Medical Board of Australia v Singh

[2017] WASAT 33

JURISDICTION     :   STATE ADMINISTRATIVE TRIBUNAL

ACT: HEALTH PRACTITIONER REGULATION NATIONAL LAW (WA) ACT 2010

CITATION:   MEDICAL BOARD OF AUSTRALIA and SINGH [2017] WASAT 33

MEMBER:   JUSTICE J C CURTHOYS (PRESIDENT)

MS H LESLIE (MEMBER)
DR A MCCUTCHEON (SENIOR SESSIONAL MEMBER)
DR P WINTERTON (SENIOR SESSIONAL MEMBER)

HEARD:   15, 16 AND 17 AUGUST 2016

DELIVERED          :   23 FEBRUARY 2017

FILE NO/S:   VR 235 of 2014

BETWEEN:   MEDICAL BOARD OF AUSTRALIA

Applicant

AND

ANISH DWARKA SINGH
Respondent

Catchwords:

National Law - Professional misconduct - Steroid prescription - No therapeutic basis - Inadequate records

Legislation:

Dental Act 1939 (WA)
Health Practitioner Regulation National Law (WA) Act 2010, s 3, s 5, s 31, s 193(1)(a)(i), s 196(1)
Medical Act 1984 (WA)
Medical Practitioners Act 2008 (WA), s 76(1), s 86(1)
Poisons Act 1964 (WA)
Poisons Regulations 1965 (WA), reg 38C
Therapeutic Goods Act 1989 (Cth), s 19(5)

Result:

Disciplinary matters arise under s 76 of the Medical Practitioners Act 2008 (WA)
Practitioner engaged in professional misconduct

Summary of Tribunal's decision:

This decision relates to three separate applications made by the Medical Board of Australia in relation to the conduct of a medical practitioner, Dr Anish Dwarka Singh.  The three applications were consolidated as VR 235 of 2014.

The Medical Board's allegations pertained to Dr Singh's general practice which included failing to keep proper records, prescribing drugs or other treatments when there was no therapeutic basis and prescribing some drugs and treatments which had potential adverse effects.  The Medical Board of Australia also made the same allegations in relation to Dr Singh's treatment of two specific patients.

During the course of the hearing, Dr Singh conceded that his medical records were inadequate.

In broad terms, the factual allegation was that Dr Singh was prescribing androgen anabolic steroids and related drugs for physical conditioning and/or body building.

The Tribunal considered all of the evidence before it, including expert evidence from a joint conferral of experts which played a large role in the resolution of the proceedings.

The Tribunal determined that disciplinary matters arise under s 76 of the Medical Practitioners Act 2008 (WA) and that Dr Singh had acted carelessly, incompetently and/or improperly which constituted professional 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):

Briginshaw v Briginshaw (1938) 60 CLR 336

Cranley v Medical Board of Western Australia (unreported, WASC, Library No 8668, 21 December 1990)

Health Care Complaints Commission v Bours (No 1) [2014] NSWCATOD  113

Jemielita v The Medical Board of Western Australia (unreported, WASC Library No 920584, 13 November 1992

Legal Profession Complaints Committee and Wells [2014] WASAT 112

Medical Board of Australia and Bernadt [2012] WASAT 108

Medical Board of Western Australia and Alizadeh [2007] WASAT 52

Medical Board of Western Australia and Bham [2006] WASAT 190

Medical Board of Western Australia and Richards [2010] WASAT 94

Medical Board of Western Australia and Wolman [2011] WASAT 69

Medical Board of Western Australia and Wright [2010] WASAT 48

NOM v Director of Public Prosecutions (2012) 38 VR 618

Ong v The Dental Board of Western Australia (unreported, WASC, Library No 960442, 25 August 1995)

Rejfek v McElroy (1965) 112 CLR 517

REASONS FOR DECISION OF THE TRIBUNAL: 

Introduction

1. The Medical Board of Australia (the Board) is established pursuant to s 31 of the Schedule to the Health Practitioner Regulation National Law (WA) Act 2010 (the National Law) (Board's Further Amended Grounds of Consolidated Application dated 25 August 2016 (Board's CG paragraph 1)).

2. Dr Anish Dwarka Singh was a registered practitioner under the Medical Practitioners Act 2008 (WA) (Medical Practitioners Act), and, subsequently, under the National Law.

3. Dr Singh practised as a specialist physician in West Perth, Western Australia (Board's CG paragraph 4).  He has been practising medicine for approximately 25 years (Dr Singh's response statement (SR) paragraph 3).

Procedural history

1. This decision relates to what were three separate applications before the Tribunal:  VR 204 of 2012, VR 230 of 2013 and VR 93 of 2014. 

2. VR 204 of 2012, filed on 11 December 2012, concerned Dr Singh's conduct in relation to Patient J. This application was brought under s 86(1) of the Medical Practitioners Act. Dr Singh's conduct in relation to this application is to be assessed under the Medical Practitioners Act.

3. VR 230 of 2013, filed on 20 December 2013, concerned Dr Singh's conduct in general practice. This application was brought under s 86(1) of the Medical Practitioners Act. Dr Singh's conduct in relation to this application is to be assessed under the Medical Practitioners Act.

4. VR 93 of 2014 concerned Dr Singh's conduct on relation to Patient B. This application was brought under s 193(1)(a)(i) of the National Law. Dr Singh's conduct in relation to this patient is to be assessed under the National Law.

5. The applications were ordered to be consolidated pursuant to an order of the Tribunal made on 16 December 2014.  The consolidated proceedings were consolidated as VR 235 of 2014.  In the consolidated proceedings the general practice allegations against Dr Singh were extended to Dr Singh's conduct after 18 October 2010, the date when the National Law commenced in Western Australia.  Dr Singh's conduct after 18 October 2010 is to be assessed under the National Law.

The respective cases

1. The Board's case falls into four main parts.  Two related to Dr Singh's general practice:

   a)prescribing drugs or other treatments when there was no therapeutic basis and, in the case of some drugs and treatments, there were potential adverse effects; and

   b)failing to keep proper records. 

2. The other two parts make the same allegations in relation to Dr Singh's treatment of two specific patients:  Patient J and Patient B. 

3. In relation to prescribing drugs or other treatments, Dr Singh contended that there was a therapeutic basis for prescribing the drugs and that there were no adverse effects.  In relation to the keeping of records Dr Singh initially denied that his records were inadequate.  During the course of the hearing, he conceded that his records were inadequate.

4. In broad terms, the factual allegation is that Dr Singh was prescribing androgen anabolic steroids and related drugs for physical conditioning and/or body building.

Patient names

1. The names of patients have not been used in these reasons.  The patients have been identified by a number or a letter.  The patient's name and the corresponding number are found in Exhibit A Volume 5.

The Board's closing submissions

1. The Board's closing submissions were extremely thorough.  The Tribunal has largely adopted those submissions, particularly in relation to the identification of extracts from the evidence.

Onus and standard

1. The Board bears the onus of proof.  In Legal Profession Complaints Committee and Wells [2014] WASAT 112 at [8], the Tribunal stated:

   The Committee bears the onus of proof. It is to the civil, not criminal standard but the principles of Briginshaw v Briginshaw (1938) 60 CLR 336 (Briginshaw) apply.  That is, while needing to be proved only on the balance of probabilities, the nature and seriousness of the allegations are relevant to the question whether the issues are proved to the reasonable satisfaction of the Tribunal and the process by which reasonable satisfaction is attained.

2. By reason of the nature of the allegations, the Tribunal must feel an actual persuasion of the occurrence or existence of the relevant facts in determining whether or not the case against the practitioner is made out: Medical Board of Western Australia and Wright [2010] WASAT 48 at [31]; and see Medical Board of Western Australia and Bham [2006] WASAT 190 at [144], Rejfek v McElroy (1965) 112 CLR 517 (Rejfek).

3. In Briginshaw v Briginshaw (1938) 60 CLR 336 (Bringinshaw) at 362, Dixon J, as he then was, observed '[i]n such matters ''reasonable satisfaction'' should not be produced by inexact proofs, indefinite testimony or indirect inferences'.

4. The standard of proof required in a civil case where serious allegations are made was stated in Rejfek, where Barwick CJ, Kitto, Taylor, Menzies and Windyer JJ observed at 521 that:

   … The 'clarity' of the proof required, where so serious a matter as fraud is to be found, is an acknowledgment that the degree of satisfaction for which the civil standard of proof calls may vary according to the gravity of the fact to be proved …

   But the standard of proof to be applied in a case and the relationship between the degree of persuasion of the mind according to the balance of probabilities and the gravity or otherwise of the fact of whose existence the mind is to be persuaded are not to be confused[.]

5. In NOM v Director of Public Prosecutions (2012) 38 VR 618 at [124], the Victorian Court of Appeal stated:

   … Mere mechanical comparison and probabilities independent of a reasonable satisfaction will not justify a finding of fact.  The fact finder must feel an actual persuasion of the occurrence or existence of the fact in issue before it can be found.  Where, as in the present case, the standard of proof is to be applied to circumstantial evidence, satisfaction as to a reasonable and definite inference is required.

The Medical Practitioners Act

1. Section 76(1) of the Medical Practitioners Act provides that a 'disciplinary matter' arises when a respondent acts carelessly, incompetently or improperly for the purposes of the Medical Practitioners Act.

