you want to not shut that down, and in case of some people it can increase blood pressure, so that's why trandolapril, and aromatase inhibitors to keep oestradiol levels low. Clomid to treat hypogonadism. And Proviron I don't use any more. Methasterone I don't use, and - what was the other one? Oxandrolone I used for burns, autoimmune problems, that sort of stuff. But the reason is, I suppose, to balance the - to limit the side-effect profile and to allow a lower dose of androgens with a wider integral between them.

...

QUAIL, MR: Right. In some of your notes in relation to various of those patients you reveal an awareness of their being involved in body building competitions and preparing for competition.

SINGH, DR: Yes.

...

QUAIL, MR: All right. So were you assisting your body builder patients in cycling and preparing for - - -

SINGH, DR: I would advise them, yes.

QUAIL, MR:- - - - competitions.

SINGH, DR: I would advise them.

QUAIL, MR: In how to go about taking steroids - - -

SINGH, DR: To avoid the side effects.

QUAIL, MR: - - - in order to minimise the side effects?

SINGH, DR: Yes, and they do it safely.

QUAIK, MR: And a number of the drugs you prescribed concurrently with the steroids were for the purposes of counteracting some of the side effects?

SINGH, DR: Yes, some of them, yes.

QUAIL, MR: So what drugs would you prescribe to counteract the effect of the steroids?

SINGH, DR: Tamoxifen.

QUAIL, MR: What was the Tamoxifen to - - -

SINGH, DR: Block oestradiol. Arimidex, aromatase inhibitor.

QUAIL, MR: Just if you can tell us what it actually - - -

SINGH, DR: Blocks oestradiol synthesis.

QUAIL, MR: Yes.

SINGH, DR: What was - - -

QUAIL, MR: So blocking what, preventing - or hoping to prevent what?

SINGH, DR: Conversion of testosterone to oestradiol, yes.

QUAIL, MR: All right. So in other words to head off gynecomastia in men.

SINGH, DR: Gynoid fat, gynecomastia, yes. Water retention. Arimidex has - reduces the oestradiol level and it is the reduced oestradiol level that feeds back on the hypothalamus to keep FSH LH going so you don't shut down pituitary function. Trandolapril is an ace inhibitor to maintain systolic blood pressure, yes. Crestor is a statin to reduce the bad lipids - sorry, the LDLs. What else? What else? Any other ones you want to ask me about?

...

QUAIL, MR: Yes, the human growth hormone, what's that for?

SINGH, DR: Human growth hormone would repair tissue, collagen repair, tendons, ligaments, that sort of thing, and - - -

QUAIL, MR: Yes, but in the context of these guys, like, up on the screen at the moment, [Patient 71], in terms of the body building what do they want the growth hormone for?

SINGH, DR: If they have a mismatch between the tensile strength of muscle and ligament; right. So there's a mismatch six to one between tensile, so muscle can generate a huge forces, but is elastic, whereas tendon is inelastic and can't sustain as much force in - as the muscle will generate, so the GH allows the tendon to repair more quickly so you don't get tendon ruptures.

QUAIL, MR: Right.

SINGH, DR: And repair of collagen because they ­ collagen is (indistinct) and around your cell, so, you know, post workout soreness that sort of thing, and activating lipolysis.

LESLIE, MS: But that's nothing to do with side effects, that's balancing the tendon and ligament strength to the increased muscle capacity - - -

SINGH, DR: Yes.

LESLIE, MS: - - - that in other steroids that they're using - - -

SINGH, DR: And it's thought that - - -

LESLIE, MS: - - - are allowing.

SINGH, DR: - - - the androgens may soften, as it were, the ligament as well, but that's debate about that. But it seems that if they just use androgens on their own they do get more ruptures of biceps, tendons, that sort of thing. So in general ligament repair, so collagen is ligaments, aponeuroses, and expansions of superficial ligaments as well.

...

(T:104­108; 22.08.16)

101 The fact that Dr Singh prescribed the drugs and treatments the subject of these proceedings was not in issue. A summary of the relevant prescriptions is contained in Exhibit A Volume 5. Dr Singh's very proper concession of the fact that he prescribed the drugs and substances saved the Tribunal significant time at the hearing.

102 The Board alleged that from early 2008 Dr Singh engaged in a general practice of prescribing to patients who consulted him seeking weight loss, physical conditioning and/or body building:

1. Anabolic androgenic steroids including Oxandrolone, Stanozolol, Methandrostenolone, Primoteston Depot and Methenolone;
2. Clenbuterol; and/or
3. Ephedrine and capsules combining Ephedrine, Aspirin and Caffeine (EAC),

103 in circumstances in which there was no proper therapeutic indication or reason for the use of those drugs or substances by the patients for whom they were prescribed and it unnecessarily exposed patients to the adverse effects of those substances or drugs.

104 The Board further alleged that from early 2008, Dr Singh engaged in a general practice of prescribing Clomid to patients who consulted him seeking weight loss, physical conditioning and/or body building in contravention of reg 38C of the of the Poisons Regulations 1965 (WA) (Poisons Regulations) made pursuant to the Poisons Act 1964 (WA) (Poisons Act).

105 The Tribunal notes that, although the Board's allegations as to Clomid related to a breach of reg 38C of the Poisons Regulations, it is in fact part of the suite of drugs prescribed to prevent the side effects of anabolic androgenic steroids.

Initially, Dr Singh denied that he prescribed anabolic androgenic steroids, Clenbuterol, Ephedrine and EAC and Clomid in circumstances in which there was no proper therapeutic indication or reason for the use of those drugs. In Dr Singh's response (SR), he stated that the rationale for treating patients using those drugs fell into one or more of the following categories:

(i) sarcopenic obesity;

(ii) opposing the catabolic effect of glucocorticoids, for example asthma, chemotherapy, IBD, autoimmune disease;

(iii) immune deficiency: C1 esterase deficiency;

(iv) hypogonadotropic hypogonadism;

(v) dysautonomia;

(vi) osteoporosis/osteopenia;

(vii) anaemia;

(viii) wasting diseases, for example HIV, malignancy, malabsorption;

(ix) obesity and hypogonadism in females taking the oral contraceptive pill;

(x) over-training syndrome;

(xi) risk minimisation in athletes;

(xii) illicit narcotic and amphetamine induced cachexia;

(xiii) poor post-operative healing;

(xiv) protein losing enteropathy;

(xv) severe refractory depression;

(xvi) idiopathic hypovolemia;

(xvii) hypereosinophilia;

(xviii) cancer cachexia;

(xix) impotence;

(xx) myalgic encephalomyelitis (chronic fatigue ­ hyperelastic variant)

(xxi) severe proximal myopathy secondary to low testosterone, thyroid disease, overuse of glucocorticoids and myositis.

(SR paragraph 51(f))

106 The Board further alleged that from early 2008, Dr Singh engaged in a general practice of prescribing

1. human growth hormone;
2. Sibutramine;
3. Tamoxifen;
4. Anastrozole;
5. Testosterone;
6. Midodrine;
7. Fludrocortisone; and
8. Erythropoietin,

107 when there was no proper therapeutic indication or reason for their prescription and it unnecessarily exposed patients to the adverse effects of those substances or drugs.

108 The Board further alleged that from early 2008, Dr Singh engaged in a general practice of ordering the infusion of iron for patients:

1. who did not suffer from any iron deficiency; and/or
2. in circumstances in which the infusion of iron was contra­indicated for patients because the patients suffered from haemochromatosis or beta­thalassaemia trait.

109 The Board further alleged that from early 2008, Dr Singh engaged in a practice of ordering fresh frozen plasma infusions for patients when there was no recognised therapeutic indication for such infusions in those patients.

110 The Board further alleged that from early 2008, Dr Singh engaged in a general practice of ordering DEXA scans when there was no recognised therapeutic indication for the performance of any such scans or alternatively, for the performance of multiple such scans, of those patients.

111 Dr Singh, in his SR, essentially denied that he engaged in a general practice of prescribing drugs or ordering substances or scans when there was no recognised therapeutic indication for prescribing those drugs or ordering those substances and denied that the quantities he prescribed or ordered exposed patients to the risk of adverse effects.

112 Professor Wittert's opinion was that the therapeutic indication for the prescription of anabolic androgenic steroids is for men with hypogonadism (low blood testosterone level) with symptoms present due to a pathological condition affecting the mechanisms regulating testosterone production. In his opinion there are no recognised indications for taking combinations of anabolic steroids (Exhibit Q Volume 3 at page 640).

113 Professor Joyce agreed with Professor Wittert (Exhibit Q Volume 3, at page 640).

114 Professor Vickery did not agree with Professor Wittert. In his opinion, short term use of anabolic steroids to treat sarcopenic obesity by increasing muscle mass is indicated (Exhibit Q Volume 3 at page 640).

115 Professor Wittert's evidence was that the patient records he examined did not support a diagnosis of any patients with sarcopenic obesity (T:184; 18.08.16).

116 The Tribunal prefers and accepts Professors Wittert's and Joyce's evidence as to the therapeutic indications for the prescription of anabolic androgen steroids.

117 The Board alleged that Dr Singh's prescription of anabolic androgenic steroids for his patients had the potential to cause, induce or exacerbate the following potential adverse signs and symptoms related to use of those drugs:

• hepatotoxicity;
• altered glucose tolerance;
• hypercalcemia;
• polycythaemia;
• aggressive behaviour;
• withdrawal symptoms;
• sodium retention;
• oedema;
• hypertension;
• impaired renal function;
• hypertension;
• increased LDL cholesterol;
• in men ­ gynaecomastia, impotence, testicular atrophy, priapism, inhibition of spermatogenesis, degenerative changes in seminiferous tubules and abnormal androgen levels; and
• in women ­ amenorrhoea, clitoral enlargement, voice changes; virilisation and hirsutism.

The expert evidence on the potential adverse effects of using anabolic androgen steroids

118 Professor Wittert's opinion as to the potential adverse effects of using anabolic steroids in his report dated 20 October 2014 was:

Anabolic/androgenic steroids cause disease of the blood vessels and/or heart by number of mechanisms which include abnormalities in blood fats, increased clotting, abnormalities of the blood vessel wall, rhythm and other electrical abnormalities and disordered function of cardiac muscle; abnormalities of the normal reproductive axis including suppression of the normal ability to make testosterone, testicular atrophy, disturbances of sex drive, the development of breast tissue, and decreased fertility; changes to mood and behaviour as well as responsiveness to stress that may persist even after use has been discontinued; liver damage; acne and accelerated balding; increased risk of injuries to tendons; periodontal disease.

Men seeking anabolic steroids may be doing so as a result of body dysmorphia, a condition which requires appropriate counselling and referral to a suitably qualified psychiatrist or psychologist. The continued provision of anabolic steroids to a person with body dysmorphia fails to treat the underlying cause of the patient seeking these drugs, and is likely to lead to ongoing abuse of anabolic steroids to the detriment of the patient's health.

(Exhibit D at page 81)

119 Professor Wittert stated that the risk of adverse effects of prescribing anabolic androgen steroids is, in general, low when treatment, in conjunction with testosterone, is initiated in accordance with appropriate therapeutic indication. He said that the adverse effects under these circumstances are most commonly elevation of haematocrit. When used outside of these indications or in large doses or in combinations, the risks are as stated above (Exhibit Q Volume 3 at page 641).

120 Professor Joyce's opinion in his written report dated 2 October 2015 (Exhibit E Volume 3 Witness Statements, at pages 579­581) as to the potential adverse effects of anabolic androgen steroids was:

The adverse effects of Primoteston Depot that are listed in TGA­approved product information are representative of the adverse effects that might be seen during treatment of male androgen deficiency with conventional therapeutic doses (Therapeutic Goods Administration, 2015). The section reads:

'The most commonly reported adverse reactions with Primoteston Depot are injection site pain, injection site erythema, and cough and/or dyspnoea during or immediately after the injection.

Injections of oily solutions such as Primoteston Depot have been associated with systemic reactions: cough, dyspnoea and chest pain. There may be other signs and symptoms including vasovagal reactions such as malaise, hyperhidrosis, dizziness, paraesthesia or syncope.

High-dosed or long-term administration of testosterone, including Primoteston Depot, increases the tendency to water retention and oedema.

Spermatogenesis is inhibited by long-term and high-dosed treatment with Primoteston Depot.

If, in individual cases, frequent or persistent erections occur, the dose should be reduced or the treatment discontinued in order to avoid injury to the penis.

Various skin reactions including injection site reactions (injection site pain, injection site erythema, injection site induration, injection site swelling, injection site inflammation) may occur.

Other events reported with Primoteston Depot include benign and malignant liver tumours, polycythaemia, hypersensitivity reactions, liver function test abnormalities, jaundice, acne, alopecia, rash, urticarial, pruritus, Prostatic Specific Antigen (PSA) increase, libido increase, libido decrease and gynaecomastia.

As with other testosterone-containing products, the use of Primoteston Depot may commonly cause an increase in haematocrit, red blood cell count or haemoglobin.

Increased hair growth has been reported under treatment with testosterone-containing preparations.

Regarding adverse effects associated with the use of androgens, please also refer to PRECAUTIONS'.

'Older patients treated with androgens may be at increased risk for the development of prostatic hyperplasia. Androgens can enhance the growth of an existing prostatic carcinoma. Therefore, carcinoma of the prostate has to be excluded before starting therapy with testosterone preparations.

As a precaution, regular examinations of the prostate are recommended. Haemoglobin and haematocrit should be checked periodically in patients on long-term androgen therapy to detect cases of polycythaemia (see ADVERSE EFFECTS).

Cases of benign and malignant liver tumours, which may lead to life-threatening intraabdominal haemorrhage, have been observed after the use of hormonal substances such as the one contained in Primoteston Depot.

The doctor must therefore be informed of the occurrence of unusual upper abdominal complaints which do not disappear spontaneously within a short time as it may then be necessary to withdraw the preparation. A hepatic tumour should be considered in the differential diagnosis when severe upper abdominal pain, liver enlargement or signs of intra-abdominal haemorrhage occur in men using Primoteston Depot. Caution should be exercised in patients predisposed to oedema. e.g. in case of severe cardiac, hepatic, or renal insufficiency or ischaemic heart disease, as treatment with androgens may result in increased retention of sodium and water. In case of severe complications characterised by oedema with or without congestive heart failure, treatment must be stopped immediately (See ADVERSE EFFECTS).

Testosterone may cause a rise in blood pressure and Primoteston Depot should be used with caution in men with hypertension.

Primoteston Depot must not be used in women, due to possible virilising effects.

Pre-existing sleep apnoea may be potentiated'.

Similar adverse risks and precautions are listed for other registered androgenic steroids.

The TGA-approved product information covers anticipated outcomes and risks when the androgenic steroids are used in conventional therapeutic doses in male androgen deficiency.

When androgenic steroids are used at doses that exceed replacement doses, the incidence and severity of the above-mentioned adverse effects will increase. Additionally, psychiatric adverse effects may emerge, principally manifesting as aggression, uncontrolled anger and rage. The risk of serious outcomes from the cardiovascular adverse effects (lipid derangements, hypertension and polycythemia) increases, with outcomes that include myocardial infarction, cardiac muscle changes and strokes. Prominent breast development and testicular shrinkage may be particular concerns for the male user, leading to adjunctive treatment with drugs such as tamoxifen and clomiphene to counter them.

The C17-alpha alkylated androgenic steroids carry an increased risk of liver tumours and other liver toxicity, compared with testosterone. Oxandrolone is one such drug. It is not registered for use in Australia.

• water retention
• psychiatric disturbances
• spermatogenesis inhibition
• polycythaemia
• liver abnormalities
• jaundice
• acne
• alopecia
• gynaecomastia
• increased blood pressure
• lipid derangement
• increased myocardial infarction risk
• benign and malignant tumour risk

122 Professor Vickery's opinion in his report dated 16 April 2015 in relation to Patient J as to the risk of adverse effects of taking androgen anabolic steroids was that there has not been shown to be a substantial risk with this combination in the short­term (Exhibit P Volume 2 Witness Statements, at pages 508-529 at 513).

123 Professor Vickery's opinion was that the risks of such prescription in short term corrective doses are minimal and limited (Exhibit Q Volume 3 at page 641).

124 The Tribunal prefers and accept the evidence of Professors Wittert and Joyce on the adverse effects of androgen anabolic steroids. The Tribunal finds that the prescription of androgen anabolic steroids other than in accordance with the therapeutic indications identified by Professor Wittert exposes patients to the adverse effects identified by Professors Wittert and Joyce.

125 The Tribunal accepts that there were in fact adverse effects as set out in Dr Wittert's report, for example, Patient 251.

The evidence in relation to the prescription of anabolic androgen steroids to Dr Singh's patients

126 Patients who were prescribed anabolic androgenic steroids over long periods of time included:

Patients 46, 52, 62, 68, 71, 74, 88, 114, 122, (128), 173, 202, 204, 213, 261, 297, 341, 351, 385, 402, 426, 436, 453, 476, 504, 514, 567, 594, 596, 612, 635, 658, 662, 693, 714, 715, 740 and 741.

127 When cross-examined about the above patients, Dr Singh agreed that all except Patients 114, 202 (in whom Dr Singh said he could not recall the reason for treatment), 261 and 476 were prescribed steroids by him for the purposes of body building.

128 On 7 February 2012, APHRA sent a notice to Dr Singh requiring the provision of information pursuant to the National Law (Exhibit A Volume 3, at page 664). Information was requested in relation to Patients 71, 46, 594, 619, 714, 64, 46, 376 and 152. In Dr Singh's letter to APHRA dated 20 July 2012, he stated that each of those patients attended him generally with the primary or secondary problems of sarcopenic obesity or sarcopenia of other cause. He went on to identify his diagnosis of individual patients as follows:

(71) obesity

(173) for 'chronic fatigue and weight loss'

(594) notes lost in change of premises ­ improve physical conditioning

...

(46) for chronic fatigue, body building and osteopaenia.

129 During the course of the cross-examination, Dr Singh also agreed that numerous other patients referred to below were prescribed anabolic steroids and related drugs for body building. They included:

1. Patient 402, who also worked at the Empire Clinic, who had a long history of abuse of illicit drugs according to the clinical notes and Dr Singh's evidence;
2. Patient 635, who Dr Singh initially agreed was there for body building purposes then later denied was, and about whom a detailed letter in Patient 635's patient notes was put to Dr Singh. The letter and related photographs (Exhibit U) clearly show that at the time of his treatment Patient 635 was preparing for a body building competition, or at least a body physique competition.
3. Patient 410;
4. Patient 407;
5. Patient 59;
6. Patient 421;
7. Patient 684;
8. Patient 418;
9. Patient 505, who Dr Singh acknowledged in cross­examination he knew was a former professional body builder who now runs the International Federation of Body Building in Western Australia and runs a gym in East Perth; and
10. Patient 426, who during cross-examination Dr Singh agreed when Patient 426 first came to see him, his colleagues were concerned about his aggressive behaviour and he was also involved in a motorcycle gang. Nonetheless, Dr Singh prescribed him anabolic steroids, again essentially for body building reasons.

There were adverse effects from Dr Singh's prescription to Patient 251 for Oxandrolone, Clenbuterol, Primoteston, Clomid, Stanozolol, Sustanon and Methandrostenolone between October 2009 and August 2011. Ultimately in 2012, Patient 251 required surgery for gynaecomastia. Dr Singh's response in his evidence was to say that the Board could not prove that the gynaecomastia was caused by steroid use but could have been caused by the patient's marijuana use. All that this does is serve to heighten the inappropriateness of the prescription for steroids in the first place if in fact Dr Singh knew that the patient was using marijuana and if Dr Singh believed that marijuana use could cause gynaecomastia.

130 Patients who received large doses of anabolic androgenic steroids at one consultation included:

1. Patient 43, to whom Dr Singh gave a prescription (or repeat prescriptions) for 18 Primoteston injections at one consultation;
2. Patient 71, to whom Dr Singh gave a prescription (or repeat prescriptions) for 500 Oxandrolone capsules, 21 Primoteston ampules and 60 Stanozolol troches at one consultation;
3. Patient 287, in relation to who Dr Singh's clinical notes record 'Friend of [D]. Naughty boy. Wants to get buff by April.'
4. Patient 359, who told Dr Singh that he competed in a body building competition the previous year and who Dr Singh gave a prescription (or repeat prescriptions) for 15 ampoules of Primoteston at one consultation;
5. Patient 380, to whom Dr Singh gave a prescription (or repeat prescriptions) for 12 ampoules of Primoteston at one consultation; and
6. Patient 532, who told Dr Singh he worked out with weights six days a week and was there to 'look good', and who Dr Singh gave a prescription for six ampoules of Primoteston at one consultation.

131 In relation to Methandrostenolone, Dr Singh's evidence in his witness statement dated 17 February 2016 at paragraphs 46 and 47 was that:

I used to prescribe Methandrostenolone for its anabolic effects, particularly treatment of anaemia, osteoporosis, tissue break-down and poor healing.

I ceased prescribing Methandrostenolone some years ago because I found it was sometimes associated with mild liver dysfunction and sodium retention.

132 The clinical notes record that a large number of patients were prescribed Methandrostenolone with either no record of any reason for the prescription and with no record that the patient was anaemic or had osteoporosis, tissue break­down or poor healing, including (but not limited to):

Patients 15, 16, 46, 61, 64, 68, 71, 74, 95, 98, 101, 113, 122, 123, 128, 130, 151, 159,162, 166, 161, 173, 201, 202, 436 and 490.

133 In relation to Methenolone, Dr Singh's evidence in his statement dated 17 February 2016 at paragraphs 49­53 was that:

I rarely prescribe Methenolone.

It is a very mild anabolic and the androgenic activity is almost completely absent. It is sometimes useful in treating cases of cancer cachexia, AIDS and prolonged post-operative convalescence.

Methenolone does not aromatise to oestrogen.

I usually prescribe Methenolone at a starting dose of approximately 25mg alternate daily once or twice a week.

In my experience, this medication has minimal side effects and therefore is particularly useful in women.

134 The clinical notes did not record any examples of occasions on which Dr Singh had prescribed Methenolone to any women, cancer patients, AIDS patients or post-operative patients (based on available clinical and pharmacy records). Dr Singh had prescribed Methenolone to:

1. Patient 410, who was prescribed Methenolone when his reason for presentation was 'Here to gain size' and he was employed as a 'protein rep and personal trainer' and who in cross-examination Dr Singh agreed was a body building patient; and
2. Patients 68, 71, 541, 567, 568 and 663 were also prescribed Methenolone when none of the medical conditions mentioned by Dr Singh were present.

135 In relation to Oxandrolone, Dr Singh's evidence in his witness statement dated 17 February 2016 at paragraphs 55­57 was that:

I use Oxandrolone to treat muscle catabolism or break-down in a variety of settings, such as wasting diseases, disuse atrophy or where catabolism has occurred as a result of low testosterone levels.

It is my usual practice to prescribe Oxandrolone at a starting dose of approximately 5mg usually alternate daily or twice weekly only. For women, the dosages are sometimes even less than this.

In my experience, Oxandrolone at this dose is not associated with significant adverse side-effects and has a good safety profile (so much so that it used to be commonly used in female children with third degree burns for its anabolic effect). In my experience, Oxandrolone is safe to use in both females and children because of its lack of androgenic effects and relative weakness. I sometimes use Oxandrolone in males or females for treatment of severe allergies due to C1 esterase deficiency, protein losing enteropathy, nephrotic syndrome, malnutrition due to cancer treatment, celiac disease and anorexia nervosa.

136 Dr Singh did not state in his witness statement that he also used Oxandrolone for his body building patients.

137 The prescription records and patient records note the following:

(i) (10) female patient prescribed Oxandrolone 10mg daily after gastric sleeve surgery.

(ii) (24) female patient prescribed Oxandrolone 10mg every second day because of 'overtraining'.

(iii) (25) female patient prescribed Oxandrolone 10mg every second day (reason for prescription not apparent from notes).

(iv) (26) prescribed Oxandrolone 20mg daily.

(v) (45) female patient prescribed Oxandrolone 10mg daily (reason for prescription not apparent from notes).

(vi) (60) female patient prescribed Oxandrolone 10mg every second day (reason for prescription 'This definitely increases the red cell synthesis and also is a known androgenising anabolic'.)

(vii) (62) prescribed Oxandrolone 20mg daily (od = once daily) (reason for prescription not apparent from notes).

(viii) (65) female patient prescribed Oxandrolone 10mg daily. Weight loss patient, reason for prescription not explained in notes.

(ix) (82) female patient prescribed Oxandrolone 10mg daily to increase red cell mass.

(x) (88) prescribed Oxandrolone 20mg daily (with other AAS). Reason for presentation 'To get advice on diet, training and to be the best he can'. Patient 'Runds (sic) most mornings, Weights 5 x / week, Attends strenght (sic) training gym' ­ 'shredded strength institute'.

(xi) (116) female weight loss patient prescribed Oxandrolone 10mg daily.

(xii) (146) female weight loss patient prescribed Oxandrolone 10mg daily.

