The parties made joint submissions as to the orders the Tribunal should make.

• - the Tribunal made findings of fact in accordance with the Statement of Agreed Facts;
• - the conduct of the respondent, occurring over a significant period, exhibited a serious disregard for the requirements of professional practice. The prescribing constituted a serious departure from the standard of care to be expected of a practitioner of the respondent's training and experience;
• - the respondent clearly behaved in a way that constitutes professional misconduct.

1. The respondent is reprimanded;
2. The respondent is disqualified for a period of two years from applying for registration as a registered health practitioner;
3. The respondent is to pay the complainant's costs as agreed.

Disciplinary - Health practitioners - Complaint by the Medical Board of Australia - Professional Misconduct - Inappropriate prescribing - Inadequate record keeping - Disqualified from applying for registration for 2 years

Disciplinary - Health practitioners - General principles - Aggravating factors

Health Practitioner Regulation National Law (South Australia) Act 2010

South Australian Civil and Administrative Tribunal Act 2013 s 60

NSW Bar Association v Evatt [1968] HCA 20; (1968) 117 CLR 177

Craig v Medical Board of South Australia [2001] SASC 169; (2001) 79 SASR 545

Health Care Complaints Commission v Litchfield [1997] NSWSC 297; (1997) 41 NSWLR 630

Physiotherapy Board of Australia v Adey [2017] SAHPT 3

Medical Board of Australia v Singh [2017] WASAT 33

Medical Board of Australia v Jansz [2011] VCAT 1026

Spicer v NSW Medical Council Unreported Court of Appeal CA No 3 of 1981

Medical Board of Australia v Hadges [2018] SAHPT 6

Pursuant to s 60 of the South Australian Civil and Administrative Tribunal Act 2013 the publication of the names of, or anything tending to identify, patients referred to in this decision have been prohibited.

1. This is a disciplinary proceeding brought by the complainant (the Board) against Peter Tunbridge (the respondent), a former medical practitioner, pursuant to the provisions of the Health Practitioner Regulation National Law (South Australia) Act 2010 (the Act).
2. Schedule 2 of the Act sets out the Health Practitioner Regulation National Law (South Australia). We shall refer to the contents of this schedule as "the National Law".
3. The respondent first obtained registration on 1 January 1978. He practised at the Norwood Village Medical and Dental Centre until April 2014 and subsequently at the Stirling Surgery.
4. In 2017 the respondent's mode of practice came to the attention of the Board and an investigation was commenced.
5. On 18 October 2018 the Board gave notice that it proposed to take immediate action. The respondent offered an undertaking that he would not prescribe or administer certain medications other than under supervision. The Board resolved to accept that undertaking pursuant to Division 7 of Part 6 of the National Law. The investigation continued.
6. On 5 August 2019 the Board referred the matter to the former SA Health Practitioners Tribunal under s 193 of the National Law. The matter was then transferred to SACAT on 7 August 2019 due to the transfer of jurisdiction occasioned by the Statutes Amendment (SACAT) Act 2019.[1]
7. On 30 September 2019 the respondent's registration lapsed and he did not seek to renew.
8. The parties have filed an Agreed Statement of Facts. The respondent admits that his behaviour constitutes professional misconduct. The parties have filed a Joint Submission as to suggested disciplinary action. They have also filed a Hearing Book containing further relevant information.
9. The parties have requested that the Tribunal determine the matter on the papers. We have proceeded to do so.

1. The Tribunal makes findings of fact in accordance with the Statement of Agreed Facts.
2. The facts are helpfully summarised in the Joint Submission and we set that out (with some adaptions and added emphases and with footnotes removed) below:

28. The Applicant is critical of the Respondent's prescribing of various medications (including GHRP, Anastrozole, Metformin, DHEA and testosterone) to 20 patients between about October 2009 and September 2017. As the Statement of Agreed Facts describes, the Respondent admits that he failed to adequately monitor the treatment provided to certain patients and that he failed to keep adequate records in relation to some patients. The Respondent's prescribing had the potential to cause harm to the patients.

29. The Statement of Agreed Facts briefly describes the relevant medications and the risks associated with the Respondent's prescribing of them. In summary:

(a) Growth Hormone Releasing Peptide (GHRP) is a peptide. It is not approved by the TGA for use in Australia. It is regarded as an experimental medication. It is a drug that may be inappropriately used by, for example, bodybuilders or weightlifters other than for a therapeutic purpose.