2. In Medical Board of Western Australia and Richards [2010] WASAT 94 at [26], the Tribunal considered the meaning of the expression 'acting carelessly' for the purposes of the Medical Practitioners Act:

   In our view, acting carelessly for the purposes of the MP Act still requires that the carelessness requires that the conduct complained of assumes a scale of gravity which is sufficiently serious to warrant, in the eyes of professional colleagues of good repute and competence, punishment and disciplinary action for the protection of the public. That is because s 76 is concerned with professional disciplinary proceedings. The objects identified in s 3 of the MP Act are designed 'for the purpose of protecting consumers of medical services'. … Acting carelessly involves, for the purposes of the MP Act, not giving sufficient attention or thought to avoiding harm or mistakes or showing no care or interest or effort in the treatment of a patient, but does not include trivial error not warranting disciplinary action.

3. In Jemielita v The Medical Board of Western Australia (unreported, WASC Library No 920584, 13 November 1992 (Jemielita), Owen J considered the meaning of incompetency in the context of the expression 'gross carelessness or incompetency' as used in the now repealed Medical Act 1984 (WA).  Owen J held that the concept of incompetency involves an unfitness to practise in a particular field of medicine or an inability to perform the techniques or judgments needed for the proper practice of medicine in that field, and that incompetency is usually suggestive of a generalised deficiency in the way in which a respondent handles his or her affairs rather than individual or sporadic shortcomings.

4. In Ong v The Dental Board of Western Australia (unreported, WASC, Library No 960442, 25 August 1995) (Ong), Murray J considered the meaning of the expression 'incompetence' in the context of the Dental Act 1939 (WA). His Honour referred to Jemielita, and continued:

   A case such as this will always involve a judgment about the standard of care and skill which, in the view of the Board, ought to have been brought to bear upon the treatment of the particular patient, in the particular field of professional discipline which was involved.  Carelessness in that regard rather implies the falling short of appropriate standards of care and skill on the particular occasion in question.  Incompetence in my opinion involves the view that such falling short of the proper standards of care and skill thought to be required on the occasion in question reveals a lack of knowledge or skill justifying an adverse judgment about the respondent's professional capacity or fitness to practice in the particular field of expertise involved.

5. In Medical Board of Australia and Bernadt [2012] WASAT 108, the Tribunal considered whether the expression 'incompetency' could relate to a single act. The Tribunal referred to Ong, and continued:

   Murray J's comments suggest that incompetency may be found in relation to a single act. That approach is consistent with the ordinary and natural meaning of the words of s 76(1)(b)(ii) which identifies a disciplinary matter where 'a person in the course of his or her practice as a medical respondent ... acted incompetently'. A person may act incompetently on a particular occasion, notwithstanding that they may not be found to be generally incompetent to practice medicine, either generally or in a particular field.

6. 'Improper' can be regarded as denoting conduct of the same kind as was contemplated by the term 'improper conduct in a professional respect' that appeared in the Medical Act 1894 (WA): Medical Board of Western Australia and Wolman [2011] WASAT 69.

7. In Cranley v Medical Board of Western Australia (unreported, WASC, Library No 8668, 21 December 1990) (Cranley) the term 'improper' was held to embrace conduct which would reasonably have been regarded as improper by professional colleagues of good repute and competence.

8. In Jemielita a distinction was articulated between carelessness and impropriety, in that the concept of 'gross carelessness' was found to involve 'unacceptable conduct without any intentional wrong doing on the part of the respondent'.  This distinction was approved in Medical Board of Western Australia and Alizadeh [2007] WASAT 52.

The National Law

1. Under s 196(1) of the National Law, the Tribunal may decide:

   a)Dr Singh has no case to answer and no further action is to be taken in relation to the matter; or

   b)relevantly, any one or more of the following ­

   i)Dr Singh has behaved in a way that constitutes unsatisfactory professional performance;

   ii)Dr Singh has behaved in a way that constitutes unprofessional conduct;

   iii)Dr Singh has behaved in a way that constitutes professional misconduct.

Professional misconduct

1. The term 'professional misconduct' is defined in s 5 of the National Law as conduct which 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[.]

2. The first and second limbs of the definition of 'professional misconduct' incorporate the term 'unprofessional conduct' which is in turn defined in s 3 of the National Law as:

   [P]rofessional conduct that is of a lesser standard than that which might reasonably be expected of the health practitioner by the public or the practitioner's professional peers[.]

3. The relevant authorities are set out in the reasons for decision of Health Care Complaints Commission v Bours (No 1) [2014] NSWCATOD  113 at [524]­[527]:

   Interpretation of the legislation is assisted by the body of common law in the area of professional disciplinary matters.  The classic common law definition of professional misconduct derives from Allinson v General Counsel of Medical Education and Registration (1894) 1 QB 755, namely:

   [Conduct] which could be reasonably regarded as disgraceful or dishonourable by his professional brethren of good repute and competency.

   The essence of this definition was restated by Priestley JA in Qidwai v Brown (1984) 1 NSWLR 100 at 105:

   ... whether the practitioner was in such breach of the written or unwritten rules of the profession as would reasonably incur the strong reprobation of professional brethren of good repute and competence[.]

   …

   Contemporary cases involving unsatisfactory professional conduct and professional misconduct primarily consider the wording of the relevant statute rather than the considerations of moral condemnation found in earlier decisions, expressing their views 'in terms of strong criticism'. (Lucire v Health Care Complaints Commission [2011] NSWSC 99; Donnelly v Health Care Complaints Commission (NSW) [2011] NSWSC 70).

Unprofessional conduct

1. Section 3 of the National Law provides that unprofessional conduct of a registered health practitioner means professional conduct that is of a lesser standard than that which might reasonably be expected of the health practitioner by the public or the practitioner's professional peers.

Unsatisfactory professional performance

1. The term 'unsatisfactory professional performance' is defined in s 5 of the National Law as meaning:

   [T]he knowledge, skill or judgment possessed, or care exercised by, the practitioner in the practice of the health profession in which the practitioner is registered is below the standard reasonably expected of a health practitioner of an equivalent level of training or experience[.]

The evidence

1. These allegations are to a large degree founded on documents obtained by the Board during the course of its investigations in response to various notices to produce issued to various parties, including Dr Singh.  These documents included:

   •the Morris Pharmacy dispensing history for Dr Singh (Exhibit A Volume 5);

   •Mckenzies Compounding Chemist dispensing history for Dr Singh (Exhibit A Volume 5);

   •clinical patient notes provided to the Board by Dr Singh on 30 April 2014 in response to a notice to produce, being 68,848 pages of notes, test results and correspondence contained on a USB drive; and

   •the evidence of Dr Singh.

2. It emerged during Dr Singh's evidence that Dr Singh was also referring patients to at least three other pharmacies, being Oxford Compounding Chemist, Friendlies Chemist in Leederville and a 777 Pharmacy in Applecross.  Dr Singh said that in the last few years Oxford Compounding Chemist has replaced Mr Balestra from the Morris Pharmacy as his primary referrer (T:59­61; 22.08.16).  The Tribunal's findings are based upon only a sample of Dr Singh's overall practice.  However, the sample provides a sufficient basis for the Tribunal's findings.

The experts

1. Expert evidence played a large role in the resolution of these proceedings.  The Board filed expert evidence from Professor Gary Wittert and Professor David Anthony Joyce.  Dr Singh filed expert evidence from Professor Sean Hood, Professor David Nutt and Professor Alistair Vickery.  Each of these professors also gave oral expert evidence.  A large part, though not all, of the evidence was given concurrently.

Professor Wittert

1. Professor Wittert was a highly qualified expert.  His curriculum vitae appears in Exhibit E, at page 539, and Exhibit A Volume 1, at pages 1-33.  Professor Wittert is a specialist physician with registration in General Medicine and Endocrinology.  He obtained his MBBch at the University of Witwatersrand, Johannesburg, in 1983.  He became a fellow of the Royal Australasian College of Physicians in 1992 and a fellow of the Royal College of Physicians, United Kingdom, in 2009.  He has an MD from the University of Otago awarded in 1994.

1. Professor Wittert is currently a Professor of Medicine (personal chair) at the University of Adelaide and head of the Discipline of Medicine at that University.  He is also head of the Freemason's Foundation Centre for Men's Health.  He practises as a Senior Consultant Endocrinologist at the Royal Adelaide Hospital and is the coordinator of the Endocrine Test Unit and the Obesity Clinic at that Hospital.  He has worked at both institutions continuously since 1994. 

2. Professor Wittert spends half a day a week in private practice.  He has particular expertise in the physiology and pathophysiology of stress, pathophysiology and management of obesity, physiology and use of androgens, disorders of sleep and their relationship to chronic disease.  He has published over 280 peer­reviewed publications, book chapters and expert reports.  In particular, he has published, or co-published, the following articles:

   53.Haren MT, Morley J, Chapman I, O'Loughlin P, Wittert G.  'Defining 'relative' androgen deficiency in aging men:  How should testosterone be measured and what are the relationships between androgen levels and physical, sexual and emotional health?'  Climacteric, (2002) 5(1):15-25

   54.Barton, C, March S, Wittert GA.  'The Low Dose Dexamethasone Suppression Test:  Effect of Time of Administration and Dose.'  J Endocrinol Inves, (2002) 25(4):RC10-2

   …

   61.Wittert G, Chapman I, Haren M, Mackintosh S, Coates P, Morley.  'Low dose oral testosterone supplementation increases muscle mass and decreases fat mass in healthy elderly males with low-normal gonadal status.'  J Gerontol, (2003) 58:618-25

   …

   69.Haren MT, Wittert GA, Chapman IM, Coates P, Morley JE.  'The effect of 12­months of oral testosterone supplementation on the cognitive function, mood and quality of life of healthy elderly males with low-normal gonadal status:  A randomised controlled trial.'  Maturitas, (Feb 2005) 50(2):124-133

