PHARMACY BOARD OF AUSTRALIA and HEGDE
[2020] WASAT 89
•7 AUGUST 2020
JURISDICTION : STATE ADMINISTRATIVE TRIBUNAL
ACT: HEALTH PRACTITIONER REGULATION NATIONAL LAW (WA) ACT 2010
CITATION: PHARMACY BOARD OF AUSTRALIA and HEGDE [2020] WASAT 89
MEMBER: MR S WILLEY, SENIOR MEMBER
MS R PETRUCCI, MEMBER
MS D PEARSON, SESSIONAL MEMBER
HEARD: 20 SEPTEMBER 2019
FINAL SUBMISSIONS ON 20 MARCH 2020
DELIVERED : 7 AUGUST 2020
FILE NO/S: VR 96 of 2017
BETWEEN: PHARMACY BOARD OF AUSTRALIA
Applicant
AND
CHETAN ANANT HEGDE
Respondent
Catchwords:
Vocational regulation - Pharmacist - Disciplinary proceedings - Professional misconduct - Dispensing of Anabolic Androgenic Steroids - Factors relevant to penalty - Permanent or indefinite unfitness to practice - Competence - Lack of remorse and insight - Registration cancelled
Legislation:
Dental Act 1939 (WA)
Health Practitioner Regulation National Law (WA) Act 2010, s 3(2)(a), s 4, s 5, s6, s 31,s 35(1)(h), s 39, s 196
Medical Act 1894 (WA)
Medical Act 1984 (WA)
Medical Practitioners Act 2008 (WA)
Medicines and Poisons Regulations 2016 (WA), reg 6
National Health (Pharmaceutical Benefits) Regulations 1960 (Cth), reg 24
National Health (Pharmaceutical Benefits) Regulations 2017 (Cth), reg 49
National Health Act 1953 (Cth)
Pharmacy Act 1964 (WA)
State Administrative Tribunal Act 2004 (WA), s 11(8), s 47(1)(c), s 62(3)Result:
Registration cancelled for a period of three years
Category: B
Representation:
Counsel:
Applicant : F Stanton Respondent : A Hershowitz Solicitors:
Applicant : Minter Ellison Respondent : Meridian Lawyers Case(s) referred to in decision(s):
Allinson v General Council of Medical Education and Registration [1894] 1 QB 750
Australian Leisure and Hospitality Group Pty Ltd v Director of Liquor Licensing [2012] WASC 463
Barwick v Council of the Law Society of New South Wales [2004] NSWCA 32
Chen v Health Care Complaints Commissions [2017] NSWCA 186; (2017) 95 NSWLR 334
Clyne v New South Wales Bar Association [1960] HCA 40; (1960) 104 CLR 186
Craig v Medical Board of South Australia [2001] SASC 169; (2001) 79 SASR 545
HCCC v Ng [2012] NSWPHT 1
Health Care Complaints Commission v Do [2014] NSWCA 407
Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630
Healthcare Complaints Commission v Epstein No 2 [2015] NSWCATOD 36
Hewett v Medical Board of Western Australia [2004] WASCA 170
Hilton v Legal Profession Admission Board [2016] NSWSC 1617
Jemielita v Medical Board of Western Australia (Unreported, WASC, Library No 940613, 8 November 1994)
Jemielita v The Medical Board of Western Australia (unreported, WASC, Library No 920584, 13 November 1992)
Khosa v Legal Professional Complaints Committee [2017] WASCA 192
Legal Profession Complaints Committee and A Legal Practitioner [2013] WASAT 37
Legal Profession Complaints Committee v Masten [2011] WASC 71
Legal Profession Complaints Committee v Segler [2014] WASC 159
Legal Professional Complaints Committee v Detata [2012] WASCA 214
Medical Board of Australia and Bernadt [2012] WASAT 108
Medical Board of Australia and Bradshaw [2014] VR 68
Medical Board of Australia and Durston [2012] VR 188
Medical Board of Australia and Ismail [2013] VR 212
Medical Board of Australia and Lal [2019] WASAT 13
Medical Board of Australia and Myers [2014] WASAT 137 (S)
Medical Board of Australia and Roberts [2014] WASAT 76
Medical Board of Australia and Singh [2017] WASAT 33
Medical Board of Australia and Singh [2017] WASAT 33 (S)
Medical Board of Australia and Stephens [2018] WASAT 13
Medical Board of Australia v Dolar [2012] QCAT 271
Mungar v Legal Practice Board of Western Australia [2009] WASC 135
New South Wales Bar Association v Cummins [2001] NSWCA 284; (2001) 52 NSWLR 279
New South Wales Bar Association v Evatt (1968) 117 CLR 177
Nursing & Midwifery Board of Australia v Corderoy [2020] WASC 247
Ong v The Dental Board of Western Australia (unreported, WASC, Library No 950442, 25 August 1995)
Panegyres v Medical Board of Australia [2020] WASCA 58
Panegyres v Medical Board of Australia [2020] WASCA 58 (S)
Pharmacy Board of Australia and Hegde [2018] WASAT 95
Pharmacy Board of Australia and Nyoni [2018] WASAT 134
Pharmacy Board of Australia and Nyoni [2018] WASAT 134 (S)
Pharmacy Board of Australia v Ang (Review and Regulation) [2019] VCAT 1402
Pharmacy Board of Australia v Booy [2011] QCAT 522
Pharmacy Board of Australia v Donnelly [2011] QCAT 584
Pharmacy Board of Australia v Kent [2012] QCAT 329
Pharmacy Board of Australia v Smith [2012] QCAT 186
Pharmacy Board of Australia v Swan [2016] QCAT 475
Quinn v Law Institute of Victoria [2007] VSCA 122; (2007) 27 VAR 1
Singh v Medical Board of Australia [2019] WASCA 51
Smith v New South Wales Bar Association [1992] HCA 36; (1992) 176 CLR 256
Stirling v Legal Services Commissioner [2013] VSCA 374
Tarvydas v Medical Board of Western Australia (Unreported, Supreme Court of Western Australia; Library No 990198)
REASONS FOR DECISION OF THE TRIBUNAL:
INTRODUCTION
1This matter concerns the determination of penalty in relation to Mr Chetan Hegde (respondent) who is a registered pharmacist.