(b) Anastrozole (Arimidex) is what is known as an aromatase inhibitor that may lead to the increased production of testosterone. While there are some limited approved circumstances in which the medication may be prescribed, it is otherwise an experimental medication. It is not approved by the TGA for the treatment of males. It is used inappropriately by people using anabolic androgenic steroids to counter the adverse effects of those drugs, for example, gynaecomastia (the development of breast tissue or breast enlargement in males).

(c) Testosterone (including Testogel) and Primoteston are anabolic androgenic steroids. These drugs can be inappropriately used off label by, for example, bodybuilders other than for therapeutic purposes. Testosterone is rarely used in the treatment of women.

(d) DHEA is an endogenous adrenal androgenic steroid. It is not approved for use by the TGA and is regarded as experimental for the use in treatment of males. It can also be inappropriately used off label by, for example, bodybuilders other than for therapeutic purposes.

(e) T3 and T4 are variations of thyroxine medications. They are used in the treatment of hypothyroidism.

(f) Metformin (Diabex) (and Januvia) may only be appropriately used in very limited circumstances, for example, the treatment of diabetes mellitus.

30. These medications described above, if used inappropriately, can have an adverse effect upon the health of a patient.

31. In summary, the Respondent inappropriately prescribed (or administered):

(a) DHEA to 10 patients, namely AR, AB, CB, FC, NR, PB, SH, TH, WD and MJ.

(b) GHRP to 19 patients, namely AR, AB, AW, CB, DF, FC, JC, KS, LP, NP, NR, PB, RS, RG, SC, SS, SH, TH, and WD.

(c) Testosterone/Primoteston (or similar) to 7 patients, namely AR, AW, FC, JC, KS, RS, and MJ.

(d) Anastrozole (Arimidex) to 6 patients, namely AR, AW, CB, FC, RS, and MJ.

(e) Metformin (Diabex) (Januvia) to 13 patients, namely AR, AW, CB, DF, FC, KS, NR, PB, RG, SC, SH, TH, and MJ.

32. Often when prescribing this medication, the Respondent failed to advise the patient the medication was experimental and obtain their informed consent. He failed to adequately monitor the patient's use of the medication. The Respondent's failure to monitor the patients, as well as the prescribing, gave rise to a risk of harm. The Respondent's record keeping was also inadequate and did not comply with the requirements of the Code of Practice.

33. Taking into consideration the treatment of all 20 patients, the Respondent accepts he systematically prescribed GHRP (a peptide) and Anastrozole in circumstances that were inappropriate and could cause harm.

34. The Statement of Agreed Facts sets out in detail the treatment provided to the patients. With respect to patient AR (patient 1), a male:

(a) The Respondent inappropriately prescribed the DHEA, GHRP, testosterone, Anastrozole (Arimidex) and Metformin (Diabex) creating a risk of harm.

(b) GHRP was prescribed 'as an adjunctive agent for promoting energy to compensate for the suppression of his testosterone and Metformin for weight loss.

(c) The patient presented with a goitre, and subsequently with an apparent stress fracture to his foot, but on both occasions no investigations were undertaken.

(d) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(e) The monitoring of the use of GHRP was inadequate and created a risk of harm.

35. Patient AB (patient 2), a female:

(a) Was inappropriately prescribed DHEA, and GHRP creating a risk of harm.

(b) The Respondent says AB 'requested both the DHEA and GHRP'. The medication was prescribed for cognitive impairment or to improve the patient's 'failing cognition'.

(c) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(d) The monitoring of the use of GHRP was inadequate.

36. With respect to patient AW (patient 3), a male:

(a) The Respondent inappropriately prescribed GHRP, Testogel (transdermal gel testosterone replacement), Anastrozole (Arimidex), Metformin (Diabex XR) creating a risk of harm.

(b) The Respondent said that AW had 'been training hard but not getting muscle mass in developing central weight gain'. The Respondent gave 'him a trial of HGHRT for 3 months to see if this would help his liver fat deposition and improve his lean body mass'. The Respondent prescribed Metformin for weight loss and pre-diabetic treatment.

