1. Significant legislative and administrative steps have been taken in South Australia to control and limit the inappropriate prescription, supply and use of drugs of dependence. The Book of Documents contains a (partly redacted) statement of Dean Piper, which outlines some of those steps.[7]
2. Section 18A of the Controlled Substances Act 1984 (SA) regulates the prescription or supply of drugs of dependence. Section 18A(1) provides:

A registered health practitioner must not prescribe any drug of dependence for, or supply any drug of dependence to -

(a) a person for regular use by the person during a period exceeding 2 months, or during a period that, together with any other period for which a drug of dependence has, to the practitioner's knowledge, been prescribed or supplied by a registered health practitioner, would result in drugs of dependence being regularly used by the person during a period exceeding 2 months; or

(b) a person who the practitioner knows or has reasonable cause to believe is dependent on drugs,

unless the practitioner prescribes or supplies the drug in accordance with an authority granted by the Minister under this section or in circumstances that are exempted from this subsection by the regulations.

Maximum penalty: $4 000 or imprisonment for 4 years.

1. An application for an authority of the Minister must be in writing and in the manner and form approved by the Minister and must contain the prescribed information.[8] An authority given by the Minister must specify the quantity of the drug which may be prescribed or supplied and the period for which it may be prescribed or supplied.[9]
2. The Controlled Substances Act (and the Controlled Substances (Poisons) Regulations 2011) are administered within the South Australian Department of Health by the Drugs of Dependence Unit (DDU).
3. The DDU receives from all community pharmacies records of drugs of dependence dispensed. It receives reports from health practitioners who have suspicions that patients are drug dependent. It is tasked with the role of monitoring compliance with the legislation.
4. The DDU also provides advice and services to health practitioners to assist them in identifying drug dependent patients and drug-seeking behaviour by such persons.[10] Further details of such services are contained in Mr Piper's statement.
5. The statutory scheme is designed to achieve important public objectives. It is essential to the success of the scheme that medical practitioners comply with the legislative requirements and are cooperative and candid in their dealings with the DDU.

1. The Tribunal makes findings in accordance with the statement of agreed facts and its consideration of the other agreed supporting documents. Our findings may be summarised as follows.
2. At all relevant times the respondent has held general registration and specialist registration in the field of general practice. During the period from 2010 to 2015 he was practising exclusively at the Norwood Village Medical and Dental Centre (the Clinic).
3. The inappropriate prescribing concerned the following drugs:
   • Oxycodone, marketed under the names OxyContin (extended release formulation) or Endone (immediate release formulation).
   • Methadone (a drug used to treat opioid dependence and chronic pain)
   • Morphine
   • Buprenorphine, and
   • Alprazolam.
4. These medications are each listed as drugs of dependence for the purposes of s 18A. They must not be prescribed without a Ministerial authority -
   • to a person the prescriber knows, or has reasonable cause to believe, to be drug dependent, or
   • to any person where the prescription will facilitate regular use of drugs of dependence by the patient for a period greater than two months. (This means that use as a result of the prescribing of other practitioners must be taken into account).

