Legislation cited: ACT Civil and Administrative Tribunal Act 2008 s 39

Health Practitioner Regulation National Law (ACT) Act 2020 ss 5, 196

Cases cited: Health Ombudsman v HSK [2018] QCAT 419

Health Ombudsman v Joy [2020] QCAT 202

Medical Board of Australia v Giorgio [2023] VCAT 50

Medical Board of Australia v Lodhi [2022] VCAT 439

Medical Board of Australia v Pang [2021] VCAT 1175

Medical Board of Australia v Dr POS [2019] VCAT 1678

Nursing and Midwifery Board of Australia v Harris [2021] VCAT 496

1. Pursuant to section 196(1)(b)(iii) of the Health Practitioner Regulation National Law (ACT) (the National Law) between 6 July 2018 and 29 September 2019 the respondent behaved in a way which constitutes professional misconduct as defined under paragraphs (a), (b) and (c) for that term under section 5 of the National Law.
2. The respondent is reprimanded for that professional misconduct.
3. Pursuant to section 196(4)(a) of the National Law, the respondent is disqualified from applying for registration as a medical practitioner for a period of 3 months from 5 June 2023.
4. Pursuant to section 39 of the ACT Civil and Administrative Tribunal Act 2008:

(a) There is to be no public access to the file for this proceeding.

(b) Publication or disclosure of the names of witnesses and third parties associated with this proceeding is prohibited.

(c) The reasons for this decision including the Annexure to the reasons are to be published with the names of witnesses and third parties anonymised.

(d) Orders 4(b) and (c) do not apply to the names of the respondent's treating professionals.

1. In this application the Medical Board of Australia (the Board) seeks determinations against the respondent pursuant to the Health Practitioner Regulation National Law (ACT) Act 2020 (the National Law).
2. The facts which led to the application are set out in an agreed statement of facts dated 16 December 2022 which is annexed to these reasons (the agreed statement of facts).[1] Having examined the documents filed in the proceedings which form part of the Tribunal Book we are comfortably satisfied that the agreed statement of facts accurately sets out the facts which establish the allegations against the respondent set out in the Notice of Allegations attached to the Application for Disciplinary Action dated 28 October 2022.

1. The respondent agreed that his conduct constituted professional misconduct and that a reprimand was appropriate for that conduct and informed the tribunal of this on 26 April 2023.[2]
2. We consider that it was appropriate for the respondent to concede that his conduct amounted to professional misconduct as defined under section 5 of the National Law. The conduct was substantially below the standard reasonably expected of a medical practitioner of his training and experience (as set out in paragraph (a) of the definition), amounts to more than one instance of unprofessional conduct that, when considered together, amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner (as set out in paragraph (b) of the definition), and was inconsistent with the respondent being a fit and proper person to hold registration in the medical profession (as set out in paragraph (c) of the definition). This does not mean that the respondent is not currently a fit and proper person to hold registration as a medical practitioner. Our finding is that the conduct he engaged in was inconsistent with being a fit and proper person.

1. On 5 June 2023, a hearing was held to determine what further determinations, if any, should be made by the Tribunal in relation to the respondent's conduct.
2. The Board's position was that the respondent, who has not practised medicine due to a voluntary undertaking not to do so that he provided to the Board on 20 November 2019, and whose registration has since expired, should be disqualified from applying for registration for a period of 12-18 months.
3. The respondent's position was that he should not be disqualified for any period because he has already been subjected to exclusion from the profession for a period in excess of three and a half years and no useful purpose would be served by disqualifying him for a further period. The respondent further submitted that the reprimand along with the period he has already been unable to work in his profession serve as sufficient deterrence from engaging in the conduct which is the subject of these proceedings.
4. The principles guiding the determination of disciplinary orders in cases concerning health practitioners have been set out and analysed in a number of previous cases[3] and were aptly summarised by counsel for the Board in the written submissions of the Board dated 10 May 2023[4] as follows:

(a) Determinations are intended to maintain proper ethical and professional standards for the protection of the public and also for the protection of the reputation of the profession.

(b) Determinations are not punitive in nature, but they may serve the objectives of specific and general deterrence.

(c) An assessment of the ongoing risk posed by the practitioner should be central to the imposition of a determination.

(d) The nature and seriousness of the conduct, any evidence of contrition, the degree to which the practitioner has acquired insight into his or her conduct, evidence of rehabilitation, character evidence, and the time between the conduct and the determination may all be relevant factors.

(e) Personal matters such as shame, personal ordeal, and financial difficulty are of little relevance.

