Medical Board of Australia v Sosnin (Review and Regulation) [2018] VCAT 221

1. Between 14 November 2005 and 30 June 2007, Dr Sosnin engaged in unprofessional conduct of a serious nature, being unprofessional conduct as defined in paragraph (c) of the definition in s 3 of the Medical Practice Act 1994 (Vic), ("MP Act") in that his prescribing of drugs of dependence to patients MW, MR and MC was clinically inappropriate and excessive.
2. Between 1 July 2007 and 30 June 2010, Dr Sosnin engaged in professional misconduct as defined in paragraphs (a) and (b) of the definition in s 3 of the Health Professions Registration Act 2005 (Vic) ("HPR Act") in that his prescribing of drugs of dependence to patients MW, MR and BC was clinically inappropriate and excessive.
3. Between 1 July 2010 and June 2012, Dr Sosnin engaged in professional misconduct as defined in paragraphs (a) and (b) of s 5 of the Health Practitioner Regulation National Law (Victoria) Act 2009, ("National Law") in that his prescribing of drugs of dependence to patients MW, MR and BC was clinically inappropriate and excessive.

28 September 2012 (original allegations 10 and 11)

1. On 28 September 2012, Dr Sosnin engaged in professional misconduct as defined in paragraph (b) of the definition in s 5 of the National Law having been convicted by the Magistrates' Court of Victoria of 96 charges of having breached the Drugs Poisons and Controlled Substances Act 1981 and/or the Drugs Poisons and Controlled Substances Regulations 2006.

1. Dr Sosnin is reprimanded under s 45A(2)(c) of the MP Act; s 77(4)(c) of the HPR Act and under s 196(2)(a) of the National Law.
2. The further education and/or conditions set out in Appendix A of this Determination are imposed on Dr Sosnin's registration under ss 45A(2)(d) and (e) of the MP Act; ss 77(4)(d) and (e) of the HPR Act and under s 196(2)(b) of the National Law.
3. The registration of Dr Sosnin is suspended for the period of 3 months commencing on 1 April 2018 under ss 45A(2)(g) of the MP Act; s 77(4)(g) of the HPR Act and s 196(2)(d) of the National Law.

1. Dr Sosnin was first registered as a medical practitioner in 1980.
2. In 2012, the Medical Board of Australia, ("the Board") received notifications in relation to Dr Sosnin's conduct from:

• a medical practitioner, who described a high level of prescribing of opioid and benzodiazepine medication by Dr Sosnin during the previous 18 months in relation to 3 patients;

• a mother in relation to Dr Sosnin's treatment of her son concerning his prescribing of drugs of dependence to her son; and

• a senior drugs and poisons officer with the Department of Health (Drugs and Poisons Regulation Unit) in relation to alleged contraventions of the Drugs Poisons and Controlled Substances Act 1981 (Vic) and the Drugs Poisons and Controlled Substances Regulations 2006 (Vic).

1. Thereafter a comprehensive investigation by the Board's Notification Assessment Committee into Dr Sosnin's professional conduct took place. On 14 June 2012, the Board decided to take immediate action under s 156(1)(a)(i) of the Health Practitioner Regulation National Law (Victoria) Act 2009, ("the National Law") with respect to Dr Sosnin's registration. On 14 June 2012, the Board's Immediate Action Committee imposed a condition on Dr Sosnin's registration to the effect that he would not possess, prescribe or administer schedule 8 poisons.
2. In due course, in a letter of referral dated 9 November 2016, the Board, referred allegations pertaining to Dr Sosnin's conduct to this Tribunal under s 193(1)(a) of the National Law.
3. The allegations covered an extended period of time between 2005 and 2012 and spanned 3 legislative regimes:

The Medical Practice Act 1994 (Vic) (MP Act) contains the relevant regulatory framework and applies to conduct which occurred prior to 30 June 2007.

The Health Professions Registration Act 2005 (Vic) (HPR Act) contains the relevant regulatory framework and applies to conduct which occurred between 1 July 2007 and 30 June 2010.

The regulatory framework and relevant provisions which apply to conduct after 1 July 2010 are provided for by Health Practitioner Regulation National Law (National Law).[1]

1. Throughout these periods, Dr Sosnin was, at all times a registered medical practitioner, (registered under the National Law or the corresponding prior Acts), carrying on practice as a general practitioner. When the National Law and related Regulations came into effect, they contained savings and transitional provisions which, (at the time of the notifications about Dr Sosnin's behaviour and the investigation of that behaviour), enabled proceedings to be taken under Part 8 of the National Law in relation to all of the alleged conduct to the extent that a notification about Dr Sosnin's behaviour could have been made, and proceedings of that type could have been taken, under the corresponding prior Act.
2. There was power under sections 22, 25 and 49 of the MP Act and sections 42, 45, 76 and 77 of the HPR Act to conduct an investigation and hearing into Dr Sosnin's alleged conduct.
3. Accordingly this Tribunal has the power to hear and deal with all of the conduct of Dr Sosnin under part 8 of the National Law. It has the power to make findings and determinations that were available at the time of the conduct under both the MP Act and/or the HPR Act and also conduct which occurred under the National Law.
4. The hearing proceeded before us on 8 February 2018.
5. Dr Sosnin has fully cooperated with the investigations pertaining to his conduct. This greatly assisted the Board and Dr Sosnin to reach an agreed position on both the facts of this matter and the findings which the parties submit are open to the Tribunal on those facts.
6. We have read the detailed material contained in Tribunal books filed with the Tribunal and are satisfied that the following Agreed Statement of Facts comprehensively and accurately reflects the particulars contained within the Notice of Allegations

1. At all relevant times Dr Sosnin was a registered medical practitioner carrying on practice as a general practitioner.
2. This agreed statement is jointly submitted to the Tribunal as providing the factual bases on which the Tribunal should deal with this matter.[2]
3. These facts are agreed in respect of each of the Allegations in the Notice of Allegations filed by the Board on 10 November 2016 (Notice of Allegations).