(xiii) (148) female weight loss patient prescribed Oxandrolone 10mg every second day.

(xiv) (152) female weight loss patient prescribed Oxandrolone 10mg daily post sleeve gastrectomy.

(xv) (157) female patient prescribed Oxandrolone 10mg daily (reason for prescription not explained in notes).

(xvi) (169) female patient prescribed Oxandrolone 10mg daily 'to block catabolic effects of Reductil'.

(xvii) (171) female weight loss patient prescribed Oxandrolone 10mg daily 'because with initial weight loss programs there is often loss of skeletal muscle'.

(xviii) (201) female weight loss patient prescribed Oxandrolone 10mg daily.

(xix) (205) described by Dr Singh as 'a fit athletic young man' prescribed Oxandrolone 20mg daily (with other AAS and HGH).

(xx) (215) female weight loss patient prescribed Oxandrolone 10mg every second day.

(xxi) (218) female weight loss patient prescribed Oxandrolone 10mg daily.

(xxii) (246) female weight loss patient prescribed Oxandrolone 10mg daily.

(xxiii) (261) prescribed Oxandrolone 10mg daily (reason for prescription not apparent from notes).

(xxiv) (302) female patient prescribed Oxandrolone 10mg daily.

(xxv) (314) prescribed Oxandrolone 20mg daily.

(xxvi) (342) female weight loss patient prescribed Oxandrolone 10mg daily.

(xxvii) (343) female weight loss patient prescribed Oxandrolone 10mg daily.

(xxviii) (353) female patient prescribed Oxandrolone 10mg every second day. [(353)] developed very elevated testosterone.

(xxix) (374) female weight loss patient prescribed Oxandrolone 10mg daily.

(xxx) (399) 'Here as always feels tired, states no strength, low libido, trains hard but poor results, wants a lean muscular appearance, carrying excess weight' prescribed Oxandrolone 20mg daily.

(xxxi) (552) female patient prescribed Oxandrolone 10mg daily.

138 The available clinical notes did not record any examples of occasions on which Dr Singh had prescribed Oxandrolone 5 milligrams alternate daily or twice weekly (10mg to 15mg per week, less for females). The available clinical notes record that the actual doses prescribed were a minimum 10 milligrams every second day (35 milligrams per week) up to 20 milligrams per day (140 milligrams per week). Doses prescribed up to nine times higher than Dr Singh's witness statement suggests.

139 When Dr Singh's prescribing practices were put to him, Dr Singh sought to justify the contents of his written statement that the dosage identified in his written statement referred to a starting dose. If it was only a starting dose then his statement was incomplete and it was misleading not to state his usual dose. His statement as to the low risk of adverse effects was put in the context of the dose he stated in cross­examination as a 'starting dose'.

140 In relation to Stanozolol, Dr Singh's evidence in his witness statement dated 17 February 2016 at paragraphs 58­62 is that:

Stanozolol is an anabolic steroid. I have found it particularly useful to increase red cell production in those who have anaemia that is refractory to treatment with just EPO alone.

I also use Stanozolol in the treatment of conditions similar to that of Oxandrolone, including in the treatment of severe allergies due to C1 esterase deficiency, protein losing enteropathy, nephrotic syndrome, malnutrition due to cancer treatment and celiac disease and anorexia nervosa.

Depending on the patient, I use Oxandrolone or Stanozolol interchangeably.

It is my usual practice to prescribe Stanozolol at a starting dose of approximately 20mg twice weekly.

In my experience, Stanozolol at this dose and frequency, the adverse side effects are rare.

141 Where doses are recorded in the clinical notes they exceed the dose that Dr Singh's witness statement stated that he prescribed (20 milligrams twice per week, that is, 40 milligrams per week). The records show that Dr Singh prescribed Stanozolol 50 milligrams on alternate days, that is, 175 milligrams per week ­ more than four times the dose stated by Dr Singh.

1. Patient 635 prescribed Stanozolol 50 milligrams daily;
2. patients prescribed Stanozolol 50 milligrams on alternate days include Patients 22, 43, 228, 404, and 407;
3. female patients prescribed Stanozolol 50 milligrams (frequency of dose unknown) include Patients 169, (293), 374, 463 and 666;
4. patients prescribed 50 milligrams Stanozolol (frequency of dose unknown) include Patients 20, 49, 54, 71, 123, 128, 151, 251, 256, 261, 287, 295, 297, 304, 341, 369, 371, 401, 402, 410, 422, 446, 453, 468, 504, 507, 509 525, 527, 541, 567, 579, 594, 596, 604, 649, 684, 713, 714, 715, 717, 726 and 741.

142 Dr Singh's evidence in his witness statement dated 17 February 2016 at paragraphs 63­67 in relation to Primoteston is that:

Primoteston is a testosterone ester.

I prescribe Primoteston to patients for its anti-catabolic activity.

It is a slow release formulation which has an effect for approximately 2 to 3 weeks. I determine the appropriate end-point by measuring levels 2 to 3 weeks post initial injection (although in most males, 2 weeks is about the right interval).

Primoteston can aromatise to oestrogen. Excess oestrogen can cause gynaecomastia, water retention and female fat distribution. To avoid these effects, I usually prescribe Anastrozole at one half tablet twice per week.

It is my usual practice to prescribe Primoteston at a starting dose of 250mg every two to three weeks in men. For women requiring testosterone (for example those on the oral contraceptive pill who had all androgens shut­down) I prescribe 1-2% topical testosterone cream every second to third day (ie 2mg in 100g of cream).

143 The following patients were prescribed Primoteston for muscle building purposes by Dr Singh:

(i) (47) clinical notes state 'Goal: has a competitive streak, wants to be the best he can be.' Consolidated dispensing history shows he was prescribed Primoteston by Dr Singh.

(ii) (56) clinical notes state 'Here to optimise physical function' and 'Exercise gym am 5x/week weights regular for 1 years'.

(iii) (59) clinical noes state 'Here to improve training, feels has lost strength 4 years ago was training for a natural body building comp' and 'Exercise 4-5 days/week for 15 years weight training 1 hr'.

(iv) (71), no reason for prescription indicated in notes. Very large body builder (photographs in ABD3 589-611).

(v) (235).

(vi) (341) clinical notes state 'Here to increase muscle mass. Was a patient of [Doctor]. Has been on 3 courses of Primo in the past. Currently 80kg goal 90kg'.

(vii) (287) 'Goal: Here for increased fitness, fat loss and muscle mass'.

(viii) (377) clinical notes state 'Here to bulk up. Long standing history of fitness 25 years, competitive cyclist, ex paramedic in USA. Personal trainer. Profession - senior security officer works away'.

(ix) (385) clinical notes state 'A 40-year-old night club owner, movie maker, kung foo expert aiming to get in shape by March/April next year.' ... 'Legs need more development, abdomen needs coming down, shoulders increase, chest defining, serratus anterior needs to be defined, increase in biceps and triceps, hamstrings also need to be defined'.

(x) (402) clinical notes state 'Here to bulk up has friends that have come through here'.

(xi) (421) clinical notes state '[J] saw [A] 1 month ago to try and bulk up. He is now on testosterone injections once a fortnight, anabolic steroid twice a day and Clenbuterol twice a week. He had decreased thiamine and testosterone.'

(xii) (527) clinical notes state 'Goal - Wants to bulk up' (consolidated dispensing history records prescription of Primoteston, not noted in clinical notes).

(xiii) (561) develops very raised PSA after prescriptions for Primoteston.

(xiv) (610) clinical notes state '27 year old here for strength, fitness, bulk. Profession - works in the mines, martial arts instructor, moderate physical exertion'.

(xv) (684) '[M] is a competitive body builder who is very conscious of the state of his skin'.

(xvi) (713) clinical notes state 'Knows of [GT] from here Goal: here for 'body building' and to lose excess fat'.

(xvii) (715) clinical notes state 'Here to change physique, bulk up'.

(xviii) (738) clinical notes state '[W] weighed 103 kgs two years ago, and decreased to 74kgs in May this year during body building competition. He currently would like to increase muscle mass'.

Conclusion in relation to androgen anabolic steroids

144 There is overwhelming evidence that Dr Singh was prescribing androgen anabolic steroids to his patients for use in physical conditioning and body building. The Tribunal accepts the evidence of Professors Wittert and Joyce that there was no therapeutic basis for Dr Singh's prescription of androgen anabolic steroids.

145 The Tribunal finds that from early 2008, Dr Singh engaged in a general practice of prescribing anabolic androgenic steroids including Oxandrolone, Stanozolol, Methandrostenolone, Primoteston Depot and Methenolone to patients who consulted him seeking weight loss, physical conditioning and/or body building when in the circumstances there was no proper therapeutic indication or reason to prescribe anabolic androgenic steroids. The Tribunal finds that Dr Singh's prescribing practice was extensive.

146 The Tribunal accepts Professor Wittert's evidence that:

The prescribing of combinations of anabolic steroids with the primary purpose of increasing muscle mass and function in the absence of any other appropriate indication is not now, nor ever has been, accepted practice.

(Exhibit D Volume 2, at page 380)

147 It follows from Professor Wittert's evidence that the prescription of drugs to prevent the side effects of the prescription of anabolic androgen steroids must also be an unacceptable practice.

148 The Board alleged that from early 2008, Dr Singh engaged in a general practice of prescribing Clenbuterol for patients who consulted him seeking weight loss, physical conditioning and/or body building when in the circumstances there was no proper therapeutic indication or reason for the use of Clenbuterol (Board's CG paragraph 50.2).

149 Dr Singh denies the allegation that Clenbuterol, Ephedrine or EAC were prescribed in circumstances in which there was no proper therapeutic indication. Dr Singh's response (SR paragraph 50(d)) stated:

1. therapy includes early medical intervention to prevent a condition from developing to a crisis point; and
2. a treatment is not precluded from being therapeutic because it has a cosmetic benefit in parallel with physical or internal benefit.

150 Both Professors Joyce and Wittert agreed that there were no recognised therapeutic indications for the prescription of Clenbuterol. It had been used in phase 1 trialling for asthma. Clenbuterol is not sold in Australia but the chemical components of Clenbuterol can still be imported and compounded.

151 Professor Wittert stated there was no proper or reasonable therapeutic indication for the prescription of Clenbuterol which outweighed the potential adverse effects.

152 Professor Vickery's opinion was that the therapeutic indication was for increasing muscle mass in sarcopenic obesity. As noted previously Dr Singh's medical records did not disclose any basis for a diagnosis of sarcopenic obesity.

153 The Tribunal accepts Professors Wittert's and Joyce's evidence as to the therapeutic indications for the prescription of Clenbuterol.

154 The Board alleged that Dr Singh's prescription of Clenbuterol for his patients had the potential to cause, induce or exacerbate:

• tremor;
• palpitations;
• headache;
• muscle cramps;
• agitation and insomnia;
• hypertension;
• ischemic heart disease;
• heart failure; and
• arrhythmia.

1. I am not aware of any evidence to establish the safety or efficacy of Clenbuterol as a medication for significantly reducing fat mass or for the maintenance of muscle mass in the context of a calorie restricted diet. Further, I do not believe that there are studies which would show that Clenbuterol is of any benefit when anabolic/androgenic steroids are already being prescribed for a patient.
2. Clenbuterol has a significant list of potential adverse effects including muscle cramps, increase in blood pressure, increase in heart rate, palpitations, insomnia, dry mouth, tremor, anxiety, nervousness and restlessness, headaches and sweating. ...
3. Some of the adverse effects may not be symptomatic (for example, increases in blood pressure).

(a) an increase in the size of the heart muscle cells which may be due to inelastic substance known as collagen resulting in less efficient muscle, making the patient prone to arrhythmias, which would increase the patient's risk of stroke;

(b) adverse effects on the structural dimensions of the heart leading to aortic dilation, particularly in response to exercise, with the risk of rupture and death, at least in theory (based on animal studies); and

(c) adverse effects on the mechanical properties of bone micro-architecture, increasing fragility in bones and thereby increasing the risk of fractures.

1. Clenbuterol is also associated with the induction of tachyphylaxis, a process by which the medication can rapidly lose its efficacy, even after 3 to 4 weeks.

(Exhibit D Volume 2 CWS at pages 291-292, see also pages 356­357)

156 The Tribunal prefers and accepts the evidence of Professor Wittert on the adverse effects of Clenbuterol.

157 The Tribunal finds that the prescription of Clenbuterol exposed patients to the adverse effects identified by Professor Wittert.

The evidence in relation to the prescription of Clenbuterol to Dr Singh's patients

158 Dr Singh's evidence in his witness statement was that he prescribed Clenbuterol as an adjunct to lifestyle modification and standard therapy for obesity. He stated that the aim in those patients was to maintain skeletal muscle mass and target only fat loss. He stated that he used it only in refractory cases and for short periods (Exhibit T Volume 1, at page 182 paragraphs 84­85).

159 In cross­examination, Dr Singh agreed that Clenbuterol was prescribed by him as an adjunct for patients who were there for the purposes of body building as outlined above.

160 Patients prescribed Clenbuterol for 12 months or more (according to clinical notes and/or dispensing histories) included (among others) Patients 12, 22, 46, 54, 88, 119, 132, 158, 169, 228, 406 and others.

161 Dr Singh's evidence in his witness statement was that his experience of prescribing Clenbuterol was that on a short term basis and at a low dose the most common potential side effect is limited to a mild tremor which can be countered with orange juice or a banana. He described it as quite safe (Exhibit T Volume 1, at page 182 paragraphs 87­89).

162 Professor Joyce stated no proper or reasonable therapeutic indication for the prescription of Clenbuterol was revealed in the notes read.

163 Professor Vickery stated that he had no experience in the prescription or use of Clenbuterol. He stated that studies have shown that the medication improves muscle mass, and strength in a small number of studies, inpatients with muscle wasting or catabolic diseases (Querin G 2013), and as such the treatment of patients with loss of muscle or sarcopenic obesity provides reasonable therapeutic indication (Exhibit P Volume 2, at page 515).

There is overwhelming evidence that Dr Singh was prescribing Clenbuterol to his patients for use in association with anabolic androgenic steroids. The Tribunal accepts the evidence of Professors Wittert and Joyce that there was no therapeutic basis for prescribing Clenbuterol.

The Tribunal finds that from early 2008, Dr Singh engaged in a general practice of prescribing Clenbuterol to patients who consulted him seeking weight loss, physical conditioning and/or body building when in the circumstances there was no proper therapeutic indication or reason for the use of Clenbuterol by the patient for whom they were prescribed. The Tribunal finds that Dr Singh's prescribing practice was extensive.

The Tribunal accepts that there were potential adverse side effects from the prescription of Clenbuterol.

The Tribunal finds that the prescribing of Clenbuterol in association with combinations of anabolic steroids with the primary purpose of increasing muscle mass and function in the absence of any other appropriate indication is not now, nor ever has been, accepted practice.

Ephedrine and /or Ephedrine, Aspirin, Caffeine (EAC)

164 The Board alleged that from early 2008, Dr Singh engaged in a general practice of prescribing for patients who consulted him seeking physical conditioning and/or body building ephedrine and/or ephedrine, aspirin, caffeine (EAC) when in the circumstances there was no proper therapeutic indication or reason for the use of Ephedrine or EAC (Board's CG paragraphs 50.3 and 50.4)

165 Dr Singh admits that from early 2008, and when he considered it medically appropriate or therapeutic, he prescribed Ephedrine and EAC.

166 Dr Singh denies the allegation that Clenbuterol, Ephedrine or EAC were prescribed in circumstances in which there was no proper therapeutic indication. Dr Singh's response (SR paragraph 50(d)) stated:

(i) therapy includes early medical intervention to prevent a condition from developing to a crisis point; and

(ii) a treatment is not precluded from being therapeutic because it has a cosmetic benefit in parallel with physical or internal benefit.

167 Professor Wittert stated that EAC has been trialled on a limited basis as an adjunct for the management of obesity. He stated that it is not currently a recognised therapeutic indication.

168 Professor Joyce stated that Ephedrine still has intravenous application in some hypotensive emergencies but that indication did not exist in these cases (Exhibit Q Volume 3, at page 645).

169 The Tribunal prefers and accepts Professors Wittert's and Joyce's evidence as to the therapeutic indications for the prescription of EAC.

The evidence in relation to Dr Singh's prescription of Ephedrine and/or EAC

170 Dr Singh's evidence was that he prescribed Ephedrine and/or EAC capsules (rarely) to promote lipolysis, to patients who suffer from a subset of myalgia encephalitis (chronic fatigue­hyperelastic variant) and in order to increase blood pressure in dysautonomia or other low blood pressure states.

171 He stated that in very rare few cases, he had prescribed Ephedrine and/or EAC capsules to patients who suffered from Ehlers-Danlos syndrome (which Dr Singh believes is another low­pressure state).

172 Dr Singh stated that he prescribed Ephedrine because of its positive effect on myocardial contractility. That is, it forces the heart to pump more vigorously, which increases blood pressure.

173 Dr Singh also stated that he prescribed EAC capsules (sparingly) to patients in order to increase lipolysis (fat burning) and in circumstances when weight loss has been refractory to other modalities. The combination of Ephedrine with Aspirin and Caffeine prolongs the effect of the Ephedrine.

174 Dr Singh further stated that he was aware that Ephedrine and EAC capsules are associated with potential adverse side effects such as anxiety. However, he did not consider that a short­term prescription of this medication to be associated with any long-term effects (Exhibit T Volume 2, at pages 186-187 paragraphs 103-108).

175 Patients who were prescribed Ephedrine and/or EAC when there was no therapeutic indication to do so in that they were not obese include Patients 46, 52, 74, 88, 128, 13, 192, 220, 385, 407, 568, 701 and 738.

(46) no record in notes of his weight or reason for prescription. Appears to be in a classic 'body building' regime (building muscle with steroids and cutting fat with ephedrine etc).

(52) no reason for prescription in notes. File note of reason for consultation in July 2008 does not identify weight as an issue. According to BMI he is in the 'overweight' not obese category.

(74) no record of weight or reason for prescription. Appears to be on a body building regime.

(88) notes record 'HT: 175 Wt: 88 BMI: 28.7', ie overweight not obese. Appears to be on body building regime.

(128) not overweight, very fit. 'Height 1.78m (3.16), weight 75kg, BMI 24.6' and 'Started cycling recently but wants to gain weight.' No reason for prescription identified in notes.

(130) no record of weight or reason for prescription recorded in notes.

(192) described as '1.71m, weight 75kg, BMI 24.5' (healthy weight range), no reason for prescription identified in notes.

(220) consulted Dr Singh because he 'Wants to look good!' Notes that he 'Trains with [JB]' (see above). No suggestion that he is overweight. Nor reason for prescription identified in notes.

(385) 'A 40-year-old night club owner, movie maker, kung foo expert aiming to get in shape by March/April next year.', 'Legs need more development, abdomen needs coming down, shoulders increase, chest defining, serratus anterior needs to be defined, increase in biceps and triceps, hamstrings also need to be defined'.

(407) based on clinical notes is not obese, trains hard in gym, exercises, no reason for prescription described in notes.

(568) residing in Switzerland, medication taken to him by his brother. No reason for prescription identified in notes. Appears to be on body building regime.

(701) 'here to lose 4kg' 'HT: 154 Wt: 54 BMI: 22.8'. Healthy weight range. No reason for prescription in notes.

(738) is described in notes as a person who competes in body building competitions, no reason for prescription identified in notes.

The expert evidence as to Dr Singh's prescription of Ephedrine and/or EAC

176 Professor Wittert stated that there was no reasonable therapeutic indication for the use of ephedrine or EAC. Professor Vickery agreed with Professor Wittert. Professor Joyce stated that the rationale does not reveal a reasonable therapeutic indication for the use of EAC capsules.

177 The Tribunal accepts the evidence of Professors Vickery, Wittert and Joyce, that there was no reasonable therapeutic indication for the use of Ephedrine and/or EAC.

178 The Tribunal finds that from early 2008, Dr Singh engaged in a general practice of prescribing Ephedrine and/or EAC to patients who consulted him seeking weight loss, physical conditioning and/or body building when in the circumstances there was no proper therapeutic indication or reason for the use of Ephedrine and EAC by the patient for whom they were prescribed. The Tribunal finds that Dr Singh's practice of doing this was extensive.

179 The Board also alleged that Dr Singh prescribed Clomid (clomiphene citrate) when his prescribing of that substance in Western Australia contravened reg 38C of the Poisons Regulations made pursuant to the Poisons Act. (Board's CG at paragraph 50.5).

180 Dr Singh admits that from early 2008, and when he considered it medically appropriate or therapeutic, he prescribed Clomid.

181 Dr Singh says that, as to his prescription of Clomid:

(i) in point of law, the proper construction of regulation 38C of the Poisons Regulations 1965 (WA) is that, when clomid is prescribed for the purpose of stimulating ovulation, clomid and other substances specifically prepared for that purpose cannot be prescribed except by:

1. a gynaecologist or obstetrician;
2. a medical practitioner authorised by the CEO of the Health Department; or

1. a veterinary surgeon for the purposes of a veterinary trial under the direction of a veterinary surgeon, and

(ii) he did not prescribe clomid to the patient/s for whom it was prescribed for the purpose of stimulating ovulation;

182 Clomid is the trade name for clomiphene citrate.

183 Regulation 38C of the Poisons Regulations provides:

Clomiphene or cyclofenil or a substance containing clomiphene or cyclofenil and other substances specifically prepared to stimulate ovulation shall not be prescribed except ­

(a) by a gynaecologist or obstetrician; or

(b) by any other medical practitioner, if authorised in writing by the CEO; or

(c) by a veterinary surgeon for the purpose of veterinary trials under the direction of a veterinary surgeon.

184 Regulation 38C provides a general prohibition against the prescription of clomiphene except in the circumstances set out in sub­paragraphs (a)-(c). Dr Singh did not fall within any of those circumstances. Dr Singh's contention that the prescription of clomiphene is restricted only when it is 'specifically prepared to stimulate ovulation' is rejected.

185 The Tribunal finds that from early 2008, Dr Singh engaged in a general practice of prescribing Clomid to patients who consulted him seeking weight loss, physical conditioning and/or body building. The Tribunal finds that Dr Singh's practice of doing this was extensive.

186 The Tribunal finds that Dr Singh prescribed Clomid contrary to reg 38C of the Poisons Regulations.

187 The Board alleged that from early 2008, Dr Singh engaged in a general practice of prescribing Human Growth Hormone (HGH) when there was no proper therapeutic indication or reason for the prescription of it and when Dr Singh's prescription of HGH unnecessarily exposed those patients to the risks of the adverse effects of HGH (Board's CG paragraph 56).

188 Dr Singh admitted that, from early 2008, and when he considered it medically appropriate or therapeutic, he prescribed recombinant HGH. Dr Singh denied the allegation that HGH was prescribed in circumstances in which there was no proper therapeutic indication or that his prescription to those patients to whom it was prescribed unnecessarily exposed those patients to the risk of the adverse effects of recombinant HGH. Dr Singh's response (SR paragraph 56(d)) stated:

(i) recombinant human growth hormone has a number of beneficial actions;

(ii) the rationale for treating these certain patient/s by, amongst other things, prescribing human growth hormone, fell into one or more of the categories outlined above and/or one or more of the following categories;

1. to slow down the rate of sarcopenia in aging;
2. collagen repair;

1. treating wounds which are slow to heal;
2. third degree burns;
3. nephrotic syndrome; and
4. severely catabolic infectious states.

(iii) specifically, the main purpose for which [Dr Singh] prescribed recombinant human growth hormone to the patient/s for whom it was prescribed was to accelerate abdominal or mesenteric lipolysis;

(iv) abdominal fat is strongly associated with heart disease, diabetes, stroke, and gut cancer, and Alzheimer's disease;

(v) the dose of recombinant human growth hormone prescribed by [Dr Singh] does not have the side effect profile of larger doses[.]

The expert evidence as to the therapeutic indication

189 Professor Wittert's evidence was that HGH was not approved for use for the purposes indicated by Dr Singh, by any regulatory agency, anywhere in the world. The approved indications for prescribing HGH in Australia are:

• Short stature due to decreased or failed secretion of pituitary growth hormone.
• Treatment of adults with severe growth hormone deficiency as diagnosed in the insulin tolerance test of growth hormone deficiency and defined by a peak GH concentration > (Exhibit E Volume 3, at page 541)

1.1 There has never been an adequately large randomized controlled trial to prove that HGH provides a significant and safe anti-aging benefit.

1.2 Claims that HGH enhances physical performance are not supported by the scientific literature. Although the limited available evidence suggests that HGH increases lean body mass, it may not improve strength; in addition, it may worsen exercise capacity and increase adverse events (1).

1.3 Some investigations in abdominally obese adults have reported significant reductions in truncal and visceral fat and improvements in insulin sensitivity following prolonged HGH administration, whereas other studies have shown that insulin resistance and glucose concentrations transiently worsen during the first few weeks of HGH treatment and that these deleterious effects can persist even after visceral adipose tissue reduction has occurred (2). A more recent study has shown that HGH replacement in abdominally obese young men improves body composition, including liver fat, mitochondrial function, and markers of CV risk. Although fasting glucose was unchanged, a slight increase in 2­hour glucose during an oral glucose tolerance test was noted (3). Women seem to fair [sic] somewhat better but some develop marked glucose intolerance. These studies have not progressed past 6 months and the ultimate benefit or risk of this approach cannot be determined.