1. Applying these principles to the circumstances of this case we start with what we regard as the most important consideration, that is the assessment of the ongoing risk posed by the practitioner. The primary risk in this case, is the case of re‑offending by engaging in similar conduct to the conduct the subject of this proceeding, that is of forging and misappropriating prescriptions of strictly controlled medication for self-use. However, the respondent's conduct also poses some secondary risks, such as the risk of failing to manage his medical conditions appropriately by seeking independent professional help so that he may not be a risk to his patients; the risk of abusing the trust placed in him by his employer and his professional privileges; and the broader risk of bringing the profession of medicine into disrepute by acting in an unethical and unlawful manner.
2. There is agreement amongst all the psychiatrists who have provided evidence in this matter that at the time that he engaged in the misconduct the respondent suffered from severe Depressive Disorder with suicidal ideation and Alcohol Misuse Disorder.[5]
3. In his witness statement signed on 18 February 2023, the respondent states that he forged the scripts in order to avoid revealing to other doctors that he needed medication to deal with his depression, anxiety, and negative thoughts. He sought help from his General Practitioner for his alcoholism but he did not divulge the extent of his drinking.[6]
4. His treating psychologist and psychiatrists attribute his inability to seek help for his mental health conditions to a very difficult developmental history which in turn has led to major depression and alcohol dependence which in turn led to the conduct of creating fraudulent prescriptions.[7]
5. Though the respondent's medical conditions are not an excuse for his misconduct, they do explain to a degree the respondent's state of mind which was impaired by those conditions during the relevant period he engaged in the misconduct. This is helpful in the assessment of whether the practitioner has taken action to address the circumstances which either caused him or contributed to him engaging in the misconduct, thus ameliorating the risk he poses to the public of re-engaging in the same or similar conduct.
6. The authorities also support that where the practitioner engaged in misconduct due to a mental illness as distinct from stress caused by the vicissitudes of life, the effect of the mental health issues on the relevant conduct is a mitigating factor.[8]
7. The expert medical evidence in this matter supports that because of the extensive rehabilitative treatment and action he has undertaken since his offending conduct was revealed, the respondent would be at extremely low risk of engaging in similar conduct or posing any risk to patients if he was to return to medical practice.[9]
8. The respondent's medical conditions of major depression and alcohol use disorder are in full remission according to the report of his treating psychiatrist.[10] He has not drunk alcohol since 28 December 2020.[11] All of the respondents' treating practitioners are of the view that due to the respondent's long standing mental health conditions he needs to continue with abstinence from alcohol as well as psychiatric and psychological help. They expressed the opinion that the risk of relapse and reoffending could be safeguarded with conditions placed on the respondent's registration.[12]
9. Based on the evidence above we do not consider that there is any significant ongoing risk posed by the respondent if he were to be re- registered, subject to monitoring conditions being placed on his registration. Because the respondent is not currently registered the Tribunal cannot impose conditions on his registration. However, that is a matter which can and should be addressed by the Board if and when the respondent applies to be registered.

1. We turn now to the subject of the nature and seriousness of the conduct, evidence of contrition and the degree to which the respondent has acquired insight into his wrongdoing.
2. There is no doubt in our mind that the conduct the respondent engaged in is longstanding and serious. It continued for over 14 months and was repeated on 32 separate occasions. The conduct was unlawful, unethical, and dishonest, and was likely to affect the good reputation and standing of the medical profession. It is for this reason that we consider, as agreed by the parties, that it constitutes professional misconduct as defined under section 5 of the National Law.
3. Counsel for the Board submitted that the respondent's dishonest conduct continued even after his fraudulent prescribing was reported to his employer and notified to the Australian Health Practitioner Regulation Agency (AHPRA) for investigation because he misled his employer and AHPRA by omission. Though the respondent admitted the conduct to his employer for the single script that was reported to the employer shortly after the allegation was put to him by his employer, he did not inform the employer that he had engaged in that conduct on more than one occasions at that time. The respondent did voluntarily inform his employer that he had engaged in that conduct on more than one occasion about nine months later, when the employer informed him that they proposed to allow him to return to work upon completion of their investigation into the allegation. However, he was not forthcoming about the full extent of his misconduct in that he minimised the number of prescriptions he had forged to "approximately half a dozen".
4. Further, though on 2 November 2020, the applicant through his solicitor wrote to AHPRA acknowledging that he had forged scripts using a hospital script pad for diazepam, temazepam and zopiclone, Schedule 4 medicines, under the Commonwealth Poisons Standard, he did not acknowledge that he had also forged more scripts for oxycodone, a schedule 8 drug under that Standard. Instead, he informed AHPRA that he believed he had not written any other scripts for schedule 8 drugs other than the one which had initially been notified to AHPRA by the employer. That information was incorrect because AHPRA's investigation uncovered nine more scripts for oxycodone.
5. The respondent has admitted in his witness statement[13] that he should have been upfront about the full extent of his behaviour earlier. Though we accept that the respondent was not entirely upfront about the extent of his misconduct during the investigation of the allegations against him, we note that during that period he was mentally unwell and in receipt of extensive treatment. His recovery was underway but by no means complete. The medical reports available to the Tribunal refer to memory loss suffered by the respondent due to his excessive use of alcohol.[14] The fact that the respondent voluntarily disclosed more of his misconduct than his employer and AHPRA were initially aware of is to his credit. His mental state was impaired, and he was struggling with feelings of shame and guild.[15] In these circumstances we are not prepared to find that the respondent's failure to be entirely upfront with the investigators about the full details and extent of his misconduct is an aggravating factor in considering the appropriate disciplinary determination. Further, we do not accept the applicant's submission that the respondent's omissions in admitting the full extent of his misconduct during his recovery undermines his treating psychologist's opinion that he showed moral growth during his recovery period. In our view the fact that the respondent made some disclosures voluntarily during that period is consistent with the fact that as his treatment progressed his thinking became clearer and his desire to act ethically emerged. The improvement of his mental state and moral growth as described by his psychologist is likely to have happened gradually over time. The Code of Conduct for doctors in Australia provides at paragraph 10.11 that doctors have a responsibility to cooperate with any complaints procedure that applies to their work. The respondent cooperated with the AHPRA investigation and his employer investigation. Given his mental state at the time the investigations were being conducted we do not consider that his behaviour was such as to aggravate the seriousness of the conduct being investigated.