   …

   71.Haren MT, Wittert GA, Chapman IM, Coates P, Morley.  'Effect of 12-month oral testosterone on testosterone deficiency symptoms in symptomatic elderly males with low-normal gonadal status.'  Age Ageing, (Mar 2005) 34(2):125-30

   …

   89.Martin DM, Wittert G, Burns NR.  'Gonadal steroids and visuo­spatial abilities in adult males implications for generalized age-related cognitive decline.'  Aging Male, (Mar 2007) 10(1):17­29,

   …

   93.Martin DM, Wittert G, Burns NR, Haren T.  'Testosterone and cognitive function in Ageing Men:  Data from the Florey Adelaide Male Ageing Study (FAMAS).'  Maturitas, (Jun 2007) 57(2):182­94

   …

   112.Martin DM, Burns NR, Wittert G.  'Free Testosterone Levels, attentional control, and processing speed performance in aging men.'  Neuropsychology, (Mar 2009) 23(2):158-67

   …

   118.Atlantis E, Martin SA, Haren MT, O'Loughlin PD, Taylor AW, Anand-Ivell R, Ivell R, Wittert GA and Members of the Florey Adelaide Male Aging Study.  'Demographic, physical and lifestyle factors associated with androgen status:  the Florey Adelaide Male Aging Study (FAMAS).'  Clinical Endocrinol (Oxf), (Aug 2009) 71(2):261-272,

   …

   134.Atlantis E, Lange K, Martin S, Haren MT, Taylor A, O'Loughlin PD, Marshall V, Wittert GA.  'Testosterone and modifiable risk factors associated with diabetes in men.'  Maturitas, (Mar 2011) 68(3):279-85,

   …

   156.Radathy A and Wittert G.  'Hypogonadism in man:  How to evaluate and when to treat.'  Modern Medicine, (Jan 2012) 13(1):47-49

   …

   174.Grossmann M and Wittert GA.  'Androgens, Diabetes and Prostate Cancer.'  Endocrine-Related Cancer.  2012 Sep 5;19(5):F47-62.  Oct 2012

   …

   188.Gates M, Mekary R, Chiu G, Ding E, Wittert G, Araujo A.  'Sex steroid hormone levels and body composition in men.'  J Clinic Endocrinol Metab.  (Jun 2013) 98(6):2442-50, PMID: 23626004

   …

   202.Atlantis E, Fahey P. Cochrane B, Wittert G, Smith S.  'Endogenous testosterone levels and testosterone supplementation therapy in chronic obstructive pulmonary disease (COPD): a systematic review and meta-analysis'.  BMJ Open.  (Nov 2013) 3(8):e003127, PMID: 23943774

   …

   225.Sato K, Samocha-Bonet D, Handelsman D, Fujita S, Wittert GA, Heilbronn LK.  'Serum sex steroids and steroidogenesis-related enzymes in skeletal muscle during experimental weight gain in men Diabetes & Metabolism' (Accepted March 2014)

   …

   259.Wittert GA.  'Sibutramine and Rimonabant:  Gone, but is their passing instructive?'  Controversies in Obesity, edited by Drs David Haslam, Arya Sharma and Carel le Roux

   260.Wittert GA.  'A Practical Approach to Obesity Management.'  Roche Press.  (2004)

3. Professor Wittert conducted a detailed review of about 240 of the 740 patient 'records' (see below).

4. Professor Wittert was the Board's principal expert witness.  He gave his evidence in a very clear and competent manner.  He demonstrated great command of the facts of this case and the relevant medical science.

Professor Joyce

1. Professor Joyce was a highly qualified expert.  His curriculum vitae appears in Exhibit E, at pages 621­623.

2. Professor Joyce holds the following qualifications:

   •Bachelor of Medicine, Bachelor of Surgery (MB BS) from the University of Western Australia 1976;

   •Fellow, Royal Australasian College of Physicians (FRACP) 1983; and

   •Doctor of Medicine (MD) from the University of New South Wales 1988.

3. Professor Joyce holds the following current appointments:

   •Professor of Medicine & Pharmacology at the University of Western Australia since 2010.  (He was a Senior Lecturer from 1987­1997 and an Associate Professor from 1997­2010);

   •Head, Department of Clinical Pharmacology & Toxicology and Consultant Physician at the Department of General Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia since 1987; and

   •Head, Clinical Pharmacology and Toxicology at Pathwest Laboratory Medicine, Nedlands, Western Australia since 2005.

4. Professor Joyce chairs the Clinical Drug Trials Committee of the Sir Charles Gairdner Hospital, which has the responsibility to assess whether there is sufficient evidence of benefit and risk to allow the use of novel drugs in experimental situations.  Under his chairmanship, the Committee makes risk­benefit assessments on an average of three to four new drug trial applications each month.  Professor Joyce personally makes a risk­benefit assessment for every one of these applications.

5. From 1989 until 2012, the Committee had responsibility for assessing applications made by medical practitioners for recognition as authorised prescribers for unregistered drugs, under s 19(5) of the Therapeutic Goods Act 1989 (Cth). The resulting recommendation was a basis for Therapeutic Goods Authority granting or withholding authorised prescriber standing.

6. Professor Joyce served, from time to time, on the Drug and Therapeutics Committee for Sir Charles Gairdner Hospital, providing advice on risk­benefit assessment for drugs that have been proposed for inclusion among the hospital's prescribable drugs.

7. Professor Joyce gave his evidence in a very clear manner.

Professor Hood

1. Professor Hood is a highly qualified expert.  His curriculum vitae appears in Exhibit O, at pages 319-339.

2. Professor Hood is a Medical Specialist (Consultant Psychiatrist) registered with the Medical Board of Australia.  He has practised as a medical practitioner since 1994; his medical degree was conferred by the University of Western Australia.

3. Professor Hood is a Fellow of the Royal Australian and New Zealand College of Psychiatrists (2004) and has unconditional registration and practice rights as a Psychiatrist in Western Australia and England.  He is a Professor in Psychiatry at the University of Western Australia.  Professor Hood is also an immediate past Chair of the Western Australian Psychotropic Drug Committee and Executive Member of the Western Australian Therapeutics Advisory Group.  He was a member of the North Metropolitan Human Research Ethics Committee in 2006.

4. Professor Hood provided one expert report, dated 21 June 2013 (Exhibit O Volume 2 Witness Statements, at pages 295-339), and took part in both of the joint expert conferrals referred to below.

5. Although Professor Hood is a highly qualified expert in psychiatry, his expertise for the purposes of these proceedings was essentially limited to two drugs, fluoxetine and sibutramine.  In his expert report at page 298, Dr Hood stated that Dr Singh's treatment for Patient J was appropriate.  In the course of his examination he made it clear that he was referring to Dr Singh's use of fluoxetine and sibutramine.  At the conclusion of the evidence, the allegations against Dr Singh in relation to fluoxetine and sibutramine were not pursued.

6. Dr Singh gave evidence that Patient J suffered from body dysmorphia syndrome with binge eating disorder.

7. Professor Hood's report considered the appropriateness of referring Patient J to a psychiatrist for treatment of the diagnosis of body dysmorphic syndrome with binge eating disorder (paragraph 3.5 at page 302). 

8. The Tribunal notes that it did not accept Dr Singh's diagnosis for Patient J.  Accordingly, Professor Hood's evidence was largely irrelevant.

9. Professor Hood was also a professional colleague of Dr Singh and worked at Dr Singh's clinic, the Empire Clinic, during some of the relevant period the subject of the allegations.  Professor Hood referred patients to Dr Singh and Dr Singh referred patients to him.  Despite Professor Hood's professional relationship with Dr Singh the Tribunal found him to be a credible expert witness.

Professor Nutt

1. Professor Nutt was a highly qualified expert.  His curriculum vitae appears in Exhibit R, at pages 363-377.

2. Professor Nutt is a Professor of Neuropsychopharmacology at Imperial College, London and an honorary Consultant Psychiatrist in the Central and Northwest London Mental Health Trust.  He has had a lifelong interest in the actions of drugs in the brain and has considerable preclinical and clinical research experience in the field.

3. Professor Nutt's clinical practice and research is in psychopharmacology.  For the past 25 years he has run a large teaching clinic in psychopharmacology treatment issues, especially for patients with depressive and anxiety disorders, addiction and sleep problems.  He has researched these illnesses and their drug treatments extensively and has published over 500 research papers as well as several hundred specialist reviews and 28 books in this field.

4. Between 1988 and 1992, Professor Nutt worked in the pharmaceutical industry and both before and since then, has conducted a great many volunteer studies of psychotropic drugs (mostly antidepressants and anxiolytics/hypnotics).  In addition, he has acted as consultant to many pharmaceutical companies with respect to experimental agents undergoing testing in phases 1, 2 and 3.  His group has been a clinical research centre in a number of trials of selective serotonin reuptake inhibitors and other new antidepressants in a depression and anxiety disorders and of new hypnotic agents and he has acted as principal investigator for some of these.

5. Professor Nutt provided one expert report, dated 15 May 2014 (Exhibit R Volume 2 Witness Statements, at pages 358-377), and took part in the joint conferral of November 2015.

6. Professor Nutt practises in the United Kingdom.  To the extent that he gave evidence of practice in Australia, he lacked experience in that practice.

7. Although Professor Nutt is a highly qualified expert in psychiatry, his expertise for the purposes of these proceedings was essentially limited to three drugs:  fluoxetine, sibutramine and diethylpropion.  In his expert report at page 360, Professor Nutt stated that Dr Singh's use of these drugs for the treatment for Patient J was appropriate.  At the conclusion of the evidence these allegations were not pursued. 

