Pursuant to s 196(1)(b)(iii) of the Health Practitioner Regulation National Law (Queensland) ('National Law'), the respondent has behaved in a way that constitutes professional misconduct as defined by subparagraph (b) of the definition of that term in section 5 of the National Law.
Pursuant to s 196(2)(a) of the National Law, the respondent is reprimanded.
Pursuant to s 196(2)(b)(i) of the National Law, the respondent is to complete an education course or courses to be nominated by the respondent and approved by the applicant, on the topics of handling and storage of Schedule 8 medications by pharmacists, maintenance of records in relation to Schedule 8 medications, and for the legislative requirements for handling Schedule 8 medications, for not less than four hours.
Pursuant to s 196(3) of the National Law, the review period for the condition is 12 months.
There is no order as to costs.
[2]
[1] The respondent is a registered pharmacist. Her registration was suspended by way of immediate action taken by the Pharmacy Board of Australia ('the Board') on 24 July 2023. On 31 October 2024, the applicant Board filed a referral with the Tribunal, which contains three allegations of professional misconduct and/or unprofessional conduct. The conduct relates to conduct engaged in by the respondent in the course of her employment as a pharmacist at Epic Pharmacy at St Andrew's Hospital, Toowoomba, between 1-4 February 2019 and 1 March 2023. The allegations relate to her professional conduct between 9 December 2022 and 30 February 2023 and relate to her conduct as a registered pharmacist in connection with the storage of, recording and dealings with, and destruction of medicines falling within schedule 8 of the Standard for the Uniform Scheduling of Medicines and Poisons.
[2] The respondent did not file a response to the referral; instead, she sent an email to the Tribunal on 13 February 2025 stating: "I am not sure as whether I needed to notify anyone regarding this matter or if it would be implied if not received, however, I have not submitted a response to the referral as I have no disputes with any of the allegations presented."
[3] Subsequently, in cooperation with the Board, the respondent joined in the filing of a statement of agreed facts. The statement of facts adopts, by way of admission by the respondent, the essential facts which form the basis of each allegation as particularised in the referral.
[4] In relation to allegation 1, by reference to the statement of agreed facts, the respondent admits that on or about 9 February 2023, she signed out 28 tablets of Targin with the reference "return to pharmacy". She, thereafter, placed the tablets in her personal locker, which was unlocked and otherwise unsecured. There was no record of the Targin in the drugs of dependence register maintained in the pharmacy within 24 hours, contrary to section 211 of the Medicines and Poisons (Medicines) Regulation 2021 (Qld) ('Poisons Regulation').
[5] In relation to allegation 2, the respondent admits that she is recorded as witnessing the sign out of the hospital ward's book of 11 tablets of Targin with the reference "return to pharmacy." She admits that on or about that date, she took the Targin from the hospital ward. She admits it was not subsequently placed in the pharmacy's schedule 8 safe or stored there, contrary to section 202 of the Poisons Regulation, and it was not otherwise accounted for in the pharmacy or hospital stock when the safe was inspected on 15 February 2023. As a result, she failed to record the storage of the drug, contrary to section 211 of the Poisons Regulation, and/or to ensure that the Targin was not stored in a schedule 8 safe, contrary to section 202 of the regulations.
[6] In relation to allegation 3, she admits that on 9 December 2022, she signed out 19 tablets of oxycodone, with the reference "return to pharmacy." She admits the medication was not returned to the patient and was not otherwise accounted for or recorded in the appropriate records, contrary to section 211 of the Poisons Regulation. In the alternative, the oxycodone was destroyed but such destruction was not witnessed as required by the Poisons Regulation. In relation to allegation 3, she makes admissions to similar conduct in relation to two other patients, namely, on 9 December 2022 (six tablets of Targin), 9 January 2023 (19 tablets of Targin); 19 January 2023 (76 tablets of dexamphetamine sulphate.)
[7] The respondent has not otherwise engaged with the Tribunal. She did not attend the hearing. The Tribunal is satisfied that she has been properly served and was aware of the final hearing date.
[8] Her email, coupled with the statement of agreed facts, constitutes a full admission of all the central factual allegations which form the basis of the alleged professional misconduct. In relation to the conduct generally, the uncontested evidence before the Tribunal establishes that in relation to the patient's Targin, the subject of allegation 1, the respondent's colleagues became aware that the medication was not in the ward or in the controlled drug safe when the patient requested the return of his medication, when he was being discharged from the hospital on 11 February 2023. Her colleagues searched her unlocked locker and found the medication.
[9] The respondent was interviewed by way of video link by Australian Health Practitioner Regulation Agency ('AHPRA') officers on 27 February 2024. She made relevant admissions but never explained why she did not remove the Targin from her unsecured locker when she came to work on 10 February 2023. She did not explain her actions in her response to the Board's notice which led to the suspension of her registration on 24 July 2023.