1. The evidence before the Tribunal supports that the respondent has expressed genuine contrition and remorse for his conduct repeatedly over the last three and a half years. This is reflected in the reports from his treating professionals[16] as well as the character references from his friends and family.[17] The character references show that by the time the matter was referred to the tribunal the respondent was able to admit the full extent of his conduct to his friends and family and to accept responsibility for his behaviour. His psychologist states that the respondent has transcended from feeling simple remorse manifested in guilt, to remorse which motivates him to mitigate the harm of his past conduct by contributing socially and helping others.[18] This is evident by his regular and ongoing offer of support to others in the Alcoholic Anonymous (AA) program.
2. We are also reasonably satisfied that the respondent has gained insight into the circumstances which led to his offending conduct through the rehabilitation he has undertaken.[19] This was necessary in order to minimise the prospect of re‑offending. By identifying the factors which led him to that conduct and by seeking support and treatment to understand their effect on his mental and physical well-being the respondent has demonstrated that he now has insight into his behaviour.

1. The respondent has attested in his witness statement that currently he engages in the following regime to manage his mental health and alcoholism:

(a) regular AA meetings three times per week;

(b) psychology support with Dr Ruefli;

(c) psychiatric support with Dr Martin;

(d) regular phone calls with his AA sponsor;

(e) supporting other people with alcoholism;

(f) regular exercise and healthy diet; and

(g) meditation, journaling and prayer.

He has not consumed any unprescribed medication since September 2019 and he has not consumed any alcohol since 28 December 2020.

1. As stated earlier, Dr Martin's opinion is that the respondent's medical issues are in full remission. He is likely to remain well if he continues with his recovery regime.

1. The respondent has filed several character references in this proceeding from former colleagues, friends and family members. The majority, if not all, attest to his remorse for the conduct which is the subject to this proceeding, the steps he has taken during his recovery process and the progress he has made in gaining insight into his conduct and health issues and the transformation of his life through that. A number also attest to the respondent's kindness, humanity and desire to assist others. These are good attributes for a medical practitioner to have. The references from two of his former colleagues in medical practice state that he was passionate, diligent, and kind in providing quality care to his patients. They also state that he was valued by his colleagues as a collaborative and hardworking team member.[20]

