Medical Board of Australia v Singh
[2017] WASAT 33 (S)
•22 JUNE 2017
| JURISDICTION | : | STATE ADMINISTRATIVE TRIBUNAL |
| ACT | : HEALTH PRACTITIONER REGULATION |
NATIONAL LAW (WA) ACT 2010
| CITATION | : | MEDICAL BOARD OF AUSTRALIA and SINGH [2017] WASAT 33 (S) |
| MEMBER | : | JUSTICE J C CURTHOYS (PRESIDENT) MS H LESLIE (MEMBER) DR A MCCUTCHEON (SENIOR SESSIONAL MEMBER) DR P WINTERTON (SENIOR SESSIONAL MEMBER) |
| HEARD | : | DETERMINED ON THE DOCUMENTS |
| DELIVERED | : | 22 JUNE 2017 |
| FILE NO/S | : | VR 235 of 2014 |
| BETWEEN | : | MEDICAL BOARD OF AUSTRALIA Applicant |
| AND | ||
| ANISH DWARKA SINGH Respondent | ||
| Catchwords: |
Disciplinary matters under Medical Practitioners Act 2008 (WA) - Professional misconduct - National Law - Inappropriate prescribing of range of drugs and other treatments - No proper therapeutic basis - Dishonesty - Incompetence - Global penalty applied - Disqualification
[2017] WASAT 33 (S)
Legislation:
Health Practitioner Regulation National Law (WA) Act 2010, s 3, s 4,
s 17(2)(b), s 196, s 196(4)
Medical Practitioners Act 2008 (WA), s 3, s 76, s 76(1)(b), s 116
Poisons Act 1964 (WA)
State Administrative Tribunal Act 2004 (WA), s 87(1), s 87(2)
Result:
Practitioner fined $5,000
Practitioner disqualified from applying for re-registration as a registered health
practitioner for period of 10 years
Practitioner pay Medical Board of Australia's costs and disbursements
Summary of Tribunal's decision:
These reasons for decision determined the appropriate penalty for a medical practitioner whose conduct constituted acting incompetently, carelessly and/or improperly for the purposes of the Medical Practitioners Act 2008 (WA) and who behaved in a way which constituted professional misconduct for the purposes of the Health Practitioner Regulation National Law (WA) Act 2010.
The Tribunal's findings that disciplinary matters existed in Medical Board and Singh [2017] WASAT 33 related to the practitioner's misconduct in respect of his specialist medical practice involving inappropriate prescribing of drugs including anabolic steroids, human growth hormone and stimulants, the inappropriate infusion of iron and fresh frozen plasma, the ordering of unnecessary DEXA scans and the prescribing of Clomid in contravention of the Poisons Act 1964 (WA) (repealed); inadequate record keeping; in relation to two patients, Patient J and Patient B; and towards the notifying medical practitioner in relation to Patient B.
The practitioner's misconduct was serious. The prescription of drugs when there was no proper therapeutic basis is a serious matter. This is all the more so because in a number of the instances identified by the Tribunal, it exposed the practitioner's patients to the risk of side effects from those drugs.
Further, the practitioner's failure to take adequate notes was a fundamental failing in his obligations to his patients and professional colleagues.
The practitioner's misconduct occurred over a long period of time and involved multiple prescriptions. The Tribunal therefore imposed a global penalty having regard to the practitioner's overall misconduct rather than isolating certain incidents and imposing separate penalties.
[2017] WASAT 33 (S)
The practitioner is no longer a registered medical practitioner so no order was required to cancel his registration. The Tribunal determined that the practitioner be disqualified from applying for registration as a medical practitioner for a period of 10 years and that he pay the Medical Board of Australia's costs and disbursements
In addition, in a separate category to the practitioner's other misconduct, the Tribunal imposed a fine of $5,000 as a penalty in relation to the practitioner's letter of abuse to the notifying medical practitioner as a discouragement to others who might be tempted to engage in such misconduct.
Category: B
Representation:
Counsel:
| Applicant | : | Mr H Quail |
| Respondent | : | In Person |
Solicitors:
| Applicant | : | MDS Legal |
| Respondent | : | N/A |
Case(s) referred to in decision(s):
A Solicitor v Council of the Law Society of NSW [2004] HCA l; (2004) 216
CLR 253
Barristers' Board v Darveniza [2000] QCA 253; (2000) 112 A Crim R 438
Barwick v Council of the Law Society of NSW [2004] NSWCA 32
Chamberlain v Law Society of the Australian Capital Territory
(1993) 118 ALR 54
Council of the Law Society (NSW) v A Solicitor [2002] NSWCA 62
| Craig | v | Medical | Board | of | South | Australia | [2001] SASC 169; |
(2001) 79 SASR 545
Dental Board of Australia and Dhillon [2017] WASAT 20
Law Society of New South Wales v Foreman (1994) 34 NSWLR 408
Law Society of New South Wales v Walsh [1997] NSWCA 185
Legal Practitioners Complaints Committee v Thorpe [2008] WASC 9
[2017] WASAT 33 (S)
Legal Profession Complaints Committee and A Legal Practitioner
[2013] WASAT 37 (S)
Legal Profession Complaints Committee and Amsden [2014] WASAT 57 (S)
Legal Profession Complaints Committee and in de Braekt [2013] WASAT 124
Legal Profession Complaints Committee and Leask [2010] WASAT 133
Legal Profession Complaints Committee v Brickhill [2013] WASC 369
Legal Profession Complaints Committee v Detata [2012] WASCA 2014
Legal Profession Complaints Committee v Lashansky [2007] WASC 211
Legal Profession Complaints Committee v Love [2014] WASC 389
Legal Profession Complaints Committee v Masten [2011] WASC 71
Legal Profession Complaints Committee v O'Halloran [2013] WASC 430
Legal Profession Complaints Committee v Segler [2014] WASC 159
Medical Board and Singh [2017] WASAT 33
Medical Board of Australia and Myers [2014] WASAT 137 (S)
Medical Board of Western Australia and Roberman [2005] WASAT 81 (S)
New South Wales Bar Association v Cummins [2001] NSWCA 284;
(2001) 52 NSWLR 279
New South Wales Bar Association v Evatt (1968) 117 CLR 177
Paridis v Settlement Agents Supervisory Board [2007] WASCA 97;
(2007) 33 WAR 361
Quinn v Law Institute of Victoria [2007] VSCA 122
Re A Practitioner (1984) 36 SASR 590
Re Maraj (a Legal Practitioner) (1995) 15 WAR 12
| Smith | v | New | South | Wales | Bar | Association | [1992] HCA | 36; |
(1992) 176 CLR 256
Stirling v Legal Services Commissioner [2013] VSCA 374
The Council of the Qld Law Society v Wright [2001] QCA 58
Veterinary Practitioners Board of NSW v Johnson [2010] NSWADT 308
Veterinary Surgeons Investigating Committee v Howe (No 2) [2003] NSWADT
159
Western Australian Planning Commission v Questdale Holdings Pty Ltd
[2016] WASCA 32
[2017] WASAT 33 (S)
REASONS FOR DECISION OF THE TRIBUNAL:
Introduction
1 In Medical Board and Singh [2017] WASAT 33 (Singh), the Tribunal found that disciplinary matters existed under s 76 of the Medical Practitioners Act 2008 (WA) (repealed) (the Medical Practitioners Act) in that Dr Anish Dwarka Singh acted incompetently, carelessly and/or improperly for the purposes of s 76(1)(b)(i), (ii) and/or (iii), and that Dr Singh behaved in a way which constituted professional misconduct for the purposes of s 196(1)(a)(i) of the Health Practitioner Regulation National Law (WA) Act 2010 (National Law), (Schedule) (Singh at [449]-[451]).