2On 16 May 2017, the Pharmacy Board of Australia (Board or applicant) commenced these proceedings in relation to the respondent's dispensing of anabolic androgenic steroids in the period from 1 January 2008 to 30 April 2009 (the Relevant Period).
3The respondent applied for orders to strike-out the applicant's proceedings as an abuse of process pursuant to s 47(1)(c) of the State Administrative Tribunal Act 2004 (WA) (SAT Act). The strikeout application was premised on an argument that there was an unreasonable delay in bringing the proceedings. The respondent's strike-out application was dismissed on 18 September 2018: Pharmacy Board of Australia and Hegde [2018] WASAT 95.
4The matter was listed for a five day final hearing commencing on 8 July 2019. On 3 July 2019, the parties agreed orders such that the final hearing was not required.
5The parties filed an agreed statement of facts and findings on or about 28 June 2019 (Agreed Facts and Findings) that address the respondent's liability for his conduct. The hearing in relation to penalty occurred on 20 September 2019 (penalty hearing) with the respondent's final submissions filed on 20 March 2020.
MATERIALS BEFORE THE TRIBUNAL
6The Tribunal has been reconstituted since the penalty hearing pursuant to s 11(8) of the SAT Act.
7Each member of the reconstituted panel has reviewed the hearing transcript, the evidence before the Tribunal as well as the parties' closing submissions filed prior, and subsequent to, the penalty hearing.
8At the penalty hearing, the Tribunal took into evidence the following:
Exhibit A:affidavit of Dr Robin Graeme Durston (dated 8/3/2018)
Exhibit B:witness statement of Chetan Hegde (dated 24/7/2019)
Exhibit C:applicant's bundles of amended documents (Volumes 1A to 1D, 2 and 3)
Exhibit D:applicant's consumer medical information pamphlets for the McKenzie's Compounding Chemist (CMIs)
Exhibit E:affidavit of Chetan Hegde (dated 15/1/2018) (respondent)
Exhibit F:affidavit of Chetan Hegde (dated 19/12/2018) (respondent)
Exhibit G:electronic dispensing schedules
Exhibit H:witness statement of Liza Schubert (dated 29/11/2018)
BACKGROUND
9The following background is drawn from the Agreed Facts and Findings (with minor editing and the inclusion of headings to improve readability).
The applicant
10The applicant is established pursuant to s 31 of the Sch to the Health Practitioner Regulation National Law (WA) Act 2010 (WA) (National Law). The applicant's functions include the referral of matters concerning registered health practitioners under a corresponding prior Act to responsible tribunals in participating jurisdictions: s 35(1)(h) National Law.
The respondent
11The respondent:
(a)was born on 26 November 1975;
(b)was first registered as a pharmacist on 2 February 2000 and has been continuously registered since that time;
(c)has Australian Health Practitioner Regulation Agency (AHPRA) registration number PHAOOO1555582;
(d)at all material times:
(i)held registration as a pharmaceutical chemist pursuant to the (now repealed) Pharmacy Act 1964 (WA);
(ii)was the sole proprietor of McKenzies Pharmacy, 869 Beaufort Street, Mount Lawley (Pharmacy); and
(iii)was the pharmacist and holder of the poisons licence at the Pharmacy.
Relevant pharmaceutical standards for dispensing
12At all material times:
(a)the Pharmaceutical Society of Australia Code of Professional Conduct 1998 (1.3) (Code of Conduct) provided that:
A pharmacist must exercise professional independent judgment to prevent the supply of products likely to constitute an unacceptable hazard to health or the supply of unnecessary and/or excessive quantities of medicines and other products, particularly those which have a potential for abuse or dependency.
(b)the Pharmaceutical Society of Western Australia Code of Ethics, July 2000 (2.8) (Code of Ethics) stated:
A pharmacist shall not supply or permit to be supplied any substance in circumstances where the pharmacist knows or could reasonably be expected to know that it is required for other than a legitimate use.
The respondent's dispensing of anabolic steroids
13During the Relevant Period, the respondent dispensed anabolic androgenic steroids (in the form of Sustanon, Deca-Durabolin, Stanozolol, Oxandrolone, Methandrostenolone and Oxymethalone) to patients:
(a)in quantities and combinations which the respondent ought to have known were not necessary for any therapeutic purpose; and
(b)by dispensing repeat authorisations and/or multiple prescriptions:
(i)in the same transaction; or
(ii)in separate transactions conducted significantly within the period in which the medication would have been consumed if taken at the usual dosage;
when the respondent ought to have known that the quantities and/or combinations of medication supplied was likely to constitute an unacceptable hazard to health and had the potential for misuse, abuse or psychological and/or physical dependency.
14Most of the prescriptions submitted to the respondent for anabolic androgenic steroids were written by two medical practitioners (Dr Mughammad Saliem Ismail and Dr Robin Graeme Durston).
15The details of the anabolic androgenic steroids dispensed by the respondent during the Relevant Period are set out in Schedule A of these reasons.
The effects of, and the risks associated with, anabolic steroids
16Anabolic androgenic steroids can be used to achieve greater muscle mass and the respondent ought to have known that they have the potential to be:
(a)misused by patients seeking to increase muscle mass;
(b)misused by patients seeking to enhance sporting ability; and
(c)on-sold by patients, who obtain anabolic androgenic steroids on prescription, to others.
17Potential adverse side effects of use of anabolic androgenic steroids or excessive or prolonged use of anabolic androgenic steroids include (but are not limited to):
(a)acne;
(b)high blood pressure;
(c)increased low-density lipoprotein and/or decreased high-density lipoprotein;
(d)liver damage;
(e)cardiovascular disease;
(f)gynaecomastia;
(g)testicular atrophy; and/or
(h)increased aggression.
The respondent engaged in professional misconduct
18The respondent admits he engaged in 'professional misconduct' (as defined in s 5 of the National Law) in that, during the Relevant Period, he:
(a)engaged in the practice of dispensing anabolic androgenic steroids to patients for a purpose which the respondent ought to have known did not accord with recognised therapeutic standards;
(b)engaged in the practice of dispensing anabolic androgenic steroids to patients in quantities and/or in combinations which the respondent ought to have known, were not necessary for any proper therapeutic purpose and were likely to constitute an unacceptable hazard to the health of patients and/or others to whom those drugs could be on-sold and had the potential for misuse, abuse or psychological and/or physical dependency;
(c)engaged in the practice of dispensing anabolic androgenic steroids to patients by dispensing repeat authorisations and/or multiple prescriptions:
(i)in the same transactions; or
(ii)in separate transactions conducted significantly within the period in which the medication would have been consumed if taken at the usual dosage,
when he ought to have known, that the quantity and/or combination of the drugs supplied was likely to constitute an unacceptable hazard to the health of patients and/or others whom those drugs could be onsold and had the potential for misuse, abuse or psychological and/or physical dependency; and
(d)failed to make any, or any adequate, clinical notes in relation to discussions with patients when counselling them on the use of anabolic androgenic steroids and/or the physical condition of the patients to whom he dispensed anabolic androgenic steroids.