1. Counsel for the respondent submitted that the Board was dilatory in referring the matter to the tribunal and this has meant that his client has been unable to apply for registration for over three and a half years. He pointed out that as part of the immediate action process, the Board initially took steps to assess the respondent's health with a view of placing conditions for protection of the public on his registration and allowing him to return to work. That process was subsequently abandoned. Counsel submitted that because of this his client has been unable to work as a medical practitioner and this should be given significant weight in determining the sanction for his conduct and particularly whether he should be disqualified from registration for a further period.
2. While we consider that the length of time the respondent has been out of practice as a result of the allegations of misconduct is a relevant consideration in determining whether a further period of disqualification ought to be imposed and that there are a number of unexplained delays in conducting the investigation and taking the decision to refer the matter to the tribunal, we do not accept the submission that the Board was entirely responsible for the delay in commencing the proceeding in the tribunal or for the respondent being unable to practise medicine for the last three and a half years.
3. We note that the respondent voluntarily gave an undertaking to the Board not to practise while the first allegation against him for a single fraudulent prescription was being investigated on 20 November 2019. That was in the context of AHPRA informing the respondent that the Board was considering taking immediate action against him. The Board, rightly in our view, decided to investigate the conduct it was notified about and to conduct an assessment as to whether the allegation Dr Stone faced related to his health. It accepted the respondent's undertaking not to practise in the meantime. That process was then thwarted by the Australian Federal Police informing AHPRA on 4 May 2020 that they had received a complaint in March 2020 about Dr Stone which they were in the process of investigating. The AFP also stated to AHPRA that it may be unhelpful to the AFP investigation for AHPRA to make further approaches to Dr Stone in relation to disciplinary action at that time and that there was clear evidence of criminal activity.
4. On 10 August 2020, AHPRA informed the respondent's solicitor by telephone that due to their investigations revealing that there were 10 oxycodone prescriptions dispensed to Dr Stone rather than just the one mentioned in the initial notification they were of the view that Dr Stone's fraudulent conduct may be greater than they originally suspected. This suggests that AHPRA had continued its investigation despite the AFP parallel process, albeit without speaking to the respondent. AHPRA advised further that the new prescriptions they discovered changed the focus of their investigation and they were unwilling to take the matter back to the Board for a decision on the immediate action flowing from the initial notification while they were investigating the new prescriptions that had come to their attention.[21] From a procedural fairness point of view, it may have been preferable for the Board to make a decision on the issue of whether the risk to public health and safety they had identified could be managed with conditions, rather than removal from practice altogether at that time. However, it is unlikely that the Board would have decided to allow the respondent to return to practice with conditions, in circumstances where the police were investigating his conduct and information about further prescriptions had been obtained. Whether the respondent's actions were caused by his health issues or not, the fact that there was evidence of further possible misconduct was very relevant to the consideration of the risk the respondent posed to the public.
5. It was open to the respondent to apply to the Board to be released from his undertaking not to practise and to provide evidence or submissions that despite the further unauthorised prescriptions it would be safe for him to return to practice with conditions. That would have effectively forced the Board to make a decision in relation to immediate action. He did not do so and in fact he chose not to renew his registration when it was due for renewal on 30 September 2020.
6. The AFP ultimately cautioned the respondent for his conduct without charging him with any criminal offences. AHPRA was informed of this on 6 April 2021.[22] It took a further 18 months for the matter to be referred to the tribunal. Counsel for the Board submitted that this was because evidence of further fraudulent prescriptions was uncovered by AHPRA's investigations which the respondent had not disclosed to AHPRA, and those further prescriptions had to be investigated. The solicitor for the respondent states in his witness statement of 17 February 2023[23] that AHPRA was aware of all 32 prescriptions forming part of the application to the tribunal since October 2021 It is not entirely clear to us from the material before us why it took a further 12 months from October 2021 for the matter to be referred to the tribunal.
7. Nevertheless, in our view the medical reports filed in the proceeding and the respondent's witness statement support that the respondent used the time during which he has been unable to practise to rehabilitate himself. Given the severity of his medical conditions and the fact that he needed to overcome addiction problems as well as trauma in order to be able to return to medical practice safely, time away from practice was necessary in our view in order for him to concentrate on his recovery. Further, the authorities support that time spent by the respondent out of practice should be taken into account in determining the appropriate sanction. As the tribunal in Medical Board of Australia v Bernard[24] said:

Delay can be relevant, not only as a mitigating factor in itself but also as providing an opportunity for the person to show rehabilitation by not reoffending...It is also relevant where the practitioner has been out of practice for several years already because of related regulatory action.[25]

1. Both parties have referred us to a number of comparative determinations in disciplinary cases concerning self-prescribing and unauthorised prescribing by health practitioners. The cases are useful in providing guidance about the range of periods of suspension that other tribunals considered adequate in comparable cases, but as the tribunal in Medical Board of Australia v Lodhi said:

every case is different and care must be taken to ensure that any case submitted as comparable identifies the information which is relevant to the case to be determined.[26]

1. The range of periods of time the health practitioners had to spend away from practice in the comparable cases concerning misappropriation of prescription medication we were referred to by the parties extends from 11 months[27] to five years.[28]

1. A significant purpose of a determination is to protect the reputation of the profession and to deter others in the profession from engaging in similar conduct. In light of the seriousness of the respondent's misconduct we consider that a period of disqualification from medical practice would achieve this. However, the respondent has already spent three years and eight months away from medical practice as a result of that misconduct. We consider this is a deterrent not only for the respondent but for the profession generally.
2. While the respondent's misconduct is serious, it is partly explained by a prolonged history of mental illness which the respondent has addressed in the last three and a half years by engaging in extensive treatment and rehabilitation. The respondent has been reasonably co-operative with the regulator and his employer and we found that there are no aggravating factors in his behaviour since the acts of misconduct were uncovered. Fortunately, no patients were harmed by the misconduct. The evidence supports that the respondent has shown genuine contrition and that he has acquired insight into his conduct. His character references are impressive and speak of qualities he possesses which would serve him well in a career in medicine. He has been unable to practise medicine for three years and eight months due to action taken during the disciplinary process.
3. Taking all of these factors into account we consider that a three-month period of disqualification from the date of the hearing of the matter is appropriate.
4. The determinations of the tribunal are as follows:

(a) Pursuant to section 196(1)(b)(iii) of the Health Practitioner Regulation National Law (ACT) (the National Law) between 6 July 2018 and 29 September 2019 the respondent behaved in a way which constitutes professional misconduct as defined under paragraphs (a), (b) and (c) for that term under section 5 of the National Law.

(b) The respondent is reprimanded for that professional misconduct.

(c) Pursuant to section 196(4)(a) of the National Law, the respondent is disqualified from applying for registration as a medical practitioner for a period of 3 months from 5 June 2023.

(d) Pursuant to section 39 of the ACT Civil and Administrative Tribunal Act 2008:

(a) There is to be no public access to the file for this proceeding.

(b) Publication or disclosure of the names of witnesses and third parties associated with this proceeding is prohibited.