(c) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(d) The monitoring of the use of GHRP was inadequate.

37. Patient CB (patient 4), a 71 year old male:

(a) Was inappropriately prescribed DHEA, GHRP, Anastrozole (Arimidex) and Metformin (Diabex XR) creating a risk of harm.

(b) The Respondent trialled CB on GHRP for 3 months to address his lean body mass, libido and fatigue. The Respondent prescribed Metformin for weight loss and pre-diabetic treatment. The Respondent prescribed Anastrozole (Arimidex) to treat gynaecomastia.

(c) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(d) The monitoring of the use of GHRP was inadequate.

38. Patient DF (patient 5), a 78 year old female:

(a) Was prescribed GHRP and Metformin (Diabex XR).

(b) DF wished to trial the use of GHRP to address her lean body mass. It was prescribed for muscle strength and "well-being". The Respondent prescribed Metformin for weight loss and pre-diabetic treatment (where it is conventionally prescribed for menstrual regulation and to improve fertility).

(c) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(d) The monitoring of the use of GHRP was inadequate and created a risk of harm.

39. Patient FC (patient 6), a male:

(a) Was inappropriately prescribed DHEA, GHRP, Testogel (testosterone replacement), Metformin (Diabex XR) and Anastrozole (Arimidex) creating a risk of harm.

(b) Respondent prescribed GHRP to assist lean body mass. The Respondent prescribed Metformin for weight loss and pre-diabetic treatment or to 'prevent progression to permanent diabetes'. The Respondent prescribed Anastrozole (Arimidex) to treat gynaecomastia.

(c) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(d) The monitoring of the use of GHRP was inadequate and created a risk of harm.

40. Patient JC (patient 7), a female:

(a) Was inappropriately prescribed GHRP and testosterone creating a risk of harm.

(b) The Respondent prescribed GHRP for muscle strength.

(c) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(d) The monitoring of the use of GHRP was inadequate and created a risk of harm.

(e) The Respondent failed to address JC's local vaginal symptoms.

41. Patient KS (patient 8), a male:

(a) Was inappropriately prescribed testosterone, GHRP Metformin (Diabex XR) creating a risk of harm.

(b) The Respondent prescribed the GHRP to promote healing and to improve libido. He prescribed the Metformin as a pre-diabetic treatment.

(c) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(d) The monitoring of the use of GHRP was inadequate and created a risk of harm.

42. Patient LP (patient 9), a female:

(a) Was inappropriately prescribed GHRP to treat low libido and splitting or fraying of her hair creating a risk of harm.

(b) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(c) The monitoring of the use of GHRP was inadequate and created a risk of harm.

43. Patient NP (patient 10), a female:

(a) Was inappropriately prescribed GHRP for low libido.

(b) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(c) The monitoring of the use of GHRP was inadequate and created a risk of harm.

44. Patient NR (patient 11), a male:

(a) Was inappropriately prescribed DHEA, GHRP Metformin (Diabex XR) creating a risk of harm.

(b) DHEA was prescribed for chronic fatigue. GHRP was prescribed for low libido and Metformin for postprandial tiredness.

(c) The Respondent failed to obtain NR's informed consent to prescribe DHEA or inform him that the medication was experimental.

(d) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(e) The monitoring of the use of GHRP was inadequate and created a risk of harm.

45. Patient PB (patient 12), a male:

(a) Was inappropriately prescribed DHEA, GHRP Metformin (Diabex XR) creating a risk of harm.

(b) The Respondent prescribed GHRP for low libido.

(c) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(d) The monitoring of the use of GHRP was inadequate and created a risk of harm.

46. Patient RS (patient 13), a male:

(a) Was inappropriately prescribed GHRP, testosterone (AndroForte), Anastrozole (Arimidex) creating a risk of harm.

(b) The Respondent prescribed GHRP to improve lean body mass. The Respondent prescribed Anastrozole (Arimidex) to treat gynaecomastia.

(c) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(d) The monitoring of the use of GHRP was inadequate and created a risk of harm.

47. Patient RG (patient 14), a male:

(a) Was inappropriately prescribed GHRP and Metformin (Diabex XR) creating a risk of harm.

(b) The Respondent prescribed GHRP purportedly to improve renal failure.

