background
39 In 2003, Mr Nyoni commenced operating the Kellerberrin pharmacy at 92 Massingham Street in Kellerberrin after Mr Nyoni purchased the pharmacy from Mr Geoffrey Lewis.
40 In 2007, Mr Frank Peczka was the Chief Executive Officer of the Shire.
41 On 16 January 2007, Mr Peczka sent a letter from the Shire to Mr Nyoni reporting on an inspection which had been carried out of the Kellerberrin pharmacy premises by Mr John Mitchell, a Shire environmental health officer. The letter referred to the existence of cobwebs within the display counter, empty boxes accumulated in the rear service entrance of the premises and the existence of further cobwebs adjacent to the water fridge.
42 On 22 January 2007, Mr Peczka wrote a letter to Mr Nyoni saying that the subsequent inspection had determined that the premises were "reasonably clean". Mr Peczka also drew Mr Nyoni's attention to ensuring that the windows and the glass work were maintained in a clean state and that the carpet was kept clean.
43 In 2007, three important customers of the pharmacy were local Kellerberrin institutions. The first was the Kellerberrin hospital, the second was the Dryandra hostel, which was a frail age care home, and the third was Iris Litis House, a care facility for people with intellectual disabilities.
44 Prior to 2007, each of these institutions had engaged the Kellerberrin pharmacy to supply it with the medications for its patients. The medications were to be supplied packed in a container referred to during the trial as a "Webster pack".
45 A Webster pack is a plastic rectangular container containing 28 compartments comprising seven vertical rows for each day of the week and four horizontal rows, representing different times during a day when a patient was to take the prescribed medication. Accordingly, each compartment in the Webster pack represented the time and the day when the pill or medication placed in that compartment was to be taken by the patient. The process operated on the basis that prescriptions for each of the patients were delivered by each institution to the Kellerberrin pharmacy. The prescribed medication for each patient was then removed by the pharmacist from its original packaging and the medication was then placed into the appropriate compartment of a separate Webster pack for each patient. The object of using a Webster pack was to make it easy for the patient to know what medication to take and when to take it.
46 From about August 2005 to January 2007, Iris Litis House drew Mr Nyoni's attention to errors in relation to the supply of medications in the Webster packs for its patients. This was done by an employee at the Iris Litis House completing a form entitled "Medication Incident Form" identifying the issue and providing the form to Mr Nyoni for him to respond. The evidence shows that there were three such incidents in 2005, 13 such incidents in 2006 and one such incident in January 2007.
47 In 2007, Ms Dawn Harvey, the manager of Iris Litis House, terminated the contract for the supply of pharmaceuticals by the Kellerberrin pharmacy to Iris Litis House on the basis of her dissatisfaction in relation to Mr Nyoni's services.
48 By a letter dated 6 March 2007 from Ms Beech to Mr Nyoni, Ms Beech gave notice that the Kellerberrin hospital no longer required the services of the Kellerberrin pharmacy to supply Webster packs to their nursing home residents. As previously mentioned, Ms Beech was then, and at all material times, the director of nursing at the Kellerberrin hospital.
49 However, the Kellerberrin hospital did not terminate the contract for the supply of Webster packs for its health and care in the community patients. The hospital, however, implemented a procedure whereby the Webster packs were checked by the home and community care nurse and coordinator, Ms Bernice Del Borrello, before being distributed to the patients.
50 On 30 March 2007, Dryandra hostel wrote to Mr Nyoni recording that there had been seven medication errors in the week of 9 March 2007, seven in the week of 16 March 2007 and five in the week of 23 March 2007. The letter stated that unless Mr Nyoni could rectify the position the Dryandra hostel would have to change its pharmacy supplier.
51 From time to time during the period 2007 to 2010, members of the public also made complaints about the Kellerberrin pharmacy to Shire officers. The complaints included complaints that the pharmacy was dirty, that it did not have sufficient stock, that the operating hours were irregular and that Mrs Nyoni dispensed medicines in the absence of Mr Nyoni.
52 On 3 July 2007, the Health Department received a complaint that Mrs Nyoni was dispensing medicines in Mr Nyoni's absence. Mr Ross Atkinson, a pharmacist employed by the Health Department, raised the complaint with Mr Nyoni, but took no action consequent upon Mr Nyoni's explanation.
53 On 17 September 2007, Ms Beech complained to Ms Harkins that there were consistent errors being made in relation to the preparation of Webster packs by Mr Nyoni in respect of patients in the hospital and other institutions. Ms Beech also advised Ms Harkins that the local health advisory group had been made aware of the complaints and the local health advisory group had written to the Pharmaceutical Council on 28 August 2007 about the complaints.
54 On 18 September 2007, Ms Harkins, Ms Beech, Ms Del Borrello and the chairperson of the Kellerberrin local health advisory group met and discussed the dispensing error complaints and then consulted Mr Murray Patterson of the Health Department who held the position of Chief Pharmacist.
55 On or about 19 September 2007, Mr Steven Britton, a Kellerberrin resident and customer of the pharmacy, complained to the Pharmaceutical Council about a dispensing error made by Mr Nyoni. Mr Nyoni elected to have the matter dealt with by the Pharmaceutical Council, rather than SAT. On 13 February 2008, the Pharmaceutical Council imposed a fine of $300 upon Mr Nyoni.