The relevant Acts for assessing penalty
The Tribunal's findings related to Dr Singh's misconduct:
a) in respect of his general practice involving inappropriate prescribing of drugs including anabolic steroids, human growth hormone (HGH) and stimulants, the inappropriate infusion of iron and fresh frozen plasma, the ordering of unnecessary DEXA scans and the prescribing of Clomid in contravention of the Poisons Act 1964 (WA) (repealed); b) inadequate record keeping; c) in relation to two patients, Patient J and Patient B; and d) towards the notifying medical practitioner in relation to Patient B.
3 The Tribunal findings in relation to Dr Singh's specialist medical
practice of medicine were made pursuant to the both the Medical Practitioners Act and the National Law. To the extent that the findings were made pursuant to the Medical Practitioners Act, a penalty may be imposed pursuant to the Medical Practitioners Act by virtue of s 17(2)(b) of the National Law, and to the extent that the findings were made pursuant to the National Law, the Tribunal may make an order pursuant to s 196 of the National Law, (Schedule).
4 The Tribunal's findings in relation to Patient J were made pursuant
to the Medical Practitioners Act. The question of penalty in relation
[2017] WASAT 33 (S)
to Patient J will be dealt with in accordance with the Medical Practitioners
Act by reason of s 17(2)(b) of the National Law.5 The Tribunal findings in relation to Patient B and the notifying
practitioner were made pursuant to the National Law, and in respect of those findings the Tribunal may impose a penalty pursuant to s 196 National Law, (Schedule).
Filing of submissions
On 23 February 2017, the Tribunal made the following order for the filing of submissions on penalty and costs:
1. The Medical Board of Australia to file and serve its written submissions on penalty and costs by 9 March 2017.
2. Dr Anish Dwarka Singh to file and serve his written submissions on penalty and costs by 23 March 2017.
3. Subject to any further order of the Tribunal, the question of penalty and costs is to be dealt with entirely on the documents.
7 On 9 March 2017, the Board emailed the Tribunal seeking a
seven day extension on its written submissions which was granted.
The Board filed its submissions on 15 March 2017.
Dr Singh failed to file his submissions by 23 March 2017. On 28 March 2017, Dr Singh wrote to the Tribunal seeking a two week extension on the basis that he had 'recently found rental accommodation' and had been 'unable to complete [his] response by 23 March 2017'. The extension was granted.
9 On 27 April 2017, the Tribunal emailed Dr Singh stating that his
submissions had not been received. On 27 April 2017, Dr Singh emailed the Tribunal stating that he had been unwell and was under the care of Drs Alistar Vickery and Mark McAndrew and that he was not fit to comply with the timelines for the submissions. He requested a further six to eight weeks to complete them.
10 On 3 May 2017, the Tribunal received confirmation from
Dr Chacko Varughese that Dr Singh was now under his care for depression and he had been admitted to hospital.
11 On 3 May 2017, the Tribunal emailed the Board advising them of
Dr Singh's medical condition and seeking its consent to an extension of time. On 12 May 2017, the Board agreed to the extension.
[2017] WASAT 33 (S)
12 On 17 May 2017, Dr Singh emailed the Tribunal stating that he was
out of hospital and asking when his submissions were due. The Tribunal emailed Dr Singh the same day allowing him until 9 June 2017 to submit his submissions.
Dr Singh has still failed to file any submissions.
14 In the absence of any submissions from Dr Singh, the Tribunal has
determined that it should now make orders for penalty and costs and hand
down its reasons.
The Tribunal thanks the Board for its detailed submissions. The Tribunal has largely adopted those submissions in its reasons.
The practitioner's misconduct
In Singh, the Tribunal made the following findings on the practitioner's misconduct:
A.
The Tribunal finds that disciplinary matters exist for the purpose of s 76(1)(b) of the Medical Practitioners Act 2008 (WA) in that between early 2008 and 17 October 2010 Dr Anish Dwarka Singh acted carelessly, incompetently and/or improperly for the purposes of s 76(1)(b)(i), (ii) and/or (iii), and that from 18 October 2010 Dr Anish Dwarka Singh behaved in a way that constitutes professional misconduct for the purpose of s 193(1)(a)(i) of the Health Practitioner Regulation National Law (WA) Act 2010, in that Dr Anish Dwarka Singh:
1.
prescribed for patients anabolic androgenic steroids when there was no proper therapeutic indication for those prescriptions and when such prescribing unnecessarily put patients at risk of the adverse effects of those drugs;
2.
prescribed for patients Clenbuterol when there was no proper therapeutic indication for those prescriptions and when such prescribing unnecessarily put patients at risk of the adverse effects of Clenbuterol;
3.
prescribed for patients Ephedrine and Ephedrine, Aspirin and Caffeine capsules when there was no proper therapeutic indication for those prescriptions for body building;
4.