[See paragraphs [5] - [8] of these Reasons on pp 3 - 4].

1. In the period from 6 June 2007 to May 2012, Dr Sosnin prescribed drugs of dependence to Patient MW.
2. Doctor Sosnin prescribed drugs of dependence to MW in circumstances where he knew MW was a drug-dependent person:
   • 2.1 from November 2004, the medical records at the clinic at which Dr Sosnin practised stated that MW had a history of drug abuse;
   • 2.2 from May 2006, the medical records at the clinic at which Dr Sosnin practised stated that MW had a history of doctor-shopping for Valium;
   • 2.3 a medical record, dated 25 May 2006, created by another medical practitioner at the clinic at which Dr Sosnin practised, stated that MW had 'used marijuana, speed, ice and has used some needles'; and
   • 2.4 medical records created by Dr Sosnin from March 2008 stated that MW had a history of drug abuse, including by way of the use of illicit drugs, and doctor-shopping.
3. MW's mother wrote to Dr Sosnin on 28 July 2008:
   • 3.1 advising that MW was unable to care for himself;
   • 3.2 stating that she had concerns that MW was being prescribed too much "zanax [sic] and painkillers";
   • 3.3 advising that MW "drugs and drinks himself to either unconsciousness or violence" and that police or ambulance attend up to three to four times per week; and
   • 3.4 asking that MW's medication be dispensed responsibly several times a week by a pharmacy.
4. MW's mother advised Dr Sosnin on one occasion on 7 June 2010 that:
   • 4.1 MW regularly overdosed, particularly on Xanax, becoming semi or completely unconscious, sometimes on roads;
   • 4.2 when MW was under the effects of Xanax, he often stumbled and fell and hit his head;
   • 4.3 when MW was under the effects of Xanax, he often became incontinent of faeces and urine;
   • 4.4 MW sometimes sold or exchanged the medication Dr Sosnin prescribed him on the street to buy alcohol or other drugs; and
   • 4.5 Dr Sosnin's prescribing to MW was interfering with the psychiatric care he was receiving from Eastern Health.
5. Dr Sosnin continued to prescribe benzodiazepine medication to MW after 12 July 2007 when another medical practitioner at the clinic at which he practised made a note in the clinic's medical records to the effect that MW was not to be prescribed benzodiazepine medication by medical practitioners practising at the clinic.
6. Dr Sosnin prescribed benzodiazepine medication to MW for periods of time in excess of four weeks without:
   • 6.1 appropriate clinical indications being recorded in MW's medical records;
   • 6.2 continually warning MW of the risk of long-term benzodiazepine use and recording any such warning as was given;
   • 6.3 continually advising MW to reduce his long-term benzodiazepine use with a view to cessation and recording any such advice as was given; and
   • 6.4 specific specialist support from a psychiatrist.
7. Despite being advised by other medical practitioners treating MW to cease or reduce prescribing certain drugs of dependence to MW, Dr Sosnin continued to prescribe those drugs of dependence to MW in a manner contrary to or inconsistent with that advice or those requests:
   • 7.1 on 27 February 2012, Dr Jaideep Thodoguli, Psychiatrist, wrote to Dr Sosnin relevantly stating:

[MW] has frequently presented to case management and medical reviews while grossly affected by substances. He is at high risk of significant harm/death due to misadventure as a result of his substance abuse (both illicit substances and prescription drugs).

In light of [MW's] history of Polysubstance abuse it would be advisable to exercise caution while prescribing drugs of dependence (opioids/benzodiazepines) and preferably avoid prescribing them. Given that [MW] has regular weekly reviews by his case manager and can be reviewed by me or Psychiatric registrar at relatively short notice, it would be preferable that any psychiatric medications (antipsychotic/benzodiazepines) are prescribed by MSTS only. Further, I request you to kindly review the need for opioid medications and consider referral to a Pain Clinic for evaluation.

Subsequently, Dr Sosnin continued to prescribe benzodiazepine medication to MW.

7.2 on 27 February 2012, Dr Tracy Soh, a practitioner with Eastern Health's Alcohol and Drug Service, wrote to Dr Sosnin relevantly stating:

Whilst he is on treatment with our clinic, we would prefer to be the only prescribers of either opiates or benzodiazepines. If [MW] presents to your surgery requesting any drug of dependence, please direct him back to our service.

Subsequently, Dr Sosnin continued to prescribe benzodiazepine medication to MW.

1. Dr Sosnin's prescribing of drugs of dependence to MW occurred:
   • 8.1 in the absence of an adequate treatment plan and an adequately recorded treatment plan; and
   • 8.2 in circumstances where he ought to have known that there was insufficient clinical indication for that prescribing.
2. On many occasions, Dr Sosnin did not adequately record his reasons for prescribing drugs of dependence to MW.
3. Dr Sosnin's prescribing of drugs of dependence to MW contributed to an ongoing dependency on the part of MW to those drugs of dependence.

