Medical Board of Australia v Moschou [2020] SACAT 110 (28 September 2020)

Medical Board of Australia v Moschou [2020] SACAT 110

The Medical Board of Australia brought a complaint against the respondent for conduct which the Board said amounted to professional misconduct. The conduct comprised of instances of inappropriately prescribing medications, inadequately monitoring patients and inadequate record-keeping.

The parties concurred upon a statement of agreed facts in which the respondent admitted that the conduct amounted to professional misconduct. However, the parties differed as to which limb of the definition of professional misconduct are engaged by the respondent's conduct.

• where it is satisfied that the practitioner has engaged in professional misconduct, the sanctions the Tribunal may impose do not vary according to which limb of professional misconduct is applicable;
• the practitioner behaved in a way that constituted professional misconduct in that he engaged in more than one instance of unprofessional conduct that, when considered together, amount to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience.

The Tribunal found the parties' joint proposal for sanctions was appropriate and made orders to that effect.

Health practitioners - Professional misconduct - Inappropriate prescribing, Inadequate record-keeping - Reprimand, Registration suspended for nine months, Conditions imposed on registration

Health practitioners - General principles - Categories of misconduct - Characterisation of professional misconduct

Health Practitioner Regulation National Law (South Australia) Act 2010 (SA) ss 5, 195, 196

South Australian Civil and Administrative Tribunal Act 2013 (SA) s 60

Medical Board of Australia v Fox [2016] VCAT 408

Craig v Medical Board of Australia [2001] SASC 169.

Mr A Crocker (instructed by Gilchrist Connell) for the respondent

Order Suspending Practitioner's Registration for a Specific Period; Order Reprimanding Practitioner; Order Imposing Conditions on Practitioner's Registration; Order Prohibiting Publication of Patients' Names; Order for costs

Made under the Health Practitioner Regulation National Law (South Australia) Act 2010 (SA) Schedule 2 ss 195, 196 and the South Australian Civil and Administrative Tribunal Act 2013 (SA) s 60

1. The Medical Board has referred this matter to the Tribunal pursuant to s 193(1) of Schedule 2 of the Health Practitioner Regulation National Law (South Australia) Act 2010 (SA) ('the National Law').
2. The parties have submitted to the Tribunal an Updated Statement of Agreed Facts with an Addendum. The Updated Statement of Agreed Facts (Attachment 1) and Addendum (Attachment 2) are attached to the Tribunal's decision. The facts will not be set out again.
3. The Tribunal makes findings of fact in accordance with paragraphs 1-6 and 12-140 of the Updated Statement of Agreed Facts. The Tribunal notes the respondent's admissions and assertions in paragraphs 7-11 of the Updated Statement of Agreed Facts.
4. The respondent admits that the conduct described in the Updated Statement of Agreed Facts amounts to professional misconduct, which is defined in s 5 of the National Law as follows:

professional misconduct, of a registered health practitioner, includes -

(a) 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

(b) 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

(c) 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.

1. The parties differ which limb/s of the definition of professional misconduct are engaged by the respondent's conduct. The applicant contends that all three limbs are engaged. The respondent disputes that limb (c) has been engaged and points out that neither party has submitted to the Tribunal that the respondent's registration as a health practitioner should be cancelled.
2. Where the Tribunal is satisfied that the practitioner has behaved in a way that constitutes professional misconduct, the sanctions that the Tribunal may impose on the respondent do not vary according to which limb/s of the definition of professional misconduct is/are applicable. In a situation where both parties agree that the practitioner has behaved in a way that constitutes professional misconduct, there appears to be little that either party could gain from a dispute between them as to which limb/s of the definition of professional misconduct is/are applicable.
3. Having considered the Updated Statement of Agreed Facts, the written submissions of both parties and the oral submissions at the hearing, the Tribunal is satisfied that the practitioner has behaved in a way that constitutes professional misconduct in that he engaged in more than one instance of unprofessional conduct that, when considered together, amount to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience.
4. Having made that finding, it is not necessary for the Tribunal to consider any other way of defining the respondent's conduct and the Tribunal declines to do so.
5. The Tribunal must consider the sanction to be applied to the respondent. The Tribunal has taken into account:

(a) The respondent co-operated with the applicant in its investigation, in voluntarily disclosing to the applicant further affected patients not revealed by the applicant's investigation, and in submitting the Updated Statement of Agreed Facts to the Tribunal;

(b) The parties have not submitted that the respondent has any prior disciplinary history in his medical career of over 40 years;

(c) The respondent was a senior practitioner when he engaged in the professional misconduct;

(d) His conduct involved self-prescribing, and failing to adequately monitor or adequately record the monitoring of his patients;

(e) The parties have co-operated and have reached a joint position on what constitutes an appropriate sanction for the respondent's conduct, which as set out in Medical Board of Australia v Fox[1] is both highly relevant and extremely important for the Tribunal to consider, as on its face the parties' joint position does not represent an arbitrary outcome but reflects a carefully and negotiated outcome that has proper regard to all relevant facts and circumstances;

(f) The parties' joint proposal for sanction meets the purposes of the imposition of a disciplinary sanction as discussed in Craig v Medical Board of Australia.[2]

1. Having considered the above factors, the Tribunal will make orders implementing the parties' joint proposal for sanction.