(c) The reasons for this decision including the Annexure to the reasons are to be published with the names of witnesses and third parties anonymised.

(d) Orders 4(b) and (c) do not apply to the names of the respondent's treating professionals.

1.1 The applicant, the Medical Board of Australia (Board), is responsible for exercising the functions and powers of a National Board under the Health Practitioner Regulation National Law,[29] in force as a law of the ACT by operation of the Health Practitioner Regulation National Law (ACT) (National Law).[30]

1.2 The respondent, Dr Liam Stone (Dr Stone), is a medical practitioner who holds the qualification of Medicinae ac Chiurgiae Doctoranda (Doctor of Medicine and Surgery) conferred by the Australian National University in December 2016.

1.3 Dr Stone was first granted provisional registration as a medical practitioner on 16 January 2017 and general registration on 9 February 2018 under the National Law. The Board was, and is, the relevant National Board for Dr Stone's profession.

1.4 Between 15 January 2018 and 20 August 2020, Dr Stone was employed with Canberra Health Services at the Canberra Hospital firstly as a Residential Medical Officer then as a Registrar.

(a) eligible to practise as a medical practitioner until 20 November 2019, when he provided an undertaking not to practise; and

(b) registered until September 2020, when his registration was due for renewal and he failed to renew his registration at the time. Dr Stone has not been registered since this time.

2.1 Between 6 July 2018 and 29 September 2019, and whilst registered as a medical practitioner under the National Law, Dr Stone forged 32 prescriptions for medication and on each occasion:

(a) used pages from a prescription pad which pages he had taken from the Canberra Hospital in the course of his employment as it was common to need to write prescriptions for patients at short notice. Dr Stone accepts that it was a misuse of the prescription pages to write prescriptions for his own use;

(b) prepared the prescription, and presented the prescription for dispensation, without the consent or authority of the relevant practitioner;

(c) forged the signature of the relevant practitioner; and

(d) did so for the purpose of obtaining the relevant medication for his own personal use.

(a) Temazepam 10mg (x 25) on about 6 July 2018 in the name of Dr A, and presented it for dispensing at the Chemist Warehouse Woden on 8 July 2018.

(b) Temazepam 10mg (x 25) on about 23 July 2018 in the name of Registrar, The Canberra Hospital, and presented it for dispensing at the Chemist Warehouse Woden on 24 July 2018.

(c) Oxycodone 5mg (x 20) on about 5 August 2018 in the name of Dr B and presented it for dispensing at the Chemist Warehouse Woden on 6 August 2018.

(d) Temazepam 10mg (x 25) on about 6 August 2018 in the name of Registrar, The Canberra Hospital, and presented it for dispensing at the Chemist Warehouse Woden on 8 September 2018.

(e) Temazepam 10mg (x 20) on about 10 August 2018 in the name of Dr C and presented it for dispensing at the Capital Chemist Southlands on 12 August 2018.

(f) Temazepam 10mg (x 25) on about 24 August 2018 in the name of Registrar, The Canberra Hospital, and presented it for dispensing at the Chemist Warehouse Woden on 26 August 2018.

(g) Temazepam 10mg (x 25) on about 1 October 2018 in the name of Dr A and presented it for dispensing at the Chemist Warehouse Woden on 6 October 2018.

(h) Oxycodone 5mg (x 20) on about 19 November 2018 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Fyshwick on 23 November 2018.

(i) Temazepam 10mg (x 25) on about 26 November 2018 in the name of Registrar, The Canberra Hospital, and presented it for dispensing at the Chemist Warehouse Woden on 26 November 2018.

(j) Oxycodone 5mg (x 20) on about 11 December 2018 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Woden on 13 December 2018.

(k) Temazepam 10mg (x 25) on about 15 December 2018 in the name of Registrar, The Canberra Hospital, and presented it for dispensing at Cooleman Court Pharmacy on 27 December 2018.

(I) Oxycodone 5mg (x 20) on about 19 December 2018 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Woden on 27 December 2018.

(m) Temazepam 10mg (x 25) on about 20 December 2018 in the name of Registrar, The Canberra Hospital, and presented it for dispensing at TerryWhite Chemmart Garran on 20 December 2018.

(n) Temazepam 10mg (x 25) on about 29 December 2018 in the name of Registrar, The Canberra Hospital, and presented it for dispensing at the Chemist Warehouse Woden on about 21 January 2019.

(o) Oxycodone 5mg (x 20) on about 3 January 2019 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Fyshwick on 3 February 2019.

(p) Oxycodone 5mg (x 20) on 4 January 2019 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Fyshwick on 12 January 2019.

(q) Oxycodone 5mg (x 20) on about 20 February 2019 in the name of Dr D, and presented it for dispensing at Capital Chemist Hughes on 25 February 2019.

(r) Temazepam 10mg (x 25) on about 25 February 2019 in the name of Dr E and presented it for dispensing at the Chemist Warehouse Woden on 1 March 2019.

(s) Temazepam 10mg (x 25) on about 27 February 2019 in the name of Registrar, The Canberra Hospital, and presented it for dispensing at the Chemist Warehouse Woden on 19 March 2019.

