(a) With respect to Allegations 1, 2 and 3, that the respondent has engaged in professional misconduct as defined by meaning (a) at section 5 of the National Law; and

(b) With respect to Allegation 4, that the respondent has engaged in unprofessional misconduct as defined at section 5 of the National Law.

(a) Reprimand the respondent under section 196(2)(a); and

(b) Suspend the respondent's registration as a medical practitioner from 21 May 2024 to 20 July 2024 (inclusive), under section 196(2)(d).

1. In October 2022, the Medical Board of Australia (the Board), under the Health Practitioner Regulation National Law (Victoria) Act 2009 (the National Law)[1] referred four allegations against Dr Thanh-Thuan Nguyen to VCAT.
2. In 2020, the Australian Health Practitioner Regulation Agency (Ahpra) received a notification concerning Dr Nguyen and his treatment of three patients: Patient 1 (P1), Patient 2 (P2) and Patient 3 (P3). The notification raised concerns about Dr Nguyen's prescribing practices of opioid based medications.
3. In January 2021, the Board took immediate action including to impose conditions on Dr Nguyen's registration by restricting his access to and prescribing of Schedule 8 medications, Schedule 4 drugs of dependence and medications subject to misuse.
4. In October 2022, on recommendation of Dr Nguyen's supervisor, Dr C. Holdstock, the Board removed the conditions on Dr Nguyen's registration. He was at the time of the VCAT hearing registered without conditions.
5. With the referral made to VCAT in October 2022, the Board alleged:
   • Allegation 1 - between 13 February 2019 and 16 October 2020, Dr Nguyen inappropriately prescribed Schedule 8 and Schedule 4 medications to Patient 1 (P1) and/or managed the care of P1 so that her safety was at risk.
   • Allegation 2 - between 12 July 2019 and 16 November 2020, Dr Nguyen inappropriately prescribed Schedule 8 and Schedule 4 medications to Patient 2 (P2) and/or managed the care of P2 so that his safety was at risk.
   • Allegation 3 - between 27 May 2019 and 2 November 2020, Dr Nguyen inappropriately prescribed Schedule 8 and Schedule 4 medications to Patient 3 (P3) and/or managed the care of P3 so that her safety was at risk.
   • Allegation 4 - Dr Nguyen failed to maintain adequate and appropriate clinical records of the three patients and/or adequately document the basis upon which he prescribed the high doses of opioids to them.
6. Before the referral came to hearing in May 2024, the Board and Dr Nguyen had agreed to the facts of the allegations and that the conduct the subject of Allegations 1 to 3 should be characterised as professional misconduct under meanings (a) or (b) of the National Law.
7. Concerning Allegation 4, the Board submitted the conduct should be characterised as professional misconduct (meaning (a) or (b)). Dr Nguyen submitted it should be characterised as unprofessional conduct.
8. On determinations, the Board submitted that VCAT should reprimand Dr Nguyen and suspend his registration for between three and six months. Dr Nguyen submitted that VCAT should reprimand him but not suspend his registration.
9. At hearing, the Board relied on the documents before the Tribunal. Dr Nguyen did likewise, excepting that he called Dr Holdstock who gave evidence.
10. We heard submissions and announced our findings and determinations saying that written reasons would follow.
11. These reasons follow, 11 months later. Deputy President Proctor providing 'results' in other cases (where the result in this case was already known to the parties) has repeatedly taken precedence. The delay is in no way attributable to VCAT's health practitioner members.
12. In deciding this proceeding, we considered the 815 page Tribunal Book, including documents from the Ahpra investigation, clinical records of the patients, SafeScript, an expert report from the Board, material related to the education and supervision program which resulted from immediate action, support letters from medical practitioners and the parties' Statement of Agreed Facts'.

1. The first step in this proceeding is to decide whether the facts of the allegations are proven.
2. Based on the statement of agreed facts and the evidence before the Tribunal, we find the following occurred.
3. At all relevant times, Dr Nguyen held general registration as a medical practitioner working at a medical centre in Melbourne (Medical Centre).
4. On 19 October 2020, Ahpra received a notification from a confidential notifier concerning Dr Nguyen and his treatment of P1, P2 and P3.

1. From around January 2010, P1 was a regular patient at the Medical Centre.
2. From around 2018, P1 was treated by a main treating general practitioner and was also treated by other practitioners at the Medical Centre, including Dr Nguyen. Between 13 February 2019 and 19 December 2019, P1 attended approximately 14 consultations with him.

1. Dr Nguyen issued P1 prescriptions to treat ongoing migraine pain and anxiety on 13 February, 15 March, 1 April, 12 June, 10 July, 23 July, 29 August, 10 September, 25 September, 18 October, 25 October, 4 November, 5 December and 19 December 2019.
2. Over those dates, Dr Nguyen's prescriptions included the following medications under the Standard for the Uniform Scheduling of Medicines and Poisons:

Schedule 4 - Benzodiazepines - Diazepam 5mg, 150 tablets - Oxazepam, 50 tablets - Lorazepam 1mg, 50 tablets via a private prescription - Clonazepam, 100 tablets via a private prescription - Serepax, 50 tablets.

Schedule 8 - Opioids - Endone (Oxycodone) 5mg, 20 tablets - Tramadol 50mg, 200 tablets.

1. Between 29 August and 28 December 2018, P1 had been prescribed 150 tablets of Diazepam by another general practitioner at the Medical Centre.
2. Between 17 August and 28 December 2018, she had been prescribed 140 tablets of Tramadol by other general practitioners at the Medical Centre.
3. Between 10 October 2019 and 19 February 2020, she had been prescribed 75 tablets of Serepax by other general practitioners at the Medical Centre.
4. Between 23 July 2016 and 26 April 2017, on five separate occasions, a another general practitioner at the Medical Centre prescribed 100 tablets of Clonazepam via a private prescription.
5. On 15 July 2020, P1 was admitted to the Emergency Department at the Austin Hospital, and subsequently admitted to the Intensive Care Unit, for an overdose of analgesic medication, after taking approximately 20 tablets of Tramadol. This medication was not prescribed by Dr Nguyen.
6. On 17 July 2020, Austin Hospital notified the Medical Centre of P1's hospital admission.
7. After the overdose hospital admission, P1 returned to see her main general practitioner at the Medical Centre, who on 28 July 2020 implemented a limited prescribing strategy, recording this in the medical records.
8. From July to October 2020, no analgesics such as Tramadol or Panadeine Forte were prescribed.
9. On 16 October 2020, P1 attended a telephone consultation with Dr Nguyen seeking treatment for her recurring migraines because her main treating general practitioner was not available that day.
10. He looked through P1's medical records to review her history before the consultation. This included checking recent prescriptions to confirm that she had not had recent analgesia since the overdose on 17 July 2020.
11. Dr Nguyen was aware of P1's overdose on 15 July 2020. He discussed the overdose with her at the consultation and recorded in his surgery consultation notes that P1 had overdosed on Tramadol 'again' in July.
12. Dr Nguyen prescribed P1, on a private token e-script, the following Schedule 4 medications for migraine and anxiety treatment: four tablets Sumatriptan 50mg, 25 tablets of Serepax (Oxazepam) 15mg and 50 tablets of Panadeine Forte 500mg/30mg.[2]
13. On 16 October Dr Nguyen provided higher dosage medication on a private script, than would have been possible on Pharmaceutical Benefits Scheme prescription.
14. He received an 'amber alert' prompting him to check SafeScript when he prescribed the medication.
15. Amber alerts notify practitioners when:

a) The daily morphine equivalent dose (calculated based on an average over the last 90 days) is between 50mg and 100mg minimum effective dose daily; or > > b) When prescriptions for a monitored medicine in the last six months have been issued by more than one prescriber, or four or more pharmacies.

16. Approximately one hour after her 16 October 2020 appointment, P1 telephoned the Medical Centre and spoke with reception. She said she had not received her e-script for Panadeine Forte issued by Dr Nguyen that day.
17. Reception staff relayed the details of the call to Dr Nguyen, who later that day issued a second private e-script to P1 for 50 tablets of Panadeine Forte 500mg/30mg.
18. He did not cancel the first private token e-script which he had issued earlier that day. Dr Nguyen says this was due to his lack of familiarity with the recently introduced e-script system.
19. SafeScript records for P1 indicate that only one of the two e-scripts for Panadeine Forte was actually dispensed.
20. On 17 October 2020, P1 was admitted to the Emergency Department, and subsequently transferred to a high dependency bed in the Intensive Care Unit, at the Austin Hospital due to an overdose. She reported that on the evening of 16 October 2020, she took 25 x 5mg Oxazepam tablets and 40 x 500/30mg Panadeine Forte tablets.
21. Dr Nguyen's prescribing on 16 October 2020 was inappropriate in that he:

a) Was aware that P1 had a history of overdose attempts involving analgesic medication; > > b) Was aware that P1 had been admitted to hospital on 15 July 2020 following an overdose; > > c) Did not verify on SafeScript whether P1's first e-script had been successfully issued or dispensed by a pharmacy before providing a second prescription; > > d) Did not cancel or re-issue the first token e-script of Panadeine Forte, which could only be used once, thereby enabling P1 to access two prescriptions of Panadeine Forte; > > e) Used private prescriptions that allowed him to prescribe a higher quantity of Panadeine Forte; and > > f) Enabled P1 to potentially access 100 Panadeine Forte tablets, with an oral morphine equivalent dose of 390mg per day.

22. By his conduct, Dr Nguyen breached, or acted inconsistently with, the following sections of Good Medical Practice: A Code of Conduct for Doctor's in Australia (October 2020) (Code of Conduct 2020):

a) Section 2.1 - Professional values and qualities of doctors: which includes, a duty to make the care of patients their first concern and practise medicine safely and effectively and a responsibility to protect and promote the health of individuals. > > b) Section 3.1.1 - Providing good care: assessing the patient, taking into account the history, the patient's views, and an appropriate physical examination. The history includes relevant psychological, social and cultural aspects. > > c) Section 3.1.2 - Providing good care: formulating and implementing a suitable management plan (including arranging investigations and providing information, a diagnosis, treatment and advice). > > d) Section 3.2.4 - Good patient care: considering the balance of benefit and harm in all clinical-management decisions. > > e) Section 3.2.6 - Good patient care: providing treatment options based on the best available information. > > f) Section 3.2.7 - Good patient care: only recommending treatments when there is an identified therapeutic need and/or a clinically recognised treatment, and a reasonable expectation of clinical efficacy and benefit for the patient.