1. The Tribunal made the following orders:
   1. Pursuant to s 196(2)(a) of Schedule 2 of the Health Practitioner Regulation National Law (South Australia) Act 2010 (SA), the Tribunal reprimands the respondent.
   2. Pursuant to s 196(2)(d) of Schedule 2 of the Health Practitioner Regulation National Law (South Australia) Act, the Tribunal suspends the respondent's registration as a medical practitioner for nine months from the date of this order namely 28 September 2020.[3]
   3. Pursuant to s 196(2)(b) of Schedule 2 of the Health Practitioner Regulation National Law (South Australia) Act, the Tribunal imposes the following conditions on the respondent's registration as a health practitioner. The conditions are to commence upon the expiration of the suspension ordered in paragraph 2 above.

1. The Practitioner must not prescribe, possess, supply, administer, handle, dispense, access, check (hereafter referred to as access), including as emergency treatment supplies or doctor's bag stock, the following substances: testosterone or growth hormone related peptides, including but not limited to human chorionic gonadotropin, CJC 1295, GHRP-6 and Ipamorelin and GRP-2, IGF1 - LR3, AOD 9604, Selective androgen receptor modulator (SARM-S22; MK-2866), Follistatin, Melanotan and dehydroepiandrosterone.
2. Within 21 days of the commencement of these conditions, the Practitioner must provide to AHPRA:

(a) Acknowledgement, on the approved form (HP1), that AHPRA may obtain reports from the Director of Medical Services, Senior Manager, Senior Partner, Proprietor, Owner, or equivalent (a senior person) at each and every place of practice on a quarterly basis or as otherwise required by the Board or AHPRA.

(b) Acknowledgement, on the approved form (HP1), that for the purposes of monitoring compliance with the condition restricting access to medication, AHPRA may contact Medicare and/or drugs and poisons regulatory authorities in relevant states or territories.

(c) Confirmation, on the approved form (HPS1), from the senior person at each place of practice that they are aware AHPRA will seek reports from them.

1. The Practitioner must submit to an audit of their practice (the audit), including any supporting records, within three months of the commencement of these conditions and thereafter on a quarterly basis, by permitting an auditor (the auditor) approved by the Medical Board of Australia (the Board) to attend any and all places of practice (public and private) for the purpose of the audit and by permitting the auditor to provide a report in relation to the findings of the audit. The audit and the audit report are to focus on ensuring compliance with the requirement not to prescribe the medications that are subject to Condition 1 above.
2. Within 28 days of the commencement of these conditions, the Practitioner must:

(a) Contact a Board approved auditor and establish an audit plan outlining the form the audit(s) will take and how the areas of concern for the Board will be addressed. The audit(s) will take the form determined by the auditor.

(b) Provide the Board approved auditor with a copy of the conditions on their registration.

(c) Provide to AHPRA, on the approved form (HP8), acknowledgement that AHPRA will seek reports from the auditor.

(d) Provide to AHPRA a copy of the audit plan, together with written acknowledgement, on the approved form (HPNA8), from the approved auditor.

1. Within 21 days of the commencement of these conditions the Practitioner must provide to AHPRA, on the approved form (HPC), the contact details of a senior person, such as the Director of Medical Services, Director of Nursing, Senior Practice Manager, Senior Manager, Senior Partner, Proprietor, Owner, or equivalent (the senior person) at each current place of practice. In providing this form, the Practitioner acknowledges that AHPRA will contact the senior person and provide them with a copy of the conditions on the Practitioner's registration or confirm that the senior person has received a copy of the conditions from the Practitioner. The Practitioner will be required to provide the same form:

(a) within seven days of the commencement of practice at each subsequent place of practice, and

(b) within seven days of each and every notice of any subsequent alteration of these conditions.

1. All costs associated with compliance with the conditions on their registration are at the Practitioner's own expense.
2. The review period for the above conditions is 12 months from the date of their imposition.
3. Pursuant to s 60 of the South Australian Civil and Administrative Tribunal Act 2013 (SA), the Tribunal prohibits the publication of the full names of, or anything tending to identify, any patient referred to in the Complaint or the Updated Statement of Agreed Facts.
4. Pursuant to Health Practitioner Regulation National Law (South Australia) Act Schedule 2 s 195, the Tribunal orders the respondent to pay the applicant's costs of and incidental to the proceeding, to be agreed, or failing agreement, to be assessed.

IN THE SOUTH AUSTRALIAN CIVIL AND ADMINISTRATIVE TRIBUNAL

UNDER THE Health Practitioner Regulation National Law

**1. Dr Christopher Moschou (Respondent) is a registered medical practitioner. His registration is currently subject to the Undertaking in the terms annexed to this statement (Appendix A). The Undertaking was given by the Respondent to the Medical Board of Australia (Complainant) as a consequence of the allegations that are the subject of this proceeding.

2. The Respondent practises at Richmond Health Clinic at 129 Marion Road, Richmond in the State of South Australia.

3. The Respondent is bound by the codes, rules and laws as they pertain to the practise of medicine, more particularly the prescribing of medications. He is also bound by the Code of Conduct "Good Medical Practice: a Code of Conduct for Doctors in Australia" (Code of Conduct) as it applied at the relevant time.