(t) a prescription for Temazepam 10mg (x 25) on about 1 April 2019 in the name of Registrar, The Canberra Hospital, and presented it for dispensing at the Chemist Warehouse Woden on 7 April 2019.

(u) a prescription for Temazepam 10mg (x 25) on about 9 April 2019 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Fyshwick on 14 April 2019.

(v) a prescription for Oxycodone 5mg (x 20) on about 20 April 2019 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Woden on 7 May 2019.

(w) a prescription for Temazepam 10mg (x 25) on about 10 May 2019 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Woden on 12 May 2019.

(x) a prescription for Temazepam 10mg (x 25) on about 1 June 2019 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Fyshwick on 9 June 2019.

(y) a prescription for Oxycodone 5mg (x 20) on about 28 June 2019 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Woden 3 July 2019.

(z) a prescription for Temazepam 10mg (x 25) on about 28 June 2019 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Fyshwick on 2 July 2019.

(aa) a prescription for Zopiclone 7.5mg (x 30) on 20 July 2019 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Woden on 27 July 2019.

(bb) a prescription for Temazepam 10mg (x 25) on 1 August 2019 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Woden on 5 August 2019.

(cc) a prescription for Oxycodone 5mg (x 20) on 20 August 2019 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Woden on 25 September 2019 (25 September 2019 Prescription). Dr Stone informed the pharmacist working at the Chemist Warehouse Woden that he had been seen in the Emergency Department and that he obtained the prescription whilst there. The pharmacist identified the prescription as suspicious. The pharmacist contacted the Canberra Hospital Emergency Department and spoke to a Senior Physician, who informed him the pharmacist that Dr Stone was not prescribed any medication by the Canberra Hospital Emergency Department. The pharmacist informed Dr Stone that the prescription was fraudulent and that the prescription would be cancelled. The pharmacist did not dispense the prescription.

(dd) a prescription for Zopiclone 7.5mg (x 30) on 9 September 2019 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Woden on 14 September 2019.

(ee) a prescription for Valpam/Diazepam 2mg (quantity unclear) on 10 September 2019 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Woden on 23 September 2019.

(ff) a prescription for Zopiclone 7.5mg (x 30) on 24 September 2019 in the name of Dr D and presented it for dispensing at the Chemist Warehouse Fyshwick on 29 September 2019.

2.3 To the knowledge of Dr Stone, at the material times:

(a) each of Temazepam, Zopiclone and Valpam/Diazepam were (and continue to be) listed under Schedule 4 of the Commonwealth Poisons Standard (which is adopted in the Australian Capital Territory under the Medicines, Poisons and Therapeutic Goods 2008 (Act));

(b) Oxycodone is listed under Schedule 8 of the Commonwealth Poisons Standard; and

(c) all of these medications are only available on prescription by an authorised medical practitioner.

1. Investigations by Canberra Health Service and notification to Ahpra

3.1 On 26 September 2019 (the day after the pharmacist called the Canberra Hospital as described in paragraph 2.2(cc)), the Canberra Health Service began investigating the 25 September 2019 Prescription.

3.2 On 14 October 2019, the Canberra Health Service suspended Dr Stone from his employment with pay and Dr Stone remained suspended (and did not work as a medical practitioner) through to the cessation of his employment on 20 August 2020.

3.3 Dr Stone did not personally notify the Australian Health Practitioner Regulation Agency (Ahpra), that his right to practise at the Canberra Hospital had been withdrawn or restricted because of his conduct, which he is required to do within 7 days in accordance with section 130 of the National Law. Dr Stone states that the reason why he did not do so are that:

(a) he had been informed that Canberra Hospital would be notifying AHPRA;

(b) he sought legal advice; and

(c) he was in the process of obtaining that advice when the relevant timeframe had passed.

3.4 On 17 October 2019, Dr F, a Clinical Director at Canberra Health Services, made a notification to Ahpra. The notification alleged that on 25 September 2019, Dr Stone presented a prescription for Oxycodone to Chemist Warehouse Woden which appeared to be fraudulent.

3.5 On 21 October 2019, Dr Stone admitted in writing to Canberra Health Service that he forged the 25 September 2019 Prescription. Dr Stone did not, at the time, notify the Canberra Health Service or Ahpra of any other prescriptions he had forged.

3.6 On 4 November 2019, the Canberra Health Service informed Dr Stone that it was referring the matter to the Australian Federal Police Professional Standards Unit for further investigation.

4.1 On 19 November 2019, a representative from Ahpra called Dr Stone to inform him that Ahpra had received a notification about the 25 September 2019 Prescription and that the matter would be referred to the Board, who might consider taking immediate action such as suspension.

4.2 On 20 November 2019, Dr Stone provided an undertaking not to practise as a medical practitioner.

4.3 On 27 November 2019 the Board decided to accept the undertaking and to commence an investigation into the notification about the 25 September 2019 Prescription pursuant to section 160(1)(a) of the National Law.