56 On 19 September 2007, Mr Patterson and Dr Geoff Masters, acting director of the Health Department, had a meeting with the Pharmaceutical Council in relation to the complaints made by Ms Harkins.
57 On 25 September 2007, Mr Patterson, Ms Harkins and Dr Masters met in relation to the complaints.
58 On 27 September 2007, consequent upon that meeting, Mr Patterson sent an email to Dr Masters and Ms Harkins saying:
I have the Senior Investigating Officer from my Branch, Robert Bateman available to visit Kellerberrin next week. He is not a pharmacist but will be able to collect statements and assess the evidence. He is also an authorised officer under the Poisons Act which provides powers to enter the pharmacy and seek information if required.
I suggest that he go to Kellerberrin next Tuesday 4 October to complete the investigation and have a discussion with Mr Nyoni.
Coral
Robert will contact you today or tomorrow to discuss the information you have…
59 Later that day, Ms Harkins sent an email to Mr Patterson which said:
Thank you for all your support with this Murray. I have spoken with Robert and discussed his plan to visit Kellerberrin on Tuesday including the information that is required.
I have advised the DON/HSM and she will be contacting Robert today to assist him in this process.
60 On 27 September 2007, Ms Harkins sent an email to Ms Beech to the following effect:
Further to our telephone conversation today (27/9):
Robert Bateman (DoH Pharmacy Services) will be in Kellerberrin on Tuesday and Wednesday 4/10/07-5/10/07 (inclusive) to investigate the pharmacy services. Robert will need all information relating to complaints, or risk management to assist him in that process. Would you please phone Robert to make those arrangements and to set up appointments for yourself and Bernice to meet with him…
Robert has advised me that he will start with a review of the Pharmacy itself, and then meet with staff and the General Practitioner (GP). Robert will contact the GP directly and set up a time to meet with him. If I can do anything to assist you in this process, or you just want to confirm the process, please do not hesitate to contact me on my mobile phone.
61 That email was copied to Mr Bateman. The reference to "Bernice" is a reference to Ms Bernice Del Borrello. Ms Beech subsequently telephoned Ms Del Borrello to arrange for her to meet Mr Bateman when he came to Kellerberrin.
62 By a letter undated, but delivered on 28 September 2007, the Dryandra hostel terminated its contract with Kellerberrin pharmacy for the supply of pharmaceuticals with effect from 7 October 2007. The letter referred to its dissatisfaction with the provision of Mr Nyoni's services.
63 On 2 October 2007, Mr Bateman went to Kellerberrin and stayed there until the next day. While in Kellerberrin, Mr Bateman conducted interviews with Ms Beech, Ms Del Borrello, Dr Andrew Bellagooyne, the doctor in Kellerberrin, Ms Noreen Bonser, the care manager at Dryandra hostel, and Mr Steven Britton. Mr Bateman prepared written statements in respect of each of the interviews. The statement of Mr Britton was dated 2 October 2007. The statement dealt with the dispensing error referred to earlier. The statement of Dr Bellagooyne is dated 2 October 2007. The statements of Ms Del Borrello and Ms Bonser were each dated 3 October 2007. Each of Ms Del Borrello's and Ms Bonser's statement dealt with complaints as to the preparation of Webster packs and records that each of them had seen Mrs Nyoni dispensing medicines when Mr Nyoni was apparently not present in the pharmacy.
64 Also, while in Kellerberrin, Mr Bateman entered the Kellerberrin pharmacy premises, inspected the premises and asked Mr Nyoni a number of questions. The circumstances of Mr Bateman's entry onto the Kellerberrin pharmacy premises and the activities in which he engaged whilst on those premises, is the subject of one of the claims made by Mr Nyoni. I will address that issue in some detail later in these reasons.
65 On 15 October 2007, Mr Bateman returned to Kellerberrin and carried out further investigations.
66 On 16 October 2007, Mr Bateman prepared a written report to Mr Patterson in relation to his inspection of the Kellerberrin pharmacy. That report refers to four matters which Mr Bateman had investigated. The first issue dealt with the complaints about dispensing errors by Mr Nyoni and Mrs Nyoni dispensing medicines in Mr Nyoni's absence from the pharmacy. The report records responses made by Mr Nyoni to queries addressed to him by Mr Bateman. The other issues dealt with in Mr Bateman's report relate to the storage and handling and record-keeping in relation to Sch 8 substances, Mr Nyoni's professional qualifications, and an allegedly false statement made by Mr Nyoni during Mr Bateman's interview with Mr Nyoni.
67 On 6 November 2007, Mr Patterson wrote a letter to Mr Brennan, registrar of the Pharmaceutical Council:
I am writing to you as an outcome of an ongoing investigation of Mr Emson Nyoni and the Kellerberrin Pharmacy.
Following the meeting we had with Dr Geoff Masters, Coral Harkins and representatives of the Pharmaceutical Council of WA on Tuesday 18 September 2007 an investigation was commenced on Tuesday 2 October 2007. The investigation has found a number of issues of concern as follows:
• Numerous dispensing errors
• Supply of Schedule 4 medicines by a non-pharmacist
• Failure to comply with the Poisons Regulations in regard to the recording of Schedule 8 medicine transactions
• Inaccuracies in the information provided by Mr Nyoni
- potentially false statutory declaration on the destruction of a Drugs of Addiction Register
- false or unsubstantiated qualifications used on pharmacy stationery.