THE NATIONAL LAW
19Section 196 of the National Law sets out the range of sanctions that may be imposed on a health practitioner. The Tribunal is a 'responsible tribunal' for Western Australia for the purposes of the National Law: s 6 Health Practitioner Regulation National Law (WA) Act 2010 (WA); Panegyres v Medical Board of Australia [2020] WASCA 58 at [137] (Vaughan JA) (Panegyres).
20As set out in the Agreed Facts and Findings, the respondent accepts that he engaged in 'professional misconduct' for the purposes of s 196(1)(b)(iii) of the National Law. Pursuant to s 5 of the National Law 'professional misconduct', by a registered health practitioner, includes
(a)unprofessional conduct by the practitioner that amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and
(b)more than one instance of unprofessional conduct that, when considered together, amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and
(c)conduct of the practitioner, whether occurring in connection, with the practice of the 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.
21Pursuant to s 196(2) of the National Law, the Tribunal may decide to do one or more of the following:
(a)caution or reprimand the respondent;
(b)impose a condition on the respondent's registration, including, for example -
(i)a condition requiring the respondent to complete specified further education or training, or to undergo counselling, within a specified period; or
(ii)a condition requiring the respondent to undertake a specified period of supervised practice; or
(iii)a condition requiring the respondent to do, or refrain from doing, something in connection with his practice; or
(iv)a condition requiring the respondent to manage his practice in a specified way; or
(v)a condition requiring the respondent to report to a specified person at specified times about his practice; or
(vi)a condition requiring the respondent not to employ, engage or recommend a specified person, or class of persons;
(c)require the practitioner to pay a fine of not more than $30, 000 to the applicant;
(d)suspend the respondent's registration for a specified period;
(e)cancel the respondent's registration.
22If the Tribunal decides to impose a condition on the respondent's registration, we must also decide a review period for the condition: s 196(3) National Law.
23If the Tribunal decides to cancel the respondent's registration, we may also decide to either:
(a)disqualify the person from applying for registration as a registered health practitioner for a specified period; or
(b)prohibit the person, either permanently or for a stated period, from either:
(i)providing any health service or a specified health service; or
(ii)using any title or a specified title: s 196(4) National Law.
24An entity with functions under the National Law, such as the Tribunal, is to exercise its functions having regard to the objectives and guiding principles of the national registration and accreditation scheme: s 4 National Law. Section 3(2)(a) of the National Law includes the following objective:
to provide for the protection of the public by ensuring that only health practitioners who are suitably trained and qualified to practise in a competent and ethical manner are registered[.]
OUR FINDINGS ON THE RESPONDENT'S CONDUCT
25As is set out in the Agreed Facts and Findings, the parties agree that the respondent engaged in 'professional misconduct' for the purposes of the National Law. That is the issue to which we will now turn.
26Under the National Law 'professional misconduct' is 'unprofessional conduct' which can be either constituted by a single act, or a series of acts considered together, that represents conduct which is substantially below the standard to be reasonably expected. Furthermore, conduct by a practitioner, whether connected to their profession or not, that is inconsistent with the practitioner being a fit and proper person to hold registration, can also be professional misconduct.
27However, as was explained by Hill J in Nursing & Midwifery Board of Australia v Corderoy [2020] WASC 247, the definition of 'professional misconduct' in s 5 of the National Law is inclusive and is not an exhaustive statement of the concept: at [61].
28The concept of 'professional misconduct' was explained in detail by Vaughan JA in Panegyres at [151]-[157] (Buss P and Murphy JA agreeing at [11]). Professional misconduct still includes the test of 'infamous conduct in a professional respect' which was adopted in Allinson v General Council of Medical Education and Registration [1894] 1 QB 750 (Allinson); Panegyres at [152]; Medical Board of Australia and Roberts [2014] WASAT 76 at [175].
29By reason of the Agreed Facts and Findings, the respondent and the Board consider that the respondent's misconduct constitutes 'professional misconduct' for the purposes of the National Law. We agree.
30The respondent's misconduct during the Relevant Period was intensive and voluminous. During the Relevant Period there were 4737 dispensing episodes (at an average dispensing rate of 296 per month). The total number of patients for whom prescriptions were dispensed during the Relevant Period is 828. The respondent undertook compounding training in order to be able to compound and dispense anabolic steroids.
31As we will explain in more detail later in these reasons, the respondent's conduct was hazardous in that his dispensing resulted in elevated risks to his patients. The misconduct extended over 16 months.
32The respondent's conduct was substantially below the standard of conduct that reasonably expected of a pharmacist with the respondent's experience. Having regard to the risks associated with the dispensing (to both his patients and also the public), it was also conduct that may properly be regarded as 'disgraceful or dishonourable' in the sense explained in Allinson (at 763). The conduct was inconsistent with the respondent being a fit and proper person to hold registration as a pharmacist.
THE APPLICABLE PRINCIPLES TO ASSESSING PENALTY
33In Medical Board of Australia and Singh [2017] WASAT 33 (S) at [23][29] (Singh Penalty) the Tribunal set out the general principles in relation to the imposition of disciplinary sanctions. These principles were generally endorsed on appeal: Singh v Medical Board of Australia [2019] WASCA 51 at [26] (Quinlan CJ & Pritchard JA) (Singh Appeal).
34The plurality in the Singh Appeal noted that the case authorities on disciplinary proceedings include those relating to the regulation and discipline of legal practitioners. While the principles identified in those cases are relevant in the context of the regulation and discipline of medical professionals, (such as, in this instance, pharmacists), in applying the National Law, it is important to bear in mind the institutional and functional differences between professions. Furthermore, the ultimate duty of the Tribunal is to give effect to the relevant statutory provisions: at [28] (Quinlan CJ and Pritchard JA).