5.1 The Board also decided to refer Dr Stone for a health assessment.

5.2 On 7 April 2020 a health assessment was performed by Dr William Knox, Psychiatrist at the request of the Board. His reports were provided to the Board on 27 April 2020 and 25 May 2020. On 22 June 2020, Dr Stone provided Ahpra with a report from Dr Michael Williamson, Psychiatrist, dated 28 April 2020.

5.3 On 25 June 2020, a meeting was held between Dr Stone, Mr McCay, Dr Kerry Kerry Bradbury (Chair of the ACT Board of the Medical Board of Australia) and Madeleine Readett (Ahpra Investigator) pursuant to section 176 of the National Law.

5.5 On 2 November 2020, Dr Stone provided Ahpra with a further report from Dr Williamson dated 10 September 2020 and a report from Dr Paul Reufi, Psychologist dated 17 August 2020.

5.6 After considering the relevant medical evidence and the discussions with Dr Stone pursuant to section 176 of the National Law, on 4 February 2022 the Board decided to take no further action in relation the matter of Dr Stone's health under section 177(3)(c).

1. Cessation of Dr Stone's employment with Canberra Health Service

6.1 By letter dated 25 June 2020 Katrina Bracher the executive director of Canberra Health Services advised Dr Stone that she was proposing to reduce Dr Stone's incremental level and provide him with a written warning and admonishment. Effectively this would have allowed Dr Stone to keep working for Canberra Health Services once his undertaking not to practise had been revoked.

6.2 On 9 July 2020, Dr Stone (by his lawyer, Harry McCay) disclosed to the Canberra Health Service that before he accepted the proposed action Dr Stone wished to make a further disclosure (on a voluntary basis) which included the following:

We are instructed that Dr Stone did not raise this matter before because he was afraid of the consequences, but realising that you are proceeding to a decision he did not expect, he needs to be completely up front about all matters impacting on your decision.

The additional information he wishes to provide is that in an effort to manage his alcohol use last year, he decided to try using benzodiazepines to limit his reliance on alcohol. He wrote scripts for diazepam, temazepam and zopiclone on approximately half a dozen occasions using a hospital script pad and signed on some occasions in the name of Dr D.

Dr Stone is very sorry for these actions and for not raising them voluntarily before now. He realises this is likely to change your decision and offers to resign from his employment with CHS.

6.3 Dr Stone did not, at the time, notify the Canberra Health Service of any other prescriptions that he had forged.

6.4 On 20 July 2020, Dr Stone (by his lawyer, Mr McCay) resigned from his employment with Canberra Health Service with effect from 6 August 2020.

7.1 During Ahpra's investigation, as a result of inquiries Ahpra made with the ACT Health Protection Service, Ahpra learned that approximately 10 prescriptions had been dispensed to Dr Stone for oxycodone.

7.2 On 10 August 2020, Ahpra informed Dr Stone's solicitor Harry McCay that:

(a) Ahpra discovered through further inquiries that more prescriptions had been dispensed to Dr Stone for medications of concern; and

(b) in light of the new information, the scope of the potentially fraudulent conduct may be larger than previously anticipated.

(c) The information about the prescriptions was being obtained and would be provided in due course.

7.3 On 23 September 2020 Harry McCay wrote to AHPRA stating that:

(a) "you indicated that you were awaiting some information from an entity monitoring dangerous drug scripts and may then invite Dr Stone to respond to some additional issues";

(b) "Dr Stone has been off work for 9 months and has recently been assessed as ready to return to work from a health point of view";

(c) "[Dr Stone] is keen to address any issues which need to be addressed, so that he can decide whether it is appropriate to apply to the Board for a release from his current undertaking not to practise";

(d) "As such could you please advise how long it will be before you provide any further material and invite a submission".

7.4 While Ahpra was continue its investigations, and after Dr Stone was still waiting to receive more information from Ahpra, Dr Stone proactively wrote to AHPRA by his lawyer (Mr McCay) on 2 November 2020, in which Dr Stone made the following admission to Ahpra

We are instructed by Dr Stone that in an effort to manage his alcohol use last year, he did write scripts for diazepam, temazepam and zopiclone using a hospital script pad and signed on some occasions in the name of Dr Shukral/a. He initially did not advise this to AHPRA or to Canberra Health Services or even his treating practitioners because he was afraid of the consequences of revealing this information.

7.5 Through further investigation by Ahpra (involving the use of its powers under Schedule 5 of the National Law and obtaining statements from a number of witnesses), Ahpra progressively identified that Dr Stone had:

(a) between 11 December 2018 and 24 September 2019, forged eighteen (18) prescriptions in the name of Dr D; and

(b) on 5 August 2018, forged one (1) prescription in the name of Dr B.

7.6 Following the production of evidence by Ahpra to Dr Stone as to the above nineteen (19) prescriptions, Dr Stone:

(a) admitted to forging sixteen (16) prescriptions in the name of Dr D, and one (1) in the name of Dr B;

(b) denied forging two (2) prescriptions in the name of Dr D and contended that Dr D wrote those prescriptions; and

(c) did not disclose to Ahpra that there were further forged prescriptions.