I will be take up the issues regarding non-compliance with the Poisons Regulations directly with Mr Nyoni.
The number and serious nature of the dispensing errors found are of great concern. Errors have been brought to the attention of Mr Nyoni but he has not accepted responsibility for the errors or put appropriate systems in place to minimise the dispensing errors. I am concerned for the welfare of those patients receiving medicines dispensed by the pharmacy and have recommended that the pharmaceutical services of another provider be sourced for patients of the Western Australian Country Health Service (WACHS) subject to the resolution of the issues identified during the audit.
I am writing to the Pharmaceutical Council of WA as the regulatory body for the registration of pharmacists under the Pharmacy Act 1964 to undertake an urgent assessment of Mr Nyoni's competence to undertake the functions of a pharmacist. As part of this process I request that the veracity of the claims made by Mr Nyoni in his application to the Australian Pharmaceutical Council for assessment of his qualification also be validated.
A copy of the interim report on the investigation to date is enclosed for your information. Please do not hesitate to contact me in regard to this issue if I can be of any further assistance.
68 On 12 February 2008, Mr Bateman and Mr Atkinson carried out another inspection of the Kellerberrin pharmacy. The inspectors were concerned that Mr Nyoni had not complied with the requirements of the Poisons Regulations in relation to the handling and storage of Sch 8 substances.
69 Consequent upon Mr Bateman's and Mr Atkinson's inspection, the Health Department wrote to Mr Nyoni, on 3 April 2008, asking him to show cause why his licence to handle Sch 8 substances should not be suspended.
70 Following the response which Mr Nyoni provided, the Health Department decided not to take any disciplinary action against Mr Nyoni. Accordingly, on 30 April 2008, Mr Patterson wrote to Mr Nyoni informing him that the number and seriousness of the breaches of the Poisons Regulations in relation to Sch 8 substances would usually have resulted in consideration of prosecution proceedings being commenced against him. However, said Mr Patterson, due to the environment where the Kellerberrin pharmacy was the only facility providing pharmaceuticals to the local community, Mr Nyoni would be permitted to continue storing and supplying Sch 8 substances under specific audit conditions. Mr Nyoni would be required to develop procedures for the recording of Sch 8 substance transactions at his pharmacy and to be the subject of regular audits of his drugs of addiction register at the Kellerberrin pharmacy by another registered pharmacist from a neighbouring town.
71 Thereafter, an audit process was arranged whereby Mr Matthew Reid, a pharmacist from a neighbouring town, audited Mr Nyoni's compliance with procedures for handling Sch 8 substances.
72 On 5 June 2008, Dr Masters wrote to the Pharmaceutical Council and their lawyers, JD Finlay & Co, with information regarding complaints made about the Kellerberrin pharmacy including complaints about dispensing errors, opening hours and lack of adequate stock.
73 On 10 June 2008, the Pharmaceutical Council advised the Health Department that it had resolved to commence proceedings in SAT alleging that Mr Nyoni was guilty of professional misconduct.
74 On 12 June 2008, Mr van Bronswijk, who as I have said was a pharmacist field officer, employed by the Pharmaceutical Council, attended the Kellerberrin pharmacy for an inspection. During that visit, Mr van Bronswijk took photographs of the premises. Mr van Bronswijk recorded that the condition of the pharmacy was extremely poor, the external appearance was shabby and rundown, the shelves were covered with dust throughout the front of the shop and the dispensary, the carpet was dirty and stained, the dispensary bench in the area for medication packing was highly disorganised and littered, and the dispensing area and sink were very dirty.
75 Mr van Bronswijk also recorded that the pharmacy references were incomplete and out of date, that there was expired stock present throughout the front of the shop and the dispensary, and that the dispensary was disorganised.
76 On 31 July 2008 and 22 October 2008, Mr van Bronswijk visited the premises of the Kellerberrin pharmacy again.
77 I infer that in late 2008, the Pharmaceutical Council verbally advised an official at the Health Department that it was unable to progress its proposed disciplinary hearing against Mr Nyoni arising from the complaints about dispensing errors made by Ms Harkins and Ms Beech, because no one was prepared to give evidence against Mr Nyoni at SAT.
78 During January 2009, Ms Harkins continued to communicate with Dr Masters about the investigation of the complaints made about the Kellerberrin pharmacy. Ms Harkins said that there were members of the staff of the Country Health Service who were willing to testify before SAT.
79 On 21 February 2009, Dr Masters wrote to the Pharmaceutical Council enclosing notes about the complaints he had received regarding dispensing errors allegedly made by the Kellerberrin pharmacy.
80 In February 2009, Mr Friend replaced Mr Peczka as Chief Executive Officer of the Shire.
81 On 3 March 2009, Ms Harkins sent an email to Ms Beech stating:
I have spoken with Robert Bateman today (8.45 am 03032009) and he is travelling to Kellerberrin to continue the investigation relating to the provision of private pharmacy services.
Robert has advised that he will be
(1) visiting the hospital to review the availability of staff to participate in an investigation by the State Administrative Tribunal (SAT); and
(2) conducting an audit of the Kellerberrin Pharmacy.