35It is useful at this point to provide a summary of these general principles that inform the question of penalty. They include:
Protection of the public and not punishment of the practitioner
36The Tribunal's jurisdiction is protective rather than punitive. The purpose of disciplinary proceedings is to protect the public, not to punish the practitioner in a criminal law sense. A disciplinary tribunal protects the public by making orders the effect of which is to prevent persons who are unfit to practise from practising, or by making orders to secure the maintenance of proper professional standards: Singh Appeal at [30] (Quinlan CJ and Pritchard JA); Khosa v Legal Professional Complaints Committee [2017] WASCA 192 at [37] (Buss P), [188] (Murphy & Beech JJA) (Khosa).
37A disciplinary tribunal will also consider protection of the public, and also the relevant profession, by making orders which will assure the public that appropriate standards are being maintained in the relevant profession: Craig v Medical Board of South Australia [2001] SASC 169; (2001) 79 SASR 545 at [41] (Doyle CJ) (Craig); Khosa at [37] (Buss P), [188] (Murphy & Beech JJA).
38The plurality in the Singh Appeal noted that protection of the public may include the need to make orders the effect of which is to 'bring home to the practitioner the seriousness of their conduct and the need to deter the practitioner from future breaches': at [32]. Such an order may be regarded as 'specific deterrence'.
39Furthermore, the plurality also observed that protection of the public may require an order to emphasise to other members of the profession, or to reassure the public, that a certain type of conduct is not acceptable professional conduct. An order of that kind may be regarded as akin to 'general deterrence': Singh Appeal at [32]. See also Craig at [47] (Doyle CJ).
40The need for deterrence of others in the pharmaceutical profession from engaging in similar conduct, as an aspect of the protection of the public, was also discussed in Pharmacy Board of Australia and Nyoni [2018] WASAT 134 at [36] (Nyoni) citing Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630 (Gleeson CJ, Meagher JA, Handley JA).
41Where there is a choice of sanctions available, it is to be expected that the Tribunal will choose that sanction which maximises the protection of the public: Quinn v Law Institute of Victoria [2007] VSCA 122; (2007) 27 VAR 1 at [31] (Maxwell P) (Quinn).
Whether the conduct was an isolated incident
42The question of whether the misconduct was an isolated incident is also relevant. Where an incident is isolated, this tends to provide a greater level of comfort that the practitioner can be relied on into the future: New South Wales Bar Association v Evatt (1968) 117 CLR 177 at 183 (Barwick CJ, Kitto J, Taylor J, Menzies J and Owen J); Singh Penalty at [30(7)].
The sanction is assessed at the time of its imposition
43The appropriate sanction is to be assessed at the time the sanction is imposed and not by reference to the date of the misconduct: Legal Profession Complaints Committee v Segler [2014] WASC 159 at [7] (Martin CJ, Beech J and Chaney J) (Segler); Legal Profession Complaints Committee and A Legal Practitioner [2013] WASAT 37 (S) at [23] (A Legal Practitioner (S)).
The sanction is for the unprofessional conduct
44It is the practitioner's conduct that attracts the sanction. Care needs to be taken to ensure that the penalty reflects the practitioner's conduct the subject of the disciplinary action and not other conduct (such as, for example, an unsuccessful defence that was raised or, in this instance, the respondent's unsuccessful strike-out application): Smith v New South Wales Bar Association [1992] HCA 36; (1992) 176 CLR 256 at 267269 (Brennan J, Dawson J, Toohey J and Gaudron J) and 271-272 (Deane J) (Smith); A Legal Practitioner (S) at [24].
45While the principle arising from Smith is accepted, we would add the following qualification as was observed by Ipp JA in Barwick v Council of the Law Society of New South Wales [2004] NSWCA 32 at [108] (Barwick):
The relevant time for determining the fitness of a practitioner to practise is the time of the determination by the disciplinary body seized with the question … The misconduct charged will have taken place before the decision is made; there will inevitably be a gap between the date of the misconduct and the date of the determination. It will not be unusual for the practitioner concerned to submit that circumstances have changed since the misconduct charged; arguments as to remorse, reform, character change and subsequent good deeds are not uncommon. 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.
Hardship to the practitioner is a secondary consideration
46The overarching purpose of the disciplinary regulation of the pharmaceutical profession is the protection of the public by the maintenance of proper standards within the profession.
47That being so, the hardship caused, or the personal factors relevant, to a practitioner guilty of misconduct are necessarily secondary considerations: Singh Appeal at [33] (Quinlan CJ & Pritchard JA); Legal Professional Complaints Committee v Detata [2012] WASCA 214 at [47] (Martin CJ); Legal Profession Complaints Committee v Masten [2011] WASC 71 at [29] (Martin CJ, Murray J and EM Heenan J).
A 'global' assessment of penalty may be appropriate
48There are circumstances in which a 'global' approach to the assessment of penalty is to be preferred against separate penalties for each unprofessional act, particularly where the facts of the case are inextricably related: Stirling v Legal Services Commissioner [2013] VSCA 374 at [72]-[75] (Warren CJ, Neave JA and Dixon AJA); A Legal Practitioner (S) at [18]; Medical Board of Australia and Myers [2014] WASAT 137 (S) at [15].
49Both parties' submissions address the question of penalty on a global basis. We agree that, having regard to the inextricable nature of the acts (and omissions) that constitute the respondent's misconduct, a global penalty is appropriate. The respondent's misconduct is constituted by a 'course of behaviour rather than separate and distinct instances': Pharmacy Board of Australia and Nyoni [2018] WASAT 134 (S) at [41] (Nyoni Penalty).
Other general observations on the principles which inform penalty
50In addition to the principles enunciated in the Singh Penalty decision, we are mindful of the analysis the plurality in the Singh Appeal at [34][40] which we set out below (footnotes omitted):
34[O]f particular significance in any given case will be whether the findings of misconduct reveal that a person is unfit to practise their profession. In Khosa v Legal Profession Complaints Committee, Murphy and Beech JJA (at [191]-[192]) discussed this consideration in the context of disciplinary proceedings against legal practitioners and said:
In general terms, where the conclusion is reached that a practitioner is presently unfit to practise, a choice may be made between suspension and striking off. If an order for suspension is made in that event, it must be made on the basis that, at the termination of the period of suspension, the practitioner will no longer be unfit to practise because, at the end of the relevant period, the practitioner's name will still be on the roll of practitioners and may resume practise. Suspension is a 'serious form of discipline which is usually imposed to discipline the legal practitioner, who has committed an act of unprofessional conduct but who, in the opinion of the court, at the end of the period of suspension, will be a fit and proper person to practise the law'. In the context of suspension, present unfitness to practise may be understood to include a serious breach of professional obligations 'reflecting, to a significant degree, upon the practitioner's fitness to practise'.