7.7 On 4 February 2022 the Board determined to refer the matter to the Tribunal pursuant to section 193(1)(a)(i) of the National Law because it reasonably believed that Dr Stone had, by forging nineteen (19) prescriptions, engaged in conduct that constituted professional misconduct.

7.8 Following further inquiry, Ahpra identified an additional thirteen (13) prescriptions of concern, with dates between 6 July 2018 to 7 April 2019.

7.9 On 6 May 2022, the Board decided to repeal its previous decision3 and further investigate Dr Stone's conduct, taking into account the additional thirteen (13) prescriptions of concern.

7.10 After Ahpra produced evidence of the additional thirteen (13) prescriptions of concern to Dr Stone (being pharmacy documents summarising the content of prescriptions, rather than copies of actual prescriptions), Dr Stone:

(a) said that he probably wrote a further three (3) prescriptions in the names of Drs A and E; and

(b) in relation to the remaining ten (10) prescriptions in the name of the Registrar, said that he accepted he had forged prescriptions for medication such as temazepam and oxycodone on multiple occasions between July 2018 and September 2019.

7.11 On 2 September 2022, after the completion of a further investigation, the Board determined to refer the matter to the Tribunal under section 193(1)(a)(i) of the National Law.

7.12 On 28 October 2022, the Board referred the matter to the Tribunal under section 193(1) of the National Law.

8.1 On 5 April 2021, Dr Stone was issued a caution by the Australian Federal Police in respect of seven (7) instances of Dr Stone forging prescriptions and contravening section 347 of the Criminal Code 2002 (ACT). The offences are recorded on the caution as follows "knowingly using a false document with the intent of dishonestly inducing someone else to accept it as genuine, and because that person accepted it as genuine, dishonestly obtained a gain.

8.2 The Australian Federal Police did not prosecute Dr Stone.

[1] Annexure 1 is a redacted version of this document

[3] See Medical Board of Australia v Pang [2021] VCAT 1175: Medical Board of Australia v Lodhi [2022] VCAT 439; Medical Board of Australia v Giorgio [2023] VCAT 50

[5] Report of Dr Knox dated 30 March 2020, T-Docs, page 895; Report of Dr Williamson dated 28 April 2020, T-Docs, page 906; and Report of Dr Martin dated 6 March 2023, T-Docs, page 950

[6] Witness statement of Liam Stone dated 18 February 2023 at [7] and [9]

[7] Report of Dr Ruefli dated 23 February 2023, T-Docs, page 934; Report of Dr Williamson dated 28 April 2020, T-Docs, page 912; Report of Dr Martin dated 6 March 2023, T-Docs, page 953

[8] Health Ombudsman v HSK [2018] QCAT 419 at [28]; Health Ombudsman v Joy [2020] QCAT 202 at [11]; Medical Board of Australia v Dr POS [2019] VCAT 1678 at [57]

[9] Report of Dr Martin dated 6 March 2023, T-Docs, page 954; Report of Dr Ruefli dated 23 February 2023, T-Docs, page 935; Report of Dr Williamson dated 28 April 2020, T-Docs, page 916

[10] Report of Dr Martin dated 6 March 2023, T-Docs, page 952

[11] Witness statement of Liam Stone dated 18 February 2023 at [33]

[12] Report of Dr Martin dated 6 March 2023, T-Docs, page 954; Report of Dr Williamson dated 28 April 2020, T-Docs, page 916; Report of Dr Ruefli dated 23 February 2023, T-Docs, page 935

[13] Witness statement of Liam Stone dated 18 February 2023 at [13]

[14] Report of Dr Martin dated 6 March 2023, Report of Dr Williamson dated 28 April 2020

[15] Report of Dr Ruefli dated 23 February 2023, T-Docs, page 935

[16] Report of Dr Martin dated 6 March 2023, T-Docs, page 952; Report of Dr Ruefli dated 23 February 2023, T-Docs, page 935

[17] Character reference written by JL dated 19 February 2023; Undated character reference written by MH; Character reference written by MS dated 23 February 2023

[18] Report of Dr Ruefli dated 23 February 2023, T-Docs, page 935

[19] Witness statement of Liam Stone dated 18 February 2023 at [27]-[36]

[20] Character reference written by RS dated 18 June 2021; Character reference written by MS dated 23 February 2023

[21] AHPRA file note dated 10 August 2020, T-Docs, page 904

[23] Witness statement of Harry McCay dated 17 February 2023 at [50(s)]

[24] [2021 VCAT 222 at [59]

[25] Quoted with approval in Medical Board of Australia v Pang [2021] VCAT 1175 at [62]

[26] Medical Board of Australia v Lodhi [2022] VCAT 439 at [76]- [77]

[27] Medical Board of Australia v Pang

[28] Nursing and Midwifery Board of Australia v Harris [2021] VCAT 496

[29] Health Practitioner Regulation National Law Act 2009 (Qld), Schedule 2

[30] Section 6 of the Health Practitioner Regulation National Law (ACT) Act 2010.