1.4 There is some evidence for a beneficial effect of HGH on bone in adults with GH deficiency due to pituitary disease (4). There are no properly designed studies looking at the effects of supplementing HGH in adults with obesity.

1.5 The statement by Dr Singh that 'there is a mountain of literature to show that it is superior to all known agents both repair of quality and quantity of bone' is not in accordance with available evidence.

(Exhibit E Volume 3, at pages 541­542)

191 Professor Wittert's opinion was that the recognised therapeutic indication of the prescription of HGH is for the treatment of short stature in growth hormone deficient children and in certain cases for short slowly growing non­growth hormone deficient children or those with certain genetic disorders affecting growth. He stated that it may be useful in certain adults with significant growth hormone deficiency as a result of hypothalamic or pituitary pathology.

192 Professor Joyce's opinion is that the therapeutic indication of the prescription of HGH is for growth hormone deficiency in children, and some adults with proven growth hormone deficiency from pituitary disease.

193 Professor Vickery's opinion is that using it for people with obesity and conditioning as a therapy, does increase muscle mass. Is it sufficient to prescribe for those indications. In the setting of weight training, he says it helps to increase muscle strength and mass. Professor Vickery believes that the dose was prescribed quite clearly in the letters. He stated that Dr Singh is using 'lowish doses' of HGH as opposed to people in athletics using extraordinarily high levels. He states there is little published literature regarding the use of HGH in obesity.

194 The Tribunal prefers and accepts Professors Wittert's and Joyce's evidence as to the therapeutic indications for the prescription of HGH.

What are the potential adverse effects of taking HGH?

1.7 Substantial experimental evidence indicates that HGH and more particularly its main effector insulin-like growth factor-1(IGF-1) in the development, growth, and dissemination of several types of cancer;

1.8 Depending on the dose the side effects of HGH include:

196 Professor Wittert's opinion was that HGH's downsides depend on the dose used and the duration of use. He stated that it is hard to determine from Dr Singh's medical notes what doses were prescribed and for what duration. Depending on the dose, risks of HGH include: carcinogenesis, metabolic abnormalities, abnormalities of muscle fibres and weakening of cartilage and tendons leading to injury.

197 Professor Joyce stated that diseases of growth hormone overproduction manifest as diabetes, joint disease, high blood pressure and disturbed body proportions, but how much of this will actually occur at the doses and durations used in these cases he did not know.

198 Professor Vickery said the adverse effects have been listed many times before and he does not want to go through it again except to note that the side effect profile in short-term use in the recorded doses is minimal and were not evident in any of the large number of patients in which this regimen was prescribed.

199 The Tribunal prefers and accept the evidence of Professors Wittert and Joyce on the adverse effects of HGH. The Tribunal finds that the prescription of HGH other than in accordance with the therapeutic indications identified by Professor Wittert exposes patients to the adverse effects identified by Professors Wittert and Joyce.

The relevant evidence as to Dr Singh's prescription of HGH

1. The main purpose for which I prescribe human growth hormone to patients is in order to accelerate abdominal or mesenteric lipolysis.
2. Abdominal fat is strongly associated with heart disease, diabetes, stroke and a range of gut cancers, and human growth hormone is the only medication which specifically accelerates abdominal fat burning.
3. The other main action of growth hormone is to increase the rate· of collagen synthesis, which accelerates tissue repair.
4. Growth hormone does not promote cancers, acromegaly, or diabetes.
5. It is my usual practice to prescribe human growth hormone at a starting dose of approximately 0.4mg per day.
6. In my experience at the doses at which I prescribe human growth hormone, water retention is the only significant side-effect (and this usually resolves with dose reduction).
7. Because of its anti-insulin effect I do not prescribe human growth hormone in patients with type I or type II diabetes.

201 The records the applicant has in relation to Dr Singh's prescription of HGH are incomplete. Those prescriptions filled at Morris Pharmacy and McKenzies Compounding Pharmacy are recorded in ABD Volume 5. In many clinical notes there is an abbreviation used by Dr Singh of either HGH or GH. Those abbreviations occur far more frequently than the consolidated prescribing history reflects. No complete record of Dr Singh's HGH prescriptions is available.

202 However it is clear from Dr Singh's evidence that he provided HGH directly to patients. He said that the Empire Clinic either obtained the drug from a supplier in Sydney and that his clinic then supplied it to patients or that the prescriptions were filled by sending them to Sydney and that the patients attended Empire Clinic for the purposes of injection.

203 By way of example of this practice, Patients 61 and 64 attended on Dr Singh from the Northern Territory on the same day for testing and, according to the patient records, were both prescribed HGH for $4,000 'as per [A]'. At the time, Patient 61's growth hormone levels were high and Patient 64's were within the reference range. There are no clinical notes explaining the reason for the prescription or the reason for the referral.

204 Dr Singh maintained in his witness statement at paragraph 137 that he did not prescribe HGH in patients with Type I or Type II diabetes. This was not correct.

1. Patient 57 has persistent elevated glucose on 5 October 2012 and 27 September 2013 for which Clinipath recommends oral glucose tolerance test (GTT) to check for diabetes (in his statement Dr Singh says he does not prescribe HGH to patients with diabetes). GTT is not organised and patient is prescribed HGH 7 June 2013 because of 'low blood volume'.
2. Patient 85 is positively diagnosed with diabetes on 18 May 2013 yet Dr Singh continues to prescribe HGH to him on 30 August 2013.
3. Patient 105 is prescribed HGH and his levels go from normal to very elevated (25 July 2013 levels are 6.20 ng/mL (0.00 ­ 2.47), 14/01/2014 levels are 6.02 ng/mL (0.00 ­ 2.47)). On 14 January 2014 his Insulin like Growth Factor (ILGF) is highly elevated (* 89 nmol/L (12 - 27) which the pathologist notes is 'associated with increased growth hormone levels as seen in acromegaly and gigantism, and in growth hormone therapy'.
4. Patient 118 has persistent borderline insulin and pathologist recommends oral glucose tolerance test. No GTT is arranged, patient is prescribed HGH at 0.66mg per day for 'fatigue'.
5. Patient 124 has a diagnosis of Type II diabetes, and Dr Singh prescribed HGH.
6. Patient 205 has 'Impaired fasting glycaemia. This is a risk factor for diabetes and Cardiovascular disease. An oral GTT should be considered' on 16 February 2010. Prescribed HGH on 23 February 2010. No evidence of oral GTT. No reason for prescription provided. Described in a referral letter in 2013 as a 'He is a fit athletic young man who has a very physical job'.
7. Patient 341 'here to increase muscle mass, was a patient of [Doctor]' prescribed HGH for no indicated reason. Develops very elevated HGH and ILGF (that is risk of gigantism).
8. Patient 384 diagnosed Type II diabetic who is prescribed HGH.
9. Patient 413 started on 0.6mg per day HGH (not 0.4mg per statement). 3 October 2011 Clinipath recommends oral GTT for diabetes due to persistently elevated glucose fasting results. No evidence test undertaken.
10. Patient 431 has elevated glucose and lipids, Clinipath recommends an oral GTT for both reasons. No oral GTT performed, patient is prescribed HGH.
11. Patient 562 Type II diabetic (extremely high glucose fasting results), prescribed HGH.

205 Other patients who appear to have been prescribed HGH for non­therapeutic purposes include:

1. Patient 1 specifically attended Dr Singh asking for HGH.
2. Patient 25.
3. Patient 128 attended to gain muscle, was prescribed HGH. 16% body fat, that is, it was not prescribed to accelerate lipolysis. Was not tested for HGH levels or diabetes markers before prescription.
4. Patient 145 very slim, fit and active (wife of [name]). Attended because she had 'gained 2kg' and was 'interested in HGH'. Prescribed HGH.
5. Patient 156.
6. Patient 202 attended for 'muscle gain', no evidence that he was overweight. Prescribed HGH among other things.
7. Patient 209, a fit young man (planning to climb Mt Everest) prescribed HGH with no explanation in the notes.
8. Patient 385 clinical notes state 'A 40-year-old night club owner, movie maker, kung foo expert aiming to get in shape by March/April next year ... Legs need more development, abdomen needs coming down, shoulders increase, chest defining, serratus anterior needs to be defined, increase in biceps and triceps, hamstrings also need to be defined.' Prescribed HGH for this purpose.
9. Patient 445, healthy weight range, exercises regularly, 'looks fit' prescribed HGH for no recorded reason. Has very elevated HGH results from time to time.
10. Patient 733.

206 Dr Singh claimed on a number of occasions that he did no harm. He was cross-examined about his treatment of Patient 22 for whom he prescribed HGH, notwithstanding that he had high HGH levels on 22 March 2012 and 7 August 2013. On 31 July 2013, Dr Singh wrote that Patient 22 experienced 'Right plantar fasciitis could be the growth hormone, likely collagen breakdown from excess Cortisol'. Dr Singh says that his note does not mean that considered the fasciitis was due to the growth hormone, but rather excess cortisol. Professor Wittert deals with Patient 22 extensively (Exhibit D Volume 2, at pages 419­421) and says that Dr Singh's approach to pharmacology is 'bizarre' and his letters are 'not founded on any principle of science or evidence that I am aware of but just stringing snippets of information together to construct a story.' He says that during treatment Patient 22 developed abnormal LFT's and renal function and abnormal thyroid function, and concludes that 'absolutely nothing good was achieved here, likely harm and considerable economic impost both privately and publicly.'

The expert evidence as to Dr Singh's prescription of HGH

207 Professor Wittert stated there was no justification for prescribing HGH and no evidence of benefit that outweighed the risks. Professor Joyce stated that there was no justification in the notes he read.

The prescribing of growth hormone in the absence of unequivocally demonstrated growth hormone deficiency or other approved indication is not now, nor ever has been, accepted practice.

(Exhibit D Volume 2, at page 380)

209 In Professor Vickery's opinion, in prescribing short doses and small courses, the benefits of HGH outweighed the risks.

210 There is overwhelming evidence that Dr Singh was prescribing HGH to his patients for use in association with anabolic androgenic steroids.

211 The Tribunal finds that from early 2008, Dr Singh engaged in a general practice of prescribing HGH to patients who consulted him seeking weight loss, physical conditioning and/or body building when in the circumstances there was no proper therapeutic indication or reason for the use of HGH by the patient. The Tribunal finds that Dr Singh's practice of doing this was extensive.

212 The Tribunal accepts that there were potential adverse side effects from the prescription of HGH by Dr Singh.

213 The Tribunal finds that the prescribing of HGH in the absence of unequivocally demonstrated growth hormone deficiency or other approved indication is not now, nor ever has been, accepted practice.

214 The Board alleged that from early 2008, Dr Singh engaged in a general practice of prescribing for patients any or all of the following drugs when there was no recognised therapeutic indication for the use of those drugs in those patients either alone, or in combination with other drugs prescribed by Dr Singh; and when, in some instances, such prescribing unnecessarily, exposed the patients to the risks of adverse effects of those drugs:

• Sibutramine;
• Tamoxifen;
• Anastrozole;
• Testosterone;
• Midodrine; and
• Fludrocortisone.

215 Dr Singh admits that from early 2008, and when he considered it medically appropriate or therapeutic he prescribed those drugs. Dr Singh denies that the medications were prescribed in circumstances in which there was no recognised therapeutic indication for the use of the medication to those patients to whom it was prescribed, either alone or in combination with other medication/s prescribed by Dr Singh, or that Dr Singh's prescription to those patients to whom it was prescribed unnecessarily exposed those patients to the risk of the adverse effects of the medications alleged by the Board.

216 Dr Singh's response (SR paragraph 57(d)) stated that:

(i) the rationale for treating these certain patient/s by, amongst other things, prescribing one or more of the [those] medications fell into one or more of the categories outlined [above in relation to androgens], and/or one or more of the following categories;

1. as regards ... sibutramine, in the treatment of obesity (in combination with lifestyle modification, supervised graded resistance training, dietary modification and regular review);

1. as regards tamoxifen, as a selective oestrogen modulator (with antagonist properties);
2. as regards anastrozole, to block aromatisation of testosterone into oestradiol, and in combination with clomiphene citrate, to promote endogenous testosterone synthesis;
3. as regards testosterone, to shift the equilibrium from catabolism to anabolism;
4. as regards midodrine as a noradrenaline agonist for its noradrenergic effect on vasculature, to promote peripheral vasoconstriction, and in management of dysautonomia;
5. as regards fludrocortisone, as a mineralocorticoid[.]

217 The Board alleged that Dr Singh's prescriptions of Sibutramine, after it was withdrawn worldwide in October 2010 due to the risks of adverse cardiac events in people with pre-existing or unstable cardiac disease was improper.

The expert evidence as to the therapeutic indications

218 Professor Wittert's evidence was that Sibutramine was a drug that had been used for weight loss. It had been withdrawn worldwide due to a risk of adverse cardiac events in people with pre-existing significant or unstable cardiovascular disease (Exhibit D Volume 2, at page 383).

219 Dr Singh continued to prescribe Sibutramine after October 2010, for example, to Patient 16 on 12 September 2012, Patient 59 on 21 August 2012 and 12 February 2013, Patient 65 on 4 September 2012 and Patient 68 on 10 January 2012. Patients 68 and 59 are among the body builders receiving the drug.

220 Dr Singh explained that although the drug had been withdrawn it was available if compounded and maintained that there were sound therapeutic reasons for the prescription of the drug.

221 Professors Joyce and Wittert maintained there were no justifiable therapeutic reasons to prescribe the drug at all and particularly after it had been withdrawn.

222 The Tribunal finds that from early 2008, Dr Singh engaged in a general practice of prescribing Sibutramine to patients who consulted him seeking weight loss, physical conditioning and/or body building when in the circumstances there was no proper therapeutic indication or reason for the use of Sibutramine by the patients for whom they were prescribed when Sibutramine had been withdrawn from sale.

223 Tamoxifen and Anastrozole have similar effects, albeit by different pathways and are dealt with together.

224 Professor Wittert's evidence as to Tamoxifen was:

Tamoxifen is a type of drug known as a selective oestrogen response modifier (SERM). This means that in some cells and tissues in the body the drug blocks oestrogen receptors but in others it may have a neutral effect or even activate a receptor for oestrogen. Tamoxifen is registered for the adjunct of treatment of breast cancers that are oestrogen receptor positive. In men a proportion of the testosterone is converted to oestrogen and this is necessary to obtain some of the beneficial effects of testosterone. If a large amount of testosterone is taken more oestrogen will be produced leading to adverse effects which include the development of breast tissue and inhibition of normal mechanisms responsible for the production of testosterone in the body. Accordingly it is my impression from the clinical notes that Dr Singh is using it to block the adverse effects but retain some of the beneficial effects of oestrogen in his patients who are taking anabolic androgenic steroids and/or overcome the suppression of the HGP axis caused by the stacking of various anabolic androgenic agents typically over 12 week cycles by body builders.

He is also prescribing it to men whom he considers should have a higher level of testosterone. It works by blocking the negative feedback of oestrogen on central mechanisms that regulate testosterone production.

(Volume 2 pages 385­386)

It is a misconception that obesity is associated with an increase in oestradiol levels and the fact that inhibition of E2 receptors increases testosterone levels does not meant that E2 levels are increased since the same phenomenon is seen in men with E2 levels in the normal range. In obese men with low testosterone, it is primarily the obesity that results in the fall in testosterone; E2 levels decrease as a result of the decrease in testosterone, but not to the same extent. The reason for this is that while aromatase expression in adipose tissue does not increase, the total mass of adipose tissue is increased resulting in a relative preservation of E2 levels.

It is also important to recognise that oestrogen has extremely important functions in males. These include maintenance of bone density; regulation of smooth muscle in the urinary bladder, stomach, blood vessels and airways, and beneficial effects on body composition and lipids.

I do not know what Dr Singh means by the statement that 'Tamoxifen has LH­type stimulatory activity'. It is not active at the LH receptor.

There is no evidence of benefit for the treatment of obesity in men. It is not indicated for this purpose.

225 Professor Wittert's evidence as to Anastrozole was:

The enzyme that converts testosterone to oestradiol in the body is called aromatase. There are a group of drugs that inhibit aromatase and one of these is Anastrozole. My interpretation from the clinical notes is that it is being used by Dr Singh to overcome suppression of testosterone production as a result of the use of anabolic androgenic steroids or to increase testosterone levels in men that are lowered for some other reason. In a 12 months trial anastrozole administration normalized androgen production in older hypogonadal men and decreased oestradiol production modestly without either adverse or beneficial effects. However, I know of no data to support the use of aromatase inhibitors such as anastrozole or SERMS such as tamoxifen in combination with each other or for that matter either or both of these agents in combination with clomiphene citrate (which also act as a form of selective oestrogen receptor modifier).

Oestrogen has beneficial effects in man. Oestrogen deficiency is associated with lower bone density and increased total body and liver fat in men.

(Volume 2 page 386)

Anastrazole is indicated for the treatment of breast cancer. It works by inhibiting the enzyme aromatase that converts testosterone to oestradiol, the main circulating oestrogen. Oestrogen (E2) is the sex steroid that primarily regulates bone mass in men. A decrease in E2 is associated with osteoporosis in men. Men with low testosterone and high aromatase activity are able to maintain a higher BMD despite low circulating testosterone, and moreover they have lower lean and higher truncal fat mass as compared to those with lower aromatase activity (18). Aromatase inhibitors have unfavourable effects on bone mineral density (BMD) in men (17).

(Volume 3 page 547)

226 Professor Wittert stated that Anastrozole is an aromatase inhibitor, used for the same reason as Tamoxifen, that is, adjunctive treatment of breast cancer. Professor Joyce and Vickery agree with Professor Wittert.

227 Dr Singh's evidence, in contrast to his witness statement, was that Tamoxifen and Anastrozole were part of the regime of drugs that he prescribed for body building or appearance enhancing purposes for their anti-oestrogen effect.

228 The consensus of Professors Wittert, Joyce, Hood and Nutt was that Tamoxifen is indicated for breast cancer.

229 Professor Wittert, with whom Professor Joyce agreed, stated that it might be used for osteoporosis in men rendered hypogonadal for the treatment of prostate cancer. He also stated there is no recognised therapeutic indication for the way it was used by Dr Singh.

230 The Tribunal prefers and accepts Professors Wittert's and Joyce's evidence that there was no recognised therapeutic indication for the prescription of Tamoxifen and Anastrozole.

231 Professor Wittert's evidence at paragraph 7.6 was that:

[Tamoxifen's] use is associated with significant adverse effects, which include lowering of IGF1 (which mediates the anabolic effects of growth hormone), abnormalities of lipid metabolism including raised blood triglycerides, accumulation of liver fat, hot flushes, decreased libido, increased clotting and cardiovascular events.

(Volume 3 pages 546­548)

232 Potential side effects of Tamoxifen were agreed by Professors Wittert, Joyce and Vickery as liver abnormalities, thrombosis and disordered lipid metabolism. Potential side effects of Anastrozole were agreed as osteoporosis, without the same risk as thrombosis that arises with Tamoxifen.

233 Professor Wittert also gave evidence about the side effects of Anastrozole in women who were breast cancer patients.

234 Professor Joyce stated that potential adverse effects of taking Anastrozole and the adverse effect is osteoporosis. It does not face the same thrombosis risk as Tamoxifen (and even that is not much). Professors Wittert and Vickery agreed.

235 The Tribunal prefers and accepts the evidence of Professors Wittert and Joyce on the adverse effects of Tamoxifen and Anastrozole. The Tribunal finds that the prescription of Tamoxifen and Anastrozole other than in accordance with the recognised therapeutic indications exposes patients to the adverse effects identified by Professors Wittert and Joyce.

Dr Singh's evidence as to Tamoxifen and Anastrozole

Dr Singh's evidence at paragraphs 171­174 (Exhibit T page 199) was that:

Tamoxifen is SERM (selective oestrogen receptor modulator).

In the obese male, central adipocytes aromatise testosterone into oestrogen resulting in gynaecomastia and gynoid fat distribution.

Tamoxifen has LH-type (Luteinizing Hormone) stimulatory activities and acts to block the peripheral binding of oestrogen.

I prescribe tamoxifen to patients to act as a selective oestrogen blocker and for its LH agonist-effect (in order to stimulate the testis).

236 Dr Singh's evidence at paragraphs 41­44 (Exhibit T page 179) was that:

Anastrozole is an aromatase inhibitor used for blocking conversion of testosterone to oestrogen.

In obese men (with large amount of gut fat), there is an increased rate of conversion of testosterone to oestrogen. This relative reduction in testosterone levels has profound effects on mind and body. In this instance, I may use anastrozole to block conversation of testosterone into oestradiol.

It is my usual practice to prescribe this medication at a starting dose of approximately 0.05mg (half a tablet) twice per week.

In my experience, Anastrozole at this dose and frequency is not associated with adverse side-effects.

237 Dr Singh's evidence was that Primoteston can aromatise to oestrogen. Excess oestrogen can cause gynaecomastia, water retention and female fat distribution. To avoid these effects, he usually prescribed Anastrozole at one half tablet twice per week (Exhibit T Volume 1, page 178 at paragraph 66).

238 The Tribunal rejects Dr Singh's evidence as to the appropriate use of Tamoxifen and Anastrozole.

239 Numerous patients of Dr Singh were prescribed Tamoxifen, including those where it was contra­indicated because:

1. they had high triglyceride levels (Patients 5, 52, 280, 328, 419, 444 and 577; or
2. they had low libido (Patients 27, 35, 79 and 127); or
3. they had cardiovascular disease or risk of clotting (Patients 27 and 450).

240 In his witness statement at paragraph 42, Dr Singh indicated that for obese men 'he may use Anastrozole to block conversion of testosterone to oestradiol'. His practice though does not bear out this claim, at least in relation to the following patients:

1. Patient 39 not obese, testosterone and free testosterone well within normal range. Dr Singh asserts he has 'low testosterone' and prescribes Anastrozole.
2. Patient 97 martial arts instructor with normal testosterone, no BMI or weight records, prescribed Anastrozole for 'low testosterone'.
3. Patient 135 prescribed Anastrozole, no record of height, weight, testosterone in the normal range.
4. Patient 180 BMI of 25, testosterone normal or elevated at every test. Prescribed Anastrozole. Appears to be part of a body building cycle.
5. Patient 243 body building/conditioning patient (not weight loss patient), no record of height, weight or BMI. Very high testosterone. Prescribed Anastrozole.
6. Patient 364 obese man with normal testosterone levels prescribed Anastrozole with no explanation in notes.
7. Patient 478 prescribed Anastrozole when his testosterone was extremely elevated at 144 (ref range 8.0-29.0) and his free testosterone was 5,560.5 (ref range 198-619).
8. Patient 719 prescribed Anastrozole when his testosterone was normal.

Conclusion in relation to Tamoxifen and Anastrozole

241 The Tribunal finds that from early 2008, Dr Singh engaged in a general practice of prescribing Tamoxifen and Anastrozole to patients who consulted him seeking weight loss, physical conditioning and/or body building when in the circumstances there was no proper therapeutic indication or reason for the use of Tamoxifen or Anastrozole in any of the patients for whom they were prescribed.

242 The Tribunal finds that the prescribing of Tamoxifen and Anastrozole in association with combinations of anabolic steroids with the primary purpose of increasing muscle mass and function in the absence of any other appropriate indication is not now, nor ever has been, accepted practice.

243 Professor Joyce's evidence was that the therapeutic indication for the use of testosterone was the replacement of testosterone in male testosterone deficiency. Professor Vickery gave evidence that it is useful in the management of sarcopenic obesity and improving muscle mass and strength. Professor Wittert's oral evidence was that it is not a currently accepted therapeutic use to use anabolic steroids and testosterone for the treatment of sarcopenic obesity (Exhibit Q page 654; T:186; 18.08.16).

244 The Tribunal prefers and accept the evidence of Professors Joyce and Wittert as to the therapeutic indications for the use of testosterone. The Tribunal also notes that it accepts Professor Wittert's evidence that there was no evidence in the medical records of any of Dr Singh's patients with sarcopenic obesity (T:256-257; 18.08.16).

Testosterone levels do not inevitably decrease with increasing age and the apparent age-related decrease is a reflection of obesity and burden of disease together with medication use and lifestyle factors rather than an effect of age as such. While it is true that low testosterone levels in turn do predict a range of poor cardio-metabolic outcomes, the cause­and­effect- relationships are not entirely resolved and the benefits as compared to the risks of testosterone treatment have for some time, and are still, a matter of ongoing research rather than in the realm of accepted therapeutic practice. Moreover, within the context of accepted practice, there are guidelines for the use of testosterone. ... It is not apparent that Dr Singh complies with such guidelines; his practice appears to more closely resemble the guidelines found on the internet sites dealing with the recreational use of anabolic steroids.