8. Dr Singh gave evidence that Patient J suffered from body dysmorphia syndrome with binge eating disorder.

9. Professor Nutt's report considered the appropriateness of referring Patient J to a psychiatrist for treatment of the diagnosis of body dysmorphic syndrome with binge eating disorder (paragraph 3 at pages 360-361). 

10. The Tribunal notes that it did not accept Dr Singh's diagnosis for Patient J.  Accordingly, Professor Nutt's evidence was largely irrelevant.

Professor Vickery

1. Professor Vickery is a general practitioner.  His curriculum vitae appears in Exhibit P at page 509 and pages 524­529.

2. Professor Vickery is a registered medical practitioner in Western Australia who is well qualified in general practice.  He has had a particular clinical interest in the management of obesity and has worked in the medical assessment and ongoing management and care of the co­morbidities of obesity in general practice, specialist practice and as a bariatric assessor for patients before and after bariatric surgery.  He graduated from the University of Western Australia with a Bachelor of Medicine and Surgery in 1985 and attained his Fellowship to the Royal Australian College of General Practitioners in 1996.  Professor Vickery has been working in general practice since 1988.  He is currently Professor of Primary Health Care at the University of Western Australia.  He continues to practice part­time as a general practitioner at the Gwelup Medical Practice and as an obesity assessor at the Mercy Bariatric Centre.  Professor Vickery is Chair of the first primary health care organisation in Western Australia, Panorama Health Network and Deputy Chair of the Postgraduate Medical Council of Western Australia and Chair of the Education Committee.

3. Professor Vickery's evidence was of very limited value.  He is a general practitioner and his Chair is in general practice.  He is neither qualified in internal medicine nor psychiatry, and although he has a part­time practice in obesity, his research and the majority of his practice is in primary health care and the delivery of health services to the community.  The expertise of the other experts far outweighs the expertise of Professor Vickery (T:175­176; 18.08.16).

4. Professor Vickery stated that he has known Dr Singh personally and professionally for the last 15 years.  He has been a patient of Dr Singh since 2002 and he worked alongside Dr Singh between 2004 and 2006 in the Metabolic Medicine Clinic in West Perth which was operated by Dr Singh.

5. Professor Vickery stated that he held Dr Singh in high regard as he had saved his life on two occasions and that he 'has a particular fondness for him' (T:176­177; 18.08.16).

6. Professor Vickery did not review the 740 patient records that were provided to him by Dr Singh's solicitors.  He described himself as obtaining a general gist of the structure of the notes and the sort of treatments that Dr Singh was prescribing.  His comments in relation to Dr Singh were based on his personal knowledge of and belief in him and his experience in working alongside Dr Singh rather than detailed analysis of the patient records  (T:180; 193­194, 197 and 240; 18.08.16).  Professor Vickery conceded that his 'independence was compromised in terms of Dr Singh' (T:179; 18.08.16).  Professor Vickery stated that he 'would have difficulty second-guessing [Dr Singh's] judgment' (T:241; 18.08.16).

7. Professor Vickery's expertise reflected the opinions and beliefs of Dr Singh rather than the opinions that he held independently.  When being cross-examined about human growth hormone, at a point where Dr Singh retracted his previous position that human growth hormone promoted lean muscle mass, Professor Vickery said that he too would change his view about human growth hormone based solely upon Dr Singh having changed his mind (T:250; 18.08.16).

8. The Tribunal is not satisfied that Professor Vickery has the requisite level of independence from Dr Singh to give expert evidence.

9. The Tribunal does not find that Professor Vickery's evidence was deliberately misleading.  He was simply too personally close to Dr Singh to give objective evidence.

10. The Tribunal has afforded Professor Vickery's expert evidence little or no weight.  The Tribunal has not addressed every point on which Professor Vickery has disagreed with Professor Wittert and Professor Joyce because it finds that Professor Vickery lacks the necessary expertise and independence to give expert evidence.

11. In reaching its conclusion, the Tribunal prefers the evidence of Professor Joyce and Professor Wittert over Professor Vickery.

The experts' joint conferral

1. Professors Wittert and Hood participated in a joint conferral of experts in November 2013.  The results of that conferral appear in Exhibit Q at pages 340­353.  Professor Yovich also participated in that conference but he was not called to give evidence and his contributions have not been relied on.

2. Professors Wittert, Joyce, Hood, Nutt and Vickery participated in a joint conferral of experts in November 2015.  The results of that conferral appear in Exhibit Q Volume 3, at pages 631-692.

3. The results of joint conferral were tabulated by reference to a series of questions and each of the expert's response, if any. 

4. The joint conferrals considerably narrowed the areas of difference between the experts.  The Tribunal is very grateful to each of the experts for the obvious time and effort they put into the joint conferrals, particularly Professor Wittert.

Dr Singh's evidence

1. Dr Singh was unrepresented at the hearing.  However, Clayton Utz acted for him until 5 July 2016.  His response to the grounds set out in the applications, his witness statement and the witness statements filed on his behalf, were all prepared during the time that Clayton Utz were acting for him.  Dr Singh cannot claim that he was not properly advised in the preparation of those documents as he had very capable and experienced legal representatives.

2. The ultimate findings of this Tribunal reflect a tragic fall from grace of a very well educated and experienced physician.

3. Dr Singh is plainly a highly qualified physician.  He obtained science degrees before commencing medicine.  He has two doctorates.  He was a Fellow of the Royal Australasian College of Physicians.  It was obvious from his evidence that he is highly intelligent.

4. It is appropriate at this point to deal in general terms with one of the principal allegations against Dr Singh, namely, that he was, in effect, prescribing drugs for physical conditioning and/or body building for non­therapeutic purposes (Board's CG paragraph 50).  Dr Singh denied that he prescribed drugs for non­therapeutic purposes, for example, in a letter Dr Singh wrote to the Board on 26 October 2009 (Exhibit A, at page 686) he stated 'I do not prescribe to body builders'.

5. In Dr Singh's written statements (Exhibit S Volume 1 Witness Statements, at pages 1­51 and 165-279), he nowhere concedes that he had prescribed drugs for body building purposes.  For example, he described his prescription of Methandrostenolone as being prescribed for its anabolic effects, particularly treatment of anaemia, osteoporosis, tissue breakdown and poor healing (Exhibit T Volume 1, at page 176, paragraph 46).

6. There is barely a hint in any of Dr Singh's witness statements that he was prescribing these drugs for physical conditioning and/or body building purposes.

7. Dr Singh's explanations as to why he prescribed those drugs to various patients are explained in his evidence in medical terms and with medical justifications.  However, the objective evidence does not support Dr Singh's explanations and paints a very different picture. 

8. The clearest example of a patient who was prescribed drugs for body building purposes by Dr Singh was Patient 71.  In his letter to the Australian Health Practitioner Regulation Agency (AHPRA) dated 20 July 2012 (Exhibit A, ABD Volume 3, at page 719), Dr Singh stated that (71) consulted him for obesity.  Photos of Patient 71 appear in Exhibit A Volume 3, at pages 588-611.  The photographs show a man who is a body builder and who is certainly not obese. Dr Singh treated Patient 71 over a number of years.  His prescription history is in Exhibit A Volume 5, at pages 1188­1195.  The prescriptions date from 15 January 2008 to 26 April 2013.  The photographs of Patient 71, particularly at page 588, from November 2007, and page 589, from Christmas 2007, that is, immediately prior to the commencement of the prescriptions in January 2008, show a man who is already a very developed body builder.  (71) was prescribed Stanozolol, Methandrostenolone, Primoteston, Sustanon, Deca­Durabolin, Oxandrolone, as well as the complementary body building drugs Clenbuterol and Clomid, in large quantities throughout 2008 to June 2013.

1. It is rarely that a witness cracks in the witness box and concedes the other party's case.  But crack, Dr Singh did.  The extent to which Dr Singh cracked is best set out in Dr Singh's own words:

   SINGH, DR:I was at the time, technically [Patient 71's steroid supplier], yes, prior to that he was getting it on the street …

   (T:96; 22.08.16)

   QUAIL, MR:And if we turn over the page, you continued to be his steroid supplier.  Page 591, this is how he looks in July of 2011.  592 is how he looks, same date, July 2011.

   SINGH, DR:Yes.    

   QUAIL, MR:Still suffering from sarcopenic obesity, is he?

   SINGH, DR:No, not then, he's a nut bag, I told you.

   QUAIL, MR:But you still kept supplying this nut bag with steroids -

   SINGH, DR:Yes, I did.

   (T:96; 22.08.16)

   SINGH, DR:So - I mean, I've seen those pictures.  What's your point?  Is he not allowed to receive - is there a law which says he cannot receive prescriptions from a doctor in anabolics? Who is to make the decision this is naughty or bad or illegal?  It's right - within his rights?

   QUAIL, MR:What therapeutic purpose were you supplying him with steroids for, Dr Singh?

   SINGH, DR: Therapeutic purpose, no conventional therapy.  Is there a law which says it's not allowed for that, it's not restricted, is it?

   HIS HONOUR:  That wasn't the question.

   SINGH, DR:Therapeutic?  Therapeutic?

   HIS HONOUR:  What was the therapeutic purpose?

   SINGH, DR:No conventional therapeutic treatment.

   QUAIL MR:Which unconventional therapeutic treatment was it?

   SINGH, DR:Keeping him off the streets and using illicit drugs.

   QUAIL, MR:Nothing more than that?

   SINGH, DR:No.  And to monitor - at least - okay.  To try and restrict his use, at least.  He - - -

   (T:97; 22.08.16)

   QUAIL, MR:In October of 2013 why were you still supplying this man with steroids?