23. As a result of his prescribing on 16 October 2020 Dr Nguyen inappropriately prescribed Schedule 4 medications to P1 and inappropriately managed the care of P1 so that her safety was at risk.

1. Dr Nguyen was aware P2 had a history of depression, anxiety, insomnia and knee pain.
2. Between 12 July 2019 and 16 November 2020, P2 attended approximately 20 consultations with Dr Nguyen who prescribed benzodiazepine and opioid medication for his chronic knee pain and insomnia.
3. On 12 July 2019, Dr Nguyen wrote a referral for P2 to attend Care in Mind, a public psychology service.
4. Between July 2019 and December 2019, Dr Nguyen issued prescriptions for the following opioids: Targin 10mg, Panadeine Forte 500mg/30mg and Endone 5mg for P2's chronic knee pain.
5. On 19 December 2019, he referred P2 to see a pain specialist and orthopaedic surgeon for review with a history of chronic knee pain.
6. On 20 January 2020, Dr Nguyen issued a prescription for P2 to increase his daily intake of the Schedule 8 opioid Targin from 10mg to 20mg.
7. On 5 February 2020, a pain specialist, Dr Ilona Meyer wrote to Dr Nguyen following a consultation with P2, stating:

[P2] is on Targin and oxycodone currently which is the only thing that he feels is helping his pain. His doses are not concerning at the moment but I have looked at SafeScript and you can see that it has escalated over the past few months. He is certainly reaching some of the limits that I would feel comfortable for a patient with chronic non-cancer pain. We certainly do not want him on anything more than 60 mg of oxycodone in total per day.

a) P2 had chronic bilateral knee pain that he described as tearing and burning in nature, causing a significant functional impairment and keeping him awake at night; > > b) P2 did not think that physiotherapy, Lyrica or gabapentinolds would work, and was clear that he felt that the only thing helping was the opioids; > > c) P2 was 'already likely becoming tolerant to the oxycodone and needing more and more'; > > d) She had told P2 opioids should be for a limited time period for example two or three months until P2 could be taught to self-manage his pain with allied health support or until the orthopaedic side was sorted out; > > e) P2 said he was hoping for a fix for his pain and for an opioid script; > > f) Her impression was that P2's main reason for presenting at the consultation was to obtain an opioid prescription; > > g) P2's mental health and trauma history was 'certainly contributing to his chronic pain and perpetuating some of his pain symptoms'; and > > h) She had given a prescription to P2 for Lyrica with instructions on how to titrate the dose up to 150mg bd[3] over the next three weeks and would run this trial for two months for him.

2. P2 did not book another appointment with Dr Meyer and he was not willing to attend a pain physiotherapist for review. He considered that Lyrica had no effect on his knee pain.
3. Dr Nguyen encouraged P2 to re-engage with a pain specialist but he reported that he had not engaged well with Dr Meyer.
4. P2 had restricted access to physiotherapy in the setting of COVID-19 restrictions.
5. After receiving Dr Meyer's advice, Dr Nguyen continued to prescribe high doses of Schedule 4 and Schedule 8 medication to P2 from 5 February to 16 November 2020, including:

a) On 11 February 2020, prescribing increased doses of Targin 20mg/10mg tablets to take in the morning and Targin 30mg/15mg tablets to take in the evening but reduced the dose of Endone 5mg to a maximum four tablets per day. At this consultation the letter from Dr Meyer was noted to still be pending; > > b) Prescribing 70 mg oxycodone per day on 3 April, 29 May and 26 August 2020; > > c) Prescribing a combination of Schedule 4 and Schedule 8 medications: > > 1. on 3 April 2020 consisting of 28 Targin 30mg, 28 Targin 20mg, 120 Endone and 25 Temazepam tablets; and > 2. on 25 September 2020 consisting of 28 Targin 30mg, 28 Targin 20mg, 120 Endone tablets and 25 Nitrazepam tablets; and > > d) Prescribing an oral morphine equivalent dose of 100mg/day or more, including on: > > 1. 3 April 2020, where he prescribed 28 tablets of Targin 30mg, 28 tablets of Targin 20mg, 120 Endone tablets and 25 Temazepam tablets; and > 2. 25 September 2020, where he prescribed 28 tablets of Targin 30mg, 28 tablets of Targin 20mg, 120 Endone tablets and 25 Nitrazepam tablets.

6. On 29 May, 11 June, 29 June, 27 July and 25 September 2020, Dr Nguyen issued prescriptions to P2 after receiving red alerts via SafeScript.
7. Red alerts notify practitioners of high risk when:

a) The daily morphine equivalent dose exceeds 100mg/day; > > b) There are high-risk drug combinations recorded on SafeScript within the last 90 days; or > > c) Where there are four or more prescribers/medical practices recorded in SafeScript within the last 90 days.

8. On 11 February, 6 March, 3 April, 29 April and 29 May 2020, Dr Nguyen did not seek authority from the Pharmaceutical Benefits Scheme (PBS) before prescribing Targin 30mg to P2.
9. On 8 January, 20 January and 11 February 2020, he did not seek PBS authority to prescribe Endone to P2.
10. There is no mandate for practitioners to seek authority from the PBS under the Drugs, Poisons and Controlled Substances Act 1981 (Vic) (DPCS Act) when issuing prescriptions.
11. However, practitioners who issue prescriptions with PBS authority enable their patients to access subsidised Schedule 8 medications, ensure they prescribe within the PBS limits and enable oversight from the Department of Human Services (DHS). Unless a general exception applies under the DPCS Act, practitioners are required to obtain a Schedule 8 permit when treating and prescribing Schedule 8 medication to a drug-dependent person, irrespective of whether the prescription is issued privately or with approval under the PBS.
12. Dr Nguyen did not obtain a Schedule 8 Permit in accordance with section 34(1) of the DPCS Act, despite P2 being a drug dependent person.
13. Between 12 July 2019 and 16 November 2020, Dr Nguyen continued to prescribe high doses of opioids to P2, as set out above, rather than suggesting an opioid substitution program.
14. By engaging in the above conduct before 1 October 2020, he breached, or acted inconsistently with, the following sections of the Good Medical Practice: A Code of Conduct for Doctor's in Australia (March 2014) (Code of Conduct 2014):

a) Section 1.4 - Professional values and qualities of doctors: doctors have a duty to make the care of patients their first concern and to practise medicine safely and effectively. > > b) Section 2.1.1 - Providing good care: assessing the patient, taking into account the history, the patient's views, and an appropriate physical examination. The history includes relevant psychological, social and cultural aspects. > > c) Section 2.1.2 - Providing good care: formulating and implementing a suitable management plan (including arranging investigations and providing information, treatment and advice). > > d) Section 2.2.4 - Good patient care: considering the balance of benefit and harm in all clinical-management decisions. > > e) Section 2.2.6 - Good patient care: providing treatment options based on the best available information.

15. By engaging in the above conduct from 1 October 2020 onwards, Dr Nguyen also breached, or acted inconsistently with, the sections of the Code of Conduct 2020 set out above.
16. Dr Nguyen inappropriately prescribed Schedule 4 and Schedule 8 medications to P2 and inappropriately managed P2's care so that his safety was at risk.

1. Between 27 May 2019 and 2 December 2020, P3 attended approximately 167 consultations with Dr Nguyen.
2. At the time of her first consultation, P3 was 38 years old.
3. She reported that she had complex issues with her abdomen since her mid-20's and suffered from chronic diarrhoea, had been taking Valium, Codeine and Lomotil for 12 years and at that time, was taking 3 x 5 mg Valium tablets and 4 x 30 mg Codeine tablets per day.
4. On 7 June 2019, Dr Nguyen recorded in his consultation notes that he had checked the 'DHS Prescription Shopper Hotline' and that P3 was 'possibly positive', in that she had seven prescribers in nine weeks (including four for Codeine).
5. On 18 June 2019, he recorded in his consultation notes that he had spoken with a female nurse who knew P3 well. The nurse advised that P3 was a 'known chronic large use[r] of Diazepam, Codeine'; and P3 had been banned from other clinics due to her behaviour and drug seeking.
6. On 2 July 2019, Dr Nguyen was faxed a letter from the then Department of Health & Human Services alerting him that he appeared to be one of a number of medical practitioners who had prescribed Codeine for P3 and P3 had obtained prescriptions for drugs of dependence from 10 different prescribers within the last 90 days.
7. On 4 July 2019, Dr Nguyen referred P3 to pain specialist, Dr Clayton Thomas, to work on a long-term plan to wean P3 off Codeine. That same day, he also referred P3 to gastroenterologist, Dr Nathan Connelly.
8. On 14 August 2019, Dr Thomas wrote that:

a) According to a rough calculation after checking SafeScript, P3 was obtaining multiple prescriptions for Codeine from different doctors, and averaging more than 30 Codeine phosphate tablets per day; > > b) He had formed the impression that P3 was a drug dependent person and should ideally be on an opioid-replacement therapy program; > > c) P3 needed to, 'start the weaning process immediately'; > > d) She needed to be limited to weekly pick-ups of Codeine from only one pharmacy; > > e) A prescribing permit needed to be applied for so that only one doctor could prescribe Codeine to P3; and > > f) It would be reasonable to start P3 on a daily pick-up limit from the pharmacy of 30 tablets of Codeine per day and, if she was not compliant with this approach, then there would be no choice, 'but to go onto an opioid-replacement program'.

