Pharmacy Board of Australia v Hanna (Review and Regulation) [2018] VCAT 1817

1. The Tribunal finds that Mr Yostus Hanna engaged in professional misconduct within the meaning of the definition of professional conduct in paragraph (a) (b) and (c) of section 5 of the Health Practitioner Regulation National Law (Victoria) Act 2009 ("the National Law") in that on or about 13 May 2016, Mr Hanna pleaded guilty in the Magistrates' Court of Victoria to 15 criminal offences.

1. Mr Hanna is reprimanded pursuant to section 196 (2) (a) of the National Law.
2. Conditions are imposed in the form outlined in the annexure to these reasons, on Mr Hanna's registration, requiring that he:

(a) undergo urine and hair drug screening at Group 2 frequency; and

(b) undertake treatment with a psychiatrist, attending at a frequency determined by the treating practitioner and enabling AHPRA to seek reports from the treating practitioner in relation to the treatment undertaken; and

(c) be mentored by another pharmacist if he engages in practice as a pharmacist in a pharmacy, in any capacity other than in execution of his role as a self-employed home medication review pharmacist within six months of the date of this decision.

1. Pursuant to section 196 (3) of the National Law, the review period for the conditions referred to in order (2) above is 12 months.

1. On 23 June 2017, pursuant to section 193(1)(a) of the Health Practitioner Regulation National Law (Victoria) Act 2009, ("the National Law"), the Pharmacy Board of Australia determined to refer the matter of Mr Hanna's professional conduct to this Tribunal because it reasonably believed that he had engaged, whilst practising as a pharmacist, in conduct that constituted professional misconduct.
2. On 23 May 2018, the parties participated in a compulsory conference convened under s. 83 of the Victorian Civil and Administrative Tribunal 1998 (Vic) ("the VCAT Act").
3. Following the compulsory conference, the parties reached a joint position in relation to proposed findings of facts, categorisation of the conduct and determinations.
4. The matter proceeded to hearing before us on 8 November 2018, in order for us to consider the parties' joint position.
5. It is our role to determine the appropriate factual findings, the characterisation of those findings and the determinations that should be imposed.[1] No agreement between a regulator and the professional person under review can supplant that duty[2].
6. The agreement reached is, nonetheless, a highly relevant matter for us to consider and we appreciated the helpful submissions of the parties in support of the agreed position and the comprehensive materials contained within the Tribunal book.
7. We turn then to a consideration of the Agreed Statement of Facts:

1.1 Mr Yostus Hanna (Mr Hanna) was first registered as a pharmacist on 4 January 2010. As detailed at paragraph 2.2 below, Mr Hanna signed an undertaking not to practise as a pharmacist on 27 February 2015, which remains in effect.

1.2 The Pharmacy Board of Australia (Board) was established and replaced the previous state and territory boards (or participating jurisdictions and co-regulatory jurisdictions) on 1 July 2010. Accordingly, Mr Hanna was subject to the Health Practitioner Regulation National Law[3] (National Law) whilst he was a registered pharmacist.

1.3 In the orders of Senior Member Wentworth dated 23 May 2018, the parties were granted leave to file the enclosed Amended Notice of Allegations, and have proceeded to refer to these amended allegations throughout this Agreed Statement of Facts.

2.1 This proceeding originates from three notifications to the Board in respect to Mr Hanna's professional conduct:

(a) Notification 1: On 25 February 2015, Ms Rebecca Nguyen (Ms Nguyen), Mr Hanna's employer and owner of Chemist Warehouse Cheltenham and Brighton, notified the Board that Mr Hanna had engaged in theft of Schedule 8 medications and falsification of Schedule 8 medication records (notification no. 00300916);

(b) Notification 2: On 27 February 2015, via telephone, Mr Hanna admitted to the Board that he had forged or dispensed scripts under false names for Alprazolam for his own personal use (notification no. 00302376); and