   SINGH, DR:He was asking for a prescription, and knowing that he had used illicitly before I didn't - I think a doctor should, at least, take control and that way we don't, as it were - it's not prohibition that we are living with here, so there is no ­ ­ ­

   QUAIL, MR:Okay. So to keep him - -

   SINGH, DR:Yes.

   QUAIL, MR:To keep him off the streets and getting the drug illegally. ­ - -

   SINGH, DR:Well - - -

   QUAIL, MR:- - - you were happy to continue supplying him with it?

   SINGH, DR:I just did supply it, yes.  Whilst - it's not an S8, it's not a restricted agent.

   (T:98; 22.08.16)

   SINGH, DR:It's within his rights to ask for it and he, by doing it openly, he's - I'm not, you know, selling them.  And if he wants to take them that is his business, isn't it?

   QUAIL, MR:And that was the basis upon which you approached the prescription of steroids generally.

   SINGH, DR:No, just with him, but that's the point, it's not illegal.  I'm not doing anything that is. - - - forbidden.

   QUAIL, MRIf that is your philosophy to us, generally, and it must be your belief more generally than [Patient 71].  Your philosophy generally is it's better for you to supply the steroids - - -

   SINGH, DR:Yes.

   QUAIL, MR:- - - than for them to go out on the street and get them; yes?

   SINGH, DR:Yes.

   (T:99; 22.08.16)

   QUAIL, MR:All right. How many were there like [Patient 71]?

   SINGH, DR:I don't think too many.

   QUAIL, MR:For those reasons in relation to body building?

   SINGH, DR: I can't put a number to it.

   QUAIL, MR:More than 20?

   SINGH, DR:Probably.

   (T:100; 22.08.16)

2. Dr Singh then conceded that he was supplying steroids for body building for a large number of patients (T:101; 22.08.16)

3. Up until that point, all of his statements and all of his evidence had been directed to a therapeutic explanation for his prescription of those drugs.

Dr Singh's credit ­ other factors

1. The Board made the following submissions as to Dr Singh's credit generally, in addition to the purpose for which he prescribed drugs:

   (a)Dr Singh's witness statement in relation to his qualifications is not accurate.  Dr Singh accepted that his claim to have Masters of Science 'with first class honours' was not true as his academic record indicates his Masters degree resulted in him achieving a 'D Pass'.  In correspondence to solicitor Mr Massey in relation to [one of his Dr Singh's patients], Dr Singh erroneously asserted that he had a Bachelor of Science in Radioisotope Chemistry when he had a Diploma in Radioisotope Chemistry (Exhibit A page 726).

   (b)Dr Singh's approach to his qualifications and his recitation of them in his witness statement reflects his approach to practice generally, his note taking and his approach to these proceedings and the preparation of his witness statements.

   (c)In his evidence generally Dr Singh lacked recall on specific matters which only served to highlight the inadequacy of his note taking and unprofessional approach to practice generally.

   (d)In relation to his witness statements Dr Singh said on a number of occasions that they were not his words and sought to blame his solicitors while still agreeing that he had signed the statements as true. He essentially indicated that he had not read them closely nor paid attention to the detail, which is again reflective of his approach to his practice of medicine and record keeping generally.

2. The Tribunal accepts the Board's submissions as stated above.

3. In the light of Dr Singh's concession, and the other evidence, it became apparent that much of Dr Singh's evidence was deliberately untrue.  Normally, the Tribunal would consider the evidence Dr Singh gave as a medical practitioner and a physician and take it into account, in answer to the expert evidence of Professor Wittert and Professor Joyce.  However, this Tribunal has been unable to place any reliance on Dr Singh's evidence.  No scientific rationale advanced by Dr Singh can be safely relied upon by this Tribunal, given that he has persisted in untruths as to the basis for his prescribing.

4. Dr Singh sought to adopt various scientific studies when it suited him but rejected those that did not.  The following exchange in evidence is illustration of this:

   …

   SINGH, MR:    A judgment, clinical judgment and experience are superior to the pseudoscience we present as pharmacology now.  And - - -

   LESLIE, MS:Can you say that again.

   SINGH, MR:Clinical - - -

   LESLIE, MS:Give me that one again.

   SINGH, MR:Clinical judgment and experience in my ­ have more value in determining drug outcome than a published paper and I will give you one good example.  All psychiatric drugs generally - - -

   LESLIE, MS:I think you used an expression like the pseudoscience that is pharmacology - - -

   QUAIL, MR:The pseudoscience of pharmacology.

   SINGH, MR:Yes.  It is. It absolutely is pseudoscience.

   QUAIL, MR: s it a pseudoscience?

   WITNESS, JOYCE:     I fear for medicine in the hands of a practitioner who pays no respect to its history and its science. If I understand it correctly, what I'm hearing is that nothing that has ever been researched, scrutinised, proven, rescrutinised and, found to still stand, has to be disregarded in favour of some pre­hippocratic shamanistic practice.

   (T:245­246; 18.08.16)

Grounds relating to Dr Singh's general practice

1. It is convenient to consider the allegations in relation to Dr Singh's general practice first as the matters raised in relation to Dr Singh's general practice are also relevant to his specific conduct in relation to each of Patient J and Patient B.

The use of a combination of anabolic androgen steroids and other drugs in body builders

1. In order to put the evidence that follows in context, it is useful to explain the reason for the use by body builders of a combination of drugs in association with androgen anabolic steroids.  Professor Wittert's evidence was:

   The prescription of concurrent and/or sequential use of various anabolic androgenic steroids as appears to be the case in the clinical notes for the patients listed above is typical of the pattern of use of these drugs by body builders.  That often occurs with the concurrent or subsequent administration of drugs that block the production or action of oestrogen (Tamoxifen, anastazole and clomiphene [Clomid]) and others such as HCG [Human Chorionic Gonadotropin] that stimulate the production of testosterone more directly in order to overcome the effects of the large doses of anabolic androgenic steroids to suppress the normal production of testosterone by the body.

   (Exhibit D Volume 2, at page 382)

2. Professor Wittert's explanation is consistent with Dr Singh's explanation of the basis of his prescribing practice for anabolic androgen steroids and associated drugs made after his concession that he was prescribing for body building purposes.

   QUAIL, MR:Why body builders would be using multiple steroids in the combinations that they do, and in the combination you prescribe them?  What's the hypothesis behind that?

   SINGH, DR:Because excess - well, androgens can convert to oestradiols, you have to (indistinct) with that.  They can also shut down endogenous production so you want to not shut that down, and in case of some people it can increase blood pressure, so that's why trandolapril, and aromatase inhibitors to keep oestradiol levels low.  Clomid to treat hypogonadism.  And Proviron I don't use any more. Methasterone I don't use, and - what was the other one? Oxandrolone I used for burns, autoimmune problems, that sort of stuff. But the reason is, I suppose, to balance the - to limit the side-effect profile and to allow a lower dose of androgens with a wider integral between them.

   …

   QUAIL, MR:Right.  In some of your notes in relation to various of those patients you reveal an awareness of their being involved in body building competitions and preparing for competition.

   SINGH, DR:Yes.

   …

   QUAIL, MR:All right. So were you assisting your body builder patients in cycling and preparing for - - -

   SINGH, DR:I would advise them, yes.

   QUAIL, MR:-     - - - competitions.

   SINGH, DR:I would advise them.

   QUAIL, MR:In how to go about taking steroids - - -

   SINGH, DR:To avoid the side effects.

   QUAIL, MR:- - - in order to minimise the side effects?

   SINGH, DR:Yes, and they do it safely.

   QUAIK, MR:And a number of the drugs you prescribed concurrently with the steroids were for the purposes of counteracting some of the side effects?

   SINGH, DR:Yes, some of them, yes.

   QUAIL, MR:So what drugs would you prescribe to counteract the effect of the steroids?

   SINGH, DR:Tamoxifen.

   QUAIL, MR:What was the Tamoxifen to - - -

   SINGH, DR:Block oestradiol.  Arimidex, aromatase inhibitor.

   QUAIL, MR:Just if you can tell us what it actually - - -

   SINGH, DR:Blocks oestradiol synthesis.

   QUAIL, MR:Yes.

   SINGH, DR:What was - - -

   QUAIL, MR:So blocking what, preventing - or hoping to prevent what?

   SINGH, DR:Conversion of testosterone to oestradiol, yes.

   QUAIL, MR:All right.  So in other words to head off gynecomastia in men.

   SINGH, DR:Gynoid fat, gynecomastia, yes.  Water retention. Arimidex has - reduces the oestradiol level and it is the reduced oestradiol level that feeds back on the hypothalamus to keep FSH LH going so you don't shut down pituitary function.  Trandolapril is an ace inhibitor to maintain systolic blood pressure, yes.  Crestor is a statin to reduce the bad lipids - sorry, the LDLs.  What else?  What else?  Any other ones you want to ask me about?

   …

   QUAIL, MR:Yes, the human growth hormone, what's that for?

   SINGH, DR:Human growth hormone would repair tissue, collagen repair, tendons, ligaments, that sort of thing, and - - -

   QUAIL, MR:Yes, but in the context of these guys, like, up on the screen at the moment, [Patient 71], in terms of the body building what do they want the growth hormone for?

   SINGH, DR:If they have a mismatch between the tensile strength of muscle and ligament; right.  So there's a mismatch six to one between tensile, so muscle can generate a huge forces, but is elastic, whereas tendon is inelastic and can't sustain as much force in - as the muscle will generate, so the GH allows the tendon to repair more quickly so you don't get tendon ruptures.

   QUAIL, MR:Right.

   SINGH, DR:And repair of collagen because they ­ collagen is (indistinct) and around your cell, so, you know, post workout soreness that sort of thing, and activating lipolysis.