failed to make any or any adequate clinical notes in relation to his consultations and treatment of patients who consulted him for obesity or consulted him seeking weight loss, physical conditioning and/or body building and/or patients for whom he prescribed anabolic androgenic
[2017] WASAT 33 (S)
steroids and/or Clenbuterol, Ephedrine and/or Ephedrine,
Aspirin and Caffeine capsules;5. prescribed for patients Human Growth hormone when there was no proper therapeutic indication for such prescribing and when such prescribing unnecessarily put patients at risk of the adverse effects of Human Growth Hormone;
6. prescribed for patients:
(a) Sibutramine (after it had been withdrawn); (b) Tamoxifen; (c) Anastrozole; (d) Testosterone; (e) Midodrine; and (f) Fludrocortisone (with Midodrine); when there was no recognised therapeutic indication for that prescribing when such prescribing unnecessarily put patients at risk of the adverse effects of those drugs;
7. ordered the infusion of iron for patients who did not suffer from iron deficiency;
8. ordered the infusion of iron for patients when the infusion of iron was contra-indicated because the patients suffered from haemochromatosis or beta thalaessaemia trait;
9. engaged in the general practice (that is on multiple occasions) of inappropriate prescribing of Erythropoietin for patients when there was no recognised therapeutic indication for the prescription of that drug;
10. ordered Fresh Frozen Plasma infusions for patients when there was no recognised therapeutic indication for such infusions in those patients;
11. engaged in the general practice of ordering excessive DEXA scans when there was no recognised therapeutic indication for the performance of any such scan or alternatively for multiple such scans of those patients; and/or
12. prescribed Clomid when the prescription of that substance in Western Australia contravened reg 38C of the Poisons
[2017] WASAT 33 (S)
Regulations 1965 (WA) made pursuant to the Poisons Act
1964 (WA).
B.
The Tribunal finds that in relation to Patient J, disciplinary matters exist for the purpose of s 76(1)(b) of the Medical Practitioners Act 2008 (WA) in that Dr Anish Dwarka Singh acted carelessly, incompetently and/or improperly for the purposes of s 76(1)(b)(i), (ii) and/or (iii) in the course of his practice as a medical practitioner in that in or about December 2009 Dr Anish Dwarka Singh:
1.
failed to make any or any adequate clinical notes in relation to attendances upon him by Patient J;
2.
did not diagnose Patient J with body dysmorphic syndrome with binge eating disorder overlap, as he claimed to have done in his letter to the Medical Board of Australia on 8 April 2010;
3.
prescribed Mesterolone, Oxandrolone and Primoteston for Patient J when there was no therapeutic indication for those drugs and when such prescribing unnecessarily put Patient J at risk of the adverse effects of those drugs;
4.
failed to take any or any adequate steps to ensure appropriate monitoring of Patient J in order to detect any adverse effects suffered by Patient J as a result of Patient J taking androgens;
5.
prescribed Clenbuterol for Patient J when there was no medical indication or necessity for the prescription of Clenbuterol;
6
failed to take any, or any adequate steps to ensure appropriate monitoring of Patient J in order to detect any adverse effects suffered by Patient J as a result of Patient J taking Clenbuterol; and
7.
prescribed Clomid for Patient J when the prescription of that substance in Western Australia contravened reg 38C of the Poisons Regulations 1965 (WA) made pursuant to the Poisons Act 1964 (WA).
C.
The Tribunal finds in relation to Patient B that between early 2008 and 17 October 2010, Dr Anish Dwarka Singh behaved in a way that constitutes professional misconduct for the purpose of s 193(1)(a)(i) of the Health Practitioner Regulation National Law (WA) Act 2010 in that Dr Anish Dwarka Singh:
1.
failed to make any adequate clinical notes in relation to attendances upon him by Patient B;
[2017] WASAT 33 (S)
2. failed to consider, investigate or advise Patient B in relation to differential diagnoses which may have accounted for Patient B's hypertension;
3. prescribed Tamoxifen for Patient B when there was no medical indication for the prescription of Tamoxifen;
4. prescribed testosterone for Patient B when there was no medical indication for the prescription of testosterone;
5. prescribed Human Growth Hormone for Patient B when there was no medical indication for the prescription of Human Growth Hormone;
6. failed to take any or any adequate steps to ensure appropriate monitoring of Patient B.
7. prescribed Clomid for Patient B when the prescription of that substance in Western Australia contravened reg 38C of the Poisons Regulations 1965 (WA) made pursuant to the Poisons Act 1964 (WA); and/or;
8. sent a letter to the notifier, a medical practitioner, on or about 14 July 2012 which was:
(a) derogatory of that medical practitioner; (b) lacking in professional courtesy; and (c) offensive towards that medical practitioner.
The Board's submissions as to appropriate penalty and costs orders
In its submissions filed on 15 March 2017, the Medical Board of Australia (Board) sought the following orders:
1. Pursuant to s 196(2)(c) of the Health Practitioner Regulation National Law (WA) Act 2010, Dr Anish Dwarka Singh is fined in the sum of $30,000;
2. Pursuant to s 196(4)(a) of the Health Practitioner Regulation National Law (WA) Act 2010, Dr Anish Dwarka Singh is disqualified from applying for re-registration as a registered health practitioner for a period of 10 years;
3. Pursuant to s 116(1)(c) of the Medical Practitioners Act 2008 and s 196(2)(a) Health Practitioner Regulation National Law (WA) Act 2010, Dr Anish Dwarka Singh be reprimanded; and
4. Dr Anish Dwarka Singh is to pay the Medical Board of Australia's costs and disbursements of the proceedings at the scale that would
[2017] WASAT 33 (S)
apply if the proceedings had been in the Supreme Court of
Western Australia.
Legal framework and principles
The Medical Practitioners Act
Section 3 of the Medical Practitioners Act sets out the objects of the Act as follows:
(a)
to ensure that only properly qualified and competent persons practise medicine and to regulate the practice of medicine by those persons; and
(b)
to establish, maintain and promote suitable standards of knowledge and skills among medical practitioners,
for the purpose of protecting consumers of medical services provided by
medical practitioners in Western Australia.