4. This proceeding relates to the Respondent prescribing medication to ten patients plus himself.**

**5. The Respondent prescribed various medications to the patients, relevantly, including those listed below:

(n) Oxazepam and Valium (restricted drugs of dependency);

(o) Amitriptyline (a tricyclic antidepressant); and

6. These medications have the potential to have side effects, some of which are described in Appendix B. The medications 5(a) - (j) are referred to herein as "the peptide medications". The medications 5 (k) - (o), are referred to herein as "steroids". The medications 5(r) are "benzodiazepine medications".**

7. The Respondent makes the following admissions with regards to the whole of the Complaint. He admits:

**(a) in the period 7 May 2010 to June 2017, he prescribed the peptide medications to his ten patients and himself;

(b) he ought not have recommended, prescribed or entertained the peptide medications as a treatment option in general practice medicine. He ought not have recommended the medications to the ten patients to whom he had prescribed the peptide medications;

(c) he ought not have recommended, prescribed or entertained a combination of peptide medications and steroids;

(d) he ought not have recommended, prescribed or entertained a combination of a controlled drug and benzodiazepine medications;

(e) the provision of the peptide medications to the ten patients by the Respondent created a risk of harm to the patients, including those side-effects particularised within Appendix B;

(f) he failed to adequately monitor the ten patients over the course of taking the peptide medications or that he failed to adequately record the monitoring in the patient's written records;

(g) his medical record-keeping setting out the ten patients' 'informed consent' was deficient:**

**_(i) it did not contain a written record of informed consent; and

(ii) it did not record the discussion or information provided as to off-label use and risks in respect of the peptide medications;_**

(h) his record-keeping with regards to the provision of information and advice and as to informed consent was not in accordance with the Code of Conduct.

**8. Notwithstanding the above admissions, and those below, the Respondent says he prescribed the medications (summarised in paragraph 5) to the patients on the basis of their symptoms and pathology at the time.

9. The Respondent asserts, and the Board does not challenge, that he provided to each of the ten patients written information and discussed it with each patient but the Respondent admits he did not record what documents he provided and what discussions he had with the patients in that regard.

10. The Respondent asserts, and the Board does not challenge, he believed in doing so he had obtained verbal informed consent from the ten patients.

11. The Respondent admits he should have realised at the time and does now acknowledge, that the provision and discussion of written information does not equate to informed consent and acknowledges that he did not obtain informed consent from the patients described herein.**

**12. Patient 1 (a male) was a patient of the Respondent prior to 1 July 2014.

14. At a consultation on 1 July 2014, the Respondent failed to record the following in relation to Patient 1:**

**15. During the course of treating Patient 1, the Respondent inappropriately prescribed the following medications for managing pain:

(a) GHRP-2 (on 17 July 2014, 8 October and 1 December 2015);

(d) Follistatin (on 2 September, 28 October, 3 November, 27 November, 15 December 2014, 27 January and 7 April 2015);

(e) CJC-1295 (on 14 October 2014 and 1 December 2015);

(f) Ipamorelin (on 14 October 2014 and 1 December 2015);

16. The prescribing of the medication described in paragraph 14 was inappropriate because there was no clinical indication for Patient 1 requiring the medication.

17. The Respondent failed to record his clinical assessment, diagnosis or reasons for prescribing the medications.

18. On 2 September 2014, the Respondent prescribed to Patient 1 Follistatin 315-R.

19. At a consultation on 8 October 2015, the Respondent prescribed HCG and GHRP to Patient 1, which was inappropriate because:**

**(a) there was no indication for prescribing the HCG or GHRP;

(b) no blood test had been conducted and results reviewed; and

(c) HCG should not have been prescribed in combination with GHRP.**

**20. On 3 November 2014, the Respondent prescribed to Patient 1 Follistatin 344-R because he says he was advised by the compounding pharmacy that Follistatin 315-R was not being manufactured anymore but failed to record this reason or discussion with Patient 1 in respect of the change.

21. On 15 December 2014, the Respondent changed the dose of Follistatin 344-R INJ prescribed to Patient 1 from 0.2ml to 0.4ml but failed to record:**

(c) evidence that he discussed the implications of a change of dose with Patient PG.**

**22. At the consultation on 15 December 2014, the Respondent recorded that Patient 1 did not want his treating renal physician to know that he was being prescribed peptide medication.

23. On 19 February 2015, the Respondent prescribed to Patient 1:**

**24. The Respondent did not record a clinical assessment, diagnosis or his reason for prescribing the abovementioned medications because the Respondent says they were long-standing medications that had been prescribed to Patient 1 on an ongoing basis.

25. At the consultation of 19 February 2015, the Respondent recorded in Patient 1's notes "BP [blood pressure] good" but failed to record the actual reading of patient 1's blood pressure.

26. On 4 September 2015 the Respondent changed the dose of SARM s22 injection prescribed to Patient 1 from 1ml to 0.5 mls five days per week but failed to record a reason for altering the prescribed dose.

27. On 8 October 2015, Patient 1 refused to provide a blood test to the Respondent as he had provided blood for dialysis. Despite this, the results of other blood tests would have been available to the Respondent.