9. On 14 August 2019, Dr Nguyen received a notification from the (then) Department of Health & Human Services (Department) that another practitioner had notified the Department that P3 was a drug dependent person and that practitioner had concerns about P3's use of prescription medicines.
10. On 29 August 2019, he received a letter from the Department advising that his permit to prescribe Codeine to P3 had expired and the Department had received recent notifications of forged prescriptions naming P3 as a patient.
11. On 22 October 2019, Dr Nguyen referred P3 to psychiatrist, Dr Marita Smith, to treat her obsessive compulsive disorder, anxiety and depression, and provide additional psychiatric support to wean P3 off Codeine.
12. Also on 22 October 2019, Dr Nguyen received confirmation from the Department that he had been granted another permit to prescribe Codeine to P3.
13. On 24 November 2019, Dr Thomas wrote to Dr Nguyen outlining a plan to reduce the number of Codeine tablets prescribed each month.
14. Dr Thomas encouraged Dr Nguyen to write a full prescription of 1,064 Codeine tablets for the month with pickups from the pharmacy of 266 tablets per week and, the following month, to reduce the prescription to 1,008 Codeine tablets with 252 tablets per week and continue to reduce the quantity each month.
15. On 6 December 2019 and 20 December 2019, Dr Smith wrote to Dr Nguyen encouraging him to prescribe a lesser dose of Codeine tablets to P3, from 34 tablets per day to 27 tablets per day, as advised by Dr Thomas.
16. On 10 January 2020, Dr Thomas wrote to Dr Nguyen advising:

a) He had spoken to an addiction specialist, Dr David Jacka; > > b) Dr Jacka had confirmed that Suboxone would cover P3's bowel issues as equally well as Codeine; > > c) Dr Jacka considered Suboxone would be 'far cheaper' than P3's current medication regime; > > d) He was happy for P3 to remain on her current Codeine dose for two months before then tapering down and that he was happy to support Dr Nguyen's permit for the next six months; and > > e) P3 was still quite medication fixated.

17. On 20 January 2020, Dr Nguyen received a letter from Dr Smith advising that as Dr Thomas described, P3 remained fixated on medications, and determined to remain on the current dosage of Codeine totalling 38 tablets per day.
18. On 27 February 2020, Dr Nguyen received a letter from Dr Thomas advising that:

a) P3 remained on 38 Codeine tablets per day and was eager to remain on the same dose for the next two months and then taper down to 36 tablets per day; > > b) Dr Thomas considered that this was reasonable only on the basis that she had cut back all of her other medications; and > > c) Dr Nguyen needed to update his permit to prescribe Codeine again.

19. On 28 February 2020, Dr Nguyen applied for a new permit to prescribe Codeine to P3, which was granted on 5 March 2020.
20. On 12 May 2020, Dr Thomas wrote to Dr Nguyen:

a) Advising that P3 told him she was having 40 30mg Codeine tablets per day, which was more than the 240 tablets it looked like she was getting on SafeScript; and > > b) Requesting confirmation that Dr Nguyen would start cutting P3's medication back by one Codeine 30mg tablet per month.

21. On 31 May 2020, Dr Thomas wrote to Dr Nguyen noting:

a) P3's Codeine levels were coming down albeit very slowly which was appropriate; > > b) He was happy for Dr Nguyen to take the front running on this without his involvement; and > > c) Dr Nguyen's prescribing permit needed to be updated.

22. On 5 June 2020, Dr Nguyen applied for another permit to prescribe Codeine to P3.
23. On 28 August 2020, he wrote to Dr Clayton confirming that P3's Codeine had been reduced to 35 tablets per day and that her use of Ditropan was much less.
24. On 8 September 2020, Dr Thomas wrote to Dr Nguyen confirming that he was not that concerned about which medication is cut back in which order as long as it is a very slow gradual taper of one or the other and ultimately both.

1. Between 27 May 2019 and 2 December 2020, Dr Nguyen prescribed P3 various Schedule 4 and Schedule 8 medications which included:

a) A combined total of 4,791 Diazepam and Temazepam tablets (benzodiazepine medications); and > > b) 18,224 Endone and Codeine tablets (opioid medications).

2. We have considered, but do not reproduce here, a 47 row table, each row showing a different date between 27 May 2019 and 27 November 2020.
3. On 3 February, 27 March, 22 May and 18 June 2020, Dr Nguyen issued prescriptions of Schedule 4 and Schedule 8 medications to P3 despite receiving red alerts via SafeScript.
4. After receiving Dr Thomas' advice in letters dated 9 August and 11 December 2019, 10 January, 27 February, 12 May and 31 May 2020, and the red alerts on SafeScript on 3 February, 27 March, 22 May and 18 June 2020, Dr Nguyen prescribed high doses of Schedule 4 and Schedule 8 medication to P3, including in combination.
5. For example, he issued high dose prescriptions on:

a) 22 November 2019, where he prescribed Codeine at an oral morphine equivalent dose of 148mg/day. Before prescribing, Dr Nguyen telephoned Dr Clayton who provided verbal confirmation that he was happy for P3 to start at 38 Codeine tablets per day before reducing by two tablets per month; > > b) 6 January 2020, where he prescribed 280 Diazepam tablets (Schedule 4) and 352 Codeine tablets (Schedule 8) in combination. Before prescribing, Dr Nguyen telephoned Dr Clayton and noted that he seemed to be supportive of maintaining the current dosage of 38 Codeine tablets but planned to consult with an addiction specialist; > > c) 27 March 2020 where he prescribed a total of 1,092 Codeine tablets at an oral morphine equivalent dose of 148mg/day; and > > d) 7 September 2020, where he prescribed Codeine and Endone at a combined oral morphine equivalent dose of 163mg/day, and also prescribed 225 Diazepam tablets.

6. Dr Nguyen did not prescribe less than 38 30mg Codeine tablets per day until 22 May 2020, when he reduced the prescription by one tablet to 37 30mg Codeine tablets per day.
7. On 13 October 2020, Dr Smith wrote to Dr Nguyen expressing 'concern that there has been no progress with weaning P3' off Codeine alongside high doses of Diazepam. He also noted that as responsible clinicians, a plan should be in place to help P3 with her 'obvious addiction issues'.
8. Dr Nguyen did not start P3 on the opioid substitution program (also known as Opioid Replacement Therapy) or refer P3 to a provider who offered this service. While he discussed this option with P3 at a number of consultations, she was not keen on Suboxone and declined.
9. On occasions between May 2019 and December 2020, Dr Nguyen prescribed high doses of medications on the same day to P3 through a combination of general PBS, PBS authority and private scripts, such as on:

a) 9 December 2019, where he prescribed 1,064 Codeine tablets with a private prescription; > > b) 27 March 2020, where he prescribed 280 Diazepam tablets and 112 Codeine tablets through a private prescription, 20 Codeine tablets with a general PBS prescription and 960 Codeine tablets with a PBS authority prescription; > > c) 22 May 2020, where he prescribed 960 Codeine tablets with a PBS authority prescription and 84 Codeine tablets with a private prescription; and > > d) 7 September 2020, where he prescribed 225 Diazepam tablets with a private prescription, 960 Codeine tablets with a PBS authority prescription and 20 Endone tablets with a general PBS prescription.

10. It is safer and more transparent to request PBS authority for Schedule 8 medications of any dose or quantity that is required for an extended time.
11. Dispensing Schedule 4 and Schedule 8 medications without PBS authority allows higher amounts of medication to be dispensed without scrutiny from the Department.
12. By engaging in this conduct, Dr Nguyen breached, or acted inconsistently with:

a) In respect of conduct before 1 October 2020, the sections of the Code of Conduct 2014 cited above; and > > b) In respect of conduct from 1 October 2020 onwards, the sections of the Code of Conduct 2020 cited above.

a) Inappropriately prescribed Schedule 8 and Schedule 4 medications to P3; and > > b) Inappropriately managed P3's care so that her safety was at risk.

1. Dr Nguyen kept inadequate clinical records.
2. In his clinical records relating to the consultation with P1 on 16 October 2020, he recorded only brief notes which lacked sufficient detail, did not document a long-term management plan; and did not document any mental state examination.
3. In his clinical records relating to P2 between 12 July 2019 and 16 November 2020, Dr Nguyen did not clearly indicate whether a consultation was face-to-face or via telehealth (such as on 26 August 2020), provide sufficiently detailed explanations for the high doses of opioids being prescribed (such as on 25 September 2020), document a long-term management plan and document any mental state examination.
4. In his clinical records relating to P3 between 27 May 2019 and 2 December 2020, he did not clearly indicate whether a consultation was face-to-face or via telehealth (such as on 6 April 2020), at times kept only brief and disorganised records of consultations which lacked adequate detail, did not document a long-term management plan and did not document any mental state examination.
5. Concerning this conduct before 1 October 2020, Dr Nguyen breached or acted inconsistently with, the following sections of the Code of Conduct 2014:

a) Section 2.2.3 - Good patient care: maintaining adequate records. > > b) Section 8.4.1 - Medical records: keeping accurate, up-to-date and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management in a form that can be understood by other health practitioners.

6. Concerning this conduct from 1 October 2020 onwards, Dr Nguyen breached, or acted inconsistently with, the following sections of the Code of Conduct 2020:

a) Section 3.2.3 - Good patient care: maintaining adequate records. > > b) Section 10.5.1 - Medical records: keeping accurate, up to date and legible records that report relevant details of clinical history, clinical findings, investigations, diagnosis, information given to patients, medication, referral and other management in a form that can be understood by other health practitioners. > > c) Section 10.5.4 - Medical records: ensuring that the records are sufficient to facilitate continuity of patient care.

Professional misconduct and/or unprofessional conduct?

1. With the alleged conduct proven, the second step is to decide whether the conduct falls within the definitions of 'professional misconduct' and/or 'unprofessional conduct' under the National Law.
2. Section 5 of the National Law of professional misconduct defines professional misconduct as:

(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. Concerning P1, P2 and P3, the parties agreed that Dr Nguyen's conduct can be characterised as professional misconduct within the meaning (a) or (b) of the definition of professional misconduct in section 5 of the National Law.

1. The Board described the 'heart' of Allegation 1 (P1), being the conduct set out from paragraph 29 above, which fell below the relevant standards.
2. That was, Dr Nguyen's prescribing on 16 October 2020 was inappropriate in that he:

a) Was aware that P1 had a history of overdose attempts involving analgesic medication; > > b) Was aware that P1 had on 15 July 2020 following an overdose been admitted to hospital and admitted to an intensive care unit; > > c) Did not verify on SafeScript whether P1's first e-script had been successfully issued or dispensed by a pharmacy before providing a second prescription; > > d) Did not cancel or re-issue the first token e-script of Panadeine Forte, which could only be used once, thereby enabling P1 to potentially access two prescriptions of Panadeine Forte; > > e) Used private prescriptions that allowed him to prescribe a higher quantity of Panadeine Forte; and > > f) Enabled P1 to potentially access 100 Panadeine Forte tablets, with an oral morphine equivalent dose of 390mg per day.