19 In respect of each finding that disciplinary matters exist for the
purpose of s 76(1)(b) of the Medical Practitioners Act, the Tribunal is
empowered pursuant to s 116 of the Medical Practitioners Act to:1) make no order,
2) order that there be an amendment to the register pursuant to which the practitioner is registered as a health practitioner;
3) caution or reprimand the practitioner;
4) require the practitioner to refund monies to the patient in relation to the services provided or to compensate the patient for the costs of services provided by another medical practitioner;
5) order the practitioner to undergo counselling;
6) order the practitioner to comply with such conditions as the Tribunal may impose on the registration of the practitioner;
7) order the practitioner to report at intervals in relation to his medical practice to a medical practitioner nominated by the applicant Board;
[2017] WASAT 33 (S)
8) order the practitioner to obtain advice on the management of his medical practice;
9) order the practitioner to pay a penalty not exceeding $25,000;
10) order that the practitioner be suspended from practice for such period as the Tribunal may consider appropriate not exceeding two years; and/or
11) order that the medical practitioner's registration be cancelled and his name removed from the register.
The National Law
Section 3 of the National Law sets out the objectives and guiding principles. Relevantly they are s 3(l)(a) and s 3(2)(a):
The object of this Law is to establish a national registration and accreditation scheme for -
the regulation of health practitioners; [and]
The objectives of the national registration and accreditation scheme are -
to provide for the protection of the public by ensuring that only health practitioners who are suitably trained and qualified to practise in a competent and ethical manner are registered[.]
Section 4 of the National Law provides:
An entity that has functions under this Law is to exercise its functions having regard to the objectives and guiding principles of the national registration and accreditation scheme set out in section 3.
22 Section 196 of the National Law provides that if a responsible
tribunal, which for present purposes is this Tribunal, finds that a practitioner has behaved in a way that constitutes professional misconduct, it may decide to do one or more of the following:
…
(2)
If a responsible tribunal makes a decision referred to in subsection (l)(b), the tribunal may decide to do one or more of the following -
(a) caution or reprimand the practitioner;
[2017] WASAT 33 (S)
(b)
impose a condition on the practitioner's registration, including, for example -
(i)
a condition requiring the practitioner to complete specified further education or training, or to undergo counselling, within a specified period; or
(ii)
a condition requiring the practitioner to undertake a specified period of supervised practice; or
(iii)
a condition requiring the practitioner to do, or refrain from doing, something in connection with the practitioner's practice; or
(iv)
a condition requiring the practitioner to manage the practitioner's practice in a specified way; or
(v)
a condition requiring the practitioner to report to a specified person at specified times about the practitioner's practice; or
(vi)
a condition requiring the practitioner not to employ, engage or recommend a specified person, or class of persons;
(c)
require the practitioner to pay a fine of not more than $30 000 to the National Board that registers the practitioner;
(d)
suspend the practitioner's registration for a specified period;
(e) cancel the practitioner's registration.
(3)
If the responsible tribunal decides to impose a condition on the practitioner's registration, the tribunal must also decide a review period for the condition.
(4)
If the tribunal decides to cancel a person's registration under this Law or the person does not hold registration under this Law, the tribunal may also decide to -
(a)
disqualify the person from applying for registration as a registered health practitioner for a specified period; or
(b)
prohibit the person from using a specified title or providing a specified health service.
[2017] WASAT 33 (S)
Disciplinary sanctions - general principles
23 The Tribunal repeats what it stated in Medical Board of Australia and Myers [2014] WASAT 137 (S). The jurisdiction of the Tribunal is protective rather than punitive, and such protection runs to both the public and the profession (Craig v Medical Board of South Australia [2001] SASC 169; (2001) 79 SASR 545 at [41] (Craig); Re Maraj (a Legal Practitioner) (1995) 15 WAR 12 at 25; Legal Profession Complaints Committee v Love [2014] WASC 389 (Love) at [19]; Law Society of New South Wales v Foreman (1994) 34 NSWLR 408 (Foreman) at 440G-441A-B; Legal Profession Complaints Committee and in de Braekt [2013] WASAT 124 at [24]-[26]; New South Wales Bar Association v Hamman [1999] NSWCA 404 (Hamman) at [21] and [77]).
24 The appropriate sanction is to be considered at the time of the
making of the sanction and not by reference to the date of the unprofessional acts (Legal Profession Complaints Committee and A Legal Practitioner [2013] WASAT 37 (S) (A Legal Practitioner (S)) at [23]; Legal Profession Complaints Committee v Segler [2014] WASC 159 at [7]; A Solicitor v Council of the Law Society of NSW [2004] HCA l; (2004) 216 CLR 253 (A Solicitor [2004] NSW) at [15]; Love at [16]).
25 It is the practitioner's conduct that attracts any sanction (A Legal Practitioner (S) at [24]; Smith v New South Wales Bar Association [1992] HCA 36; (1992) 176 CLR 256 at 267-268 and 271-272; A Solicitor [2004] NSW).
As the Tribunal explained in A Legal Practitioner (S) at [24]:
[I]n determining the appropriate penalty, care needs to be taken that the penalty reflects the matters with which the practitioner is charged and not other conduct including the defence of the action by the practitioner which is ultimately held to be unsuccessful: Smith v New South Wales Bar Association [1992] HCA 36; (1992) 176 CLR 256 (Smith) at 267-268 and 271-272[.]
27 Where there is a choice of sanctions, the Tribunal will choose that
sanction which maximises the protection of the public (Quinn v Law
Institute of Victoria [2007] VSCA 122 at [31]).28 The dominant purpose of the disciplinary regulation of the
medical profession is the protection of the public by the maintenance of proper standards within the profession. Hence, the impact which
[2017] WASAT 33 (S)
an appropriate penalty would have upon a practitioner guilty of misconduct, and personal hardship to a practitioner, are necessarily secondary considerations (see Legal Profession Complaints Committee v Detata [2012] WASCA 2014 at [47]; Legal Profession Complaints Committee v Masten [2011] WASC 71 at [29]; and Legal Profession Complaints Committee and Leask [2010] WASAT 133 at [54]).
29 There are circumstances in which a 'global' approach to sanction,
rather than the imposition of separate sanction for each unprofessional act, may be more appropriate in vocational disciplinary proceedings namely, where the facts of the case are so inextricably woven as to make it difficult to meet a clear standard of prescription (A Legal Practitioner (S) at [5]; Stirling v Legal Services Commissioner [2013] VSCA 374 (Stirling) at [72]-[75]).
Twelve matters for consideration
30 In determining an appropriate sanction, twelve matters may require
consideration. Those matters are interrelated and are not mutually
exclusive. The list of matters is not exhaustive. The twelve matters are:1) Any need to protect the public against further misconduct by the practitioner (Legal Profession Complaints Committee and Amsden [2014] WASAT 57 (S) (Amsden (S)) at [8]; Foreman at 440C; Hamman at [77]).