28. At the consultation on 8 October 2015, the Respondent prescribed HCG and GHRP to Patient 1, which was inappropriate because no blood test had been conducted and results reviewed.

29. At the consultation on 26 October 2015, the Respondent inappropriately prescribed HCG in combination with SARM s22.

30. The Respondent did not communicate, or adequately communicate, with other practitioners involved in the care of Patient 1.

31. The Respondent issued repeat prescriptions of the medication outlined in the aforementioned paragraphs to Patient 1.

32. The Respondent failed to adequately record his monitoring of Patient 1 in the course of him taking the above noted medications.**

**33. The Respondent first consulted 2 (a female) on 22 October 2014. Patient 2 was an amateur bodybuilder.

34. The Respondent saw Patient 2 about the patient's strength and appearance and noted: "perimenopausal generally well and healthy about to embark seriously on weight training for competitive purposes after discussion wants check on hormones so do bloods and saliva + Q and rev (sic)".

35. During the course of the initial consultation, the Respondent ordered a number of tests in respect of Patient 2 but failed to record the following:**

(b) psychosocial and or occupational factors, suffice these details appeared in the new patient form completed by the patient in October 2014;

(c) health related behaviours, suffice these details appeared in the new patient form completed by the patient in October 2014;

(d) the outcome of any clinical examination performed; and

36. On 9 January 2015, the Respondent inappropriately prescribed to Patient 2 for weight training, strength and appearance:

**37. The Respondent did not record a clinical assessment or reason for prescribing the peptide medications and the Respondent admits there was no clinical reason to prescribe the peptide medications to Patient 2.

38. The prescription of the peptide medications for weight training, strength and appearance was otherwise inappropriate because:**

**(a) the Respondent failed to conduct appropriate clinical examinations of Patient 2;

(b) the Respondent failed to document further advice in respect of nutrition, physical activity or co-morbidities in relation to Patient 2.**

**39. The Respondent first consulted Patient 3 on 2 December 2014.

40. Patient 3 consulted the Respondent for fibromyalgia and systemic lupus erythematosus (SLE). The patient sought to be prescribed HCG and AOD9604 as treatment for these conditions.

41. During the initial consultation, the Respondent failed to record the following in relation to Patient 3:**

(e) whether a clinical examination was conducted; and

(f) in the event a clinical examination was conducted, the results of same.**

**42. On 3 December 2014, the Respondent requested laboratory investigations in respect of Patient 3 but subsequently failed to record whether the results informed future treatment and, if so, in what way.

43. On 8 December 2014, the Respondent inappropriately prescribed to Patient 3:**

**44. The Respondent did not record a clinical assessment or reason for prescribing the peptide medications and the Respondent admits there was no clinical reason to prescribe the peptide medications to Patient 3.

45. On 11 December 2014, the Respondent inappropriately prescribed to Patient 3 DHEA to counterbalance Patient 3's use of steroid medication."

46. The Respondent did not record a clinical assessment or reason for prescribing the DHEA and there was no clinical reason to do so.

47. The Respondent issued repeat prescriptions of the medication outlined in the aforementioned paragraphs to Patient 3.

**(a) adequately monitor Patient 3 over the course of taking the above noted medications; or

(b) in the event that he did so, failed to adequately record monitoring of same.**

49. The Respondent failed to inform Patient 3's rheumatologist about her use of peptides and instead, the responsibility fell to Patient 3 to update her rheumatologist about her prescriptions.

**50. The Respondent first treated Patient 4 (a female) on 1 April 2015.

51. At the appointment, Patient 4 presented with chronic musculoskeletal pain and she sought to be prescribed AOD 9604 as treatment for same.

52. During the initial consultation, the Respondent failed to record the following in relation to patient 4:**

**(a) details about specific sites of pain where Patient 4 reported widespread pain throughout her whole body and that she had 'degenerative spondylosis' and 'recent foot surgery';

(c) factors affecting and relieving the pain but noted she was on narcotic analgesia;

(d) the pain's relationship with exercise and activity;

(f) assessment of the Patient IH's other health conditions;

**53. On 1 April 2015, the Respondent inappropriately prescribed to Patient 4 AOD 9604 injection 0.5 mls.

54. On 13 April 2005, the Respondent inappropriately injected a total of 1ml AOD 9604 into the "lower lumbar" of Patient 4.

55. The Respondent inappropriately injected Patient 4 with AOD 9604 on further occasions, namely 16, 21 and 23 April 2015.

56. There was no clinical indication for prescribing the AOD 9604.

57. During the period in which he injected Patient 4 with AOD 9604, the Respondent:**

(b) failed to record the reasons for the increase in the dose;

(c) failed record whether he advised the patient the reason for the increase in dose; and

58. The Respondent failed to monitor the progress for Patient 4, including, but not limited to:

(c) BP, weight or any other clinical assessments.**

**59. On or around 5 May 2015, the Respondent consulted with Patient 4 but failed to record any clinical notes about same other than "AOD to R ankle and back".

60. The Respondent failed to obtain informed written consent from Patient 4 in relation to the prescription of the above noted medications but says that he did receive verbal consent noted in the records terms of "discuss AOD use; discuss not curative discuss safety discuss off label use and protocol of admin; outcomes are basically as altern to pain relief. understands off label use and willing to trial discuss costs of AOD (sic)" (1 April 2015) and "wants AOD discuss its off label use and pain relief not guaranteed and happy to proceed...". (13 April 2015) but he accepts that this was inadequate. The Respondent refers to paragraphs 7(d), 8, 9 and 10 hereof.