(Volume 3 pages 547­548)

246 Professor Wittert's evidence was that although there was some evidence of a benefit to elderly people the measure of benefit in the elderly population is not shown to generalise to any other population such as healthy young men. He stated that one can observe that at replacement levels of testosterone, which might be multiples of physiological replacement, then there is a well-recognised progression to definable adverse events which, in turn, reflect as cardiovascular disease, psychiatric disease and liver disease (T:189; 18.08.16).

247 The Tribunal prefers and accepts the evidence of Professor Wittert as to the potential adverse effects of taking testosterone.

248 Dr Singh's evidence was (Exhibit T page 179 at paragraphs 68­72):

I prescribe testosterone to patients with low testosterone levels, to prevent skeletal muscle atrophy and to shift the equilibrium from catabolism to anabolism.

Low testosterone levels in persons over 35 years of age (males and females) is a major adverse prognostic indicator for a number of conditions including heart disease, diabetes, Alzheimer's disease, osteoporosis, depression, obesity, depression and cancer of the colon, rectum, endometrium, breast, and prostate.

The prevention of skeletal muscle atrophy is important in that skeletal muscle is one of the major determinants of resting energy expenditure. Skeletal muscle, in its resting state, promotes lipolysis (i.e. it burns fat as its fuel, during exercise, it uses glucose), prevents osteoporosis and the development of metabolic syndrome.

Loss of skeletal muscle ultimately means less fat is burnt and therefore more is stored (usually, in the gut). Mesenteric fat (gut fat), has the effect of blocking insulin's effect on uptake of glucose into cells. Therefore more insulin is required to facilitate uptake of the same amount of glucose from the blood but, insulin also stores fat. This explains why gut fat promotes high insulin and in turn explains why a high insulin leads to more fat stores in the gut.

249 In relation to testosterone, Dr Singh's evidence in his statement dated 17 February 2016 was that:

(i) Patient 73 It is my usual practice to prescribe testosterone at a starting dose of 250 mg every two to three weeks in men. For women requiring testosterone (for example those on the oral contraceptive pill who had all androgens shut down) I prescribe 1­2% topical testosterone cream every second to third day (ie 2 mg in 100g of cream).

(ii) Patient 74 I am aware that Primoteston and testosterone can be associated with adverse side effects. These include acne, mild liver dysfunction, hypertension, and an increased red cell count. However, in my experience prescribing Primoteston at the above dosage intervals, is not associated with significant adverse side effects are minor.

Contrary to what was stated in his witness statement, Dr Singh conceded in cross-examination that he regularly prescribed testosterone to women not in a topical form. Female patients prescribed Sustanon (IMJ) (that is, not topical testosterone) included:

Patients 1, 50, 73, 77, 81, 153, 255, 272, 273, 284, 293, 321, 360, 374, 375, 376, 383, 445, 449, 455, 463, (469), 471, 480, 524, 529, 537, 555, 571, 591 and 730.

250 The Tribunal finds that from early 2008, Dr Singh engaged in a general practice of prescribing testosterone to patients who consulted him seeking weight loss, physical conditioning and/or body building when in the circumstances there was no proper therapeutic indication or reason for the use of any of testosterone by the patient for whom they were prescribed.

251 The Tribunal accepts that there were potential adverse side effects from the prescription of testosterone.

252 The Tribunal finds that the prescribing of testosterone in association with combinations of anabolic steroids with the primary purpose of increasing muscle mass and function in the absence of any other appropriate indication is not now, nor ever has been, accepted practice.

253 Professor Joyce stated that the only recognised therapeutic indications for Midodrine are its use in maintaining blood pressure in some patients with orthostatic hypotension. Profession Wittert agreed with Professor Joyce and added that it is used for the maintenance of blood pressure in severe proven orthostatic hypotension where there is no other effective therapy. Professor Vickery stated that it improves peripheral perfusion by improving blood pressure.

254 Professor Wittert stated that his main concern as to the potential adverse effect of taking Midodrine is severe recumbent hypertension (that is, very high blood pressure when lying down). Professors Joyce and Vickery agreed.

255 The Tribunal finds that the potential adverse effect of taking Midodrine is severe recumbent hypertension

Midodrine is a noradrenaline agonist and I prescribe it to patients for its noradrenergic effect on vasculature, to promote peripheral vasoconstriction and in the management of dysautonomia.

I am aware that midodrine is associated with potential adverse side­effects including severe hypertension and agitation, because it acts as noradrenalin. For this reason, I advise patients to cease taking this medication if they do not report a significant and immediate improvement of their symptoms after 2 ­ 3 days of taking midodrine.

258 Particular concerns in relation to Dr Singh's use of Midodrine arises in relation to the following patients:

1. Patient 184 whose 24 hour blood pressure test noted that she was variably hypotensive and hypertensive, and who was noted to have become 'very hypertensive and confused' after a trial of Midodrine.
2. Patient 200, who underwent a 24 hour blood pressure test on 16 January 2014 which identified hypertension and for which a practitioner at Cardiovascular Services (CVS) recommended the commencement of antihypertensive therapy in conjunction with non-pharmacological blood pressure lowering dietary and lifestyle measures. Instead, Dr Singh commenced the patient on Midodrine (which elevates blood pressure) on 23 January 2014. No explanation of the reason for that prescription is found in the patient notes.
3. Patient 242, who underwent a 24 hour blood pressure test on 29 August 2012 which recorded that he had normal blood pressure during the day and was mildly hypertensive during the night, which was described as deterioration from a normal test in 2011. Notwithstanding the diagnosis of mild hypertension, the patient was first prescribed Midodrine by Dr Singh on 31 August 2012.
4. Patient 329, the notes for whom establish that Midodrine was commenced in February 2013, and who underwent numerous 24 hour blood pressure tests including:

1. on 20 February 2012 he was found to have sub-optimally controlled hypertension with residual moderately severe hypertension through the recording, and a practitioner at CVS recommended commencement of antihypertensive therapy; 2. on 19 December 2012 he was found to have well controlled hypertension during the day with borderline diastolic hypertension overnight;

1. on 25 February 2013 the patient was found to have mild to moderate labile systolic hypertension throughout the day with severe hypertension overnight and a loss of normal nocturnal BP drop. A practitioner at CVS recommended recommencing antihypertensive therapy and considering non-pharmacological blood pressure lowering dietary and lifestyle measures;

1. on 27 March 2013 the patient was noted to be on a trial of Midodrine, and was found to have moderate labile hypertension through the daytime and a practitioner at CVS recommended review of his medication regime; 2. on 27 May 2013 Dr Singh wrote to Centrelink advising that he had trialed various medications in an attempt to increase the patient's blood pressure; and 3. on 9 December 2013 the patient was found to be severely hypertensive throughout the recording period, and a practitioner at CVS recommended commencement of antihypertensive therapy.
2. Patient 513, who was prescribed Midodrine on or about 5 February 2014, and who underwent numerous 24 hour blood pressure tests, including:

1. on 23 May 2011 the patient was found to have severe labile hypertension during the day and mild hypertension overnight, with preservation of normal nocturnal blood pressure drop. This was said to be a significant increase in hypertension since 11 May 2004 and a practitioner at CVS recommended a 2D/Doppler echo study and commencement of antihypertensive therapy; 2. on 26 February 2014 the patient was found to have severe hypertension throughout the recording period with some lability of blood pressure recordings. There had been a mild deterioration in blood pressure control since 23 May 2011;

1. on 28 February 2014 the patient was found to have severe hypertension throughout the recording period, with a loss of normal nocturnal blood pressure; and

1. on 19 March 2014 the patient was found to have moderately labile hypertension throughout the recording period, with a mild improvement in overall blood pressure control since 28 February 2014.
2. Patient 517, who was prescribed Midodrine in February, March, April and June 2013, and who underwent numerous 24 hour blood pressure tests, including:

1. on 7 May 2008 the patient was noted by a practitioner at Echo Services to have poorly controlled hypertension with severe residual labile hypertension during the day and moderate sustained hypertension overnight; 2. on 18 January 2013 the patient as noted to have mild labile hypertension throughout the recording period, with an improvement in overall blood pressure control since 7 May 2008. A practitioner at CVS recommended a review of antihypertensive therapy;

1. on 1 March 2013 Dr Singh noted that the patient was 'a little hypertensive';

1. on 8 April 2013 the patient was noted to have mild hypertension through the day and moderate hypertension overnight, with a loss of normal nocturnal blood pressure drop. A practitioner at CVS noted a mild improvement in blood pressure control since 18 January 2013 and recommended review of antihypertensive therapy and consideration of obstructive sleep apnoea as a contribution; and 2. on 5 June 2013 the patient was noted to have moderately severe labile hypertension through the day, with night time readings unable to be made.

259 Professor Wittert, and to a lesser extent Professor Joyce, gave evidence about Dr Singh's prescription of Midodrine for dysautonomia. Professor Wittert was highly critical of Dr Singh's practices in relation to the prescription of Midodrine and said that he does not proceed along the path of proper diagnosis, fails to undertake the necessary testing, and that in all the cases that he had examined, Dr Singh's use of the drug was not for an established therapeutic purpose.

260 The Tribunal finds that from early 2008, Dr Singh engaged in a general practice of prescribing Midodrine to patients who consulted him seeking weight loss, physical conditioning and/or body building when in the circumstances there was no proper therapeutic indication or reason for the use of Midodrine in any of the patients for whom it was prescribed.

261 The Tribunal accepts that there were potential adverse side effects from the prescription of Midodrine.

262 The Tribunal finds that the prescribing of Midodrine in association with combinations of anabolic steroids with the primary purpose of increasing muscle mass and function in the absence of any other appropriate indication is not now, nor ever has been, accepted practice.

263 The Board maintained this allegation insofar as Dr Singh prescribed Fludrocortisone concurrently with Midodrine.

264 Profession Joyce states that the therapeutic indication for Fludrocortisone is for patients with orthostatic hypotension. Its use is broader than Midodrine and also may be used for mineralocorticoid replacement in some patients with Addison's disease.

265 Professors Wittert and Joyce agree that it is not appropriate to combine Fludrocortisone with Midodrine.

I prescribe fludrocortisone to patients for its effects as a mineralocorticoid (meaning, it holds salt and water and constricts peripheral vessels thus promoting venous return to the heart). I use it in the treatment of dysautonomia and orthostatic intolerance. It is also a well-established treatment for Aldosterone resistance in dysautonomia.

267 Dr Singh's evidence at paragraphs 122 and 123 was that:

It is my usual practice to prescribe fludrocortisone at a starting dose of approximately 15 - 20µg twice daily. I am aware that the usual dose is 100µg twice daily.

I am aware that fludrocortisone is associated with potential adverse-side effects including low potassium and excess water retention. However, in my experience at the dose at which I prescribe fludrocortisone, these potential adverse side-effects are minimal. I also advise patients to eat high potassium fruit including oranges, bananas and other citrus fruit (approximately 3 pieces per day).

268 Dr Singh prescribed Fludrocortisone concurrently with Midodrine for numerous patients (for example, Patients 176, 329, 517, 754 and 675). Some of those patients also had hypertension, and/or were being treated with antihypertensive medication.

269 Professor Wittert stated that the adverse effects of Fludrocortisone include hypertension, fluid retention and abnormalities of blood electrolytes. Professors Joyce and Vickery agree.

270 The Tribunal finds that from early 2008, Dr Singh engaged in a general practice of prescribing Fludrocortisone concurrently with Midodrine to patients who consulted him seeking weight loss, physical conditioning and/or body building when in the circumstances there was no proper therapeutic indication or reason for the use of Fludrocortisone in any of the patients for whom it was prescribed.

271 The Tribunal accepts that there were potential adverse side effects from the prescription of Fludrocortisone concurrently with Midodrine.

272 The Tribunal finds that the prescribing of Fludrocortisone concurrently with Midodrine in association with combinations of anabolic steroids with the primary purpose of increasing muscle mass and function in the absence of any other appropriate indication is not now, nor ever has been, accepted practice.

273 The Board alleged that from early 2008, Dr Singh engaged in a general practice of inappropriately prescribing Erythropoietin (EPO) when there was no recognised therapeutic indication for the prescription of that drug and when such prescribing unnecessarily exposed the patients to the risks of adverse effects of those drugs (Board's CG paragraph 59).

274 Dr Singh admits that, from early 2008 and when he considered it medically appropriate or therapeutic, he prescribed EPO to certain patients who consulted him. Dr Singh denies the allegation that EPO was prescribed to patient/s inappropriately, and/or in circumstances in which there was no recognised therapeutic indication for the prescription of the medication, and/or that Dr Singh's prescription to those patients to whom it was prescribed unnecessarily exposed those patients to the risk of the adverse effects of EPO. Dr Singh's response (SR paragraph 59(d)) stated that:

(i) the rationale for treating these certain patient/s by, amongst other things, prescribing erythropoietin, fell into one or more of the categories outlined in [SR paragraph 51(f)]:

1. postural orthostatic tachycardia syndrome; and
2. as a diagnostic test in chronic fatigue and dysautonomia.

275 Professors Wittert and Vickery agreed that EPO is neither appropriate nor safe to use by a recreational sportsperson (Exhibit Q page 664).

276 Professor Joyce stated that a therapeutic indication is anaemia due to failure to make red blood cells. He states that the most common use is for people with advanced renal disease and that there is some experimental use in patients who had orthostatic hypotension and who had demonstrably low red cell mass. He said that it never got beyond phase 2 trialling and is not a recognised therapeutic indication but it was his opinion that if red cell mass had been measured and was low, then you could justify trying it (Exhibit Q page 664).

277 Professors Joyce and Wittert agree that they had not seen any instance in the notes they examined where the prescription of EPO by Dr Singh was justified.

278 Professor Vickery's opinion was that in moderate doses in short­term prescription, the benefits in increased muscle mass and training outweighed the minimal potential adverse effects.

279 Professor Wittert's evidence was that there was not a proper and/or reasonable therapeutic indication for the prescription of EPO which outweighed the potential adverse effect of taking EPO and does not think it is reasonable and could definitely not see any instance where its use was justified.

280 Dr Singh's evidence (Exhibit T pages 188­189 at paragraphs 112 and 114­115) was that:

I prescribe erythropoietin to patients in respect to postural orthostatic tachycardia syndrome and as a diagnostic test in chronic fatigue syndrome and dysautonomia.

...

EPO has potent vasoconstrictive properties and thus has utility in managing orthostatic intolerance of primary or secondary types (i.e. it constricts blood vessels to push blood back from dependant regions such as the feet back to the heart).

EPO also improves mitochondrial function and therefore oxygen utilisation. This effect occurs well before there is an increased red cell number (approximately 90 days before).

281 Dr Singh claimed in his evidence that he prescribed EPO to improve brain function and that it was not of reliable effect in all patients and that you would only know if it was effective after 90 days. On the basis of this explanation (which is different to the explanation he provided in his witness statement), there could be no reasonable justification for prescribing EPO to those patients that he did. To do so would be purely experimental. Patients prescribed EPO by Dr Singh (among those from A to D) include Patients 22, 24, 28, 30, 35, 54, 57, 78, 90, 167 and 187.

282 Dr Singh's evidence in his written statement at paragraph 119 was:

I am aware that EPO is associated with potential adverse side­effects including an increase in the red cell concentration (haematocrit). In my experience, at the dose at which I prescribe EPO and in my patient group, this is a very uncommon side-effect.

283 The Tribunal finds that from early 2008, Dr Singh engaged in a general practice of prescribing EPO to patients who consulted him seeking weight loss, physical conditioning and/or body building when in the circumstances there was no proper therapeutic indication or reason for the use of any of EPO by the patient for whom they were prescribed.

284 The Tribunal finds that the prescribing of EPO in association with combinations of anabolic steroids with the primary purpose of increasing muscle mass and function in the absence of any other appropriate indication is not now, nor ever has been, accepted practice.

285 The Board alleged that from early 2008 Dr Singh engaged in a general practice of ordering the infusion of iron for patients who did not suffer from any iron deficiency, and/or in circumstances in which the infusion of iron was contra­indicated for patients because the patients suffered from haemochromatosis or beta­thalassaemia trait (Board's CG paragraph 58).

286 Dr Singh admits that from early 2008, and when he considered it medically appropriate or therapeutic, he ordered, for certain patient/s who consulted him, iron infusion/s. He said further that:

(i) iron deficiency and anaemia are not one and the same. Iron deficiency refers to depleted stores without regard to the degree of depletion or to the presence of anaemia, whereas anaemia refers to a haemoglobin count outside of the reference range;

(ii) a patient may be iron deficient without being anaemic;

(iii) a diagnosis of iron deficiency in a particular patient/s is a diagnosis of exclusion because differing haemoglobin or steady state haemoglobin is appropriate for different patients;

(iv) iron is central to all metabolic processes and has pleiotropic effects ultimately affecting tissue specific oxygenation. Relative iron deficiency, can occur in a patient without the patient meeting the standard reference range for iron, which has been established with reference to haemoglobin level alone.

(v) iron is necessary for a number of purposes, including for redox cytochromes, nitric oxide synthesis, prostaglandin synthesis, oxidative phosphorylation, the cytochrome P450 system, myoglobin, and hydrogen peroxide bursts in myeloid cells of the immune system;

(vi) iron deficiency is associated with a number of symptoms, including exercise intolerance, mood lability, impaired immune surveillance, slow mentation, mucosal dysfunction and inefficient oxygenation of energy substrates;

(vii) in relation to patient/s who suffer from haemochromatosis or beta­thalassaemia trait:

1. this does not exclude the patient/s from being iron deficient; and
2. before a decision is made to order or not order iron infusions in such a patient/s, [Dr Singh] instigates a number of investigations and weights up the benefits and risks to each such a patient/s[.]

287 Professor Wittert's evidence at paragraphs 138 and 139 was that:

In addition to increasing haemoglobin levels, iron is necessary for many non-haem functions. These include redox cytochromes, nitric oxide synthesis, prostaglandin synthesis, oxidative phosphorylation, cytochrome P450 system, myoglobin, and hydrogen peroxide bursts in neutrophil.

Iron deficiency is associated with a number of symptoms, including exercise intolerance, mood lability, impaired immune surveillance, slow mentation, mucosal dysfunction and inefficient oxygenation of energy substrates.

288 Professor Wittert's opinion was that haemochromatosis and/or beta­thalassaemia trait are contraindications for the infusion of iron. They are both contraindications unless for some reason significant iron deficiency has been documented. Professor Joyce agreed and added that these are diseases of iron excess, so iron deficiency must be very unusual.

289 Professors Wittert, Vickery and Joyce agreed that the recognised therapeutic indications for the infusion of iron is iron deficiency.

The evidence as to Dr Singh's treatment using iron infusions

290 Dr Singh ordered infusions of iron to the following people within the list (dealing only with those from A to D) when their iron levels were within the normal range:

Patients 7, 13, 22, 24, 26, 28, 29, 35, 38, 54, 57, 59, 78, 87, 90, 91, 94, 126, 153, 156, 160, 168 and 169.

291 Dr Singh's evidence when attempting to explain why he did so by reference to the blood results was unsatisfactory and contradicted by Professor Wittert's reports and evidence. Dr Singh's interpretation of the blood results in relation to iron levels is idiosyncratic in much the same way as his interpretation of testosterone levels is.

292 In his witness statement, Dr Singh acknowledges the risks of iron infusion for patients with haemochromatosis and/or beta­thalassaemia and says that on a limited number of occasions he has nonetheless ordered iron infusions for those patients including Patients 54 and 187. His explanation for doing so was unconvincing and not supported by the expert evidence of Professors Wittert or Joyce.

293 Professor Wittert stated that, for the most part, he could see no reasonable indication for the ordering of iron transfusions. Professor Joyce stated that the context of the question is not clear but that it was 'not reasonable in the absence of iron deficiency'. Professor Vickery agreed.

294 Professor Joyce's opinion was that Dr Singh's rationale for the ordering of iron infusions generally, and specifically for patients with haemochromatosis or beta-thalassaemia trait, the ordering of iron infusions was not reasonable. Professors Vickery and Wittert agreed.

295 The Tribunal finds that from early 2008, Dr Singh engaged in a general practice of prescribing Iron to patients who consulted him seeking weight loss, physical conditioning and/or body building when in the circumstances there was no proper therapeutic indication or reason for the use of any of Iron by the patient for whom they were prescribed.

296 The Tribunal finds that Dr Singh's rationale for the ordering of iron infusions generally and specifically for patients with haemochromatosis or beta­thalassaemia trait, the ordering of iron infusions was not reasonable.

297 The Board alleged that from early 2008, Dr Singh engaged in a practice of ordering fresh frozen plasma (FFP) infusions for patients when there was no recognised therapeutic indication for such infusions in those patients (Board's CG paragraph 60).

298 Dr Singh admitted that, from early 2008, on a very limited number of occasions, and when he considered it medically appropriate or therapeutic, he ordered for certain patients who consulted him FFP infusion/s. Dr Singh denies the allegation that there was no recognised therapeutic indication for the ordering of fresh frozen plasma infusion/s for those patient/s for whom it was ordered. He says further that the rationale for treating these certain patient/s by, amongst other things, ordering fresh frozen plasma, fell into one or more of the categories outlined in relation to anabolic androgen steroids.

299 Professors Joyce and Wittert agreed that the infusion of FFP is only used for clotting factor replacement.

300 Professors Wittert and Joyce agreed there was no therapeutic indication for the ordering of FFP infusions which outweighed the potential adverse effect of a FFP infusion.

I order FFP infusions for patients in the management of dysautonomia in order to increase blood volume (and thereby, blood pressure). I give it to those patients because normal saline rapidly equilibrates across all three fluid compartments and therefore has minimal effect on raising blood pressure. Isotonic albumin is expensive, is associated with increased mortality and equilibrates (although more slowly than saline) across all three compartments. In my experience, its effect on blood pressure is thus minimal.

I am aware that FFP is associated with potential adverse side­effects including allergy to the FFP (usually occurring on the fourth or fifth infusion) treat any such allergies by pre-treating patients with intravenous hydrocortisone and antihistamines. However, four to five infusions are the maximum for most people.

303 Dr Singh conceded in cross-examination that all of his patients who received FFP suffered side effects and he knew that they would when he ordered it. He could give no adequate explanation for why he prescribed FFP and agreed that in relation to Patient 320 his prescription of FFP was experimental therapy for variant C1 esterase deficiency. In that case, the FFP was administered by a doctor at a pathology clinic on behalf of Dr Singh in circumstances where there were no appropriate anaesthesiology services which may have been required in the event of a severe reaction. The procedure on Patient 320 had to be aborted by the doctor at the pathology clinic because she experienced shortness of breath. Other patients experienced moderate to severe reactions to FFP including Patients 110, 133, 320, 375 and 392.

304 The Tribunal finds that from early 2008, Dr Singh engaged in a general practice of prescribing FFP to patients who consulted him seeking weight loss, physical conditioning and/or body building when in the circumstances there was no proper therapeutic indication or reason for the use of any of FFP by the patient for whom they were prescribed.

305 The Tribunal accepts that there were actual adverse side effects from the treatment with FFP.

306 The Tribunal finds that the use of FFP in association with combinations of anabolic steroids with the primary purpose of increasing muscle mass and function in the absence of any other appropriate indication is not now, nor ever has been, accepted practice.

307 The Board alleged that from early 2008, Dr Singh engaged in a general practice of ordering DEXA scans when there was no recognised therapeutic indication for the performance of any such scans or alternatively, for the performance of multiple such scans, of those patients (Board's CG paragraph 61).

308 Dr Singh admits that from early 2008, and when he considered it medically appropriate, he ordered for certain patients who consulted him, DEXA scans but otherwise denied the allegations (SR paragraph 61).

The expert evidence as to the therapeutic indications for the use of DEXA scans

309 Professor Wittert's opinion was that the recognised therapeutic indications for the performance of DEXA scans was for the assessment of bone mineral density in order to diagnose osteoporosis and monitor the response to treatment.

310 Professor Wittert saw no utility or need for Dr Singh's routine use of DEXA scans when as he said scales and a tape measure were all that was required in circumstances when it was not necessary to also test bone density. Professor Wittert's opinion was that there was not a proper and/or reasonable therapeutic indication for the ordering of one or more DEXA scans. He stated that it is a research tool and it would not be routinely used in obesity clinics where reliance would be placed on the use of anthropometric measurements or in other instances bio electrical impedance where there is no radiation exposure whatsoever.

311 Professor Vickery's opinion was that a DEXA scan was a well­known monitoring use for management of obesity and muscle mass. He agreed it was not routine but that it was used as a 'gold standard' for measuring fat mass and muscle mass.

312 There are few DEXA scans among the clinical notes and this allegation depends primarily on the evidence of Patient 81 and Dr Singh. Dr Singh has confirmed that he routinely used DEXA scans for the assessment of BMI and maintained that he was experienced in interpreting them and found them more reliable than traditional BMI measurements.