Where, however, the present unfitness to practise reveals that the practitioner lacks the character and trustworthiness necessary to discharge the responsibilities of legal practice, or that the practitioner is permanently or indefinitely unfit to practise, striking off rather than suspension will (at least ordinarily) be the appropriate response. (footnotes omitted)
35These principles may, in a qualified way, be applied by analogy to medical practitioners.
36As Khosa demonstrates, in the context of legal practitioners, a choice may often arise between suspension and striking off (i.e. removing the practitioner's name from the roll of practitioners). In relation to the medical profession, the order under the National Law that is most analogous to 'striking off' is cancellation of the practitioner's registration. The analogy is not, however, perfect. For example, an order cancelling a medical practitioner's registration may be made by the Tribunal, whereas an order to remove a legal practitioner's name from the roll of practitioners may only be made by the Full Court.
37Nevertheless, the approach identified by Murphy and Beech JJA in Khosa v Legal Profession Complaints Committee in our view provides a useful guide as to whether suspension or cancellation of registration of a medical practitioner is appropriate in any given case. Applying that approach, it may be said that where a medical practitioner is 'permanently or indefinitely unfit to practise, [cancellation of registration] rather than suspension will (at least ordinarily) be the appropriate response'.
38On this approach, permanent or indefinite unfitness to practice (at least ordinarily) will be a sufficient basis for cancelling the practitioners' registration. It must be recognised, however, that permanent or indefinite unfitness to practice, is not a necessary condition for cancellation. As the Court in Chen v Healthcare Complaints Commission recognised, the National Law does not elevate any consideration relevant to the power to cancel registration to the status of a precondition to that power.
39As Basten JA stated in Chen v Healthcare Complaints Commission:
There is no category of unsatisfactory professional conduct which is not capable, depending on the circumstances, of giving rise to professional misconduct and hence engaging the power of either suspension or cancellation of registration. The only requirement is that it be 'sufficiently serious' to justify such an order, a characterisation which must depend upon an evaluative judgment made by the Tribunal. Some, perhaps all, categories include conduct which may reveal a defect of character as to which the Tribunal may conclude that the person should not be allowed to practise his or her profession unless at some future date the practitioner is able to satisfy the Tribunal that the defect has been overcome. Incompetence or inadequate care may in some circumstances be remediable by specific steps; in other circumstances the Tribunal may be concerned that the carelessness, for example, is such as to cast doubt on the suitability of the person to practise medicine. Each of the criteria for cancellation or suspension may be analysed in this way. Each case will depend upon an evaluative judgment to be made by the Tribunal as to the nature and seriousness of the conduct.
40However, in contrast to the disciplinary provisions concerning legal practitioners, the Tribunal has the power, under s 196(4)(a) of the National Law, to make an order specifying a period within which a person is disqualified from applying for registration as a registered health practitioner.
51Furthermore, as the plurality observed in the Singh Appeal, it will be a matter for the Tribunal as to the weight to be given to the various considerations relevant to the exercise of discretion in relation to sanction: at [45].
ORAL EVIDENCE AT THE PENALTY HEARING
52At the penalty hearing on 20 September 2019, Dr Durston gave evidence on behalf of the Board. The respondent also gave evidence.
Doctor Durston's evidence
53Doctor Durston gave evidence about the extent of interactions between himself and the respondent, his medical practice, prescribing practices as well as his own disciplinary history.
54Doctor Durston was cross-examined at some length about his relevant professional and personal history. In giving his evidence, Dr Durston gave evidence about his own health condition. At the penalty hearing, the Tribunal ordered that the details of Dr Durston's health condition be the subject of a non-publication order pursuant to s 62(3) of the SAT Act.
55The substance of Dr Durston's evidence was inter alia that he:
(a)and the respondent never spoke in the context of the prescriptions he wrote for anabolic steroids;
(b)did not endorse his prescriptions for anabolic steroids under reg 24 of the National Health (Pharmaceutical Benefits) Regulations 1960 (Cth) (NH(PB) Regulations)[1];
(c)ceased prescribing anabolic steroids by July 2009; and
(d)did not hold himself out as a 'specialist endocrinologist' whose practice comprised patients with muscular atrophy, weight loss and inability to increase muscle mass due to loss testosterone levels.
[1] The text of reg 24 of the NH(PB) Regulations is now contained in reg 49 of the National Health (Pharmaceutical Benefits) Regulations 2017 (Cth).
56Doctor Durston struggled with his health condition. During his evidence he disclosed (for the first time) that he had falsified prescriptions on numerous occasions and frequently obtained prescriptions in other peoples' names at the Pharmacy.
57Doctor Durston also gave evidence that he was not practicing as a medical practitioner (because he was suspended) between 26 December 2009 and June 2011. He therefore was not writing prescriptions during these times. Dr Durston's affidavit (Exhibit A) outlined that he did not present prescriptions in other patients' names to the Pharmacy nor did the Pharmacy ever refuse to dispense any medication to him on presentation of a prescription. By reason of the admissions (set out at [56] above and also at [158(e)] below) that aspect of Dr Durston's affidavit evidence is plainly false.
The respondent's evidence
58The respondent gave evidence inter alia about his dispensing practices including the level of interactions between he and Dr Durston (as well as other prescribing doctors). He was asked questions about his decision to commence compounding anabolic steroids, the CMIs as well as the evidence of Mrs Seubert (Exhibit H). The respondent's evidence addressed his protocols for dealing with prescriptions endorsed under reg 24 of the NH(PB) Regulations and whether Dr Durston told him that he was a 'specialist endocrinologist'.
59The respondent was also questioned about the audits undertaken by the Department of Health, his competency as a pharmacist (including indications for certain drugs) and the profitability of the Pharmacy.
Evaluating the evidence
60It will be necessary for the Tribunal to address the evidence of Dr Durston and the respondent throughout these reasons.
61It is apparent that Dr Durston and the respondent give very different accounts of their interactions during the Relevant Period. The Tribunal will evaluate their evidence at [193]-[213] (and in particular their conflicting evidence at [207]-[213]) of these reasons.