Robert has also asked (SRC) that you give him any evidence that you have of tablets and scripts that have been incorrectly dispensed so that he may review those errors as part of the process.
82 On 3 March 2009, Mr Bateman again visited Kellerberrin. Whilst he was there he met with Ms Beech at the Kellerberrin hospital who handed him a Webster pack which Ms Beech said had been prepared by the Kellerberrin pharmacy and had contained an error. Ms Beech also gave Mr Bateman a document dated 9 February 2009 that she had prepared, which identified three "issues" in relation to Mr Nyoni's business practices. These were:
(a) frequent lack of commonly used prescription drugs in stock;
(b) shop closed during normal business hours without notice; and
(c) dirty shop.
83 Also, Mr Bateman was given the names of two persons who were said to be willing to give evidence against Mr Nyoni before SAT. Mr Patterson passed on the information given to Mr Bateman, to Mr Brennan by letter dated 10 March 2009.
84 On his visit of 3 March 2009, Mr Bateman found no infringements of the Poisons Act.
85 On 10 March 2009, a Ministerial memorandum was prepared and was signed by Dr Tarun Weeramanthri, the executive director, public health division, and Dr Andrew Robertson, director, disaster management, regulation and planning directorate, consequent upon a request by the Pharmaceutical Council to meet with the Minister for Health, Dr Kim Hames, in relation to the complaints that had been made about the Kellerberrin pharmacy.
86 The Ministerial memorandum recorded the fact that the public health division had received verbal advice from the Pharmaceutical Council that it had not been able to progress the proposed action in SAT due to inadequate evidence and the unwillingness of patients to testify. The memorandum then recorded under the heading "Current Status" that:
• The Kellerberrin pharmacy has been regularly audited and currently meets the requirements of the Poisons Act 1964 and associated regulations. There are currently no grounds to withdraw Mr Nyoni's poisons licence, although the Department will continue to closely monitor his performance and ensure that monthly audits continue for the foreseeable future.
• Matters relating to the opening hours of the pharmacy and the amount of stock held at the pharmacy are not controlled through either the Poisons Act 1964 or the Pharmacy Act 1964. Medicare Australia may have some interest in these aspects of practices at the Kellerberrin Pharmacy, as the pharmacy is approved to supply medicines under the PBS. We understand that the Council has brought this to their attention.
• The Department will forward to the Council information obtained at the most recent audit on 3 March 2009 of an alleged dispensing error and the details of people in Kellerberrin who have indicated that they are willing to testify at the SAT. The Council is responsible for ensuring this information is acted upon and that Mr Nyoni's professional practice is reviewed.
87 On 12 March 2009, JD Finlay & Co, the Pharmaceutical Council's lawyers, wrote to Dr Masters in response to his letter of 21 February 2009, as follows:
We have been instructed to respond to the matters raised in the briefing notes attached to your letter on behalf of the Pharmaceutical Council of Western Australia. The notes are inaccurate in many respects. some of the more significant errors are dealt with below.
1. Complaints concerning opening hours of Pharmacy and stock
This matter was addressed in our letter to you dated 27 February 2009.
2. Dispensing Errors
The Pharmaceutical Council of Western Australia was provided with a report from the Department of Health which contained correspondence from Dryandra Hostel, Activ Foundation Inc and Kellerberrin Health Services. Also included with the report were statements from members of the Kellerberrin community containing allegations of dispensing errors.
In 2008 we wrote to Mr Nyoni concerning various allegations that had been made of dispensing errors throughout 2007 informing him that we had been instructed to initiate proceedings in the State Administrative Tribunal concerning alleged dispensing errors and other matters.
Mr Nyoni subsequently engaged Guild Legal Limited of Sydney and we received a request for copies of the relevant complaints from Guild Legal.
Council is obliged to provide adequate particulars of the complaints to enable Mr Nyoni to respond and defend any proceedings that may be commenced against him. Procedural fairness requires that these particulars be provided.
Due to privacy considerations, before providing copies of the written complaints to Mr Nyoni's solicitors, we wrote to the various complainants seeking consent to provide copies of the complaints to Guild Legal. Two of the lay complainants refused to give authority to provide the information to Mr Nyoni, Dryandra Hostel and Kellerberrin Health Services did not reply and only Activ Foundation Inc consented to its complaints being made available. The Active Foundation complaints referred to matters alleged to have occurred in 2007 and was not supported by complaints from specific patients.
In a telephone conversation that the writer had with Ms Kay Lamplugh (a member of the Kellerberrin community) he was advised that the some complainants are not prepared to consent to the complaints being made available to Mr Nyoni because of the likely ramifications once the identity of the complainants is made known to him.
In these circumstances we do not consider that Council could successfully bring an application to the State Administrative Tribunal in respect to any of these allegations.
It should be noted that Council does not administer the Poisons Act or the Regulations and has no jurisdiction to prosecute alleged breaches of the act or regulations.
1. State of the Premises
A number of the complainants were concerned that the condition of the premises from which Kellerberrin Pharmacy operated was unsatisfactory. Council arranged for inspection of the premises to be carried out by its Field Officer, Mr T Van Bronswyk in June 2008. We are instructed that the initial inspection of the pharmacy premises showed that the state of cleanliness and repair was unsatisfactory.