   LESLIE, MS:But that's nothing to do with side effects, that's balancing the tendon and ligament strength to the increased muscle capacity - - -

   SINGH, DR:Yes.

   LESLIE, MS:- - - that in other steroids that they're using - - -

   SINGH, DR:And it's thought that - - -

   LESLIE, MS:- - - are allowing.

   SINGH, DR:- - - the androgens may soften, as it were, the ligament as well, but that's debate about that.  But it seems that if they just use androgens on their own they do get more ruptures of biceps, tendons, that sort of thing.  So in general ligament repair, so collagen is ligaments, aponeuroses, and expansions of superficial ligaments as well.

   …

   (T:104­108; 22.08.16)

Dr Singh's general practice ­ prescribing

1. The fact that Dr Singh prescribed the drugs and treatments the subject of these proceedings was not in issue.  A summary of the relevant prescriptions is contained in Exhibit A Volume 5.  Dr Singh's very proper concession of the fact that he prescribed the drugs and substances saved the Tribunal significant time at the hearing.

2. The Board alleged that from early 2008 Dr Singh engaged in a general practice of prescribing to patients who consulted him seeking weight loss, physical conditioning and/or body building:

   1)Anabolic androgenic steroids including Oxandrolone, Stanozolol, Methandrostenolone, Primoteston Depot and Methenolone;

   2)Clenbuterol; and/or

   3)Ephedrine and capsules combining Ephedrine, Aspirin and Caffeine (EAC),

3. in circumstances in which there was no proper therapeutic indication or reason for the use of those drugs or substances by the patients for whom they were prescribed and it unnecessarily exposed patients to the adverse effects of those substances or drugs.

4. The Board further alleged that from early 2008, Dr Singh engaged in a general practice of prescribing Clomid to patients who consulted him seeking weight loss, physical conditioning and/or body building in contravention of reg 38C of the of the Poisons Regulations 1965 (WA) (Poisons Regulations) made pursuant to the Poisons Act1964 (WA) (Poisons Act).

5. The Tribunal notes that, although the Board's allegations as to Clomid related to a breach of reg 38C of the Poisons Regulations, it is in fact part of the suite of drugs prescribed to prevent the side effects of anabolic androgenic steroids.

   Initially, Dr Singh denied that he prescribed anabolic androgenic steroids, Clenbuterol, Ephedrine and EAC and Clomid in circumstances in which there was no proper therapeutic indication or reason for the use of those drugs.  In Dr Singh's response (SR), he stated that the rationale for treating patients using those drugs fell into one or more of the following categories:

   (i)sarcopenic obesity;

   (ii)opposing the catabolic effect of glucocorticoids, for example asthma, chemotherapy, IBD, autoimmune disease;

   (iii)immune deficiency:  C1 esterase deficiency;

   (iv)hypogonadotropic hypogonadism;

   (v)dysautonomia;

   (vi)osteoporosis/osteopenia;

   (vii)anaemia;

   (viii)wasting diseases, for example HIV, malignancy, malabsorption;

   (ix)obesity and hypogonadism in females taking the oral contraceptive pill;

   (x)over-training syndrome;

   (xi)risk minimisation in athletes;

   (xii)illicit narcotic and amphetamine induced cachexia;

   (xiii)poor post-operative healing;

   (xiv)protein losing enteropathy;

   (xv)severe refractory depression;

   (xvi)idiopathic hypovolemia;

   (xvii)hypereosinophilia;

   (xviii)cancer cachexia;

   (xix)impotence;

   (xx)myalgic encephalomyelitis (chronic fatigue ­ hyperelastic variant)

   (xxi)severe proximal myopathy secondary to low testosterone, thyroid disease, overuse of glucocorticoids and myositis.

   (SR paragraph 51(f))

6. The Board further alleged that from early 2008, Dr Singh engaged in a general practice of prescribing

   1)human growth hormone;

   2) Sibutramine;

   3)Tamoxifen;

   4)Anastrozole;

   5)Testosterone;

   6)Midodrine;

   7)Fludrocortisone; and

   8)Erythropoietin,

7. when there was no proper therapeutic indication or reason for their prescription and it unnecessarily exposed patients to the adverse effects of those substances or drugs.

8. The Board further alleged that from early 2008, Dr Singh engaged in a general practice of ordering the infusion of iron for patients:

   1)who did not suffer from any iron deficiency; and/or

   2)in circumstances in which the infusion of iron was contra­indicated for patients because the patients suffered from haemochromatosis or beta­thalassaemia trait.

9. The Board further alleged that from early 2008, Dr Singh engaged in a practice of ordering fresh frozen plasma infusions for patients when there was no recognised therapeutic indication for such infusions in those patients.

10. The Board further alleged that from early 2008, Dr Singh engaged in a general practice of ordering DEXA scans when there was no recognised therapeutic indication for the performance of any such scans or alternatively, for the performance of multiple such scans, of those patients.

11. Dr Singh, in his SR, essentially denied that he engaged in a general practice of prescribing drugs or ordering substances or scans when there was no recognised therapeutic indication for prescribing those drugs or ordering those substances and denied that the quantities he prescribed or ordered exposed patients to the risk of adverse effects.

Anabolic androgen steroids

Therapeutic indications ­ the expert evidence

1. Professor Wittert's opinion was that the therapeutic indication for the prescription of anabolic androgenic steroids is for men with hypogonadism (low blood testosterone level) with symptoms present due to a pathological condition affecting the mechanisms regulating testosterone production.  In his opinion there are no recognised indications for taking combinations of anabolic steroids (Exhibit Q Volume 3 at page 640).

2. Professor Joyce agreed with Professor Wittert (Exhibit Q Volume 3, at page 640).

3. Professor Vickery did not agree with Professor Wittert.  In his opinion, short term use of anabolic steroids to treat sarcopenic obesity by increasing muscle mass is indicated (Exhibit Q Volume 3 at page 640). 

4. Professor Wittert's evidence was that the patient records he examined did not support a diagnosis of any patients with sarcopenic obesity (T:184; 18.08.16).

5. The Tribunal prefers and accepts Professors Wittert's and Joyce's evidence as to the therapeutic indications for the prescription of anabolic androgen steroids.

Adverse effects

1. The Board alleged that Dr Singh's prescription of anabolic androgenic steroids for his patients had the potential to cause, induce or exacerbate the following potential adverse signs and symptoms related to use of those drugs:

   •hepatotoxicity;

   •altered glucose tolerance;

   •hypercalcemia;

   •polycythaemia;

   •aggressive behaviour;

   •withdrawal symptoms;

   •sodium retention;

   •oedema; 

   •hypertension;

   •impaired renal function;

   •hypertension;

   •increased LDL cholesterol;

   •in men ­ gynaecomastia, impotence, testicular atrophy, priapism, inhibition of spermatogenesis, degenerative changes in seminiferous tubules and abnormal androgen levels; and

   •in women ­ amenorrhoea, clitoral enlargement, voice changes; virilisation and hirsutism.

   (Board's CG paragraph 51)

The expert evidence on the potential adverse effects of using anabolic androgen steroids

1. Professor Wittert's opinion as to the potential adverse effects of using anabolic steroids in his report dated 20 October 2014 was:

   Anabolic/androgenic steroids cause disease of the blood vessels and/or heart by number of mechanisms which include abnormalities in blood fats, increased clotting, abnormalities of the blood vessel wall, rhythm and other electrical abnormalities and disordered function of cardiac muscle; abnormalities of the normal reproductive axis including suppression of the normal ability to make testosterone, testicular atrophy, disturbances of sex drive, the development of breast tissue, and decreased fertility; changes to mood and behaviour as well as responsiveness to stress that may persist even after use has been discontinued; liver damage; acne and accelerated balding; increased risk of injuries to tendons; periodontal disease.

   Men seeking anabolic steroids may be doing so as a result of body dysmorphia, a condition which requires appropriate counselling and referral to a suitably qualified psychiatrist or psychologist.  The continued provision of anabolic steroids to a person with body dysmorphia fails to treat the underlying cause of the patient seeking these drugs, and is likely to lead to ongoing abuse of anabolic steroids to the detriment of the patient's health.

   (Exhibit D at page 81)

1. Professor Wittert stated that the risk of adverse effects of prescribing anabolic androgen steroids is, in general, low when treatment, in conjunction with testosterone, is initiated in accordance with appropriate therapeutic indication.  He said that the adverse effects under these circumstances are most commonly elevation of haematocrit.  When used outside of these indications or in large doses or in combinations, the risks are as stated above (Exhibit Q Volume 3 at page 641). 

2. Professor Joyce's opinion in his written report dated 2 October 2015 (Exhibit E Volume 3 Witness Statements, at pages 579­581) as to the potential adverse effects of anabolic androgen steroids was:

   The adverse effects of Primoteston Depot that are listed in TGA­approved product information are representative of the adverse effects that might be seen during treatment of male androgen deficiency with conventional therapeutic doses (Therapeutic Goods Administration, 2015).  The section reads:

   'The most commonly reported adverse reactions with Primoteston Depot are injection site pain, injection site erythema, and cough and/or dyspnoea during or immediately after the injection.

   Injections of oily solutions such as Primoteston Depot have been associated with systemic reactions:  cough, dyspnoea and chest pain.  There may be other signs and symptoms including vasovagal reactions such as malaise, hyperhidrosis, dizziness, paraesthesia or syncope.

   High-dosed or long-term administration of testosterone, including Primoteston Depot, increases the tendency to water retention and oedema.

   Spermatogenesis is inhibited by long-term and high-dosed treatment with Primoteston Depot.

   If, in individual cases, frequent or persistent erections occur, the dose should be reduced or the treatment discontinued in order to avoid injury to the penis.