3. The Board submitted that this multifaceted conduct was at least careless and showed a poor understanding of safety systems in place at the time, posing high risk to the patient.
4. It cited a report from Dr Chris Clohesy dated 23 May 2025[4] which in part addressed Allegation 1.
5. He has the specialist general practice qualifications FRACGP and FACRRM, is a member of the NT Schedule 8 Clinical Advisory Committee and a member of the RACGP SA/NT Faculty Council. Dr Clohesy had previously undertaken performance assessments and provided independent opinion reports for Ahpra, being experienced in evaluating clinical records and practitioner performance.
6. The Board asked Dr Clohesy a number of detailed questions concerning Dr Nguyen's treatment of the three patients including requesting his opinion as to whether Dr Nguyen's performance in relation to the patients was of a standard reasonably expected of a health practitioner of his level of training and experience.
7. It provided Dr Clohesy with a summary of the notifications, clinical records for each patient, records of permits issued concerning P3, Dr Nguyen's submissions to the Board, letters in support of Dr Nguyen and Medicare and SafeScript data for the three patients.
8. Concerning P1, Dr Clohesy provided a summary of key issues:

a) Dr Nguyen prescribed high dose analgesic medication to P1 on 16 October 2020, despite being aware she had been admitted to hospital on 15 July 2020 with an overdose of analgesic medication; > > b) After the consultation, when P1 rang to say she had not received the first e-script for Panadeine Forte, Dr Nguyen should have checked SafeScript. SafeScript would have verified whether the e-script had been successfully issued and if the medication had been dispensed by a pharmacy. Instead, Dr Nguyen issued a completely new e-script. As a result, the patient accessed one hundred Panadeine Forte tablets, with an oral Morphine equivalent dose of 390mg/day; > > c) Dr Nguyen's documentation in the medical record for the 16 October 2020 consultation is inadequate. The notes are very brief, lacking any detail. There is no documented mental state examination; > > d) The prescribing of multiple benzodiazepine medications to P1 over twelve consultations was inappropriate and did not follow clinical guidelines; and > > e) Dr Nguyen's use of private scripts for the benzodiazepines, Lorazepam and Clonazepam was inappropriate, and did not follow clinical guidelines.

9. Concerning Allegation 2, the Board submitted that P2 repeatedly presented with reliance on Schedule 4 and Schedule 8 medications, over time displayed drug seeking behaviours and clearly fell into the category of being a drug dependent person. Dr Nguyen failed to closely follow advice from pain specialists.
10. Dr Clohesy summarised key issues concerning P2:

a) The DPCS Act and its 2017 regulations outline the requirements to seek an authorisation (Treatment Permit) from the Medicines and Poisons Regulation Branch to prescribe Schedule 8 opioids. In particular, the legislation refers to the requirement to obtain a permit if the treatment is for a 'continuous period greater than 8 weeks'. Despite P2 being drug dependent, Dr Nguyen did not seek a permit to prescribe the Schedule 8 opioid medications Endone and Targin. It is an offence not to comply with the legislation; > > b) It is wise practice and more transparent for doctors to request PBS authority for Schedule 8 medications of any dose or quantity, that is required for an extended period of time. The PBS Authority scheme not only allows patients to access subsidised Schedule 8 medications, but the PBS Authority also serves as a deterrent to doctors to prescribe inappropriately.

Dr Nguyen did not seek an Authority to prescribe Endone and Targin on multiple occasions. For example, see scripts for Targin 30mg dated 11 February, 6 March, 3 April, 29 April and 29 May 2020 and see scripts for Endone dated 11 January, 20 January and 11 February 2020.

Dispensing Schedule 4 and Schedule 8 medication without an Authority or on a private script avoids scrutiny, allows higher amounts of medication to be able to be dispensed, and allows dispensing outside the normal guidelines and recommendations.

Dr Nguyen provided private scripts for Endone on 20 December 2019, Panadeine Forte on 3, 14 and 19 December 2019 and Zopiclone on 12 July 2019;

1. On numerous occasions, a number of Schedule 4 and Schedule 8 medications were dispensed in combination on the same day. For example, on 3 April 2020, he prescribed 28 Targin 30mg, 28 Targin 20mg, 120 Endone and 25 Temazepam tablets. On the 25 September 2020, he prescribed 28 Targin 30mg, 28 Targin 20mg, 120 Endone and 28 Nitrazepam tablets;

d) Dr Nguyen should have considered starting the patient on the opioid substitution program. This programme has been established as it is a safer and more transparent way of prescribing opioids to patients.

Dr Nguyen's resume says he is trained in opioid replacement therapy. If this was the case, Dr Nguyen, should have considered this course of action for the patient;

e) High dose opioid prescribing is associated with an increased risk of harm, including death. Prescribing medication with an oral Morphine equivalent dose of 100mg/day or more elevates the risk of death by a factor of 11.

Dr Nguyen regularly prescribed medication with an oral Morphine equivalent dose of 100mg/day or more to this patient. For example, on 3 April, 29 May and 26 August 2020, he prescribed an oral Morphine equivalent dose of 105mg/day;

f) The trigger for a red alert warning on SafeScript is an oral Morphine equivalent dose of 100mg/day or more. Dr Nguyen continued to prescribe high dose opioid medication despite receiving multiple red alerts via SafeScript regarding his prescribing. Dr Nguyen ignored these warnings.

g) His prescribing of Schedule 4 and Schedule 8 medications for P2 was unsafe and did not follow clinical guidelines; and

h) His documentation in the medical record is inadequate. It is brief and disordered. Nowhere is a mental state examination documented.

1. Concerning P3, Dr Clohesy provided a summary of key issues:

a) Dr Nguyen should have started the patient on an opioid substitution program eg. Suboxone/Methadone or referred the patient to a provider who offered this service. The pain specialist wrote to Dr Nguyen on 9 August 2019, 'Ideally, she should be on an opioid replacement therapy program'; > > b) He documented in the consultation record dated 19 June 2019, 'patient was not keen on Suboxone'. Dr Nguyen should have made it clear to the patient that the opioid substitution program was safer than prescribing Codeine medication. He should have only offered the opioid substitution program to P3, not high dose Codeine. This was also a safer and more transparent alternative for Dr Nguyen; > > c) With Dr Nguyen's resume saying that he is trained in opioid replacement therapy, he should have considered this course of action for the patient; > > d) Prescribing medication with an oral Morphine equivalent dose of 100mg/day or more elevates the risk of death by a factor of 11;

Dr Nguyen regularly prescribed medication with an oral Morphine equivalent dose of 100mg/day or more to this patient. For example, at the consultation on 2 November 2019, he prescribed Codeine at an oral Morphine equivalent dose of 148mg/day. At the consultation on 7 September 2020, he prescribed Codeine and Endone and a combined oral Morphine equivalent dose of 163mg/day;

e) Dr Nguyen continued to prescribe high dose opioid medication despite receiving multiple red alerts via SafeScript regarding his prescribing morphine equivalent doses of 100mg/day or more. For example, see consultations dated 7 March, 22 May and 18 June 2020. He ignored these warnings;

f) It is wise practice and more transparent for doctors to request PBS Authority for Schedule 8 medications of any dose or quantity, that is required for an extended period of time. The PBS Authority scheme not only allows patients to access subsidised Schedule 8 medications, but the PBS Authority also serves as a deterrent for doctors to prescribe inappropriately.

Dispensing Schedule 4 and Schedule 8 medication without an authority or on a private script avoids scrutiny, allows higher amounts of medication to be dispensed, and allows dispensing outside the normal guidelines and recommendations.

Dr Nguyen did not seek an Authority to prescribe Codeine on multiple occasions.

He provided multiple high dose private scripts for Codeine on multiple occasions throughout 2019 and 2020. For example, on 27 March 2020, he prescribed 1,092 tablets, on 22 May 2020, he prescribed 1,044 tablets, on 18 June 2020, he prescribed 1,016 tablets, on the 25 November 2019, he prescribed 532 tablets and on the 9 December 2019, Dr Nguyen prescribe 1064 tablets.

He supplied P3 with 18,064 Codeine tablets between 27 May 2019 and 2 December 2020. This equals approximately 32 Codeine tablets a day.

He provided multiple high dose private scripts for Diazepam on numerous occasions throughout 2019 and 2020.

He supplied P3 with 4,666 Diazepam tablets between 27 May 2019 and 2 December 2020. This equals approximately eight Diazepam 5mg tablets a day;

g) On numerous occasions, a number of Schedule 4 and Schedule 8 medications were dispensed in combination on the same day. For example, on the 6 January 2020, 280 Diazepam tablets and 352 Codeine tablets were prescribed on the same day. On 7 September 2020, Dr Nguyen prescribed 225 Diazepam tablets, 20 Endone tablets and 960 Codeine tablets.

Also, combinations of PBS, Private and Authority prescribing was used by Dr Nguyen on the same day for the same medication. This practice lacks transparency and is very unsafe for the patient. For example, on 27 March 2020, Dr Nguyen prescribed 280 Diazepam tablets (Private script), 112 Codeine tablets (Private script), 20 Codeine tablets (PBS script) and 960 Codeine tablets (Authority script). The Codeine tablets prescribed amounted to a total of 1,092 tablets, with an oral morphine equivalent dose of 148mg/day.

On 7 September 2020, Dr Nguyen prescribed 225 Diazepam tablets (Private script), 960 Codeine tablets (Authority script) and 20 Endone 5mg tablets (PBS script). The Codeine and Endone tablets amounted to a total oral Morphine equivalent dose of 163mg/day;

h) His prescribing of Schedule 4 and Schedule 8 medications for P3 was unsafe and did not follow clinical guidelines;

1. Dr Nguyen had referred P3 to a pain specialist. It is apparent in the correspondence that the pain specialist was uncomfortable with Dr Nguyen's prescribing of high quantities of Codeine. Also, despite the pain specialist recommending that the Codeine dose should be reduced, Dr Nguyen delayed this process; and

j) Dr Nguyen's documentation in the medical record is inadequate. It is brief and disordered. Nowhere is a mental state examination documented.