61. The Respondent failed to record any evidence to demonstrate that Patient 4 experienced improved functionality as a consequence of receiving the medication.**

**62. Patient 5 (a male) was a patient of the Respondent prior to 6 January 2015.

63. At a consultation on 6 January 2015, the Respondent recorded that Patient 5 presented with ongoing knee pain and arthritis and that Patient 5 was "unhappy re surgeons".

64. The Respondent failed to evidence in the patient records that he considered, other relevant issues pertinent to Patient 5, namely:**

(e) documenting the patient's concerns about surgery,

however, the Respondent says these issues had all been discussed at a time prior to 6 January 2015.**

**65. On 14 January 2015, the Respondent noted in Patient 5's medical record "discuss AOD 9604 transdermal made aware or not being widely used results variable but side effects minimal / non-existent". The Respondent then inappropriately prescribed to Patient DM AOD 9604 transdermal cream.

66. On 3 February 2015, the Respondent noted in Patient 5's medical record that the below medications had "ceased". The Respondent says by this notation he updated Patient 5's medical record to reflect that Patient 5 had not had prescriptions of the below medications for a time:**

**67. The prescription of AOD 9604 to Patient 5 was inappropriate because there was no clinical basis by which it might be considered effective and otherwise there was no clinical basis for prescribing the medication.

68. The Respondent failed to adequately monitor Patient 5 whilst he received the above noted peptides and failed to record:**

**69. Patient 6 (a female) was a patient of the Respondent prior to 10 October 2014.

70. Patient 6 consulted on that date with the Respondent and says he consulted her in respect of her osteoarthritis and osteoporosis.

71. On 10 October 2014, the Respondent prescribed to Patient 6:**

**72. The Respondent did not record that Patient 6 attended for assessment and treatment of osteoporosis and osteoarthritis suffice he provided a prescription of medication to Patient 6 for treatment of osteoporosis.

73. The Respondent conducted an inadequate clinical assessment of Patient 6's osteoporosis and osteoarthritis prior to prescribing the medications.

74. The Respondent's treatment of Patient 6's pain management was also inadequate.

75. In subsequent consultations, the Respondent prescribed Patient 6 medications including: Antenex (diazepam), Alepam (oxazepam), Durogesic patches (Fentanyl), Neulactil (periciazine), Endep, Depomedrol.

76. It was inappropriate and there was no clinical basis for the Respondent to prescribe to Patient 6 a combination of Fentanyl with two different benzodiazapines, amitriptyline, and periciazine in varying combinations.

**(a) adequately monitor Patient 6 over the course of taking the above noted medications; or

(b) in the event that he did so, failed to adequately record monitoring of same.**

**78. On 31 October 2014, the Respondent inappropriately prescribed to Patient 6 AOD 9604 injection.

79. The respondent did not document his diagnosis or reasons for issuing the prescription.

**(a) injected Patient 6 with AOD 9604 on further occasions, namely 10, 14, 19, 21, 24, 25, 27, 28 November 2014, and on 19 January, 23 February, 2, 6 March, 10, 13, 16, 21, 23, 29 April, 5 and 12 May 2015; and

(b) prescribed to Patient 6 AOD 9604 on 13 May 2015.**

81. During the period in which he inappropriately prescribed or injected Patient 6 with AOD 9604, the Respondent:

(b) failed to record the reasons for the division in dosage; and

(c) failed to record whether he advised the patient the reason for the division in the dose.**

82. On 19 January 2015, the Respondent inappropriately administered to Patient 6:

**in three areas: subscapular, right and left lumbar L3/4 facet region.

83. It was inappropriate for the Respondent to prescribe AOD 9604 to Patient 6 for the following reasons:**

**(a) he did not record a clinical assessment, diagnosis or reason for prescription;

(b) there was no therapeutic indication for prescribing same;

(c) there was no theoretical basis for prescribing off label;

(d) there was no indication for the prescription; and

84. There was no clinical indication for the Respondent to prescribe HCG to Patient 6. Further, the Respondent failed to:

**(a) record a clinical assessment, diagnosis or reason for prescription;

(c) in the event that the Respondent did so, record evidence that he had discussed same; and

(d) record a prescription for HCG issued to Patient 6 which raises questions about the vial from which the drug was drawn from.**

**85. On 27 November 2014, the Respondent injected AOD 9604 into the right knee. On 5 December 2014, the Respondent injected 80 mg Depomedrol (a steroid medication) into the Patient 6's right knee. This is an accepted procedure for general practitioners to manage an arthritic knee but it was inappropriate given the earlier AOD 9604 injection.

86. On 25 May 2015, the Respondent prescribed to Patient 6, for the management of osteoporosis, replacing the earlier daily medication, Prolia syringe 60 mg.