1. For the period from 9 September 2006 to 19 November 2011, Dr Sosnin prescribed drugs of dependence to MR.
2. From February 2007, Dr Sosnin prescribed for MR morphine slow release capsules 100 mg twice daily as well as oral morphine mixture at a dose of 30 to 60 mg twice daily.
3. From April 2007 until around 11 May 2011, Dr Sosnin prescribed doses and quantities of opioid medication to MR which were excessive:
   • 13.1 from April 2007, Dr Sosnin prescribed for Patient MR a dose of morphine slow release capsules 150 mg twice daily; and
   • 13.2 from approximately 2008, Dr Sosnin prescribed for Patient MR a dose of morphine slow release capsules 600 mg daily.
4. From 18 January 2007 Dr Sosnin prescribed drugs of dependence to MR in circumstances where he knew that MR was a drug-dependent person:
   • 14.1 on 18 January 2007, Dr Peter Ellims, Consultant Physician, wrote to Dr Sosnin relevantly stating:

Further to my most recent letter concerning [MR], she came into hospital and had an epidural injection at the L4/5 level and there is significant improvement in her pain. This surprised me given all the opiates and benzodiazepine that she is taking and obviously has become dependent on it ... ;

14.2 on 11 February 2008, Dr Timothy McCarthy, Specialist Anaesthetist, wrote to Dr Sosnin relevantly stating that Patient MR had been on Methadone for 10 years prior to 2005;

14.3 on 26 May 2009, Dr Daniel Lee, Rehabilitation and Pain Consultant, wrote to Dr Sosnin regarding MR relevantly stating:

So the impressions I formed on 22 May, 2009 was we have an opioid tolerant and dependent woman with a strong medication-focus, coming from an environment of high medication usage and a background of previous drug misusage and high risk behaviours. I feel her usage of her medications are inappropriately high. I feel her usage of medications is also inappropriate. Given that she has a chronic pain condition, I do not think her usage of short release morphine is appropriate. She would be in the top 1% of opioid users in Australia; and

14.4 on 11 May 2011, Dr Timothy McCarthy, Specialist Anaesthetist, wrote to Dr Sosnin relevantly stating:

As you know, [MR] used significant amounts of street drugs, mainly Amphetamines, in the past and suffered Hepatitis C. In the 1990s she was on Methadone for some time ...

She tells me that in 2006, she was taking no opioids but by the time I saw her in 2008, she was already on Kapanol 600mg a day and wanting more.

1. Despite being advised by another medical practitioner treating MR to cease or reduce prescribing certain drugs of dependence to MR, Dr Sosnin continued to prescribe drugs of dependence to MR in a manner contrary to that advice:
   • 15.1 subsequent to receiving the correspondence referred to at [14] (above), Dr Sosnin continued to prescribe Ordine to MR at the same or similar levels as he had previously; and
   • 15.2 on 7 January 2011, Dr Tracy Soh, a practitioner with Eastern Health's Alcohol and Drug Service, wrote to Dr Sosnin relevantly stating:

I saw [MR] with the Addiction Medicine Consultation Liaison team on 4th January 2011 ... She was noted to show marked sedation whilst on the ward, and the concerns relating to her respiratory function persisted. My recommendation to the medical team was complete cessation of Ordine as the relatively quick acting nature of Ordine would increase the risk of sedation and respiratory depression ...

The use of Ordine - a short acting agent - in the management of chronic pain is an unusual choice of treatment, particularly when it is taken as a regular dose. In general terms, short acting narcotics are not appropriate for the management of chronic pain as they tend to create a cycle of intoxication/sedation followed by an increase in pain as the dose wears off.

I strongly recommend that Ordine is not recommenced when [MR] returns to see you as this would increase her risk of significant further morbidity or possibly even death. She is also likely to benefit from a future gradual reduction in her Kapanol and oxazepam doses in order to further reduce her risks related to the use of sedating medications.

Subsequently, on 15 January 2011, Dr Sosnin prescribed MR Ordine for MR (a form of short release morphine) albeit at lower levels than previously prescribed.

1. Dr Sosnin prescribed benzodiazepine medication to MR for periods of time in excess of four weeks without:
   • 16.1 appropriate clinical indications being recorded in MR's medical records;
   • 16.2 continually warning MR of the risk of long-term benzodiazepine use and recording any such warning as was given;
   • 16.3 continually advising MR to reduce her long-term benzodiazepine use with a view to cessation and recording any such advice as was given; and
   • 16.4 specific specialist support from a psychiatrist.
2. Dr Sosnin's prescribing of drugs of dependence to MR occurred in the absence of an adequate treatment plan and any adequately recorded treatment plan.
3. On many occasions, Dr Sosnin did not adequately record his reasons for prescribing drugs of dependence to MR.
4. On a number of occasions, Dr Sosnin prescribed drugs of dependence to MR without a current and applicable permit as required under the Drugs, Poisons and Controlled Substances Act 1981 (DPCS Act) and the Drugs, Poisons and Controlled Substances Regulations 2006 (DPCS Regulations). Dr Sosnin did so despite being warned by the then Department of Health (Department) that his prescribing of drugs of dependence to MR extended beyond the periods covered by the permits:
   • 19.1 Dr Sosnin held a permit to prescribe morphine up to 300 mg daily to MR between 22 January 2007 to 23 July 2007;
   • 19.2 on 22 January 2008, the Department wrote to Dr Sosnin because, inter alia, he had continued to prescribe morphine to MR notwithstanding that his permit had expired six months earlier;
   • 19.3 Dr Sosnin subsequently applied for and was granted a new permit to prescribe morphine up to 1200 mg daily to MR. That permit was valid from 12 March 2008 to 10 September 2008;
   • 19.4 on 23 February 2009, Dr Sosnin applied for and was granted a new permit to prescribe morphine up to 1200 mg daily to MR. That permit was valid between 27 February 2009 to 26 February 2010. Dr Sosnin's application for the new permit was made more than five months beyond the expiry date on Dr Sosnin's previous permit, and Dr Sosnin had continued to prescribe morphine in the interim;
   • 19.5 on 20 August 2009, Dr Sosnin applied for and was granted a new permit to prescribe morphine up to 2500 mg daily to MR. That permit was valid between 21 August 2009 and 20 November 2009;
   • 19.6 Dr Sosnin continued prescribing morphine after this permit expired on 20 November 2009;
   • 19.7 on 9 September 2010, the Department sent an intervention letter to Dr Sosnin because he appeared to be prescribing beyond the permit expiry date;
   • 19.8 on 18 October 2010, Dr Sosnin applied for and was granted a new permit to prescribe morphine up to 2700 mg daily to MR. That permit was valid from 25 October 2010 to 27 December 2010; and
   • 19.9 Dr Sosnin continued prescribing morphine to MR after this last permit expired on 27 December 2010.
5. Dr Sosnin's prescribing of drugs of dependence to Patient MR contributed to an ongoing dependency on the part of MR to those drugs of dependence.