1. We found that the conduct as alleged and proven concerning each of Allegations 1, 2 and 3 constitutes professional misconduct under meaning (a).
2. Concerning each allegation, his conduct clearly amounted to conduct substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience.
3. We agreed with the Board's submissions concerning the nature of the conduct that it was extremely serious. Dr Nguyen prescribed to three patients numerous highly addictive medications over extended periods (over 19 months), frequently and in high doses.
4. His conduct involved breaches of relevant laws and regulations, including that Dr Nguyen failed to comply with requirements of the DPCS Act and related regulations_._
5. Given his experience and expertise, Dr Nguyen should have been aware of the serious implications and serious risk which arose from his conduct.
6. He ignored repeated 'amber' and 'red' alerts in SafeScript about each patient, specific advice from pain specialists in relation to P2 and P3, and warnings from the Department of Health and Human Services in relation to P3 and her drug seeking behaviours.
7. We accepted that such conduct has the obvious potential to undermine the professions good standing and public confidence in the medical profession.
8. We accepted the opinion provided by Dr Clohesy describing risks of increased dependency on drugs and/or fatal overdose.
9. Concerning Allegation 4, we rejected the Board's submission that Dr Nguyen's conduct amounted to professional misconduct. We accepted the submission on behalf of Dr Nguyen that the conduct amounted to unprofessional conduct.
10. While there were deficiencies in his record keeping, they were of better quality than other examples of inadequate record-keeping that VCAT has dealt with.

1. Once VCAT has made findings in a proceeding such as this, the third step is to make determinations.
2. VCAT's role is to protect the public, not to punish the practitioner. That said, its decisions may involve a degree of punishment for the purpose of:
   • specific deterrence (to deter the individual from repeating the misconduct);
   • general deterrence (to warn others in the profession against such misconduct); and
   • to uphold the medical profession's reputation.
3. In this case, as the Board and Dr Nguyen submitted, we accepted there is no need to make determinations to achieve specific deterrence. We are confident that the conduct identified is unlikely to ever occur again.
4. Since made aware of the notifications Dr Nguyen exhibited remorse and insight making early admissions, cooperating with the investigation, observing conditions on his registration, successfully engaging with supervision and undertaking further education.
5. We reach this view based on evidence of supervision, education and its results.
6. Dr John Hodgson, the educator for Dr Nguyen, said:[5]

He responded very well and was adept at discussing and viewing the problems from the GP's perspective. He understood his professional role as being in charge of such consultations and how to use motivational interviewing techniques, and other services to assist the patient to change their perspective. He explained he now understands there were alternative ways to manage such patients, and that he had found his readings and learnings extremely valuable.

During the sessions, the facilitator made reference to the patient who Dr Nguyen prescribed to in an unsafe manner. Dr Nguyen was able to demonstrate that he has reflected on his management, and was able to describe how he would check with other prescribing doctors before embarking on prescribing, check Safe- Scripts, prescribe safely, ensure compliance with not only medication, but overall management, and use services such as DACAS for professional advice.

Dr Nguyen was able to identify which aspects of his record keeping did not meet best practice and noted with interest the suggestions provided by the facilitator. Dr Nguyen acknowledged that he had a better understanding of expectations in relation to his record keeping, particularly in relation to the continuity of care.

He was able to identify strategies to improve his record keeping practices.

Dr Nguyen stated that the whole process had been very helpful. Applying the concepts and principles addressed during the education program will now be a matter for Dr Nguyen to incorporate into his practice...

1. His conclusions are endorsed by Dr Nguyen's supervisor, Dr Holdstock.
2. She supervised Dr Nguyen weekly for over 18 months, providing quarterly reports to the Board. She also provided letters in support of the removal of conditions arising as a result of the immediate action process.
3. On 11 February 2022, she wrote:[6]

Supervision Findings

I have observed significant improvements in Dr Nguyen's clinic skills, records keeping, communication skills and his overall performance as a senior medical practitioner working in the very intense space in General Practice. He has continued to show that he can focus his attention, enthusiastically listen, learn, reflect on various case scenarios and augment his clinical practice skills.

We have covered a very broad range of cases and also various complex concepts

including privacy, confidentiality, mature-minor, breaching confidentiality, assessing various clinical risk scenarios and suicidal risk, as well as reiterating the most important goal of a medical consultation with a patient: practising as a safe and thorough doctor.

As he has realised both the potential short term and long term risks of Schedule 4 and 8 drugs of dependence, Dr Nguyen has developed and demonstrated safe prescribing patterns e.g. by regularly checking the online real-time Safescript® system, prescribing for clear indicated conditions, short term and with small quantities and generally no repeats. Especially when assessing the risks of complicated or difficult patients he has learnt the importance to stay in control and to say NO to those who are non-compliant or at risk of harm.

He is now confidently aware and advising his patients more commonly to use the

various lifestyle and non-pharmacological treatment options, 'analgesia escalation principles', the Schedule 8 Permit System and the various support options like DACAS, Direct Line, Pain specialists, other specialists and Allied Health including psychologists.

We also covered the communication skills expected of the general practitioner which included how to manage a difficult patient and their relative/s. Furthermore, we have covered how to explain things more simply and clearly to patients and their relatives.

Currently, Dr Nguyen works 4 days a week in the clinic, in order to keep a work life balance and look after himself as well as spend time with his family and friends and exercise and participate in leisure actives regularly. He has a young family with 2 children, enjoys playing tennis and going to the beach. He sees his own GP as needed.

Summary

In summary, I can confirm that Dr Nguyen has shown deep regret, good insight and he has reflected very well on the issues raised in the notification. He feels he has become an even more thorough GP and exhibits priority focus on safe prescribing. I would like to show my support for the hard work and continual improvement and dedication to his work, his patients and his family. Over the past 14 months, he improved impressively in clinical skills, prowess and overall confidence, so I clearly support the removal of the remaining AHPRA requirement of supervision.

1. Concerning Dr Nguyen's improved record keeping processes, Dr Holdstock's 20 April 2022 Supervisor Report Number 5 opined:

In the supervision sessions, Dr Nguyen has showed that he can take his time more with each patient. This has enabled him to take a more thorough clinical history and then record his contemporaneous notes in an active and timely manner. I have observed him doing this for over 12 months now. He has shown he can focus attention, enthusiastically listen, learn and augment his clinical practice skills in a variety of ways. His clinical medical record keeping in each section of his medical notes including reason for visit, history, examination and action.

1. In a report dated 30 September 2022, Doctor Holdstock wrote:

Dr Nguyen has been working with me weekly for 21 months now. We have covered a variety of professional domains of education topics during this time as described in the past six reports. He has improved significantly in his history taking, medical record keeping, clarity of diagnoses and management plans and follow-up and communications with his patients. In addition he uses SafeScript strictly now and has very clear boundaries with his patients for the provision of their scripts including size of initial boxed tablets and number of repeats of strong and addictive medications.

1. She gave evidence at the VCAT hearing. She confirmed her significant range of experience in medical practice, including as a supervisor, 'on the side', for the last five or six years. She had recently been appointed as an educator for the College of General Practitioners, in part to prevent general practitioners getting to the situation that Dr Nguyen had found himself in.
2. Dr Holdstock acknowledged the very significant issues that had arisen, and described Dr Nguyen's distress at what happened. She described his serious and respectful approach to the education and his determination to improve.
3. While the initial required education was to be for 12 months, it was extended to run for over 18 months, with the prescribing restrictions lifted after a year. They addressed the clinical issues as well as issues of self-care in a professional sense.
4. Dr Holdstock noted that using tools such as SafeScript, now mandatory, is a matter of 'learning on the job' with, in her view, no satisfactory educational materials available, not even an educational webinar. She described the 'doctor shopper line' in similar terms.
5. She had taught Dr Nguyen to skilfully use the available practice software, that knowledge all too often lacking with general practitioners. She spoke of providing training on using PBS scripts, with private scripts only playing a very small role in medical practice.
6. She taught Dr Nguyen concepts such as the pain ladder, first prescribing low-dose pain medications and only if necessary, with the patient returning, may be repeatedly, moving up the ladder in terms of higher doses.
7. Dr Holdstock regards the results of the education being that Dr Nguyen is a significantly improved informed general practitioner, with significant improvement in him routinely making detailed clinical notes, more detail than those kept by many general practitioners.
8. She spoke of delivering 20 educational messages to him, time and time again over the course of the training.
9. Dr Holdstock reflected on the need for general practitioners to keep themselves healthy human beings, to assist them, those around them and their patients. Many general practitioners do not have a treating general practitioner. This essential need is not taught to students nor doctors early in their careers. It is burnt out medical practitioners who get into trouble. During the education, while respecting Dr Nguyen's privacy and so not directly asking, Dr Holdstock continually stressed the need for him to ensure that by consulting appropriate medical practitioner/s he was looking after himself.
10. Dr Nguyen completed a persuasive detailed reflection, saying in part:[7]

I deeply and sincerely regret my past non-intentional, but in hindsight indeed concerning and potentially harmful prescribing pattern of S4+S8 drugs of dependency. This Process has highly alerted me truly on the potential and real dangers of the so called "Opioid Prescribing Pandemic" created throughout previous GP decades. As outlined in my reflections, I have been learning so much and now I am fully aware of my responsibilities in safe prescribing and good documentation.

1. With no need for specific deterrence, the issue was what determinations will appropriately provide general deterrence and uphold the medical profession's reputation.

1. We reprimanded Dr Nguyen, following our findings of professional misconduct and unprofessional conduct. Reprimand is a serious form of censure and condemnation, combined with a finding of professional misconduct.

1. The Board submitted that VCAT should reprimand Dr Nguyen and suspend his registration for between three and six months.
2. It submitted that period of suspension is appropriate in the circumstances of this case. Dr Nguyen's conduct, in relation to these matters, fell so far short of the standards required of medical practitioners, that general deterrence and protection of the community can only be achieved by way of a period out of practice.
3. It described the factors supporting finding of professional misconduct and Dr Clohesy's opinion highlighting the seriousness of the conduct.
4. Three to six month's suspension was submitted as proportionate:

a) To meets the need for general deterrence - a period of suspension is required to send a strong message to the community and the profession that conduct of this nature, will result in meaningful disciplinary action. All medical practitioners are expected to act in a manner which prioritises patient safety and with strict adherence to regulatory requirements. The systems which have been established to ensure the safe dispensing of Schedule 4 and 8 medications, hinge on practitioners paying proper regard to warnings. The wider profession must be deterred from engaging in similar conduct. > > b) To maintain of professional standards - Dr Nguyen's conduct represents a significant departure from the standards of the profession. Suspension will reflect to the profession at large, the seriousness by which those practicing ought to have regard to the standards and guidelines which apply to their practice. > > c) To meet community expectations and address risk to the reputation of the profession - It is imperative that the Tribunal make clear to practitioners that conduct of this nature is at odds with community expectations of the profession, undermines the reputation of the profession and negatively impacts people's trust in it. Medical practitioners are expected to act with care as well as integrity and diligence.