87. The Respondent issued repeat prescriptions of the medication outlined in the aforementioned paragraphs to Patient 6.

88. The Respondent does not resile from the admissions in paragraph 7. The Board asserts that the Respondent was treating Patient 6 for osteoporosis. The Respondent says he treated Patient 6 for osteoporosis and osteoarthritis. He says he provided the peptide mediations to Patient 6 for the purpose of managing symptoms of osteoarthritis.**

**89. Prior to the period of this proceeding, Patient 7 (a female) had been a patient of the Respondent. She moved interstate for a period of time. Upon her return, Patient 7 again, became a patient of the Respondent. He first saw her after her return on 19 December 2014.

90. During this consultation, the Respondent failed to adequately record:**

91. On 19 December 2014, the Respondent inappropriately prescribed to Patient 7:

92. The Respondent's treatment of Patient 7 was inappropriate for the following reasons:

**(a) the Respondent failed to perform an adequate clinical assessment of Patient 7;

(b) the Respondent failed to record his clinical assessment, diagnosis or reasons for prescribing medications to Patient 7;

(c) there was no adequate indication for the prescribing of CJC1295;

(d) there was no adequate indication for the prescribing of GHRP-6;

(e) there was no adequate indication for the prescribing of Progesterone;

(f) there was no adequate indication for the prescribing of Pregnenolone; and

(g) there is no rationale for prescribing the aforementioned medication for the purported reason of weight loss.**

**(a) adequately monitor Patient 7 over the course of taking the above noted medications; or

(b) in the event that he did so, failed to adequately record monitoring of same.**

**94. The Respondent first consulted Patient 8 (a male) on 7 May 2010. Patient 8 consulted the Respondent for a range of complaints including hypertension, lethargy and weight loss.

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medications. There was no clinical basis for prescribing the DHEA in combination with Secretropin.

1. On 25 January 2012, Patient 8 saw the Respondent for hypertension. The Respondent prescribed certain medications including:

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medications.

1. On 1 June 2012, Patient 8 saw the Respondent for hypertension. The Respondent prescribed certain medications including:

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medication.

1. On 24 July 2012, Patient 8 saw the Respondent and noted the patient would continue "to try to lose weight" and would continue bioidentical hormone replacement therapy. The Respondent prescribed certain medications including:

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medications.

1. On 6 May 2013, Patient 8 saw the Respondent and noted he had "been greatly helped with DHEA and GHRP". The Respondent prescribed certain medications including:

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medications.

1. On 12 July 2013, Patient 8 saw the Respondent for hypertension. The Respondent prescribed certain medications including:

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medications. On 4 November 2013, Patient 8 saw the Respondent for hypertension. The Respondent prescribed certain medications including:

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medications.

1. On 27 March 2014, Patient 8 saw the Respondent for hypertension. The Respondent prescribed certain medications including:

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medications.

1. On 5 May 2014, Patient 8 saw the Respondent for hypertension. The Respondent prescribed certain medications including:

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medications.

1. On 3 October 2014 Patient 8 consulted the Respondent. The Respondent noted:

'had episode of AF seen at FMC reverted had stopped Micardis some mnths (sic) back has also stopped GHRP / DHEA last mnth (sic) or so PH of ? AF and on oral antiarythmics some 4 + yrs ago will need cardiac re assessment

1. At a consultation on 11 May 2015, the Respondent noted:

'no AF episodes since before Xmas has declined ablation discuss issues with it will wait another episode of note AF episodes have come when not on DHEA/GHRP as well as on these.'

The Respondent prescribed to Patient 8 DHEA 50 capsules, GHRP-2 spray. The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medications.

1. On 14 July 2016, Patient 8 saw the Respondent for hypertension. The Respondent prescribed certain medications including:

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medications.

1. At a consultation on 23 March 2017, the Respondent prescribed certain medications including GHRP-2 spray. He did not conduct or record an adequate clinical assessment or record the reason for prescribing the medications. However, the Respondent says he continued to prescribe the medication on the basis of symptoms and pathology.
2. At a consultation on 9 June 2017, the Respondent recorded that:

'Discuss role of lifestyle replact (sic) of hormones but generally the inflasmmatory (sic) cause of chronic disease via stress load.'

The Respondent did not conduct or record a clinical assessment or record the reason for prescribing the medication.

to Patient 8 was inappropriate as there was no clinical reason to do so.

1. The Respondent first consulted Patient 9 (a female) on 23 February 2015. Patient 9 consulted the Respondent for hormonal symptoms post menopause, and for weight loss.
2. Patient 9 had a history of having had a gastric lap band and took antidepressants.
3. At the initial consultation on 23 February 2015, the Respondent took a brief history and arranged for certain pathology tests to be undertaken.
4. At the consultation on 3 March 2015, the Respondent prescribed Progesterone 20 BiEst 0.5 DHEA 15 cream. At that consultation, the Respondent says he discussed the pathology results which the Respondent ordered on 23 February 2015. The pathology results dated 24 February 2015 showed some deficiencies which the Respondent discussed with Patient 9. The Respondent did not record an adequate clinical assessment or record the reason for prescribing the medication.
5. At the consultation on 19 May 2015, the Respondent saw Patient 9 and noted 'also wanted info re→GH. Discuss role of GH, discuss secretagogues advice to have pap and mammogram and rept labs first'. The Respondent prescribed Progesterone 20 BiEst 0.5 DHEA 15 cream. At a previous consultation on 31 March 2015, the Respondent noted that Patient 9's symptoms had improved. The Respondent did not record a clinical assessment or record the reason for prescribing the medication on 19 May 2015.
6. At a consultation on 19 June 2015, the Respondent noted:

'Fe levels down, had colonoscopy 2 years yrf ago had 1 polp, says will be recalled for another suggest at least an FBOT but declined saying she doesn't touch meat and most likely cause. Discussed further GHRP and willing to trial S/L form'.