(c) Notification 3: On 21 August 2015, Mr Chris Falcke (Mr Falcke) of the Department of Health and Human Services (DHHS) notified the Board (notification no. 00311927) that in an interview with Mr Hanna on 21 July 2015, Mr Hanna:

(i) admitted misappropriating Alprazolam tablets from two additional pharmacies, Hampton Pharmacy and Pascoe Vale Day & Night Pharmacy (typically 50 tablets on each occasion);

(ii) admitted self-administration of the Alprazolam;

(iii) admitted falsifying or omitting records to conceal his activities;

(iv) admitted that his episode of self-administration had commenced during 2014 - the earliest identified misappropriation was during June 2014; and

(v) had deliberately responded untruthfully during the earlier interview with Mr Falcke on 14 April 2015, at which time he:

(A) admitted misappropriating Alprazolam tablets from two Chemist Warehouse pharmacies (Brighton and Cheltenham) at which he had been employed, for the purpose of self-administration;

(B) admitted falsifying or omitting records to conceal his activities; and

(C) claimed that his episode of self-administration had commenced only during 2015.

2.2 On 27 February 2017, following the receipt of Notification 1 and Notification 2, Mr Hanna signed an undertaking whereby he agreed to not work as a pharmacist until approved to do so by the Board. This undertaking was accepted by the Board and remains in effect.

2.3 On 17 February 2016, Mr Falcke filed charge-sheets and summons, containing 39 charges under the Drugs, Poisons and Controlled Substances Act 1981 (Vic) and Drugs, Poisons and Controlled Substances Regulations 2006 (Vic), in the Magistrates' Court of Victoria.

2.4 On 13 May 2016, Mr Hanna pleaded guilty to 15 charges, which are the subject of the amended notice of allegations, and outlined at paragraph 3.1 below. Mr Hanna was that day sentenced to pay a fine, without conviction, in the sum of $10,000.

3.1 On 23 June 2017, pursuant to section 193(1)(a) of the National Law, the Board determined to refer the matter of Mr Hanna's professional conduct to the Tribunal because it reasonably believed that he had engaged in conduct that constituted professional misconduct.

3.2 As indicated at paragraph 1.3, by consent, the Board seeks leave to file the enclosed Amended Notice of Allegations.

3.3 The allegations contained in the Amended Notice of Allegations are as follows:

(a) professional misconduct within the meaning of the definition of professional misconduct in paragraph (a) and/or (b) and/or (c) of section 5 of the National Law;

(b) unprofessional conduct within the meaning of paragraph (c) of the definition of unprofessional conduct in section 5 of the National Law;

in that, on or about 13 May 2016, Mr Hanna pleaded guilty in the Magistrates' Court of Victoria to 15 criminal offences.

(i) On 13 May 2016, Mr Hanna pleaded guilty to the following charges numbered 1, 2, 3, 4, 7, 21, 22, 23, 28, 31, 35, 36, 37, 38 and 39 on case number G10887949:

(I) Supply schedule 8 poison namely Alprazolam, without taking reasonable steps to verify that the prescription was written by the purported prescriber on 14/05/14, contrary to regulation 28 of the Drugs, Poisons and Controlled Substances Regulations 2006 (Vic);

(II) Possession of Alprazolam between 18/6/2014 and 20/12/2014, contrary to section 73(1) of the Drugs, Poisons and Controlled Substances Act 1981 (Vic);

(III) Use of schedule 8 poison to self-administer without prescription between 18/6/2014 and 20/12/2014, contrary to regulation 48 of the Drugs, Poisons and Controlled Substances Regulations 2006 (Vic);

(IV) Knowingly making a false entry regarding section schedule 8 poison on 18/6/2014, contrary to regulation 42 of the Drugs, Poisons and Controlled Substances Regulations 2006 (Vic); and

(V) Failure to record schedule 8 poison transaction details between 5/7/2014 and 19/7/2014, contrary to regulation 40(1) of the Drugs, Poisons and Controlled Substances Regulations 2006 (Vic).