1. The respondent prescribed oxycodone to Patient 1 (P1) on 18 occasions during the period from December 2014 to May 2015. The details are set out in paragraph 1.2 of the statement of agreed facts. The patient notes[11] indicate that other practitioners from the Clinic also prescribed that drug to the patient on 4 June 2014, 13 October 2014, 16 December 2014, 23 December 2014 and 31 December 2014.
2. At no time was such prescribing the subject of a Ministerial authority.
3. The respondent states that he assumed that another Doctor at the Clinic had obtained an authority.[12] There was no basis for such an assumption. The patient notes contained no suggestion that any authority had been sought or granted. Moreover, even if there had been an authority, the respondent would have been unaware of what prescriptions it authorised, for what period, and on what conditions. The respondent's approach was inconsistent with the legislative requirements and with his professional responsibilities. At best, the respondent was reckless and unconcerned as to compliance with the legal requirements.
4. After initially prescribing 20 Endone tablets, designed to be taken at the rate of 3 per day, the respondent increased the number prescribed on 25 January 2015 to 120 tablets. One would expect that this supply would last for about 40 days. On 1 February 2015 the patient reported that she had inadvertently thrown out the medicine and she was provided by the respondent with a further script for 120 tablets. The patient then returned on 16 February and received a further script for 120 tablets.
5. The pattern of prescribing continued, albeit that there was a period where Oxy-Contin was prescribed and then a return to Endone. There could be no doubt that the patient was taking drugs of dependence regularly in significant quantities and had been doing so for well over two months. An authority was required.
6. There were also increasing indications that the patient was, or was becoming, dependent on such drugs. On 3 April 2015 the respondent prescribed 56 tablets of OxyContin 15mg. On 13 April 2015 the patient returned and reported that she had lost the prescription together with her money, bag and cards at the Footy. The respondent provided her with a further prescription for 56 tablets. Despite the concern that should have been raised by such circumstances, the respondent subsequently provided prescriptions on six occasions between 1 May 2015 and 24 May 2015 for a total of 200 Endone 5mg tablets.[13]
7. On 10 April 2015 the DDU wrote to the respondent (the DDU letter) concerning the patient.[14] The patient notes[15] suggest that this letter was uploaded to the electronic file (patient notes) on 15 April 2015. It would have been available to the respondent when he next examined the patient notes.
8. The respondent suggests[16] that hard-copy correspondence received at the Clinic at Norwood was forwarded to head office in NSW for uploading and it often took a week or two for that to occur. However, the letter in question was addressed to the PO Box in NSW and the notes themselves suggest that it was uploaded on 15 April 2015. We would expect that priority would be given to uploading correspondence of this nature. We find that this letter was uploaded on 15 April 2015 as the notes suggest.
9. The respondent states[17] that he did not see the letter until 18 May. That may be so if he did not check the electronic patient notes carefully enough when he wrote prescriptions for the patient on 1 May 2015, 8 May 2015, 11 May 2015 and 16 May 2015.
10. The DDU letter suggested that the patient was a drug-seeker and was obtaining drugs of dependence from various medical practitioners. The letter sought information from the respondent to assist in assessing whether the patient was drug dependent. The respondent was requested to complete and return an attached form. He was specifically asked to indicate the period over which he had prescribed, or the number and dates of prescriptions.
11. The respondent states that he first saw this letter on 18 May 2015. It is an agreed fact that, by this date, the respondent knew or had reasonable grounds to believe that the respondent was dependent on drugs.[18] We accept this agreed fact, but simply comment that strong grounds for suspicion (and arguably belief) existed well before that.
12. On 18 May 2015 the respondent completed and signed the form that had been sent to him by DDU.[19] He indicated on that form that treatment of the patient with drugs of dependence had commenced in June 2014 to treat back pain and sciatica and in September 2014 to treat cervical radiculopathy. He stated that such treatment was not continuing and had been discontinued on 18 May 2015. This was false. In fact, on 18 May 2015 he prescribed a further 40 Endone tablets. Subsequently, on 24 May 2015, he prescribed a further 40 Endone tablets. He did not correct the false information provided to DDU.
13. Under a heading, "Additional Remarks (including possible dependency issues)", the respondent wrote:

Lost medication syndrome twice: No correspondence from specialists yet.

He provided no further information as to the extent or frequency of the prescribing or any view as to the patient's drug dependency.

1. The respondent accepts that he was aware, by 18 May 2015, that there was no authority in existence. He had reasonable cause to believe the patient was drug dependent. He knew that regular use had occurred for well over two months and that, for all of those reasons, an authority was required. Nonetheless, he prescribed Endone in significant quantities without an authority on 18 May and again on 24 May.
2. It was not until 29 May 2015 that the respondent first applied for an authority to prescribe.[20] On this form he indicated that the prescribing had commenced in March 2015. This was incorrect. His application was refused[21]. The respondent saw the patient on 6 July 2015 after the letter of refusal. His note records "Further opioids declined with regret".

1. Patient 2 (P2) was a patient of the Clinic from November 2005 to October 2015. The respondent states that he saw the patient on 3 occasions in 2006 and 2007 but started seeing him more regularly in about July 2012. The patient also continued to see other practitioners at the clinic.[22]
2. From February 2012 the patient was regularly prescribed OxyContin by other doctors at the clinic.[23] Between 21 July 2012 and 26 January 2014 the respondent prescribed OxyContin to the patient on 10 occasions. The details of this prescribing are set out in paragraph 2.2 of the statement of agreed facts.[24]
3. It is common ground that the patient's regular use of this drug gave rise to the requirement to obtain an authority under s 18A.[25] No authority was ever obtained.
4. The respondent states that he assumed that an authority had been obtained by one of his colleagues.[26] Prescribing on the basis of such an unfounded assumption was irresponsible and inconsistent with his professional responsibilities and the legislative requirements.
5. The respondent prescribed Oxycontin on 21 July 2012, 27 July 2012, 31 July 2012, and 3 August 2012.
6. On 9 August 2012 the patient was seen by another practitioner at the Clinic. The consultation note reads:

Came in limping, has chronic back pain after playing soccer in Europe, wants oxycontin, didn't realise Dr TR was on leave.

Records noted, had 28 oxycontin on 03-08-12, said that he was in earlier in the week and not that Fri, even so far too much oxycontin unaccounted for. Admits to sometimes taking more than prescribed dose.

Advised that will not prescribe more oxycontin for him. Advised that if he is taking more and more, may be developing tolerance/addiction and should see Dr Holmwood at Warinilla.