1. Between 14 November 2005 and 13 June 2012, Dr Sosnin prescribed drugs of dependence to BC.
2. Dr Sosnin prescribed doses and quantities of opioid medication to BC that were excessive:
   • 22.1 from 14 November 2005 to 14 March 2006 Dr Sosnin prescribed to BC codeine phosphate 30 mg tablets at the rate of 10.5 tablets daily;
   • 22.2 from 16 April 2008 to 3 April 2009, Dr Sosnin prescribed to BC codeine phosphate 30 mg tablets at the rate of 14.6 tablets daily;
   • 22.3 from April 2009, Dr Sosnin prescribed to BC oxycodone in an immediate release form at 10 mg per dose and in a slow release form at 20 mg per dose, with an approximate daily dose of 97 mg;
   • 22.4 from July 2009, Dr Sosnin prescribed to BC morphine in a slow release form at 30 mg dose; and
   • 22.5 as at 1 July 2010, Dr Sosnin was prescribing to Patient BC morphine in a slow release form at 30 mg dose, with an approximate daily dose that rose to 180 mg by May 2011.
3. Dr Sosnin prescribed doses and quantities of benzodiazepine medication to BC that were excessive:
   • 23.1 from 14 November 2005 Dr Sosnin prescribed to BC oxazepam 30 mg 25 tablets every four to five days, with an approximate daily dose of 166 mg of oxazepam; and
   • 23.2 from December 2010, Dr Sosnin prescribed to Patient BC oxazepam 30 mg 25 tablets and diazepam 5 mg 50 tablets every three days, with an approximate daily dose of 250 mg of oxazepam and 83 mg of diazepam.
4. On 16 November 2006, Dr Sosnin submitted a notification of drug dependency to the Department in respect of BC. Thereafter, Dr Sosnin continued to prescribe the abovementioned doses and quantities of drugs of dependence to BC in circumstances where he knew BC was a drug-dependent person.
5. Dr Sosnin prescribed benzodiazepine medication to BC for periods of time in excess of four weeks without:
   • 25.1 appropriate clinical indications being recorded in BC's medical records;
   • 25.2 continually warning BC of the risk of long-term benzodiazepine use and recording any such warning as was given;
   • 25.3 continually advising BC to reduce her long-term benzodiazepine use with a view to cessation and recording any such advice as was given; and
   • 25.4 specific specialist support from a psychiatrist.
6. On a number of occasions, Dr Sosnin prescribed drugs of dependence to BC without having obtained a permit as required under the DPCS Act and the DPCS Regulations in relation to his prescribing of those drugs of dependence to BC in doses and quantities exceeding those allowable under a permit that he did hold:
   • 26.1 Dr Sosnin held a permit to prescribe codeine up to 300 mg daily to Patient BC from 17 November 2005 to 17 May 2006;
   • 26.2 Dr Sosnin regularly prescribed Schedule 8 poisons to Patient BC from at least 2 March 2009 without applying for a new permit;
   • 26.3 on 9 September 2010, the Department sent the letter referred to at [19.7] (above);
   • 26.4 on 29 October 2010, Dr Sosnin applied for and was granted a new permit to prescribe morphine up to 240 mg daily and oxycodone up to 120 mg daily to BC. That permit was valid from 8 November 2010 to 10 May 2011; and
   • 26.5 Dr Sosnin continued prescribing morphine and oxycodone after his permit expired on 10 May 2011.
7. Despite being recommended by another medical practitioner treating BC to cease or reduce prescribing certain drugs of dependence to BC, Dr Sosnin continued to prescribe to BC in a manner contrary to that recommendation:
   • 27.1 on 25 March 2011, Dr Tracy Soh, a practitioner with Eastern Health's Alcohol and Drug Service, wrote to Dr Sosnin stating, amongst other things:

I believe that [BC] is at significant risk of developing dependence to prescribed medications as she has had previous issues with OTC analgesics, and her coping mechanisms are already stretched. She is also at risk of an accidental overdose considering the combination of medications she is on ...