We are instructed that the Council informed Mr Nyoni that the state of the premises was unsatisfactory and required substantial work to be carried out to bring the premises to a satisfactory state. In July and October 2008 Mr Van Bronswyk carried out further inspections of the premises. The subsequent inspections indicated that Mr Nyoni had made a significant attempt to improve the state of the premises and the state of the premises is now acceptable.
We now understand that the Council intends to carry out regular inspections of the premises to ensure that the proprietor does not allow the premises to revert back to the previous unsatisfactory state. We are instructed that Mr Van Bronswyk attempted to inspect the premises on 4 March 2009 but the premises were closed. A further inspection will be carried out shortly.
In our opinion, the action taken by the Pharmaceutical Council of Western Australia in relation to the state of the premises is sufficient.
2. Absence from Pharmacy
Various residents of Kellerberrin have alleged that Mr Nyoni is not present in the pharmacy at all times during business hours.
Council engaged a private investigator to visit the pharmacy on several occasions to ascertain whether or not the allegation that Mr Nyoni was absent from the pharmacy from time to time could be verified. A written report from the investigators provided some support for the allegation that Mr Nyoni absents himself from the pharmacy from time to time.
Council was also provided with some anecdotal evidence from a relieving pharmacist employed at the pharmacy during 2006, to the effect that dispensing medicines or drugs are not referred to Mr Nyoni to be checked as a matter of course.
In our opinion, there is insufficient evidence to justify the commencement of any disciplinary proceedings because
(a) Most of the complainants from the Kellerberrin community are not prepared to give evidence to support the allegations that they make against Mr Nyoni.
Without this evidence any allegation that the pharmacist is absent from the pharmacy premises during business hours or that he does not supervise the dispensing of medicines or drugs from the pharmacy (if he is at the premises) cannot be proved.
(b) There is no compelling evidence that leads to the conclusion that the pharmacy business is operated without Mr Nyoni being present. The lay complainants are not able to state categorically that Mr Nyoni was not on the premises at the times when it is alleged that Mr Nyoni is absent.
Whilst it is noted that WACHS is forced to expend considerable resources to check medications dispensed at Kellerberrin pharmacy, you should be aware that Council has also expended considerable time and money in dealing with the various complaints made against Mr Nyoni. In the main this expenditure has been wasted due to the continued failure of most complainants to support the allegations that they make against Mr Nyoni.
We have been instructed to repeat our client's position on this matter, namely that specific complaints will continue to be dealt with where there is supported evidence of professional misconduct.
88 In October 2009, the Pharmaceutical Council imposed a fine of $300 on Mr Nyoni after he did not contest a complaint by a customer that Mr Nyoni had provided the customer with the wrong medicine.
89 In late 2009, Mr Nyoni sold his PBS approval number for $500,000 and then applied for a new PBS approval number for the Kellerberrin location. Mr Nyoni did not make it known that he had sold his PBS approval number and had applied for a new PBS approval number.
90 The Shire found out that Mr Nyoni had sold his PBS approval number and that he had applied for a new one, when Mr Friend, who was then the chief executive officer of the Shire, was advised of that fact by Mr Matthew Reid, a pharmacist who owned pharmacies in the towns of Northam and York. The fact that Mr Nyoni sold his PBS approval number meant that there was a period during which there was no pharmacy in Kellerberrin which was licenced to sell subsidised pharmaceuticals under the PBS Scheme. At around this time, Mr Friend and Mr McDonnell also learned that an application for a PBS approval number for the Kellerberrin location, had also been submitted to ACPA by Mr Matthew Reid or by an associate of his.
91 On 6 January 2010, Mr Friend, on behalf of the Shire, sent a letter to the Minister for Health, Dr Kim Hames, making a formal complaint about the operations of the Kellerberrin pharmacy and asking that the complaint be investigated. The letter said that the Shire had received complaints that the pharmacy was "regularly closed during normal business hours", that there were instances when incorrect medication was given, and that Mrs Nyoni, who was not licenced to do so, regularly dispensed prescription medicines in Mr Nyoni's absence from the pharmacy. The letter also alleged that the Kellerberrin pharmacy was short of prescription stock.
92 On 7 January 2010, Mr Friend wrote the following letter to Mr Matthew Reid:
I refer to our previous discussions and subsequent visit to Kellerberrin to look at the possibility of setting up a Pharmacy to service Kellerberrin and its surrounding districts.
Council has signed off on an offer and acceptance form to purchase 96 Massingham Street from the current owner Craig Yarran. An early settlement of the property has been requested to expedite the transfer.
93 The named applicant for the PBS approval number for the Kellerberrin location was, however, Ms Ashburn, who I infer, had a professional association with Mr Reid.
94 On 18 January 2010, Mr McDonnell, the Shire President, sent a letter to ACPA urging ACPA not to grant a new PBS approval number to Mr Nyoni for the Kellerberrin pharmacy. Mr McDonnell's letter referred to the Kellerberrin pharmacy as keeping inadequate stock and having irregular opening hours, as well as being in a dirty state.
95 Mr McDonnell's letter of 18 January 2010, was copied to the Federal Minister for Health and Ageing, Mr Wilson Tuckey, Federal Member for O'Connor, and Mr Barry Haase, Federal Member for Kalgoorlie.