Wasn't happy but accepted this and wasn't aggressive.[27]

(Emphasis added)

1. On 3 August 2012 a senior consultant from the Pain Management Clinic at the Royal Adelaide Hospital wrote to a practitioner at the Clinic concerning the patient (the PMU letter).[28] The letter, which was documented in the patient notes on 9 August 2012,[29] outlined that the patient had lied about his recent use of oxycontin and had promised to cease such use, but had not done so. It continued:

Unfortunately [P2] has not been honest and it is not safe to continue prescribing opioids for him in the traditional manner. I recommend that he have no more prescriptions or authorities for opioids. If he wishes to continue taking opioids for his back pain, he should be referred to Warinilla for daily pick-ups via the drug substitution scheme.

I will report him to the Drugs of dependence Unit.

(Emphasis added)

1. The patient saw another practitioner at the clinic on 24 August 2012, seeking OxyContin. The PMU letter was discussed with him and the requested prescription was refused. The patient was advised to attend Warinilla.[30]
2. The following day (25 August 2012) the patient again attended the Clinic and was seen by the respondent. The respondent's consultation note reads:

Chronic pain

Poor impulse control and DDU involvement noted.

Marked analgesic gait ... even when unobserved.

Smells like a brewer's dray horse.

Repeat script(s) (q.v.)[31]

(Emphasis added)

1. On this day (25 August 2012) the respondent prescribed 28 OxyContin tablets 20mg. It is conceded (and properly so) that by this time the respondent knew, or had reasonable cause to believe, that the patient was dependent on drugs. Yet on this date and on 5 subsequent occasions he prescribed OxyContin for the patient without ensuring that an authority had been obtained.
2. After 25 August 2012, the respondent next saw the patient on 8 January 2013 and then 9 March 2013. He prescribed OxyContin on both occasions.
3. On 11 April 2013 the DDU wrote to the respondent concerning the patient (the DDU letter)[32]. A large bold capitalised entry was placed in the patient notes on 12 August:

DRUG SEEKER

SEE RECENT DDU LETTER

1. In the letter the Manager of the DDU advised that the patient was drug dependent and likely to seek drugs by dubious means. He stated:

The Controlled Substances Act provides that it is an offence for a medical practitioner to prescribe without the authority of the Minister responsible for the Act for a person , whom he/she knows or has reasonable cause to believe to be dependent on a drug of dependence, for the purpose of maintaining that person's dependence.

It is recommended supplies of drugs of dependence be refused and this patient be referred to Eastern Drug and Alcohol Services ...[33]

1. It must have been obvious to the respondent by this time that there was no authority in existence. Furthermore, the legal requirements as to drug dependent patients had been spelt out to the respondent by the DDU. It is an agreed fact that all prescribing after 11 April 2013 occurred after the DDU had told the respondent to refuse further prescriptions and to refer the patient to DASSA.[34]
2. The respondent did not see the patient again until 7 December 2013. In the interim period, another practitioner at the Clinic had prescribed OxyContin on 30 October 2013.
3. On 7 December 2013 the respondent prescribed OxyContin, noting that "chemist told him to get all scripts renewed". On 18 January 2014 the respondent again prescribed OxyContin, noting: "Depression, et al."
4. On 20 January 2014 the respondent telephoned the DDU.[35] He was advised that no authority had been granted since 2009. He was advised to prescribe no schedule 8 drugs and to refer to DASSA. This advice was noted in the patient notes on 20 January.
5. The advice was confirmed by letter from DDU dated 20 January 2014.[36] It was confirmed that the patient was a drug dependent person and that it was an offence to prescribe without an authority.
6. Despite all this the respondent saw the patient on 26 January 2014 and again prescribed OxyContin 10mg (28 tablets).[37]
7. On 26 January 2014, the respondent applied for an authority.[38] The application was refused on 18 March 2014.[39] The letter of refusal stated:

You must cease prescribing or supplying drugs of dependence to this patient unless done in accordance with a s 18A authority, or an exemption under the Controlled Substances (Poisons) Regulations 2011 (SA).

1. Despite that advice the respondent prescribed methadone for the patient on 7 June 2015 without an authority and in contravention of the legislative requirements.

1. The respondent prescribed morphine to patient 3 (P3) on 15 occasions between September 2013 and July 2015. The details of the prescribing are set out in the agreed facts at paragraph 3.2.[40]
2. The respondent first prescribed morphine to the patient on 10 September 2013. He telephoned the DDU that day and was thereafter aware at all times that no authority to prescribe had been given. He prescribed again on 17 September 2013. He was aware the patient was being seen at Warinilla Clinic.
3. At the next appointment on 15 October 2013 the respondent telephoned DDU to seek a temporary authority. The patient pleaded with the DDU delegate on speaker phone. The application was refused. It was agreed the respondent would send a written application, supported by blood and urine tests.
4. The tests indicated that the patient was not taking the morphine in the doses prescribed. The respondent made a note on 29 October 2013: "Had scripts for Kapanol, therefore selling it".[41] He telephoned the DDU and cancelled the request for an authority.[42] He advised DDU that he suspected the patient of selling the morphine.
5. The respondent again applied for an authority on 24 December 2013 and 14 January 2014.[43] His applications were refused on 5 March 2014.[44] The Minister's delegate stated:

You must cease prescribing or supplying drugs of dependence to this patient unless done in accordance with a section 18A authority or an exemption under the Controlled Substances (Poisons) Regulations 2011 (SA).