(B) At Pascoe Vale Day and Night Pharmacy:

• (I) Use of schedule 8 poison to self-administer without prescription between 17/11/2014 and 27/02/2015, contrary to regulation 48 of the Drugs, Poisons and Controlled Substances Regulations 2006 (Vic);

• (II) Supply of schedule 8 poison without verifying prescription taking reasonable steps to verify that the prescription was written by the purported prescriber on 17/11/2014, contrary to regulation 28(1) of the Drugs, Poisons and Controlled Substances Regulations 2006 (Vic);

• (III) Supply of schedule 8 poison on a prescription which he had reason to believe had been forged or was fraudulent on 17/11/2014, contrary to regulation 31(1) of the Drugs, Poisons and Controlled Substances Regulations 2006 (Vic);

• (IV) Knowingly making a false entry regarding schedule 8 poison on 27 February 2015, contrary to regulation 42 of the Drugs, Poisons and Controlled Substances Regulations 2006 (Vic).

(C) At Chemist Warehouse, Cheltenham:

• (I) Knowingly making a false entry regarding schedule 8 poison between 7 February 2015 and 17 February 2015, contrary to regulation 42 of the Drugs, Poisons and Controlled Substances Regulations 2006 (Vic);

• (II) Possession of schedule 8 poison between 14 January 2015 and 17 February 2015, contrary to section 73(1) of the Drugs, Poisons and Controlled Substances Act 1981 (Vic); and

• (III) Use of schedule 8 poison to self-administer without prescription between 14 January 2015 and 17 February 2015, contrary to regulation 48 of the Drugs, Poisons and Controlled Substances Regulations 2006 (Vic).

(D) At Chemist Warehouse, Brighton:

• (I) Possession of schedule 8 poison on 28 January 2015, contrary to section 73(1) of the Drugs, Poisons and Controlled Substances Act 1981 (Vic);
• (II) Use of schedule 8 poison to self-administer without prescription on 28 January 2015, contrary to regulation 48 of the Drugs, Poisons and Controlled Substances Regulations 2006 (Vic); and
• (III) Knowingly making a false entry regarding schedule 8 poison on 28 January 2015, contrary to regulation 42 of the Drugs, Poisons and Controlled Substances Regulations 2006 (Vic).

1. Mr Hanna admits that the Agreed Statement of Facts describes the conduct in which he engaged. Mr Hanna's admissions are consistent with his plea in the Magistrates' Court and the materials placed before us.
2. We are accordingly satisfied that the Agreed Statement of Facts, accurately and succinctly sets out the substance of the factual matrix and that Mr Hanna engaged in the conduct as alleged.
3. We find the allegation proved.

1. Mr Hanna admits that his conduct amounts to professional misconduct within the meaning of paragraphs (a), (b) and (c) of the definition of professional misconduct contained in section 5 of the National Law, which reads as follows:

professional misconduct, of a registered health practitioner, includes-

(a) unprofessional conduct by the practitioner that amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and

(b) more than one instance of unprofessional conduct that, when considered together, amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and

(c) conduct of the practitioner, whether occurring in connection with the practice of the health practitioner's profession or not, that is inconsistent with the practitioner being a fit and proper person to hold registration in the profession.

1. Given the facts outlined above, Mr Hanna's admission is an appropriate one.
2. Obligations are imposed on pharmacists in relation to the appropriate possession, prescribing, supply and use of alprazolam under schedule 8 of the Drugs Poisons and Controlled Substances Act 1981 and the Drugs Poisons and Controlled Substances Regulations 2017. Mr Hanna breached those obligations.
3. Mr Hanna not only misappropriated Schedule 8 medications from three separate employers, but also created false and misleading dispensing records. He failed to record receipt of Alprazolam tablets delivered to a pharmacy where he was working. He knowingly dispensed a forged prescription and failed to comply with his obligation to report a forged prescription. He was untruthful or misleading in an interview with his employer regarding the misappropriation of the Schedule 8 medication and was untruthful or misleading in an interview with Drugs and Poisons Regulation as well as during a health assessment.
4. These are extremely serious matters.
5. It would be a serious matter for any health professional to self-administer Alprazolam. It is particularly serious for a dispensing pharmacist to do so. The community entrusts pharmacists with the safe and appropriate dispensing of pharmaceuticals.
6. Mr Hanna's conduct took place over an extended period between the period May 2014 to February 2015. It did not stop until Mr Hanna was detected. Even when his conduct was detected, Mr Hanna, whilst cooperative to a degree, did not immediately admit to the full extent of his conduct.
7. Mr Hanna's conduct breached the trust placed in him as a registered pharmacist, by the community, and his employer(s). It brought the profession of Pharmacy into disrepute. We are satisfied that his conduct amounts to professional misconduct.