The Respondent prescribed Patient 9 GHRP-2 spray. The Respondent did not record a clinical assessment or record the reason for prescribing the medication.

1. At a consultation on 23 July 2015, the Respondent noted:

'DISCUSS bhrt AND ghrp wants to try a different secretague to see if gets better results suggest needs to consider diet stress levels amt of exercise etc as it's not a magic formula for convenience use ipamorelin transdermal.'

The Respondent prescribed to Patient 9 Ipamorelin transdermal cream. He did not conduct or record an adequate clinical assessment or record the reason for prescribing the medication.

1. At a consultation on 11 August 2015, the Respondent:

(b) prescribed Progesterone 20 BiEst 1 DHEA 15 cream.

The Respondent did not conduct or record a clinical assessment or record the reason for prescribing the medication.

(b) prescribed Progesterone 20 BiEst 1 DHEA 15 cream.

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medication.

1. At a consultation on 11 January 2016, the Respondent recorded:

'Feels has come to a standstill with weight gain, feeling uncomfortable with body image 'old and hadit' after discussion. Ipamorelin and start Follistatin'.

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medication.

1. At a consultation on 16 March 2016, the Respondent ceased prescribing Patient 9 Follistatin 344-R and noted:

'Has had ongoing issues with fatigue and myalgias.. is due for rheumatology appoint... is concerned because doesn't want to give up dhea peptides etc as feels she is benefited..'

1. At a consultation on 13 July 2016, the Respondent consulted Patient 9 for 'HRT', namely hormone replacement therapy. He noted:

'..follistatin has been good but as a change (sic) to ipamorelin. Labs next visit has maintained mscl (sic) mass no→ in fat appreciable.'

(b) prescribed Progesterone 20 BiEst 1 DHEA 15 cream.

The Respondent did not record a clinical assessment or record the reason for prescribing the medication.

1. At a consultation on 31 August 2016, the Respondent saw Patient 9 with respect to her weight. He noted her weight as 66 kg. The Respondent prescribed Patient 9 Follistatin 344-R injection. The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medication.
2. At a consultation on 15 November 2016, the Respondent:

(b) prescribed Progesterone 20 BiEst 1 DHEA 15 cream.

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medication.

1. At a consultation on 8 March 2017, the Respondent prescribed to Patient 9 Progesterone 20 BiEst 1 DHEA 15 cream but did not conduct or record a clinical assessment or record the reason for prescribing the medication. The only notation of the consultation he made was:

'Wanted info on new peptides of which I am not aware so CT as is for now.'

1. At a consultation on 20 June 2017, the Respondent:

(b) prescribed Progesterone 20 BiEst 1 DHEA 15 cream.

The Respondent did not record a clinical assessment or record the reason for prescribing the medication.

to Patient 9 was inappropriate as there was no clinical reason to do so.

1. The Respondent first consulted Patient 10 (a male) on 23 February 2015. He consulted the Respondent with respect to mid-life hormonal deficiencies. Patient 10 also consulted the Respondent for weight loss.
2. At a consultation on 23 February 2015, the Respondent noted:

'FLAT NO ENERGY WORKS OUT 3-4 DAYS PW SUPPLEMENTS WITH AMINO ACIDS CREATINE PROTEIN ETC. Hoever (sic) wants to improve self fel (sic) better etc Discuss midlife hormonal deficiencies and mmanaging (sic) these thu (sic) diet exercise but avoid burn outs. ... understands this is off label for some products and non medicare for some lab work etc....'

1. At the initial consultation, the Respondent failed to record:

(d) an assessment of Patient 10's other health conditions;

1. At a consultation on 3 March 2015, the Respondent noted:

'as part of feeling well, energetic etc, discussed use of DHEA add chrysin as aromatase blocker high protein diet supplements avoid starches and sugars discuss theoretical small risk of Prostate issues via down regulation chrysin should help.'

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medication.

1. At a consultation on 31 March 2015, the Respondent noted:

'feels well more energy doing more in the gym looks after diet..'

1. At a consultation on 28 May 2015, the Respondent noted:

'results good, suggest ct with current regime and review 3-6/12 or earlier if concerned.'

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medication.

1. At a consultation on 20 August 2015, the Respondent recorded:

'WANTED TO DISCUSS PEPTIDES AS SPENDING LOTS OF MONEY ON SUPPLEMENTS ETC. AND WANTS TO KNOW IF PEPTIDES MAY BE BETTER.'

1. On a consultation on 12 October 2015, the Respondent recorded:

'discuss IGF 1. wants to lose some 10 kgs esp of fa (sic) around waist as well otherwise. Discussed ways to do so incl. 5/2 diet esp if combined with no breakfast. also discuss HCG use and has opted out, discuss the strict cal diet and see Greens pharmacy for supplements (sic)'.