1. It is an admitted fact that, at all relevant times after 29 October 2013, the respondent knew, or had reasonable cause to believe, that the patient was drug dependent.[45] The respondent knew that no authority had been granted. Nonetheless, the respondent prescribed morphine to the patient on a further 13 occasions (and for regular use over a period far in excess of two months).
2. On 27 August 2014 the DDU again wrote to the respondent concerning this patient.[46] He was directed to stop prescribing drugs of dependence without an authority. He subsequently prescribed morphine on 11 further occasions. He acted in blatant disregard of the legislative requirements and the directions from DDU.[47]
3. The complainant also drew attention to the application for an authority made by the respondent on 24 December 2013.[48] The respondent had said at interview that he had made this application "in the expectation that it would be refused, just to get him out of my office".
4. This fact was not disclosed on the form, nor did the respondent reveal his beliefs concerning the patient's dependency or the suspicion that he was selling the morphine.[49] Furthermore the respondent filled out the form so as to suggest that the date of commencement of the medication was unknown when he knew (because he had prescribed it) that the relevant date was 10 September 2013. These matters are dealt with at paragraph 3.6 of the statement of agreed facts.[50] It was unprofessional for the respondent to provide inadequate and incorrect information on the form.

1. The respondent prescribed oxycodone to patient 4 (P4) on nearly 100 occasions between 17 May 2010 and 6 March 2011. He also prescribed buprenorphine and fentanyl. The details of the prescribing are set out at paragraph 4.2 of the statement of agreed facts.[51]
2. The patient had previously seen other practitioners of the Clinic, but the records before the Tribunal do not suggest any prescription of Oxycodone.[52] After commencing such prescriptions on 17 May 2010, the respondent states that he made application for an authority on 14 July 2010.[53] The patient notes refer to this application, although no copy is before the Tribunal.[54]
3. There is, in the evidence before the Tribunal, no record of a response to that application for an authority. However, it is common ground that no authority was granted during the period from May 2010 to 6 March 2011.[55]
4. The respondent was fully aware that his application had not been granted. He claims that he thought that he was entitled to continue prescribing until a determination was made.[56] This was, of course, incorrect as a matter of law. The respondent's behaviour was also disingenuous, in our view, as he continued prescribing whilst making no attempt to follow up an application which apparently received no response over a period of about seven months.
5. Be that as it may, it is agreed that the respondent prescribed during the relevant period without ensuring an authority was in force. The nature of that prescribing meant that an authority was required after the initial two months.[57]
6. Furthermore, it is agreed that the respondent was aware by 1 October 2010 that the patient was drug dependent. He continued to prescribe after that date without an authority.[58]
7. The DDU wrote to the respondent on 25 February 2011 concerning his prescribing for the patient. The letter made it clear that no authority had been granted and that no prescriptions should be given. The respondent states that he did not see this letter until 6 March 2011.[59] The patient notes record that he discussed this letter with the patient on 6 March 2011. However, despite the clear instruction from DDU, he again prescribed oxycodone to the patient at that appointment.[60]
8. There is a further matter concerning patient 4 which occurred in 2013. On 25 February 2013 the respondent was granted an authority to prescribe the opioid, buprenorphine, with naloxone in sublingual film form, to the patient. The authority made it clear that prescriptions must be limited to the drugs specifically authorised.[61] This authority remained in force until 28 February 2014.[62]
9. On 26 July 2013, in addition to prescribing in accordance with the authority, the respondent also prescribed the opioid, codeine phosphate (codeine linctus 5mg/1ml 100ml) to the patient without authority.

1. The respondent prescribed oxycodone and morphine to patient 5 (P5) without an authority on 60 occasions between 20 November 2012 and 1 May 2015. The details of the prescribing are set out at paragraph 5.2 of the statement of agreed facts.[63]
2. Between those dates, there was not an authority that permitted the prescribing of oxycodone, nor was there an authority that permitted the prescribing of morphine until 7 January 2015, notwithstanding that regular use required an authority to be obtained.[64]
3. At the time of prescribing oxycodone and morphine for regular use by the patient for a period exceeding two months, the practitioner failed to ensure that there was an authority issued by the Minister's delegate.[65]
4. The respondent states that his colleagues had previously prescribed for this patient and he assumed that an authority must have been obtained. He concedes that this assumption was inappropriate and ought not to have been made.[66] We agree. He had no basis to conclude that an authority had been granted. If an authority had been granted[67], he did not know what it authorised, for what period, or on what conditions. He continued prescribing for a period of years without bothering to check.
5. After receiving a letter from DDU, the respondent applied in December 2014 for an authority to prescribe oxycodone to the patient.[68] He was granted an authority to prescribe morphine. The authority made it clear that no other drug could be prescribed.[69]
6. Notwithstanding this, the respondent again contravened the legislation by prescribing Endone on 3 April 2015 and 1 May 2015 without authority.
7. The respondent admits that he was aware that the patient was drug dependent, but states that he was not aware of his legal responsibilities[70]. They had been pointed out to him by the DDU on various previous occasions. Furthermore, he was contravening the clearly stated conditions of the authority he had been granted in January 2015[71].