5. The Board accepted that Dr Nguyen has demonstrated insight into the seriousness of his conduct through his early admissions, cooperation with investigators and adherence to conditions imposed on his registration. Since this conduct was detected, he has engaged with supervision and has undertaken further education and training.
6. Therefore, specific deterrence was not now needed.
7. If, in May 2024, there was still a need for specific deterrence, the Board would have submitted that a significantly longer suspension was required, assuming in that hypothetical case that there could be confidence that after a further period of suspension, the practitioner would be fit for reregistration.
8. Concerning P2, quoted Dr Meyer's letter to Dr Nguyen:[8]

[P2] is on Targin and oxycodone currently which is the only thing he feels is helping his pain. His doses are not concerning at the moment but I have looked at SafeScript and you can see that it has escalated over the past few months. He is certainly reaching some of the limits that I would feel comfortable for a patient with chronic noncancer pain. We certainly do not want him on anything more than 60 mg oxycodone in total per day.

1. Counsel for Dr Nguyen made detailed submissions, which we set out, without repeated statements such as, 'it was submitted ...'.
2. P1 was a highly complex patient with a significant past medical history. She had been treated by other general practitioners at the Medical Centre before Dr Nguyen provided treatment.
3. Her past history included morbid obesity, migraines (since 1977), generalised anxiety disorder (2014), restless legs (2016 & 2020), schizophrenia (2017) and overdose on Tramadol in October/November 2018 and again in April 2019. There is no suggestion that the prescription of Schedule 4 medication was inappropriate.
4. In the year before Dr Nguyen's treatment of P1, other medical practitioners at the Medical Centre had on multiple occasions prescribed benzodiazepines and opioid medication. These included Oxazepam, Endone, Diazepam and Tramadol as well as the migraine medications, Sumatriptan and Ondanestron.
5. According to prescription records, when Dr Nguyen treated P1, from 13 February to 19 December 2019, over 14 dates, other doctors at the practice were involved in similar prescribing to that prescribed by Dr Nguyen.
6. From 19 December 2019, the prescribing pattern continued in largely the same way with the main treating doctor until, on 16 October 2020, Dr Nguyen saw P1. The main treating doctor was not available.
7. P1 presented with migraine, a recurring problem. Dr Nguyen asked P1 if she had an idea about the cause. She thought it might be using facemasks and the lights at her work. Conscious that previously prescribed medications are not addressed the migraine, Dr Nguyen decided to prescribe Panadeine Forte. This was a considered decision.
8. That day, Dr Nguyen prescribed Serepax and Sumatriptan (both as last prescribed by the other doctor in September 2020), as well as the Panadeine Forte prescription where the script was issued twice.
9. Dr Nguyen considered the clinical records available to him and decided that Panadeine Forte should be prescribed. He was aware of the previous overdose.
10. He failed to, understanding there was a previous overdose and cautioning the patient, was not enough, implement a risk management strategy to prevent P1 taking too much medication and instructing P1 to return to him to check progress.
11. Shortly after the appointment, P1 called back saying that she had not received the first Panadeine Forte prescription. Dr Nguyen issued a second script for the Panadeine Forte. It was never his intention that both scripts would be filled and the SafeScript records indicate that only one of the two e-scripts was actually dispensed.
12. At the time, e-scripts were relatively new and Dr Nguyen was aware of specific instances of e-scripts disappearing into the digital ether. When Dr Nguyen was told that P1 had not received the script, he, not unreasonably, believed that this was another instance of teething problems with the system.
13. Dr Nguyen did not appreciate, as he now does, that e-scripts could simply be cancelled or that the same e-script could be re-sent. This would have avoided the risk of double dispensing.
14. He issued a second e-script, accepting he should not have done so. Dr Nguyen accepts he should have had a fuller understanding of the e-script system.
15. He was deeply shocked and upset to learn of P1's overdose and hospitalisation. The episode served as the most graphic reminder to be particularly cautious when prescribing any medications, particularly in the context of previously documented self-harm behaviour.
16. Dr Nguyen accepts making an error of judgement in prescribing the amount of Panadeine Forte that he did and that the better course would have been to prescribe a lower quantity to enable ongoing review and support of P1.
17. At the time the medication was dispensed, he did not have any concerns as to P1's mental state or risk of self-harm. However, he acknowledges that a better documented risk assessment should have been recorded. That said in the immediate aftermath.
18. Dr Nguyen made contact with the local pharmacy and made a note for the provision of very limited amounts and pick up restrictions for her prescriptions in the future.
19. On P1's return to the Medical Centre on 5 November 2020, Dr Nguyen recorded, amongst other things:

attended with daughter same

1 week post discharge following drug overdose triggered by not wanting to go to work due to Covid fear

didnt want to end her life just escape for a while taken off all medication by psychiatrist at Austin

1. P1's explanation as to the reasons for her overdose as disclosed to the main doctor at the Medical Centre had not been raised with Dr Nguyen at the 16 October 2020 appointment. At the time of prescribing Panadeine Forte, Dr Nguyen was acting on the continuing report of severe migraines that were not being controlled with her existing medications.

1. Patient P2 was another highly complex patient with a significant past medical history. Before Dr Nguyen treated her, other doctors at the Medical Centre had done so.
2. Her medical history included major depression with suicidal thinking (2003), bilateral knee pain (2013), tinnitus (2018), right distal quadriceps pain (2019) and insomnia (2020). This complex combination of issues was 'overlaid' with a history of sexual abuse.
3. Again, there was no suggestion that the prescription of Schedule 4 and Schedule 8 medication was not indicated or inappropriate.
4. Dr Nguyen's care of P2 included a variety of treatment and referrals all designed to create a multi-disciplinary approach to his management. This included referrals to St Vincent's dermatology department, Collingwood Community Health Centre (which bulk billed), a psychologist while P2's regular psychiatrist was on leave, Mr Wang (orthopaedic surgeon), a sports medicine clinic and a pain specialist giving rise to Dr Meyer's report.
5. The Board's case places some emphasis on Dr Meyer's report.
6. Dr Meyer saw P2 once on 5 February 2020. Her report to Dr Nguyen[9] noted P2's, 'complex past trauma and mental health history with chronic bilateral knee pain...causing significant functional impairment'.
7. Dr Meyer's opinion quoted at paragraph 164, also said:[10]

...I informed him that we do not write opioid prescriptions for patients, especially with the start of SafeScript, we are trying to minimise any opioids from our practice and would prefer him to get this via yourself, his GP.

1. In this extremely complex background where Dr Meyer sought the continuation of medications via Dr Nguyen, he prescribed oxycodone reaching some of the limits that Dr Meyer felt were applicable.
2. Dr Meyer formed her impressions of P2 based on a single appointment, limited history and non-exploration of his trauma history.
3. Dr Nguyen continued to prescribe oxycodone for P2's pain management in circumstances where P2 reported no adverse side effects and that it addressed his pain. This was also what P2 had reported to Dr Meyer. P2 had not responded to other pain medications including Panadeine Forte and the oxycodone was never prescribed in combination with Endone and on only one occasion with Targin. In relation to the prescribing of benzodiazepines, Dr Nguyen only ever prescribed Temazepam or Nitrazepam. This was never done in combination and always at standard doses.
4. His management was always guided by his clinical impression that P2 was in genuine pain. He had presented over many years reporting severe bilateral knee/patella pain which he had attributed to multiple patella dislocations since childhood.
5. When Dr Nguyen started treating P2 in July 2019, he reported that the pain was increasingly affecting his ability to sleep and exercise. Another doctor at the Medical Centre had started P2 on Panadeine Forte on 26 November 2019 when P2 presented 'in tears' due to bilateral knee pain.[11] On 20 November 2019, P2 had also reported very painful knees to the other doctor.
6. Dr Nguyen added Meloxicam and later Lyrica after P2 had been provided with 'Nurofen 400mg ps stat for severe pain knees...'. This was after P2 had presented to the Medical Centre on 27 November 2019 'tearful +++' and was 'very emotional, burst into tears c/o pain' to the other doctor and the practice nurse.[12]
7. P2's reports of severe knee pain continued.

1. On 19 December 2019, Dr Nguyen added Targin which P2 reported was not effective. Dr Nguyen was also making referrals to Mr Wang and Dr Meyer. On 20 December 2019 Dr Nguyen trialled Endone which was prescribed with advice.[13]
2. On 2 January 2020, the other doctor at the Medical Centre prescribed a combination of, amongst other things, Targin and Endone, causing an Amber alert.[14] This was continued by Dr Nguyen and was also consistent with the recommendation of orthopaedic surgeon Dr Brett Jackson of a conservative treatment plan as opposed to more invasive approaches, such as arthroscopy, for P2's patella issues.[15]
3. At all times Dr Nguyen's prescribing was guided by P2's presentation and his consistent ongoing reports of severe pain. Dr Nguyen accepted these reports as genuine and for which other medications had been trialled and were ineffective.
4. Concerning Dr Meyer's report, clinical notes reveal that Dr Nguyen had regard to it.[16] He noted that Panadeine Forte was not effective and that the plan 'for now' was to keep, 'Targin 20mg mane, Targin 30 mg nocte, PRN Endone up to 4x/day'.[17]
5. His error was that he allowed something of a holding pattern to continue for P2's opioid medication. A further reason for this was the impact of COVID-19 on the ability to access physiotherapy treatment and the associated struggle P2 was having as a result of the pandemic itself in addition to his pain.[18]
6. Dr Nguyen, as the notes make clear, encouraged P2 to engage in multi-disciplinary treatment and referred him to many other specialists for their assistance and input with his management of P2.
7. During submissions Member McRae asked Mr Reid to respond to the fact that medical records reveal several practitioners at the Medical Centre prescribing for neuropathic pain (where the nerve signals pain, rather than nociceptive pain, the nerve responding to actual physical injury) where there were very high doses of opiates.
8. Mr Reid responded that Dr Nguyen fell short, failing to have proper regard to the addictive and complex presenting factors that went to inform potential drug seeking behaviours. However, in a case of complexity and nuance, he was trying his best to get specialist assistance. Maintaining a 'holding pattern' was wrong. The high level of prescribing for the period of time was professional misconduct.