[10] By her admitted contact in relation to allegation 1, the respondent has contravened multiple provisions of the Poisons Regulation and has breached relevant provisions of the AHPRA and Board's shared Code of Conduct,[1] and standards set out in the Pharmaceutical Society of Australia's Professional Practice Standards.[2] In August 2020, she had signed the pharmacy substance management plan, which she has substantially breached by her admitted conduct.
[11] The Board relies on the expert opinion of Mark Lock, pharmacist, provided in a report filed in the Tribunal on 1 May 2025. The Tribunal accepts his opinion that the respondent's admitted conduct breaches various principles of the Pharmaceutical Society of Australia's Code of Ethics.[3]
[12] The admitted and proved conduct in relation to allegation 1 constitutes multiple breaches of the law, relevant professional codes and practice standards and the respondent's employer's substance plan.
[13] It is axiomatic that the role of registered pharmacists in dealing with controlled drugs is instrumental in ensuring patient and public safety.
[14] Similar observations and conclusions are relevant to characterisation applied in relation to the respondent's admitted and proved conduct in relation to both allegations 2 and 3.
[15] The Tribunal is satisfied that the admitted and proved conduct amounts to professional misconduct as defined at section 5(b) of the Health Practitioner Regulation National Law (Queensland) ('National Law').
[3]
[16] The principles relating to the discretionary power of the Tribunal to sanction health practitioners found to have engaged in professional misconduct are well-known and need not be repeated.
[17] The purpose of sanction is to protect and not to punish. The guiding principle for the administration of the National Law is that the protection of the public and public confidence in the safety of services provided by registered health practitioners are paramount.
[18] In its submission, the Board has analysed a number of Tribunal decisions involving registered pharmacists who have engaged in a range of conduct; however, as the Board observes - and the Tribunal agrees - there are no previous decisions involving the conduct of a hospital pharmacist who has failed to ensure the safe storage and accurate documentation of dealings with schedule 8 medicines on several occasions over a period of months.
[19] There is no evidence that the respondent deliberately failed to make records of her dealings with the medication for the purpose of keeping or on-selling the medicines.
[20] I agree with the Board that the respondent's conduct was careless and demonstrates a lack of regard for her obligations and the risk posed by noncompliance, despite her experience and her awareness (as indicated in her interview with AHPRA) of what was required of her as a professional pharmacist.
[21] At the time of her conduct, the respondent had been a pharmacist with over 10 years' experience. She had worked at the pharmacy at the hospital for two and a half years. Her failure to keep accurate records placed both the hospital and the pharmacy in breach of their statutory obligations to document dealings with schedule 8 medicines.
[22] The failure to document her dealings with the medicines, and to ensure safe storage, means that 19 tablets of oxycodone and 20 tablets of Targin are unaccounted for. This is an aggravating feature of her conduct relating to public risk and safety.
[23] In her interview, she appeared to blame her workload and suggests that the issues such as secure storage and proper documentation were, unfortunately, not given priority by her because she was "very busy and distracted."
[24] After the cessation of her employment, the respondent consulted a psychiatrist in March 2023. He diagnosed her with her attention deficit hyperactive disorder, opining that: "ADHD...causes significant difficulties with attention, focus, concentration, organisation and planning, which had impacted significant (sic) with her work."
[25] She has been prescribed medication to treat her ADHD. As Ms Nixon observes today, because the respondent has disengaged from the Tribunal proceedings, the Tribunal and the Board do not know whether she maintains that treatment and maintains contact with a treating medical practitioner.
[26] In her interview, she reflected on her conduct and accepted responsibility. The Tribunal accepts that she has demonstrated some insight, which is also reflected in her cooperation with the Board in the finalisation of these disciplinary proceedings. As against that, she did not comply with a directions order to file material, which may be explained by the sentiment expressed in her email.
[27] The respondent has not worked as a pharmacist since her registration was suspended, a period of approximately 27 months.
[28] In the interim, she has worked in administrative roles in various hospitals. In the circumstances, the Tribunal makes the following orders:
Pursuant to s 196(1)(b)(iii) of the National Law, the respondent has behaved in a way that constitutes professional misconduct as defined by subparagraph (b) of the definition of that term in section 5 of the National Law.
Pursuant to s 196(2)(a) of the National Law, the respondent is reprimanded.
Pursuant to s 196(2)(b)(i) of the National Law, the respondent is to complete an education course or courses to be nominated by the respondent and approved by the applicant, on the topics of handling and storage of Schedule 8 medications by pharmacists, maintenance of records in relation to Schedule 8 medications, and for the legislative requirements for handling Schedule 8 medications, for not less than four hours.
Pursuant to s 196(3) of the National Law, the review period for the condition is 12 months.