1. The respondent prescribed buprenorphine for patient six (P6) on six occasions between 8 March 2015 and 11 May 2015. The details of the prescribing are set out in paragraph 6.2 of the statement of agreed facts.[72]
2. The respondent concedes that he had reasonable cause to believe that the patient was dependent on drugs.[73]
3. For this reason, and because the prescribing facilitated regular use for a period exceeding two months, an authority was required. The respondent applied for an authority on 14 March 2015[74] and this was refused by letter from DDU dated 30 March 2015.[75]
4. The patient notes suggest that this letter was uploaded to the patient file on 7 April 2015. However, the respondent continued to prescribe buprenorphine on 11 April 2015, 1 May 2015, and 11 May 2015.
5. The respondent states that he did not see the letter from DDU until 3 May 2015 when the notes suggest that he discussed it with the patient. He claims that he was not aware that he was prescribing illegally before that date because:

(a) he wrongly believed that he did not need an authority to prescribe for a drug dependent person if the regular use did not exceed two months; and

(b) even if regular use extended beyond two months, he wrongly believed that he could continue to prescribe while awaiting the determination of an application; and

(c) he was not aware of the letter of refusal uploaded to the patient file on 7 April. [76]

1. This degree of naivety is remarkable, especially given the correspondence which he had previously received from the DDU concerning other patients. Even more remarkable is that the respondent again prescribed buprenorphine to the patient on 11 May 2015, after he was fully aware of the refusal and the illegality of doing so.

1. The respondent prescribed oxycodone for the patient on 25 March 2014 and alprazolam on 8 August 2014. However, we did not understand the Board to be pursuing allegations related to the appropriateness of that prescribing.[77] Rather the Board focussed on an application for an authority to prescribe Alprazolam made by the respondent on 6 October 2014.[78]
2. In that application, the respondent was required to state the "Date Medication commenced" He simply inserted a question mark, thereby indicating that he did not know the date. In fact, he did know that he had prescribed alprazolam on 8 August 2014. He should have provided that information. He should also have provided information about possible dependency issues, given a previous history of dependency noted in the patient notes[79] and his own note made on 25 March 2014.[80] It was unprofessional for the respondent to have withheld relevant information from the DDU.

1. It is clear from the above summary that the respondent's conduct was irresponsible and reckless. He regularly demonstrated indifference towards the statutory requirements and on many occasions contravened those requirements in a contumacious manner. He actively misled the DDU and withheld relevant information about his patients. His conduct undermined the regulatory regime which had been established by legislation for the very purpose of protecting those patients and the public generally. His prescribing no doubt placed his patients at risk of harm. He was prepared to accede to the requests of patients rather than acting in their best interests. His conduct fell substantially below the standard of conduct reasonably expected of a practitioner of his level of training and experience. In our view, the conduct, at the time it occurred, was conduct inconsistent with him being a fit and proper person to be registered. We have no hesitation in making a finding of professional misconduct.
2. We consider that such conduct should normally lead to a cancellation or significant suspension of registration. This is necessary in order to bring home to the practitioner and other registered persons that such conduct is totally unacceptable, that it will not be tolerated, and that it will be visited with significant sanctions (Marin v Chiropractors Board of Australia [2020] SASCFC 74 per Kourakis CJ at [73]). It is also necessary to reassure the public that standards within the profession will be maintained and that the public will be appropriately protected. However, there are other important aspects of this matter to be considered.

The respondent's personal circumstances at the time of the conduct

1. The Tribunal received a statutory declaration made by the respondent on 18 June 2020.[81] It outlines matters concerning the respondent's personal history prior to and during the period of misconduct. We also received a report of Dr Tony Davis, consultant psychiatrist which documents and comments on that history.[82] We have considered these documents carefully as they set out the context in which the misconduct occurred.
2. We refrain from setting out all of the detail contained in the documents mentioned. Suffice to say that between 2005 and 2012 the respondent had to cope with a number of extraordinarily difficult circumstances concerning his personal and family life. His son suffered from serious mental illness which led to him assaulting and killing a friend. He was incarcerated on mental health grounds for a lengthy period and, on release, he lived with the respondent and his current wife. His current wife was run down by a vehicle in an alleged attempted murder.[83] She sustained permanent disabilities as a result. His former wife suicided. His daughter's husband suicided. The full context goes beyond these events and is apparent from the documents.[84] We have no hesitation in accepting that the respondent would have experienced ongoing mental anguish and stress as a result of his personal circumstances throughout the time that he practiced at the Clinic.
3. The respondent also states that he worked long hours at the Clinic, often ten to twelve hours a day, six days a week.[85] In late 2013 or early 2014 the respondent was appointed as the 'lead independent doctor" at the Clinic, placing an increased burden of an administrative nature on his shoulders. At a time which is not identified, his additional responsibilities led to some souring of relationships with colleagues.
4. The respondent told Dr Davis that there was significant pressure in the practice to "keep moving" with consultations.[86] We consider that this was likely a significant factor. Giving a prescription was an easy way of moving on to the next patient.
5. The respondent saw his GP during this period and was prescribed medication that was helpful. He opines, with the benefit of hindsight, that he was suffering from depression during this period, but that is not supported as a clinical diagnosis by Dr Davis.
6. Dr Davis opined as follows:[87]