2) The need to protect the public through general deterrence of other practitioners from similar conduct (Veterinary
Practitioners Board of NSW v Johnson
[2010] NSWADT 308 (Johnson) at [103]; Hamman
at [77]).3) The need to protect the public and maintain public confidence in the profession by reinforcing high professional standards and denouncing transgressions and thereby articulating the high standards expected of the profession (Amsden (S)) at [8]; Foreman at 444F; and Hamman at [77] and at [79]), such that, even where there may be no need to deter a practitioner from repeating the conduct, the conduct is of such a nature that the Tribunal should give an emphatic indication of its disapproval (Craig at [64]; Johnson at [103]).
[2017] WASAT 33 (S)
4) In the case of conduct involving misleading conduct, including dishonesty, whether the public and fellow practitioners can place reliance on the word of the practitioner (Johnson at [109]; Foreman at 445B-445G).
5) Whether the practitioner has breached any:
a) Act; b) Regulations; c) Guidelines or Code of Conduct, issued by the relevant professional body; and d) whether the practitioner has done so knowingly. 6) Whether the practitioner's conduct demonstrated incompetence, and if so, to what level.
7) Whether or not the incident was isolated such that the Tribunal can be satisfied of his or her worthiness or reliability for the future (Foreman at 442E-442G;
New South Wales Bar Association v Evatt
(1968) 117 CLR 177 at 183; Council of the Law Society (NSW) v A Solicitor [2002] NSWCA 62 at [80];
Chamberlain v Law Society of the Australian Capital
Territory (1993) 118 ALR 54 at 62 and 63).
8) The practitioner's disciplinary history (Legal Profession Complaints Committee v O'Halloran [2013] WASC 430 at [93]).
9) Whether or not the practitioner understands the error of his ways, including an assessment of any remorse and insight (or a lack thereof) shown by the practitioner, since a practitioner who fails to understand the significance and consequences of misconduct is a risk to the community (Law Society of New South Wales v Walsh [1997] NSWCA 185 per Beazley JJA (Walsh); Legal
Profession Complaints Committee v Lashansky
[2007] WASC 211 at [31]-[52] and (second) at [35];
Amsden (S) at [8]; Foreman at 444E; Love at [9]).10) The desirability of making available to the public any special skills possessed by the practitioner.
[2017] WASAT 33 (S)
11) The practitioner's personal circumstances at the time of the conduct and at the time of imposing the sanction. However, the weight given to personal circumstances cannot override the fundamental obligation of the Tribunal to provide appropriate protection of the public interest in the honesty and integrity of legal practitioners and in the maintenance of proper standards of legal practice (Love at [59]); Paridis v Settlement Agents Supervisory Board [2007] WASCA 97; (2007) 33 WAR 361 at [30(5)]).
12) The Tribunal may consider any other matters relevant to the practitioner's fitness to practise and other matters which may be regarded as aggravating the conduct or mitigating its seriousness (A Legal Practitioner (S) at [25]). In general, mitigating factors such as no previous misconduct or service to the profession are of considerably less significance than in the criminal process because the jurisdiction is protective not punitive (Walsh).
Cancellation of registration
31 The jurisdiction of the Tribunal to cancel a practitioner's registration
is exercised not for the purpose of punishing the practitioner concerned, but for the protection of the public and the reputation and standards of the medical profession: Legal Practitioners Complaints Committee v Thorpe [2008] WASC 9 at [43].
32 Where an order for cancellation of a practitioner's registration is
contemplated, the ultimate question is whether the material demonstrates that the practitioner is not a fit and proper person to remain a medical practitioner: A Solicitor [2004] NSW at [15].
33 A practitioner is not a fit and proper person to be a registered
practitioner and should be removed from the register where the unprofessional conduct is so serious that the practitioner is permanently or indefinitely unfit to practise (Veterinary Surgeons Investigating Committee v Howe (No 2) [2003] NSWADT 159 at [27]; Barristers' Board v Darveniza [2000] QCA 253; (2000) 112 A Crim R 438 at [38]; Love at [17]-[18]; A Legal Practitioner (S) at [21]-[25]; Legal Profession Complaints Committee v Brickhill [2013] WASC 369 at [19]-[20] (Thomas JA, McMurdo P and White J agreeing); New South Wales Bar
[2017] WASAT 33 (S)
Association v Cummins [2001] NSWCA 284; (2001) 52 NSWLR 279 at [26]-[28]); Love at [17]-[18]).
34 The practical effect of a cancellation is that the onus is on the
practitioner to establish that he is a fit and proper person should he seek
to resume practice.
Suspension
35 Suspension is a less serious result and differs from cancellation of
a practitioner's registration because suspension is for a specified limited
period.36 The proper use of suspension is in cases where the practitioner has
fallen below the high standards to be expected of such a practitioner, but not in such a way as to indicate that he/she lacks the qualities of character which are the necessary attributes of a person entrusted with the responsibilities of a practitioner (A Legal Practitioner (S) at [26]; Re A Practitioner (1984) 36 SASR 590 at 593 per King CJ). That is, suspension is suitable where the Tribunal is satisfied that, upon completion of the period of suspension, the practitioner will be fit to resume practice (A Legal Practitioner (S) at [27]).
37 The practical effect of a suspension is that the practitioner can
resume practice without the need to establish that he is a fit and proper
person.
The seriousness of Dr Singh's misconduct
38 Dr Singh's misconduct was serious. The inappropriate prescription
of drugs when 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.
39 The range of drugs and treatments prescribed without a proper
therapeutic basis and the combinations of drugs to a large number of patients shows that Dr Singh's conduct was not isolated, is further discussed below.
40 Dr Singh's failure to take adequate notes is a fundamental failing in
his obligations to his patients. Dr Singh's failure to take adequate notes
was extensive.
Dr Singh's misconduct in relation to Patients J and B are particular examples of his broader failings.