96 On 1 February 2010, Dr Kim Hames responded to Mr Friend's letter of complaint about Mr Nyoni saying that the complaints should be made to the appropriate bodies.
97 On 15 February 2010, Mr Barry Haase wrote a letter to the ACPA reiterating the complaints made about Mr Nyoni's pharmacy and urging the ACPA to "ensure a robust and transparent process when granting the Kellerberrin PBS licence".
98 On 16 February 2010, there was a meeting of the Shire Council.
99 The minutes of that meeting record that the pharmacist, who was the rival applicant to Mr Nyoni for the PBS approval number (referred to in the minutes as "the proponent") was required as part of the application process, to have access to a suitably zoned premises in Kellerberrin from which to operate a pharmacy. The minutes also record that the Shire Council ratified the actions of Mr McDonnell and Mr Friend in purchasing a property at 96 Massingham Street, Kellerberrin, and stated that the Council was prepared to enter into an agreement to lease the premises at 96 Massingham Street to the proponent for a minimum term of 12 months, subject to the proponent being the successful applicant for the PBS approval number. The minutes went on to record that the Shire Council would, if the proponent was the successful applicant, also source a suitable private dwelling to accommodate "the pharmacist and his/her family".
100 The minutes also contained statements about Mr Nyoni's pharmacy which Mr Nyoni alleges reflected adversely upon him and his business. The minutes of the Shire Council meeting were published on the Shire's website. The publication of those minutes is the subject of a claim brought by Mr Nyoni. I will deal in detail with that claim later in these reasons.
101 On 4 March 2010, the delegate of the chief executive officer on behalf of the Secretary to the Department of Health and Ageing, responded to Mr McDonnell's letter of 18 January 2010 as follows:
Thank you for your letter of 18 January 2010 in which you raise concerns about the supply of pharmaceutical benefits at the Kellerberrin pharmacy, 92 Massingham Street, Kellerberrin WA 6410.
Please be assured that Medicare Australia is concerned to ensure that a pharmacist approved to supply PBS medicines is meeting the conditions of an approval and other requirements specified in the National Health Act 1953.
I note your comments about the opening hours of the pharmacy and the supplies of pharmaceutical items kept on hand. These types of issues are relevant considerations when deciding whether to grant an approval to a pharmacist to supply medicines subsidised under the Pharmaceutical Benefits Scheme (PBS) or whether to cancel an approval.
I will consider the information you have provided in conjunction with the legislative requirements for a pharmacy approval specified in the National Health Act 1953 in any decision I may make regarding the supply of PBS medicines at pharmacy premises in Kellerberrin.
I note your concern about the condition of the pharmacy premises. This matter is the responsibility of the Pharmacy Council of Western Australia and information about the Council can be found at http://www.pswa.org.au/. I trust this information is of assistance.
102 On 15 March 2010, Mr Peter Mitchell, the fifth respondent, an electrical contractor, disconnected the power to the Kellerberrin pharmacy. The circumstances surrounding the disconnection of the electricity is the subject of one of the stated issues in the case and I will discuss this matter later in these reasons.
103 Also, on 15 March 2010, after the electricity had been disconnected to the pharmacy, Mr Garry Tucker, the environmental health officer employed by the Shire, telephoned Ms Joy Knight of the Health Department and advised that the electrical power had been disconnected and the pharmacy had been without electrical power from 8:00 am on Monday, 15 March 2010.
104 Ms Knight then contacted Mr Nyoni. He confirmed that the electrical power was off. Ms Knight advised him that he should not be dispensing medication as he had no ability to access customers' records kept on his computer. Mr Nyoni advised Ms Knight that he had removed all refrigerated items from his pharmacy and placed them in his personal refrigerator at his home which was fully operational.
105 On 15 March 2010, Mr Tucker also contacted Mr van Bronswijk to advise him that the power had been disconnected.
106 Shortly before 17 March 2010, Mr Friend also learned from Mr Reid that Ms Ashburn's application for the PBS approval number in respect of a proposed pharmacy in Kellerberrin had not been successful.
107 On 17 March 2010, the electrical power was restored to the Kellerberrin pharmacy.
108 Also, on or about 17 March 2010, Mr Nyoni was advised that a new PBS approval number had been issued to him.
109 On 17 March 2010, Mr Tucker entered the Kellerberrin pharmacy, on the instructions of Mr Friend, and undertook an extensive inspection of the pharmacy and its premises. I observe that Mr Tucker claimed in his evidence that he had decided to undertake this inspection on his own accord. Mr Friend said that he instructed Mr Tucker to undertake the inspection of the pharmacy premises. I prefer the evidence of Mr Friend.
110 Mr Tucker, without having obtained the consent of Mr Nyoni or Mrs Nyoni, who was present in the pharmacy at the time, then took a number of photographs of the pharmacy premises. These photographs showed the pharmacy to be in a dirty condition. Mr Tucker subsequently provided those photographs to the Pharmaceutical Council and the Health Department.
111 Further, on 17 March 2010, Mr Friend hand delivered a letter signed by Mr McDonnell to Mr Nyoni at the pharmacy. The letter stated:
I write on behalf of the Council and the Kellerberrin community concerning the operations of the Kellerberrin Pharmacy and its effect on the general business community in town.