313 The Tribunal finds that from early 2008, Dr Singh engaged in a general practice of ordering DEXA scans for patients who consulted him seeking weight loss, physical conditioning and/or body building when in the circumstances there was no proper therapeutic indication or reason for the ordering of DEXA scans for the patient for whom they were ordered. The Tribunal finds that Dr Singh's practice of doing this was extensive.

314 In his evidence, Dr Singh claimed repeatedly that he had done no harm and that 'no-one had died on [him]'. It is hardly necessary to state that it is not necessary that someone should die before conduct can be the subject of criticism.

315 Professors Joyce and Wittert dealt extensively in their evidence with Dr Singh's approach to risk assessment and why it was not clinically acceptable.

316 In his witness statement dated 20 October 2014 (Exhibit D page 394), Professor Wittert stated:

There is in my opinion clear evidence of at least some harm to a number of patients that is potentially attributable to the treatments administered:

e.g. (2), (2A), (7), (9), (10), (12), (13), (16), (18), (22), (38), (99), (71), (35), (39), (48), (70), (84), (85), (87), (96), (98), (99), (159), (163), (166), (173), (187), (402) and (511).

There is evidence of severe harm likely attributable to the treatments administered:

Dr Singh's failure to make any or any adequate clinical notes

317 The Board alleged that Dr Singh failed to make any or any adequate clinical notes in relation to his consultations and treatment of patients who consulted him for obesity or consulted him seeking weight loss, physical conditioning and/or body building and/or patients for whom he prescribed anabolic androgenic steroids and/or Clenbuterol, Ephedrine and/or EAC capsules. In his closing submissions, Dr Singh conceded that his notes were inadequate.

318 The Board alleged that it is mandatory for a medical practitioner, including a specialist physician, to make clinical notes in respect of the practitioner's consultations with patients which include:

1. the date of the consultation;
2. the patient's clinical history given at the consultation including the symptom or symptoms which constituted the patient's reason for consulting the practitioner;
3. the practitioner's relevant clinical findings and/or observations on examination of the patient;
4. the practitioner's working diagnosis and any differential diagnoses;
5. the practitioner's medical advice to the patient and the practitioner's recommended management plan for the patient;
6. the names of any medicines prescribed for the patient including their strength, the directions given for use and the number of repeats given;
7. any relevant medical treatment that the patient was receiving at the time of the consultation; and
8. any warnings or instructions given to the patient in relation to their condition.

319 Dr Singh admits that item 1.1f of the Code of Ethics issued by the Australian Medical Association, which guides doctors' conduct, provided for doctors to maintain accurate contemporaneous clinical records.

320 In setting the standards of ethical behaviour expected of doctors in relation to 'Patient Care', item 1.1f of the Code of Ethics states that the doctor '[m]aintain accurate contemporaneous clinical records'.

Code of Conduct for registered health practitioners

321 The Code of conduct for registered health practitioners (Code of Conduct) states at section 2.2(e):

Maintaining a high level of professional competence and conduct is essential for good care. Good practice involves:

Maintaining clear and accurate health records (see section 8.4).

322 Sections 8.4(a) and 8.4(d) of the Code of Conduct state:

Maintaining clear and accurate health records is essential for the continuing good care of patients or clients. Practitioners should be aware that some National Boards have specific guidelines in relation to records. Good practice involves:

1. keeping accurate, up-to-date, factual, objective and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients or clients, medication and other management in a form that can be understood by other health practitioners[; and]

1. ensuring that records are sufficient to facilitate continuity of care[.]

323 The Board requested of and obtained from Dr Singh his medical records for the approximately 740 patients who are listed in the summary of prescriptions which appear in Exhibit A Volume 5.

324 Those records were admitted into evidence in the form of a USB memory stick ­ Exhibit H. The records comprise some 68,000 pages. Although the records comprise 68,000 pages the volume is not indicative of their quality. In many cases a page consists of little more than a short sentence. Despite the number of pages, the quality of the notes was uniformly poor.

325 The Tribunal has not read all of those records because there was little utility in doing so. All of those records were read by Professor Wittert and his comments in relation to some 200 patients, principally those alphabetically listed under A-D, appear in Exhibit D Volume 2 at pages 398­507. In the light of Professor Wittert's summary, the Tribunal regarded it as unnecessary to read each record. None of the other experts performed the same detailed analysis of Dr Singh's records as Professor Wittert.

326 Professor Wittert described Dr Singh's records as:

... uniformly deficient in terms of the contemporaneous recording of the clinical information that would be expected from a specialist physician including the documentation of clinical findings, assessment and formulation of a diagnosis and problem orientated follow-up notes. ...

(Exhibit D at page 394)

327 In Professor Wittert's original report dated 15 April 2013, which was in the form of a witness statement, he stated that 'clinical notes are essential for the safe and effective management of patents. Dependence upon recall makes it impossible for a practitioner to assess the validity of a working diagnosis' (Exhibit D page 282 at paragraph 9).

328 At the November 2013 joint conferral in relation to Patient J, it was agreed that Dr Singh should have kept clinical notes. It was also agreed that the notes should contain a diagnosis, the justification for the diagnosis, why 'off label' use of medication was chosen and instructions for follow up. It was agreed that there might be circumstances where you would not write to the patient's general practitioner but that you should write to the patient (Exhibit Q at page 342).

329 At the November 2015 joint conference, Professor Joyce stated that the necessary records for a prescription would include:

• the diagnosis that justifies the prescription;
• the prescription itself (drug, dose, frequency, duration);
• a plan to mitigate adverse effects if they are relevant with the drug in question;
• if it is truly experimental, some indication that it is the patient's will to proceed.

330 Professor Hood stated that, in general, one endeavours to write clinical notes that reflect the clinical consultation so that you can refer to it for ongoing patient care and for handover (Exhibit Q Volume 3, at page 647).

331 It is clear from his records generally that Dr Singh's notes, where they exist, are confined for the most part to lists of prescribed drugs without reference to dose, frequency or period of prescription. It appears to be the practice of his nurse to take a history at the first consultation which then was generally not updated and not added to by Dr Singh. In some cases, although there might be no entries in his clinical notes, there are what appear to be dictated file notes or correspondence by Dr Singh which provide some further information in relation to the treatment of patients.

332 Insofar as the allegation relates to Dr Singh failing to make any notes, a number of patients who were prescribed one or more of these five drugs, anabolic androgenic steroids, Clenbuterol, Ephedrine, Clomid or HGH and in relation to whom there insufficient no clinical notes include:

1. (17), who filled prescriptions for eight Deca Durabolin injections, six Primoteston injections and eight Sustanon injections on 10 August 2010 (no clinical notes);
2. (23), who filled prescriptions for Clenbuterol 20mcg/1mL 200mL and 100 Oxandrolone capsules on 22 December 2009 and 100 Oxandrolone capsules on 13 March 2010 (no clinical notes);
3. (42), who filled prescriptions for 100 Methandrostenolone capsules on 17 March 2008, 100 Oxandrolone capsules on 4 May 2010, 30 Clomid 50mg tablets and six Primoteston injections on 12 July 2010 and three Sustanon injections on 4 October 2010 (no clinical notes);
4. (115), who filled a prescription for 100 Oxandrolone capsules on 10 July 2008 (no clinical notes);
5. (150), who filled prescriptions for 100 Oxandrolone capsules and 12 Primoteston injections on 3 December 2013 (no clinical notes);
6. (170), who filled prescriptions for nine Deca Durabolin injections and nine Sustanon injections on 24 December 2008 (no clinical notes);
7. (175), who filled prescriptions for 30 Clomid tablets, eight Deca Durabolin injections and nine Primoteston injections on 4 May 2010, eight Deca Durabolin injections, nine Primoteston injections and three Sustanon injections on 29 June 2010 and 12 Primoteston injections and 12 Sustanon injections on 30 May 2011 (no clinical notes);
8. (254), who filled a prescription for 100 Oxandrolone capsules on 8 March 2010 (no clinical notes);
9. (294), who filled a prescription for six Sustanon injections on 30 November 2009 (no clinical notes);
10. (319), who filled a prescription for 100 Oxandrolone capsules on 25 March 2009 and Clenbuterol 20mcg/1mL 200mL on 15 May 2009 (no clinical notes);
11. (333), who filled a prescription for 60 Clomid tablets on 2 December 2009 (no clinical notes);
12. (398B), who filled prescriptions for 30 Clomid tablets and three Sustanon injections on 12 August 2009 (clinical notes record name, address in the Northern Territory and date of birth but no medical history or other information);
13. (411), who filled a prescription for Clenbuterol 20mcg/1mL 200mL on 13 August 2010 (clinical notes record name but no date of birth, address, medical history or any other information);
14. (417), who filled prescriptions for Clenbuterol 20mcg/1mL 200mL, 60 Clomid tablets, 100 Oxandrolone capsules, six Primoteston injections and six Sustanon injections on 5 November 2009 (clinical notes record name, address, date of birth and Medicare number but no medical history or other information);
15. (438), who filled prescriptions for Clenbuterol 20mcg/1mL 200mL, three Primoteston injections and three Sustanon injections on 12 November 2009, 60 Clomid tablets, 100 Oxandrolone capsules, three Primoteston injections and one Reandron injection on 17 December 2009, Clenbuterol 20mcg/1mL 200mL on 20 March 2010 and 100 Oxandrolone capsules, three Primoteston injections and three Sustanon injections on 14 May 2010 (no clinical notes);
16. (439), who filled prescriptions for 100 Oxandrolone capsules on 24 November 2008, Clenbuterol 20mcg/1mL 200mL and 200 Oxandrolone capsules on 29 January 2009 and 200 Oxandrolone capsules on 15 July 2009 (no clinical notes);
17. (440), who filled prescriptions for Clenbuterol 20mcg/1mL 200mL and 30 Clomid tablets on 18 February 2010, Clenbuterol 20mcg/1mL 200mL and 30 Clomid tablets on 24 March 2010, two Reandron injections on 13 May 2010, three Primoteston and one Reandron injection on 4 August 2010, 100 Oxandrolone tablets, six Primoteston injections and six Sustanon injections on 30 September 2010, nine Primoteston injections on 16 October 2011, 15 Primoteston injections on 8 May 2011, six Primoteston injections on 7 May 2013 and six Primoteston injections on 10 October 2013 (no clinical notes);
18. (447), who filled prescriptions for 30 Clomid tablets, eight Deca Durabolin injections and eight Sustanon injections on 4 May 2010 (no clinical notes);
19. (418), who filled prescriptions for 21 Deca Durabolin injections and 21 Sustanon injections on 26 February 2008 (clinical notes record name, address in New South Wales and date of birth but no medical history or any other information). In cross-examination about (418), Dr Singh confirmed that he had also seen (418) in New South Wales and believed he had taken notes in an exercise book. However, these handwritten records, as with all of his handwritten records, have never been provided to the applicant and Dr Singh has not been able to explain what happened to them. He says that generally he would have given his hand written records to a secretary or nurse to transcribe but apparently did not check that that had occurred or that they were included in the patient database. Whatever the explanation, Dr Singh's systems for record management and indeed practice management generally were woefully inadequate (even if the Tribunal accepts Dr Singh's evidence about how he says he managed his practice);
20. (458), who filled a prescription for Clenbuterol 20mcg/1mL 200mL on 2 November 2010 (clinical notes record name but no date of birth, address, medical history or any other information);
21. (472), who filled prescriptions for six Primoteston injections on 28 April 2008 (no clinical notes);
22. (505), who filled prescriptions for 300 Oxandrolone capsules on 14 November 2008 (clinical notes record name, address, date of birth and Medicare number but no medical history or any other information). When cross­examined Dr Singh agreed that he knew (505) ran a gym in East Perth and also that (505) currently runs the International Federation of Body Building in Western Australia;
23. (506), who filled prescriptions for Clenbuterol 20mcg/1mL 200mL and 30 Clomid tablets on 21 January 2010 (no clinical notes);
24. (618), who filled a prescription for nine Primoteston injections on 31 March 2008 (clinical notes record name, address in New South Wales and date of birth but no medical history or any other information);
25. (624), who filled prescriptions for 100 Oxandrolone capsules on 27 November 2008 and Clenbuterol 20mcg/1mL 200mL on 20 February 2009 (no clinical notes); and
26. (668), who filled prescriptions for five Deca Durabolin injections and six Primoteston injections on 28 May 2008 (clinical notes record name, date of birth and Medicare number, but the address is recorded as that of Empire Clinic and no medical history or any other information is recorded).

333 The Tribunal finds that Dr Singh's notes were totally inadequate.

334 Dr Singh claimed that he had failed to take notes because his patients did not wish him to do so because of their public profile.

335 At the November 2015 joint conference, Professor Joyce stated that in respect of medical care of prominent people where privacy may be at greatest risk:

• He has never failed to create sufficient records;
• In some cases, he has handled all the communications himself and prepared the notes himself without secretarial assistance; and
• There is also the option of placing records in the hands of the patient and not keeping them himself.

336 Professor Wittert believes that prominent people should be treated the same as others in respect of note taking (Exhibit Q Volume 3, at page 647).

337 Professor Hood stated that, where there are patients of high media interest and/or medical renown, they are in a different type of patient cohort to most routine clinical practice. Professor Nutt agreed with Professor Hood. He believes that ultimately it is the patient's decision. If they lose out medically because of that, as long as they are informed of what they are doing, it is their choice. Professor Nutt does not agree that you need to get the patient's consent for the use of off-licence or off-label drugs. His opinion is that you get into an unnecessary level of complexity (Exhibit Q Volume 3, at page 647).

338 The Tribunal prefers the opinion of Professor Wittert and the Tribunal does not accept that the fact that the patient is a public figure excuses a medical practitioner from taking adequate notes.

339 The Tribunal is satisfied, to the Bringinshaw standard, on the basis of the findings set out above that disciplinary matters arise in relation to Dr Singh's general practice for the period prior to 1 October 2010 and that Dr Singh engaged in professional misconduct for the period from and after 1 October 2010.

340 The prescription of anabolic androgen for the purpose of body building enhancement without any therapeutic basis has never been accepted practice. Such conduct would be regarded as improper by professional colleagues of good repute and competence. Such conduct was substantially below that standard reasonably expected of a registered medical practitioner of an equivalent level of training or experience.

341 The prescription of Clomid in breach of s 38C of the Poisons Regulations is illegal and would be regarded as improper by professional colleagues of good reputation and competence. Such conduct was substantially below that standard reasonably expected of a registered medical practitioner of an equivalent level of training or experience.

1. human growth hormone;
2. Sibutramine;
3. Tamoxifen;
4. Anastrozole;
5. Testosterone;
6. Midodrine;
7. Fludrocortisone; and/or
8. Erythropoietin.

343 when there was no therapeutic basis for prescribing them and where it exposed patients to potential adverse effects would be regarded as improper by colleagues of good reputation and competence. Such conduct was substantially below that standard reasonably expected of a registered medical practitioner of an equivalent level of training or experience.

344 The prescription of iron infusions, FFP and DEXA scans when there was no recognised therapeutic indication, would be regarded as improper by professional colleagues of good repute and competence. Such conduct was substantially below the standard reasonably expected of a registered medical practitioner of an equivalent level of training or experience.

345 The failure to keep proper medical records would be regarded as improper by professional colleagues of good repute and competence and the standard reasonably expected of a registered medical practitioner of an equivalent level of training or experience. Such conduct was substantially below that standard reasonably expected of a registered medical practitioner of an equivalent level of training or experience.

346 Dr Singh's conduct was, on the basis of the evidence and findings set out above, substantially below the standard reasonably expected of a registered medical practitioner of an equivalent level of training or experience.

347 The Board alleged that in or about December 2009 Dr Singh was consulted by Patient J (Board's CG paragraph 5).

348 Dr Singh stated that Patient J consulted him in person twice in about December 2009 and subsequently he was consulted by Patient J by telephone on one or more occasions (SR paragraph 5).

349 The Board alleged that at the time or times of the Patient J consultation or consultations, Patient J informed Dr Singh that:

1. he resided in Darwin in the Northern Territory; and
2. he was visiting Perth, Western Australia, for the purpose of consulting Dr Singh.

(i) [Patient J] informed [him] that he was a long­term user of illicitly acquired androgens;

(ii) [Patient J] also informed [him] that he was consulting with [him] because he did not trust that any General Practitioner in Darwin would maintain his privacy; and

(iii) [Patient J] expressly requested that [he] make and maintain no notes of the consultations between him and [Dr Singh].

(SR paragraph 6)

351 The Board alleged that during Patient J's consultation or consultations and/or upon review of test results obtained by Dr Singh in respect of Patient J, Dr Singh made a working diagnosis of body dysmorphic syndrome with binge eating disorder overlap in respect of Patient J, as Patient J had described:

• a fear of shrinking;
• loss of appetite control;
• mood lability;
• nocturnal binge eating;
• deteriorating interpersonal relationships; and
• psychological dependence on androgens.

352 The Board alleged that during Patient J's consultation or consultations, Dr Singh prescribed for Patient J:

...

9.4. Mesterolone;

9.5. Oxandrolone;

9.6. Primoteston;

9.7. Clenbuterol Hydrochloride (Clenbuterol);

9.8. Simvastatin;

9.9. Trandolapril; and

9.10. Clomiphene citrate (Clomid).

(Board's CG paragraph 9)

353 Dr Singh stated that he prescribed Mesterolone, Oxandrolone and Primoteston to Patient J.

(i) to assist with normalising [Patient J's] excessive androgen levels over time;

(ii) to reduce [Patient J's] drive to consume illicit androgens; and

(iii) to complement the prescription of clomiphene citrate as:

354 Dr Singh said that he prescribed the medications at low doses and in the combinations and sequence as follows:

1. Mesterolone, one tablet taken two or three times a week;

1. Oxandrolone, two tablets taken on most days of the week;

1. Primoteston, with one shot to be administered every two to three weeks;
2. Clenbuterol, twice a week, starting at a lower dose, with the potential to increase the dose to a higher dose depending on [Patient J's] tolerance to that medication;
3. Simvastatin taken together with Trandolapril daily; and
4. Clomiphene citrate, taken on alternate evenings for 10 days, with the potential for further courses following further review of [Patient J] by Dr Singh; and

(ii) [Dr Singh] informed [Patient J] as to the potential adverse side effects of using the medications he had prescribed for [Patient J];

(iii) [Dr Singh] instructed [Patient J]:

1. not to increase or otherwise adjust the prescribed dose of any of the medications he had prescribed for [Patient J];
2. to return for further consultation with [Dr Singh] 6 to 8 weeks after the consultations in about December 2009; and

1. to telephone [Dr Singh] at any time of day or night should [Patient J] have any concerns or questions; and

(iv) despite [Dr Singh's] instruction to [Patient J] referred to above, [Patient J] did not return in person for any further consultation with [Dr Singh] after about December 2009.

(SR paragraph 9)

355 Each of the drugs prescribed to Patient J by Dr Singh has been dealt with above in relation to the therapeutic indications for prescribing, the potential adverse effects and the inappropriateness of prescribing them.

356 The Board alleged that Dr Singh's prescription of the androgens Mesterolone, Oxandrolone and Primoteston for Patient J (for which there was no medical indication or necessity) required Dr Singh to ensure that Patient J's condition was monitored by a medical practitioner in order to ascertain whether Patient J was suffering from adverse effects of those androgens (Board's CG paragraph 37).

357 Dr Singh denied each of the allegations contained in the Board's CG paragraph 37 (SR paragraph 37).

358 The Board alleged that Dr Singh failed to take any, or alternatively any adequate steps to ensure monitoring of Patient J's condition in order to detect any adverse effects suffered by Patient J as a result of taking those androgens (Board's CG paragraph 38).

359 Dr Singh denied each of the allegations in the Board's CG paragraph 38 (SR paragraph 38).

360 In the joint report Professor Joyce stated that there was no adequate monitoring of Patient J and there was no proven monitoring program that would protect Patient J from the consequences of excessive anabolic exposure. He said it would have been prudent to monitor blood pressure, lipids and his psychiatric state. Professor Wittert agrees with Professor Joyce and says that it was absurd for Patient J to be permitted to 'run off' to Darwin with those medications.

361 Dr Singh says in his witness statement that he instructed Patient J to return for further consultation and review in six to eight weeks. There is no evidence from Dr Singh to the effect that he had a recall system to alert him to the need for Patient J to attend a further appointment, or that he made any attempt to contact Patient J when he failed to attend a follow-up appointment.

362 It is evident from the Travel Doctor notes made by [Dr M] on 9 December 2009 that, as at that date, Patient J had plans to leave Australia for at least three months on 8 January 2010 (that is one month after his consultations with Dr Singh). Dr Singh was aware that Patient J intended to leave Australia. Dr Singh's claim in his witness statement that he intended to review Patient J in six to eight weeks is rejected by the Tribunal.

363 Dr Singh claimed that he provided the steroids to Patient J to reduce his drive for illicit steroids. That evidence is rejected. Dr Singh prescribed the steroids for use in body building purposes

364 In any event, Professor Joyce's evidence was that prescribing anabolic steroids to reduce a patient's drive for illicit steroids is not analogous to providing methadone for opioid addiction, where there is a measurable improvement in health because of the treatment. He said that it was more analogous to giving alcohol to an alcoholic, because in both cases the prescription would bring happiness but at a cost to health. Professor Joyce said that Dr Singh was trading off the health of the patient for the satisfaction of the patient, and that there was no reason to believe that this was going to solve Patient J's concerns about his body image. He said that there was no indication for and no benefit from the prescriptions.

365 Professor Wittert agreed with Professor Joyce that there was no indication for the prescription of Mesterolone, Oxandrolone and Primoteston for Patient J. He said there was no evidence, no outcome and no data on which to base any finding of benefit to the patient. He said that Patient J was happy because he was after drugs for recreation, but that his use of steroids was illegal and wrong. Professor Wittert said that there was no evidence of the purported diagnosis in the notes, and that Patient J got what he wanted, with Dr Singh perpetuating the problem without any justification.

366 The Board alleged that Dr Singh failed to make any or any adequate notes of the consultation or consultations with Patient J.

367 The Board alleged that Dr Singh did not make any, or alternatively any adequate note or any adequate written or printed record, as to:

1. the date or dates of Patient J consultation or consultations;
2. Patient J's clinical history given at the Patient J's consultation or consultations including the symptom or symptoms which constituted Patient J's reason for consulting Dr Singh;
3. Dr Singh's relevant clinical findings and/or observations on examination of Patient J;
4. Dr Singh's working diagnosis and any differential diagnoses;
5. Dr Singh's medical advice given to Patient J as to Dr Singh's diagnosis of Patient J's condition and Dr Singh's recommended management plan for Patient J;
6. the names of any medicines prescribed for Patient J including their strength, the directions given for use and the number of repeats given;
7. any relevant medical treatment that Patient J was receiving; or
8. any warnings or instructions given to Patient J in relation to Patient J's medical condition.

368 Dr Singh's response was, other than notes of the prescriptions and test results, he did not keep any notes or record of his consultations with Patient J.

369 The requirements of adequate notes are set out above.

370 The notes of the consultation on 4 December 2009 are:

Clomid 60/Proviron

pro/red

pro ten

clenx3

eac x2

lipitor40/gop4

hgh .15 bd

combantrin x6

lonovar 2 am

preg b4 he goes away

(Exhibit A pages 455­456)

371 There is no clinical note of a consultation other than 4 December 2009. The 4 December 2009 clinical note does not provide any information in relation to the reason for the consultation, Patient J's symptoms, any working diagnosis, any advice provided to the patient or any other medical treatment that Patient J was receiving. The clinical note does record, in an often abbreviated form, 'b4 he goes away', the medication that was prescribed to Patient J and a reference to his travel plans.

372 The requirements as to clinical notes are set out above.

373 In the joint report of the experts, Professors Joyce and Wittert agree that Dr Singh's clinical notes in relation to Patient J were inadequate (Exhibit Q at page 668).

374 The Tribunal accepts the evidence of Professors Wittert and Joyce that Dr Singh's note taking was inadequate. Given the requirements of note taking, a list of medications prescribed and one or two other lines did not begin to meet the requirements for proper record keeping.

Dr Singh's explanation for not keeping notes for Patient J

375 Dr Singh stated that Patient J expressly requested that he did not make and maintain notes of the consultation (Exhibit S Volume 1, at page 7).

376 In a letter to the Medical Board of Western Australia dated 8 April 2010 specifically in relation to Patient J, Dr Singh said:

I do not keep written notes on sensitive cases such as this unless a GP refers me a patient and therefore has to be involved in management. I can however reconstruct the necessary clinical details from the comprehensive data I always acquire pre-treatment.

(Exhibit A at page 708)

377 Dr Singh also asserted in that letter that Patient J told him that he came to Dr Singh rather than a general practitioner in Darwin because he 'trusted none of them'. Dr Singh did not assert in that letter that Patient J had asked him not to take notes (Exhibit A at pages 708-713).

378 Dr Singh stated that Patient J told him that 'he did not trust any general practitioners in Darwin to keep his privacy' and that Patient J requested that he not keep any notes of the consultations. Dr Singh says in his witness statement that he did not keep any notes or record of his consultations with Patient J other than his test results (Exhibit S page 7, at paragraphs 28­30).