[2017] WASAT 33 (S)
The 12 factors
| Factor 1 | Is there a need to protect the public against further misconduct by Dr Singh? |
The Board submitted that:
…
21. Anabolic steroids and HGH are well recognised by medical practitioners to be sought after by particular groups of patients including bodybuilders, models and patients who wish to increase their muscle bulk and gain a leaner appearance for sporting, aesthetic and vocational purposes. The circumstances which drive demand for such drugs vary from patient to patient, but all such patients are vulnerable in that they are seeking drugs which can give rise to serious health risks. The evidence of Professors Wittert and Joyce as to adverse effects of the relevant drugs is set out in Singh at [118]-[121]. Among the most serious health risks are adverse psychiatric effects manifesting as aggression, uncontrolled anger and rage, serious adverse effects involving the kidneys and the liver and serious cardiovascular effects including changes to cardiac muscle. For some patients that vulnerability is likely to be complicated by psychiatric illness. Professor Wittert identified one such group as patients suffering from body dysmorphia, who are driven by their illness to abuse anabolic steroids. 22. All patients seeking anabolic steroids, stimulants and/or HGH require counselling as to the dangers associated with the use of those drugs. Meeting the demands of such patients for such drugs unnecessarily puts the patients at risk of serious adverse effects and deprives them of proper management of underlying social or psychiatric issues. Such conduct is antithetical to the proper practice of medicine, and poses a serious risk to public safety. 23. Dr Singh's conduct was particularly serious having regard to the quantities of anabolic steroids and other drugs he prescribed and the significant periods of time over which the misconduct occurred, both in total and in respect of individual patients. Dr Singh's misconduct is among the worst of its kind to have been aired in any of the responsible tribunals under the National Law. 24. Dr Singh was at the material time a registered specialist, from whom the public and referring practitioners were entitled to expect a high standard of medical care. Dr Singh's prescribing of anabolic steroids and his engagement in inappropriate and idiosyncratic prescribing of other drugs was conduct substantially below the standard of practice expected of a specialist physician[.]
The Tribunal broadly accepts the Board's submissions.
[2017] WASAT 33 (S)
44 Dr Singh's misconduct occurred on repeated occasions and over
a long period of time. The number of instances of inappropriate prescribing and failure to take notes and the prolonged period over which it occurred led the Tribunal to conclude that there is a very substantial risk of Dr Singh engaging in such conduct again. The penalty must prevent such further misconduct.
| Factor 2 | Is there a need to protect the public through general deterrence of other practitioners? |
The Board submitted that:
…
25. The ready market for these drugs and the financial benefit to a practitioner in prescribing them (evidenced by the number of patients who received the relevant prescriptions and the large consultation fees that the respondent was able to charge his patients), together with the potential for significant short-term and long-term harm as a result of their use, make it vital that penalties for inappropriately prescribing anabolic steroids and associated drugs are sufficiently severe to deter medical practitioners from engaging in such conduct. 26. The Board contended that it is necessary in the public interest for the penalty imposed to constitute a significant financial disincentive to engage in such conduct[.]
The Tribunal accepts the Board's submissions. Money is often a powerful incentive for the inappropriate prescribing of drugs.
The penalty must be sufficient to deter other practitioners from engaging in similar misconduct.
| Factor 3 | Is there a need to protect the public by reinforcing high professional standards and denouncing transgressions? |
The Board submitted that:
…
27.
Dr Singh's conduct was inconsistent with the high professional standards expected of medical practitioners. The penalty required must be of sufficient severity to reassure the public that other medical practitioners will be deterred from such conduct so that high professional standards are promoted in respect of the profession[.]
[2017] WASAT 33 (S)
49 The Tribunal accepts the Board's submissions. Public confidence in
the ability and integrity of medical practitioners is essential. Misconduct
such as Dr Singh's undermines the public's confidence in the profession.
| Factor 4 | Dishonesty |
The Board submitted that:
…
28.
This factor is relevant where a practitioner's conduct is such that the public and fellow practitioners cannot place reliance on the word of the practitioner; Legal Profession Complaints Committee and Wells [2014] WASAT 112 at [5] and [20] and the cases referred to therein; Dhillon (supra) at [33] - [40].
29.
Honesty is a critical quality required in the character of a medical practitioner; McBride v Walton (NSWCA), 15 July 1994, unreported, BC9402907, per Handley JA at 86; Dhillon (supra) at [38] - [40].
30.
The Tribunal made an express finding that much of Dr Singh's evidence was deliberately untrue; Singh at [96].
31.
Dr Singh did not make any admissions prior to the commencement of the hearing. It was only during the hearing that Dr Singh conceded for the first time that he prescribed steroids to more than 20 patients for the purpose of bodybuilding; Singh at [91] to [93].
32.
An example of Dr Singh's dishonesty in relation to the basis of his prescribing is found in relation to Patient 71. Dr Singh advised the Australian Health Practitioner Regulation Agency (AHPRA) in a letter dated 20 July 2012 that Patient 71 consulted him for obesity. When Dr Singh was asked questions about photographs of Patient 71 during cross-examination, he eventually conceded that he was providing Patient 71 with steroids and other drugs for body building purposes and not for any conventional therapy. Until that concession was made, Dr Singh had dishonestly represented to AHPRA and to the Tribunal in these proceedings that he prescribed steroids to Patient 71 for the treatment of obesity, and that he did not provide steroids to body builders.
33.
A further example of Dr Singh's dishonesty arises in relation to his qualifications, which were misrepresented in his witness statement filed in these proceedings and in correspondence to the solicitor Mr Massey; Singh at [94].
34.
The Tribunal found that Dr Singh's 'explanations as to why he prescribed drugs to various patients are explained in his evidence in medical terms and with medical justifications, but that the objective
[2017] WASAT 33 (S)
evidence does not support those explanations and paints a very different picture'; Singh at [89]. The scientific rationales advanced by Dr Singh during the hearing, many of which the Tribunal has found to be deliberately untrue, were largely the same rationales that he advanced to his patients and colleagues[.]
51 The factor of dishonesty relates to the nature of the conduct rather
than the conduct of the proceedings. Paragraphs 30 to 34 of the Board's submissions relate to the latter. However, it is clear that Dr Singh's conduct was dishonest in that his misconduct involved cloaking prescriptions with the veil of a proper therapeutic basis when in fact there was no proper therapeutic basis. His conduct was plainly dishonest. The Tribunal agrees with paragraphs 28 and 29 of the Board's submissions.
| Factor 5 | Breach of an Act, Regulations, Guidelines or Code of Conduct |
The Board submitted that:
…
35. The Tribunal has found that Dr Singh's prescriptions of Clomid were given contrary to reg 38C of the Poisons Regulations 1965 (WA) made pursuant to the Poisons Act 1964 (WA) (repealed); Singh at [186]. 36. Dr Singh's failure to make any or any adequate clinical notes was contrary to the Good Medical Practice: A Code of Construct for Doctors Australia (Code of Conduct). The Tribunal has found that Dr Singh's clinical notes were totally inadequate; Singh at [333]. There can be no doubt that Dr Singh was aware of his duty to make adequate clinical notes. 37. Dr Singh's other breaches of the Code of Conduct included failing to provide treatment options based on the best available information, failing to recognise and work within the limits of his competence and scope of practice and failing to consider the balance of benefit and harm in all clinical-management decisions[.]