(c) The Respondent failed to take certain assessments before prescribing Metformin (Diabex XR). Despite RG's medical history he was prescribed Metformin (Diabex XR).

(d) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(e) The monitoring of the use of GHRP was inadequate and created a risk of harm.

48. Patient SC (patient 15), a female:

(a) Was inappropriately prescribed GHRP and Metformin (Diabex XR) creating a risk of harm.

(b) The Respondent prescribed the GHRP to treat low libido. The Respondent prescribed Metformin for weight loss and pre-diabetic treatment.

(c) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(d) The monitoring of the use of GHRP was inadequate and created a risk of harm.

49. Patient SS (patient 16), a female:

(a) Was inappropriately prescribed GHRP to improve renal function55 creating a risk of harm.

(b) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(c) The monitoring of the use of GHRP was inadequate and created a risk of harm.

(d) The Respondent prescribed SS Frusemide (Lasix) for fluid retention but did not record his clinical assessment, diagnosis and reason for prescribing the medication.

50. Patient SH (patient 17), a female:

(a) Was inappropriately prescribed DHEA, GHRP, Metformin (Diabex XR), Progesterone and T3 creating a risk of harm.

(b) The Respondent prescribed Metformin (Diabex XR) for weight loss and prediabetic treatment. He prescribed GHRP for low libido.

(c) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(d) The monitoring of the use of GHRP was inadequate and created a risk of harm.

51. Patient TH (patient 18), a female:

(a) Was inappropriately prescribed DHEA, GHRP and Metformin (Diabex XR) creating a risk of harm.

(b) The Respondent prescribed GHRP purportedly for general health and Metformin for weight loss and pre-diabetic treatment.

(c) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(d) The monitoring of the use of GHRP was inadequate and created a risk of harm.

52. Patient WD (patient 19), a male:

(a) Was inappropriately prescribed GHRP for low libido and muscle strength and prescribed DHEA creating a risk of harm.

(b) The Respondent failed to inform WD that DHEA was experimental and did not obtain WD's consent prior to prescribing the medication.

(c) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(d) The monitoring of the use of GHRP was inadequate and created a risk of harm.

53. Patient MJ (patient 20), a male:

(a) Was inappropriately prescribed various medication including Testogel (testosterone), Metformin (Diabex XR), DHEA and Anastrozole (Arimidex) creating a risk of harm.

(b) The Respondent purportedly prescribed testosterone for muscle strengthening and to prolong life. He prescribed Metformin for weight loss and pre-diabetic treatment.

(c) The Respondent failed to inform MJ that DHEA was experimental and did not obtain WD's consent prior to prescribing the medication.

(d) The Respondent failed to record certain information obtained and provided during the consultations, including informed consent and the reasons for prescribing the medication.

(e) The monitoring of the use of GHRP was inadequate and created a risk of harm.

1. As indicated in the Statement of Agreed Facts, the above conduct variously occurred over a period between 2009 and 2018. It will be noted that it was agreed that the prescribing gave rise to a risk of harm to the patients concerned. We refer to the Statement of Agreed Facts where the nature of that potential harm was specified with respect to each of the medications prescribed.
2. The Board obtained independent expert evidence from Dr Paul Glendenning. He provided reports in September 2018[2] and February 2019.[3] Dr Glendenning's evidence was not contested, and we accept his evidence. The Joint Submission highlights the following aspects of Dr Glendenning's opinions:

56. With respect to the Respondent's use of GHRP (a peptide), Dr Glendenning says:

...there were no studies to verify the use of GHRP treatment in opiate induced hypogonadism (patient 1), cognitive dysfunction (patient 2), to increase 'lean body mass' (patients 3, 4, 6, 8) improve muscle strength (patients 7, 20), for unknown reasons (patients 9, 13, 15), to improve libido (patients 10, 11, 12, 17, 18), and improve renal function (patients 14, 16) or to treat hypopituitarism (patient 19). To avoid any ambiguity, the risks and benefits of GHRP treatment are unknown and this fact establishes the importance of informed patient consent. Such informed written consent was not documented by Dr Tunbridge_[4]_.

57. Dr Glendenning states that the Respondent's monitoring of GHRP treatment was predominantly based on patient symptoms'[5]. Only some patients were monitored. Otherwise, the monitoring was inconsistent and inadequate_[6]_.