   Various skin reactions including injection site reactions (injection site pain, injection site erythema, injection site induration, injection site swelling, injection site inflammation) may occur.

   Other events reported with Primoteston Depot include benign and malignant liver tumours, polycythaemia, hypersensitivity reactions, liver function test abnormalities, jaundice, acne, alopecia, rash, urticarial, pruritus, Prostatic Specific Antigen (PSA) increase, libido increase, libido decrease and gynaecomastia.

   As with other testosterone-containing products, the use of Primoteston Depot may commonly cause an increase in haematocrit, red blood cell count or haemoglobin.

   Increased hair growth has been reported under treatment with testosterone-containing preparations.

   Regarding adverse effects associated with the use of androgens, please also refer to PRECAUTIONS'.

   The relevant sections of PRECAUTIONS then read:

   'Older patients treated with androgens may be at increased risk for the development of prostatic hyperplasia.  Androgens can enhance the growth of an existing prostatic carcinoma.  Therefore, carcinoma of the prostate has to be excluded before starting therapy with testosterone preparations.

   As a precaution, regular examinations of the prostate are recommended.  Haemoglobin and haematocrit should be checked periodically in patients on long-term androgen therapy to detect cases of polycythaemia (see ADVERSE EFFECTS).

   Cases of benign and malignant liver tumours, which may lead to life-threatening intraabdominal haemorrhage, have been observed after the use of hormonal substances such as the one contained in Primoteston Depot.

   The doctor must therefore be informed of the occurrence of unusual upper abdominal complaints which do not disappear spontaneously within a short time as it may then be necessary to withdraw the preparation.  A hepatic tumour should be considered in the differential diagnosis when severe upper abdominal pain, liver enlargement or signs of intra-abdominal haemorrhage occur in men using Primoteston Depot.  Caution should be exercised in patients predisposed to oedema.  e.g. in case of severe cardiac, hepatic, or renal insufficiency or ischaemic heart disease, as treatment with androgens may result in increased retention of sodium and water.  In case of severe complications characterised by oedema with or without congestive heart failure, treatment must be stopped immediately (See ADVERSE EFFECTS).

   Testosterone may cause a rise in blood pressure and Primoteston Depot should be used with caution in men with hypertension.

   Primoteston Depot must not be used in women, due to possible virilising effects.

   Pre-existing sleep apnoea may be potentiated'.

   Similar adverse risks and precautions are listed for other registered androgenic steroids.

   The TGA-approved product information covers anticipated outcomes and risks when the androgenic steroids are used in conventional therapeutic doses in male androgen deficiency.

   When androgenic steroids are used at doses that exceed replacement doses, the incidence and severity of the above-mentioned adverse effects will increase.  Additionally, psychiatric adverse effects may emerge, principally manifesting as aggression, uncontrolled anger and rage.  The risk of serious outcomes from the cardiovascular adverse effects (lipid derangements, hypertension and polycythemia) increases, with outcomes that include myocardial infarction, cardiac muscle changes and strokes.  Prominent breast development and testicular shrinkage may be particular concerns for the male user, leading to adjunctive treatment with drugs such as tamoxifen and clomiphene to counter them.

   The C17-alpha alkylated androgenic steroids carry an increased risk of liver tumours and other liver toxicity, compared with testosterone.   Oxandrolone is one such drug.  It is not registered for use in Australia.

3. Professor Joyce identified the risks as:

   •water retention

   •psychiatric disturbances

   •spermatogenesis inhibition

   •polycythaemia

   •liver abnormalities

   •jaundice

   •acne

   •alopecia

   •gynaecomastia

   •increased blood pressure

   •lipid derangement

   •increased myocardial infarction risk

   •benign and malignant tumour risk

   (Exhibit Q Volume 3 at page 641)

4. Professor Vickery's opinion in his report dated 16 April 2015 in relation to Patient J as to the risk of adverse effects of taking androgen anabolic steroids was that there has not been shown to be a substantial risk with this combination in the short­term (Exhibit P Volume 2 Witness Statements, at pages 508-529 at 513). 

5. Professor Vickery's opinion was that the risks of such prescription in short term corrective doses are minimal and limited (Exhibit Q Volume 3 at page 641).

6. The Tribunal prefers and accept the evidence of Professors Wittert and Joyce on the adverse effects of androgen anabolic steroids. The Tribunal finds that the prescription of androgen anabolic steroids other than in accordance with the therapeutic indications identified by Professor Wittert exposes patients to the adverse effects identified by Professors Wittert and Joyce.

7. The Tribunal accepts that there were in fact adverse effects as set out in Dr Wittert's report, for example, Patient 251.

The evidence in relation to the prescription of anabolic androgen steroids to Dr Singh's patients

1. Patients who were prescribed anabolic androgenic steroids over long periods of time included:

   Patients 46, 52, 62, 68, 71, 74, 88, 114, 122, (128), 173, 202, 204, 213, 261, 297, 341, 351, 385, 402, 426, 436, 453, 476, 504, 514, 567, 594, 596, 612, 635, 658, 662, 693, 714, 715, 740 and 741.

2. When cross-examined about the above patients, Dr Singh agreed that all except Patients 114, 202 (in whom Dr Singh said he could not recall the reason for treatment), 261 and 476 were prescribed steroids by him for the purposes of body building. 

3. On 7 February 2012, APHRA sent a notice to Dr Singh requiring the provision of information pursuant to the National Law (Exhibit A Volume 3, at page 664).  Information was requested in relation to Patients 71, 46, 594, 619, 714, 64, 46, 376 and 152.  In Dr Singh's letter to APHRA dated 20 July 2012, he stated that each of those patients attended him generally with the primary or secondary problems of sarcopenic obesity or sarcopenia of other cause.  He went on to identify his diagnosis of individual patients as follows:

   (71)obesity

   (173)for 'chronic fatigue and weight loss'

   (594)notes lost in change of premises ­ improve physical conditioning

   …

   (46)for chronic fatigue, body building and osteopaenia.

4. During the course of the cross-examination, Dr Singh also agreed that numerous other patients referred to below were prescribed anabolic steroids and related drugs for body building.  They included:

   1)Patient 402, who also worked at the Empire Clinic, who had a long history of abuse of illicit drugs according to the clinical notes and Dr Singh's evidence;

   2)Patient 635, who Dr Singh initially agreed was there for body building purposes then later denied was, and about whom a detailed letter in Patient 635's patient notes was put to Dr Singh.  The letter and related photographs (Exhibit U) clearly show that at the time of his treatment Patient 635 was preparing for a body building competition, or at least a body physique competition.

   3)Patient 410;

   4)Patient 407;

   5)Patient 59;

   6)Patient 421;

   7)Patient 684;

   8)Patient 418;

   9)Patient 505, who Dr Singh acknowledged in cross­examination he knew was a former professional body builder who now runs the International Federation of Body Building in Western Australia and runs a gym in East Perth; and

   10)Patient 426, who during cross-examination Dr Singh agreed when Patient 426 first came to see him, his colleagues were concerned about his aggressive behaviour and he was also involved in a motorcycle gang.  Nonetheless, Dr Singh prescribed him anabolic steroids, again essentially for body building reasons.

   There were adverse effects from Dr Singh's prescription to Patient 251 for Oxandrolone, Clenbuterol, Primoteston, Clomid, Stanozolol, Sustanon and Methandrostenolone between October 2009 and August 2011.  Ultimately in 2012, Patient 251 required surgery for gynaecomastia.  Dr Singh's response in his evidence was to say that the Board could not prove that the gynaecomastia was caused by steroid use but could have been caused by the patient's marijuana use.  All that this does is serve to heighten the inappropriateness of the prescription for steroids in the first place if in fact Dr Singh knew that the patient was using marijuana and if Dr Singh believed that marijuana use could cause gynaecomastia.

5. Patients who received large doses of anabolic androgenic steroids at one consultation included:

   i)Patient 43, to whom Dr Singh gave a prescription (or repeat prescriptions) for 18 Primoteston injections at one consultation;

   ii)Patient 71, to whom Dr Singh gave a prescription (or repeat prescriptions) for 500 Oxandrolone capsules, 21 Primoteston ampules and 60 Stanozolol troches at one consultation;

   iii)Patient 287, in relation to who Dr Singh's clinical notes record 'Friend of [D].  Naughty boy.  Wants to get buff by April.'

   iv)Patient 359, who told Dr Singh that he competed in a body building competition the previous year and who Dr Singh gave a prescription (or repeat prescriptions) for 15 ampoules of Primoteston at one consultation;

   v)Patient 380, to whom Dr Singh gave a prescription (or repeat prescriptions) for 12 ampoules of Primoteston at one consultation; and

   vi)Patient 532, who told Dr Singh he worked out with weights six days a week and was there to 'look good', and who Dr Singh gave a prescription for six ampoules of Primoteston at one consultation.

6. In relation to Methandrostenolone, Dr Singh's evidence in his witness statement dated 17 February 2016 at paragraphs 46 and 47 was that:

   I used to prescribe Methandrostenolone for its anabolic effects, particularly treatment of anaemia, osteoporosis, tissue break-down and poor healing.

   I ceased prescribing Methandrostenolone some years ago because I found it was sometimes associated with mild liver dysfunction and sodium retention.

7. The clinical notes record that a large number of patients were prescribed Methandrostenolone with either no record of any reason for the prescription and with no record that the patient was anaemic or had osteoporosis, tissue break­down or poor healing, including (but not limited to):

   Patients 15, 16, 46, 61, 64, 68, 71, 74, 95, 98, 101, 113, 122, 123, 128, 130, 151, 159,162, 166, 161, 173, 201, 202, 436 and 490.