Her medications should be rationalised to a single form of long acting opiate and a single for of benzodiazepine.

I suggest that instead of having both OxyContin and MSContin, her dose is converted through to a single dose of OxyContin. An initial step would be to cease MSContin completely and simultaneously increase her OxyContin up to 80 mg bd ...

I also recommend getting her benzodiazepines down to a single agent - either oxazepam or diazepam - and get the dose down to as low as possible, as this will help reduce sedation and overdose risk.

Subsequently, Dr Sosnin continued to prescribe to Patient BC oxazepam and diazepam, and OxyContin and MSContin.

1. Dr Sosnin's prescribing of drugs of dependence to BC:
   • 28.1 occurred in the absence of an adequate treatment plan and an adequately recorded treatment plan; and
   • 28.2 contributed to BC's ongoing dependency on those drugs of dependence.
2. On many occasions, Dr Sosnin did not record or did not adequately record his reasons for prescribing drugs of dependence to BC.

Convictions for breach of Drugs, Poisons and Controlled Substances Legislation

1. On 28 September 2012, Dr Sosnin pleaded guilty before, and was convicted by, the Magistrates' Court of Victoria of 96 charges of having breached the DPCS Act and/or the DPCS Regulations, the nature of which offences may affect Dr Sosnin's suitability to continue to practise in the profession of medicine. The charges concerned Dr Sosnin:
   • 30.1 prescribing Schedule 8 poisons to persons who were not drug-dependent for a continuous period greater than eight weeks, without a permit issued by the Secretary of the Department (Secretary) or authorisation under the DPCS Act;
   • 30.2 prescribing Schedule 8 poisons to patients who were the subject of permits issued by the Secretary other than for the period specified in the permits;
   • 30.3 prescribing Schedule 8 poisons to patients whom he had reason to believe were drug-dependent without a permit issued by the Secretary or authorisation under the DPCS Act;
   • 30.4 prescribing Schedule 8 poisons to patients who were the subject of permits issued by the Secretary in quantities exceeding the quantities specified in the permits;
   • 30.5 prescribing a Schedule 8 poison, namely methadone, to persons in respect of whom a permit had not been issued by the Secretary; and
   • 30.6 failing to notify the Secretary that he had reason to believe that a patient was a drug-dependent person.

The charges included conduct constituted by the prescribing referred to above in relation to MR and BC.

1. We are satisfied that the summary accurately and comprehensively captures the conduct engaged in by Dr Sosnin.
2. It is clear from the summary that Dr Sosnin prescribed drugs of dependence in circumstances where he knew his patients were drug dependent and that he did so in the face of strong advice or directives to the contrary from other practitioners and specialists in pain management and medication.
3. He regularly prescribed in circumstances where there were insufficient clinical indications for the prescription.
4. He regularly prescribed in circumstances where there was no clear management plan established to deal with patients who had complex medical and/or psychological difficulties.
5. In the case of two of the patients Dr Sosnin prescribed in excessive quantities.
6. Dr Sosnin prescribed for periods of time in excess of four weeks without appropriate specialist support or appropriate advice regarding the use of drugs of dependence which was prescribed for his patients.
7. Dr Sosnin prescribed drugs of dependence without the appropriate permits.
8. Dr Sosnin pleaded guilty to and was convicted of 96 charges of breaching the DPCSA and the DPCS regulations which included conduct in relation to patients MR and BC.

1. As previously discussed, the Board's letter of referral to the Tribunal of 9 November 2016 and the structure of the Notice of Allegations span three different regulatory regimes.
2. We were invited by the parties jointly to make the following four "rolled up" findings under the applicable legislative schemes in satisfaction of the matters alleged in the Notice of Allegations.

14 November 2005 - 30 June 2007 (original allegations 1, 4 and 7)

1. Between 14 November 2005 and 30 June 2007, Dr Sosnin engaged in unprofessional conduct of a serious nature, being unprofessional conduct as defined in paragraph (c) of the definition in s 3 of the MP Act, in that his prescribing of drugs of dependence to patients MW, MR and MC was clinically inappropriate and excessive. The particulars are referred to above at:

1. [2.1] - [2.3], [6] and [8] - [10] (regarding MW), 2. [13], [14.1] - [14.3], [15.1], [16] - [18] and [20] (regarding MR); and

1. [22.1], [25] and [28] - [29] (regarding BC).

1 July 2007 - 30 June 2010 (original allegations 2, 5 and 8)

1. Between 1 July 2007 and 30 June 2010, Dr Sosnin engaged in professional misconduct as defined in paragraphs (a) and (b) of the definition in s 3 of the HPR Act in that his prescribing of drugs of dependence to patients MW, MR and BC was clinically inappropriate and excessive. The particulars are referred to above at:

1. [2] - [6] and [8] - [10] (regarding MW); 2. [13], [14.1] - [14.3], [15.1], [16] - [18], [19.2], [19.4], [19.6] and [20] (regarding MR); and

1. [29.5],[23.2], [24], [25], [26.5] and [27] - [29] (regarding BC).

1 July 2010 - June 2012 (original allegations 3, 6 and 9)

1. Between 1 July 2010 and June 2012, Dr Sosnin engaged in professional misconduct as defined in paragraphs (a) and (b) of s 5 of the National Law in that his prescribing of drugs of dependence to patients MW, MR and BC was clinically inappropriate and excessive. The particulars are referred to above at:

1. [2], [5] - [10] (regarding MW); 2. [13] - [18], [19.9] and [20] (regarding MR); and

1. [22.5], [23.2], [24], [25], [26.5] and [27] - [29] (regarding BC).