1. P3 was another highly complex patient with a significant past medical history, over many years before Dr Nguyen began treating him. His medical history included chronic diarrhoea for over 10 years, obsessive compulsive disorder, codeine and benzodiazepine dependence, anxiety/depression and adjustment disorder.
2. Dr Nguyen's started treating P3 after her long standing general practitioner retired. Prescribing codeine was not contra-indicated or inappropriate.
3. After appraising himself of P3's complex history, Dr Nguyen made various referrals to assist him to manage this complex patient, to:
   • Dr Thomas, with a referral marked urgent, to work on a plan to wean P3 off codeine (4 July 2019);[19]
   • Dr Connelly, gastroenterologist; and
   • Dr Smith for psychiatric assessment to help with P3's OCD, anxiety and depression and to provide additional support to wean her off codeine (10 September 2019).[20]
4. These were the steps of a capable, compassionate and caring general practitioner.
5. During 2019 and 2020, Dr Nguyen held five Schedule 8 permits which allowed him to prescribe up to 1140mg (= 38 tablets) of codeine to P3 per day.
6. There were short periods when he prescribed outside the timeframe of those permits while awaiting pain specialist review. He did not renew the permits when he should have.
7. That said, Dr Nguyen always attempted to seek the necessary approvals, for the Schedule 8 applications.[21] He recalls that Schedule 8 permits would normally be scanned onto the Medical Centre's computer software when received routinely within a few days by Fax from DHHS. However, this did not occur during the COVID-19 pandemic.
8. Instead, the Department's Hotline was not attended but for an automatic voicemail which referred the caller to check SafeScript. This made it harder to keep track of permit expiry dates and whether permits had not been granted. In addition, the Department somewhat ceased or was slower in issuing previous routine fax reminders about permit expiries. Nevertheless, Dr Nguyen accepts that the responsibility to ensure that Schedule 8 permits are up to date rests solely with him.
9. Carefully reviewing all of the correspondence with Dr Thomas and medical records reveals that Dr Nguyen was valiantly trying to gradually wean P3 off codeine:

a) On 3 July 2019, Dr Nguyen wrote to P3 recommending that she stay with Dr Paul Grinzi (a suboxone licenced prescriber) and take necessary steps like undertaking a Suboxone program;[22] > > b) On 15 October 2019, he wrote to DHHS applying for renewal of a Schedule 8 permit; > > c) Dr Thomas' letter of 10 January 2020 confirms the complexity of P3 saying, 'I am happy for her to remain on the current codeine dose for now two months before then tapering down...';[23] > > d) His letter of 19 February 2020 says, 'she has cut back all her other medications and her weight and that she seems to be doing quite well from an emotional perspective, that this is reasonable' [38 codeine tablets per day]. Dr Thomas reminded Dr Nguyen to update his permit;[24] > > e) On 28 February 2020, Dr Nguyen wrote to the Department seeking a further Schedule 8 permit, commenting that P3's 'Codeine 'addiction' has been built previously over a messy 10 years, it will take patience and time to wean her off';[25] > > f) On 28 February 2020, Dr Nguyen noted that P3 was making progress;[26] > > g) Dr Thomas' letter dated 31 May 2020 says:[27]

The codeine phosphate level is coming down albeit very slowly which is appropriate. I am happy for you to take the front running on this without necessarily my involvement. I suggested that I see [P3] prior to Christmas ...'

h) On 28 August 2020, Dr Nguyen wrote to Dr Thomas with a positive report concerning P3, thanking Dr Thomas,[28] who on 8 September 2020 replied appreciating Dr Nguyen's letter; and

1. On 20 October 2020, Dr Smith consultant psychiatrist, wrote to Dr Nguyen, concerned about P3's continued codeine use.[29]

1. While Dr Nguyen admits professional misconduct, he took meaningful steps to manage a very complicated patient, for which P3 told him she was grateful.[30]
2. Dr Nguyen was treating a highly complex patient, engaging the assistance and support specialists. Rather than not properly taking Dr Thomas' views, he was attempting to, very slowly, reduce codeine prescribing.
3. Concerning the criticism of not referring P3 to an opioid substitution program, P3 declined to do this, relevant in the context of weaning down from very high doses. Dr Nguyen was taking positive proactive steps. He was attempting to seek approvals, which were delayed during the pandemic.

Clinical Records (Allegation 4) - submissions for Dr Nguyen

1. Dr Nguyen's accepts that his clinical records were inadequate.
2. Medical records serve a number of purposes including:

a) Helping GP's make decisions about patient care by providing information about the particular presentation, providing a structure for thoughts and decision making and a record of previous consultations; > > b) Recording consultations provided by other health professionals to facilitate safe and effective care for patients; > > c) Providing a source of information to be shared appropriately with other health professionals to facilitate safe and effective care; and > > d) Providing a source of information to be shared with patients to facilitate a partnership in healthcare based on trust and respect.

3. Concerning the inadequacies, the contents of the clinical records themselves are of a nature and quality better than other examples of inadequate record keeping that have been heard by the Tribunal. The inadequacies alleged are at the lower end of the scale.
4. While the notes fell short of serving the purposes of clinical notetaking, they did not fall that far short. Concerning P1, as an example it was agreed the notes were brief and lacking sufficient detail. However, there was some detail. While Dr Nguyen did not document a long-term management plan, a 'plan of attack' with respect to the presenting problem was evident.
5. Allegation 4, as agreed between the parties and the records themselves which were in evidence at VCAT shows that inadequacies here were magnitudes below the deficiencies in a case such as Medical Board of Australia v Pham.[31]
6. Dr Nguyen's improved record keeping were observed by Dr Holdstock, who in her 20 April 2022 Supervisor Report said:[32]

In the supervision sessions, Dr Nguyen has showed that he can take his time more with each patient. This has enabled him to take a more thorough clinical history and then record his comprehensive notes in an active and timely manner. I have observed him doing this for over 12 months now.

He has shown he can focus attention, enthusiastically listen, learn and augment his clinical practice skills in a variety of ways:

• His clinical medical record keeping in each section of his medical notes including reason for visit, history, examination and action plan are more complete now with significant detail and a clearer management for his colleagues to follow.

Appropriate determinations - submissions for Dr Nguyen

1. What is necessary in any particular case to meet the objectives of determinations will depend on all the facts and circumstances.
2. The Board's submissions do not give sufficient weight to the extensive improvements seen in Dr Nguyen's work, as reported by his supervisor, to the completion of education and reflection, and the now significant time between the concerns identified to May 2024.
3. The events in question were (when VCAT heard this matter and made orders) approaching four years ago. The Board's submissions place too high an emphasis on general deterrence, focusing too heavily on a comparative exercise between other cases and what happened in those and fails to appropriately consider and apply the particular circumstances of Dr Nguyen's situation.
4. Dr Nguyen accepts and has acknowledged the serious nature of his misconduct.
5. That said, he:

a) Was actively trying to manage three extremely complicated patients having arrived into their care well into their respective health journeys; and > > b) Sought to engage in multi-disciplinary management and a referral framework.

6. VCAT should conclude, in context of the admitted deficiencies in the conduct that it is at the lower end of the scale in terms of possible examples of departures of this type.
7. Given Dr Nguyen's, comprehensive steps to address the deficiencies, imposing a suspension, in addition to a reprimand, is not necessary.
8. Suspension of his registration would adversely impact him financially and impact his ability to deliver reliable, timely and continuity of care to his numerous patients.
9. For example, he has a number of dedicated patients who continue to seek their care from him which started at his previous places of employment. This includes a patient who Dr Nguyen first saw while working on Phillip Island. This patient travels approximately 140km to see Dr Nguyen.
10. The Medical Centre is located in inner Melbourne, where there is a real sense of community, rapport, care and support between patient and practitioner. These factors, nurtured over years in many cases, come with a great sense of personal responsibility in his therapeutic relationships.
11. Dr Nguyen has no prior regulatory matters. This points to a practitioner who is otherwise competent, capable and professional, delivering care to the community in which he operates.
12. Also, in Pharmacy Board of Australia v Elias,[33] it is recognised that if a matter is hanging over a practitioner's head for an extended period, is a mitigating factor.
13. In Medical Board of Australia v Proctor,[34] VCAT held it was relevant to take into account the length of time from instigation of complaint to completion of the hearing and that this in itself is a punishment emphasising the consequences of previous unacceptable conduct.
14. In Stirling v Legal Services Commissioner,[35] the Supreme Court of Victoria Court of Appeal held that where there is a period of delay, attention can focus on what the practitioner did during the period. In this instance, Dr Nguyen has continued to work and at a high level, education has been completed and a reflective statement composed all of which points to character, insight and remorse which in turn properly points to consideration of what purpose a suspension serves.

Dr Nguyen's personal circumstances - submissions for Dr Nguyen

1. Dr Nguyen is a 46-year-old, happily married man with two young children. He was born in 1977 in Vietnam just after the Vietnam war ended, migrating to Germany as part of the global outflow of Vietnamese 'Refugee Boat People' when he was 3 years old.
2. He attended the Medical University of Luebeck in North Germany, graduating in medicine in 2005. After practicing in Germany as an intern at a small hospital for approximately one and a half years, at the end of 2007 he migrated to Melbourne.
3. From 2008 to 2010, Dr Nguyen as an International Medical Graduate (IMG) underwent the necessary medical education and registration process to have his international qualifications recognised and he passed all of his examinations on his first attempt.
4. After obtaining his Australian Medical Council certificate, Dr Nguyen shortly thereafter applied for, and received, his general registration as a medical practitioner.
5. He was admitted into the Australian GP Training Program (SGPT) South Eastern Region (2012 to 2015) and he practised for a total of eight and a half years in rural Victoria at various locations.
6. In 2016, he achieved Fellowship of the RACGP in 2016.
7. Dr Nguyen should be seen to have made an impressive contribution to the practice of medicine in his adopted country.
8. In 2018, he moved to live and work in Melbourne and since 2019, had worked at the Medical Centre.
9. He has built a fine reputation as a caring, compassionate and capable doctor. The updated references, in addition to the materials included within the Tribunal Book, speak to the fine reputation of Dr Nguyen.
10. One tends to forget just how disruptive and frightening the initial stages of the COVID-19 pandemic were at the time. Although Dr Nguyen does not seek to proffer this as an excuse, it is submitted that the challenges (both professional and personal) during a pandemic may provide an additional context for what occurred here.