379 As the Board submitted, it is difficult to reconcile Dr Singh's response and the evidence of Dr Singh in relation to the keeping of clinical notes with:

1. the fact that Dr Singh did make a clinical note (albeit inadequate) of his consultation with [Patient J] on 4 December 2009 (this is inconsistent with a request by [Patient J], and an agreement by Dr Singh, that notes would not be taken of the consultation);
2. the fact that [Patient J] informed [Dr M] in Darwin on 8 December 2009 (4 days after the 4 December 2009 consultation with Dr Singh) of the complete list of medication prescribed to him by Dr Singh and told him that the medication was essentially for body building (this is inconsistent with [Patient J]'s purportedly extreme concern about his privacy and lack of trust of doctors in Darwin); and
3. the clinical notes made by Dr Singh in relation to the 4 December 2009 consultation with [Patient J] are effectively identical to the clinical notes he made in respect of consultations with many patients to whom he prescribed a similar list of medication.

380 Dr Singh's explanation for not taking notes in relation to Patient J is rejected. As noted above, he could have anonymized the notes. His statement that Patient J asked him not to take notes is completely at odds with the fact that Patient J told a practitioner in Darwin about his drug use.

381 The Board alleged that there was no medical indication for Patient J to be prescribed Clenbuterol (Board's CG paragraph 39).

382 The Board further alleged that Dr Singh's unnecessary prescribing of Clenbuterol for Patient J unnecessarily placed Patient J at risk of the adverse effects of that medication (Board's CG paragraph 40).

383 Dr Singh denied each of the allegations in the Board's CG paragraphs 39­40 (SR paragraphs 39­40).

384 The Board alleged that Dr Singh's prescription of Clenbuterol for Patient J (for which there was no medical indication or necessity) required Dr Singh to ensure that Patient J's condition was monitored by a medical practitioner in order to ascertain whether Patient J was suffering from the adverse effects of Clenbuterol (Board's CG paragraph 41).

385 Dr Singh admits that Clenbuterol can increase blood pressure and can increase heart rate. He does not admit that it is associated with restlessness, anxiety and increased appetite. Dr Singh states that:

(i) Clenbuterol can be used to aid fat loss without skeletal muscle catabolism; and

(ii) [Dr Singh] prescribed Clenbuterol to [Patient J] to increase fatty acid metabolism and reduce [Patient J's] body fat without skeletal muscle catabolism.

(SR paragraph 14(d))

The Board alleged that Dr Singh failed to take any or alternatively any adequate steps to ensure monitoring of Patient J's condition in order to detect any adverse effects suffered by Patient J as a result of taking Clenbuterol (Board's CG paragraph 42).

Dr Singh denied each of the allegations in the Board's CG paragraph 41­42 (SR paragraphs 41­42).

386 There is no explanation in the notes for the prescription but Dr Singh said in his evidence that he prescribed the drug as part of his overall treatment plan for his diagnosis of body dysmorphia, to aid fat loss without skeletal muscle wastage.

387 Dr Singh admits that Clenbuterol is a drug that is often used for patients whom he saw for the purposes of body building and that Clenbuterol is used to cut fat and was complementary to the steroids which were to build muscle.

388 Professors Wittert and Joyce state that there was no recognised therapeutic indication for the prescription and no adequate monitoring.

389 The Tribunal finds that Dr Singh failed to take any, or any adequate steps to ensure appropriate monitoring of Patient J in order to detect any adverse effects suffered by Patient J as a result of Patient J taking Clenbuterol.

390 The expert evidence of Professors Wittert and Joyce, that there was no therapeutic indication for the drugs and that they were in that sense unnecessary and inappropriate, is preferred to that of Dr Singh.

391 Dr Singh prescribed Clenbuterol for Patient J when there was no medical indication or necessity for the prescription of Clenbuterol.

392 The Board alleged that Simvastatin is used for treatment of hypercholesterolaemia (Board's CG paragraph 15).

(i) Simvastatin reduces the risk of cardiovascular disease by lowering a particular subfraction of cholesterol, namely LDL;

(ii) long­term illicit androgen use can increase the risk of cardiovascular disease and cerebrovascular disease; and

(iii) [Dr Singh] prescribed simvastatin in combination with Trandolapril to decrease [Patient J's] risk of cardiovascular disease and cerebrovascular disease.

(SR paragraph 15(c))

394 The Board alleged that Trandolapril is used for the treatment of hypertension (Board's CG paragraph 16). Dr Singh says that hypertension is a common cause of cardiovascular and cerebrovascular disease (SR paragraph 16).

395 The Board alleged that there was no medical indication for the prescription of Simvastatin for Patient J (Board's CG paragraph 43).

396 Dr Singh denied each of the allegations in the Board's CG paragraph 43 (SR paragraph 43).

397 The Board alleged that there was no medical indication for the prescription of Trandolapril for Patient J (Board's CG paragraph 44).

398 Dr Singh denied each of the allegations in the Board's CG paragraph 44 (SR paragraph 44).

399 The Board alleged that neither Simvastatin nor Trandolapril could treat Patient J's hypertriglyceridaemia (evident from his lipid profile results received by Dr Singh on or about 4 December 2009 and referred to in the Board's CG paragraph 8) and Dr Singh failed to offer or alternatively to provide to Patient J any treatment or any recommendations for management of Patient J's hypertriglyceridaemia (Board's CG paragraph 45).

400 Dr Singh admitted that neither Simvastatin nor Trandolapril could treat Patient J's hypertriglyceridaemia. Otherwise he denied each of the allegations in the Board's CG paragraph 45. Dr Singh stated that:

(i) he did not prescribe Simvastatin and Trandolapril to treat [Patient J's] hypertriglyceridaemia; and

(ii) he informed [Patient J] that he could take protein-free fish oil to manage his hypertriglyceridaemia.

(SR paragraph 45(d))

401 The Board alleged that Dr Singh had prescribed Clomid to Patient J (Board's CG paragraph 46).

402 Dr Singh admits that he prescribed Clomid to Patient J. The prescription of Clomid to Patient J was a breach of reg 38C of the Poison Regulations for the reasons stated above.

403 The lack of notes and Dr Singh's untruths in relation to the diagnosis he purportedly made in relation to other patients, leads the Tribunal to conclude that Dr Singh's diagnosis in Patient J of body dysmorphia with an overlap of binge eating disorder was simply a cover for the prescription of drugs for body building.

404 The Tribunal finds that Dr Singh did not in fact diagnose Patient J as he alleged. Accordingly, the statements made by Dr Singh in his letter to Australian Health Practitioner Regulation Agency (AHPRA) of 8 April 2010, (Exhibit A page 709) were untrue.

405 The Tribunal is satisfied on the balance of probabilities, applying the Briginshaw test, on the basis of the findings set out above, that disciplinary matters arise in relation to Patient J.

406 The prescription of anabolic androgen steroids and the associated drug Clenbuterol for the purpose of body building enhancement to Patient J without any therapeutic basis has never been accepted practice.

407 Such conduct would be regarded as improper by professional colleagues of good repute and competence.

408 The prescription of Clomid to Patient J in breach of reg 38C of the Poisons Regulations is illegal and would be regarded as improper by professional colleagues of good reputation and competence.

409 The prescription of Simvastatin and Trandolapril when there was no therapeutic basis for prescribing them and as it exposed Patient J to potential adverse effects would be regarded as improper by colleagues of good reputation and competence.

410 The failure to adequately monitor Patient J when using the prescribed drugs would be regarded as improper by colleagues of good reputation and competence.

411 The failure to keep proper medical records amounted to acting carelessly by Dr Singh.

On 1 November 2011, the Board received a notification from a medical practitioner employed at a Queensland hospital in relation to Patient B (Board's CG paragraph 63). The email from the medical practitioner at Exhibit A Volume 2, at page 583 stated:

I am a doctor working at [Queensland] Hospital. I admitted a male after a first episode seizure. The likely precipitant for this was an acute benzodiazepine withdrawal.

On further questioning, it became apparent that the patient was receiving Human Growth Hormone and Testosterone for his body building pursuits, and was also being prescribed Clomiphene and Tamoxifen to help balance out the effects of the testosterone.

412 Dr Singh was consulted by Patient B on a number of occasions in 2011 (Board's CG paragraph 64).

413 At Patient B's consultation or consultations Patient B informed Dr Singh that he:

1. had a poor diet;
2. consumed minimal alcohol;
3. did not have a history of drug use;
4. was asthmatic;
5. was allergic to peanuts and shellfish;
6. worked long hours as an immigration agent'; and
7. was 'keen to get himself back into shape'.

414 On or about 14 January 2011, Dr Singh obtained a 24 hour blood pressure report in respect of Patient B (Blood Pressure Report), which report concluded that Patient B had moderate labile systolic hypertension throughout the day with severe systolic hypertension during the night (Patient B's Hypertension) (Board's CG paragraph 66).

415 Dr Singh stated that he made a working diagnosis of circadian rhythm disruption in respect of Patient B (Board's CG paragraph 67)

416 The Board alleged that Dr Singh did not consider, investigate or advise Patient B in relation to differential diagnoses which may have accounted for Patient B's hypertension, including:

1. obstructive sleep apnoea;
2. hyperaldosteronism;
3. phaeochromocytoma;
4. chronic renal disease;
5. renal artery stenosis; and/or
6. coarctation of the aorta.

417 The Board alleged that following consultation with Patient B, Dr Singh prescribed:

1. Tamoxifen;
2. Testosterone;
3. HGH; and
4. Clomid.

418 The Board alleged that there was no medical indication for Patient B to be prescribed those drugs and that they had potential severe adverse effects.

419 The Board also alleged that Dr Singh failed to monitor Patient B's use of the prescribed drugs.

420 The Tribunal is satisfied, on the balance of probabilities applying the Briginshaw standard on the basis of the findings set out above, that Dr Singh engaged in professional misconduct in relation to his treatment of Patient B.

421 The prescription of anabolic androgen steroids and the associated drugs for the purpose of body building enhancement without any therapeutic basis has never been accepted practice.

422 Such conduct was substantially below that standard reasonably expected of a registered medical practitioner of an equivalent level of training or experience.

423 The prescription of Clomid in breach of reg 38C of the Poisons Regulations is illegal and was substantially below the standard reasonably expected of a registered medical practitioner of an equivalent level of training or experience.

424 The prescription of HGH when there was no therapeutic basis for prescribing it exposed Patient B to potential adverse effects and was substantially below that standard reasonably expected of a registered medical practitioner of an equivalent level of training or experience.

425 The failure to keep proper medical records was substantially below the standard reasonably expected of a registered medical practitioner of an equivalent level of training or experience.

426 The expert evidence of Professors Joyce and Wittert who gave extensive evidence about the steps Dr Singh should have taken to consider particularly sleep apnoea as an alternative and more likely cause of Patient B's hypertension. The diagnostic path followed by Dr Singh in relation to Patient B was indicative of his approach generally and was what Professor Wittert described as pigeon holing by Dr Singh of patients who came to see him into a pre­conceived diagnosis rather than following a conventional diagnostic path. Professor Wittert was particularly critical of Dr Singh for resorting in the first instance to polypharmacy for Patient B without investigating and treating Patient B's hypertension in a conventional manner. When asked by the Tribunal, Professor Wittert outlined in detail exactly how he would have gone about treating Patient B which is to be contrasted to the approach taken by Dr Singh.

427 The Board alleged that the prescription of Clomid was in breach of s 38C of the Poisons Regulations. The general evidence and findings above relating to these prescriptions applies equally to Patient B.

428 It became apparent during Dr Singh's evidence in the course of the hearing that Patient B had also been abusing Benzodiazepines, although this is not recorded in his clinical notes. He also said in opening submissions that Patient B would come to Perth, indulge in prostitutes, amphetamines and cocaine and only sleep an hour or two during the day.

429 Dr Singh prescribed Stillnox to Patient B which on Professor Wittert's evidence, has a Benzodiazepine like effect, although Dr Singh denied that it does. It is clear from Dr Singh's evidence that he continued to prescribe Stillnox to Patient B while he was in Queensland and arranged for Stillnox to be flown to Queensland for Patient B to collect on at least one occasion, and that on one other occasion a prescription was sent to Queensland for Patient B to obtain Stillnox. To a large degree this evidence relies on what Dr Singh has said because the only evidence is a note on the final page of the patient file that was referred to in the course of the evidence in Exhibit A Volume 2 at page 569.

430 It is difficult to know how long the scripts for Stillnox provided by Dr Singh would have lasted Patient B (as the amount of Stillnox prescribed to Patient B is not recorded in the clinical notes). Dr Singh's evidence was that Patient B was also doctor shopping and in all likelihood obtaining Benzodiazepines elsewhere. What is clear is that, even on his own evidence, Dr Singh failed to monitor Patient B in relation to his prescriptions to him of Testosterone, HGH or Stillnox.

431 The hospital records in relation to Patient B's admission ascribe his collapse to either or both of Benzodiazepine withdrawal and to inappropriate drug use. Dr Singh's failure to monitor Patient B and the prescription of the drugs he continued to provide to him may well have contributed to that collapse.

432 It is apparent from the evidence that Patient B was another body builder and that the drugs were prescribed to Patient B by Dr Singh for that purpose. The issues with prescribing each of these drugs are dealt with above.

433 Dr Singh conceded that there were some sleep issues.

434 As the Board submitted, in any event, Professor Wittert's evidence was to the effect that Dr Singh took Patient B, an essentially healthy young man, failed to treat his hypertension, put him on an unjustifiable body building regime of polypharmacy and that by the end of his treatment, he was very unhealthy and his pathology results demonstrated that.

435 The Board alleged that Dr Singh did not make any adequate note or any adequate written or printed record as to:

84.1. the date or dates of the [Patient B] Consultation or Consultations;

84.2. [Patient B's] clinical history given at the [Patient B] Consultation or Consultations including the symptom or symptoms which constituted [Patient B's] reason for consulting [Dr Singh];

84.3. [Dr Singh's] relevant clinical findings and/or observations on examination of [Patient B];

84.4. [Dr Singh's] working diagnosis and any differential diagnoses;

84.5. [Dr Singh's] medical advice given to [Patient B] as to [Dr Singh's] diagnosis of [Patient B's] condition and [Dr Singh']s recommended management plan for [Patient B];

84.6. the names of any medicines prescribed for [Patient B] including their strength, the directions given for use and the number of repeats given;

84.7. any relevant medical treatment that [Patient B] was receiving; or

84.8. any warnings or instructions given to [Patient B] in relation to [Patient B's] medical condition.

(Board's CG paragraph 84)

436 Having reviewed the clinical notes for Patient B, Professors Wittert and Joyce maintained that the notes were inadequate. Dr Singh failed to document the symptoms which he claimed in his witness statement in relation to Patient B's supposed fatigue, anxiety and panic, exercise intolerance, diminished libido, benzodiazepine dependence, drug use and escalating alcohol use.

437 Dr Singh conceded that these medical notes were inadequate.

438 The email from the notifying practitioner at Exhibit A Volume 2, at page 583 says:

I am a doctor working at [the Hospital]. I admitted a male after a first episode seizure. The likely precipitant for this was an acute benzodiazepine withdrawal.

On further questioning, it became apparent that the patient was receiving Human Growth Hormone and Testosterone for his body building pursuits, and was also being prescribed Clomiphene and Tamoxifen to help balance out the effects of the Testosterone.

439 On or about 14 July 2012, Dr Singh wrote a letter to the notifying medical practitioner.

440 Dr Singh admits that he wrote the letter to the medical practitioner. He says that the letter was incorrectly dated 14 July 2012, and was sent on 16 April 2013 (SR paragraph 85).

441 The Board alleged that the tone and content of the letter was;

1. derogatory of the medical practitioner; and
2. lacking in professional courtesy; and/or offensive towards that medical practitioner.

442 The last paragraph in Dr Singh's letter to the medical practitioner read:

In summary, I believe you owe the patient an apology for violating doctor/patient confidentiality. I believe you have jeopardised his future career. I believe you have acted in an unnecessarily adversarial and combative manner. I believe you have made unfounded assumptions on my prescribing ability which really should have been a matter for doctor to doctor consultation. I believe you need to address and understand the concept of harm minimisation. I believe you need to go back and study your physiology and pharmacology. I believe you owe me an apology for your idiotic behaviour.

443 The Tribunal finds that Dr Singh's letter was totally inappropriate. As the Board alleged, it was derogatory, lacking in professional courtesy and offensive. The use of the words such as 'idiotic' and the suggestion that the medical practitioner needed 'to go back and study your physiology and pharmacology' are particularly offensive. The sting in the complaint by the medical practitioner that brought such a reaction from Dr Singh is of course that the medical practitioner was correct. Dr Singh was prescribing medication for body building purposes.

444 The Board alleged that on 8 October 2010 Dr Singh provided a medical certificate for patient KB which was false.

[KB] is being treated by me for an endocrine problem. It is a serious lifelong condition which could be life threatening if not regularly monitored and treated. Any emergency surgery or infection will require specialist attention prior to intervention. The problem was identified in October 2010 and she will be formally reviewed again in 3 months.

Psychological or physical stressors could precipitate a medical crisis which could manifest as cardiovascular collapse, confusion, nausea, vomiting, profound weakness and immune system compromise.

Her condition significantly impacts on her quality of life and will limit her tolerance for both mental and physical exertion.

She is unfit for work until at least November 2011. I will review her at 2­3 monthly intervals.

(Board's CG paragraph 62)

(a) he was investigating in the patient a possible diagnosis of subclinical Addison's disease;

(b) the patient was suffering from unremitting stress in her personal life; and

(c) he felt it necessary and appropriate to protect the patient from further undue external stress.

(SR paragraph 62)

447 Aspects of the medical certificate are odd. In particular, given that KB was self­employed there was no requirement for a certification as to KB's inability to work. However, despite Dr Singh's general unreliability as a witness the Tribunal is not persuaded that the certificate was false.

448 The fact that some patients, including those who gave evidence on Dr Singh's behalf, may have had outcomes that they regard as beneficial does not alter the findings as to the inadequacy of Dr Singh's treatment of other patients.

Findings as to disciplinary matters and professional misconduct

1. disciplinary matters exist for the purpose of s 76(1)(b) of the Medical Practitioners Act in that between early 2008 and 17 October 2010, Dr Singh acted carelessly, incompetently and/or improperly for the purposes of s 76(1)(b)(i), (ii) and/or (iii), and that from 18 October 2010 Dr Singh has behaved in a way that constitutes professional misconduct for the purpose of s 193(1)(a)(i) of the National Law, in that Dr Singh has:
   1. prescribed for patients anabolic androgenic steroids when there was no proper therapeutic indication for those prescriptions and when such prescribing unnecessarily put patients at risk of the adverse effects of those drugs;
   2. prescribed for patients Clenbuterol when there was no proper therapeutic indication for those prescriptions and when such prescribing unnecessarily put patients at risk of the adverse effects of Clenbuterol;
   3. prescribed for patients Ephedrine and EAC when there was no proper therapeutic indication for those prescriptions for body building;
   4. failed to make any or any adequate clinical notes in relation to his consultations and treatment of patients who consulted him for obesity or consulted him seeking weight loss, physical conditioning and/or body building and/or patients for whom he prescribed anabolic androgenic steroids and/or Clenbuterol, Ephedrine and/or EAC capsules;
   5. prescribed for patients Human Growth Hormone when there was no proper therapeutic indication for such prescribing and when such prescribing unnecessarily put patients at risk of the adverse effects of human growth hormone;
   6. prescribed for patients:

1. Sibutramine (after it had been withdrawn); 2. Tamoxifen;

1. Testosterone; 2. Midodrine; and 3. Fludrocortisone (with Midodrine);

when there was no recognised therapeutic indication for that prescribing when such prescribing unnecessarily put patients at risk of the adverse effects of those drugs;

1. ordered the infusion of iron for patients who did not suffer from iron deficiency;
2. ordered the infusion of iron for patients when the infusion of iron was contra­indicated because the patients suffered from haemochromatosis or beta­thalassaemia trait;
3. engaged in the general practice (that is on multiple occasions) of inappropriate prescribing of Erythropoietin (EPO) for patients when there was no recognised therapeutic indication for the prescription of that drug;
4. ordered Fresh Frozen Plasma infusions for patients when there was no recognised therapeutic indication for such infusions in those patients;
5. engaged in the general practice of ordering excessive DEXA scans when there was no recognised therapeutic indication for the performance of any such scan or alternatively for multiple such scans of those patients; and/or
6. prescribed Clomid when the prescription of that substance in Western Australia contravened reg 38C of the Poisons Regulations.

450 The Tribunal finds in relation to Patient J that:

1. disciplinary matters exist for the purpose of s 76(1)(b) of the Medical Practitioners Act in that Dr Singh acted carelessly, incompetently and/or improperly for the purposes of s 76(1 )(b)(i), (ii) and/or (iii) in the course of his practice as a medical practitioner in that in or about December 2009 Dr Singh:
   1. failed to make any or any adequate clinical notes in relation to attendances upon him by Patient J;
   2. did not diagnose Patient J with body dysmorphic syndrome with binge eating disorder overlap, as he claimed to have done in his letter to the Board on 8 April 2010 (Exhibit A page 709);
   3. prescribed Mesterolone, Oxandrolone and Primoteston for Patient J when there was no therapeutic indication for those drugs and when such prescribing unnecessarily put Patient J at risk of the adverse effects of those drugs;
   4. failed to take any or any adequate steps to ensure appropriate monitoring of Patient J in order to detect any adverse effects suffered by Patient J as a result of Patient J taking androgens;
   5. prescribed Clenbuterol for Patient J when there was no medical indication or necessity for the prescription of Clenbuterol;
   6. failed to take any, or any adequate steps to ensure appropriate monitoring of Patient J in order to detect any adverse effects suffered by Patient J as a result of Patient J taking Clenbuterol; and
   7. prescribed Clomid for Patient J when the prescription of that substance in Western Australia contravened reg 38C of the Poisons Regulations 1965 (WA) made pursuant to the Poisons Act 1964 (WA).

451 The Tribunal finds in relation to Patient B that:

1. Between early 2008 and 17 October 2010, Dr Singh has behaved in a way that constitutes professional misconduct for the purpose of s 193(1)(a)(i) of the National Law in that Dr Singh has:
   1. failed to make any adequate clinical notes in relation to attendances upon him by Patient B;
   2. failed to consider, investigate or advise Patient B in relation to differential diagnoses which may have accounted for Patient B's hypertension;
   3. prescribed Tamoxifen for Patient B when there was no medical indication for the prescription of Tamoxifen;
   4. prescribed testosterone for Patient B when there was no medical indication for the prescription of testosterone;
   5. prescribed Human Growth Hormone for Patient B when there was no medical indication for the prescription of Human Growth Hormone;
   6. failed to take any or any adequate steps to ensure appropriate monitoring of Patient B.
   7. prescribed Clomid for Patient B when the prescription of that substance in Western Australia contravened reg 38C of the Poisons Regulations 1965 made pursuant to the Poisons Act 1964 (WA); and/or
   8. sent a letter to the notifier, a medical practitioner, on or about 14 July 2012 which was;

1. derogatory of that medical practitioner; 2. lacking in professional courtesy; and/or

1. The Tribunal finds that disciplinary matters exist for the purpose of s 76(1)(b) of the Medical Practitioners Act 2008 (WA) in that between early 2008 and 17 October 2010 Dr Anish Dwarka Singh acted carelessly, incompetently and/or improperly for the purposes of s 76(1)(b)(i), (ii) and/or (iii), and that from 18 October 2010 Dr Anish Dwarka Singh behaved in a way that constitutes professional misconduct for the purpose of s 193(1)(a)(i) of the _Health Practitioner Regulation National Law (WA) Act 201_0, in that Dr Anish Dwarka Singh:
   1. prescribed for patients anabolic androgenic steroids when there was no proper therapeutic indication for those prescriptions and when such prescribing unnecessarily put patients at risk of the adverse effects of those drugs;
   2. prescribed for patients Clenbuterol when there was no proper therapeutic indication for those prescriptions and when such prescribing unnecessarily put patients at risk of the adverse effects of Clenbuterol;
   3. prescribed for patients Ephedrine and Ephedrine, Aspirin and Caffeine capsules when there was no proper therapeutic indication for those prescriptions for body building;
   4. failed to make any or any adequate clinical notes in relation to his consultations and treatment of patients who consulted him for obesity or consulted him seeking weight loss, physical conditioning and/or body building and/or patients for whom he prescribed anabolic androgenic steroids and/or Clenbuterol, Ephedrine and/or Ephedrine, Aspirin and Caffeine capsules;
   5. prescribed for patients Human Growth hormone when there was no proper therapeutic indication for such prescribing and when such prescribing unnecessarily put patients at risk of the adverse effects of Human Growth Hormone;
   6. prescribed for patients:

when there was no recognised therapeutic indication for that prescribing when such prescribing unnecessarily put patients at risk of the adverse effects of those drugs;

1. ordered the infusion of iron for patients who did not suffer from iron deficiency;
2. ordered the infusion of iron for patients when the infusion of iron was contra-indicated because the patients suffered from haemochromatosis or beta­thalaessaemia trait;
3. engaged in the general practice (that is on multiple occasions) of inappropriate prescribing of Erythropoietin for patients when there was no recognised therapeutic indication for the prescription of that drug;
4. ordered Fresh Frozen Plasma infusions for patients when there was no recognised therapeutic indication for such infusions in those patients;
5. engaged in the general practice of ordering excessive DEXA scans when there was no recognised therapeutic indication for the performance of any such scan or alternatively for multiple such scans of those patients; and/or
6. prescribed Clomid when the prescription of that substance in Western Australia contravened reg 38C of the Poisons Regulations 1965 (WA) made pursuant to the Poisons Act 1964 (WA).