The history indicates that from May 2010 to July 2015 Dr Riddings was generally functioning well in clinical practice, reporting no symptoms of significant medical or psychiatric illness.

He acknowledged that he was prone to some reactive emotional symptoms in response to significant personal stressors and that states of "stress" did contribute to some errors of judgement. He indicated that he was generally able to contain and manage such feelings at work, describing the workplace as a form of refuge from personal problems.

From 2005 onwards he was prescribed the anti-depressant medication, Sertraline (Zoloft) by his General Practitioner. Dr Riddings considers that this medication helped him maintain a stable mental state over many years. I agree with this opinion. ...

The history indicates that Dr Riddings psychological condition did not impact negatively on his ability to practice safely and effectively as a General Practitioner.

I consider that a number of factors contributed to Dr Riddings conduct in relation to the prescription of Schedule 8 medications for multiple patients. It is highly likely that at times Dr Riddings was overwhelmed by the clinical and administrative demands of the practice, at a time that he was committed to the care of many complex and challenging patients with chronic pain syndromes and chronic anxiety disorders. I have referred to a number of administrative issues that added to the complexity of his work. The history indicates that Dr Riddings gave priority to clinical rather than administrative matters, a position that he now acknowledges was unprofessional.

I consider that despite his best efforts to contain worry and distress related to his personal life, Dr Riddings was at times affected by these external stressors in terms of his lack of attention to detail at work, particularly of an administrative sort, and his inability to set limits with patients, giving rise to errors of judgement.

The experience of some conflict with work colleagues in his role as LED of the practice may also have contributed to a state of tension and a lack of focus on important administrative matters.

Dr Riddings now reflects on the fact that he had trouble setting limits with challenging and manipulative patients and that he was at times easily manipulated by these people presenting with complex clinical needs and substance dependence.

Thus, I have not identified a psychiatric disorder per se that has impacted on work performance, but rather psychological issues that are likely to have impacted on Dr Ridding's equanimity and ability to attend fully to all aspects of clinical practice.

1. In commenting on Dr Davis' opinion, we would want to stress that the misconduct in this case is not properly categorised as a failure to attend to administrative matters. Nor is it limited to what we would describe as "errors of judgement". The failure to comply with the provisions of the Controlled Substances legislation meant that patients were prescribed drugs when it was illegal to do so and when in many cases such prescription had been determined by the DDU to be contra-indicated. The misconduct of the respondent related to clinical matters. The respondent proceeded to treat patients in the way he chose without any adequate regard for the expert advice of other practitioners or the legal restrictions imposed in the public interest on the prescribing of drugs of dependence. His conduct was in many instances contumacious and in others reckless. Whilst the respondent no doubt made errors of judgement, the totality of his conduct cannot be properly categorised in this way. Nor was it simply a "failure to attend fully to his responsibilities".
2. With those qualifications, we accept and are assisted by the views of Dr Davis as to psychological issues which may have impacted upon the respondent and affected his ability to attend fully to his responsibilities. It is impossible not to have considerable sympathy for the respondent in the personal circumstances he had to endure. However, the evidence does not suggest that such circumstances can be identified as the substantial cause of the misconduct. The personal circumstances do not explain the most serious aspects of the misconduct. In summary, the misconduct was very serious, and it remains so despite the personal circumstances of the respondent.

1. In his statutory declaration made on 18 June 2020, the respondent states:

I acknowledge that, in the past, there were occasions on which I was not as cognisant as I ought to have been as to my prescribing obligations in respect of Schedule 4 and Schedule 8 medications. I recognise and accept this shortcoming. In my opinion, this shortcoming was attributable to my mental exhaustion and depression given the events I have described. I did not have the time or energy to concentrate on compliance with the relevant legislation in respect of the prescribing of controlled medications.[88]

1. In giving a history to Dr Davis on 8 October 2020, the respondent described his misconduct as having made "errors of judgement" at certain times and in relation to certain patients.[89] He also stated that, in hindsight, he had been a "soft touch" and easily manipulated by certain patients.[90] Counsel for the Board submitted that the evidence fell short of demonstrating full insight as to the gravamen of his misconduct and appropriate contrition. We consider that there is some merit in this submission. The respondent has not really owned the contumacious and stubborn nature of the conduct to which we have already alluded. That aspect cannot be explained away in the manner the respondent would suggest.