62It is, however, sufficient to say at this point that neither witness was particularly impressive. The Tribunal does not entirely accept the evidence of either Dr Durston or the respondent. However, as we will explain, we consider that Dr Durston generally gave truthful evidence at the penalty hearing (although, as we have explained, some aspects of his affidavit evidence were false).
APPLICANT'S SUBMISSIONS
63The applicant filed an outline of opening submissions, made brief remarks at the penalty hearing and filed closing submissions on 10 February 2020.
64The applicant refers to the decision of the Queensland Civil and Administrative Tribunal in Medical Board of Australia v Dolar [2012] QCAT 271 (at [13]) (Dolar) where it was observed that a prescribing doctor may be seen as 'the front line of defence' against the misuse or abuse of anabolic steroids, and that the pharmacist 'is the last line of defence': Applicant's Closing Submissions at para 23.
65The applicant submits that the 'community relies upon pharmacists to always protect the safety of patients and others by employing proper dispensing practices'. Given the volume of pharmaceutical transactions, it is simply not possible to supervise all dispensing. For that reason 'the community relies upon the honesty and professionalism of pharmacists in their practice of pharmacy': Applicant's Closing Submissions at para 23.
66The applicant further submits that on account of the 'ready market' for anabolic androgenic steroids, in the context of the potential for significant shortterm and longterm harm as a result of their misuse, it is 'vital in the public interest that disciplinary penalties', in these types of matters, 'are sufficiently severe to achieve specific and general deterrence': Applicant's Closing Submissions at para 24.
Factors which inform the question of penalty
67The Board points to a range of general factors which may inform the question of penalty for matters concerning the dispensing of anabolic androgenic steroids (Applicant's Closing Submissions at para 26):
(a)the period during which the inappropriate prescribing or dispensing took place;
(b)the number of prescriptions or dispensing episodes;
(c)the number of patients involved;
(d)whether multiple prescriptions were given at one consultation or dispensed in one transaction or on the same date or in quick succession such that patients were able to have in their possession large quantities of the drugs;
(e)whether combinations of different anabolic androgenic steroids were dispensed at the same time;
(f)whether the prescribing and dispensing continued whether the prescriber or dispenser knew that patients were suffering from adverse effects of the prescribing or dispensing, and in particular, serious adverse effects such as damage to organs or serious psychiatric disturbance such that the patient was at risk of harming themselves or others;
(g)whether the conduct itself or the practitioner's attempts to justify or defend the conduct demonstrated incompetence;
(h)aggravation by the continuation of the conduct after the commencement of investigation and the commencement of disciplinary proceedings;
(i)aggravation by breach of undertakings to cease the conduct;
(j)dishonesty in the investigation and/or prosecution of the conduct;
(k)mitigating conduct in that the practitioner demonstrated insight into the impropriety of the prescribing or dispensing and made early and comprehensive admissions as to the fact of the prescribing or dispensing and the reasons for it and conversely, a lack of insight into the impropriety of the conduct; and
(l)a lack of contrition and remorse.
The respondent's admissions
68The applicant submits that only limited weight should be given to the respondent's admissions contained in the Agreed Facts and Findings. The applicant submits the admissions were made late (shortly before the commencement of the penalty hearing) and therefore may have been made for strategic reasons, rather than evincing genuine insight into the nature of his conduct: Healthcare Complaints Commission v Epstein No 2 [2015] NSWCATOD 36 at [32]; Medical Board of Australia and Stephens [2018] WASAT 13 at [42]-[43].
69The applicant further submits where a practitioner has made admissions, but proceeds to then give evidence in a penalty hearing which evince a lack of insight into the nature and severity of the admitted conduct, the mitigatory effect of the previous admissions will be lost.
70The applicant submits that the respondent's evidence at the penalty hearing demonstrates a lack of insight in the nature and effect of his misconduct and therefore detracts from the mitigatory effect of the admissions that were ultimately made. Further, in giving evidence, the respondent continued in an effort to minimise the penalty to be imposed and, in doing so, gave false evidence: Applicant's Closing Submissions at para 53.
The respondent's dispensing practices
The volume of the respondent's dispensing
71As set out at [30] above, in terms of the volume of dispensing, the electronic schedule (ExhibitG) shows that during the Relevant Period there were 4737 dispensing episodes at an average of 296 dispensing episodes per month.
72The electronic schedule was, however, incomplete. The respondent did not include Primoteston Depot in the electronic schedule but which he, by his own evidence, did dispense during the Relevant Period.
73The electronic schedule refers to 907 patients. Of those, only 79 were not the subject of a dispensing episode during the Relevant Period. The total number of patients for whom prescriptions were dispensed during the Relevant Period is 828.
74In terms of the respondent's dispensing practice, the applicant submits that for patients in respect of whom there was a recognised therapeutic indication for the drugs, would never require more than one anabolic androgenic steroid at one time to treat the relevant condition: Exhibit C, page 669. However, the electronic schedule shows that the respondent (and his employees) routinely dispensed multiple anabolic androgenic steroids to patients in single transactions.
75Furthermore, the respondent would dispense multiple prescriptions to individual patients on the same date and in quick succession. The applicant's submissions refer to the report of Ms Seubert who provided an opinion to AHPRA on the respondent's dispensing practice on 11 November 2016.
76Ms Seubert noted that a patient had been dispensed 87 injectable doses of anabolic steroids as well as 200 oral doses in a 47 week period. Ms Seubert outlined that if a patient was using the maximum injectable dosage (one ampoule every two weeks) only 24 ampoules would have been required. Ms Seubert's opinion was that the patient was provided with anabolic steroids at a rate of 3.6 times the maximum required number of injectable doses as well as the oral doses: Exhibit C, pages 669-670.
77Another example involved the dispensing of 369 doses of anabolic steroids as well as 630 oral doses. If the patient was using the maximum injectable dosage (one ampoule every two weeks) only 25 ampoules would have been required. Ms Seubert considered that the dispensing rate was 14.8 times higher than the maximum required number of injectable doses as well as the oral doses. Other examples were also provided: Exhibit C, pages 669-670.
Dispensing pursuant to reg 24 of the NH(PB) Regulations
78The applicant does not accept the respondent's evidence that from 2003 telephone calls were made to prescribing doctors whenever prescriptions were endorsed pursuant to reg 24 of the NH(PB) Regulations.