The Tribunal accepts the Board's submissions.
| Factor 6 | Incompetence |
The Board submitted that:
…
[2017] WASAT 33 (S)
38. The Tribunal has found that the responded acted carelessly, incompetently and/or improperly in relation to numerous aspects of his practice of medicine.
39. In his evidence Dr Singh gave convoluted and purportedly scientific explanations for his mode of prescribing. The Tribunal accepted evidence from Professor Wittert that Dr Singh's approach to pharmacology was 'bizarre' and 'not founded on any principle of science or evidence that I am aware of but just stringing snippets of information together to construct a story'; Singh at [206]. Dr Singh was at least to some extent found to have been disingenuous in giving both medical advice and evidence before the Tribunal to the effect that his prescribing was justified when he knew that his mode of prescribing was inappropriate and harmful to patients. His stated justifications also reveal incompetence[.]
The Tribunal accepts the Board's submissions.
| Factor 7 | Was the incident isolated? |
The Board submitted that:
…
40. The Tribunal found that Dr Singh had an extensive prescribing practice in relation to anabolic androgenic steroids (Singh at [145]), Clenbuterol (Singh at [163]), Ephedrine and/or EAC (Singh at [178]), Clomid (Singh at [185]), HGH (Singh at [211]) and ordering DEXA scans without proper therapeutic indication (Singh at [313]). Dr Singh's conduct did not arise from an isolated lapse of judgment. Dr Singh's general practice of medicine was affected by his misconduct[.]
57 The sheer magnitude of Dr Singh's prescription of drugs and other
treatments as set out in Singh, is extremely worrying. There were some 740 patients (Singh at [323]). Dr Singh's misconduct commenced in early 2001 and continued until late 2015 - a very long period.
| Factor 8 | Dr Singh's disciplinary history |
Dr Singh has no relevant disciplinary history.
| Factor 9 | Whether or not Dr Singh understands the error of his ways, including an assessment of the any remorse and insight (or a lack thereof) shown by Dr Singh |
The Board submitted that:
…
[2017] WASAT 33 (S)
42. Dr Singh has not demonstrated any regret, contrition or remorse with respect to the treatment that he provided to his patients.
43. During the hearing Dr Singh attempted to justify his conduct and maintained that the treatment provided to his patients the subject of these proceedings was appropriate. Dr Singh claimed at hearing that he had done no harm and that 'no-one had died on [him]' (Singh at [314]).
44. Even after having the advantage of considering the expert evidence filed in these proceedings, Dr Singh appeared not to understand or accept that the treatment he provided to Patient J or Patient B, or his general prescribing practices as outlined in these proceedings, had potentially serious consequences for his patients. Dr Singh's apparent persisting lack of insight into the potentially serious consequences of his conduct demonstrates that the public would be at ongoing risk if the respondent was able to continue to practise medicine.
45. Dr Singh's lack of insight is exemplified by his conduct in writing to the notifier, a fellow practitioner, in relation to Patient B as follows:
In summary, I believe you owe the patient an apology for violating doctor/patient confidentiality. I believe you have jeopardised his future career. I believe you have acted in an unnecessarily adversarial and combative manner. I believe you have made unfounded assumptions on my prescribing ability which really should have been a matter for doctor to doctor consultation. I believe you need to address and understand the concept of harm minimisation. I believe you need to go back and study your physiology and pharmacology. I believe you owe me an apology for your idiotic behaviour.
46. As the Tribunal found in Singh at [443], Dr Singh's letter was totally inappropriate, derogatory, lacking in professional courtesy and offensive, particularly having regard to the fact that the medical practitioner's concerns about the prescriptions given to Patient B by the respondent were correct[.]
The Tribunal accepts the Board's submissions.
61 The Tribunal's submissions in relation to dishonesty, as set out in
paragraphs 30 to 34 in Factor 4 above, are also relevant to his conduct of
the proceedings and whether Dr Singh has shown any insight or remorse.62 As the Board correctly submitted, the practitioner's conduct of the
defence and the veracity and candour of his or her testimony will often be
[2017] WASAT 33 (S)
the best evidence as to whether these mitigating circumstances are to be accepted: Barwick v Council of the Law Society of NSW [2004] NSWCA 32 at [108].
63 A practitioner's denial of the charges and the consequent need for the
regulator to prosecute the charges to conclusion will deny the practitioner the mitigating benefit of immediate remorse and cooperation: The Council of the Qld Law Society v Wright [2001] QCA 58 at [43]- [46].
64 Dr Singh has failed to show any remorse or insight. The Tribunal
cannot have any confidence that he would not engage in such misconduct
again given the opportunity.
| Factor 10 | Are there any special skills possessed of Dr Singh? |
There is no evidence that Dr Singh has special skills not otherwise available to the public in Western Australia.
| Factor 11 | Dr Singh's personal circumstances |
The Board submitted that:
…
48. In May 2015 Dr Singh ceased to be a Fellow of the Royal Australasian College of Physicians as a consequence of his failure to pay his fees. 49. On 6 November 2015 Dr Singh became aware that his registration had expired. 50. Dr Singh has not successfully renewed his registration, and has been not been registered as a medical practitioner since expiry[.]
67 Obviously, any restrictions on Dr Singh's ability to practise will have
a significant effect on his income. However, as noted above, the principal purpose of disciplinary proceedings is the protection of the public. Dr Singh's loss of income is outweighed by the need to protect the public.
| Factor 12 | Are there any other matters related to Dr Singh's fitness to practise? |
This factor does not apply.
[2017] WASAT 33 (S)
Penalty
69 Part of Dr Singh's misconduct was in breach of the Medical
Practitioners Act and part was in breach of the National Law. Dr Singh's misconduct was substantially identical under both Acts.
70 The relevant penalties under the Medical Practitioners Act are a
reprimand or a fine. The Medical Practitioners Act did not empower the Tribunal to disqualify a practitioner from applying for registration for a period.