1. The parties jointly submitted that the appropriate determinations, should be as follows:

(a) that Mr Hanna be reprimanded pursuant to section 196 (2) (a) of the National Law.

(b) that conditions be imposed in the form outlined at the annexure to these reasons, on Mr Hanna's registration, requiring that:

(i) he undergo urine and hair drug screening at group 2 frequency; and

(ii) he undertake treatment with a registered psychiatrist and furnish reports to AHPRA once every three months; and

(iii ) pursuant section 196 (3) of the National Law, the review period for the conditions referred to in (b) above is 12 months.

1. Given the serious nature of the conduct, it would have been open to us to consider the need to impose a suspension or cancellation of Mr Hanna's registration. We accept however that the proposed determinations sensibly address the issues canvassed before us. It is appropriate for the following reasons that the focus now be on Mr Hanna's safe return to practice. He has been punished for his conduct and has had a significant period to reflect on it.
2. We mirror the words of His Honour Magistrate Kumar who said in sentencing Mr Hanna:

... It is sad to see somebody who is 27 years old, a pharmacist, you have the responsibility and privilege, you have been given a great privilege in the community because of your own occupation. You are there to do the right thing by the community and the responsibility you have. You abused that and you find yourself now charged with very serious offences. As your counsel rightly pointed out, some of the charges carry substantial fines and, as I said, I took into account your plea of guilty. I took into account what Dr Singh, your treating psychiatrist has put, and other doctors, and some very good references. One of the references I was quite impressed with is from Mr Hanna, he is not related to you, but a pharmacist, speaks very highly of yourself and the work that you have done in the community. So I have taken all of those matters into account.

1. Mr Hanna received a significant fine of $10 000, (without a conviction being recorded). He was ordered to pay costs in the sum of $9000.
2. After Mr Hanna's conduct was uncovered, he was immediately terminated from his employment.
3. On 27 February 2015, Mr Hanna signed an undertaking whereby he agreed not to work as a pharmacist until approved to do so by the Board. The undertaking was accepted by the Board and remains in effect. Because of his undertaking, Mr Hanna has not been permitted to practice as a pharmacist for approximately 3 ½ years.
4. We accept that for an individual who has never faced the criminal courts in relation to any matter, or previously had disciplinary action taken against him, this will have had a significant personal deterrent effect against his repeating the conduct. In considering the future safety of the public, this is also a relevant consideration.
5. We also accept that the involvement of the criminal law process coupled with his inability to practice over an extended period acts as a deterrent to other practitioners from engaging in like conduct.
6. In Nursing and Midwifery Board of Australia v Faulkner [2018] QCA 97 per Holmes CJ, Philippides and McMurdo JJA as follows:

In general, the practitioner's punishment under the criminal law is not a factor which should moderate the disciplinary sanction, because the purpose of that sanction is not to punish the practitioner, but to protect the public. It is recognised that the protection of the public extends beyond protection against further default by the particular practitioner to protection against similar defaults by other practitioners. There is a deterrent element involved in the protection of the public in this context. In that way, where a substantial punishment has been imposed on the practitioner under the criminal law for the misconduct for which the practitioner is to be disciplined, that punishment can be relevant. But its relative importance will obviously depend upon the facts and circumstances of the particular case.