1. The objective of general deterrence, being the only relevant or overriding objective in the present case, can be achieved in Dr Nguyen's case by imposing a reprimand.
2. A reprimand is a determination of significance and substance. The Tribunal recently restated as such in Osteopathy Board of Australia v Canagasabai:[36]

General deterrence is an important consideration, namely the deterrence of other practitioners who may be minded to conduct themselves similarly. The characterisation of the conduct as professional misconduct sends a message to other practitioners that a breach of the Code of Conduct is viewed by the Tribunal as amounting to conduct that is substantially below the standard reasonably expected of an osteopath. Any practitioner reading this decision will take heed of the consequences of Mr Canagasabai's behaviour.

The Tribunal has determined to reprimand Mr Canagasabai which is a powerful general deterrent. This constitutes a significant professional sanction, a serious matter for any professional person. As described in the factors outlined in Lee, 'any form of official censure is a consequence.

1. Members of the public suitably informed of the facts of this case, would not demand Dr Nguyen's suspension and would also accept that the maintenance of professional standards in their eyes has been met by this outcome.
2. Likewise, practitioners viewing Dr Nguyen's trajectory since these matters in 2020 (comprising of intensive supervision, education and reflection) would consider that other members of the profession would be appropriately deterred.
3. There is also a positive message to send to the profession, that a doctor who transgresses and then recognises such, and takes all available measures to learn and reach a point where specific deterrence is no longer required, can also reach the point where suspension is not required as a matter of general deterrence. This would be incentive for such conduct by future practitioners.
4. It was submitted that the cases cited as precedents here provide only limited guidance. This case has many differentiating features as already discussed, such as Dr Nguyen now a very different medical practitioner to the one who engaged in the professional misconduct.
5. To suspend Dr Nguyen in circumstances where on the evidence there is little to no possibility of repeat conduct would amount to a punishment rather than protection of the public.

1. We determined that general deterrence and upholding the reputation of the profession required a two-month suspension, noting that specific deterrence was not required here.
2. We agreed with the Board's submissions concerning the professional misconduct found in this case, with the unprofessional conduct related to recordkeeping, which as serious as that is, playing a lesser role in this context.
3. We accepted Dr Clohesy's expert opinion as to Dr Nguyen's professional misconduct concerning:

a) P1 at paragraph 120(a) to (e); > > b) P2 at paragraph 122(a) to (h); and > > c) P3 at paragraph 123(a) to (j).

4. There are many very complex patient circumstances in the community. That is the modern nature of Australian medical practice, for which medical practitioners are educated and holistically trained.
5. Within the patient community, there are some patients who may be persuasively manipulative to their own ends. Medical practitioners must be alert to this, identify when such circumstances are present, and manage these with thought and care. Other patients may not be completely compliant with, or supportive of, medically recommended alterations to past, long-term, prescribing patterns. They may resist substitution to a potentially more effective treatment regime, based on an evidence-based approach.
6. Pain has many neurological, physical and psychological origins. Each pain situation requires specific analysis of what is occurring, and where they may overlap. In doing so, it is the practitioner's responsibility to regularly consider pain origins, pain management options and the threat of dependence and abuse of medications.
7. Nociceptive pain and neuropathic pain are separate, but real, medical presentations. They require specific analysis of what is occurring, when and why, where they may overlap.
8. It is therefore unacceptable to fail to grapple with the complexity of a case such as P1, and to merely 'copy' what others have done earlier, including increasing prescribed medication doses without careful thought and analysis.
9. There is a fundamental requirement to make an individual assessment as to what is occurring and why, every time any prescription is produced. Otherwise there becomes a substantial risk of simply increasing prescribed medications to such an extent, creating profound risk of precipitating overdose levels of medications, potentially resulting in patient harm.
10. It is important to continue to assist patients, which is more than leaving them in a 'holding pattern' in cases, such as with P2.
11. There is a fundamental imperative to assist patients to improve their circumstances, even in difficult situations such as P3 declining a substitution strategy, against her best interests.
12. While Dr Nguyen is to be commended for his insightful response, which results in him now being a medical practitioner who is well-informed and able to provide reasonable and relevant treatment, including prescribing Schedule 4 and paragraph 8 medications, a strong message is required through suspension.
13. We do not intend the two-month suspension as punishment of Dr Nguyen, although, as is well recognised, determinations may unavoidably amount to something in the nature of punishment. We do intend that a strong message be sent.
14. One of the key messages we send is, if you are a medical practitioner in the Australian medical system, who finds yourself 'out of your depth' when treating complex patients seeking high-level opioid prescriptions, the question that has to be asked is whether your continuing to treat the patient has the risk of exposing that patient to harm, or even death.

1. The courageous decision in such circumstances, is to refuse to treat the patient, and perhaps undertake further training and education to be better equipped at a later time. Patients ought to have their care transferred to a specialist in pain therapies.
2. We view Dr Nguyen, who we accept is a caring and compassionate medical practitioner, admired by patients, as finding himself, then, well out of his depth.
3. This is in part demonstrated by the unusually lengthy supervision and education which Dr Nguyen with dedication undertook, in part with Dr Holdstock.
4. While Mr Reid provided extensive skilful submissions in mitigation of Dr Nguyen's professional misconduct, the reality is the seriousness of his professional misconduct remains.
5. We did not accept that to the extent that Dr Nguyen may have extended patterns of prescribing by previous medical practitioners, provides some form of excuse, noting that Dr Nguyen from an early stage took responsibility for his conduct.
6. As far as we are aware, no notifications about any of the other medical practitioners were received. We do not know the context in which previous prescribing occurred.
7. In any case, each medical practitioner when a patient comes before that practitioner is responsible for appropriate treatment of that patient. If there had been previous, say (wholly hypothetically) dangerous prescribing, that could provide no excuse.
8. We have not accepted that Dr Nguyen's commendable educational efforts led to only reprimand being the appropriate determination in this case. As the Board submitted, if he had failed to well respond to the situation, the period of suspension would have been longer.
9. In our view, the message from determinations here should not be that if a medical practitioner's prescribing of opioid medications constitutes professional misconduct, the prospect of avoiding suspension should serve as motivation for engaging in professional development. Sufficient motivation should come from improving one's professional practice such that professional misconduct never reoccurs and, secondarily, the prospect of avoiding an even longer suspension.
10. We do not accept that the admitted deficiencies are at the lower end of the scale, where risk of death through inappropriate prescribing arose.
11. While we acknowledge the negative personal and professional consequences of suspension for Dr Nguyen and that for a time his patients will be denied treatment by him, that is outweighed by the objectives of suspension here.
12. In a situation where Dr Nguyen has continued to work since the events in question, for some time unable to prescribe opioid medication, in the context of the objectives of suspension, we have not reduced the suspension period.
13. Submissions from the Board and Dr Nguyen cited previous Tribunal decisions, in Victoria, New South Wales and Queensland, including the following.
14. In Health Complaints Commissioner v Chen,[37] a registered specialist general practitioner inappropriately prescribed and overprescribed a range of Schedule 4 and Schedule 8 drugs to 15 patients without conducting appropriate medical examinations or obtaining authority to prescribe to drug dependent patients, in instances where authority was required. The conduct included providing drugs to drug dependent persons who were exhibiting drug seeking behaviours. The Tribunal found that the conduct met the definition of 'professional misconduct'. The practitioner's registration was cancelled, with an 18 month review period set.
15. In Medical Board of Australia v RRB,[38] a registered medical practitioner prescribed a family member with high quantities of drugs of dependence including benzodiazepines and opioids. The prescriptions were provided despite the patient having a history of drug dependence, displaying drug seeking behaviours and hospitalisation for an overdose. The Tribunal found that the practitioner had engaged in professional misconduct. The practitioner was reprimanded and disqualified for 18 months.
16. In Medical Board of Australia v Griffiths,[39] a registered medical practitioner inappropriately prescribed opioids and benzodiazepines to nine drug dependent people. The conduct involved the medical practitioner prescribing Schedule 8 medications either without a permit, after the permit had expired or in doses that exceeded the maximum allowed under the permit. The Tribunal found that the practitioner had engaged in 'professional misconduct' under the definition within (a) and (b). The Tribunal reprimanded the practitioner, suspended him for three months and imposed education and mentoring conditions on his registration. The Tribunal expressed concern that three months may not be sufficient to address the serious nature of the conduct but gave weight to evidence of community support and the need for the practitioner to continue to practice in a regional area.
17. In Medical Board of Australia v Ong,[40] a medical practitioner was referred to the Tribunal in relation to inappropriate and excessive prescribing of pseudoephedrine and restricted drugs of dependence. The conduct related to 12 patients and also involved inadequate medical records. The Tribunal found that the practitioner's conduct met the definition for 'professional misconduct'. The Tribunal suspended the practitioner's registration for one month and imposed conditions on her registration, including mentoring and auditing of the practitioner's records. The practitioner had demonstrated insight into her conduct and had engaged in further education.
18. Noting the limited usefulness of previous decisions, none of which deal with a scenario close to the scenario here, we view two months as sitting comfortably in 'the range'.

[1] As set out in the schedule to the Health Practitioner Regulation National Law Act 2009 (Qld) adopted in Victoria under the Health Practitioner Regulation National Law (Victoria) Act 2009 (Vic).

1. [2] These prescriptions are in addition to the list of medication above at [20].

[31] [2024] VCAT 388.

[33] [2020] VCAT 496.

[34] [2018] VCAT 576.

[35] [2013] VSCA 374.

[36] [2024] VCAT 358 at [123]-[124].

[37] [2016] NSWCATOD 144.

[38] [2023] VCAT 666.

[39] [2017] VCAT 822.

[40] [2016] QCAT 54.