The Respondent prescribed an injection of HCG 150 I u/25ml. He did not conduct or record an adequate clinical assessment or record the reason for prescribing the medication.

1. At a consultation on 16 March 2016, the Respondent noted:

'going okay but wants to trial cream form of dhea/chrysin. Also discussed pros and cons of follistatin use as he wants to use aka his partner for muscle repair and build as well as some fat loss ...'

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medication.

1. At a consultation on 13 July 2016, the Respondent recorded:

'try to lose xs fat, some success with follistatin but wants to try something different by way of peptides as they don't cause any issues change to cjc/ghrp6 inj ct dhea.'

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medication.

1. At a consultation on 15 November 2016, the Respondent recorded:

'Feels better with Regimen now, better energy, better sleep, memory better, thinking clearer, feels better toned up.'

The Respondent did not conduct or record an adequate clinical assessment or record the reason for prescribing the medication.

1. At a consultation on 20 June 2017, the Respondent prescribed to Patient 10:

The Respondent did not record a clinical assessment or record the reason for prescribing the medication.

1. On 6 January 2015, 15 April 2015 and 15 July 2015 the Respondent self-prescribed and treated himself with peptide medication.

**139. The Respondent self-prescribed and treated himself with peptide medication as part of his investigation or experimentation.

140. The Respondent accepts he ought not have self-prescribed and certainly not in the context of personally exploring risks and benefit of such medication.**

141. The Respondent admits the conduct described in this Statement of Agreed Facts amounts to professional misconduct as defined by the National Law.

It has been decided by the Senior Member that it is unnecessary to include the Undertaking with this decision.

(a) are not approved for therapeutic human use in Australia;

(c) their use is not in accordance with recognised therapeutic standards;

(iii) appearance such as anti-ageing, weight loss or tanning;

(d) is not appropriate, or has little or no therapeutic benefit for use in enhancing appearance such as weight loss or anti-ageing;

(e) is inappropriately used by, for example, body builders other than for therapeutic purposes.

(f) when used inappropriately may have adverse effects upon the health of a patient, including:

(c) is inappropriately used by, for example, body builders other than for a therapeutic purpose such as to enhance appearance;

(d) when used inappropriately may have adverse effects upon the health of a patient, including:

(i) acromegaly (a disorder where the pituitary gland produces too much growth hormone);

(a) is a synthetic hexapeptide that stimulates growth hormone secretion from the pituitary;

(b) otherwise has little or no therapeutic benefit;

(c) may have adverse effects upon the health of a patient.

(b) has little or no therapeutic benefit for use in weight loss or soft tissue repair;

(c) there is no data to suggest it has an effect on pain as it has not been the subject of a clinical trial;

(d) is inappropriately used, for example by body builders or sportsman other than for a therapeutic purpose;

(e) the controversy concerning its use became well known in about 2012;

(f) may have adverse effects upon the health of a patient.

(c) is a inappropriately used by, for example, body builders other than for a therapeutic purpose such as to enhance appearance;

(d) when used inappropriately may have adverse effects upon the health of a patient.

(b) is not approved for use and is regarded as experimental for use in the treatment of males;

(c) has little or no therapeutic benefit for use to treat sexual desire, erectile function or antiaging;

(d) is inappropriately used off-label by, for example, body builders other than for a therapeutic purpose such as to enhance appearance;

(e) when used inappropriately may have adverse effects upon the health of a patient.

(a) is approved for use in women in sterility due to the absence of follicle-ripening or ovulation;

(ii) delayed puberty associated with insufficient gonatrophic pituitary function;

(iii) cryptorchidism (failure of the testes to descend);

(c) has little or no therapeutic use to treat weight loss;

(d) is inappropriately used off-label by, for example, body builders other than for a therapeutic purpose such as to enhance appearance;

(e) when used inappropriately may have adverse effects on the health of a patient including:

(ii) coronary artery dissection due to fibromuscular hyperplasia;

(iii) lower extremity DVT and pulmonary embolism; and

(c) is inappropriately used, for example, by body builders other than for a therapeutic purpose such as to enhance appearance;

(d) may have adverse effects upon the health of a patient.

10. Selective androgen receptor modulator (SARM-S22; MK-2866).

b) is regarded as an experimental drug for use in cancer related cachexia (weight loss and muscle atrophy);

c) when used may have adverse effects upon the health of a patient, including cardiovascular and liver damage.

(a) has been shown to have muscle-enhancing effects;

(b) is used experimentally for the possible treatment of muscular dystrophy and preservation of muscle mass in cachexia;

(c) is inappropriately used by, for example, body builders other than for therapeutic purposes such as to enhance appearance.

(d) when used may have adverse effects upon the health of a patient, including:

IN THE SOUTH AUSTRALIAN CIVIL AND ADMINISTRATIVE TRIBUNAL

UNDER THE Health Practitioner Regulation National Law

ADDENDUM TO THE UPDATED STATEMENT OF AGREED FACTS

to Patient LL was inappropriate as there was no clinical reason to do so.

[1] [2016] VCAT 408 at [6].

[2] [2001] SASC 169 at [41-67].

[3] The date was added to this order as per slip rule issued on 28 January 2021 under s 84 of the South Australian Civil and Administrative Tribunal Act 2013 (SA).