1. The Board obtained an independent psychiatric report from Dr Peter Smith (consultant psychiatrist) who reported a diagnosis of substance abuse-alprazolam-in remission.
2. Mr Hanna also provided a report from his treating psychiatrist, Dr Singh, dated 22 May 2018 who opined that:

Since he has seen me he has stopped completely using the drugs.

1. We accept that Mr Hanna's conduct occurred in the context of an addiction to Alprazolam and that he has now been drug-free for some years.
2. Dr Matthew Frei, who is the Clinical Director of Turning Point Eastern Health, in a report dated 13 September 2018 Dr Frei said:

Mr Hanna has a past diagnosis of substance use disorder, specifically benzodiazepine addiction. This is based on reported loss of control of use of alprazolam characterised by high risk behaviour to acquire the drug. This appears to be out of character for Mr Hanna, who has no background of other drug use and has not displayed any similar loss of control or impulsivity and was other aspects of his life.

Given the insight he displays, and the long period of abstinence (based on history), in my opinion his risk use of pharmaceutical drugs and resulting workplace impairment is low.

Despite the low levels of risk, I would recommend he undertake some form of biochemical monitoring if he returns to clinical care. This would apply for returns to any form of pharmacy work including Home Medicine Review work or standard retail pharmacy roles. This monitoring would ideally include supervised urine drug screens and optional additional hair testing. Urine testing will be more practical, given its immediacy of results, and the fact that he has little scalp air. However, if axillary or other body hair is acceptable, hair testing could be added as an additional monitoring tool to a program of urine testing.

Initial random testing at a frequency of at least once weekly would be reasonable, and this could be combined with three monthly reports from his treating psychiatrist. Reports from his general practitioner would be of limited value given he is not on regular medications and rarely attends his GP.

1. The recommendations of Dr Frei are sensible and well considered.
2. As he returns to practice, regular biochemical monitoring in combination with three monthly reports from his treating psychiatrist reviewable at 12 months is an appropriate way of monitoring Mr Hanna's ongoing progress to ensure he remains fit for practice.
3. We are mindful that Mr Hanna has much to offer. We read impressive character references about the manner in which Mr Hanna usually conducts himself within society. There is no doubt he has been a previously contributing member of the community. Mr Hanna enjoys a number of leisure activities including playing tennis and soccer; is an active member of the Gypsy and Christian church and has a supportive social network of friends. As a practising pharmacist, there had been no earlier incidents of concern pertaining to his practice or his conduct generally.
4. Mr Hanna is still young. He had only been practising for a period of four years when he engaged in the conduct. Young people can move on and learn from their mistakes. With the passage of time, Mr Hanna has reflected on his conduct.
5. Mr Hanna has gained employment with pharmaceutical companies. Whilst the employment does not require registration as a pharmacist, it does reflect Mr Hanna's desire even through this troubling period to maintain a connection with his profession.
6. We were also impressed that in the intervening years Mr Hanna has undertaken studies to obtain accreditation in the hope that he can return to practice in a Home Medicine Review role. In this role, Mr Hanna would attend patients' homes to educate the patient on safe, effective and appropriate use of medicines. We accept that this is the area in which he wishes to practice in the future possibly in conjunction with his current employment.
7. Mr Hanna has used this time away from practice productively. Mr Hanna's progress to date is promising.
8. Given all of the above, we agree that the proposed determinations are appropriate determinations.
9. We remained concerned however that if Mr Hanna were to return to community pharmacy practice within the next six months that he will be exposed to (some of), the stresses that lead to his current predicament. His drug addiction evolved during a confusing/distressing phase of Mr Hanna's life following the death of his father, work pressures and when his own life was entering a new phase of marriage and mortgages. These are however, of course, whilst challenging, common occurrences in modern human lives. We need to be confident that when faced in the future with such stressors, that there will be no repeat of the conduct.
10. Into the future Mr Hanna will face other challenges. It is pleasing in this respect that following the discovery of these matters he immediately sought professional assistance through psychologists and psychiatrists. It is also pleasing that he is willing to continue that treatment on an ongoing basis. We are confident that this will assist him in his endeavours to remain a contributing member of the society.
11. In addition to the conditions proposed by the parties, we propose however to add a requirement, that should Mr Hanna return to clinical practice within six months, he be assisted by a professional mentor who is also pharmacist.
12. In this respect, we note the report of Dr Singh dated 26 March 2015 which touched on work pressures experienced by Mr Hanna and the observations of Dr Matthew Frei in an email dated 3 October 2018 in which he said:

... it is sometimes preferable to resume work in a graduated manner, starting with low risk or low stress work, and for this reason I would support a less demanding and lower risk setting for Mr Hanna's return to work (such as may be the case with her medication review duties).

1. We consider that if Mr Hanna quickly returns to clinical practice he should have the benefit of engagement with a mentor for a six-month period. This would enable him to develop a relationship with the mentor and to be assisted by the mentor in the event of stressors directly related to his pharmacy practice. The history before us showed a marked and rapid escalation to drug abuse when the right triggers arose.

1. We will reprimand Mr Hanna.
2. In Peeke v Medical Board of Victoria (unreported, Supreme Court of Victoria no 10170 of 1993, 19 January 1993), His Honour Justice Marks observed that a reprimand being a serious form of censure and condemnation "does not trivialise a serious lapse of professional standards and has the potential for serious adverse implications".
3. A reprimand is an important and serious form of censure and condemnation for a health professional.
4. We will also require Mr Hanna to undertake random urine and hair drug screening at group 2 frequency, in accordance with the applicable Drug and Alcohol Screening Protocol, (October 2017). Group 2 screening involves urine screens (on average four per month) and hair analysis (quarterly). This level of screening is in line with the sensible observations of Dr Frei.
5. We will require Mr Hanna to continue to undertake treatment with his psychiatrist and require three-monthly reports to AHPRA from his psychiatrist.
6. Should Mr Hanna return to clinical practice within six months we will impose a further condition that he must be mentored by another pharmacist.
7. We were impressed by all that Mr Hanna has achieved in the interim period. It is a credit to him that he has used his time constructively to advance his skills. We wish him all the best for the future.
8. We will make the following orders:

1. Mr Hanna is reprimanded pursuant to section 196 (2) (a) of the National Law.
2. Conditions are imposed in the form outlined in the annexure to these reasons, on Mr Hanna's registration, requiring that he:

(a) undergo urine and hair drug screening at Group 2 frequency; and

(b) undertake treatment with a psychiatrist, attended a frequency determined by the treating practitioner and allow AHPRA to seek reports from the treating practitioners in relation to the treatment undertaken and

(c) be mentored by another pharmacist if he engages in practice as a pharmacist in a pharmacy, in any capacity other than in execution of his role as a self-employed home medication review pharmacist within six months of the date of this decision.

1. Pursuant section 196 (3) of the National Law, the review period for the conditions referred to in order (2) above is 12 months.

1. The Practitioner must only take substances prescribed, approved, or administered by a nominated treating practitioner(s) and such nominated treating practitioner(s) may not be a relative, friend, professional colleague or in a contractual or financial relationship with the Practitioner.

For the purposes of this condition 'substance' is defined as any illicit substance as well as any pharmacist only, prescription only and any controlled drug medication as contained in Schedule 3, 4 or 8 in the Standard for the Uniform Scheduling of Medications and Poisons (the SUSMP) as amended from time to time and as published at https://www.tga.gov.au/publication/poisons-standard-susmp.