58. Dr Glendenning described that since the use of GHRP treatment is experimental, it is important to assess before and during treatment. Dr Glendenning refers to a single review which recommends that patients taking growth hormones be followed with "regular examinations for changes in body composition and IGF-1 levels during [HGH] treatment and with blood glucose and HbA1c monitoring"[7].

59. Dr Glendenning stated:

In patient 1, IGF-1 was measured but was consistently elevated before the patient was prescribed GHRP. The degree of IGF-1 elevation could be consistent with early Acromegaly and no further investigation, such as glucose suppression test was performed before the commencement of GHRP treatment. The prescription of GHRP to a patient with Acromegaly could result in clinical harm.

In patient 3, IGF-1 was not measured. In patient 5, GHRP was prescribed on 14 separate occasions between 2011 and 2017. RGF-1 was first measured in 2017 according to the records reviewed. In patient 7, IGF-1 was first measured the year after GHRP was prescribed. In patient 9, IGF-1 was not measured. In patient 11, IGF-1 was measured several years after GHRP was prescribed. In patient 15, IGF-1 was measured 5 years after starting GHRP treatment. In patients 16 and 17, IGF-1 was measured but after starting GHRP treatment. In patient 18, IGF-1 was not measured.

In patient 1, total cholesterol increase from 7.3 (27/08/10...) to 8.0M on 20/03/13... but triglycerides, HDL or LDL cholesterol were not requested.

Patient 9 and patient 17 did not have any glucose measurements.

I conclude that the monitoring of patients before and after the prescription of GHRP was not consistent or adequate. In 2 patients IGF-1 was not measured and in 6 patients IGF-1 was not measured after starting GHRP, in some cases years after starting treatment. The prescription of GHRP to patient 1 with a pre-existing and consistent increase in IGF-1 level was of particular concern_[8]_.

60. Dr Glendenning otherwise stated:

There is no evidence that the potential side effects of GHRP treatment were explained to any patient and in patient 16, the symptoms described by the patient could represent a side effect of GHRP use. The prescription of GHRP to a patient with a preceding persistent elevated IGF-1, as is evident in patient 1...could also cause potential harm_[9]_.

61. Dr Glendenning observed that the Respondent's records did not include 'any written evidence that he has explained the potential side effects of GHRP treatment to any of the 20 patients'[10].

62. In conclusion, Dr Glendenning proffered the opinion that:

...the provision of any treatment that was not clinically indicated, the provision of any experimental treatment, inadequate monitoring of treatment and in particular if those medications prescribed could increase the risk of clinical harm were reasons that would qualify for performance that fell substantially below the reasonable expected standard of care for a general practitioner. Applying those criteria, the prescription of 2 specific treatments, GHRP and Anastrozole, by Dr Tunbridge indicates his performance fell substantially below the reasonably expected standard of general practice care...

63. Dr Glendenning formed the opinion that Dr Tunbridge's prescription of GHRP and Anastrozole indicated that his performance had fallen substantially below the reasonably expected standard of general practice care on the basis that:

(a) both treatments could be considered as experimental;

(b) there was no clinical evidence that substantiated those treatments were required in the patient records;

(c) the prescribing of GHRP to 20 patients and the prescribing of Anastrozole to 5 patients indicated that these were not isolated incidents and confirmed a practice of systematic prescribing;

(d) there was no evidence that the patients were counselled about the experimental nature of the medication;

(e) there was inadequate monitoring of potential adverse effects of the treatment; and

(f) when a potentially adverse effect of treatment was noted for patient 16, the prescription of GHRP was not stopped_[11]_.