1. Following the notification, the Board took immediate action against the respondent. On 11 September 2015 conditions were imposed on his registration, prohibiting him from prescribing Schedule 8 medications, any benzodiazepine medications, or any preparations listed in Schedule 4 containing codeine. The respondent accepted these conditions and states that he has subsequently complied with them. He has not sought to rescind or vary the conditions and says he has no intention of doing so in the future. He describes it as a "relief" that he can no longer be asked to prescribe those medications.[91]
2. The respondent continued to work at the Clinic until 2018. He then moved to Queensland and obtained a position at Sonic HealthPlus in Moranbah from June 2018 to April 2020. Since April 2020 he has practised at the Medicrew Medical Centre, Twin Waters. The Tribunal received letters from the directors of the Medicrew Medical Centre and the practice manager.[92] The Centre is fully aware of the conditions attaching to the respondent's registration and ensures that he practises within those conditions. In addition, there is a long-standing practice that doctors at the Twin Waters Centre will not prescribe any benzodiazepines or opioids. It is stated that the respondent enjoys a high reputation amongst his patients and has a large and growing practice. These patients would be detrimentally affected if his registration was suspended. The Directors express the view that the respondent is a "highly experienced and careful practitioner". They express support for his continued practice and will happily accommodate any further conditions that may be placed on his registration. Dr Simona Eremia, a colleague who practised with the respondent at Twin Waters, has also provided a letter in which she expresses similar views about the respondent's competence.[93]
3. There is evidence indicating that the respondent has established a relationship with a general practitioner and a consultant psychiatrist and intends to maintain those relationships as required by the proposed conditions. A report from Dr Todd Cash, the consultant psychiatrist, expresses the view that there is presently no psychiatric reason why the respondent cannot continue work as a general practitioner.[94]
4. The respondent has completed two courses offered by the Medical Insurance Group Australia: "Medical Notes" in November 2016 and "Just Sign Here Doctor" in February 2017.
5. It has not been suggested that the respondent has engaged in any professional misconduct since 2015.

1. Before turning to the crucial issue, it is relevant for the Tribunal to note that the respondent has been practising as a general practitioner since 1967. He has no previous disciplinary history.

1. The purpose of disciplinary action is entirely protective and does not involve any element of punishment. The purposes for which disciplinary sanctions may be imposed are discussed in many cases and need not be restated here.[95] The Tribunal has recently reviewed some of the leading authorities in Medical Board of Australia v Tunbridge [2020] SACAT 34 at [19]- [24].
2. The respondent has engaged in serious professional misconduct and a reprimand is clearly appropriate.
3. We also consider that it is appropriate to impose the Conditions jointly suggested by the parties.[96] Those Conditions will maintain the restrictions currently in place with respect to the supply or prescription of medications. The conditions also implement several strategies for ensuring and monitoring the safety of the respondent's practice. He must practice only at approved locations and for approved hours. The number of consultations per day is regulated. Reports may be obtained from a senior person at the practice and the respondent must submit to an audit of his practice. There are mechanisms to monitor compliance. The respondent must regularly attend a general practitioner from whom reports may be sought. The costs of compliance with the conditions must be met by the respondent.
4. We have referred to the fact that we have some reservations about the respondent's level of insight and contrition. However, with these Conditions in place, we consider that the respondent does not pose an unacceptable risk of further professional misconduct in the future. We hope and trust that this experience and the order that we make will convince him of the importance of respecting and complying with legislative and professional requirements.
5. The respondent submits that no further disciplinary action is required or necessary. We do not agree with this submission. It is of the greatest importance that practitioners are persuaded to comply with, and support, the legislative regime designed to protect patients and the public generally in relation to supply of drugs of dependence. Reckless prescribing and blatant defiance of the legislative requirements are matters of the utmost seriousness. It is necessary to send a message, not only to the respondent, but to other members of the profession, that such misconduct will not be tolerated and that it will lead to significant sanctions.[97] It is also important to reassure the public that standards will be maintained in the profession.
6. We have not received great assistance from the comparative cases to which we have been referred.[98] The sanctions imposed in those cases are very diverse and often difficult to reconcile.[99] We are of the view that serious professional misconduct of this nature would commonly lead to a substantial suspension or disqualification. We accept that a reprimand and conditions are not insignificant matters for a practitioner.[100] However, for serious misconduct of this nature, and in the circumstances of this case, they are insufficient to send the necessary message.
7. The respondent submitted that, if we were of the view that a reprimand and conditions were insufficient, we should consider imposing a fine rather than a suspension.
8. We have seriously considered the imposition of a suspension. That (or cancellation) would almost certainly have been the outcome if the matter had come before the Tribunal in a timely way. There has been a delay of over five years since the notification. The respondent has had this matter hanging over his head for a long time. We are sure he would not want to be involved in such a process again, nor would other practitioners wish for such a fate. In this limited way, there is an aspect of deterrence arising from the delay. More significantly, the respondent's circumstances have changed, and he has demonstrated a degree of insight and contrition. He appears to be practising successfully in a very different environment. Given that he is 80 years of age, a suspension would disrupt the twilight of his career and the treatment of his patients. It appears to us that the complainant has recognised the force of these considerations by seeking a period of suspension which is shorter than might otherwise have been suggested.
9. In the somewhat extraordinary circumstances of this case, we consider that it would be an adequate disciplinary response to impose a very significant fine. Such will underline for the respondent and other members of the profession the seriousness of the professional misconduct and the fact that it will not be tolerated. The public can be assured that standards will be maintained and that such conduct will give rise to serious consequences.
10. We impose a fine of $25,000.00. It is a large amount, but anything less would fall short of adequately achieving the disciplinary objectives. Indeed, we regard the fine as lenient in comparison to the suspension that might otherwise have been imposed. We have it in mind that this fine might be paid in monthly instalments over a period of about 12 months, but we will give liberty to apply if orders are required in relation to any such ancillary matters.