28 September 2012 (original allegations 10 and 11)

1. On 28 September 2012, Dr Sosnin engaged in professional misconduct as defined in paragraph (b) of the definition in s 5 of the National Law by reason of the matters referred to above at [30].

1. We agree with the parties that the findings are appropriate.
2. In respect of each regulatory period, the finding sought is of professional misconduct or its equivalent. We accept that the conduct for each period was blameworthy and warranting of more than passing censure. We are satisfied that the conduct fell substantially short of the standard observed by professionals of good repute and competency.
3. The conduct in which Dr Sosnin engaged was in significant breach of the applicable regulatory context occurring on multiple occasions over an extended period despite advice to the contrary from other practitioners including relevant specialists and in one instance a concerned parent.
4. We agree that a medical practitioner who prescribes and handles drugs of dependence recklessly and contrary to law engages in professional misconduct. Dr Sosnin's conduct represents a very substantial and persistent departure from appropriate standards. His conduct continued despite complaints and advice. His conduct was ultimately only halted through the intervention of the MBA.

1. The principles which guide the making of determinations in disciplinary proceedings are well-established.
2. The purpose of the imposition of determinations in disciplinary matters is to maintain proper ethical and professional standards, and act as a deterrent to other practitioners, so as to protect the public and protect the profession in the sense of maintaining stature and integrity in the eyes of the public and the profession. Determinations are not punitive.
3. We are mindful of the fact that Dr Sosnin immediately made full admissions and has co-operated fully with the Board.

1. The Board invited us to reprimand Dr Sosnin for his conduct.
2. Dr Sosnin acknowledges that he ought to be reprimanded for his conduct.
3. We agree that it is appropriate that we express our condemnation of the nature and extent of Dr Sosnin's conduct by reprimanding him.
4. We note that a reprimand is a serious matter for a professional person. It will remain on Dr Sosnin's registration as an ongoing reminder of the serious nature of his conduct.
5. Dr Sosnin is reprimanded under s 45A(2)(c) of the MP Act; s 44(4)(c) of the HPR Act and under s 196(2)(a) of the National Law.

1. The Board invited us to impose conditions on Dr Sosnin's registration.

1. The Board and Dr Sosnin agree that it is appropriate for us to impose conditions requiring Dr Sosnin to advise AHPRA of his place of employment and obtain reports from the senior person at each practice.
2. We will impose such a condition and impose a review period of 12 months.

1. The Board submitted that it remains necessary in the interests of protecting the public that Dr Sosnin continue to be prevented, for an appropriate period of time - pending his successful completion of a period of education - from having any role in the possession, prescribing or handling of schedule 8 poisons.
2. We agree, that should we decide to impose a condition requiring further education that such a condition would naturally follow. Given our findings that Dr Sosnin was unable/unwilling to comply with his legislative obligations with demonstrably negative consequences for his patients, it would be remiss of us to enable him to have, possess, prescribe or handle schedule 8 poisons until such time as we were satisfied that he is sufficiently educated to do so in a manner that does not place his patients at risk.
3. We turn then to a consideration of whether we should impose such a condition.

1. Dr Sosnin has already, of his own volition, undertaken the following education:

- At the time of the immediate action he undertook an educational seminar through Avant (his insurer).

- In approximately May 2015, he undertook a further Avant webinar on the prescribing perils of opioids, polypharmacy and medication errors.

- On 2 August 2016, Dr Sosnin undertook education with Eastern Melbourne PHN on schedule 8 Management: permits without pain.

- On 2 May 2017, Dr sosnin successfully undertook an education session with Dr Tanya Scott who is a GP/medical educator in relation to clinical record-keeping, the relevant standards for medical record keeping and the need to ensure sufficient detail is provided for continuity of care.

- Dr Sosnin has completed an extensive online education plan prepared by Avant (38 CPD points) with learning modules focusing on "taking the best possible medication history", communication strategies for challenging patient behaviours; medication safety (multiple modules), medical records and documentation, prescribing principles and practices and medication safety case studies.

- On 5 July 2017, he completed a course on demystifying opioid treatment replacement therapy at Eastern Melbourne PHN