71 A global approach to penalty may be appropriate, rather than
separate sanctions for each unprofessional act, where the facts of the case are so inextricably woven so as to make it difficult to meet a clear standard of prescription; A Legal Practitioner (S) at [5]; Stirling at [72]-[75]; Dental Board of Australia and Dhillon [2017] WASAT 20 (Dhillon) at [9]. A global penalty is also appropriate if the appropriate penalty for particular conduct would be subsumed by the appropriate penalty for more serious conduct; Dhillon at [9].
72 Factually, there is a clear connection between the facts. Although
Patients J and B were the subject of particular complaints, Dr Singh's misconduct in relation to them were specific instances of Dr Singh's general practice.
73 Dr Singh's misconduct occurred over a long period of time and
involved multiple prescriptions. It is appropriate to impose a global penalty having regard to Dr Singh's overall misconduct rather than isolating certain incidents and imposing separate penalties.
Cancellation
Dr Singh is no longer a registered medical practitioner so no order is required to cancel his registration.
75 Had Dr Singh not allowed his registration to lapse, there is no
question that this Tribunal would have cancelled his registration. Dr Singh's misconduct was so serious that he is permanently or indefinitely unfit to practice.
Period of disqualification
| 76 | The National Law came into effect in October 2010 in Western Australia. The majority of Dr Singh's offending occurred under the National Law. Dr Singh's previous offending under the Medical |
[2017] WASAT 33 (S)
Practitioners Act may be taken into account in fixing a period of disqualification under the National Law.
77 Dr Singh's misconduct extended over a long period of time,
involving multiple patients and multiple prescriptions of drugs and other treatments and multiple failures to take proper notes. Only a long period of disqualification can accurately reflect the seriousness of Dr Singh's misconduct.
78 The Tribunal finds that Dr Singh should be disqualified from
applying for registration as a medical practitioner for a period of 10 years
from the date of this order, pursuant to s 196(4) of the National Law.
Reprimand and/or fine?
79 The Board sought an order that Dr Singh be reprimanded.
The Tribunal does not see that any purpose would be served by a reprimand. Disqualification from applying for registration for 10 years is an appropriate remedy.
80 Similarly, the Tribunal does not regard it as appropriate to impose
a fine as a separate penalty except in relation to Dr Singh's letter to the
notifier.
It is important that notifiers of potential misconduct be able to do so without abuse by the health practitioner about whom they complain.
Dr Singh's letter stands in a separate category to his other misconduct. The Tribunal has determined that he should be fined $5,000 as a discouragement to others who might be tempted to engage in such misconduct.
| Costs |
Section 87(1) and s 87(2) of the State Administrative Tribunal Act
2004 (WA) provide:
Unless otherwise specified in this Act, the enabling Act, or an order of the Tribunal under this section, parties bear their own costs in a proceeding of the Tribunal.
Unless otherwise specified in the enabling Act, the Tribunal may make an order for the payment by a party of all or any of the costs of another party or of a person required to produce a document or other material on the application of the party under section 35.
[2017] WASAT 33 (S)
84 In Western Australian Planning Commission v Questdale Holdings Pty Ltd [2016] WASCA 32, Murphy JA (Martin CJ and Corboy J agreeing) stated:
46 The effect of s 87(1) of the SAT Act is, relevantly, that each party in proceedings before the Tribunal is to bear its own costs, unless the Tribunal otherwise orders.
… 51 Section 87(2) is to be construed in the context that the legal rationale for an order for costs is not to punish the person against whom the order is made, but to compensate or reimburse the person in whose favour it is made. That rationale is evident in s 87(3) of the SAT Act. Accordingly, even in a statutory context where the presumptive position is that no costs will be ordered, generally speaking, the question is whether, in the particular circumstances of the case, it is fair and reasonable that a party should be reimbursed for the costs it incurred. The onus is on the party seeking an order in its favour.
In Medical Board of Western Australia and Roberman
[2005] WASAT 81 (S) (Roberman (S)) at [30], the Tribunal stated:
Section 87(2) gives the Tribunal the discretion to order the payment by a party of all or any of the costs of another party. Where a regulatory authority successfully brings a complaint of conduct which, if proved, justifies disciplinary action by the Tribunal, there will usually be a strong case for the exercise of that discretion in favour of the regulatory body. That is because such bodies perform a function which promotes the public interest, and usually with limited resources. The financial burden of bringing disciplinary action if the body had no capacity to recover some or all of its costs may be such as to provide a disincentive to bring disciplinary action, or when brought, to ensure that the allegations against the practitioner concerned are properly and thoroughly presented. It is in the public interest that such bodies have an expectation that, if the allegations are made out, the offending professional will meet or at least contribute to the costs incurred in bringing the application. The question of an award of costs is, of course, a matter of discretion to be exercised in the circumstances of each case.
86 Although the decision in Roberman (S) does not limit the discretion of the Tribunal in awarding costs, the public obligations of the Board to prosecute practitioners who breach the National Law is an important factor to be considered.
In the particular circumstances of this case:
[2017] WASAT 33 (S)
a)
where many of the costs were incurred by reason of Dr Singh's lack of insight; and
b)
Dr Singh's persistence in denying the nature of his conduct in communications with the Board and his conduct before this Tribunal;
it is fair and reasonable that the Board should be reimbursed for the costs
and disbursements it incurred.88 It will be a rare case where costs of Tribunal proceedings are ordered
on the Supreme Court Scale. The Tribunal has determined that this is not
such a case.89 The Tribunal order that Dr Singh pay the Board's costs and
disbursements to be assessed by the State Administrative Tribunal Scale. It is a matter between the Board and Dr Singh as to whether he should be given time to pay.
| Orders |
1. Pursuant to s 196(2)(c) of the Health Practitioner
Regulation National Law (WA) Act 2010, Dr Anish Dwarka Singh is fined $5,000.
2. Pursuant to s 196(4)(a) of the Health Practitioner
Regulation National Law (WA) Act 2010, Dr Anish Dwarka Singh is disqualified from applying for re-registration as a registered health practitioner for a period of 10 years.
3. Dr Anish Dwarka Singh is to pay the Medical Board of Australia's costs and disbursements of the proceedings at the scale that applies for proceedings in the State Administrative Tribunal.
I certify that this and the preceding [89] paragraphs comprise the reasons for decision of the State Administrative Tribunal.
___________________________________
JUSTICE J C CURTHOYS, PRESIDENT
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