8. In relation to Methenolone, Dr Singh's evidence in his statement dated 17 February 2016 at paragraphs 49­53 was that:

   I rarely prescribe Methenolone.

   It is a very mild anabolic and the androgenic activity is almost completely absent.  It is sometimes useful in treating cases of cancer cachexia, AIDS and prolonged post-operative convalescence.

   Methenolone does not aromatise to oestrogen.

   I usually prescribe Methenolone at a starting dose of approximately 25mg alternate daily once or twice a week.

   In my experience, this medication has minimal side effects and therefore is particularly useful in women.

9. The clinical notes did not record any examples of occasions on which Dr Singh had prescribed Methenolone to any women, cancer patients, AIDS patients or post-operative patients (based on available clinical and pharmacy records).  Dr Singh had prescribed Methenolone to:

   i)Patient 410, who was prescribed Methenolone when his reason for presentation was 'Here to gain size' and he was employed as a 'protein rep and personal trainer' and who in cross-examination Dr Singh agreed was a body building patient; and

   ii)Patients 68, 71, 541, 567, 568 and 663 were also prescribed Methenolone when none of the medical conditions mentioned by Dr Singh were present.

10. In relation to Oxandrolone, Dr Singh's evidence in his witness statement dated 17 February 2016 at paragraphs 55­57 was that:

    I use Oxandrolone to treat muscle catabolism or break-down in a variety of settings, such as wasting diseases, disuse atrophy or where catabolism has occurred as a result of low testosterone levels.

    It is my usual practice to prescribe Oxandrolone at a starting dose of approximately 5mg usually alternate daily or twice weekly only.  For women, the dosages are sometimes even less than this.

    In my experience, Oxandrolone at this dose is not associated with significant adverse side-effects and has a good safety profile (so much so that it used to be commonly used in female children with third degree burns for its anabolic effect).  In my experience, Oxandrolone is safe to use in both females and children because of its lack of androgenic effects and relative weakness.  I sometimes use Oxandrolone in males or females for treatment of severe allergies due to C1 esterase deficiency, protein losing enteropathy, nephrotic syndrome, malnutrition due to cancer treatment, celiac disease and anorexia nervosa.

11. Dr Singh did not state in his witness statement that he also used Oxandrolone for his body building patients.

12. The prescription records and patient records note the following:

    (i)(10) female patient prescribed Oxandrolone 10mg daily after gastric sleeve surgery.

    (ii)(24) female patient prescribed Oxandrolone 10mg every second day because of 'overtraining'.

    (iii)(25) female patient prescribed Oxandrolone 10mg every second day (reason for prescription not apparent from notes).

    (iv)(26) prescribed Oxandrolone 20mg daily.

    (v)(45) female patient prescribed Oxandrolone 10mg daily (reason for prescription not apparent from notes).

    (vi)(60) female patient prescribed Oxandrolone 10mg every second day (reason for prescription 'This definitely increases the red cell synthesis and also is a known androgenising anabolic'.)

    (vii)(62) prescribed Oxandrolone 20mg daily (od = once daily) (reason for prescription not apparent from notes).

    (viii)(65) female patient prescribed Oxandrolone 10mg daily.  Weight loss patient, reason for prescription not explained in notes.

    (ix)(82) female patient prescribed Oxandrolone 10mg daily to increase red cell mass.

    (x)(88) prescribed Oxandrolone 20mg daily (with other AAS).  Reason for presentation 'To get advice on diet, training and to be the best he can'.  Patient 'Runds (sic) most mornings, Weights 5 x / week, Attends strenght (sic) training gym' ­ 'shredded strength institute'.

    (xi)(116) female weight loss patient prescribed Oxandrolone 10mg daily.

    (xii)(146) female weight loss patient prescribed Oxandrolone 10mg daily.

    (xiii)(148) female weight loss patient prescribed Oxandrolone 10mg every second day.

    (xiv)(152) female weight loss patient prescribed Oxandrolone 10mg daily post sleeve gastrectomy.

    (xv)(157) female patient prescribed Oxandrolone 10mg daily (reason for prescription not explained in notes).

    (xvi)(169) female patient prescribed Oxandrolone 10mg daily 'to block catabolic effects of Reductil'.

    (xvii)(171) female weight loss patient prescribed Oxandrolone 10mg daily 'because with initial weight loss programs there is often loss of skeletal muscle'.

    (xviii)(201) female weight loss patient prescribed Oxandrolone 10mg daily.

    (xix)(205) described by Dr Singh as 'a fit athletic young man' prescribed Oxandrolone 20mg daily (with other AAS and HGH).

    (xx)(215) female weight loss patient prescribed Oxandrolone 10mg every second day.

    (xxi)(218) female weight loss patient prescribed Oxandrolone 10mg daily.

    (xxii)(246) female weight loss patient prescribed Oxandrolone 10mg daily.

    (xxiii)(261) prescribed Oxandrolone 10mg daily (reason for prescription not apparent from notes).

    (xxiv)(302) female patient prescribed Oxandrolone 10mg daily.

    (xxv)(314) prescribed Oxandrolone 20mg daily.

    (xxvi)(342) female weight loss patient prescribed Oxandrolone 10mg daily.

    (xxvii)(343) female weight loss patient prescribed Oxandrolone 10mg daily.

    (xxviii)(353) female patient prescribed Oxandrolone 10mg every second day. [(353)] developed very elevated testosterone.

    (xxix)(374) female weight loss patient prescribed Oxandrolone 10mg daily.

    (xxx)(399) 'Here as always feels tired, states no strength, low libido, trains hard but poor results, wants a lean muscular appearance, carrying excess weight' prescribed Oxandrolone 20mg daily.

    (xxxi)(552) female patient prescribed Oxandrolone 10mg daily.

13. The available clinical notes did not record any examples of occasions on which Dr Singh had prescribed Oxandrolone 5 milligrams alternate daily or twice weekly (10mg to 15mg per week, less for females).  The available clinical notes record that the actual doses prescribed were a minimum 10 milligrams every second day (35 milligrams per week) up to 20 milligrams per day (140 milligrams per week).  Doses prescribed up to nine times higher than Dr Singh's witness statement suggests.

14. When Dr Singh's prescribing practices were put to him, Dr Singh sought to justify the contents of his written statement that the dosage identified in his written statement referred to a starting dose.  If it was only a starting dose then his statement was incomplete and it was misleading not to state his usual dose.  His statement as to the low risk of adverse effects was put in the context of the dose he stated in cross­examination as a 'starting dose'. 

15. In relation to Stanozolol, Dr Singh's evidence in his witness statement dated 17 February 2016 at paragraphs 58­62 is that:

    Stanozolol is an anabolic steroid.  I have found it particularly useful to increase red cell production in those who have anaemia that is refractory to treatment with just EPO alone.

    I also use Stanozolol in the treatment of conditions similar to that of Oxandrolone, including in the treatment of severe allergies due to C1 esterase deficiency, protein losing enteropathy, nephrotic syndrome, malnutrition due to cancer treatment and celiac disease and anorexia nervosa.

    Depending on the patient, I use Oxandrolone or Stanozolol interchangeably.

    It is my usual practice to prescribe Stanozolol at a starting dose of approximately 20mg twice weekly.

    In my experience, Stanozolol at this dose and frequency, the adverse side effects are rare.

Cancellation of registration

1. 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].

2. 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].

3. 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 Association v Cummins [2001] NSWCA 284; (2001) 52 NSWLR 279 at [26]-[28]); Love at [17]­[18]).

4. 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

1. Suspension is a less serious result and differs from cancellation of a practitioner's registration because suspension is for a specified limited period.

2. 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]).

3. 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

1. 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.

2. 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.

3. 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.

4. Dr Singh's misconduct in relation to Patients J and B are particular examples of his broader failings.

The 12 factors

Factor 1        Is there a need to protect the public against further misconduct by Dr Singh?

1. 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[.]

2. The Tribunal broadly accepts the Board's submissions.

3. 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?

1. 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[.]

2. The Tribunal accepts the Board's submissions.  Money is often a powerful incentive for the inappropriate prescribing of drugs.

3. 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?

1. 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[.]

2. 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

1. 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 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[.]

2. 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

1. 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[.]

2. The Tribunal accepts the Board's submissions.

Factor 6        Incompetence

1. The Board submitted that:

   …

   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[.]

2. The Tribunal accepts the Board's submissions.

Factor 7        Was the incident isolated?

1. 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[.]

2. 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

1. 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

1. The Board submitted that:

   …

   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[.]

2. The Tribunal accepts the Board's submissions.

3. 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.

4. 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 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].

5. 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:  TheCouncil of the Qld Law Society v Wright [2001] QCA 58 at [43]-[46].

6. 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?

1. 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

1. 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[.]

2. 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?

1. This factor does not apply.

Penalty

1. 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.

2. 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.

3. 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].

4. 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.

5. 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

1. Dr Singh is no longer a registered medical practitioner so no order is required to cancel his registration.

2. 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

1. 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 Practitioners Act may be taken into account in fixing a period of disqualification under the National Law.

2. 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.

3. 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?

1. 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.

2. 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.

3. It is important that notifiers of potential misconduct be able to do so without abuse by the health practitioner about whom they complain.

4. 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 

1. Section 87(1) and s 87(2) of the State Administrative Tribunal Act2004 (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.

2. In Western Australian Planning Commission v Questdale Holdings PtyLtd [2016] WASCA 32, Murphy JA (Martin CJ and Corboy J agreeing) stated:

   46The 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.

   …

   51Section 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.

3. 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.

4. 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.

5. In the particular circumstances of this case:

   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.

6. 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.

7. 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.

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JUSTICE J C CURTHOYS, PRESIDENT