1. The Tribunal made the following orders:
   1. The Tribunal decides pursuant to s 196 (1) of the National Law that the respondent has behaved in a way that constitutes professional misconduct.
   2. The Tribunal imposes the following disciplinary action pursuant to s 196 (2) of the National Law:

(2) Conditions are imposed on the respondent's general and specialist registration in the terms set out at pages 516-518 of the Joint Book of Documents (Exhibit C2). The review period for these conditions is 12 months.

(3) The respondent is required to pay a fine of $25,000.00 to the Medical Board of Australia.

1. The respondent is ordered to pay the costs of the complainant to be agreed or fixed by the Tribunal.
2. Pursuant to s 60 of the SACAT Act 2013, we make an order prohibiting the publication of the names of, or any material tending to identify, the patients named in the complaint or in other documents before the Tribunal.

[1] Health Care Complaints Commission v Litchfield [1997] NSWSC 297, (1997) 41 NSWLR 630 at 637_; Craig v Medical Board of South Australia_ [2001] SASC 169; (2001) 79 SASR 545 at [61]; Medical Board of Australia v Lee [2019] SACAT 72 at [57]; Medical Board of Australia v Konidaris [2019] SACAT 52 at [48] - [50]; Nursing and Midwifery Board of Australia v Parnis [2020] SACAT 78 at [52]- [54].

[6] Complainant's written submission paragraph 5.

[10] For details of the services provided and available, see the statement of Piper at BD pages 43-46.

[47] See agreed fact BD page 36, paragraph 3.7.

[49] But note that the respondent had advised DDU of his suspicion the drug was being sold during a telephone call on 29 October 2013.

[54] BD page 152 - note dated 15 Jul 20.

[55] Agreed facts BD page 38 paragraph 4.3.

[57] BD page 38 paragraphs 4.3 and 4.4.

[62] Agreed facts BD page 38 paragraph 4.6.

[73] R4 at paragraph 62; statement of agreed facts BD 40 at paragraph 6.5; see patient note on 8 March 2015 BD page 196.

[77] BD page 29 where it is indicated that paragraphs 7.3 and 7.4 were not pursued.

[79] BD page 207 - note on 10 March 2014.

[83] The evidence does not reveal the outcome of charges apparently laid against the perpetrator.

[84] We have refrained, for privacy reasons, from mentioning some aspects, but we have taken them all into account.

[91] R4 paragraphs 6-8; see also BD page 512.

[95] Craig v Medical Board of South Australia [2001] SASC 169 at [41] - [48]; Nursing and Midwifery Board of Australia v Symons [2020] SACAT] 8 at [50]- [51]; Marin v Chiropractors Board of Australia [2020] SASCFC 74 at [70]- [74].

[97] Marin v Chiropractors Board of Australia [2020] SASCFC 74 per Kourakis CJ at [73].

[98] See, for example, Medical Board of Australia v Fox [2016] VCAT 408 (suspension for 12 months - agreed between parties_); Health Care Complaints Commission v Sallam_ [2018] NSWCATOD 161 (cancellation & disqualification for 12 months); Medical Board of Australia v Bajpe [2014] VCAT 1162 (disqualification for just over two years); Medical Board of Australia v Ong [2016] QCAT 54 (suspension for one month); Medical Board of Australia v Watts [2019] VCAT 1471 (suspension for 1 month); Medical Board of Australia v Griffiths [2017] VCAT 882 (suspension 3 months); Medical Board of Australia v Sayeed [2020] VCAT 432 (suspension for 3 months); Medical Board of Australia v Waddell [2018] VR 76 (agreed outcome - no suspension); Medical Board of Australia v Lang & Lang [2017] SAHPT 5 (Fine imposed - no suspension)

[99] See the comments of Kourakis CJ in Marin v Chiropractors Board of Australia [2020] SASCFC 74 at [79].

[100] See Medical Board of Australia v Xie [2019] VCAT 1924 at [58].