I request that you make yourself available to meet with a delegation from Council as soon as possible to discuss this most important matter.
Please contact the Chief Executive Officer Darren Friend on…to arrange a suitable time for the meeting.
I ask that you give this matter your most urgent attention.
112 Mr Nyoni never responded to Mr Friend's letter.
113 On 31 March 2010, Mr McDonnell wrote a letter to Mr Nyoni on behalf of the Council stating:
Council is of the belief, given the repeated complaints received in this office concerning the operations of the pharmacy, that the impact on the business community and the Kellerberrin community in general is extremely detrimental to the efforts of the Council in trying to progress the Shire of Kellerberrin forward.
Your inability to provide the goods and services that the community deserves, (ie irregular opening hours, lack of pharmaceutical items, cleanliness of the establishment, sale of your PBS licence and lack of stock) is seen as a slight on the community whose Council financially assisted you into the business following the departure of Geoff Lewis in 2005. To this end, on behalf of the Council I am prepared to offer you the sum of $250,000 for the commercial premises located at 92 Massingham Street and the house located at lot 101(6) Bedford Street Kellerberrin. I believe that the offer represents fair market value for the two properties at present.
This offer is valid until close of business on Friday 16 April 2010. The offer stated is genuine however, if you wish to discuss or negotiate this matter further, I welcome you contacting me prior to the closure of the offer period.
114 Mr Nyoni never responded to the offer from Mr McDonnell.
115 On Tuesday, 13 April 2010, Mr Bateman and Mr van Bronswijk travelled to Kellerberrin together and both attended the Kellerberrin pharmacy on the same day. Prior to attending the pharmacy, Mr van Bronswijk and Mr Bateman had a meeting with Mr Friend and Mr Tucker of the Shire.
116 Mr Bateman subsequently provided a report to Ms Anna Gelavis of the Health Department stating that the examination of the pharmacy's addictive drugs register was unremarkable and that he could find no evidence of non-compliance with the Poisons Regulations.
117 In his report of the 13 April 2010 visit, Mr van Bronswijk noted that the pharmacy did not have complying scales, the 2010 edition of the reference book, and that there were some items of expired stock. Mr van Bronswijk went on to say that as far as the overall condition of the pharmacy was concerned, it was now in an acceptable state, compared to the condition of the pharmacy shown in photographs supplied by the Shire four weeks earlier.
118 On 13 April 2010, a member of the secretariat of the ACPA responded to Mr Haase's letter of 15 February 2010 (see [97] above). The letter included the following paragraph:
The Australian Community Pharmacy Authority (the Authority) considers all applications to establish a new pharmacy or relocate an existing pharmacy to determine whether the requirements of the [Pharmacy Location Rules] have been satisfied. An application to establish a new pharmacy in Kellerberrin was assessed against the Rules by the Authority at its meeting on 26 February 2010. As the application met the requirements of the rules, the Authority was required to recommend to the Delegate in Medicare Australia that the application be approved.
119 The letter then went on to state that the letter raised matters relating to the professional practice of a particular pharmacist and that those complaints were matters for the Pharmaceutical Council. Mr Haase sent a copy of this letter and his response to that letter to Mr McDonnell.
120 On 16 April 2010, a petition was released for circulation in Kellerberrin. The petition was headed "Kellerberrin Pharmacy Users", and beneath that heading were the words:
Please sign the petition below if you feel dissatisfied with the services of our local Pharmacy located at 92 Massingham Street, Kellerberrin.
121 During the period 16 April 2010 to 2 June 2010, whilst the petition was in circulation, 149 people signed the petition.
122 On 3 May 2010, the electrical power to Mr Nyoni's pharmacy was again disconnected. On the next day, an officer of the Shire telephoned Mr Bateman and advised him that the electrical power to the pharmacy had been disconnected "sometime yesterday".
123 On 4 May 2010, Mr Friend, using the "contact us" form on the Department of the Premier and Cabinet website, sent the following message to the Minister for Health:
Minister, you are aware of the operations of the Kellerberrin Pharmacy and in its inability to provide the required service to the people of Kellerberrin and surrounding district. Once again the Pharmacist has had his power disconnected at the shop and residence. How will the temperature sensitive drugs be safely stored and when will you provide the necessary leadership by closing this "facility" down and revoking the licence from Mr Nyoni?
124 I reject Mr Friend's evidence that he did not send the message. That is inconsistent with the objective evidence, particularly, the fact that the Minister responded to Mr Friend. The letter which Mr Friend received in response included the following paragraphs:
The DoH has contacted Mr Nyoni regarding the power cut. Mr Nyoni advised that he had arranged for alternative storage of the refrigerated items at the time. It appears that Mr Nyoni followed the correct procedure by removing the temperature sensitive drugs to an alternative refrigerator. Mr Nyoni advised an officer of the DoH that there has been no further loss of power since 18 March 2010.
The complaints relating to the competency of Mr Nyoni to practise as a pharmacist are matters managed by the Pharmaceutical Council of WA under the Pharmacy Act 1964. I understand that the Pharmaceutical Council is addressing the situation.