1. The Tribunal finds that in relation to Patient J, disciplinary matters exist for the purpose of s 76(1)(b) of the Medical Practitioners Act 2008 (WA) in that Dr Anish Dwarka Singh acted carelessly, incompetently and/or improperly for the purposes of s 76(1)(b)(i), (ii) and/or (iii) in the course of his practice as a medical practitioner in that in or about December 2009 Dr Anish Dwarka Singh:
   1. failed to make any or any adequate clinical notes in relation to attendances upon him by Patient J;
   2. did not diagnose Patient J with body dysmorphic syndrome with binge eating disorder overlap, as he claimed to have done in his letter to the Medical Board of Australia on 8 April 2010;
   3. prescribed Mesterolone, Oxandrolone and Primoteston for Patient J when there was no therapeutic indication for those drugs and when such prescribing unnecessarily put Patient J at risk of the adverse effects of those drugs;
   4. failed to take any or any adequate steps to ensure appropriate monitoring of Patient J in order to detect any adverse effects suffered by Patient J as a result of Patient J taking androgens;
   5. prescribed Clenbuterol for Patient J when there was no medical indication or necessity for the prescription of Clenbuterol;
   6. failed to take any, or any adequate steps to ensure appropriate monitoring of Patient J in order to detect any adverse effects suffered by Patient J as a result of Patient J taking Clenbuterol; and
   7. prescribed Clomid for Patient J when the prescription of that substance in Western Australia contravened reg 38C of the Poisons Regulations 1965 (WA) made pursuant to the Poisons Act 1964 (WA).

1. The Tribunal finds in relation to Patient B that between early 2008 and 17 October 2010, Dr Anish Dwarka Singh behaved in a way that constitutes professional misconduct for the purpose of s 193(1)(a)(i) of the _Health Practitioner Regulation National Law (WA) Act 201_0 in that Dr Anish Dwarka Singh:
   1. failed to make any adequate clinical notes in relation to attendances upon him by Patient B;
   2. failed to consider, investigate or advise Patient B in relation to differential diagnoses which may have accounted for Patient B's hypertension;
   3. prescribed Tamoxifen for Patient B when there was no medical indication for the prescription of Tamoxifen;
   4. prescribed testosterone for Patient B when there was no medical indication for the prescription of testosterone;
   5. prescribed Human Growth Hormone for Patient B when there was no medical indication for the prescription of Human Growth Hormone;
   6. failed to take any or any adequate steps to ensure appropriate monitoring of Patient B.
   7. prescribed Clomid for Patient B when the prescription of that substance in Western Australia contravened reg 38C of the Poisons Regulations 1965 (WA) made pursuant to the Poisons Act 1964 (WA); and/or;
   8. sent a letter to the notifier, a medical practitioner, on or about 14 July 2012 which was:

1. Based on the findings above, the Tribunal orders:
   1. The Medical Board of Australia to file and serve its written submissions on penalty and costs by 9 March 2017.
   2. Dr Anish Dwarka Singh to file and serve his written submissions on penalty and costs by 23 March 2017.
   3. Subject to any further order of the Tribunal, the question of penalty and costs is to be dealt with entirely on the documents.

I certify that this and the preceding [451] paragraphs comprise the reasons for decision of the State Administrative Tribunal.

___________________________________

ACT : HEALTH PRACTITIONER REGULATION NATIONAL LAW (WA) ACT 2010

CITATION : MEDICAL BOARD OF AUSTRALIA and SINGH [2017] WASAT 33 (S)

Disciplinary matters under Medical Practitioners Act 2008 (WA) - Professional misconduct - National Law - Inappropriate prescribing of range of drugs and other treatments - No proper therapeutic basis - Dishonesty - Incompetence - Global penalty applied - Disqualification

Health Practitioner Regulation National Law (WA) Act 2010, s 3, s 4, s 17(2)(b), s 196, s 196(4)

Medical Practitioners Act 2008 (WA), s 3, s 76, s 76(1)(b), s 116

Poisons Act 1964 (WA)

State Administrative Tribunal Act 2004 (WA), s 87(1), s 87(2)

Practitioner disqualified from applying for re­registration as a registered health practitioner for period of 10 years

Practitioner pay Medical Board of Australia's costs and disbursements

These reasons for decision determined the appropriate penalty for a medical practitioner whose conduct constituted acting incompetently, carelessly and/or improperly for the purposes of the Medical Practitioners Act 2008 (WA) and who behaved in a way which constituted professional misconduct for the purposes of the Health Practitioner Regulation National Law (WA) Act 2010.

The Tribunal's findings that disciplinary matters existed in Medical Board and Singh [2017] WASAT 33 related to the practitioner's misconduct in respect of his specialist medical practice involving inappropriate prescribing of drugs including anabolic steroids, human growth hormone and stimulants, the inappropriate infusion of iron and fresh frozen plasma, the ordering of unnecessary DEXA scans and the prescribing of Clomid in contravention of the Poisons Act 1964 (WA) (repealed); inadequate record keeping; in relation to two patients, Patient J and Patient B; and towards the notifying medical practitioner in relation to Patient B.

The practitioner's misconduct was serious. The prescription of drugs when there was no proper therapeutic basis is a serious matter. This is all the more so because in a number of the instances identified by the Tribunal, it exposed the practitioner's patients to the risk of side effects from those drugs.

Further, the practitioner's failure to take adequate notes was a fundamental failing in his obligations to his patients and professional colleagues.

The practitioner's misconduct occurred over a long period of time and involved multiple prescriptions. The Tribunal therefore imposed a global penalty having regard to the practitioner's overall misconduct rather than isolating certain incidents and imposing separate penalties.

The practitioner is no longer a registered medical practitioner so no order was required to cancel his registration. The Tribunal determined that the practitioner be disqualified from applying for registration as a medical practitioner for a period of 10 years and that he pay the Medical Board of Australia's costs and disbursements

In addition, in a separate category to the practitioner's other misconduct, the Tribunal imposed a fine of $5,000 as a penalty in relation to the practitioner's letter of abuse to the notifying medical practitioner as a discouragement to others who might be tempted to engage in such misconduct.

A Solicitor v Council of the Law Society of NSW [2004] HCA l; [2004] HCA 1; (2004) 216 CLR 253

Barristers' Board v Darveniza [2000] QCA 253; (2000) 112 A Crim R 438

Barwick v Council of the Law Society of NSW [2004] NSWCA 32

Chamberlain v Law Society of the Australian Capital Territory [1993] FCA 527; (1993) 118 ALR 54

Council of the Law Society (NSW) v A Solicitor [2002] NSWCA 62

Craig v Medical Board of South Australia [2001] SASC 169; (2001) 79 SASR 545

Dental Board of Australia and Dhillon [2017] WASAT 20

Law Society of New South Wales v Foreman (1994) 34 NSWLR 408

Law Society of New South Wales v Walsh [1997] NSWCA 185

Legal Practitioners Complaints Committee v Thorpe [2008] WASC 9

Legal Profession Complaints Committee and A Legal Practitioner [2013] WASAT 37 (S)

Legal Profession Complaints Committee and Amsden [2014] WASAT 57 (S)

Legal Profession Complaints Committee and in de Braekt [2013] WASAT 124

Legal Profession Complaints Committee and Leask [2010] WASAT 133

Legal Profession Complaints Committee v Brickhill [2013] WASC 369

Legal Profession Complaints Committee v Detata [2012] WASCA 2014

Legal Profession Complaints Committee v Lashansky [2007] WASC 211

Legal Profession Complaints Committee v Love [2014] WASC 389

Legal Profession Complaints Committee v Masten [2011] WASC 71

Legal Profession Complaints Committee v O'Halloran [2013] WASC 430

Legal Profession Complaints Committee v Segler [2014] WASC 159

Medical Board and Singh [2017] WASAT 33

Medical Board of Australia and Myers [2014] WASAT 137 (S)

Medical Board of Western Australia and Roberman [2005] WASAT 81 (S)

New South Wales Bar Association v Cummins [2001] NSWCA 284; (2001) 52 NSWLR 279

New South Wales Bar Association v Evatt [1968] HCA 20; (1968) 117 CLR 177

Paridis v Settlement Agents Supervisory Board [2007] WASCA 97; (2007) 33 WAR 361

Quinn v Law Institute of Victoria [2007] VSCA 122

Re A Practitioner (1984) 36 SASR 590

Re Maraj (a Legal Practitioner) (1995) 15 WAR 12

Smith v New South Wales Bar Association [1992] HCA 36; (1992) 176 CLR 256

Stirling v Legal Services Commissioner [2013] VSCA 374

The Council of the Qld Law Society v Wright [2001] QCA 58

Veterinary Practitioners Board of NSW v Johnson [2010] NSWADT 308

Veterinary Surgeons Investigating Committee v Howe (No 2) [2003] NSWADT 159

Western Australian Planning Commission v Questdale Holdings Pty Ltd [2016] WASCA 32

1 In Medical Board and Singh [2017] WASAT 33 (Singh), the Tribunal found that disciplinary matters existed under s 76 of the Medical Practitioners Act 2008 (WA) (repealed) (the Medical Practitioners Act) in that Dr Anish Dwarka Singh acted incompetently, carelessly and/or improperly for the purposes of s 76(1)(b)(i), (ii) and/or (iii), and that Dr Singh behaved in a way which constituted professional misconduct for the purposes of s 196(1)(a)(i) of the Health Practitioner Regulation National Law (WA) Act 2010 (National Law), (Schedule) (Singh at [449]­[451]).

2 The Tribunal's findings related to Dr Singh's misconduct:

1. in respect of his general practice involving inappropriate prescribing of drugs including anabolic steroids, human growth hormone (HGH) and stimulants, the inappropriate infusion of iron and fresh frozen plasma, the ordering of unnecessary DEXA scans and the prescribing of Clomid in contravention of the Poisons Act 1964 (WA) (repealed);
2. inadequate record keeping;

1. in relation to two patients, Patient J and Patient B; and

1. towards the notifying medical practitioner in relation to Patient B.

3 The Tribunal findings in relation to Dr Singh's specialist medical practice of medicine were made pursuant to the both the Medical Practitioners Act and the National Law. To the extent that the findings were made pursuant to the Medical Practitioners Act, a penalty may be imposed pursuant to the Medical Practitioners Act by virtue of s 17(2)(b) of the National Law, and to the extent that the findings were made pursuant to the National Law, the Tribunal may make an order pursuant to s 196 of the National Law, (Schedule).

4 The Tribunal's findings in relation to Patient J were made pursuant to the Medical Practitioners Act. The question of penalty in relation to Patient J will be dealt with in accordance with the Medical Practitioners Act by reason of s 17(2)(b) of the National Law.

5 The Tribunal findings in relation to Patient B and the notifying practitioner were made pursuant to the National Law, and in respect of those findings the Tribunal may impose a penalty pursuant to s 196 National Law, (Schedule).

6 On 23 February 2017, the Tribunal made the following order for the filing of submissions on penalty and costs:

1. The Medical Board of Australia to file and serve its written submissions on penalty and costs by 9 March 2017.
2. Dr Anish Dwarka Singh to file and serve his written submissions on penalty and costs by 23 March 2017.
3. Subject to any further order of the Tribunal, the question of penalty and costs is to be dealt with entirely on the documents.

7 On 9 March 2017, the Board emailed the Tribunal seeking a seven day extension on its written submissions which was granted. The Board filed its submissions on 15 March 2017.

8 Dr Singh failed to file his submissions by 23 March 2017. On 28 March 2017, Dr Singh wrote to the Tribunal seeking a two week extension on the basis that he had 'recently found rental accommodation' and had been 'unable to complete [his] response by 23 March 2017'. The extension was granted.

9 On 27 April 2017, the Tribunal emailed Dr Singh stating that his submissions had not been received. On 27 April 2017, Dr Singh emailed the Tribunal stating that he had been unwell and was under the care of Drs Alistar Vickery and Mark McAndrew and that he was not fit to comply with the timelines for the submissions. He requested a further six to eight weeks to complete them.

10 On 3 May 2017, the Tribunal received confirmation from Dr Chacko Varughese that Dr Singh was now under his care for depression and he had been admitted to hospital.

11 On 3 May 2017, the Tribunal emailed the Board advising them of Dr Singh's medical condition and seeking its consent to an extension of time. On 12 May 2017, the Board agreed to the extension.

12 On 17 May 2017, Dr Singh emailed the Tribunal stating that he was out of hospital and asking when his submissions were due. The Tribunal emailed Dr Singh the same day allowing him until 9 June 2017 to submit his submissions.

13 Dr Singh has still failed to file any submissions.

14 In the absence of any submissions from Dr Singh, the Tribunal has determined that it should now make orders for penalty and costs and hand down its reasons.

15 The Tribunal thanks the Board for its detailed submissions. The Tribunal has largely adopted those submissions in its reasons.

16 In Singh, the Tribunal made the following findings on the practitioner's misconduct:

1. The Tribunal finds that disciplinary matters exist for the purpose of s 76(1)(b) of the Medical Practitioners Act 2008 (WA) in that between early 2008 and 17 October 2010 Dr Anish Dwarka Singh acted carelessly, incompetently and/or improperly for the purposes of s 76(1)(b)(i), (ii) and/or (iii), and that from 18 October 2010 Dr Anish Dwarka Singh behaved in a way that constitutes professional misconduct for the purpose of s 193(1)(a)(i) of the Health Practitioner Regulation National Law (WA) Act 2010, in that Dr Anish Dwarka Singh:
   1. prescribed for patients anabolic androgenic steroids when there was no proper therapeutic indication for those prescriptions and when such prescribing unnecessarily put patients at risk of the adverse effects of those drugs;
   2. prescribed for patients Clenbuterol when there was no proper therapeutic indication for those prescriptions and when such prescribing unnecessarily put patients at risk of the adverse effects of Clenbuterol;
   3. prescribed for patients Ephedrine and Ephedrine, Aspirin and Caffeine capsules when there was no proper therapeutic indication for those prescriptions for body building;
   4. failed to make any or any adequate clinical notes in relation to his consultations and treatment of patients who consulted him for obesity or consulted him seeking weight loss, physical conditioning and/or body building and/or patients for whom he prescribed anabolic androgenic steroids and/or Clenbuterol, Ephedrine and/or Ephedrine, Aspirin and Caffeine capsules;
   5. prescribed for patients Human Growth hormone when there was no proper therapeutic indication for such prescribing and when such prescribing unnecessarily put patients at risk of the adverse effects of Human Growth Hormone;
   6. prescribed for patients:

when there was no recognised therapeutic indication for that prescribing when such prescribing unnecessarily put patients at risk of the adverse effects of those drugs;

1. ordered the infusion of iron for patients who did not suffer from iron deficiency;
2. ordered the infusion of iron for patients when the infusion of iron was contra-indicated because the patients suffered from haemochromatosis or beta thalaessaemia trait;
3. engaged in the general practice (that is on multiple occasions) of inappropriate prescribing of Erythropoietin for patients when there was no recognised therapeutic indication for the prescription of that drug;
4. ordered Fresh Frozen Plasma infusions for patients when there was no recognised therapeutic indication for such infusions in those patients;
5. engaged in the general practice of ordering excessive DEXA scans when there was no recognised therapeutic indication for the performance of any such scan or alternatively for multiple such scans of those patients; and/or
6. prescribed Clomid when the prescription of that substance in Western Australia contravened reg 38C of the Poisons Regulations 1965 (WA) made pursuant to the Poisons Act 1964 (WA).

1. The Tribunal finds that in relation to Patient J, disciplinary matters exist for the purpose of s 76(1)(b) of the Medical Practitioners Act 2008 (WA) in that Dr Anish Dwarka Singh acted carelessly, incompetently and/or improperly for the purposes of s 76(1)(b)(i), (ii) and/or (iii) in the course of his practice as a medical practitioner in that in or about December 2009 Dr Anish Dwarka Singh:
   1. failed to make any or any adequate clinical notes in relation to attendances upon him by Patient J;
   2. did not diagnose Patient J with body dysmorphic syndrome with binge eating disorder overlap, as he claimed to have done in his letter to the Medical Board of Australia on 8 April 2010;
   3. prescribed Mesterolone, Oxandrolone and Primoteston for Patient J when there was no therapeutic indication for those drugs and when such prescribing unnecessarily put Patient J at risk of the adverse effects of those drugs;
   4. failed to take any or any adequate steps to ensure appropriate monitoring of Patient J in order to detect any adverse effects suffered by Patient J as a result of Patient J taking androgens;
   5. prescribed Clenbuterol for Patient J when there was no medical indication or necessity for the prescription of Clenbuterol;
   6. failed to take any, or any adequate steps to ensure appropriate monitoring of Patient J in order to detect any adverse effects suffered by Patient J as a result of Patient J taking Clenbuterol; and
   7. prescribed Clomid for Patient J when the prescription of that substance in Western Australia contravened reg 38C of the Poisons Regulations 1965 (WA) made pursuant to the Poisons Act 1964 (WA).

1. The Tribunal finds in relation to Patient B that between early 2008 and 17 October 2010, Dr Anish Dwarka Singh behaved in a way that constitutes professional misconduct for the purpose of s 193(1)(a)(i) of the Health Practitioner Regulation National Law (WA) Act 2010 in that Dr Anish Dwarka Singh:
   1. failed to make any adequate clinical notes in relation to attendances upon him by Patient B;
   2. failed to consider, investigate or advise Patient B in relation to differential diagnoses which may have accounted for Patient B's hypertension;
   3. prescribed Tamoxifen for Patient B when there was no medical indication for the prescription of Tamoxifen;
   4. prescribed testosterone for Patient B when there was no medical indication for the prescription of testosterone;
   5. prescribed Human Growth Hormone for Patient B when there was no medical indication for the prescription of Human Growth Hormone;
   6. failed to take any or any adequate steps to ensure appropriate monitoring of Patient B.
   7. prescribed Clomid for Patient B when the prescription of that substance in Western Australia contravened reg 38C of the Poisons Regulations 1965 (WA) made pursuant to the Poisons Act 1964 (WA); and/or;
   8. sent a letter to the notifier, a medical practitioner, on or about 14 July 2012 which was:

The Board's submissions as to appropriate penalty and costs orders

17 In its submissions filed on 15 March 2017, the Medical Board of Australia (Board) sought the following orders:

1. Pursuant to s 196(2)(c) of the Health Practitioner Regulation National Law (WA) Act 2010, Dr Anish Dwarka Singh is fined in the sum of $30,000;
2. Pursuant to s 196(4)(a) of the Health Practitioner Regulation National Law (WA) Act 2010, Dr Anish Dwarka Singh is disqualified from applying for re-registration as a registered health practitioner for a period of 10 years;
3. Pursuant to s 116(1)(c) of the Medical Practitioners Act 2008 and s 196(2)(a) Health Practitioner Regulation National Law (WA) Act 2010, Dr Anish Dwarka Singh be reprimanded; and
4. Dr Anish Dwarka Singh is to pay the Medical Board of Australia's costs and disbursements of the proceedings at the scale that would apply if the proceedings had been in the Supreme Court of Western Australia.

The Medical Practitioners Act

18 Section 3 of the Medical Practitioners Act sets out the objects of the Act as follows:

(a) to ensure that only properly qualified and competent persons practise medicine and to regulate the practice of medicine by those persons; and

(b) to establish, maintain and promote suitable standards of knowledge and skills among medical practitioners,

for the purpose of protecting consumers of medical services provided by medical practitioners in Western Australia.

19 In respect of each finding that disciplinary matters exist for the purpose of s 76(1)(b) of the Medical Practitioners Act, the Tribunal is empowered pursuant to s 116 of the Medical Practitioners Act to:

1. make no order,
2. order that there be an amendment to the register pursuant to which the practitioner is registered as a health practitioner;
3. caution or reprimand the practitioner;
4. require the practitioner to refund monies to the patient in relation to the services provided or to compensate the patient for the costs of services provided by another medical practitioner;
5. order the practitioner to undergo counselling;
6. order the practitioner to comply with such conditions as the Tribunal may impose on the registration of the practitioner;
7. order the practitioner to report at intervals in relation to his medical practice to a medical practitioner nominated by the applicant Board;
8. order the practitioner to obtain advice on the management of his medical practice;
9. order the practitioner to pay a penalty not exceeding $25,000;
10. order that the practitioner be suspended from practice for such period as the Tribunal may consider appropriate not exceeding two years; and/or
11. order that the medical practitioner's registration be cancelled and his name removed from the register.

20 Section 3 of the National Law sets out the objectives and guiding principles. Relevantly they are s 3(l)(a) and s 3(2)(a):

The object of this Law is to establish a national registration and accreditation scheme for ­

the regulation of health practitioners; [and]

The objectives of the national registration and accreditation scheme are ­

to provide for the protection of the public by ensuring that only health practitioners who are suitably trained and qualified to practise in a competent and ethical manner are registered[.]

21 Section 4 of the National Law provides:

An entity that has functions under this Law is to exercise its functions having regard to the objectives and guiding principles of the national registration and accreditation scheme set out in section 3.

22 Section 196 of the National Law provides that if a responsible tribunal, which for present purposes is this Tribunal, finds that a practitioner has behaved in a way that constitutes professional misconduct, it may decide to do one or more of the following:

...

(2) If a responsible tribunal makes a decision referred to in subsection (l)(b), the tribunal may decide to do one or more of the following -

(b) impose a condition on the practitioner's registration, including, for example -

(i) a condition requiring the practitioner to complete specified further education or training, or to undergo counselling, within a specified period; or

(ii) a condition requiring the practitioner to undertake a specified period of supervised practice; or

(iii) a condition requiring the practitioner to do, or refrain from doing, something in connection with the practitioner's practice; or

(iv) a condition requiring the practitioner to manage the practitioner's practice in a specified way; or

(v) a condition requiring the practitioner to report to a specified person at specified times about the practitioner's practice; or

(vi) a condition requiring the practitioner not to employ, engage or recommend a specified person, or class of persons;

(c) require the practitioner to pay a fine of not more than $30 000 to the National Board that registers the practitioner;

(d) suspend the practitioner's registration for a specified period;

(3) If the responsible tribunal decides to impose a condition on the practitioner's registration, the tribunal must also decide a review period for the condition.

(4) If the tribunal decides to cancel a person's registration under this Law or the person does not hold registration under this Law, the tribunal may also decide to -

(a) disqualify the person from applying for registration as a registered health practitioner for a specified period; or

(b) prohibit the person from using a specified title or providing a specified health service.

23 The Tribunal repeats what it stated in Medical Board of Australia and Myers [2014] WASAT 137 (S). The jurisdiction of the Tribunal is protective rather than punitive, and such protection runs to both the public and the profession (Craig v Medical Board of South Australia [2001] SASC 169; (2001) 79 SASR 545 at [41] (Craig); Re Maraj (a Legal Practitioner) (1995) 15 WAR 12 at 25; Legal Profession Complaints Committee v Love [2014] WASC 389 (Love) at [19]; Law Society of New South Wales v Foreman (1994) 34 NSWLR 408 (Foreman) at 440G­441A-B; Legal Profession Complaints Committee and in de Braekt [2013] WASAT 124 at [24]- [26]; New South Wales Bar Association v Hamman [1999] NSWCA 404 (Hamman) at [21] and [77]).

24 The appropriate sanction is to be considered at the time of the making of the sanction and not by reference to the date of the unprofessional acts (Legal Profession Complaints Committee and A Legal Practitioner [2013] WASAT 37 (S) (A Legal Practitioner (S)) at [23]; Legal Profession Complaints Committee v Segler [2014] WASC 159 at [7]; A Solicitor v Council of the Law Society of NSW [2004] HCA l; [2004] HCA 1; (2004) 216 CLR 253 (A Solicitor [2004] NSW) at [15]; Love at [16]).

25 It is the practitioner's conduct that attracts any sanction (A Legal Practitioner (S) at [24]; Smith v New South Wales Bar Association [1992] HCA 36; (1992) 176 CLR 256 at 267-268 and 271-272; A Solicitor [2004] NSW).

26 As the Tribunal explained in A Legal Practitioner (S) at [24]:

[I]n determining the appropriate penalty, care needs to be taken that the penalty reflects the matters with which the practitioner is charged and not other conduct including the defence of the action by the practitioner which is ultimately held to be unsuccessful: Smith v New South Wales Bar Association [1992] HCA 36; (1992) 176 CLR 256 (Smith) at 267-268 and 271-272[.]