1. We also read a number of impressive testimonials from Dr Sosnin's peers which attested to his ongoing commitment to the care of his patients. We accepted, and the Board accepts, that Dr Sosnin now fully understands that his practices were dangerous and placed his patients at risk. It was equally non-contentious to accept that Dr Sosnin now takes a "helicopter view" of medical practice in which he continually assesses and reassesses what he is doing in his patient care.
2. We accept that his "helicopter view" of practice has become an integral part of the way in which he now manages patient care. We also accept that there have been IT changes within the practice that have arisen partly as a result of these proceedings and that appropriate alerts are in place on the computer-generated systems.
3. There is no doubt that Dr Sosnin has, of his own volition, undertaken a significant amount of education addressing many of the issues which brought him before the Tribunal. He is keen to avoid a repeat of his previous conduct.
4. The Board nevertheless contended that a condition requiring Dr Sosnin to undertake Board-approved education was warranted.
5. The Board contended that the nature and duration of Dr Sosnin's past prescribing practices and the extent to which they persisted despite warnings and requests to desist, means that in the absence of the proposed further education we could not be confident that Dr Sosnin necessarily conducts a safe practice.
6. We wondered whether much more could be obtained through an additional 6 hours of education than had already been gained by Dr Sosnin during the education already described. We asked the Board to clarify its position. It is never appropriate for this Tribunal to impose unnecessary or unclear conditions on a health practitioner. We wanted any future educator to also understand what the focus of the education should be.
7. Dr Sosnin did not seek to avoid the imposition of a condition requiring he undertake further education. He too, however, was keen to ensure that such education added meaningfully to his previous learning.
8. We were ultimately persuaded that further education relating to chronic non-malignant pain and communication with patients would be beneficial to Dr Sosnin. Such further education, provided one-on-one, by a nominated educator, will enable Dr Sosnin's learnings to be rounded off. It will also enable him to demonstrate to the satisfaction of the Board that he has reflected on all of the issues that gave rise to the imposition of the conditions and provided written reflection of how he has incorporated the lessons learnt in the education into his practice. We will impose the condition sought.
9. The Board asked that we set the review period at 12 months.
10. We are concerned about the passage of time that it has taken for these matters to be resolved and the impact that this has had on Dr Sosnin's practice. It is highly desirable that the further education is not protracted. We will set the review period for this condition at 8 months. This would enable Dr Sosnin to return to full practice in a timely manner. We will similarly set a review period of 8 months in relation to the prohibition on access to medication. We consider that once Dr Sosnin has completed the education to the Board's satisfaction, that there should be no ongoing need for the prohibition.

1. The Board sought a condition requiring Dr Sosnin to submit to an audit of his practice and any supporting records by an auditor approved by the Board. In the circumstances of this case, we agreed, as did Dr Sosnin, that such a condition was necessary to take effect within two weeks of the removal of the condition effecting a prohibition on access to medication.
2. We will impose such a condition.

1. The Board contended that a suspension is demanded in this matter to serve the purposes of both specific and general deterrence.
2. The Board contended that without a meaningful period of suspension, the protective purposes of disciplinary proceedings would not have been adequately served in the circumstances of this case.
3. The Board contended that our determination must reflect:

- to the medical profession at large the seriousness with which those practising within it must have regard to their clinical and legal obligations when treating patients who seek or require drugs of dependence for pain management and;

- show the community that medical practitioners who fail to take those obligations seriously will be the subject of meaningful disciplinary action.

1. The Board conceded that Dr Sosnin would be fit to resume practice after a period of suspension assuming the education referred to above was undertaken.
2. The Board submitted that a period of six months suspension would be a meaningful imposition on Dr Sosnin's capacity to practise but would not be so long as to be disproportionate or punitive. The Board contended that a six-month suspension would adequately reflect the co-operation, admissions and historical nature of the conduct.
3. It was submitted on behalf of Dr Sosnin that a suspension of his registration would be excessive and unwarranted. It was emphasised that he has already suffered greatly, both emotionally and financially, in respect of these matters and that he is unlikely to transgress again.
4. It was emphasised that he now has insight and remorse and has undertaken personal professional development and that there has been a considerable lapse in time between the conduct the subject of the allegations and the imposition of any sanction.

1. We agree that it is unlikely that Dr Sosnin will repeat his conduct. We are mindful of the fact that Dr Sosnin has remained in practice during the period of five and half years since these matters came to light, during which time he has reflected upon his conduct. He has not breached the conditions on his registration and he has made changes within his work practice which give us confidence that he will not allow himself to fall into such a situation again. We accept he has undertaken further education.
2. Nevertheless, given the seriousness of our findings, we ultimately agree with the submissions of the Board that a period of suspension is necessary.
3. The conduct objectively warrants a suspension. The medical profession at large needs to fully understand that ongoing, deliberate disregard of professional obligations has the potential to cause grave harm to vulnerable patients and to the reputation of the profession as a whole.
4. Such conduct must attract serious repercussions in order to dissuade other practitioners from engaging in it.
5. We do not however agree that a six month suspension is necessary or appropriate.
6. In many cases such as this, a lengthy suspension or cancellation of a practitioner's registration will be warranted for the protection of the public, where for example a practitioner continues to demonstrate a lack of understanding of his professional obligations[3].
7. That is not the case here.
8. It is a guiding principle of the National Registration and Accreditation scheme that restrictions on the practice of a health professional are to be imposed under the scheme only if it is necessary to ensure health services are provided safely and are of appropriate quality.
9. These matters have been now been plaguing Dr Sosnin for many years. During that time, Dr Sosnin has co-operated fully with the Board, he has undertaken further education, he has attended before the Board, the Criminal Court and now this Tribunal. We accept that these have had a significant deterrent effect on him. There are other protective factors surrounding him. His colleagues, specialists with whom he engages and patients, are all well aware of these proceedings. He has continued to practise whilst awaiting the finalisation of these matters, without further transgression.
10. Where as in this case, the practitioner is, demonstrably safe to return to practice, it is important, sensible and appropriate to set a minimal period of disruption to a practitioner's practice in order to enable the practitioner to serve the ongoing needs of his clientele, complete his education and continue safely practising under the watchful eye of the Board.
11. We consider the 3 month period achieves this end whilst still conveying the important message that blatant, ongoing disregard for one's obligations as a medical practitioner will result in an interference with that practitioner's registration.
12. We understand that the imposition of a suspension will have a significant impact on Dr Sosnin's practice and patients. In order to ensure that his patients are not disadvantaged, we will delay the commencement period of the suspension, which will commence effect on 1 April 2018.