79During the Relevant Period, reg 24 of the NH(PB) Regulations allowed a practitioner to direct supply on one occasion a greater quantity of a drug than would otherwise be permissible provided the practitioner was satisfied that:
(a)the maximum quantity of the pharmaceutical benefit is insufficient for the medical treatment of the person for whom the prescription is written; and
(b)that person requires the pharmaceutical benefit for the treatment of a chronic illness or is residing in a place remote from the approved pharmacist nearest to that person's place of residence; and
(c)that person could not, without great hardship, obtain the required quantity or number of units of the pharmaceutical benefit by means of repeated supplies on separate occasions.
80As stated at [30] and [71] above, the dispensing schedule shows that there were 4737 dispensing episodes during the Relevant Period. The applicant submits that of the dispensing episodes, 2328 (or 49%) related to prescriptions from Dr Durston and 2090 (or 44%) relate to prescriptions from Dr Ismail. These two doctors accounted for 93% of the dispensing of anabolic steroids in the dispensing schedule: Exhibit G.
81The applicant does not accept that the respondent called these doctors to check when prescriptions were endorsed with reg 24 of the NH(PB) Regulations. It says that the respondent's evidence in this regard cannot be accepted as truthful because Dr Durston's evidence was that he never endorsed what were private prescriptions with a reg 24 endorsement. This was because reg 24 did not apply to such prescriptions because they were private prescriptions, and not part of the Pharmaceutical Benefits Scheme (PBS), governed by the National Health Act 1953 (Cth): Exhibit A at paras 10 - 12.
82Furthermore, in giving his evidence the respondent could not recall the location of Dr Durston's practice. Given the volume of calls that would have been made (having regard to the fact that 44% of the Pharmacy's dispensing of anabolic androgenic steroids were from prescriptions written by Dr Durston) the applicant observes that there would have been very frequent contact between the two. Furthermore, the applicant notes that given the very large of number of telephone calls that would have occurred during the Relevant Period, the applicant called no employees to give evidence as to the practice of calling doctors to discuss prescriptions.
83The applicant submits that even where a prescription is endorsed with reg 24, it is incumbent on the pharmacist (as the 'gatekeeper') to consider whether that endorsement was appropriate. The pharmacist ought to consider the relevant therapeutic indication and, if required, to make necessary enquiries and to seek necessary explanations and to be satisfied of their credibility.
84Furthermore, where a pharmacist does dispense larger quantities of drugs than otherwise permissible on account of a reg 24 endorsement, and the relevant patient was frequently in attendance at a pharmacy, there would be obvious grounds for a pharmacist to refuse supply. The applicant submits the respondent dispensed excessive quantities of anabolic steroids to multiple patients, apparently on the basis of reg 24 endorsements, when the requirements of the regulations were plainly not met.
85In addition, if, as the respondent's evidence suggests, he regularly spoke with Dr Durston in relation to such prescriptions, then he should have informed Dr Durston that the necessary requirements for the making of a reg 24 endorsement were not met as the patients were regularly able to attend the Pharmacy.
86The applicant submits that the respondent still does not understand his obligation as a pharmacist in a situation where a reg 24 prescription is presented. For example, under crossexamination the respondent deferred to the fact that the prescription had been written by the doctors, but did not consider the underlying false premise under which the reg 24 endorsement had been made - that the patient could attend the Pharmacy without difficulty: ts 68, 20 September 2019.
87Furthermore, the respondent also sought to justify the dispensing of anabolic steroids on the basis of reg 24 endorsements where patients had, apparently, 'lost' the drugs: ts 71-72, 20 September 2019. The applicant submits that the respondent's evidence does not address the fundamental issue that there was no basis for a reg 24 endorsement given that patients were able to frequently attend the Pharmacy.
88The respondent was carefully cross-examined on this aspect of his dispensing practice: ts 7175, September 2019. The applicant submits that the respondent's answers demonstrated a persistent lack of knowledge and understanding of his professional obligations and that, as a result, the respondent 'cannot be relied upon to meet the fundamental obligations of a pharmacist necessary to safeguard the public': Applicant's Closing Submissions at para 78.
89The respondent's evidence (Exhibit F at para 29) is that:
(a)Dr Ismail told him that many of his prescriptions related to patients with low testosterone levels and that he was trying to 'boost them up in an attempt to normalise testosterone levels'; and
(b)Dr Durston told him that 'he was a specialist endocrinologist his practice consisted of patients with muscular problems, including issues associated with muscular atrophy, weight loss and inability to increase muscle mass due to low testosterone levels'.
90The applicant submits that the respondent's evidence is 'implausible' in that two doctors, who never practised together, would both use the term 'muscular problems': Applicant's Closing Submissions at para 81.
91The applicant notes that such comments were 'conspicuously absent' from the respondent's witness statement prepared for the penalty hearing (Exhibit B): Applicant's Closing Submissions at para 82. Doctor Durston's evidence was that he never said to anyone that he had patients suffering from 'muscular problems': Exhibit A at [23]. Furthermore, Dr Durston's evidence was that he never described himself to the respondent as a 'specialist endocrinologist': Exhibit A at paras 20, 21 and 29. The applicant submits that Dr Durston's evidence in this regard was 'unshaken' during cross-examination: ts 57, 20 September 2019.
92To the extent the evidence of Dr Durston and the respondent conflicts in terms of telephone calls to discuss prescriptions and that Dr Durston had told the respondent that he was a 'specialist endocrinologist', the applicant says that Dr Durston is likely being truthful. This is because he has been frank with the Medical Board of Western Australia (Medical Board) in that he told the Medical Board he prescribed drugs for body building purposes, that his patients' clinical notes reflect his prescribing for anabolic steroids for body building purposes, and for a period of time in which the respondent says these calls were taking place, Dr Durston was under suspension and not practising: refer Exhibit C, Vol 2.
93The applicant submits that the respondent's evidence that he made routine telephone calls to discuss prescriptions featured in only his most recent witness statement (Exhibit B) and not his earlier affidavits (Exhibits E and F).
94The applicant submits that the Tribunal should reject the respondent's evidence that he was entitled to feel reassured by the conversations he says he had with Dr Durston and Dr Ismail. Even if that evidence were true, the applicant notes, it would still not then justify the dispensing actually undertaken by the respondent.