27 Where there is a choice of sanctions, the Tribunal will choose that sanction which maximises the protection of the public (Quinn v Law Institute of Victoria [2007] VSCA 122 at [31]).

28 The dominant purpose of the disciplinary regulation of the medical profession is the protection of the public by the maintenance of proper standards within the profession. Hence, the impact which an appropriate penalty would have upon a practitioner guilty of misconduct, and personal hardship to a practitioner, are necessarily secondary considerations (see Legal Profession Complaints Committee v Detata [2012] WASCA 2014 at [47]; Legal Profession Complaints Committee v Masten [2011] WASC 71 at [29]; and Legal Profession Complaints Committee and Leask [2010] WASAT 133 at [54]).

29 There are circumstances in which a 'global' approach to sanction, rather than the imposition of separate sanction for each unprofessional act, may be more appropriate in vocational disciplinary proceedings namely, where the facts of the case are so inextricably woven as to make it difficult to meet a clear standard of prescription (A Legal Practitioner (S) at [5]; Stirling v Legal Services Commissioner [2013] VSCA 374 (Stirling) at [72]­[75]).

30 In determining an appropriate sanction, twelve matters may require consideration. Those matters are interrelated and are not mutually exclusive. The list of matters is not exhaustive. The twelve matters are:

1. Any need to protect the public against further misconduct by the practitioner (Legal Profession Complaints Committee and Amsden [2014] WASAT 57 (S) (Amsden (S)) at [8]; Foreman at 440C; Hamman at [77]).
2. The need to protect the public through general deterrence of other practitioners from similar conduct (Veterinary Practitioners Board of NSW v Johnson [2010] NSWADT 308 (Johnson) at [103]; Hamman at [77]).
3. The need to protect the public and maintain public confidence in the profession by reinforcing high professional standards and denouncing transgressions and thereby articulating the high standards expected of the profession (Amsden (S)) at [8]; Foreman at 444F; and Hamman at [77] and at [79]), such that, even where there may be no need to deter a practitioner from repeating the conduct, the conduct is of such a nature that the Tribunal should give an emphatic indication of its disapproval (Craig at [64]; Johnson at [103]).
4. In the case of conduct involving misleading conduct, including dishonesty, whether the public and fellow practitioners can place reliance on the word of the practitioner (Johnson at [109]; Foreman at 445B­445G).
5. Whether the practitioner has breached any:

1. Guidelines or Code of Conduct, issued by the relevant professional body; and

1. whether the practitioner has done so knowingly.
2. Whether the practitioner's conduct demonstrated incompetence, and if so, to what level.
3. Whether or not the incident was isolated such that the Tribunal can be satisfied of his or her worthiness or reliability for the future (Foreman at 442E-442G; New South Wales Bar Association v Evatt [1968] HCA 20; (1968) 117 CLR 177 at 183; Council of the Law Society (NSW) v A Solicitor [2002] NSWCA 62 at [80]; Chamberlain v Law Society of the Australian Capital Territory [1993] FCA 527; (1993) 118 ALR 54 at 62 and 63).
4. The practitioner's disciplinary history (Legal Profession Complaints Committee v O'Halloran [2013] WASC 430 at [93]).
5. Whether or not the practitioner understands the error of his ways, including an assessment of any remorse and insight (or a lack thereof) shown by the practitioner, since a practitioner who fails to understand the significance and consequences of misconduct is a risk to the community (Law Society of New South Wales v Walsh [1997] NSWCA 185 per Beazley JJA (Walsh); Legal Profession Complaints Committee v Lashansky [2007] WASC 211 at [31]- [52] and (second) at [35]; Amsden (S) at [8]; Foreman at 444E; Love at [9]).
6. The desirability of making available to the public any special skills possessed by the practitioner.
7. The practitioner's personal circumstances at the time of the conduct and at the time of imposing the sanction. However, the weight given to personal circumstances cannot override the fundamental obligation of the Tribunal to provide appropriate protection of the public interest in the honesty and integrity of legal practitioners and in the maintenance of proper standards of legal practice (Love at [59]); Paridis v Settlement Agents Supervisory Board [2007] WASCA 97; (2007) 33 WAR 361 at [30(5)]).
8. The Tribunal may consider any other matters relevant to the practitioner's fitness to practise and other matters which may be regarded as aggravating the conduct or mitigating its seriousness (A Legal Practitioner (S) at [25]). In general, mitigating factors such as no previous misconduct or service to the profession are of considerably less significance than in the criminal process because the jurisdiction is protective not punitive (Walsh).

31 The jurisdiction of the Tribunal to cancel a practitioner's registration is exercised not for the purpose of punishing the practitioner concerned, but for the protection of the public and the reputation and standards of the medical profession: Legal Practitioners Complaints Committee v Thorpe [2008] WASC 9 at [43].

32 Where an order for cancellation of a practitioner's registration is contemplated, the ultimate question is whether the material demonstrates that the practitioner is not a fit and proper person to remain a medical practitioner: A Solicitor [2004] NSW at [15].

33 A practitioner is not a fit and proper person to be a registered practitioner and should be removed from the register where the unprofessional conduct is so serious that the practitioner is permanently or indefinitely unfit to practise (Veterinary Surgeons Investigating Committee v Howe (No 2) [2003] NSWADT 159 at [27]; Barristers' Board v Darveniza [2000] QCA 253; (2000) 112 A Crim R 438 at [38]; Love at [17]-[18]; A Legal Practitioner (S) at [21]-[25]; Legal Profession Complaints Committee v Brickhill [2013] WASC 369 at [19]- [20] (Thomas JA, McMurdo P and White J agreeing); New South Wales Bar Association v Cummins [2001] NSWCA 284; (2001) 52 NSWLR 279 at [26]- [28]); Love at [17]­[18]).

34 The practical effect of a cancellation is that the onus is on the practitioner to establish that he is a fit and proper person should he seek to resume practice.

35 Suspension is a less serious result and differs from cancellation of a practitioner's registration because suspension is for a specified limited period.

36 The proper use of suspension is in cases where the practitioner has fallen below the high standards to be expected of such a practitioner, but not in such a way as to indicate that he/she lacks the qualities of character which are the necessary attributes of a person entrusted with the responsibilities of a practitioner (A Legal Practitioner (S) at [26]; Re A Practitioner (1984) 36 SASR 590 at 593 per King CJ). That is, suspension is suitable where the Tribunal is satisfied that, upon completion of the period of suspension, the practitioner will be fit to resume practice (A Legal Practitioner (S) at [27]).

37 The practical effect of a suspension is that the practitioner can resume practice without the need to establish that he is a fit and proper person.

38 Dr Singh's misconduct was serious. The inappropriate prescription of drugs when there was no proper therapeutic basis is a serious matter. This is all the more so because in a number of the instances identified above, it exposed Dr Singh's patients to the risk of side effects.

39 The range of drugs and treatments prescribed without a proper therapeutic basis and the combinations of drugs to a large number of patients shows that Dr Singh's conduct was not isolated, is further discussed below.

40 Dr Singh's failure to take adequate notes is a fundamental failing in his obligations to his patients. Dr Singh's failure to take adequate notes was extensive.

41 Dr Singh's misconduct in relation to Patients J and B are particular examples of his broader failings.

Factor 1 Is there a need to protect the public against further misconduct by Dr Singh?

1. Anabolic steroids and HGH are well recognised by medical practitioners to be sought after by particular groups of patients including bodybuilders, models and patients who wish to increase their muscle bulk and gain a leaner appearance for sporting, aesthetic and vocational purposes. The circumstances which drive demand for such drugs vary from patient to patient, but all such patients are vulnerable in that they are seeking drugs which can give rise to serious health risks. The evidence of Professors Wittert and Joyce as to adverse effects of the relevant drugs is set out in Singh at [118]-[121]. Among the most serious health risks are adverse psychiatric effects manifesting as aggression, uncontrolled anger and rage, serious adverse effects involving the kidneys and the liver and serious cardiovascular effects including changes to cardiac muscle. For some patients that vulnerability is likely to be complicated by psychiatric illness. Professor Wittert identified one such group as patients suffering from body dysmorphia, who are driven by their illness to abuse anabolic steroids.
2. All patients seeking anabolic steroids, stimulants and/or HGH require counselling as to the dangers associated with the use of those drugs. Meeting the demands of such patients for such drugs unnecessarily puts the patients at risk of serious adverse effects and deprives them of proper management of underlying social or psychiatric issues. Such conduct is antithetical to the proper practice of medicine, and poses a serious risk to public safety.
3. Dr Singh's conduct was particularly serious having regard to the quantities of anabolic steroids and other drugs he prescribed and the significant periods of time over which the misconduct occurred, both in total and in respect of individual patients. Dr Singh's misconduct is among the worst of its kind to have been aired in any of the responsible tribunals under the National Law.
4. Dr Singh was at the material time a registered specialist, from whom the public and referring practitioners were entitled to expect a high standard of medical care. Dr Singh's prescribing of anabolic steroids and his engagement in inappropriate and idiosyncratic prescribing of other drugs was conduct substantially below the standard of practice expected of a specialist physician[.]

43 The Tribunal broadly accepts the Board's submissions.

44 Dr Singh's misconduct occurred on repeated occasions and over a long period of time. The number of instances of inappropriate prescribing and failure to take notes and the prolonged period over which it occurred led the Tribunal to conclude that there is a very substantial risk of Dr Singh engaging in such conduct again. The penalty must prevent such further misconduct.

Factor 2 Is there a need to protect the public through general deterrence of other practitioners?

1. The ready market for these drugs and the financial benefit to a practitioner in prescribing them (evidenced by the number of patients who received the relevant prescriptions and the large consultation fees that the respondent was able to charge his patients), together with the potential for significant short-term and long-term harm as a result of their use, make it vital that penalties for inappropriately prescribing anabolic steroids and associated drugs are sufficiently severe to deter medical practitioners from engaging in such conduct.
2. The Board contended that it is necessary in the public interest for the penalty imposed to constitute a significant financial disincentive to engage in such conduct[.]

46 The Tribunal accepts the Board's submissions. Money is often a powerful incentive for the inappropriate prescribing of drugs.

47 The penalty must be sufficient to deter other practitioners from engaging in similar misconduct.

Factor 3 Is there a need to protect the public by reinforcing high professional standards and denouncing transgressions?

1. Dr Singh's conduct was inconsistent with the high professional standards expected of medical practitioners. The penalty required must be of sufficient severity to reassure the public that other medical practitioners will be deterred from such conduct so that high professional standards are promoted in respect of the profession[.]

49 The Tribunal accepts the Board's submissions. Public confidence in the ability and integrity of medical practitioners is essential. Misconduct such as Dr Singh's undermines the public's confidence in the profession.

1. This factor is relevant where a practitioner's conduct is such that the public and fellow practitioners cannot place reliance on the word of the practitioner; Legal Profession Complaints Committee and Wells [2014] WASAT 112 at [5] and [20] and the cases referred to therein; Dhillon (supra) at [33] ­ [40].
2. Honesty is a critical quality required in the character of a medical practitioner; McBride v Walton (NSWCA), 15 July 1994, unreported, BC9402907, per Handley JA at 86; Dhillon (supra) at [38] ­ [40].
3. The Tribunal made an express finding that much of Dr Singh's evidence was deliberately untrue; Singh at [96].
4. Dr Singh did not make any admissions prior to the commencement of the hearing. It was only during the hearing that Dr Singh conceded for the first time that he prescribed steroids to more than 20 patients for the purpose of bodybuilding; Singh at [91] to [93].
5. An example of Dr Singh's dishonesty in relation to the basis of his prescribing is found in relation to Patient 71. Dr Singh advised the Australian Health Practitioner Regulation Agency (AHPRA) in a letter dated 20 July 2012 that Patient 71 consulted him for obesity. When Dr Singh was asked questions about photographs of Patient 71 during cross-examination, he eventually conceded that he was providing Patient 71 with steroids and other drugs for body building purposes and not for any conventional therapy. Until that concession was made, Dr Singh had dishonestly represented to AHPRA and to the Tribunal in these proceedings that he prescribed steroids to Patient 71 for the treatment of obesity, and that he did not provide steroids to body builders.
6. A further example of Dr Singh's dishonesty arises in relation to his qualifications, which were misrepresented in his witness statement filed in these proceedings and in correspondence to the solicitor Mr Massey; Singh at [94].
7. The Tribunal found that Dr Singh's 'explanations as to why he prescribed drugs to various patients are explained in his evidence in medical terms and with medical justifications, but that the objective evidence does not support those explanations and paints a very different picture'; Singh at [89]. The scientific rationales advanced by Dr Singh during the hearing, many of which the Tribunal has found to be deliberately untrue, were largely the same rationales that he advanced to his patients and colleagues[.]

51 The factor of dishonesty relates to the nature of the conduct rather than the conduct of the proceedings. Paragraphs 30 to 34 of the Board's submissions relate to the latter. However, it is clear that Dr Singh's conduct was dishonest in that his misconduct involved cloaking prescriptions with the veil of a proper therapeutic basis when in fact there was no proper therapeutic basis. His conduct was plainly dishonest. The Tribunal agrees with paragraphs 28 and 29 of the Board's submissions.

Factor 5 Breach of an Act, Regulations, Guidelines or Code of Conduct

1. The Tribunal has found that Dr Singh's prescriptions of Clomid were given contrary to reg 38C of the Poisons Regulations 1965 (WA) made pursuant to the Poisons Act 1964 (WA) (repealed); Singh at [186].
2. Dr Singh's failure to make any or any adequate clinical notes was contrary to the Good Medical Practice: A Code of Construct for Doctors Australia (Code of Conduct). The Tribunal has found that Dr Singh's clinical notes were totally inadequate; Singh at [333]. There can be no doubt that Dr Singh was aware of his duty to make adequate clinical notes.
3. Dr Singh's other breaches of the Code of Conduct included failing to provide treatment options based on the best available information, failing to recognise and work within the limits of his competence and scope of practice and failing to consider the balance of benefit and harm in all clinical-management decisions[.]

1. The Tribunal has found that the responded acted carelessly, incompetently and/or improperly in relation to numerous aspects of his practice of medicine.
2. In his evidence Dr Singh gave convoluted and purportedly scientific explanations for his mode of prescribing. The Tribunal accepted evidence from Professor Wittert that Dr Singh's approach to pharmacology was 'bizarre' and 'not founded on any principle of science or evidence that I am aware of but just stringing snippets of information together to construct a story'; Singh at [206]. Dr Singh was at least to some extent found to have been disingenuous in giving both medical advice and evidence before the Tribunal to the effect that his prescribing was justified when he knew that his mode of prescribing was inappropriate and harmful to patients. His stated justifications also reveal incompetence[.]

1. The Tribunal found that Dr Singh had an extensive prescribing practice in relation to anabolic androgenic steroids (Singh at [145]), Clenbuterol (Singh at [163]), Ephedrine and/or EAC (Singh at [178]), Clomid (Singh at [185]), HGH (Singh at [211]) and ordering DEXA scans without proper therapeutic indication (Singh at [313]). Dr Singh's conduct did not arise from an isolated lapse of judgment. Dr Singh's general practice of medicine was affected by his misconduct[.]

57 The sheer magnitude of Dr Singh's prescription of drugs and other treatments as set out in Singh, is extremely worrying. There were some 740 patients (Singh at [323]). Dr Singh's misconduct commenced in early 2001 and continued until late 2015 ­ a very long period.

Factor 9 Whether or not Dr Singh understands the error of his ways, including an assessment of the any remorse and insight (or a lack thereof) shown by Dr Singh

1. Dr Singh has not demonstrated any regret, contrition or remorse with respect to the treatment that he provided to his patients.
2. During the hearing Dr Singh attempted to justify his conduct and maintained that the treatment provided to his patients the subject of these proceedings was appropriate. Dr Singh claimed at hearing that he had done no harm and that 'no-one had died on [him]' (Singh at [314]).
3. Even after having the advantage of considering the expert evidence filed in these proceedings, Dr Singh appeared not to understand or accept that the treatment he provided to Patient J or Patient B, or his general prescribing practices as outlined in these proceedings, had potentially serious consequences for his patients. Dr Singh's apparent persisting lack of insight into the potentially serious consequences of his conduct demonstrates that the public would be at ongoing risk if the respondent was able to continue to practise medicine.
4. Dr Singh's lack of insight is exemplified by his conduct in writing to the notifier, a fellow practitioner, in relation to Patient B as follows:

In summary, I believe you owe the patient an apology for violating doctor/patient confidentiality. I believe you have jeopardised his future career. I believe you have acted in an unnecessarily adversarial and combative manner. I believe you have made unfounded assumptions on my prescribing ability which really should have been a matter for doctor to doctor consultation. I believe you need to address and understand the concept of harm minimisation. I believe you need to go back and study your physiology and pharmacology. I believe you owe me an apology for your idiotic behaviour.

1. As the Tribunal found in Singh at [443], Dr Singh's letter was totally inappropriate, derogatory, lacking in professional courtesy and offensive, particularly having regard to the fact that the medical practitioner's concerns about the prescriptions given to Patient B by the respondent were correct[.]

61 The Tribunal's submissions in relation to dishonesty, as set out in paragraphs 30 to 34 in Factor 4 above, are also relevant to his conduct of the proceedings and whether Dr Singh has shown any insight or remorse.

62 As the Board correctly submitted, the practitioner's conduct of the defence and the veracity and candour of his or her testimony will often be the best evidence as to whether these mitigating circumstances are to be accepted: Barwick v Council of the Law Society of NSW [2004] NSWCA 32 at [108].

63 A practitioner's denial of the charges and the consequent need for the regulator to prosecute the charges to conclusion will deny the practitioner the mitigating benefit of immediate remorse and cooperation: The Council of the Qld Law Society v Wright [2001] QCA 58 at [43]- [46].

64 Dr Singh has failed to show any remorse or insight. The Tribunal cannot have any confidence that he would not engage in such misconduct again given the opportunity.

Factor 10 Are there any special skills possessed of Dr Singh?

65 There is no evidence that Dr Singh has special skills not otherwise available to the public in Western Australia.

1. In May 2015 Dr Singh ceased to be a Fellow of the Royal Australasian College of Physicians as a consequence of his failure to pay his fees.
2. On 6 November 2015 Dr Singh became aware that his registration had expired.
3. Dr Singh has not successfully renewed his registration, and has been not been registered as a medical practitioner since expiry[.]

67 Obviously, any restrictions on Dr Singh's ability to practise will have a significant effect on his income. However, as noted above, the principal purpose of disciplinary proceedings is the protection of the public. Dr Singh's loss of income is outweighed by the need to protect the public.

Factor 12 Are there any other matters related to Dr Singh's fitness to practise?

69 Part of Dr Singh's misconduct was in breach of the Medical Practitioners Act and part was in breach of the National Law. Dr Singh's misconduct was substantially identical under both Acts.

70 The relevant penalties under the Medical Practitioners Act are a reprimand or a fine. The Medical Practitioners Act did not empower the Tribunal to disqualify a practitioner from applying for registration for a period.

71 A global approach to penalty may be appropriate, rather than separate sanctions for each unprofessional act, where the facts of the case are so inextricably woven so as to make it difficult to meet a clear standard of prescription; A Legal Practitioner (S) at [5]; Stirling at [72]­[75]; Dental Board of Australia and Dhillon [2017] WASAT 20 (Dhillon) at [9]. A global penalty is also appropriate if the appropriate penalty for particular conduct would be subsumed by the appropriate penalty for more serious conduct; Dhillon at [9].

72 Factually, there is a clear connection between the facts. Although Patients J and B were the subject of particular complaints, Dr Singh's misconduct in relation to them were specific instances of Dr Singh's general practice.

73 Dr Singh's misconduct occurred over a long period of time and involved multiple prescriptions. It is appropriate to impose a global penalty having regard to Dr Singh's overall misconduct rather than isolating certain incidents and imposing separate penalties.

74 Dr Singh is no longer a registered medical practitioner so no order is required to cancel his registration.

75 Had Dr Singh not allowed his registration to lapse, there is no question that this Tribunal would have cancelled his registration. Dr Singh's misconduct was so serious that he is permanently or indefinitely unfit to practice.

76 The National Law came into effect in October 2010 in Western Australia. The majority of Dr Singh's offending occurred under the National Law. Dr Singh's previous offending under the Medical Practitioners Act may be taken into account in fixing a period of disqualification under the National Law.

77 Dr Singh's misconduct extended over a long period of time, involving multiple patients and multiple prescriptions of drugs and other treatments and multiple failures to take proper notes. Only a long period of disqualification can accurately reflect the seriousness of Dr Singh's misconduct.

78 The Tribunal finds that Dr Singh should be disqualified from applying for registration as a medical practitioner for a period of 10 years from the date of this order, pursuant to s 196(4) of the National Law.

79 The Board sought an order that Dr Singh be reprimanded. The Tribunal does not see that any purpose would be served by a reprimand. Disqualification from applying for registration for 10 years is an appropriate remedy.

80 Similarly, the Tribunal does not regard it as appropriate to impose a fine as a separate penalty except in relation to Dr Singh's letter to the notifier.

81 It is important that notifiers of potential misconduct be able to do so without abuse by the health practitioner about whom they complain.

82 Dr Singh's letter stands in a separate category to his other misconduct. The Tribunal has determined that he should be fined $5,000 as a discouragement to others who might be tempted to engage in such misconduct.

83 Section 87(1) and s 87(2) of the State Administrative Tribunal Act 2004 (WA) provide:

Unless otherwise specified in this Act, the enabling Act, or an order of the Tribunal under this section, parties bear their own costs in a proceeding of the Tribunal.

Unless otherwise specified in the enabling Act, the Tribunal may make an order for the payment by a party of all or any of the costs of another party or of a person required to produce a document or other material on the application of the party under section 35.

84 In Western Australian Planning Commission v Questdale Holdings Pty Ltd [2016] WASCA 32, Murphy JA (Martin CJ and Corboy J agreeing) stated:

1. The effect of s 87(1) of the SAT Act is, relevantly, that each party in proceedings before the Tribunal is to bear its own costs, unless the Tribunal otherwise orders.

1. Section 87(2) is to be construed in the context that the legal rationale for an order for costs is not to punish the person against whom the order is made, but to compensate or reimburse the person in whose favour it is made. That rationale is evident in s 87(3) of the SAT Act. Accordingly, even in a statutory context where the presumptive position is that no costs will be ordered, generally speaking, the question is whether, in the particular circumstances of the case, it is fair and reasonable that a party should be reimbursed for the costs it incurred. The onus is on the party seeking an order in its favour.

85 In Medical Board of Western Australia and Roberman [2005] WASAT 81 (S) (Roberman (S)) at [30], the Tribunal stated:

Section 87(2) gives the Tribunal the discretion to order the payment by a party of all or any of the costs of another party. Where a regulatory authority successfully brings a complaint of conduct which, if proved, justifies disciplinary action by the Tribunal, there will usually be a strong case for the exercise of that discretion in favour of the regulatory body. That is because such bodies perform a function which promotes the public interest, and usually with limited resources. The financial burden of bringing disciplinary action if the body had no capacity to recover some or all of its costs may be such as to provide a disincentive to bring disciplinary action, or when brought, to ensure that the allegations against the practitioner concerned are properly and thoroughly presented. It is in the public interest that such bodies have an expectation that, if the allegations are made out, the offending professional will meet or at least contribute to the costs incurred in bringing the application. The question of an award of costs is, of course, a matter of discretion to be exercised in the circumstances of each case.

86 Although the decision in Roberman (S) does not limit the discretion of the Tribunal in awarding costs, the public obligations of the Board to prosecute practitioners who breach the National Law is an important factor to be considered.

1. where many of the costs were incurred by reason of Dr Singh's lack of insight; and
2. Dr Singh's persistence in denying the nature of his conduct in communications with the Board and his conduct before this Tribunal;

it is fair and reasonable that the Board should be reimbursed for the costs and disbursements it incurred.

88 It will be a rare case where costs of Tribunal proceedings are ordered on the Supreme Court Scale. The Tribunal has determined that this is not such a case.

89 The Tribunal order that Dr Singh pay the Board's costs and disbursements to be assessed by the State Administrative Tribunal Scale. It is a matter between the Board and Dr Singh as to whether he should be given time to pay.

1. Pursuant to s 196(2)(c) of the Health Practitioner Regulation National Law (WA) Act 2010, Dr Anish Dwarka Singh is fined $5,000.
2. Pursuant to s 196(4)(a) of the Health Practitioner Regulation National Law (WA) Act 2010, Dr Anish Dwarka Singh is disqualified from applying for re-registration as a registered health practitioner for a period of 10 years.
3. Dr Anish Dwarka Singh is to pay the Medical Board of Australia's costs and disbursements of the proceedings at the scale that applies for proceedings in the State Administrative Tribunal.

I certify that this and the preceding [89] paragraphs comprise the reasons for decision of the State Administrative Tribunal.

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