1. Upon returning to practice, the Practitioner must commence random urine drug screening (UDS) and hair analysis for drug screening (hair analysis) in accordance with AHPRA's protocol for UDS and hair analysis (the protocol) in force at the date these conditions are imposed and then amended from time to time.
2. The Practitioner must commence UDS and hair analysis at Group Two frequency or as otherwise advised by AHPRA and must continue to attend at this frequency until the Board approves otherwise.
3. At least fourteen (14) days prior to returning to practice, the Practitioner must provide to AHPRA:
   1. Acknowledgement, on the approved form (HPF6), that they understand the requirements of the protocol as it pertains to urine and hair drug screening and they are aware of AHPRA's monitoring of this condition.
   2. The details, on the approved form (HPF6), of all current substances that have been prescribed or administered to or approved for them, along with the contact information of all prescribing practitioners who have, or are likely to, prescribe, approve or administer substances.

1. The Practitioner must undertake treatment with a psychiatrist (the treating practitioner(s)) and attend at a frequency determined by the treating practitioner(s).
2. At least fourteen (14) days prior to returning to practice, the Practitioner must provide the following to AHPRA:
   1. The contact details, on the approved form (HPF3), of all treating practitioners.
   2. Acknowledgement, on the approved form (HPF3), from the Practitioner that AHPRA may seek reports from the treating practitioners in relation to the treatment undertaken by the practitioner:

1. Confirmation, on the approved form (HPNA3), from the treating practitioner(s) that they have seen a copy of the conditions on the Practitioner's registration and are aware AHPRA may contact them to seek reports.

1. If the Practitioner commences practice as a pharmacist in a position other than as a self-employed home medication review pharmacist, he must provide to AHPRA, on the approved form (HPC), the contact details of a senior person, such as the Pharmacist Manager or equivalent (the senior person) at each current place of practice. In providing this form, the practitioner acknowledges that:
   1. AHPRA will contact the senior person and provide them with a copy of the conditions on the Practitioner's registration or confirm that the senior person has received a copy of the conditions from the Practitioner, and
   2. The Practitioner will be required to provide the same form:
      1. within seven days of the commencement of practice at each and every subsequent place of practice, and
      2. within seven days of each and every notice of any subsequent alteration of these conditions.

1. If the practitioner engages in practice as a pharmacist in a pharmacy, in any capacity other than in execution of his role as a self-employed home medication review pharmacist within six (6) months of the date of the Tribunal's published decision, the Practitioner must be mentored by another pharmacist with general registration in relation to:

professional practice as a pharmacist, including the dispensing and record keeping of Schedule 4 and 8 poisons (such Schedule 4 poisons referred to in the Pharmacy Board of Australia's 'Guidelines on Practice Specific Issues - Drugs of Abuse').

For the purposes of this condition, 'mentoring' is defined as a relationship in which a skilled registered practitioner (the mentor) helps to guide the professional development of another practitioner.

1. The mentoring must comprise of at least one (1) session per month with each session being of a minimum of one (1) hour duration occurring over a six (6) month period.

1. Within one (1) month of commencing practice in any capacity in a pharmacy, the Practitioner must, on the approved form (HPN16), nominate a person(s) to be approved by the Pharmacy Board of Australia to act as mentor. The Practitioner must ensure that the nomination is accompanied by acknowledgement, on the approved form (HPNA16), from the nominated person.
2. Within one (1) month of commencing practice in any capacity in a pharmacy, the Practitioner must provide to AHPRA, on the approved form (HP16), acknowledgement that AHPRA will seek reports from the approved mentor on any or all of the following occasions:

1. by the first day of each month 2. at the conclusion of the mentoring relationship in order to confirm the outcomes of the mentoring

1. whenever the mentor has a concern or becomes aware of a concern regarding the Practitioner's professional or legal conduct or professional performance, and

1. when otherwise requested by AHPRA or the Board.
2. In the event an approved mentor is no longer willing or able to provide the mentoring required the Practitioner is to provide a new nomination in the same terms as previous nominations. Such nomination must be made by the Practitioner within 21 days of becoming aware of the termination of the mentoring relationship.
3. All costs associated with compliance with the conditions on their registration are at the Practitioner's own expense.

[1] Medical Board of Australia v Fox [2016] VCAT 408 at [16].

[2] Medical Board v McGrath [2014] VCAT 641 at [19]- [20].

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