125 Also, in May 2010, there was a meeting which was chaired by Mr Haase which was attended by Mr Friend, as well as Mr van Bronswijk and representatives of the Health Department about the Kellerberrin pharmacy. At the meeting, Mr Friend referred to the circumstance of Colac, a regional town in Victoria, of similar size to Kellerberrin, which had succeeded in getting approval for a second pharmacy within the shire boundaries. Mr van Bronswijk who had some knowledge of the pharmacy location rules pursuant to which PBS approval numbers were issued, said that he would look into the matter.
126 In June 2010, Mr Raymond Griffiths, the deputy chief executive officer of the Shire, was the acting chief executive officer of the Shire in Mr Friend's absence. On 21 June 2010, Mr Griffiths received a report from an employee of the Shire that Mr Nyoni was seen driving out of Kellerberrin and that Mrs Nyoni was alone in the pharmacy. Mr Griffiths sent an email to Mr van Bronswijk in the following terms:
One of our staff has just been issued with scripts for people in Tammin.
We noticed that Emson left town about half an hour ago and she is in the shop by herself. Is there anything we can do.
127 On the next day, Mr Griffiths received a call from a customer of the Kellerberrin pharmacy who said that she had presented a script to Mrs Nyoni and had been supplied with generic medicines in circumstances where, said the customer, the script had precluded the supply of generic medicines. Mr Griffiths then emailed Mr van Bronswijk in the following terms:
Around 4.20 pm yesterday afternoon I fielded a call from Mrs Pauline Graham as she was disgusted with the service she had been provided. Mrs Graham had a script which advised that it was not to be changed with Generic drugs. Mrs Nyoni was adamant that the script can be filled by generic drugs, Mrs Graham asked for the script back and left the chemist.
As the Council was aware that Mr Nyoni was not in the chemist we asked Mrs Graham if she would go back and try to get the remainder of the script filled to see whether or not Mrs Nyoni is dispersing drugs. Mrs Graham entered the shop around 4.40 pm and was getting her script filled until our Manager Development Services went into the shop and then she quickly advised that this could not be filled because Mr Nyoni was not there.
The script was dropped off later that afternoon at 5.30 pm. Tom and I went around and he wasn't back then.
128 Mr van Bronswijk then instituted an investigation in relation to the matters the subject of Mr Griffith's two emails and later issued Mr Nyoni with a notice to produce documents pursuant to s 31C of the Pharmacy Act. This investigation did not lead to any disciplinary action being taken by the Pharmaceutical Council because it ceased to exist in October 2010, before the investigation was completed.
129 At a date unknown, but prior to 15 July 2010, the Shire approached a pharmacy consultant, Mr Rollo Manning, in relation to how the Shire should proceed in relation to Mr Nyoni and the Kellerberrin pharmacy. In an email dated 15 July 2010 to Dr Robertson, Mr Friend described Mr Manning's role as "assisting Council and making inquiries on its behalf". In an email to Dr Felicity Jefferies of the Health Department, on 21 July 2010, Mr Manning stated that he had been asked to "make some preliminary inquiries and to report back to the Shire of Kellerberrin with some recommendations on how they should proceed given sufficient evidence to warrant action" about the quality of the pharmaceutical care being given to the residents of Kellerberrin.
130 Mr Manning was communicating with Dr Jefferies in order for him to obtain the permission of the Health Department to speak to Ms Beech about her complaints about the Kellerberrin pharmacy. The Health Department refused that permission.
131 On Sunday, 1 August 2010, Mr Friend met with the Minister for Health, Dr Kim Hames, about Mr Nyoni and the Kellerberrin pharmacy.
132 On 14 October 2010, Mr Mitchell disconnected the electrical power to the Kellerberrin pharmacy by entering the pharmacy in the afternoon and removing the fuses from the meter box which was located inside the pharmacy premises. Before he disconnected the electricity, Mr Mitchell advised Mr Friend that he intended to disconnect the electricity to Mr Nyoni's pharmacy later that day. Mr Friend then passed that information on to Mr van Bronswijk and the Health Department. It was common ground that the disconnection was carried out without the authority of the supplier of the electricity to Mr Nyoni's pharmacy.
133 This incident is the subject of a claim in this proceeding and I will deal with this matter in detail later in these reasons.
134 In January 2013, Mr Nyoni entered into a contract with Mr Chee Koon Hee for the sale of the Kellerberrin pharmacy for a sale price of $255,000 including goodwill of $195,000.
135 Mr Nyoni subsequently sought to resist specific performance of the contract for the sale of the pharmacy but was unsuccessful in these attempts and the pharmacy was transferred to the purchaser in about April 2014.
136 On 23 January 2013, Mr Nyoni was convicted in the Magistrates Court of Western Australia on six counts of contravention of the Poisons Regulations. The evidence in support of the charges was from two representatives of the Health Department who had attended the Kellerberrin pharmacy premises on 17 August 2011. Mr Nyoni was fined a total of $14,000 and ordered to pay costs of $2,500. On 26 July 2013, the fine was reduced on appeal by EM Heenan J (Nyoni v Murphy [2013] WASC 298) to a total of $10,000.
137 As a consequence of his conviction, Mr Nyoni's authority to store and supply Sch 8 substances was revoked by the Health Department in or about May 2013.
138 I make findings of fact in relation to the matters set out at [39] to [137] above.