64. Dr Glendenning describes that Metformin is conventionally prescribed for menstrual regulation and potentially improve fertility. He is not aware of any evidence to support the prescription of Metformin to prevent the early onset of diabetes. He states:

...The prescription of 1,000mg of metformin to patient 14 who had in stage renal failure... was of concern. Despite a known history of glomerulonephritis and the knowledge that the patient was attending a specialist renal physician, serum creatinine, a measure of renal function and serum bicarbonate, in the measure of acid based balance, were not measured on 28/05/15 before metformin was prescribed... patient 14 had chronic kidney disease stage 5 (CKD 5) which predisposes to an increased risk of lactic acidosis and that risk may have been increased by the prescription of metformin treatment. There was no mention in the consultation 07/09/15 indicating Dr Tunbridge was aware of the results of risk of renal function or acid based balance test, informed the patient of the potential risk of continuing metformin treatment nor reconsidered that either the dose should be reduced or the medication ceased.[12]

65. On occasions, the Respondent failed to adequately address patients' symptoms. For example, as described at paragraph 40(e) above, the Respondent failed to address patient JC's local vaginal symptoms. Dr Glendenning states the patient:

...was a postmenopausal woman who was prescribed supra-physiological doses of testosterone replacement as confirmed by biochemically on 2 occasions. Despite the patient's local vaginal symptoms documented during consultations on 30/09/10 and 15/02/12 local vaginal estrogen treatment, more appropriate treatment, was not considered or prescribed.'[13]

66. Testosterone is rarely used in the treatment of women.

67. Finally, Dr Glendenning expressed concern that, having considered the Respondent's submission75, a number of the Respondent's justifications for prescribing certain medications (such as Metformin and DHEA) demonstrated an 'unconventional understanding'

1. The respondent provided an initial response to the concerns raised by AHPRA in January 2018.[14] He essentially defended his practice and prescribing for the patients concerned.
2. The respondent was later provided with a copy of Dr Glendenning's first report dated 19 September 2018. On 18 October 2018, the Board gave notice to the respondent that it proposed taking immediate action, namely the imposition of conditions of practice. The respondent through his solicitor offered an undertaking in substantially the same terms as the proposed conditions. On 24 October 2018, the Board took immediate action by accepting that undertaking.
3. However, the respondent provided a further letter dated 12 February 2019 in which he responded in detail to the report of Dr Glendenning.[15] Whilst accepting that his record-keeping was deficient and offering to undertake a course to remedy this, the respondent sought to justify much of the conduct now admitted to be unprofessional. He took issue with many of Dr Glendenning's views.
4. The respondent now does not challenge Dr Glendenning's views. This change of approach on the part of the respondent became apparent after the matter was referred to the Tribunal. The Tribunal was advised that he was relinquishing his practice. The respondent allowed his registration to lapse on 30 September 2019.
5. The provisions of Part 8 of the National Law continue to apply to a person who is no longer registered.[16]

1. In NSW Bar Association v Evatt (1968) 117 CLR 177; [1968] HCA 20 at [12], the High Court confirmed that the purpose of disciplinary proceedings for a barrister was:

"entirely protective, and, notwithstanding that its exercise may involve a great deprivation to the person disciplined, there is no element of punishment involved."

1. This statement was adopted and applied to the discipline of health practitioners in Craig v Medical Board of South Australia [2001] SASC 169; (2001) 79 SASR 545 at 553-554, where Doyle CJ (Williams & Martin JJ agreeing) stated:

"The purpose of disciplinary proceedings is to protect the public, not to punish a practitioner in the sense in which punishment is administered pursuant to the criminal law. A disciplinary tribunal protects the public by making orders which will prevent persons who are unfit to practise from practising, or by making orders which will secure the maintenance of proper professional standards. A disciplinary tribunal will also consider the protection of the public, and of the relevant profession, by making orders which will assure the public that appropriate standards are being maintained within the relevant profession."

1. The protection of the public may sometimes require disciplinary action which has a greater adverse effect on the practitioner than may be warranted if punishment was the relevant consideration.[17] Unlike the process of sentencing for a criminal offence, personal circumstances of a practitioner may be of limited significance in the process of determining what is necessary in the public interest.[18]
2. In Health Care Complaints Commission v Litchfield [1997] NSWSC 297; (1997) 41 NSWLR 630, the Court of Appeal made it clear that:

"The gravity of professional misconduct is not to be measured by reference to the worst cases but by the extent to which it departs from the proper standards. If this is not done, there is a risk that the conduct of delinquents in a profession will indirectly establish the standards applied by the Tribunal."[19]

1. In Physiotherapy Board of Australia v Adey [2017] SAHPT 3, the SA Health Practitioners Tribunal observed that:

"...the imposition of disciplinary action may serve one or all of the following purposes:

• preventing practitioners who are unfit to practice from practising;
• securing maintenance of professional standards;
• assuring members of the public and the profession that appropriate standards are being maintained and that professional misconduct (or unprofessional conduct) will not be tolerated;
• bringing home to the practitioner the seriousness of their conduct;
• deterring the practitioner from any future departures from appropriate standards;
• deterring other members of the profession who might be minded to act in a similar way;
• imposing restrictions on the practitioners' right to practice so as to ensure that the public is protected"[20]

1. In Medical Board of Australia v Jansz [2011] VCAT 1026 at paragraph [368] - [372], the Tribunal stated:

"The objectives of determinations can be achieved through a variety of mechanisms, including by deterring the person concerned from further inappropriate conduct (specific deterrence), deterrence of other practitioners minded to conduct themselves similarly (general deterrence), and facilitation of rehabilitation on the part of the practitioner.

The likelihood of recidivism, or, put another way, an assessment of the ongoing risk posed by the practitioner, should be central to the imposition of a determination.

Personal matters such as shame, personal ordeal, financial difficulty likely to be occasioned by a determination are of little relevance save insofar as they contribute to the specific deterrence of the practitioner.

The degree to which the practitioner has acquired insight into his or her conduct has been held to be of potential relevance to the determination in that it goes to the continuing risk posed by the practitioner. In this regard the opportunity to see and assess the practitioner is important, as is the capacity for a tribunal which consists partly of practitioners of the relevant discipline is important. In context, this "insight" might be reflected in a variety of ways, such as an understanding of the nature of the conduct, an acceptance that the conduct was wrong, an appreciation of why the practitioner engaged in that conduct, empathy with the consequences, and/or a willingness to take measures to identify risk factors and to do that which is necessary to avoid further transgressions."

1. The parties jointly submit that the Tribunal should make the following orders:

(a) a finding that the Respondent has engaged in professional misconduct.

(b) an Order that the Respondent be disqualified from applying for re-registration as a health practitioner for a period of 2 years from the date of the Tribunal's order; and

(c) an Order that the Respondent pay the Applicant's costs as agreed.

1. It is acknowledged, however, that the Tribunal is in no way bound by the joint recommendation of the parties and must impose the disciplinary sanctions it considers appropriate in the circumstances.

1. We were referred to various cases concerning inappropriate prescription of medication.
2. In Spicer v NSW Medical Council[21], Hope JA (Reynolds and Hutley JJA agreeing) remarked that:

"In my opinion it is clear beyond argument that the proper handling and prescribing of drugs by medical practitioners are of the greatest importance to the community. If a medical practitioner handles or carries out that very great responsibility in a way that is reckless and which shows a disregard to the law it cannot be said that he is fitted at such a time to be a medical practitioner..."

1. In Medical Board of Australia v Singh,[22] Curthoys J stated:

"The inappropriate prescription of drugs where there was no proper therapeutic basis is a serious matter. This is all the more so because in a number of the instances identified above, it exposed Dr Singh's patients to the risk of side effects.

...Dr Singh's failure to take adequate notes is a fundamental failing in his obligations to his patients.".

We note that the failure to keep adequate records (and, indeed, the failure to obtain informed consent in writing) is a significant aggravating feature where it is suggested that unproven and potentially harmful medications may have been prescribed without appropriate warnings or advice to patients.

1. The Tribunal in Singh's case referred to the ready market for off-label drugs that are sought by patients for non-therapeutic purposes such as body-building or other comparable purposes. It referred to the fact that it can be lucrative for practitioners to service this market. The Tribunal expressed the view that sanctions must be of sufficient severity to provide a disincentive for such behaviour. Dr Singh was disqualified for a period of 10 years. The Supreme Court of WA upheld the decision of the Tribunal.[23]
2. In Medical Board of Australia v Hadges,[24] the SAHPT relevantly stated:

"There is no doubt that the inappropriate prescription of drugs when there is no proper therapeutic basis is a serious matter and is clearly professional misconduct."