1. We will reprimand Dr Sosnin.
2. We will impose education and conditions on Dr Sosnin's registration, the full terms of which are set out in Appendix A.
3. We will suspend Dr Sosnin's registration for 3 months effective from 12 midnight on 31 March 2018.

1.1 All costs associated with compliance with these conditions are at Dr Sosnin's expense.

1.2 Within 21 days of the imposition of these conditions, Dr Sosnin must provide to the Australian Health Practitioner Regulation Agency (AHPRA), on the approved form (HPC):

• (a) the contact details of the Director of Medical Services / Senior Practice Manager / Senior Manager / Senior Partner / proprietor / owner and/or other as appropriate (the senior person) at each place at which Dr Sosnin practised at the time these conditions were imposed; and

• (b) an acknowledgement that AHPRA will contact the senior person and provide them with a copy of the conditions on Dr Sosnins registration or confirm that the senior person has received a copy of the conditions from Dr Sosnin.

1.3 Dr Sosnin must provide the same form to AHPRA, containing the same acknowledgement:

• (a) within seven days of the commencement of practice at each and every subsequent place of practice; and

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

1.4 Within 6 months of the imposition of these conditions, Dr Sosnin must provide to AHPRA:

• (a) acknowledgement, on the approved form (HP1), that AHPRA may obtain reports from the senior person at each and every place of practice on a monthly basis or as otherwise required by the Medical Board of Australia (Board) or AHPRA;

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

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

1.5 The review period for this condition is 12 months.

2.1 Upon return to practice, Dr Sosnin must not prescribe, possess, supply, administer, handle, dispense and/or access, including as emergency treatment supplies or doctor's bag stock, any substance listed in Schedule 8 of the Standard for the Uniform Scheduling of Medicines and Poisons (SUSMP) as amended from time to time and as published at https://www.tga.gov.au/publication/poisons-standard-susmp and/or pharmaceutical items containing any active ingredient listed within Schedule 8 of the SUSMP.

2.2 The review period for this condition is 8 months.

3.1 Dr Sosnin must, as set out below, undertake and successfully complete a program of education (the education) approved by the Board and provide to AHPRA a reflective practice report in relation to:

• (a) prescribing drugs of dependence;

• (b) managing patients with non-malignant chronic pain; and

• (c) practice management (the education topics).

3.2 The education must consist of a minimum number of 6 hours completed, as set out below, within a 6 month period following the imposition of these conditions and must include content relevant to the education topics.

3.3 Within 1 month of the imposition of these conditions, Dr Sosnin must, on the approved form (HPN11):

• (a) nominate a person or persons to be approved by the Board to act as educator (the approved educator), and

• (b) provide acknowledgement that AHPRA will obtain a report from the approved educator at the conclusion of the education.

3.4 Dr Sosnin must ensure that the nomination of the approved educator is accompanied by:

• (a) an acknowledgement, on the approved form (HPNA11) from the person or persons nominated to be the approved educator; and

• (b) an education plan outlining the form the education will take and how the education topics will be addressed.​

3.5 Within 6 months of notice of the Board's approval of the education being communicated to him, Dr Sosnin must:

• (a) complete the education;

• (b) provide evidence to the Board of successful completion of the education; and

• (c) provide a report demonstrating, to the satisfaction of the Board, that he has reflected on the issues that gave rise to the imposition of the conditions and how he has incorporated the lessons learnt in the education into his practice.

3.6 The review period for this condition is 8 months.

4.1 Dr Sosnin must submit to an audit of his practice and any supporting records (an audit) by an auditor approved by the Board (the approved auditor):

• (a) as set out below, upon the communication to him of notice of the removal of the above condition effecting a prohibition on access to medication (as set out below); and

• (b) quarterly thereafter.

4.2 Dr Sosnin must, as part of the audits, permit the approved auditor to:

• (a) attend any and all places of practice (public and private) for the purpose of the audit and to review any relevant records; and

• (b) provide a report to AHPRA in relation to the findings of the audit.

4.3 The audits and the audit report are to focus on prescribing drugs of dependence, managing patients with non-malignant chronic pain and practice management.

4.4 Within 2 weeks of the removal of the above condition effecting a prohibition on access to medication, Dr Sosnin must nominate to AHPRA on the approved form (HPN12) a proposed approved auditor.

4.5 Within 1 month of the approval of the approved auditor being communicated to him, Dr Sosnin must:

• (a) make contact with the approved auditor and establish an audit plan outlining the form the audits will take and how the areas of concern for the Board will be addressed. The audits will take the form determined by the approved auditor;

• (b) provide the approved auditor with a copy of the conditions on their registration;

• (c) provide to AHPRA, on the approved form (HP8), acknowledgement that AHPRA will seek reports from the approved auditor;

• (d) provide to AHPRA a copy of the audit plan, together with written acknowledgement, on the approved form (HPNA8), from the approved auditor; and

• (e) undergo the first audit.

4.6 In the event the approved auditor is no longer willing or able to conduct any audit, Dr Sosnin must notify AHPRA within 14 days of becoming aware of this and provide a new nomination of a proposed auditor to AHPRA in the same terms as the previous nomination.

4.7 The review period for this condition is 18 months.

[1] The National Law as applicable in Victoria is set out as a schedule to the Health Practitioner Regulation National Law (Victoria) Act 2009.

[2] To the extent the agreed facts differ from the particulars in the Notice of Allegations, these agreed facts form the factual basis for the Allegations before the Tribunal for its consideration.

[3] See for example Medical Practitioners Board of Victoria v Naik (Occupational and Business Regulation) [2009] VCAT 755.