95As stated, the Tribunal will address the conflicting evidence of Dr Durston and the respondent at [207]-[213] below.
'Doctor shopping'
96The applicant further submits that the respondent should have been alerted to the fact that he was receiving prescriptions for anabolic steroids for the same patient but from different doctors. For example, one patient presented prescriptions for 152 ampoules of Sustanon during the Relevant Period from four different doctors in circumstances where the prescription dates were in close proximity: Applicant's Closing Submissions at para 89.
97The applicant submits that the presentation of multiple prescriptions in such circumstances would have alerted a competent pharmacist that the patient was at risk from the abuse or misuse of such drugs.
The respondent is incompetent
98The applicant submits that the respondent is incompetent. This submission is put on a number of bases. The applicant says it would have been obvious to any competent pharmacist who was receiving so many prescriptions for anabolic steroids from just two doctors (who were not specialists but general practitioners) at the Pharmacy, that the doctors were not prescribing the steroids for any proper therapeutic purpose. This is because the quantities and drug combinations prescribed were inconsistent with any proper dosing regimen for such drugs.
99The applicant submits that the respondent was a 'singularly unimpressive witness - rambling, often nonsensical and evasive': Applicant's Closing Submissions at para 102. The applicant further submits that the respondent's incompetency is evinced by the respondent's apparent reliance on reassurances provided by others and that he was seemingly unaware of the risk of the diversion of the drugs: ts 109, 20 September 2019.
100The respondent's ignorance of the risk of diversion of anabolic steroids evinces 'gross incompetency' especially given the volume of drugs he dispensed and the fact that he was pharmacist who compounded such drugs: Applicant's Closing Submissions at paras 103 and 105.
101At the penalty hearing, the respondent's evidence of indications for anabolic androgenic steroids included 'muscular dystrophy' and 'muscle wasting' in the context of Acquired Immune Deficiency Syndrome. However, the respondent agreed that 75% of the patients to whom he dispensed these drugs did not have an appearance consistent with a chronic or life-threatening illness: ts 86, 20 September 2019. In the context of this submissions, the Tribunal notes the Facebook screenshots of some of the respondent's patients found in Vol 3 of Exhibit C.
102The respondent also suggested that low testosterone might be a further indication. However, the respondent was aware at the penalty hearing that the treatment for low testosterone involved only a single agent rather than multiple anabolic androgenic steroids as were being dispensed by the Pharmacy in the vast majority of cases: Applicant's Closing Submissions at para 107.
103Notwithstanding this, the respondent was not able to recall whether he questioned either Dr Durston or Dr Ismail about prescribing multiple anabolic steroids for single patients, but would not 'discount that it did not happen': ts 88-89, 20 September 2019.
104The respondent's incompetency is also demonstrated, the applicant submits, in his reliance on 'assurances' given following audits by the Department of Health. The applicant notes that the appropriate avenue for the respondent to obtain information about the propriety of dispensing anabolic androgenic steroids would have, during the Relevant Period, been the Pharmaceutical Council of Western Australia.
105Furthermore, during the Relevant Period, the respondent was a relatively experienced pharmacist having graduated from university in 1998 and purchasing the Beaumaris Pharmacy in 2000. The respondent's incompetency cannot be explained by youth or inexperience.
106The applicant also refers to the respondent's CMIs (relating to Stanazolol, Oxymetholone (Oxandrolone) and Methandrostenolone) as being 'deficient as a resource for patients to inform them of the potential adverse effects of [these] drugs'. This is because the risks of:
(a)taking the drugs for the purposes of body building or increasing muscle mass;
(b)taking more than one anabolic androgenic steroid at one time; and
(c)taking large quantities of the drugs to increase muscle mass as opposed to therapeutic quantities,
are not explained at all in the respondent's CMIs. The applicant submits the CMIs aggravate the misconduct and further evince the respondent's incompetence: Applicant's Closing Submissions at paras 116-117.
Lack of insight, contrition and remorse
107The applicant submits that a practitioner who is genuinely remorseful would take guidance from the expert witness who has been called to highlight the deficiencies in his dispensing practices that form the basis of his professional misconduct. The respondent has not demonstrated remorse. When asked about the 'notorious fact' of there being an illicit trade in anabolic androgenic steroids, as outlined in the evidence of Ms Seubert, the respondent replied to the effect that 'he looked at [her] evidence when it was first received but had not reviewed it since': ts 111, 20 September 2019.
108Likewise, when asked about Dr Durston's evidence that he was not practising medicine in 2010 and therefore was not writing prescriptions, the respondent gave the following evidence (ts 96, 20 September 2019):
MS STANTON: You just said you had seen him in 2010? - - -
MR HEGDE: Well, this is my - who cares, like - like, this is all like - like, looking back from so many years ago.
109The applicant further submits that the respondent's lack of insight, contrition and remorse is most illuminated by what has not been said. That is, the respondent has not articulated any understanding of the 'important role of pharmacists in protecting the community from inappropriate dispensing of anabolic androgenic steroids': Applicant's Closing Submissions at para 120.
Applicant's case authorities
110The applicant refers to the decision of Tarvydas v Medical Board of Western Australia (Unreported, Supreme Court of Western Australia; Library No 990198) (Tarvydas) where Wheeler J was dealing with an application to extend time in which to appeal a decision made by the Medical Board. Dr Tarvydas was denied leave to appeal the penalty of a 12 month suspension in respect of his dispensing anabolic steroids to one patient over a three year period. Wheeler J agreed with the characterisation of the conduct as 'serious and deserved substantial punishment': Tarvydas at 13.
111Wheeler J also referred to the conduct of Dr Tarvydas at the inquiry and noted that he (at 14):
… attempted to excuse his conduct by saying that he had prescribed the drugs for the purpose of treating sexual dysfunction, and the respondent appears to have found that this excuse was fabricated … [showing] a lack of remorse and an unwillingness to face the consequences of what was in any event wrong, and apparently recklessly wrong, treatment[.]
112The applicant also refers to the Tribunal's published orders in Medical Board of Australia and Bradshaw [2014] VR 68 (Bradshaw) in relation to the prescribing of Sustanon, Primoteston Depot and Clenbuterol to one patient in the absence of any clinical inclination. A 12 month suspension was imposed and a condition placed on his registration permanently preventing him from prescribing anabolic steroids or stimulants to any patient as well as requiring regular audits.
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