1. The conduct of the respondent, occurring over a significant period, exhibited a serious disregard for the requirements of professional practice. The prescribing constituted a serious departure from the standard of care to be expected of a practitioner of the respondent's training and experience.[25] The respondent repeatedly put patients at risk of harm by his inappropriate prescribing. He magnified the risk of harm by failure to adequately monitor patients under his care when he had prescribed inappropriately. On occasions he failed to appropriately address or investigate patients' symptoms. The respondent failed on occasions to obtain informed consent to treatments that were unconventional, of unproven benefit, and potentially harmful. On other occasions he failed to document such informed consent. His record keeping was inadequate.
2. The respondent clearly behaved in a way that constitutes professional misconduct. We so find. The conduct is serious and, although not suggested in the joint submission of the parties, we consider that a reprimand should be imposed. The conduct requires nothing less than the fullest expression of the Tribunal's disapproval. The disciplinary response would be inadequate if a reprimand were not administered.
3. The admitted conduct demonstrates, in our view, that the respondent is unfit to be registered. As recently as February 2019 the respondent was defending his conduct and challenging the views of Dr Glendenning. The admission of facts and of professional misconduct came at a time that the respondent relinquished his practice and allowed his registration to lapse. There has been no explanation for this change in the respondent's stance. It may have been prompted by purely practical considerations, divorced from any real insight on the respondent's part. We do not know. There has been a passing reference to the respondent's state of health, and it may be that he has decided to permanently retire, but we have not been advised to that effect.
4. Other than the acknowledgements made in the Statement of Agreed Facts, the respondent has made no attempt to convince the Tribunal that he has now gained insight into his behaviour or that he could now be trusted to practise in a safe manner. We must regard him as currently unfit to practise. On the information before us, we can have no confidence that he would practise safely and appropriately in the future.
5. A period of disqualification is appropriate. Not only is the respondent presently unfit to practise, but a lengthy disqualification is required to secure the maintenance of professional standards and to assure the public and members of the profession that such standards will be enforced. It is important to bring home to the respondent and others the seriousness of the professional misconduct and to express the Tribunal's emphatic disapproval. This is necessary to maintain public confidence in the profession and its regulation.
6. We agree that a disqualification for a period of two years is appropriate. We have considered the wide range of disciplinary responses in the cases to which we have been referred. This range reflects the fact that each case is different. Some practitioners were at an early stage of their careers; others were experienced and still others were nearing the end of their careers. In some cases the behaviour was extensive and sustained; in others it was more limited. Importantly, some practitioners have steadfastly defended the proceedings and their conduct, showing no insight or remorse. Others have shown contrition, remorse and insight. Some have taken proactive steps to ensure the conduct will not be repeated. The respondent in this case has admitted and acknowledged his wrongdoing, but not addressed the issues of insight and future practice in any other way. The period of two years is appropriate to the circumstances of this case.
7. This does not mean that the respondent can return to practice after that time. It sets the period after which he would be entitled to make application to the Board. He would have to convince the Board that he could then be trusted to practise safely and was a fit and proper person to be registered.
8. We impose the following disciplinary sanctions:

(a) The behaviour of the respondent constitutes professional misconduct.

(c) The respondent is disqualified for a period of two years from applying for registration as a registered health practitioner.

1. The respondent is to pay the complainant's costs as agreed.
2. Pursuant to s 60 of the South Australian Civil and Administrative Tribunal Act 2013 we prohibit the publication of the names of, or anything tending to identify, patients referred to in the complaint.

[17] Craig v Medical Board of South Australia [2001] SASC 169; (2001) 79 SASR 545 at 554.

[18] Craig v Medical Board of Australia at page 556; Health Care Complaints Commission v Litchfield [1997] NSWSC 297; (1997) 41 NSWLR 630 at page 637; Medical Board of Australia v Singh [2017] WASAT 33.

[19] Health Care Complaints Commission v Litchfield [1997] NSWSC 297; (1997) 41 NSWLR 630 at page 637.

[20] See also Medical Board of Australia v Singh [2017] WASAT 33.

[21] Unreported Court of Appeal CA No 3 of 1981 at [51].

[22] [2017] WASAT 33; see also Health Care Complaints Commission v Epstein [2015] NSWCATOD 21.

[23] Singh v Medical Board of Australia [2018] WASCA 125 and [2019] WASCA 51.

[24] [2018] SAHPT 6.

[25] Cf. Health Care Complaints Commission v Epstein [2015] NSWCATOD 21.